[
    {
        "Introduction": "hello and welcome to chapter 20 endocrine and hematologic emergencies of the emergency care and transportation of the sick and injured 12th edition\nfavorite chapters and this is because the endocrine system directly or indirectly influences nearly every cell organ and function of the body and endocrine disorders are often seen with a multiple of signs and symptoms hematologic emergencies they're difficult to assess and treat in the pre-hospital setting",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will understand the significance and characteristics of diabetes sickle cell disease clotting disorders and the complications associated with each you will be able to demonstrate knowledge of the characteristics of type 1 and type 2 diabetes you will be able to list appropriate steps for assessment and pre-hospital treatment of diabetic emergencies and you will also be able to discuss hematologic emergencies and describe sickle cell disease hemophilia thrombophilia and deep vein thrombosis okay so let's get started with one of my",
        "Anatomy and Physiology": "so let's talk about some of the anatomy and physiology the endocrine system is a communication system that controls functions inside the body so we'll talk about the endocrine glands and they secrete messenger hormones which travel through the blood to end organs tissues or cells that they affect endocrine disorders are caused by an internal communication problem if a gland is not functioning normally it may produce more hormones and this is called hyper secretion or not enough hormones and this is hypo secretion a gland may be functioning correctly but the receiving organ may not be responding",
        "Anatomy and Physiology 3 of": "so there's glucose metabolism now we know that the brain needs two things to survive and that's glucose and oxygen insulin is necessary for glucose to enter those cells we say the insulin is the key that unlocks the door right to let the sh the glucose into the cells without enough insulin the cells do not get fed the pancreas produces and stores two hormones so it produces and stores glucagon and insulin the inlets of lagrange are found in small portions of the pancreas with the within these inlets are alpha and beta cells now alpha cells produce glucagon and beta cells produce insulin the pancreas stores and secretes insulin and glucagon in response to the level of glucose in the blood",
        "Pathophysiology": "so let's talk about the pathophysiology so diabetes mellitus is a disorder of glucose metabolism such that the body has an impaired ability to get glucose into the cells to be used for energy without treatment blood glucose levels become high in severe cases it may cause life-threatening illness or coma and death if not managed well it can have severe complications such as blindness cardiovascular disease and kidney failure there are three types of diabetes you have diabetes mellitus type 1 diabetes mellitus type 2 and then pregnancy induce we call that gestational diabetes treatments for diabetes include medications and injectable hormones that lower blood glucose levels if administered correctly or incorrectly it can create a medical emergency for the patients with diabetes low blood glucose levels hypoglycemia if unrecognized and untreated can be life-threatening you must also recognize the signs and symptoms of high blood glucose levels and we this is hyper glycemia and it can result in a common death and if treated treatment exceeds a patient's needs it can cause a life-threatening state of hypoglycemia meaning if the patient took too much insulin it can cause life-threatening hypoglycemia hyperglycemia and hypoglycemia can occur with both diabetes mellitus type 1 and type 2. you will encounter many patients displaying the signs and symptoms of high and low blood glucose levels hyperglycemia and hypoglycemia can be quite similar in their presentation patients present with altered mental status and can often mimic alcohol intoxication intoxicated patients often have abnormal glucose levels as well so let's talk about hypoglycemia low blood sugar it can develop if a person takes his or her medications but fails to eat enough food so if a person takes too much medication and this will result in low blood glucose levels and despite eating their normal dietary intake okay all hypoglycemic patients require prompt transport\npathophysiology of sickle cell disease also called hemoglobin s disease and that's inherited blood disorder that affects red blood cells it's pre it's found predominantly in people of african caribbean or south american ancestry people with sickle cells disease have misshapen red blood cells that lead to dysfunction in oxygen binding and unintentional clot formation fickle cells have a short life span and this results in more cellular waste products in the bloodstream and contributes to sludging and that's clumping of the blood so maintaining hydration is important and insufficient hydration leads to increased clumping complications associated with sickle cell disease include anemia gallstones jaundice and spleen dysfunction vascular occlusion with ischemia and so you could have acute chest syndrome strokes joint necrosis pain crisis acute or chronic organ dysfunction or failure retinal hemorrhages or increased risk of infections and so you could see the sickled cells on this slide they're shaped like a sickle and many of these complications are very painful and potentially life-threatening the patient is also more susceptible to in functions infections all right so now after sickle cells let's talk about clotting disorders and we're going to talk about hemophilia it's very rare only about 20 000 americans have this disorder hemophilia a affects mostly males people with hemophilia a have a decreased ability to create a clot after an injury which can be life-threatening so patients with hemophilia a can be prescribed medications to replace these missing clotting factors that are released and stored clotting factors or prevent the breakdown of blood clots common complications of hemophilia a include long-term joint problems that may require joint replacements or bleeding in the brain or thrombosis due to treatment thrombophilia that's a disorder of the body's ability to maintain smooth flow of blood through the venous and arterial systems the concentration of particular elements in the blood creates clogging or blockage issues thrombophilia is a general term for many different conditions that result in the blood clotting more easily than normal so you could have an inherited or genetic disorder or medications or other factors or patients with cancer clots can spontaneously develop in the blood of a patient\nso that leads us right into deep vein thrombosis okay so or dvts it's a common medical problem in sedimentary patients and the patients who have had recent injury or surgery methods to prevent blood clot formation include they could take blood thinning medications or compression stockings or also mechanical devices will help risk factors what we just talked about is a recent history of some type of replacement or and or complications of leg swelling so remaining sedimentary for long periods of time can also be a risk factor treatment for dvts include anticoagulation therapy oral medications are typically administered for at least three months after diagnosis of a dvt and a clot from the dvt it may travel from the patient's lower extremity to the lung causing a pulmonary emboli next we're going to talk about is anemia so this is an abnormally low number of red blood cells they can result from chronic or acute bleeding deficiency in certain vitamins or minerals or there could be some underlying disease process happening so blood is unable to deliver adequate amounts of oxygen to the tissues and pulse ox may indicate in an adequate saturation even though the underlying tissues are hypoxic so let's talk about the assessment of these disorders so we're going to start with the zinc size up and we have to ensure scene safety and most sickle cell patients will have had a crisis before of course we're going to wear gloves and eye protection at a minimum and determine the number of patients involved we're going to be alert for possible trauma and consider advanced life support and next is our primary assessment we're",
        "Diabetes Mellitus Type": "diabetes mellitus type one so let's talk about this first this is an autoimmune disorder in which the immune system produces antibodies against the patriotic beta cells so missing the pancreatic hormone insulin is what it's going to cause and the glucose cannot enter the cell without that insulin so the pancreas isn't producing any of its own insulin",
        "Diabetes Mellitus Type 16 of": "the onset usually happens from early childhood through the fourth decade of life the immune system destroys the ability of the pancreas to produce insulin and the patient must obtain insulin from an external source so patients with diabetic type 1 diabetes cannot survive without insulin many people with type 1 diabetes have an implanted insulin pump it continuously measures glucose levels and provides insulin and and correction doses of insulin based on the carbohydrate intake at meal times this limits the number of times the patients have to check their finger stick glucose level it can malfunction and diabetic emergencies can develop so always inquire about the presence of an insulin pump type 1 diabetes is the most common metabolic disease of childhood a patient with new onset type 1 diabetes will have the symptoms related to eating and drinking okay so they will have polyuria which means increased urination polydipsnia increased thirst polyphagia increased hunger weight loss and fatigue normal blood glucose is between 80 and 120 when a patient's blood glucose level is above normal the kidneys filtration system becomes overwhelmed and glucose spills into the urine when glucose is unavailable to the cells the body turns to burning fat when the body burns fat rather than glucose it produces acid waste which are ketones as ketone levels go up in the blood they spill into the urine kidneys will become saturated with glucose and ketones and cannot maintain acid-base balances in the body the patient breathes faster and deeper as the body attempts to produce the acid level by re reducing acid level by releasing more carbon dioxide through the lungs known as couch mall respirations if fat metabolism and ketone production continue a life-threatening illness called diabetic ketoacidosis or dka can develop dka may present as generalized illness along with abdominal pain body aches nausea vomiting alter mental status or unconsciousness is severe if not rapidly recognized and treated dka can result in death so obtain a glucose level with a finger stick using a lancet and a glucometer diabetic ketoacidosis is uh generally higher than a blood glucose level of 400 millimeters or milligrams of deciliter diabetes mellitus type 2 so this is caused by resistance to the effects of insulin at a cellular level obesity predisposes patients to type 2 diabetes the pancreas will produce insulin to make up for the increased levels of blood glucose and dysfunction of cellular insulin receptors so insulin resistance can sometimes be improved by exercise and dietary modification oral medications used to treat type 2 diabetes so some increase secretion of insulin and pose a high risk of hypoglycemic reaction and then some stimulate receptors for insulin others decrease the effects of glucagon and decrease the release of glucose stored in the liver injectable medications and insulin are also used for type 2 diabetes so type 2 diabetes is often diagnosed at a yearly medical exam from complaints related to high blood glucose levels and these complaints can include recurrent infections or change in vision or numbness in the feet",
        "Symptomatic Hyperglycemia": "symptomatic hyperglycemia occurs when blood glucose levels are very high the patient is in a state of altered mental status resulting from several combined problems so let's talk about type 1 diabetes this leads to ketoacidosis with dehydration from excessive urination in type 2 diabetes this leads to a non-chaotic hypo somalia state of dehydration due to discharge of fluids from all of the body systems and eventually out through the kidneys leading to fluid imbalance an individual has hyperglycemia for a protracted length of time consequences of diabetes may present as you could have wounds that do not heal or numbness in the hands and feet perhaps blindness renal failure or gastric motility problems when blood glucose levels are not controlled in diabetes mellitus type 2 a condition known as hyperosmalia hyper glymatic non-chaotic syndrome so its hns can develop and key signs and symptoms of hhs include hyperglycemia altered mental status drowsiness lethargy severe dehydration thirst and dark urine because remember they're urinating often visual and sensory defects partial paralysis or muscle weakness and perhaps seizures higher glucose levels in the blood causes excretion of glucose into the urine so patients respond by increasing their fluid intake which causes polyuria in hhns the patient cannot drink enough fluid to keep up with that exceedingly high glucose levels in the blood urine becomes dark and concentrated the patient may become unconscious or have a seizure activity due to that severe dehydration symptomatic hypoglycemia okay so this is the exact opposite low sugar so an acute emergency in which the patient's blood glucose level drops and must be corrected swiftly they can occur in patients who inject their insulin or use oral medications to stimulate the pancreas to produce more insulin so when insulin levels remain high glucose is rapidly taken out of the blood if glucose levels fall there may be an insufficient amount of supply to the brain",
        "Symptomatic Hypoglycemia": "the mental status of the patient declines and he or she may become aggressive or display unusual behavior unconsciousness or and or permanent brain damage can quickly follow so common reasons for low blood sugar level to develop include correct dose of insulin with change in the routine or more insulin than normal or correct dose of insulin without the patient eating or correct dose of insulin and the patient developed an acute illness okay\nso signs and symptoms of hypoglycemia it's normal to shallow or rapid respirations they can be pale moist skin diaphoresis dizziness a headache rapid pulse or normal to low blood sugar blood pressure altered mental status anxious or combative behavior seizures fainting or coma weakness on one side of the body it may mimic a stroke or rapid changes and they met in mental status so hypoglycemia is quickly reversed by giving the patient glucose without glucose the patient can can sustain permanent brain damage",
        "Scene Size-up": "so let's start talking about the patient assessment of diabetes and of course we're going to start with that scene size up and we need to be careful of the presence of syringes used by patients with diabetes further insulin okay so be alert for clues um also of course syringes insulin bottles maybe some food or some orange juice that may help you decide what is wrong with the patient use standard precautions question bystanders on events leading to your arrival and keep open the possibility that trauma may have also occurred determine the mechanism of injury moi or nature of illness which is the noi",
        "Primary Assessment": "and now let's get into a primary assessment so how does the patient look remember we're going to get our general impression that's the very first thing of our primary assessment we're going to identify those threats and provide life-saving interventions particularly when it comes to airway management determine the level of consciousness we're going to use that avpoo scale alert verbal painful or unresponsive so if unresponsive and you suspect that patient has diabetes of course you need to call for advanced life support a patient may have undiagnosed diabetes so if the patient has altered mental status assess blood glucose levels if you have proper equipment and training perform cervical spine immobilization when necessary and provide rapid transport now we're going to go to the a and the b so assess the patient's breathing patients showing signs and symptoms of inadequate breathing a pulse ox level less than that of 94 or any type of altered mental status should receive high flow oxygen at 12 to 15 liters via a non-rebreather mask hyperglycemic patients will have a rapid or deep which is koosh mall respirations and sweet fruity breath you'll also hear them say acetone type breath okay so like fingernail polish remover hypoglycemic patients will have a normal or shallow or rapid respirations if the patient is not breathing or having difficulty breathing of course we're going to open that airway insert an adjunct administer oxygen or assist ventilations and continue the monitor ventilations throughout patient care next is the c after a and the b we're going to go to the c and that's dry warm skin for hypo or hyper glycemic and then moist pale skin for hypoglycemia also a rapid weak pulse can be a symptomatic hypoglycemic and then there's the d so after abc we're going to have the d and that's the transport decision so patients with altered mental status and impaired ability to swallow should be transported properly patients capable of swallowing and conscious enough to maintain their own airway may be further evaluated unseen and interventions can be performed\ngoing to perform that cervical immobilization if we need to and form the general impression and then into the abs and c so um for patients with inadequate breathing or altered mental status of course we're going to get that high flow oxygen at 12 to 15 liters via a non-rebreather mask patients experiencing a sickle cell crisis will have increased respirations or exhibit signs of pneumonia so for patients with difficulty breathing open that airway in certain adjuncts administer oxygen and assist ventilations if needed assess the patient's circulatory statuses next the c sickle cell crisis patients will have increased heart rate to force those sickled cells through smaller blood vessels and so for suspected hemophilia patients though be alert for signs of blood loss and no bleeding of an unknown origin and be alert for signs of hypoxia which could be due to that blood loss and then of course the d abcd and that's that decision we need to transport them to an emergency room and it's always recommended to any patient who's experiencing a sickle cell crisis or hemophilia",
        "History Taking 2 of": "history taking so we want to investigate that chief complaint obtain the history of the present illness and that's that opqrst and then obtain the history of the patient and if the patient has eaten but not taken insulin hyperglycemia is more likely obtain that sample history and that's that history of the patient okay so for a known patient with diabetes ask them do you take insulin or pills to lower your blood sugar and do you wear an insulin pump is it working properly have you taken your insulin or the usual insulin dose or the pills of course or have you eaten normally today have you had an illness unusual amount of activity or stress look for an emergency medical identification tag and these can include maybe a wallet card or necklace or bracelet",
        "Secondary Assessment": "then we move to that secondary assessment and when we're doing with the nature of illness we're going to do that physical exam we're going to focus we're going to focus on a neurological assessment okay so we're going to assess not unresponsive patients from head to toe with the secondary assessment of the entire body to look for clues so be alert for secondary injury or illness such as trauma because they're altered mental status okay and when you suspect a diabetes related problem we want to focus on that mental status ability to swallow and the ability to protect their airway so obtain a glass calcoma score and that's a gcs score vital signs is our next thing we want to make sure we get that blood glucose\nlevel level so we're going to use a glucometer if available and protocols allow overall hypoglycemia the respirations are going to be normal to rapid pulse is going to be weak and rapid and skin is typically pale and clammy with a low blood sugar hyperglycemia however is going to have wrapper respirations may be deep and rapid pulse may be rapid weak and thready and the skin may be warm and dry with a normal blood pressure\nso we need a portable glucometer and so you need to study the operator's manual for proper use in the field get to know the upper and lower ranges at which the glucometer functions so normal non-fasting adult and child blood glucose levels should be like we said earlier between 80 to 120 neonate should be above 70.",
        "Reassessment": "then we get to the reassessment so reassess the patient with diabetes frequently to assess changes has their mental status improved are their abcs still intact has or how is the patient acting to the interventions that we've performed and how must you adjust or change your interventions based on administration of glucose on serial glucometer readings or a deteriorating level of consciousness okay so provide the indicated interventions for hypoglycemic conscious conscious is the key word patients who can swallow they have to be able to swallow we need to encourage them to take some glucose tablets if available or drink some juice containing sugar you also might have a gel prepared such as the glucose tubes or sugar drink if local protocol permits provide rapid transport to the hospital for unconscious unconscious hypoglycemic patients or patients with risk of aspiration meaning they can't maintain their airway they're going to need an iv with glucose or an intramuscular shot or an intranasal gluca glucagon is what they need so which most emts are not permitted to give if in doubt whether the patient is symptomatic hyper glycemia or hypoglycemia most protocols will err on the side of giving some sugar so determining blood glucose levels in a patient with diagnosed diabetes can be difficult when signs and symptoms are confusing and you have no way to test for the blood glucose value in these situations perform a thorough assessment contact the hospital to help sort out some of the signs and symptoms coordinate communication and documentation patients who refuse transport because their symptoms improve after taking oral glucose may require even more thorough documentation",
        "Emergency Medical Care for Diabetic Emergencies": "okay so giving emergency care to a diabetic so this is what i was talking about the the oral glucose there are three types of oral glucose preparations available commercially there's the rapidly dissolving gel there's large chewable tablets and then there's a liquid formulation the only concentration or contraindications are the inability to swallow and of course the patient being unconscious we want to wear gloves before putting anything in a patient's mouth and follow local protocols for glucose administration reassess the patient frequently and provide transport to the next level of care",
        "The Presentation of Hypoglycemia": "so the presentation of hypoglycemia you could have seizures and hypoglycemia is uh is a possible causes of seizures so though brief seizures are not harmful they may indicate a potentially life-threatening underlying condition so management of the seizures we have to maintain that airway place the patient on his or her side if there is no possibility of cervical spine trauma do not place anything in the patient's mouth have suction equipment ready in case the patient vomits and if the patient is cyanotic or appears to be breathing inadequately provide oxygen or artificial ventilations and of course transport promptly treatment of altered mental status and\nthis may be caused by complications of the disease so it could be hypoglycemia or ketoacidosis use the mnemonic aeiou tips okay and always suspect to check for blood glucose in a patient with altered mental status so\nmanagement ensure the airway is clear be prepared to provide artificial ventilations be prepared to suction if they vomit and provide transport promptly misdiagnosis of a neurological dysfunction so occasionally patients with a diabetic emergency are thought to be intoxicated a diabetic patient confirmed by police is at risk all right so an emergency medical identification bracelet necklace or card may help to save the patient's life in such situations a blood glucose test performed on scene if the protocol allows of course or in the emergency department will identify the real problem so be alert to the potential for diabetes and alcoholism to coexist in the same patient relationship to airway management so may not have a gag reflex and vomit or tongue may obstruct that airway so carefully monitor the airway place the patient in the lateral recumbent position make sure the suction is readily available at all times",
        "Hematologic Emergencies": "all right so now let's get into the hematologic emergencies we've moved from endocrine to the hematologic and hematology is the study of blood-related diseases three disorders that can create pre-hospital emergencies are sickle cell disease hemophilia thrombophilia and anemia so let's talk about the anatomy and physiology first blood is made up of four components we know that's the erythrocytes leukocytes platelet and plasmas and each of these components of the blood serves a purpose in maintaining the body's hemostatic balance so red blood cells of course contain hemoglobin and they carry the oxygen to the tissues white blood cells respond to infection and collect dead cells and provide their provide for correct disposal then we have platelets and they are essential for clotting plasma serves as that transport medium for blood components proteins and minerals",
        "History Taking of": "and then the history taken so we're going to investigate that chief complaint and obtain the history of the present illness from responsive patients family or bystanders be alert for signs indicating sickle cell crisis and these are going to include swelling of the fingers and toes of prypism or jaundice and then ask some questions okay so is the pain isolated to that single location or are you feeling it throughout the body is the patient having any visual disturbances and is the patient experiencing nausea vomiting or abdominal cramping and is the patient experiencing chest pain or shortness of breath then of course we're going to obtain that sample history for uh from responsive patients or we could get it from a family member if needed and have you had a crisis before when was the last crisis and how did your crisis resolve or how or have you had any illnesses unusual amount of activity or stress lately then the secondary so systemically examine that patient focus on the joints evaluate and document the mental status and obtain a complete set of vital signs and including oxygen saturation levels normal sickle cell crisis vital signs will be normal to rapid weak rapid pulse pale clammy skin or low blood pressure use pulse ox if available to monitor that oxygen set readings may be inaccurate due to patients who are in an anemic state and it's our reassessment so we're going to reassess vital signs frequently to determine changes in the patient's condition we're going to evaluate those interventions and then we're going to communicate with the hospital staff for continuity of care and document clearly",
        "Emergency Medical Care for Hematologic Disorders": "now we're going to talk about the emergency medical care we can provide for these emergencies okay or disorders emergency care is mainly supportive and symptomatic okay so for patients with inadequate breathing or altered mental status we could give them high flow oxygen at 12 to 15 liters we could place them in the position of comfort and transport rapidly to the hospital",
        "Review": "okay so this concludes the chapter 20 endocrine in hematologic emergencies of the emergency care and transportation of the sick and injured 12th edition so now we're going to see how much we've learned through the review questions type 1 diabetes is a condition in which let's see glucose utilization is impaired and that's a fancy way of just saying that the cells cannot get the glucose because of course it does not have the insulin so type 1 diabetes is the disease in which the pancreas fails to produce that insulin a 45 year old man with type 1 diabetes is found unresponsive which of the following questions is most approp important to ask his wife so the insulin did he take it today how long has he been a diabetic has he seen the physician recently or what kind of insulin does he take i would think it would be did he take his insulin today yeah all of those are pretty important but you want to see if he took the insulin today okay all right a diabetic patient presents with blood glucose level of 310 and severe dehydration so the patient's dehydration is a result of well i think it's the excretion of glucose and water from the kidneys remember the kidneys are trying to maintain that balance and so you're going to get polyuria okay so it is a excretion of glucose and water from the kidneys which of the following combination of factors would most likely cause hypoglycemic crisis in a diaper diabetic patients hypo so low sugar i think it's skipping a meal but still taking their insulin right yeah because you're going to take the insulin combination of yep that's right so skipping that meal but still taking their insulin they're not going to have any sugar okay a 19 year old diabetic male is found unresponsive on the couch by his roommate after confirming that the patient is unresponsive you should well the first thing we need to do is i'm pretty sure is open that airway if he's unresponsive right immediately determine and the first action should be to open the airway yeah we need to open that airway to see if he's breathing what breathing pattern would most likely encounter during a patient with diabetic ketoacidosis so dka we know that these are going to be usually rapid and deep they're trying to blow off any of that sugar they can right that's right koosh malls that's the rapid and deep breathing pattern okay so a woman called ems because her 12 year old son who has been experiencing excessive urination thirst and hunger for about 36 hours and now has altered mental status he's breathing fast so this sounds like deep diabetic ketoacidosis you should of most be suspicious for and we're right away hyper glycemic crisis he has not been diagnosed yet and so he's going to have high blood sugar yes polyuria plot ledepsnia polyphasia hyperglycemic crisis okay if the cells do not receive glucose they will begin to metabolize we know this we know this right they're going to begin to metabolize fat okay so fat metabolism results in that keto acids right so ketoacidosis is going to result in contrast to a hyperglycemic crisis hypoglycemic crisis let's see i'm going to say immediately response to treatment because we're going to give them sugar yep immediately usually responds immediately after treatment all right patients with diabetic ketoacidosis experiencing polydipsnia because all right they're thirsty so let's see they're usually dehydrated secondary to that excessive urination right yeah because their kidneys are trying to excrete okay this concludes chapter 20 endocrine and hematologic emergencies and thank you for joining us today"
    },
    {
        "Introduction": "hello and welcome to chapter 15 medical overview of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will understand the need for proper assessment techniques when called to patients with the chief complaint of a medical nature",
        "Introduction to Medical and Trauma Emergencies": "okay so let's get started patients who need ems assistance generally have experienced a medical emergency a trauma trauma emergency or both trauma emergencies involve injuries resulting from physical forces being applied to the body and medical emergencies involve illness and conditions that caused by disease it's important to remember that patients may have a combination of medical and trauma conditions okay so let's talk about some",
        "Types of Medical Emergencies": "types of medical emergencies you can have respiratory emergencies and they occur when patients have trouble breathing or when the amount of oxygen supplied to the tissues is inadequate you can have cardiovascular emergencies and they are caused by conditions affecting the circulatory system neurological emergencies involve the brain and gastrointestinal conditions involve appendicitis diverticulitis pancreatitis and many others",
        "Additional Types of Medical Emergencies": "a urologic emergency may involve kidney stones and the most common endocrine emergencies are caused by complications of diabetes hematologic emergencies may be the result of sickle cell disease or various types of blood clotting disorders such as hemophilia immunologic emergencies involve the body's response to foreign substances and toxological emergencies involve",
        "Complex Medical Emergencies": "poisoning and substance abuse results in other types of medical emergencies so some medical emergencies are caused by physiological or behavioral problems and may be especially difficult to deal with because patients often do not present with typical signs and symptoms gynological conditions are a special category of emergencies that involve female reproductive organs this table shows types of common medical emergencies",
        "Patient Assessment": "all right so let's talk about the patient assessment so an assessment of a medical patient is similar to an assessment of a trauma patient but with one different focus medical patient assessments they focus on the nature of illness the symptoms and the chief complaint okay so you want to establish an accurate medical history you use dispatch information to guide your initial response but do not get locked into preconceived idea of a patient's condition so injuries may distract you from underlying conditions tunnel vision occurs when you become focused on one aspect of the patient's condition and exclude all the others which may cause you to miss an important injury or illness okay assessment may be difficult with an uncooperative or hostile patient so maintain a professional calm non-judgmental demeanor at all times refrain from labeling patients and displaying their uh your personal biases okay a frequent caller may have a frequent a different complaint this time",
        "Scene Size-up": "so let's start with the scene size up you have to ensure your safety for you your crew and your patient use standard precautions and determine the number of patients and whether you need additional help next is going to be to determine the nature of illness so the index of suspicion is your awareness and concern for potentially serious underlying and unseen injuries or illnesses and initiate spinal immobilization if needed",
        "Primary Assessment": "when you get to your primary assessment develop your general impression depression perform a rapid exam of the patient to identify life threats and quickly determine the patient's level of consciousness using avu scale then we're going to go into the airway breathing circulation and decisions so airway and breathing in conscious patients ensure the airways open and they are breathing adequately check the respiratory rate depth and quality and consider applying oxygen if breathing has been affected for unconscious patients of course we need to make sure we open the airway using the proper technique and take several seconds to evaluate their breathing we're going to apply some oxygen so always when we have a patient in shock or with difficulty breathing or when low oxygen saturations are measured with spo2 less than 94 percent unconscious patients may need airway adjuncts and ventilatory assistance with a bag valve mask all right now our c part of our abcs so in a conscious patient we are going to check the radial pulse and observe for the patient's skin color type of condition for unconscious patients we are checking the circulation at the carotid artery and now it's our d so our transport decision the following patient should be considered in a in serious condition and in need of rapid transport so anybody who is unconscious or who has an altered mental status patients with airway or breathing problems or patients with obvious circulation problems such as bleeding or signs of shock if the patient did not meet the criteria for rapid transport continue your assessment on scene and prepare for transport when you have completed the assessment and treatment",
        "History Taking": "next remember we're going to go into history taking so determine what the problem is or what may be causing the problem we need to gather a thorough history investigate the nature of illness by inquiring about the chief complaint for an unconscious patient survey the scene for medication containers and medical devices we're going to obtain the history of the patient by asking sample so sample stands for allergies medications past pertinent medical history last oral intake and events leading up to this okay and then we're going to get the history of the patient's chief complaint by using that opqrst pneumonic and that's onset provocation quality radiation severity and tender and time and record all allergies medications and medicines and some patients take numerous meds so take the medicines with you to the hospital and list them in your report",
        "Secondary Assessment": "okay so the secondary assessment the secondary assessment may occur on scene or in route to the emergency department in some cases you may not have time to con conduct that secondary so physical exam so all conscious patients should undergo a limited or detailed physical exam that's based on their chief complaint for an unconscious patient you should always perform a secondary assessment of the entire body or head to toe exam to obtain clues to assess the problem a full body assessment should help you obtain clues and should be performed quickly so it does not delay transport if the patient's condition warrants the secondary assessment examine the head scalp face the neck then the chest and abdomen palpate the legs and arms and examine the patient's back treatment will depend on the conditions found and your local protocols now we're going to take the vital signs so what do we mean by vital signs we're going to check for the pulse and we're going to check the rate rhythm and quality of the pulse at the appropriate site okay so identify the rate quality and regularity of the respirations as well and any difficulties that may be apparent next we're going to obtain an initial blood pressure so we're going to measure both systolic and diastolic pressures and we're going to consider using the automatic blood pressure cuff for future assessments at regular intervals consider obtaining blood glucose levels and pulse oximetry as well",
        "Reassessment": "now our reassessment so once the assessment and treatment have been completed reassessment should begin and continue throughout transport repeat the primary assessment and reassess the chief complaint consider the need for advanced life support backup repeat your physical examination to identify the tr and treat in changes in the patient's condition now obtain vital signs every five minutes if your patient is unstable and every 15 minutes if the patient is stable so review all treatments that you have performed and document any changes that have been that has been developed as a result of treatments and if needed adjust any of the treatments accordingly",
        "Management: Transport and Destination": "so let's talk about transport and destination so most emergencies require a level of treatment beyond that available in the pre-hospital setting may require advanced testing available in the hospital so it may be beyond the scope of the emt to administer medicines to a patient any administration of a medicine by an emt requires direct permission from medical control emts can use an aed on a patient who is pulseless and ethnic",
        "Management: Scene Time": "so let's talk about scene time scene time may be longer for medical patients than for trauma because we want to gather as much information as possible to transmit to the emergency department critical patients always need rapid transport and like we said these include altered mental status airway or breathing difficulties um any signs of circulatory compromise and and some who are very old or very young okay",
        "Management: Types of Transport": "in the type of transport if a life-threatening conditions exist the transport should include lights and sirens if the patient's not critical we're going to consider non-emergency transport and modes of transport ultimately come in one of two categories so you have ground transport or air transport now ground transport ems units are generally staffed by an emt and paramedics air transport ems units are generally staffed by critical care transport professionals and paramedics so let's talk about the destination selection generally the closest hospital should be your destination however sometimes the patient will benefit from going to another hospital that is capable of handling his her own particular condition",
        "Infectious Diseases": "infectious diseases so general assessment so when we're going to approach the patient with an infectious disease like any other medical patient we want to perform scene size up take standard precautions and complete primary assessments we want to gather patient history using opqst to elaborate on the patient's chief complaint we want to obtain that sample history and set a baseline vital signs we're going to pay particular attention to medicines and the events leading up to today's problem ask whether the patient has recently traveled or has come in contact with someone who has traveled and then general management principles for infectious diseases so we want to focus on any life-threatening conditions identified in that primary assessment we're going to be empathetic we want to place the position income the patient in the position of comfort on the stretcher and keep them warm and then we're going to use standard precautions so always follow your agency's exposure control plan in cleaning equipment and properly discard any disposable supplies and wash linens",
        "Epidemic and Pandemic Considerations": "epidemic and pandemic considerations just understand that an epidemic is when new cases of disease in a human population substantially exceed what is expected a pandemic is a disease outbreak that occurs on a global scale",
        "Influenza": "common or serious communicable diseases include we're going to start off with influenza so those with chronic medical conditions comprise immune systems and the very young and the very old are susceptible to complications of influenza transmitted by direct contact with nasal secretions and air slice droplets from coughing and sneezing by affected people for diseases that can be passed by the respiratory route we need to always wear ppe and this includes gloves eye protection and a hipaa h-e-a-h-e-p-a respirator or an n95 mask at a minimum we have to wash hands frequently place a surgical mask on the patient with suspected or confirmed respiratory disease wear a hepa respirator or an n95 during air slice generating procedures such as suctioning of airway secretions performing cpr or assisting with an endotracheal tube innervation any annual influenza immunization is important for ems personnel to protect providers and patients",
        "Herpes Simplex": "next type of communicable disease we're going to talk about is herpes simplex so this is a common virus strain carried by humans it is um symptomatic infections cause eruptions of tiny fluid blisters placed blisters cause vesicles that appear on the lips and genitals so it can cause more serious illness like pneumonia and meningitis in the very young very old or immunocompromised the primary mode of infection is through close personal contact so you use standard precautions and are generally sufficient to prevent form or spread to healthcare workers",
        "HIV Infection": "okay the next we're going to talk about is hiv infection emts face a risk of exposure to the virus that causes aids on a regular basis aids can still be fatal however with treatment patients can expect a near normal lifespan so hiv infection is potentially hazard only when deposited on mucous membranes or directly into the bloodstream if it is not easily transmitted in a work setting it's not easy your risk of infection is limited to exposure to an infected patient's blood and bodily fluids many patients with human immunodeficiency virus show no symptoms always wear wear the proper type of gloves and take great care and handling and properly disposing of nasals and other sharp objects cover any wounds that you have whenever you are on the job so if you think that a patient's blood or secretions may have entered your system seek medical advice as soon as possible and notify your infectious disease officer",
        "Hepatitis": "okay so hepatitis is the next disease we're going to talk about and that is inflammation of the liver and it can be caused by a number of different viruses and toxins there is no sure way to tell which hepatitis patients are contagious so hepatitis a can be transmitted only from a patient who has an actual acute infection whereas b and c can be transmitted from long-term carriers who have no signs of illness okay so a carrier is a person or animal in whom an infectious organism has taken a permanent residence and may or may not cause an active disease so hepatitis a is transmitted orally or through oral or fecal contamination hepatitis b is far more contagious than hiv and vaccination with hepatitis b is highly recommended for emts the table shows the characteristics of different types of hepatitis",
        "Meningitis": "and then you have meningitis so this is an inflammation of the meningeal covering of the brain and spinal cord most forms of meningitis are not contagious one form though menolococcal meningitis is highly contagious so take standard precautions gloves in a mask will go a long way to prevent the patient's secretions from getting into your nose and mouth and vaccines are rarely used so meningitis can be treated at the emergency department with antibiotics and after treating a patient with meningitis contact your employer's health representative",
        "Tuberculosis": "so the next infectious disease we're going to talk about is tuberculosis and most infected patients are well most of the time a chronic myocobacterial disease that strikes the lungs so disease this disease that occurs shortly after infection is called the primary tuberculosis and this is a reactive tuberculosis is common and can be much more difficult to treat okay so patients who pose a high risk almost always have a cough so consider respiratory tuberculosis to be the only contagious form because it is the only one that can spread by airborne transmission okay so in droplet nuclei that's the remnants of the droplets produced by coughing after the excess water has evaporated so n95 and hepa mass are required to stop that droplet type nuclei okay so absolute protection from infection with tuberculosis does not exist according to the centers for disease control and prevention one-third of the world's population is infected with tuberculosis the mechanism of transmission is not very efficient so have tuberculin skin tests regularly and if the infection is found before you become ill preventative therapy is almost 100 effective",
        "Whooping Cough": "whooping cough that's what we're going to talk about next and this is also called pertussis whooping cough is an airborne disease caused by bacteria that mostly affects children younger than six years old so symptoms incur include a fever and a whoop sound that occurs when inhaling after a coughing attack the best way to prevent exposure to is to be vaccinated with the dpt or tdap and you can also place a mask on the patient and yourself",
        "Methicillin-Resistant Staphylococcus aureus": "next is mrsa so mrsa is a bacterium that causes infections and is resistant to many antibiotics in health care settings mrsa is transmitted from patient to patient by the unwashed hands of healthcare providers factors that increase the risk of developing mrsa include antibiotic therapy prolonged hospital stays a stay in intensive care or burn unit exposure to an infected patient the incubation period for mrsa appears to be between 5 to 45 days immersive results in soft tissue infections skin signs and symptoms include localized skin abscesses and sepsis in older patients",
        "Global Health Issues": "okay next we're going to talk about covid19 so the 2019 novel coronavirus it originated in wu hand spread quickly infecting millions and killing hundreds of thousands controlling the virus included social distancing symptoms include fever cough shortness of breath that appear between two to 14 days after exposure to the infected person for current updates on coven 19 use the cdc website now we're going to talk about mers covid so it's a middle eastern respiratory syndrome so first human case of mers kovi it was discovered in 2012 in saudi arabia most human infections found in the middle east cases of that mers kovi have been found in europe in the u.s and if you suspect mr kovi place a surgical mask on the patient and notify the receiving facility next we're going to talk about ebola and in 2014 an outbreak of ebola virus in west africa spread when infected people traveled to other countries it caused international concern incubation period is from 6 to 12 days after the exposure symptoms may not appear for as long as 21 days after infection fatality rate can be as high as 70 percent if treated in an icu is not initiated promptly if you suspect ebola place a surgical mask on the patient follow ppe precautions as outlined by local protocols and the cdc and notify the receiving facility",
        "Travel Medicine": "next we're going to talk a little bit about travel medicine so you must be aware of travel acquired infections when assisting a patient who has recently been outside the united states patients can present with a variety of symptoms including fever cough vomiting bloody diarrhea body aches and rashes so when you encounter an ill patient with a recent travel history please place a mask on the patient and gather as much information as possible important questions to ask are where did you recently travel did you receive any vaccinations before your trip were you exposed to any infectious diseases is there anyone else in your travel party who is sick and what types of food did you eat what was your source of drinking water and if you suspect the patient has a communicable disease follow your appropriate ppe precautions and notify the receiving facility",
        "Conclusion": "so in conclusion the assessment and treatment of medical patients can be challenging and interesting because of the nature of medical conditions the condition of the medical patient may not be as apparent as in the trauma and treatment may not be as straightforward delays in an attempt to diagnose a condition can be harmful to your patient so keep calm use your patient assessment skills treat the patient's symptoms report to medical control and transport the patient safely to the emergency department be prepared to handle any combination of conditions including conditions of medical patients who have also been involved in trauma",
        "Review": "so this concludes a chapter 15 lecture next we're going to start the review questions see what we learned okay so a seizure patient is having what type of emergency and we didn't specifically go over this however it's going to be a neurologic emergency okay so neurologic emergencies involve the brain and may be caused by a seizure stroke or fainting if an injury distracts an emt from assessing a more serious underlying illness the emt has suffered from and i'm going to say it's tunnel vision yes so you should use the dispatch information to guide your response but do not get locked into preconceived ideas of the patient's condition a frequent flyer calls 9-1-1 because of a suspected head injury you should never assume you know what the problem is so c every case is different and you don't want to miss a potential serious problem if your medical patient is not critical how long should you stay on scene i'm going to say however long it takes to gather as much information as possible and that's correct your patient is having respiratory difficulty and is not responding to your treatment what is the best method of transport i'm going to say with lights and sirens to the closest hospital yes exactly so with lights and sirens when assessing a patient with an infectious disease what is the first action you should perform i think it would be standard precautions of course okay so it looks like they have the slides a little mixed up but your patient believes that he has hepatitis and he's now accepting signs of cirrhosis of the liver he mostly has and we're going to say it's hep c yep hep c okay your patience completing a fever headache stiffness of the neck and red blotches he's most likely okay so anytime you get that stiffness of the neck with those red blotches that's going to be meningitis stiffness of the neck neck complaints all right and you what should you do if you are exposed to a patient who is found to have pulmonary tuberculosis okay so if you suspect that you need to get a tb test okay and all the following are factors that increase the risk of developing mrsa except close contact with wild birds that would be close contact with wild birds okay so this concludes the chapter 15 medical overview so if you like this lecture go ahead and subscribe because we're going to be getting the whole book chapters of the of the whole book and you don't want to miss them thanks"
    },
    {
        "Introduction to Behavioral Health Emergencies": "hello and welcome to chapter 23 behavioral health emergencies of the emergency care and transportation of the sickening year 12th edition after you complete this chapter and the related",
        "National EMS Education Standard Competencies": "coursework you will be able to recognize behaviors that pose a risk to the emt patient and others and the basic principles of the mental health system additionally you will have the knowledge and skills to successfully assess and manage patients suffering from a behavioral health emergency within the legal parameters of your scope of practice",
        "Introduction to Behavioral Crisis Emergencies": "okay so let's get started emts often care for patients experiencing behavioral crisis emergencies the crisis may be the result of an acute medical situation a mental illness a mind-altering substance stress and other causes",
        "Myth and Reality of Mental Health": "when we talk about the mithras versus reality at some point most people experience an emotional crisis so this does not mean though that everyone develops a mental illness otherwise healthy people may sustain acute or temporary mental health disorders do not jump to a conclusion that a patient is mentally ill the most common misconception about mental illness is that if you are feeling bad or depressed you must be sick there are many justifiable reasons for feeling depressed such as a divorce or a loss of a job perhaps death of a relative or friend this is a normal reaction to an acute crisis some people believe that all individuals with mental health disorders are dangerous violent or otherwise unmanageable only a small percentage of people with mental health problems fall into these categories emts may be exposed to a higher proportion of violent patients because they are seeing people who are in by definition considered to be having a behavioral crisis communication is the key in some cases patients will de-escalate when a level of trust is established so although you cannot determine what has caused a person's crisis you may be able to predict whether the person will become violent",
        "Defining a Behavioral Crisis": "so let's talk about defining a behavioral crisis behavior is what you see of a person's response to the environment meaning his or her actions over time people learn to adapt to a situation in daily life including stress so sometimes stress is so great that the normal ways of coping are not enough or the person uses negative coping mechanisms such as withdrawing or drugs and alcohol reactions to stress that are acute and those that develop over time can create a crisis the change in behavior may be considered inappropriate or not normal by the person who calls 9-1-1 a behavioral crisis includes patients of all ages who exhibit agitated violent or uncooperative behavior or who are in a danger to themselves or others ems is called when a behavior has become unacceptable to the patient family or community usually if an abnormal or disturbing pattern of behavior lasts for a month or more it is a matter of concern for from a health mental health standpoint when a behavioral health emergency arises the patient may show agitation or violence or may become a threat to their self or others",
        "The Magnitude of Mental Health Disorders": "so let's talk about the magnitude of mental health disorders",
        "Common Mental Health Disorders": "all right so according to the national institute of mental health mental health disorders are common throughout the united states affecting tens of millions of people each year a psychiatric disorder is an illness with a psychological or behavioral symptoms that may result in impaired functioning so anxiety disorders are among the most common mental health disorders you could have a generalized anxiety disorder or panic disorder social or other phobias post-traumatic stress disorder or some type of obsessive-compulsive disorder",
        "Mental Health System and Treatment": "the us mental health system provides many levels of assistance to people with psychological conditions professional counselors are available for marital conflicts and parenting issues and the most serious issues such as clinical depression are often handled by psychologists some of the most severe psychological conditions such as schizophrenia and bipolar disorder require psychiatrists and that's because they need to prescribe medicine most psychological disorders can be handled through outpatient visits but some require hospitalization in a specialized behavioral health unit behavioral health disorders have many underlying causes you could have a social or situational stress such as a divorce or a death of a loved one you could have the disease such as schizophrenia physical illness such as a diabetic emergency a chemical problem such as alcohol or drug use or a biological disturbances such as some type of electrolyte imbalance sometimes these conditions are compounded by non-compliance with prescribed medications let's talk about the pathophysiology of",
        "Pathophysiology of Behavioral Disorders": "what's happening as an emt um it's not you're not responsible for diagnosing the underlying cause of the behavioral crisis or emergency you should understand though two basic diagnosis a physician will use so the first is organic and that's a physical condition and then the section second is a functional and that's a psychological condition okay so let's talk about organic disorders an organic brain syndrome is a temporary or permanent dysfunction of the brain caused by a disturbance in the physical or psychological functioning of the brain tissue okay so causes can be sudden illness traumatic brain injury perhaps a seizure disorder drug and alcohol abuse overdose or withdrawal and these diseases of the brain such as alzheimer's disease and meningitis altered mental status can arise from hypoglycemia hypoxia impaired cerebral blood flow hyperthermia or hypothermia in the absence of a psychologic case or physiologic case ultimate mental status may be an indicator of a psychiatric disorder such as bipolar disorder so a functional disorder so physiological disorders that impair body function when the body seems to be structurally normal these include schizophrenia some anxiety conditions and depression",
        "Safe Approach to a Behavioral Crisis": "so the safe approach to the behavioral crisis is all emts should up with patient approach assessment patient communication obtaining a history and providing care are used in a behavioral crisis",
        "Scene Size-up": "so let's just go right into that patient assessment and of course the first thing is the scene size up and scene safety so the first things to consider are the scene safety and the patient's response to the environment and is the situation potentially dangerous for you and your partner do you need immediate law enforcement backup or should you stage until law enforcement personnel has secured the scene does the patient's behavior seem typical or normal for the circumstance and are there legal issues involved so is the the is it a crime scene or do you need to get consent or obtain a refusal so take appropriate standard precautions and request any additional resources you may need such as law enforcement or additional personnel early mechanism of injury and nature of illness so note any medications or substances that may contribute to the complaint or that may be a treatment for a relevant medical condition now we're into the primary assessment so",
        "Primary Assessment": "of course the very first thing you're going to do when you look at the patient is you're going to form that general impression begin your assessment from the doorway or from a safe distance perform a rapid physical exam observe the patient closely and use avpu scale to check for alertness so alert verbal painful unresponsive establish a rapport with the patient most medical or trauma situations will include a behavioral component and then",
        "Primary Assessment - ABCs": "of course is the abcs and d and with the a and the b if your patient is in physical distress you need to assess the airway to make sure that it's patent and adequate evaluate the patient's breathing and obtain a rate and effort",
        "Primary Assessment - Circulation": "if pulse ox is available use that and provide the appropriate interventions based on your assessment findings then c so assess the pulse rate rhythm and quality evaluate the presence of shock and bleeding and assess the patient's perfusion and so we're going to do this by evaluating the skin color temp and cap refill and then the d of course i use unless the patient is unstable from a medical problem or trauma prepare to spend some time with that patient",
        "History Taking": "now after the abcs of that primary is going to be the history taken and so when we do the history taking with this medical patient we're going to do a sample history and we want to consider four major areas of possible contributors okay so is the patient's central nervous system functioning properly and are hallucinogens or other drugs or alcohol effector and are significant life changes symptoms or illness in this caused by mental rather than physical factors okay so and is there a history of this behavioral health illness you may be able to get the information that would be helpful um to the hospital staff okay so in geriatric patients consider alzheimer's disease and dementia as possible causes of abnormal behavior identify the patient's baseline mental status is very important with those patients use reflective listening to gain insight into the patient's thinking so the table on the slide lists some questions to ask when you're trying to evaluate the mental health issue okay so um and you could read those but does the patient appropriately answer the questions and is that behavior seeming appropriate there's a few more on the slide and then the secondary the secondary is that physical exam and in a con unconscious patient we want to begin with a physical exam to look for any reason for that unresponsiveness we want to rule out trauma especially the head and consider whether prior events such as a physical agitation use of stimulants alcohol withdrawal or taser exposure may be contributing to the patient's condition and we want to check for track marks indicated drug abuse or for some signs of self mutilation right a conscious patient may not respond to your questions okay you can tell a lot by a patient's emotional state from their facial expressions their heart rate respirations as well tears sweating and blushing may also be a significant indicator of states of mind so look at the patient's eyes a blank glaze or rapidly moving eyes may mean the patient is experiencing some type of central nervous system dysfunction next is that transport decision so when available have law enforcement personnel or firefighters accompany you to the back of the in the back of the ambulance during transport there may be a specific facility to which the patients with behavioral health emergencies are transported transport by ground rather than air okay and try and make the patient feel comfortable",
        "Reassessment": "so when it comes to reassessments never let your guard down and if restraints are necessary we're going to reassess and document the patient's respiration pulse motor and sensory functions and all the restrained extremities we need to do this every five minutes and then intervention so diffuse and control the situation the best treatment may be to be a good listener intervene only as much as it takes to accomplish tasks and if you encounter a situation where you think a pharmalogical restraint might be necessary request advanced life support early communication documentation so we're going to get that receiving hospital advance warning when we have a patient experiencing a behavioral health emergency because we want to report whether restraints will be required when the patient arrives at the hospital and give them some time to get ready for that so we need to document thoroughly and carefully if restraints are used say what type is used and why they were used",
        "Acute Psychosis": "when it comes to acute psychosis so psychosis is a state of delusion in which the person is out of touch with reality and affected people live in their own reality of ideas and feelings and causes of psychotic episodes include altered mind-altering substances intense stress or delusional disorders and also schizophrenia so let let's talk about schizophrenia then okay schizophrenia is a complex disorder that is not easily defined or easily treated the typical onset occurs during early adulthood with symptoms becoming more prominent over time influences thought to contribute to the disorder include brain damage genetics physiologic or and social influences symptoms are delusions hallucinations a lack of interest and pleasure erratic speech and guidelines for dealing with this are you need to determine if the situation is safe or dangerous okay so clearly identify yourself be calm direct and straightforward and maintain an emotional distance do not argue explain what you're going to do involve people whom the patient trusts such as family members and friends to gain the patient's cooperation",
        "Excited Delirium": "next we're going to talk about excited delirium okay so excited delirium you'll also hear it um called agitated delirium or exhaustive mania in delirium that's a condition of impairment in cognitive function that can present with disorientation hallucinations or delusions agitation is a behavior characterized by restlessness and irregular physical activity so some symptoms of excited delirium include hyperactive irrational behavior vivid hallucinations hypertension tachycardia diaphoresis dilated pupils if you think you can safely approach the patient be calm supportive and empathetic approach the patient slowly and purposefully and respect the patient's personal space limit physical contact as much as possible and do not leave the patient unattended use careful interviewing to assess the patient's functioning okay so cognitive functioning determine the patient's ability to communicate and observe the patient's appearance dress and personal hygiene if the patient appears to be experiencing an overdose take all medicine bottles or legal substances with you to that medical facility the patient should be transported to the hospital with behavioral health facility and refrain from using lights and sirens the patient is if their agitation continues you need to request advanced life support assistance so chemical restraints can be considered excited delirium can lead to sudden death and this is from cardiac arrest physical agitation thought to result from a metabolic acidosis physical control measures including tasers stimulant drugs or positional affixia okay so when we talk about um excited delirium and it just we just kind of",
        "Restraint Protocols": "progress into using restraints okay so pre-hospital patient restraints reduce the possibility of a patient injury and the potential for injury to emergency medical service providers it also allows for safe and appropriate treatment of an uncooperative patient the national association of emergency medical services physicians recommends that every pre-hospital care transport provider create and follow a pre-hospital patient restraint protocol in these this patient uh restraint protocol should address the appropriateness of the restraint the types that we would use the care provided to the patients following a restraint your protocol must consider the laws of your state pre-hospital patient restraint protocols vary widely so protocols should include only the use of restraint devices that have been approved by the state's health department or local ems agency the method of restraint chosen should be the least restrictive method that will ensure the safety of the patient and the providers there are risks associated with patient restraints okay improper use of restraints can lead to life-threatening conditions including positional asphyxia aspiration severe acidosis and possibly cardiac arrest restraint of a person without authority in a non-emergency situation can result in legal aspects actions so you could it could be assault battery false imprisonment or violation of civil rights restraints are only to protect yourself and others from broadly harm or to prevent the patient from injuring him or herself you need to involve law enforcement personnel if you are called to assist a patient in a severe behavioral crisis or behavioral health emergency prior to using physical restraint use a verbal de-escalation techniques to diffuse the situation the process of restraining a patient so once the decision has been made to restrain the patient you should carry it out quickly ideally five people should be present to carry out this restraint you need to have one person on each extremity and one responsible for the head there should be a team leader who directs the process of a plan of action before you begin and use the minimum force necessary to control the patient the level of force will vary depending on the following factors so the degree of force that is necessary to keep the patient from injuring themselves or others also the patient's size strength sex and mental status including the possibility of drug induced states so the type of abnormal behavior the patient is exhibiting will also make the level of force dependent it's important that you and your partner talk to the patient throughout the process you need to treat the patient with dignity and respect at all times and if possible a provider of the same gender should tend the patient okay wear appropriate barrier protection during the restraint process avoid direct eye contact and respect the patient's personal space until necessary so never leave a restrained patient unattended and four point restraints meaning both arms and the legs are preferred for uncooperative patients respiratory and circulatory problems have been known to occur in combative patients who are restrained restraints applied in the field should not be removed until the patient is evaluated at a at the receiving hospital okay performing patient restraint so you you need to follow the skill drill in 23-1 to implement a four-point restraint a two-point restraint technique is an option if allowed per local protocol",
        "Assessing Potentially Violent Patients": "all right so the potentially violent patient violent patients account for only a small percentage of the patients undergoing a behavioral crisis you want to assess the level of danger based on the following risk factors so the history has a patient previously exhibit a hostile overly aggressive or violent behavior and the posture is the patient sitting or standing is the patient tense rigid or sitting on the edge of his or her seat also the scene is going to give you some clues so is the patient holding or near",
        "Potentially Violent Patient Indicators": "potentially lethal objects such as a knife gun glass poker or a bat or near a glass near window or a glass door and vocal activity so which kind of speech is the patient using is it loud or obscene erratic or bizarre um speech patterns usually indicate emotional distress and then physical activity so the motor activity of a person undergoing a psychiatric emergency may be most telling factor of all so a patient requiring careful watching is one who has tense muscles or clenched fists is pacing cannot sit still or it's fiercely protecting personal space poor muscle impulse or control okay a history of uh truancy or fighting or uncontrollable temper a history of substance abuse depression which accounts for 20 percent of violent acts and also a functional disorder so if the patient tells you um they hear voices and they're telling him or her to kill um believe it",
        "Understanding Suicide Risks": "next we're going to talk about suicide so depression is the most significant factor that contributes to suicide it is a common um misconception that people who threaten suicide will never commit it threatening suicide is an indication that someone is in a crisis and that he or she cannot handle alone immediate intervention is necessary some of the warning signs are going to be feelings of sadness despair hopelessness and that suggests depression appearing detached or inability to talk about the future suggestions of suicide and specific plans for committing suicide or related to death so the table on this slide lists some of those risk factors for suicide",
        "Additional Suicide Risk Factors": "consider the following additional risk factors for suicide so are there unsafe objects uh in the patient's hands or nearby is the environment unsafe is the is either evidence of self-destructive behavior or is there an immediate threat to the patient or others is there an underlying medical problem in our cultural religious and social beliefs promoting the suicide and has there been trauma a suicidal patient may be also homicidal",
        "Posttraumatic Stress Disorder and Veterans": "so let's talk about post-traumatic stress disorders and returning combat veterans so ptsd can occur after exposure to or injury from a traumatic event examples could be sexual or physical assault child abuse or some type of serious accident maybe a natural disaster war a loss of a loved one or a stressful life event ptsd is not necessarily the result of one isolated or recent event an estimated seven to eight percent of the general population will experience signs of ptsd at some point in their lives military personnel who have experienced combat have a high incidence of ptsd signs and symptoms include helplessness anxiety anger or fear and frequently they avoid things that remind them of the trauma so they suffer constant nervous system arousal that is not easily suppressed heart rate increases pupils dilate in the systolic blood pressure increases incenses are sharpened and mental acuity is heightened often the traumatic event they relive this through thoughts nightmares or even flashbacks and ptsd occurs when the person attempts to find and escape from constant internal distress or a particularly disturbing event okay alcohol and drug use are common veterans have an increased risk of suicide and veterans may develop a variety of physical conditions related to injuries sustained during combat as well as from unfocused pain that is not associated with any specific body part combat veterans have a higher incident of tbi which is traumatic brain injury sustained from trauma and this is secondary to an explosion of an improm improvised explosive device or an iad so you want to eliminate excess noise refrain from touching or doing anything to that veteran without an explanation and keep the diesel equipment far away if you can caring for a combat vet so um the returning vet is a patient who will require a level of understanding compassion and specialized attention be careful how you phrase your questions use a calm form of worries but do not but be in charge and respect a veteran's personal space limit the number of people involved and move to a private and quiet space if possible and ask about suicidal intentions military personnel are trained to use weapons and are resourceful in improvising weapons so ensure there is nothing the patient can assess and use as a weapon physical restraint will not be effective with this population and may simply escalate the prof the problem",
        "Medicolegal Considerations": "okay so next we're going to talk about medical legal considerations so legal considerations the medical and legal aspect of emergency medical care become more complicated when the patient is undergoing a behavioral health emergency once you have determined the patient is impaired or has an impaired mental capacity you must decide whether he or she requires immediate emergency medical care a patient in a mentally unstable condition may resist your attempt to provide care but do not leave this patient alone you should request law enforcement personnel to handle the patient you do need consent though implied consent is assumed with the patient who is not mentally competent to grant consent so consent matters are not always clear cut in a behavioral health emergency if you're not sure request the assistance of law enforcement personnel or guide from medical control limited legal authority so the emt has limit limited legal authority to require or force a patient to undergo emergency medical care when no life-threatening emergency exists a competent adult has a right to refuse treatment even if life-saving care is involved in psychiatric cases a court of law would probably consider your actions in providing life-saving care as appropriate a patient who is in any way impaired may be may not be considered competent to refuse treatment and transport always maintain a high index of suspicion regarding the patient's condition assume the worst and hope for the best error on the side of treatment and transport carefully document the patient's statements and behaviors to support your actions okay so this concludes chapter 23 behavioral health emergencies and next we're going to go into the review to see what we've learned",
        "Review of Behavioral Health Emergencies": "so a behavioral crisis is most accurately defined as what do we think it is is it acute is it a reaction to a stressful event it is any reaction of the events so any reaction to events that interferes with activities of daily living or has become unacceptable to the patient family or community depression and schizophrenia those are examples of what did we say are those functional or are those organic brain syndromes they are organic disorders a functional disorder that can't be linked to any type of change so it's a functional disorder okay when assessing a patient with a behavioral crisis your primary concern is i think it's probably we're worried about ourselves of course but we also want to know whether the patient will cause harm to you or your partner okay general guideline to follow when caring for a patient with a behavioral crisis include all of the following except so we want to be honest um we want to have a plan and we want to avoid arguing but rapidly transporting that is not always the case you're usually going to take some time reflective listening is an assessment technique used when caring for patients with an emotional crisis so what does that do i'm pretty sure it's repeating what the patient's going to tell you so repeating in a question form what the patient tells you which of the following patients is the highest risk for suicide so a woman who's successfully being treated 29 year old male who recently is promoted 33 who regularly consumes alcohol okay so right there the alcohol and the gun purchase of that 33 year old that should um that is the highest risk when caring for a patient with emotional crisis who is calm and not in need of immediate emergency care your best course of action is what do you think so we want to obtain consent from the patient to treat when physically restraining a violent patient what should the empty do and i'm pretty sure that you want you to continually talk to the patient throughout the process okay upon arrival of residents a young male with an apparent emotional crisis a police officer tells you that the man has been acting bizarrely you find him sitting on the couch he's conscious but confused he takes meds but cannot remember why his skin is pale and diaphoretic and he has noticeable tremors what should you do what should you rule out first i would say hypoglycemia right away right away he's altered pale cool which diaphragm the following signs is least indicative of a patient's potential for violence okay so i'm going to say right away it's uh is tall his height and weight has nothing to do with the violence okay so right yep the height and weight is the correct answer okay thank you for uh joining us tonight for chapter 23 and uh if you like this like this lecture go ahead and subscribe to the channel because we're going to complete the whole book all right thank you"
    },
    {
        "Introduction to Allergy and Anaphylaxis": "hello and welcome to chapter 21 allergy and anaphylaxis of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will understand the anatomy physiology and pathophysiology of hypersensitivity disorders and anaphylactic reactions additionally you will have knowledge and skills to recognize and manage hypersensitivity disorders and anaphylactic reactions okay so let's get started emts often",
        "Introduction to Allergy-Related Emergencies": "respond to calls involving allergic reactions allergy related emergencies involve acute airway obstruction and cardiovascular collapse you must be able to treat these life-threatening complications and you must be able to distinguish between the body's usual response to an allergen and an allergic reaction this chapter describes immunology which is the study of the body's immune system and the five categories of stimuli that may provoke an allergic reaction okay so let's talk about the anatomy and",
        "Anatomy and Physiology of Allergic Reactions": "physiology the immune system protects the body from foreign substances and organisms when a foreign substance invades the body the body initiates a series of responses to active inactivate the invader so a little bit about the pathophysiology an allergic reaction is an exaggerated immune response to a substance it is not caused directly by an outside substance such as a bite or sting it is caused by the body's immune system which releases chemicals to combat the stimulus these chemicals include histamines and leukotrienes both of which contribute to an allergic reaction some patients may not know what is causing their allergic reaction so you must be able to recognize the signs and symptoms and maintain a high index of suspicion an allergic reaction may be mild and local characterized by itching redness and tenderness or severe and systemic a condition known as anaphylaxis anaphylaxis is an extreme life-threatening allergic reaction it involves multiple organ systems and in severe cases it can rapidly result in shock and death there are three common signs first you have the uticaria and that's hives then you have the angioedema and then wheezing strider may be heard on inspiration if there's an upper airway narrowing you could have hypotension due to vasodilation as well as an increased capillary permeability and patients may experience nausea vomiting and abdominal cramps okay so let's talk about some common allergens",
        "Common Allergens": "the most common allergen falls into one of the following five categories so you have food food allergies and that certain foods such as shellfish and peanuts may be the most common trigger of anaphylaxis the symptoms include it may take more than 30 minutes to appear and may not include skin signs such as hives the reaction may be severe and involve respiratory and or cardiovascular systems then a common allergy the second one is medications so medications are the second most common source of anaphylactic reactions particularly antibiotics such as penicillin or non-steroidal anti-inflammatory drugs such as nsaids if the medication is injected the reaction may be immediate and severe reactions to oral medications may take more than 30 minutes to appear but can also be very severe okay so then the third most common allergen is going to be plants and this includes dust pollens and other plant material can cause rapid and severe allergic reactions okay so common plant allergens include ragweed rye grass maple and oak okay chemicals are the fourth most common allergen and certain chemicals such as makeup soap paradigm latex and various other substances can cause severe allergic reactions latex is of particular concern to healthcare providers so use latex alternatives such as nitrile gloves and then finally insect bites and stings and venomation that's the process of the insect injecting its venom the reaction can be localized or may be severe in systemic",
        "Insect Stings and Reactions": "insect stings approximately 2 million americans are allergic to the venom of bees wasps and hornets and allergic reactions to stings account for at least 62 deaths in the united states per year in about half of these deaths the victim had never experienced a reaction prior the stinging organ of most insects is a small hollow spine and it projects from the abdomen honey bees cannot withdraw their stinger if the stinger is not removed it can continue to inject venom for up to 20 minutes and wasp and hornets they can sting multiple times some ants especially fire ants strike repeatedly signs and symptoms include sudden pain swelling localized heat widespread urticaria redness in light-skinned individuals itching and possibly a wheel in more severe such as anaphylactic cases patients may experience stridor bronchiospasm and wheezing test tightness and coughing dyspnea anxiety gastrointestinal complaints and hypotension occasionally they can experience respiratory failure and if untreated an anaphylactic reaction can rapidly proceed to death more than two-thirds of patients who die of anaphylaxis do so within the thirst first 30 minutes",
        "Patient Assessment in Immunologic Emergencies": "so let's start talking about the patient assessment aspect okay so seeing size up of course scene safety that's most important to us in the patient's environment or recent activity may indicate the source of an allergic reaction a respiratory problem reported by dispatch may be an allergic reaction until a field impression of a allergic reaction is firmly established be mindful of other potential causes of respiratory distress traumatic injury may also be present secondary to the medical emergency so follow standard precautions with a minimum of gloves and eye protection consider the need for additional resources such as advanced life support personnel",
        "Primary Assessment": "so then you're going to do your primary assessment and quickly identify and treat any immediate or potential life threats your abc's should be reassessed repeatedly throughout transport you want to form your general impression allergic reactions may be present as a respiratory condition or a cardiovascular distress in the form of shock if the patient is anxious and in distress immediately call for advanced life support backup if available look for a medical identification tag if the patient is found unresponsive or unable to answer questions",
        "Airway and Breathing Concerns": "airway breathing of course is a major concern and anaphylaxis can rapidly swelling of the upper airway not all allergic reactions though are anaphylactic reactions quickly assess for increased work of breathing use of accessory muscles head bobbing tripod position nasal flaring and abnormal breath sounds assist the patient into a comfortable position which is generally in the high fowler's position to minimize ventilations so if signs of shock emerge immediately place the patient in the supine position as tolerated for a patient in severe respiratory distress you may have to assist ventilations using a bag valve mask attached to high concentration of oxygen now after the a and the b we're going to talk about c some patients in anaphylaxis may present with signs and symptoms of circulatory stress such as hypotension assess for signs of hypoperfusion treat for shock the definitive treatment for anaphylaxis is epi your transport decision if it's an anaphylaxis is suspected or if a round relatively mild allergic reaction appears to be worsening immediate transport is warranted if the patient is calm and does not exhibit signs and symptoms consider continuing the assessment but err on the side of emergency transport next is the history taking of the assessment so investigate the chief complaint or history of the present illness and identify the signs and symptoms the table above shows additional signs and symptoms of an allergic reaction and then obtain your sample history if the patient is responsive obtain the history from them and ask him or her the following questions specific to allergic reaction has and have any interactions already been completed in our interventions and has the patient experienced a severe allergic reaction in the past the alert for any statements regarding the ingested ingestion of foods commonly causing which cause allergic reactions inquire about the presence of gastrointestinal complaints such as nausea and vomiting",
        "Secondary Assessment": "next your secondary assessment so when you do that physical exam if indicated perform a rapid exam from the body of the body from the head to the toe or conduct a physical exam focus on the areas of the chief complaint if the patient is unconscious or otherwise unable to communicate removes clothing as necessary and look for the presence of bee stingers signs of contact with chemicals or other clues suggestion of suggestive of the reaction look for a medical alert tag that could indicate a severe allergy auscultate for abnormal breast sounds such as wheezing or strider and carefully inspect the skin for swelling rashes or uticarian next you're going to check your vital signs so you're going to bait you're going to assess the baseline including pulse and respiratory rate blood pressure pupillary response and oxygen saturation skin signs may be unreliable indicators of hypoperfusion as they may be widely or hidden by rashes and swelling next you're monitoring devices so a pulse ox can be very useful for assessing the patient's perfusion status the decision to apply oxygen should be based on airway patency work of breathing and abnormal lung sounds on auscultation not solely on your pulse oximetry readings",
        "Reassessment and Interventions": "and your reassessment so enroll to the hospital repeat the primary assessment reassess the patient's vital signs and repeat a focus exam of the affected body system if the patient is unable or unstable reassess every five minutes if the patient's stable every 15 and watch for signs of shock and treat immediately if present now your interventions so treatment is determined by the severity of the reaction mild reactions may require only supportative care and monitoring anaphylaxis requires more aggressive treatment including epi and ventilatory support so recheck your interventions even if the patient is experiencing relief transport to the emergency department is still warranted because the medications effect will wear off and symptoms will return",
        "Communication and Documentation": "communication and documentation so documents should include signs and symptoms found during the assessment reasons why you chose to provide the care you did and the patient's response to the treatment",
        "Emergency Medical Care of Immunologic Emergencies": "emergency care and of an immunologic emergency so if the patient appears to be having a severe allergic or anaphylactic reaction administer bls and provide prompt transport to the hospital if the stinger is present scrape this skin with a sharp edge stiff object such as a credit card do not use tweezers or forceps gently wash the area with soap or mild anesthetic remove jewelry from the area before sweat swelling begins position the injection site slightly below the level of the heart apply ice or cold packs to the area but not directly to the skin and not for more than 10 minutes at a time be alert for signs of swelling airway and other signs of anaphylaxis such as nausea vomiting and abdominal cramps and do not give the patient anything by mouth place the patient the supine physician as indicated and give oxygen if needed monitor the patient's vital signs and be prepared to provide further support if needed let's talk about epi epi is a sympathomimetic hormone okay it mimics the sympathetic fight or flight response it causes the blood vessels to constrict which reverses vasodilation hypotension caused by the anaphylactic reaction other properties of epi increase cardiac contractility and relieves bronchospasms in the lungs it can rapidly reverse this effects of anaphylaxis epi is prescribed by a physician and comes pre-dosed in an an automatic fb injector some ems systems are authorized to carry epi as part of their regular onboard medications and in others ems providers may be permitted to help patients self-assist our medicine refer to local product protocols or consult online medical control the adult epipen system delivers 0.3 milligrams of epi via spring-loaded needle and syringe system the infant child system delivers 0.15 milligrams we're going to see skill drill 21-1 to use the epi auto injector epinephrine can have an effect within one minute so it is the primary way to save the life of someone with a severe allergic reaction but there are side effects and they include high blood pressure increased pulse rate anxiety cardiac arrhythmias polar dizziness chest pain headache nausea and vomiting patients without signs of respiratory compromise or hypotension and who do not meet the criteria for a diagnosis of anal anaphylaxis should not be given epi okay so that concludes chapter 21 anaphylaxis reactions and now we're to the review slide so let's see what we've learned the signs and symptoms of an allergic reaction are caused by the release of it's both histamine and leukotrienes the two chief chemicals okay the negative effects associated with anaphylactic shock are a result of we know it's vasodilation and bronchial constriction all right you are called to a local baseball park for a 23 year old man with difficulty breathing he states that he ate a package of peanuts 30 minutes ago and denies any allergies your assessment reveals widespread uticarian tachycardia and the blood pressure of 90 over 60. you can hear him wheezing even without the stethoscope you should be most suspicious of i think it's an anaphylactic reaction see what is a wheel and it's a raised swollen or well-defined area on the skin you're treating a woman who was stung numerous times by hornets on assessment you note that some of the stingers are still embedded in her skin you should we're not going to leave them in we're going to scrape them we're not going to use tweezers because that could inject more and venom into her and cover the stings with tight dressings no so we're going to scrape them a young male is experiencing signs and symptoms of anaphylactic shock after being stung by a scorpion his level consciousness is diminished his breathing is severely labeled and you can hear inspiratory strider and his face is cyanotic the patient has for has a prescribed epi auto injector what should you do first it's a system the patient's not breathing so you want to therefore you need to assist with the bvm the most reliable indicator of an upper airway swelling during a severe allergic reaction is so upper airway right away is going to be strider right strider wheezes our lower airway the most common trigger of anaphylaxis is remember what we saw the very first one foods okay the adult epipen delivers it's a 0.3 and the infant child delivers 0.15 so that's going to be b when administering an epi by auto injector the empty should hold the injector in place and i don't know if we talked about this but it's going to be b for at least 10 seconds as the medication is injected okay thank you for joining me tonight for chapter 21 allergy and anaphylaxis if you liked this lecture go ahead and subscribe to the channel we're going to be going through the whole book thank you have a good night"
    },
    {
        "Introduction to Gynecologic Emergencies": "hello class and welcome to chapter 24 gynecologic emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter",
        "National EMS Education Standard Competencies": "and the related coursework you will understand the anatomy and physiology including the developmental changes during puberty and menopause of the female reproductive system and identify and describe assessment and treatment for gynecologic emergencies special considerations and precautions that an EMT must observe when arriving at the scene of a suspected case of sexual assault and raped are also discussed okay so women are amazing and",
        "Unique Design of Women": "we are uniquely designed to conceive and give birth but women are susceptible to problems that men do not occur okay so let's talk about the",
        "Anatomy and Physiology of the Female Reproductive System": "anatomy and physiology first the female reproductive system includes internal and external structures and the internal female genitalia is the vaginal opening the labia the clitorus and the perum okay so this uh figure on the slide it shows the external female genitalia the internal structures are the ovaries and they lie on each side of the lower abdomen and produce an ovm which is the egg then you have the Fallopian tubes they connect each ovary to the uterus the uterus is the muscular organ that the fetus grows during pregnancy and the narrowest part of the uterus is the cervix and that's that uh opening of um of the uterus and it and it goes down and opens into the vagina okay the vagina is the outermost cavity of the woman's reproductive system and then on this slide there's a figure and it shows the internal female genitalia when a female reaches puberty she begins to ovulate and experience menstration so Monarch that is the onset of menstruation and it usually occurs between ages 11 and 16 any female who reaches Monarch is capable of becoming pregnant women continue the cycle of ovulation and menstruation until they reach menopause and the end of the menstrual activity usually occurs around 50 years old each month one ovom is released into the fian tubes and that's called ovulation the process of fertil begins fertilization begins in the vagina sperm is deposited into the vagina from the M penis and the sperm passes through the cervix into the uterus and eventually up into the floian tubes the floian tubes is where the ovom is fertilized the embryo then travels to the uterus and attaches to the uterine wall and continues to grow if fertilization does not occur within about 14 days of ovulation the lining of the uterus begins to separate and menstration occurs female hormones produced primarily in the ovaries control the process of ovulation and menstration so let's talk a little bit",
        "Pathophysiology of Gynecologic Emergencies": "about the pathopysiology ology okay the causes of gynecologic emergencies vary ranging from sexually transmitted diseases to",
        "Pelvic Inflammatory Disease": "trauma the first one we're going to talk about is pelvic inflammatory disease and that's Pi that's an infection of the upper organs of the reproductive system okay it occurs almost exclusively in sexually active women infection expands to the fallopian tubes it will um and can cause some scarring and that can result in increased risk of eoic pregnancy or sterility if infection expands to the ovaries it can lead to a development of lifethreatening abscesses most common presenting sign of PID is generalized lower abdominal pain other signs include abnormal or foul foul smelling vaginal discharge increased pain with intercourse fever General malaise and nause and vomiting risk factors for PID include multiple sexual partners or a partner who has had multiple sexual partners untreated sexual transmitted diseases a history of PID being sexually active younger than 26 years of age douching or using an IUD for birth",
        "Sexually Transmitted Diseases": "control so after pelv inflamate dis disas we're going to talk about STDs and that's sexually transmitted diseases STDs can lead to more serious conditions such as PID chlamidia uh is the first one we're going to talk about and that's the most common STD in the US it's usually milder absent symptoms the infection of the cervix can spread to the rectum and can progress to PID bacterial vaginosis this is most common infection to um afflict women between 15 and 44 untreated it can lead to premature birth or low birth weight in cases of pregnancy make the patient more it can make the patient more susceptible to other serious infections and cause pelvic inflammatory disease and then there's gonorrhea caused by bacteria that grow and multiply in warm moist areas of the reproductive tract the cervix uterus and Fallopian tubes in women and the urethra in men and women severe infections present with cramping abdominal pain nausea vomiting and bleeding between periods untreated it can enter the bloodstream and spread to other body parts including the",
        "Vaginal Bleeding": "brain okay so now let's talk about an overall umbrella of the abdominal or vaginal bleeding possible causes include abnormal menstration vaginal trauma a topic pregnancy an a spontaneous abortion or polyps or",
        "Patient Assessment": "cancer so next let's get into the patient assessment so we're going to just follow down through the patient assessment form and first thing you want to do is obtain an accurate and detailed assessment it's critical in dealing with gynecological issues so scene safety is the scene safe",
        "Scene Size-up": "do you need assistance and how many patients do you have what's the nature of the illness and have you taken standard precautions those are questions you're going to ask on every call you're going to okay gynecologic emergencies can involve large amounts of blood and body fluids potentially contaminated with organisms that can cause communicable diseases so where or in what position did you find the patient if she's at home what is the condition of the residence if it's a crime scene you may be required to testify in court regarding conditions on your arrival so documentation needs to be accurate accurate and thorough involve the police if any type of assault is suspected and in cases of sexual assault it is important to have a female EMT provide patient care mechanism of injury so thei the Moi in some patients with gynecologic problems may be easily understood from the dispatch information such as a sexual res assault in other patients patient history may reveal the nature of the condition",
        "Primary Assessment": "next we're into the primary assessment and that's when we form that general impression so is the patient stable or unstable use the avpo scale to determine the patient's level of Consciousness so alert verbal painful or unresponsive always evaluate the airway and breathing immediately to ensure they are adequate okay then palpate the pulse and evaluate skin color temperature and moisture to help identify blood loss in a patient most cases of a gynecologic emergency are not life-threatening if patient has signs and signs of shock transport uh is warranted next into the history taking",
        "History Taking": "right so we're going to investigate that Chief complaint and some questions may be extremely personal to the patient so be sensitive to the patient's feelings and protect her privacy and dignity for abdominal pain ask about the onset duration quality rate radiation provoking and relieving factors so those opqrst questions are are very big deal um with this type of um of signs and symptoms so in Associated symptoms such as Syncopy have they passed out have they had been laded or nausea vomiting or fever okay for vaginal bleeding",
        "History Taking - Continued": "ask then after the opqrst questions you know you're going to do your sample history so you want to ask about birth control pills and devices also ask a patient about medical conditions and the last the date of that last menstrual period okay secondary assessment so this is",
        "Secondary Assessment": "when we're going to focus in on the um the area of the chief complaint so pertinent secondary assessment finding should include we want to make sure we do the vital signs the abdomen is it distended or Tender and then is there visible bleeding or how is the mental status and then physical exams it should be limited and professional only exam in the genitalia if it is necessary to do so to treat the patient patients age 65 and older may have concerns related to hormone replacement therapy cancer pelvic floor collapse or urinary incontinence for vaginal bleeding visualize the bleeding and ask about the quality and quantity observe for vaginal discharge so fever nausea and vomiting are considered uh specific in gynecologic emergencies or significant okay so Syncopy is considered significant as well and treat as if they're in shock until proven otherwise when it comes to assessing the patients's vital signs of course we're going to do the heart rate Rhythm and quality respiratory rate Rhythm and quality skin color temp condition you want to do the cap refill time blood pressure and then consider obtaining orthostatic um vital signs if bleeding is known or suspected okay reassessment of course we're going",
        "Reassessment": "to repeat the primary and then there are very few interventions of course with that gynecologic emergency so communicate all relevant information to the staff of the Receiving Hospital and including the possibility if the patient could be pregnant okay now emergency care for these cases",
        "Emergency Medical Care": "um the biggest thing with Emergency Care is you want to maintain the patient's privacy as much as you can if in public um we want to get them to the back of the ambulance or some place private okay have the female empt participate in patient care if possible that cannot be stated enough now when it comes to excessive internal vaginal bleeding we want to use sanitary pads on the external genitalia to absorb the blood you need to document the number of pads that were saturated with blood okay in the external genitalia they have a rich nerve Supply so this makes injuries uh very painful treat external lacerations abrasions or tears with steril compresses under no circumstances should you pack or place dressings in the vagina when it comes to assessment and",
        "Assessment and Management of Specific Conditions": "management of specific conditions first we're going to talk about PID pelvic inflam atory disease so a patient with P will complain of abdominal pain pain usually starts during an after normal menstration the pain may be worse by walking and so patients often present with this uh distinctive gate they appear to shuffle so prehospital treatment is limited non-emergency transport is usually recommended and sexual assaults so",
        "Sexual Assault": "sexual assaults and rape are common in the United States States one in five women have reported being raped and one in three will be sexually molested often before the ages of 12 EMTs called on to treat a Vic of a victim of sexual assault face many complex issues so issues range from obvious medical ones to Serious psychological and legal issues you may be the first person the victim has come in contact with after the encounter professionalism tacted kindness and sens sensitivity are important when performing your assessment be aware of drugs used during sexual assault and rape to incapacitated a person if possible give the patient the option of being treated by a female EMT your focus should be on medical treatment of the patient psychological care of the patient and your ability to preserve the evidence it may be necessary to persuade the patient not to clean themselves after the call um the local Rape Crisis Center for the patient so offer to call uh if the take the patients's history and limit any physical exam to a brief survey for life-threatening injuries the table on this uh slide shows treatment principles for victims of sexual assault okay so that concludes uh",
        "Review and Conclusion": "chapter 24 the gynecologic emergencies it's a really short chapter um and next we're just going to go over some of the the key things that we've learned today okay so what is the narrowest portion of the uterus and we know the narrowest portion that opens when giving birth of course is that's the cervix cervix is the narrowest portion what is the outermost cavity of the woman's reproductive system and we we know that that is the vagina okay the vagina is the outermost cavity if fertilization has not occurred within about how many days following ovulation how many days we know that that is 14 right so women menstrate about 14 days following ovulation the onset of menstration is called and we know that's Monarch about 11 to 16 years old which of the following can cause vaginal bleeding all right well looks like it's all of the above what what is the most common presenting sign of a PID and that's lower abdominal pain that's the most common sign when obtaining a sample history which of the following pieces of information is important to obtain this looks like it's another all of the above what is the emt's first priority when dealing with a patient experiencing excessive of vaginal bleeding so the very first thing of course we want to treat uh treat for shock and transport that's always our primary right so treat treat and uh transport which of the following drugs are commonly used to facilitate an assault and so we didn't talk too much about this but it's going to be ruol so that's that's considered the date rap drug ruol is a sedative okay and finally number 10 you should encourage you should discourage a rape or sexual assault victim from doing which um and that's of course all of the above again we um we need to preserve the evidence okay thank you for joining us for this short little chapter on the gynecologic emergencies chapter 24 if you like this video or lecture go ahead and subscribe to the channel because we're going to be completing the whole book very soon okay thanks have a great one"
    },
    {
        "Chapter Introduction": "hello and welcome to chapter 36 geriatric emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the physiologic and psychological changes that occur with the aging process you will also learn and understand the types of illness and injuries common in the geriatric population and you'll understand the gems triangle use of advanced directives and signs and symptoms of elder abuse bariatrics is",
        "Introduction to Geriatric Care": "the assessment and treatment of disease in a person who is age 65 or older it is projected that between 2012 and 2050 the population age 65 years and older is expected to nearly double bariatric patients present as a special challenge for health care providers because the classic presentation of illness and injuries are often altered by the presence of chronic conditions multiple medications and the physiology of aging",
        "Generational Considerations": "so let's talk about some generational considerations it's important to understand and appreciate how the life of an older person might differ from yours it takes time and patience to interact with an older person always treat the patient with respect make every attempt to avoid ageism the stereotyping of older people that often leads to discrimination older people can stay fit be active even though they are not able to perform at the same level as they did in their youth",
        "Communication with Older Adults": "so let's talk about communication with older adults okay effective verbal communication skills are essential to the successful assessment and treatment of an older patient communication with older people can be challenging and challenges and communication abilities accompanying aging such as dementia and other disease so let's talk about communication techniques in general when caring for older individuals use their name to communicate with them if you do not know their name you sir or ma'am asking the patient how he or she prefers to be a dress can build trust and when you interview an older patient the following techniques should be used you want to identify yourself you want to be aware of how you present yourself you want to look directly at the patient at the eye level and ensure good lighting and speak slowly and distinctly",
        "Effective Communication Techniques": "have one person talk to the patient and ask only one question at a time do not assume that all older patients are hard of hearing give the patient time to respond unless the condition appears urgent listen to the answer the patient gives you explain what you're going to do before you do it and do not talk to the patient in front of him or her as though the patient is not there",
        "Common Complaints and Leading Causes of Death": "okay so let's talk about some common complaints and the leading disease of death or leading causes of death in older people the changing physiology of geriatric patients can predispose this population to a host of problems not seen in youth a simple rib fracture in an 80 or 90 year old can cause or result in pneumonia or even death a hip fracture from a low mechanism fall is common in older people and may have dire consequences hip fractures are more likely to occur when bones are weakened by osteoporosis or infection and sedimentary behavior while healing can predispose a patient to pneumonia and blood clots many older people who experience hip fractures do not re return to their pre-injury level of activity okay and so on this chart it shows some of the common conditions and the leading causes of death in geriatric patients",
        "Physiological Changes with Aging": "there are also changes in the body human growth and development peaks at it in the late 20s and early 30s at which point the aging process begins the aging process is inevitable it's accompanied by changes in physiologic functions such as the decline and function of the liver and kidneys all tissues in the body undergo aging the decrease in function capacity of various organ systems in normal can is normal and can affect the way in which a patient responds to illnesses",
        "Respiratory System Changes": "so let's first talk about changes in the respiratory system for and we're going to talk about the anatomy and physiology okay so age-related changes can predispose an older adult to respiratory illnesses what happens is there's weakening of the airway musculature and it can cause decreased breathing capacity alveoli can become enlarged and elasticity decreases making it harder to expel air chemoreceptors slow with age and this causes the body to respond more slowly to hypoxia and loss of mechanisms that protect the upper airway include decreased cough and gag reflexes so let's first talk about pneumonia it's a chronic lower respiratory disease such as influenza and pneumonia are the top five causes of geriatric death inflammation infection of the lung from bacteria viral or fungal causes it's a leading cause of death from infection in older americans older than 65 years old and aging causes some immune suppression and increases the risk of contracting infections like pneumonia increased mucus production pulmonary secretions and the inflammatory effects of infection all interfere with the ability of the alveoli to oxygenate the blood management of pneumonia is the same for any patient however maintain a high index of suspicion for any geriatric patient with signs and symptoms of pneumonia",
        "Pulmonary Embolism": "pulmonary emboli so causes a sudden blockage of an artery by a venous clot a patient with a pulmonary emboli or embolism will present with shortness of breath and sometimes chest pain it can be confused with a cardiac lung or muscular skeletal problem so let's talk about the risk factors living in a nursing home or recent hospitalization for medical illness or surgery trauma cancer a history of blood clots or heart failure the presence of a pacemaker or central venous catheter paralyze extremities obesity smoking or recent long distance travel are all risk factors patients present with tachycardia a sudden onset of dyspnea shoulder pain back or chest pain cough syncope in patients in whom the clot is larger and anxiety apprehension sometimes a low-grade fever leg pain redness and unilateral penile pedal edema fatigue cardiac arrest in worst case scenario treatment should focus on the airway ventilatory and circulatory support supplemental oxygen and ventilatory support may be needed",
        "Cardiovascular System Changes": "okay so we've talked about the respiratory changes now we're going to talk about the cardiovascular system changes in particular right now we're going to talk about the anatomy and physiology changes okay so the heart hypertrophies with age probably in response to the chronically increased afterload imposed by stiffening of the blood vessels so over time cardiac output declines mostly as a result of decreasing stroke volume and arterial sclerosis contributes to systolic hypertension which places an extra burden on the heart",
        "Heart Function and Risks": "the ability to speed up contractions increase contraction strength and constrict or narrow blood vessels is decreased because of stiffer vessels over time cardiac output declines mostly as a result of decreasing stroke volume and arterial sclerosis contributes to systolic hypertension which places an extra burden on the heart so the figure on this slide shows atherosclerosis the buildup of fat and cholesterol in the arteries older people are also at an increased risk for from formation of an aneurysm severe blood loss can occur when the aneurysm ruptures the blood vessels become stiff which result in a higher systolic blood pressure then stiffening and generation degeneration of the heart valves that may impede blood flow into the heart in the now the electrical conduction system of the heart undergoes changes leading to an abnormal heart rate or rhythm and orthostatic hypotension is a drop in blood pressure with a change in position the body is less able to adapt to rapid postural changes venous stasis can cause clots to develop in the veins leading to deep vein thrombosis or pulmonary emboli loss of proper function of the veins in the legs that normally carry blood back to the heart then myocardial infarcts so the classic symptoms of a heart attack are often not present in geriatric patients as many as one-third of older patients have silent heart attacks and because the usual chest pain is not present more common in women and patients with diabetes signs and symptoms of cardiovascular disease include dipstick epigastric and abdominal pain loss of bladder and bowel control nausea and vomiting weakness dizziness lightheadedness and syncope fatigue and confusion other signs and symptoms include diaphoresis pale cyanotic or mottled skin abnormal or decreased breast sounds increased peripheral edema and how we're going to treat it is airway ventilatory and circulatory support administer aspirin or assist a patient to administer their nitro",
        "Heart Failure": "heart failure so the signs and symptoms will differ depending on the extent to which the right or left side of the heart is not functioning correctly when you have right-sided heart failure it occurs when fluid backs up into the body you will see jugular vein distension ascites and peripheral edema an enlarged liver may also be present which is determined by palpation right-sided heart failure is often caused by left-sided heart failure so it is common to see the signs of both with left-sided heart failure fluid backs up into the lungs this causes pulmonary edema and shortness of breath severe shortness of breath and the hypoxia also crackles in the lungs",
        "Nocturnal Dyspnea": "proximal nocturnal dipsnia is characterized by a sudden attack of respiratory depress that wakes a person up at night when he or she is reclining so it's caused by fluid accumulation in the lungs and signs and symptoms include coughing feeling of suffocation cold sweats and tachycardia treatment consists of airway ventilatory and circulatory support",
        "Stroke": "and then there's stroke so it's the leading cause of death in older people preventable factors include smoking hypertension diabetes and afib obesity and a sedimentary lifestyle controllable factors include age race and gender signs and symptoms include altered level of consciousness numbness weakness or paralysis on one side of the body slurred speech aphasia visual disturbances headache dizziness incontinence and in the worst case a seizure hemorrhagic strokes in which broken blood vessels cause leading cause bleeding into the brain are less common and more likely to be fatal ischemic strokes occur when blood clots break the flow of blood to a portion of the brain determining the onset of the symptoms is important if the symptoms occur within the past few hours the patient can be a candidate for stroke center therapy a transient ischemic attack can present with it the same signs and symptoms as a stroke always manage the patient as if he or she is having a stroke",
        "Nervous System Changes": "next we're going to talk about changes to the nervous system okay and so changing in thinking speed memory and posture stability are the most common normal findings in older people the brain decreases in terms of weight so about 10 to 20 percent and volume as the person ages increasing the amount of space in the cranium and increasing the change for or change for head injuries there is about five to fifty percent loss of neurons in older people this affects the control of the rate and depth of breathing rate heart pressure hunger thirst and body temperature the performance of most of the sense organs decline with increasing age and vision vision acuity depth perception and the ability of the eyes to accommodate to light changes with age cataracts interfere with vision and make it difficult to distinguish colors and see clearly increasing the likelihood of falls and medication errors decreased tear duct production leads to drier eyes older people develop an inability to differentiate colors and have decreased night vision the inability to see up close is called prebysphobia and it can it is caused by a less elasticity of the lens a number of other diseases processes plague the vision of older adults and these include glaucoma macular degeneration and retinal detachment",
        "Hearing and Sensory Changes": "and then there's hearing changes in the inner ear make hearing high frequency sounds difficult changes in the ear can cause also cause problems with balance and make falls more likely so hereditary and long-term exposure to loud noises are the main factors that contribute to hearing loss when assessing your patient check for the use of hearing aids and then there's taste that taste the sense of taste can diminish because of the decrease in the number of taste buds which can cause and lead to lessened interesting interest in eating weight loss malnutrition and fatigue and touch to decrease sense of touch and pain perception from the loss of end nerve fibers okay so any person with any person who may be injured and they may not know it so decreased sensation of hot and cold also happens",
        "Dementia": "and then there's dementia so the slow onset of progressive disorientation shortened attention span and loss of cognitive function a chronic generally irreversible condition that causes a progressive loss of cognitive ability psychomotor skills and social skills potential causes of alzheimer's disease parkinson's disease stroke and genetic factors determine the patient's normal mental status by questioning family members or friends evaluate history risk factors and current medications the patient might exhibit loss of cognitive function patients may have short and long term memory problems and decreases attention span or they may be able to perform their daily routines they also may show a decreased ability to communicate and appear confused",
        "Delirium": "and then there's delirium so this is a sudden change in mental status consciousness or cognitive processes it's marked by the inability to focus think logically and maintain attention it affects 15 to 50 percent of hospitalized people aged 70 and older usually it's a result of a reversible physical ailment such as a tremor fever or some type of metabolic cause it's important to look and think um about histories okay so intoxication or withdrawal from alcohol withdraw from some sedative and medical conditions such as a uti bowel obstruction dehydration fever cardiovascular disease hyperglycemia hypoglycemia depression malnutrition and environmental emergencies",
        "Delirium Assessment": "so you want to assess and manage patient for hypoxia hypovolemia hypoglycemia and hypothermia you may see changes in circulation breath sounds motor function and pupillary response",
        "Syncope": "syncope syncope is you want to always assume that it's an underlying life-threatening problem until it's proven otherwise often causes uh it's caused by interruption and blood flow to the brain",
        "Neuropathy": "in neuropathy so this is a disorder of the nerves of the peripheral nervous system in which the function and structures of the peripheral motor sensory and autonomic neurons are impaired symptoms depend on whether the nerves affect our the motor sensory or autonomic and where the nerves are located",
        "Gastrointestinal System Changes": "okay so now let's talk about the change in the gastrointestinal system so there are some changes in the mouth and then they include the reduction in the volume of saliva with a resulting dryness in the mouth also dental loss is widespread in older populations and contributes to nutritional and digestive problems and gastric secretions are reduced as a person ages so include these changes in gastric mobility leads to slower gastric emptying the incidence of certain diseases such as bowel increases as the person grows older and blood flow to the liver declines so enzyme activity decreases",
        "Gastrointestinal Pathophysiology": "so age-related changes um in the gastrointestinal system such as related to the pathophysiology include poor muscular tone of the smooth muscle in the sphincters between the esophagus and stomach and this can lead to regurgitation and often heartburn and acid reflux also have weakening of the rectal sphincter changes in the liver predispose older patients to a number of problems including blood flow to the liver it declines and there is a decreased metabolism this has a direct result an effect on how the medications may affect patients and then there's gi bleeding issues and common causes are inflammation or infection and obstruction of the upper and lower gi tract usually you'll see hemoemesis okay so bleeding that travels through the lower digestive tract usually manifests as malia and this is uh black tari stools okay so red blood usually means a local source of bleeding such as a hemorrhoid and a patient with a gi bleeding may experience weakness dizziness or syncope bleeding in the gi system can be life-threatening specific gi problems that are common in older patients are diverticulitis leading in the upper and lower gi system peptic ulcer disease gallbladder disease or a bowel obstruction when assessing patients ask about incense and alcohol use orthostatic vital signs can help determine if the patient is hypovolemic treatment consists of airway ventilatory and circulatory support",
        "Acute Abdomen and Renal System": "the acute abdomen non-gastrointestinal complaints so in the pre-hospital setting the most serious threat of abdominal complaints and blood loss which can lead to shock and death so abdominal aortic aneurysm or aaa is one of the most rapidly fatal conditions next we're going to talk about changes in the renal system okay so age-related changes specific to kidney and include a reduction in renal function and a reduction in renal blood flow decreased bladder capacity decline in",
        "Renal System Changes": "sphincter control decline in voiding senses increase in nocturnal voiding",
        "Benign Prostate Hypertrophy and Incontinence": "benign prostate hypertrophy so this is an enlarged prostate decreased weight of the kidney results in a loss of functioning leading to a smaller effective filtering surface and renal blood flow decreases as much as 50 percent so acute illnesses in older patients is often accompanied by electrolyte imbalance so this is a markedly decreased thirst mechanism which may cause rapid development and severe dehydration incontinence is not a normal part of aging and can lead to skin irritation skin breakdown and urinary tract infections as people age the capacity of the bladder decreases so two major types of incontinence are distinguished there's stress and then urge so stress incontinence occurs during activities such as coughing laughing sneezing lifting and exercise and then there's urge incontinence and it's triggered by hot or cold fluids running water and even thinking about going to the bathroom the opposite of incontinence is urinary retention or difficulty urinating and men an enlarged prostate can lead to pressure on the urethra making voiding difficult bladder and urinary tract infections can cause inflammation and in severe cases of urinary tension patients may experience renal failure",
        "Endocrine System Changes": "now let's talk about the changes in the endocrine system so a significant change occurs in older persons is a decrease in meta metabolism okay so this decrease affects the body's metabolism temperature growth and heart rate most of the signs and symptoms people experience are attributed to the process of aging and this includes slower heart rate fatigue drier skin and hair cold intolerance and weight gain they could also have an increase in secretions of antidiuretic hormone and this causes a fluid imbalance hyperglycemia and increases in the levels of norepi possibly having a harmful effect on the cardiovascular system hypersmaller hyperglycemic non-chaotic syndrome hhns is a diabetic complication in older people and occurs in more often in people with type 2 diabetes signs and symptoms of hhns and diabetic ketoacidosis often overlap these include hyperglycemia polydypsnia polyuria polyphagia dizziness confusion altered mental status and possibly seizures onset you may see changes in circulation such as warm flush skin poor skin turgor pale dry oral mucosa and a furrowed tongue the patient may present with signs and symptoms of hypotension shock including tachycardia the blood glucose level will vary in dka whereas in hhns the value is typically 600 or higher dka will present with cushmal's respirations while hhns will not treatment should include airway inflammatory ventilatory and circulatory support",
        "Immune System Changes": "okay and then there's changes in the immune system so older people may be unable to develop a fever in fact may become hypothermic as a manifestation in severe systemic infections anorexia fatigue weight loss falls or changes in mental status may be the primary symptom of an infection in these patients pneumonia and urinary tract infections are common in patients who are bedridden when infection occurs signs and symptoms may be decreased or minimized in that patient",
        "Musculoskeletal System Changes": "aging brings a widespread decrease in bone mass in women and men but especially among postmenopausal women bones become more brittle and tend to break more easily the discs between the vertebrae of the spine begin to narrow and a decrease in height between about two to three inches may occur through the lifespan along with changes in posture joints lose their flexibility and may be further immobilized by arthritic changes a decrease in motion and the amount of muscle mass often results in less strength",
        "Musculoskeletal System and Mobility": "changes in the physical abilities can affect older adults confidence in their",
        "Musculoskeletal System Degeneration": "mobility so the muscle system atrophies and weakens with age strength declines ligaments and cartilage of the joints lose their elasticity cartilage goes through degenerative change the stooped posture of older people comes from atrophy of supporting structures of the body and kyphosis occurs and this is a forward curling of the spine also called hunchback or humpback osteoporosis is a condition that affects men and women and it's characterized by that decrease in bone mass leading to a reduction in bone strength and greater susceptibility of fracture the extent of bone loss that the person undergoes is influenced by a number of factors including genetic smoking level of activity diet alcohol consumption hormonal factors and body weight osteoarthritis is a progressive disease of the joints that destroys cartilage promotes the found formation of bone spurs in the joints and leads to joint stiffness this affects several joints of the body most commonly those in the hands knees hips and spine patients complain of pain and stiffness that gets worse with worse with exertion",
        "Skin Changes": "and then there's changes in the skin so the proteins that make the skin pliable decline with age the layer of fat under the skin also becomes thinner because of the redistribution of fluids and proteins bruising becomes more common because the skin can tear more easily exocrine which are the sweat glands do not respond as readily to heat because of atrophy and causes and changes the tissues of the dermal layer of the skin and then there's pressure ulcers so these are known as bed sores and the pressure from the weight of the body cuts off the blood flow to an area of",
        "Pressure Ulcers": "the skin with no blood flow to the skin a sore develops to prevent these ulcers take special care to pad under any bony premises and in the voids of a patient who may become immobilized for an extended period you may see these ulcers in the following various stages of development so a decubitus ulcer can be painful and cause complications such as bleeding sepsis and bone inflammation",
        "Toxicology": "toxicology so older people may be more susceptible to toxicology because of a decreased kidney function altered gi absorption or decrease vascular flow in the liver the kidneys undergo many changes with age decreased liver function makes it harder for the liver to detoxify the blood and eliminate substances such as medications and alcohol typical over-the-counter medications used by older people include aspirin antacids cough syrups and decongestants many people believe over-the-counter medicines cannot be dangerous but these medicines can have negative effects when mixed with other herbal substances alcohol or prescription medicines polypharmia polypharmacy refers to the use of multiple prescription medications by one patient negative effects can include overdosing and negative medication interaction so medication non-compliance in older patients is also an issue and may occur because of financial changes inability to open containers and impaired cognitive vision and hearing ability",
        "Depression": "and then let's talk about next behavioral emergencies okay so depression it's not a part of normal aging but rather a medical disease the common often debilitating psychiatric disorder affects millions of older americans it's treatable with medical with medication and therapy if depression goes unrecognized or untreated it is associated with a higher suicide rate in the geriatric population than in any other age group",
        "Depression Risk Factors": "risk factors include history of depression chronic disease loss the following conditions contribute to the onset of specific depression so substance abuse isolation prescription medicine use or chronic medical conditions",
        "Suicide": "suicide most older adult suicide victims have recently been diagnosed with depression and have seen their primary care physician within a month before the event older men have the highest suicide suicide rate of any age group in the us older persons who attempt suicide choose a much more lethal means than younger victims and generally have diminished capacity to survive the attempt common predisposing events and conditions include a death of a loved one physical illness depression and hopelessness alcohol abuse or alcohol dependence or loss of meaningful life roles when assessing the patient who is displaying signs of depression it is appropriate to ask if he or she is considering suicide if the answer is yes the next question should be do you have a plan you need to include this information in your report",
        "The GEMS Diamond": "okay so next let's talk about the gems triangle the gems diamond it was created to help you remember what is different about older patients and this serves as an acronym for the issues to be considered when assessing an older patient g stands for geriatric so consider the older patients are different from",
        "The GEMS Diamond Components": "younger okay and so be familiar with the normal changes of aging and treat older patients with compassion and respect e stands for environmental assessment so you need to assess the environment and it can give you clues to the patient's condition and the cause of the emergency so preventative care is very important for a geriatric patient who may not carefully study the environment or maybe not realize where risks exist m stands for medical assessment so older patients tend to have a variety of medical problems and may be taking numerous prescriptions over the counter and medical herbal medications so obtaining a thorough medical history is very important and s stands for social assessment so older people may have less of a social network because of the death of a spouse family member and friend older people may also need assistance with activities of daily living so consider obtaining information pamphlets about some agencies to help older people in your area",
        "Assessing Geriatric Medical Patients": "all right so let's talk about special considerations when we're assessing a geriatric medical patient okay so there could be communication issues or hearing and visual deficits and there could be an alteration in their consciousness complicated medical histories and effects of medications can also affect the assessment",
        "Scene Size-up": "so now let's start in with the assessment okay and of course scene safety so geriatric patients are commonly found in their own homes retirement homes and skilled nursing facilities access to them may be hampered if their condition present prevents them from getting to the door so take note of negative and unself and unsafe environmental conditions look for clues that might explain the patient's medical history or current problem in a nursing home or residential care facility you will need to locate the patient's room and find the staff member who can explain why you are called in any case in which the patient's mental status is altered you need to find someone who can tell you the patient's history and whether the patient's behavior or level of consciousness is normal or altered",
        "Mechanisms of Illness and Injury": "mechanisms of the illness and injury so the noi can be different",
        "Scene Size-up Considerations": "and difficult to determine in older people who may have an altered mental status or dementia you must ask a family member caregiver or bystander why he or she called multiple or chronic disease processes may also complicate the determination of the noi chest pain shortness of breath and an altered level of consciousness should always be considered serious",
        "Primary Assessment": "so now is our primary assessment of course we need to address those life threats and determine the transport priority of our patient based on his or her medical condition and maintain a high index of suspicion for serious injuries even when mechanism of an injury might not may seem minor to in younger patients okay so as you approach the patient you should be able to tell if the patient is generally in a stable or unstable condition use the abdo scale to determine the patient's level of consciousness next is our a and b and so aging and disease can compromise the patient's ability to protect his or her airway and there's a loss of the gag reflex and normal swallowing mechanisms ensure the patient's airway is open and is not obstructed by dentures vomit fluid or blood suction may be necessary anatomic changes can also affect the person's ability to breathe effectively and loss of mechanisms that protect the upper airway such as a cough and gag reflex cause a decreased ability to clear secretions an airway and breathing issues should be treated with oxygen as soon as possible and then there's the c so poor perfusion is a serious issue in an older adult and there's changes that can negatively affect circulation so lower heart rates and weaker or irregular pulses are also common in older patients vascular changes and circulatory compromise may might lead to difficult to feel that radial pulse so circulation problems in older adults should be treated with oxygen as soon as possible and determine if a cardiac abnormality in an older patients indicate an acute emergency or a chronic condition so an acute emergency should be managed rapidly and then there's the d so our transport decision any complaints that compromise airway breathing or circulation should result in transportation of the patient as a priority patient your most important task is to determine conditions that are life-threatening treat them to the best of your ability and provide transport to priority patients older people do not have the res reserves that younger people do and they will easily decompensate consider early on if advanced life support treatment is necessary and immediate transport is appropriate and available",
        "History Taking": "and then there's the history taking so we need to find an account for all medications communication may be more complicated with an older adult but it's critical that you obtain a thorough patient history determination should be made early as to whether an altered mental or alter level of consciousness is acute or chronic multiple disease processes and multiple other vague complaints can make assessments complicated so take a full set of vital signs and ask yourself what's normal for the patient the chief complaint may be related to a chronic medical condition obtain a list of the patient's medications and take the medications with you to the hospital if possible transport to a facility that knows the patient's medical history if possible and the last oral intake is important in a patient with diabetes and may indicate that the patient may be high dehydrated",
        "Secondary Assessment": "and then your secondary assessment so your older patients may not be comfortable with being exposed protect his or her modesty and consider the need to keep your patient warm during the exam vital signs so medications such as beta blockers keep the heart rate low and prevent tachycardia commonly seen in dehydration and shock weak and irregular pulses are common in older patients circulatory compromise may make it difficult to feel a radial pulse in an older patient and other pulse points may need to be considered blood pressure tends to be higher in older patients cap refill is not a good assessment because skin changes and reduce circulation to the skin the respiratory rate should be the same rate as a younger adult but remember that the chest rise will be compromised by increased chest wall stiffness careful interpretation of pulse ox data is necessary in older patients because the pulse ox device requires adequate perfusion to get an accurate reading",
        "Reassessment": "and then there's a reassessment so you want to reassess the geriatric patient often because the condition of an older person or older adult may deteriorate quickly recheck interventions and identify and treat changes in the patient's condition and then of course you want to document",
        "Documentation": "all history medication assessment and intervention information the table on the slide provides guidelines for cis for assessing geriatric patients",
        "Trauma in Geriatric Patients": "okay now let's talk about trauma so in general the risk of serious injury or death is more common in older patients who experience trauma than younger patients conditions that increase risk and complicate the assessment of geriatric patients include a slower homeostatic compensate compensatory mechanism limited physiologic reserves and normal effects of aging on the body and existing medical conditions physical findings in an adult older adult may be more subtle and easily missed and the healing process is longer older pedestrians are more likely to have life-threatening complications after being struck by a vehicle and secondary impacts can also lead and cause serious injuries older people are more likely to experience burns because of altered mental status inattention and compromised neurologic status the risk of mortality from burns is increase when pre-existing medical conditions exist and the immune system is weakened fluid replacement is also complicated by renal compromise there is a higher mortality from penetrating trauma in older dots because of the cause especially in the case of gunshot wounds penetrating trauma can easily cause serious internal bleedings and falls are the leading cause of fatal and non-fatal injuries in older adults nearly half of fatal falls in geriatric patients result in traumatic brain injuries okay so changes in the pulmonary cardiovascular neurologic and muscular skeletal systems make older patients more susceptible to trauma the brain shrinks leading to higher risk of cerebral bleeding following head trauma and skeletal changes causes curvature of the spine that often requires additional padding during spinal immobilization and loss of strength sensory impairment and medical illness all increase the risk of falls a geriatric patient's overall physical condition may lessen the ability of the patient's body to compensate for the effects of even simple injuries and osteoporosis predisposes older patients to hip and pelvis fractures compression fractures of the spine are more likely to occur because the brain shrinks with age older patients are more likely to sustain close head injuries such as subdural hematomas acute subdural hematomas are among the deadliest of all head injuries serious injuries to the head are often missed in older patients because the mechanisms may be relatively minor other factors that predispose other patients or older patients to have serious head injuries occur include long-term abuse of alcohol recurrent falls or repeated head injuries and anticoagulation medications",
        "Environmental Injuries": "so then there's environmental injuries and this is changes in the endocrine system results in delayed internal internal temperature regulation heat gain and loss is further delayed by impaired circulation decreased sweat production chronic diseases medication use and alcohol use half of all deaths from hypothermia occur in older people most indoor hypothermia deaths involve geriatric patients death rates from hyperthermia more than double in older people compared to younger people people older than 85 are at the highest risk",
        "Assessing Geriatric Trauma Patients": "so trauma is never isolated to a single issue when you are assessing and caring for a geriatric patient let's talk about the trauma size up okay so or trauma assessment so we want to look for clues that indicate whether our patient's traumatic incident may have been preceded by a medical incident",
        "Primary Trauma Assessment": "of course we have to address life threats determine the transport priority and it is recommended that older patients be transported to a trauma center when we form our general impression we need to try and get the information from someone familiar with the patient if possible use the avpoo and glass gall coma score to determine mental status older patients may have a diminished ability to cough so suctioning is important we also want to assess for the presence of dentures but do not remove them unless they are creating an airway problem and then circulation so drinking alcohol and taking anticoagulant medications can be can make internal bleeding worse or external bleeding more difficult to control older patients can more easily go into shock and patients who are hypertensive prior to injury may have a normal blood pressure when they are when they are actually in shock now we need to investigate that chief complaint we need the considerations in our assessment of the patient's condition and stability may include past medical conditions even if you're not currently or those are not currently an acute or symptomatic for those conditions",
        "Secondary Trauma Assessment": "our secondary assessment so physical exams should be performed on a geriatric trauma patient in the same manner as we would for an adult but we need to consider the likelihood of damage from trauma okay so any head injury can be life-threatening and when examining the chest we need to consider that breathing may be impaired we also need to look for bruising and other evidence of trauma we need to assess pulse blood pressure and vital signs cap refill again is unreliable in older adults because of the compromised circulation and remember that older people take beta blockers which will inhibit their heart rate from becoming too high to cart tachycardia as you would expect in shock",
        "Reassessment of Trauma Patients": "and then repeat the primary assessment a geriatric patient has a higher likelihood of decompensating after trauma broken bones are common and should be splinted in the manner appropriately for the injury and just do not force kyphosis into the normal position we want to also provide blankets and heat to prevent hypothermia we need to provide psychological support as well as medical treatment and document assessment treatment and reassessment including any changes in the patient's status",
        "Response to Nursing and Skilled Care Facilities": "okay so let's talk about response to nursing and skilled facilities any calls will occur at a nursing home or skilled facility calls to these types of facilities can sometimes be challenging patients als often have an altar level of consciousness and may not be able to give you a nature of illness or mechanism of injury the most important piece of information you need to establish is what's wrong with the patient and what is different today that made you call 9-1-1 so talk to the staff who directly care for the patient on a daily basis",
        "Infection Control in Facilities": "infection control needs to be a high priority for mts when we visit these facilities mrsa infections are common among older people who are living in close quarters such as nursing home the organism can be found in ulcers feeding tubes and on dwelling indwelling urinary catheters protect your self and reduce the spread of immerse infections you should wash your hands before and after every patient contact properly dispose of or disinfect all medical equipment and take appropriate standard precautions with every patient many infections in the hospitals are caused by vre okay vancomycin resistance the respiratory rsv causes an infection of the upper and lower respiratory tracts the virus is also highly contagious and is found in discharges from the nose throat of an effective person you need to wear appropriate ppe and decontaminate your ambulance and diagnostic equipment okay so c diff is a bacterium responsible for most common cause of hospital-acquired infectious diarrhea healthcare workers may carry this bacterium following contact with contaminated feces typical alcohol-based hand sanitizers do not inactivate or kill c-diff contact precautions with gowns and gloves and hand-washing with soap and water after each and every patient contact is essential to prevent transmission sars cov2 is a strain of coronavirus that causes covid19 a respiratory illness that may affect older more vulnerable people especially those with pre-existing medical conditions spread from person to person through airborne droplets created by speaking coughing and sneezing",
        "Dying Patients and Palliative Care": "next we're going to change the subject and talk about dying patients as older patients are living longer more terminally ill are choosing to die at home rather than in the hospital dying patients re receive what is called palliative or comfort care it focuses on relieving just pain and providing emotional support and comfort for the patient and his or her loved ones your interaction with a dying patient will have a long-term effect on the family so be understanding sensitive and compassionate",
        "Advance Directives": "advance directives are specific legal papers that direct relatives and caregivers about what kind of medical treatment may be given to patients who cannot speak for themselves advanced directives may take the form of a do not resuscitate order or dnr a dnr gives you permission to not attempt to resuscitate the patient from cardiac arrest for a dni order to be valid the form must be signed by the patient and legal surrogate and by one or more physicians or licensed health care providers dnr does not mean do not treat if a patient is still alive you're obligated to provide supportive measures that may include oxygen pain relief and comfort a healthcare power of attorney is an advanced directive that is exercised by the person who has been authorized by the patient to make medical decisions for him or her another type of order is a p-o-l-s-t so pulsed physician orders for sustaining treatment which gives medical orders in addition to advance directives orders may be specific to the person who has that life-threatening condition or is in frail health if there is any question regarding orders or when there are no orders written you need to initiate resuscitation",
        "Elder Abuse and Neglect": "okay so next let's talk about elder abuse and neglect elder abuse is defined as any action on the part of an older person family member caregiver or other associated person that takes advantage of an older person property or emotional state abuse can result from acts of commission and this is words or actions that cause harm such as verbal physical or sexual assault abuse can also result from acts of omission and that's a failure to act okay so such as denying an older person adequate nutrition or medical care elder abuse is a problem that has largely been hidden from society the definitions of abuse and neglect among the geriatric population vary victims of elder abuse are often hesitant to report the problems that law enforcement agencies or human or and social welfare personnel victims of elder abuse are often hesitant because the abused person may feel traumatized by the situation or be afraid that the abuser will punish him or her the abused person is often frail and multiple chronic medical conditions or dementia elder abuse occurs most often in women older than 75 abusers of older persons are sometimes products of child abuse themselves and the abuse is inflicted on the older person may be retaliatory most of these abusers are not trained in a particular care of older persons in environments such as nursing convalescence and continuing care centers are also sites where older people sustain physical physiological financial and pharmacological harm so assessment of an elderly abuse so be suspicious of the abuse when answers to questions about the cause of injury are concealed or avoided suspect abuse when you're not given unbelievable when you are given unbelievable answers so information that may be important in assessing possible abuse includes caregiver apathy about the patient's condition or overly defensive reaction by the caregiver to your questions or the caregiver does not allow the patient to answer or repeated visits to emergency department a history of being accident prone soft tissue injuries or unbelievable vague or inconsistent explanation of injuries so chronic pain without medical explanation self-destructive behavior eating and sleep disorders depression or lack of energy substance or sexual abuse history many patients who are being abused are so afraid of retribution that they make false statements okay so these are some categories of elderly abuse",
        "Signs of Physical Abuse": "signs of physical abuse are in um inflicted bruises can usually be found on buttocks or lower back genitals or inner thighs cheeks or ear lobes neck upper lip or inside of the mouth pressure bruises caused by a human hand may be identified by an oval grab mark pinch marks or hand prints human bites are typically inflicted on the upper extremities and can cause lacerations and infections so you want to expect the patient's earlobes for indications of twisting pulling or pinching and investigate multiple bruises in various states or the appearance of being undernourished okay typical abuse and burns are caused by contact with cigarettes matches heated metal forced immersion in hot liquids chemicals and electrical power sources check for signs of neglect such as evidence of lack of hygiene poor dental hygiene poor temperature regulation or lack of reasonable amenities in the home regard injuries to the genitals or rectum with no reported trauma and evidence of sexual abuse in any patient okay so that brings us to the conclusion of the lecture of chapter 36 and geriatric emergencies and now we're just going to go through the review questions to see what we've learned okay the least common cause of death in patients over 65 is what and it's d so uh drug overdose according to the gems diamond the person's activities of daily living are evaluated during which one of those and we know that it is b limits is the social assessment condition that clouds the lens of the eyes is called we know that's called a cataract okay you're called to a neatly kept resident of an 80 year old woman who lives by herself she burned her hand on the stove and experienced a full thickness burn when we treat the patients it's important to note what are we looking for we're looking for the d so that's that slowing of reflexes and it causes delays and pain okay the slow onset of progressive disorientation shortened attention span and loss of cognitive function is and we know that's dementia okay 71 year old man with a history of high blood pressure and vascular disease presents with tearing abdominal pain oh my goodness okay heart rate blood pressure is low heart rate's high respirations are high your assessment reveals his abdomen is rigid and distended we want to consider uh what are we looking for and i think that that's an aortic aneurysm right yes absolutely so that it's that tearing abdominal pain that gives that away okay which of the following is a physiologic sign that occurs during the aging process all right so what do we got we know that that is a decline in kidney function which of the following conditions makes the elderly patient prone to fractures from even minor trauma we know that's osteoporosis right osteoporosis yes polypharmacy is a term often describe patients who takes and we know that that's multiple meds right multiple meds poly is multi-pharmacy medicines okay inflicted bruisings are commonly found in all of the following areas except um so uh inflicted bruisings are usually not found on the forearms they're they're hidden areas okay so that concludes the chapter 36 geriatric emergencies lecture um thank you for joining us today"
    },
    {
        "Introduction": "hello and welcome to chapter 19 gastrointestinal and neurologic emergencies of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will understand the anatomy and physiology of gastrointestinal and renal systems you should be able to assess and manage various patient populations with numerous related gastrointestinal complaints which include but are not limited to direct or referred abdominal pain hypoglycemia hyperglycemia shock related to acute which is medical versus trauma or chronic gastrointestinal disorders hemorrhage peritonitis and complications related to the renal system such as renal dialysis so let's get started abdominal pain is a common complaint the",
        "Introduction Continued": "cause of abdominal pain is often difficult to identify as an emt you don't do not need to determine the exact cause of the abdominal pain you should be able to recognize life-threatening problems and act swiftly in response the patient in pain is probably anxious requiring application of your skills of rapid assessment and emotional support",
        "Anatomy and Physiology": "so let's talk about the anatomy and physiology so you have the abdominal cavity\nand this contains solid and hollow organs that make up three separate systems you have the gastrointestinal system you have the genital system and you have the urinary system injury to a solid organ can cause shock and bleeding if perforation of a hollow organ occurs that the contents will leak and contaminate the abdominal cavity so on this slide is an illustration and on the left it shows the hollow organs and the illustration on the right shows the solid organs of the abdomen",
        "The Gastrointestinal System": "okay so the gastrointestinal system it's responsible for digestion process digestion begins when the food is put into the mouth and chewed and the stomach is the main organ of the digestive system it breaks down gastric juices the liver assists with digestion it secretes bile filters toxic substances that produce by digestion creates glucose stores and produces substances necessary for blood clotting and immune function then you have the gallbladder and that is the reservoir for bile food then travels to the small intestines which consists of three sections you have the duodenum and digestive juices from the pancreas and liver mixed together there and the pancreas secretes enzymes that break down starches fats and proteins have the jejunum it plays a major role in absorption of digestive products it does uh much of the work of the small intestines then you have the ilium it absorbs nutrients that were not absorbed earlier and it absorbs bile acids so that they can be returned to the liver for for future use such as vitamin b for making nerve cells and red blood cells next is the colon which is the large intestines and food not broken down and used moves into the colon as a waste product water is absorbed and stool is formed okay so the spleen the spleen is located in the abdomen but has no digestive function",
        "The Genital System": "all right so the next system we're going to talk about is the genital system and the abdominal space also holds reproductive organs so for the male reproductive system you have the testicles the epididymis the vas differentia the seminal vesicles prostate gland and the penis and then for the female reproduction the reproductive system you have the ovaries fallopian tubes the uterus cervix and the vagina",
        "The Urinary System": "next you have the urinary system and this controls discharge of certain waste filtered by blood by the kidneys okay from the blood the kidneys are solid organs and the ureters bladder and urethra are hollow organs there are two kidneys one on each side the ureters join each kidney to the bladder the urinary bladder is located immediately behind the pubic symphysis and the bladder empties to the outside of the body through the urethra normal adults form 1.5 to 2 liters of urine per day the illustration on this slide displays the male urinary system let's talk about the pathophysiology",
        "Pathophysiology": "the abdominal cavity is lined by a membrane called the peritoneum the peritoneum also covers the organs of the abdomen you have the parental peritoneum this lines the walls of the abdominal cavity then you have the visceral peritoneum and it covers the organs the presence of any foreign material such as blood pus bile pancreatic juice or amniotic fluid can irritate the peritoneum and this causes peritonitis acute abdomen refers to the sudden onset of abdominal pain it's often associated with a progressive problem requiring medical condition\nand then peritonitis it can cause ileas which is paralysis of muscular contractions that normally propel material through the intestines such as retain gas and feces and it causes distension and stomach empties by emesis then you can have diverticulitis and this is an inflammation of the small pockets at weak areas in the muscle walls and then you have cholecystitis that's gallbladder inflammation and then acute appendicitis",
        "Abdominal Pain": "so abdominal pain there are two different types of nerves which supply the peritoneum you have the parented parental peritoneum and this is supplied by the same nerves that supply the skin of the abdomen so it can be easily identified and localized a point of irritation then you have the visceral peritoneum and is supplied by the autonomic nervous system the nerves are less able to identify and localize the pain and then there's also referred pain the results from the connection point between the body's two separate nervous systems",
        "Causes of Acute Abdomen": "common causes of acute abdomen include ulcers and that's when the protective layer of the mucous lining erodes allowing acid to eat into the organ common causes are most peptic ulcers are caused by an infection in the stomach chronic use of inflammatory drugs such as nsaids and signs and symptoms include gnawing pain in the stomach or nausea vomiting belching and heartburn so complications include hemosis molena or periotonitis you could also have gall stones and it may form this is a form and block the outlet from the gallbladder so if the blockage is not relieved inflammation of the gallbladder can occur so signs and symptoms include constant severe pain in the right upper or mid abdominal region that may refer to the right upper back shoulder area or flank nausea vomiting indigestion bloating gas and belching are common symptoms you have pancreatitis common causes of include an obstructing gallstone or alcohol abuse signs and symptoms are severe pain in the upper left and right quadrants that can irritate or radiate to the back nausea vomiting abdominal distension and tenderness and complications include sepsis and hemorrhage then there's appendicitis and this is an inflammation or infection in the appendix signs and symptoms occur uh include initial pain that is generalized dull and diffuse which may center in the abdomen umbilical area pain later radiates to the right lower quadrant it may have referred pain and nausea vomiting and aurexia fever and chills you could also have rebound tenderness some complications include you could have abscesses peritonitis or shock now gastrointestinal hemorrhage so symptoms of another disease it's not the disease itself it may be acute or chronic it can occur in upper and lower gi tract so common occurrences so the upper gi tract it could be um esophageal varices or a mallory wise tear and the lower gi could be inflammation diverticulitis cancer and hemorrhage or hemorrhoids signs and symptoms of the upper gi tract includes vomiting blood the lower gi tract is bright red stools let's talk about esophagitis and this occurs when the lining of the esophagus becomes inflamed by infections or acids from the stomach now esophageal reflex disease which is gerd um and then signs and symptoms are pain with swallowing and feeling like there's something stuck in the back your throat you could have heartburn nausea vomiting and sores in the mouth then there's esophageal varices okay so the amount of pressure within the blood vessels surrounding the esophagus increases and it's frequently as a result of liver failure common causes include alcohol in industrialized countries and viral hepatitis in developing countries with a gradual disease process patients will initially show signs of liver disease rupture of the varices is far more sudden so you'll have signs and symptoms it's a sudden onset of discomfort in the esophagus difficulty swallowing or vomiting of bright red blood hypotension and signs of shock and complications are of course that significant amount of blood loss then there's the mallory y syndrome and this is the junction between which the esophage the esophagus and the stomach when it tears so common causes include violent coughing or vomiting and signs and symptoms are shock upper abdominal pain hemiamsis and molina gastroenteritis and this is an infection combined with diarrhea nausea and vomiting it can also be caused by non-infectious conditions signs and symptoms are diarrhea with or without pus abdominal cramping nausea vomiting fever anorexia and complications include dehydration and shock then diverticulitis so diverticulitis due to the lack of fiber in the diet it causes the consistency of stools to become more solid this is requires more intestinal contractions and it causes pressure on the colon you'll have bulges in the walls which result in increased intestinal contractions and fecal matter becomes caught in those bulges allowing bacteria to collect and resulting in inflammation and infection so signs and symptoms include abdominal pain localized more to the left lower quadrant complications include perforation of the intestinal walls leading to severe infection and shock okay next we're going to talk about is hemorrhoids and they are created by swelling and inflammation in the blood vessels surrounding the rectum common causes are conditions that increase pressure in the rectum or irritation of the rectum signs and symptoms are painless bright red bleeding during defecation okay so let's talk about urinary systems you have cystitis which is a back a bladder inflammation it's caused by urinary tract uti common cause is bacterial infection signs and symptoms include midline lower abdominal pain blood in the urine and urgency and frequency in urination pressure and pain around the bladder and complications include kidney infections",
        "Kidneys": "so then let let's talk about the kidneys they play a major role in maintaining homeostasis so when the kidneys fail uremia results kidney stones can grow over time and they can cause blockages so acute kidney failure is a sudden decrease in function and the causes of the common causes are some type of hemorrhage dehydration trauma shock sepsis heart failure medications drug abuse and kidney stones it can be reversible with prompt diagnosis and treatment then you have a chronic kidney failure and this is a progressive and irreversible damage common causes are diabetes and hypertension signs and symptoms are lethargy nausea headaches cramps anemia in the extremities and phase seizures and coma will eventually require treatment with dialysis these patients have an increased risk of heart failure and cardiac arrest",
        "Female Reproductive Organs": "so next let's talk about the female reproductive organs gynecologic problems are a common cause of acute abdominal pain lower quadrant pain may relate to the ovaries fallopian tubes or uterus so chapter 23 gynecologic emergencies covers those emergencies in depth",
        "Other Organ Systems": "and then there's other organs the aorta lies immediately beyond behind the peritoneum so weak areas can result in abdominal aortic aneurysm or aaa a triple a is difficult to detect back pain with a tearing sensation use extreme caution when trying to assess or detect a triple a if the aneurysm tears or ruptures massive hemorrhage may occur and then there's the hernia so this is a protrusion on the organ or tissue through a hole or opening into the body cavity where it does not belong common causes are congenital defects or a surgical wound that has failed to hear heal and or a natural weakness in the area such as the groin hernias may not always produce a noticeable mass or lump reducible hernias pose little risk and can be pushed back into the abdominal cavity strangulation of the um of the hernia is a serious medical injury though and this is when blood supply is compromised by the compressed surrounding tissues serious hernia signs and symptoms include a formally reduced mass that is no longer no longer reducible so pain at the hernia site or tenderness when the hernia is palpated red or blue skin discoloration over the hernia",
        "Scene Size-up": "okay so let's talk about the patient assessment aspect of these emergencies so patient assessment you have the scene size up and of course standard precautions you're going to do the mechanism of injury or the nature of illness so with an acute abdomen it can be the result of violence such as a blunt or penetrating trauma so you use assessment results to develop an early index of suspicion for life threats",
        "Primary Assessment": "next of course is our primary assessment and the first priority is to identify and treat life-threatening conditions so we're going to form our general impression of course the a b c and d's are next so airway and breathing may present with shallow or inadequate respirations because of pain and then circulation we want to assess for major bleeding ask the patient about blood or vomit or black tarry stools okay so pulse rate quality and skin condition may indicate shock and check pulses in both feet a difference in pulse rate strength may indicate an aortic dissection okay so transport decision immediate transport is warranted if there's any signs and signs of significant illness okay the next of course we're going to",
        "History Taking": "get that history taking history of the patient is the sample history and that includes we're also going to ask about nausea and vomiting changes in bowel habits urination weight loss or belching pain or other signs and symptoms or concurrent chest pain",
        "Secondary Assessment": "and then we're going to do that secondary assessment so we're going to the positioning of the patient may give clues to the nature of illness okay so that physical exam the normal abdomen is soft and not tender to the touch so pain and tenderness are most common symptoms of acute abdomen it can be localized and that may give clues to the problem organ or muscles of the abdominal wall may be rigid involuntary which is called guarding then we're going to do the vital signs a high respiratory rate with a normal pulse rate and blood pressure may indicate improper ventilations a high respiratory rate and pulse rate with signs of shock may indicate septic or hypovolemic shock and if a patient has a dialysis shunt in his or her arm avoid taking a blood pressure in that arm as the shunt may be may be damaged",
        "Reassessment": "okay then we're going to do the reassessment because it is often difficult to determine the cause of abdominal pain frequent reassessments are important so assess interventions including treatment for shock and provide emotional support and transport in the most comfortable position for the patient consider advanced life support and communication and documentation",
        "Emergency Medical Care": "so with when it comes to the emergency care aspect for these patients although you cannot treat the causes of the abdominal pain you can take steps to provide comfort and lessen the effects of the shock so treat the patient for shock even when obvious signs of shock are not apparent position the patient who are vomiting to maintain their airway and so contain the vomit to to prevent a spread of infectious diseases such as using a biohazard bag wear gloves eye protections and gown and a mask and when the patient has been released to hospital staff clean the ambulance and equipment wash your hands even though you were wearing gloves and provide low flow oxygen it may decrease the nausea and anxiety",
        "Dialysis Emergencies": "so when it comes to dialysis emergencies in patients with end-stage renal disease or chronic renal failure dialysis is the only definitive treatment and what happens is dialysis filters the blood cleanses it of all toxins and returns it to the body if a patient misses this treatment weakness and pulmonary edema can be the first in a series of conditions that become progressively more serious in some services transport patients to and from the dialysis centers a dialysis machine functions much like the normal kidneys do and so a patient undergoing long-term hemodialysis they have a shunt that connects the vein in the artery this allows blood flow from the body to the dialysis machine peritoneal dialysis allows large amounts of dialysis fluid to be infused into the abdominal cavity the fluid stays in the cavity for about one to two hours and it carries a high risk of peritonitis adverse effects of dialysis include hypotension dysrhythmias chest pain muscle cramps nausea and vomiting and hemorrhage from the access site there could also become an infection at that access site so management of a dialysis patient includes you want to start with the abcs provide high flow oxygen if indicated manage any bleeding from the access site position the patient sitting up in case of pulmonary edema or supine if the patient is in shock and then we want to transport them properly promptly some dialysis patients also have urinary catheters and this catheter can often be the site of the infection okay so that concludes chapter 19 gastrointestinal emergencies and next we're going to go over and to see what we've learned",
        "Review": "okay so let's see the blank lies in the retroperitoneal space and we know it is the what do we think it's the pancreas kidneys and ovaries those are all in the space behind that peritoneum which of the following is not a solid organ okay i think it's the kidneys oh it's the gallbladder and um okay the gallbladder a 34 year old woman with a recent history of pelvic inflammatory disease presents with this acute severe abdominal pain her abdomen is distended and diffusely tender to palpate based on your findings thus far you should suspect it's peritonitis yep which is an inflammation in that membrane that lines the abdominal cavity most patients with an acute abdomen present with tachycardia so a heart rate above 100 which of the following signs and symptoms would you be least likely to find within a patient with acute abdomen least likely i think it's non soft non-distended abdomen yep so usually they're gonna have some pain right okay from guarding maybe hard okay a common condition and persons experiencing a lapa a lack of appetite is called and that's anorexia a medical term for inflammation in the urinary bladder do you guys remember what that is and that's cystitis the hernia is so greatly compressed that the circulation is compressed the hernia said to be strangulated strangulated a 70 year old man presents with an acute onset of severe tearing abdominal pain that radiates to his back his blood pressure is low heart rate's high and respirations are high treatment of this patient includes i would think rapid transport to the hospital because we're suspecting a triple-a right yes when you see tearing abdominal pain that radiates to the back yes typical signs of a aaa in which position do most patients with acute abdominal pain prefer to be transported what do you think and i think it's on their side with their leg their knees flexed kind of drawn up in the fetal position okay thank you for joining me for chapter 19 those gastrointestinal emergencies if you like this chapter go ahead and subscribe because we're going to complete the rest of the book soon"
    },
    {
        "Introduction": "hello and welcome to chapter 22 toxicology lecture from the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will be familiar with the classes of compounds involved in substance abuse and poisoning the rats by which poisons enter the body and the sign symptoms and assessment and treatment for various poisoning emergencies so let's get started every day we come into contact with things that are potentially poisonous acute poisonings affect over 2 million people each year so acute meaning a sudden onset of or chronic poisonings they are more common so a longer term poisoning and we'll talk about this yes caused by poisonings are fairly rare and deaths rates of deaths as a result of poisonings in children have decreased steadily since the 1960s due to child resistant caps and deaths caused by chronic poisoning in adults have been rising as a result of drug abuse okay so what is toxicology toxicology is the study of toxic or poisonous substances a poison is any substance whose chemical action can damage body structures or impair body function a toxin specifically is a poisonous substance produced by a bacteria animals or plants that acts by changing the nat the normal metabolism of cells or destroying them and toxins can have acute so fast or chronic slower effects substance abuse is the misuse of any substance that prod to produce a desired effect so a common complication of substance abuse is overdosing and that's when the patient takes a toxic dose of a substance your primary responsibility to the patient who has been poisoned is to recognize that a poisoning has occurred so for your own safety you must pay attention to your surroundings or you could become exposed to the same substance very small amounts of some poisons can cause considerable damage or death if you suspect that ingestion or exposure to a toxic substance has occurred you need to notify your medical control and begin emergency treatment at once the signs and symptoms of poisoning vary according to the specific agent so the table on this slide shows the signs and symptoms of specific types of overdoses okay and we're going to talk about them throughout this lecture so if possible while obtaining the sample history ask the patient what substance did they take when did they take it how much did they ingest did you have anything to eat or drink before or after you took it has anyone given you an antidote or substance orally since you've ingested it and how much do you weigh and we'll talk about the reasons why you ask those questions okay try to determine the nature of the poison so you want to look around the immediate area for any overturned bottles maybe a syringe or scattered pills chemicals or remains of food or drink items or even an overturned turned or damaged plant so take any suspicious material with you to the emergency department containers at the scene can provide critical information such as the name and concentration of the drug ingredients the number of pills originally in the bottle in the name of the manufacturer or this prescribed dose if the patient vomits examine the contents for pill fragments and note and document anything unusual that you see how you provide treatment depends on how the poison got into the patient's body in the first place so let's talk about how the poisons get into the body and there are four main routes okay so there's inhalation absorption and that's the surface contact you could have ingestion or injection all four routes of poisonings can lead to life-threatening conditions the figure on this slide shows the four routes of poison and how they can enter the body okay so inhalation absorption ingestion and injection so let's break those down okay so first is the inhaled poisons and they move the patient what you want to do is move the patient into fresh air immediately the patient may require supplemental oxygen and if you suspect the presence of a toxic gas please call for spread specialized resources such as the hazmat team okay some patients may need decontamination by the hazmat team after removal from the toxic environment all patients who have inhaled poison require immediate transport to the emergency department be prepared to use supplemental oxygen via a non-rebreather mask or ventilatory support with a bag valve mask if necessary so make sure a suction unit is also available in case the patient vomits some patients use inhaled poisons to commit suicide in a vehicle so what happens is they leave a car engine running in an enclosed garage and it can cause the exhaust fumes which contain high levels of carbon monoxide to cause the patient to lose consciousness and eventually stop breathing all right so next we're going to talk about absorbed or surface contact poisons okay so this is the next route um they can affect the patient in many ways so a skin mucous membrane or eye damage chemical burns rashes or lesions or systemic effect okay it's important to to distinguish between a contact burn and a contact absorption signs and symptoms of absorbed poisonings include a history of exposure liquid or powder on the patient's skin burning itching irritation redness of the skin or a typical odor of some type of substance okay emergency treatment for a topical contact poisoning include you want to avoid contaminating yourself or others and while protecting yourself you want to remove the substance from the patient as rapidly as possible and also remove all contaminated clothing and flush and wash the skin if it's dry powder and it's spilled the first thing you want to do is brush off the powder then flood the area with water for 15 to 20 minutes then wash the skin with soap and water okay if liquid has been skilled uh spilled onto the skin flood for 15 to 20 minutes if a chemical agent is introduced into the eyes you need to irrigate them quickly and thoroughly many chemical burns occur in an industrial setting safety showers and specific protocols for handling surface burns may be available so a hazmat team should be available to assist you ensure you your team members and the exposed patient are thoroughly decontaminated after decontamination promptly transport to the emergency department for definitive care you also want to obtain a material safety data sheet on the chemical that was spilled all right so now we're into ingested poisons so the third type of way that it could get to the body is ingested about 80 of poisonings are by mouth okay so the highest concentration they could be liquids household cleaners contaminated food plants or drugs ingested poisoning is usually accidental in children and deliberate in adults so signs and symptoms are going to vary greatly because of the it could the type of poison the age of the patient and the time that's passed since that ingestion okay signs and symptoms include burns around the mouth gi pain vomiting you can have cardiac dysrhythmias and seizures treat the signs and symptoms and notify poison control and medical control of the patient's condition if the patient has an altered mental status protect the patient from aspirating on vomit and consider whether there is an unabsorbed poison remaining in the gi tract and whether you can safely and effectively prevent that absorption okay and this is how so activated charcoal it comes in this premix suspension and some ems systems allow the emts to administer activated charcoal you should always immediately assess the abcs of every patient who has been poisoned okay and next the fourth way is injected so injected poisons exposure by injection includes iv or intravenous drug abuse and envenomation by insects arachnoids and reptiles so injected poisons are usually absorbed very quickly into the body or cause intense tissue destruction okay they cannot be diluted or removed from the body in the field signs and symptoms of this injected poisons are include weakness dizziness fever chills unresponsiveness or excitability you want to monitor the airway provide high flow oxygen and be alert for nausea and vomiting you want to remove any rings or watches or bracelets from the area around the injection site because if swelling occurs it could cut off the circulation okay",
        "Scene Size-up": "so now that we've covered those uh four routes let's do the patient assessment talk about our patient assessment of these toxins okay so scene size up of course always first thing standard precautions and you're looking for clues that might indicate that substance involved is there an odor in the room if so is the scene safe right so are the medication bottles laying around the patient on the scene if so is there a medication missing that might indicate an overdose say for example the patient got there some type of of opiate filled yesterday and all the pills are missing from the bottle right so or are there alcoholic beverage containers around the patient are there syringes or other drug paraphernalia on scene and is there a suspicious odor or drug paleophonia present that may indicate the presence of some type of dry drug laboratory keep a constant eye on the surroundings and keep an open mind when questioning the patient or bystanders to avoid mistaken conclusions okay next is the primary assessment so determine the severity of the patient's condition so you want to obtain that general impression assess his or her level of consciousness determine any life threats do not assume a conscious alert and oriented patient is in stable condition next is the abc and d so the airway and breathing so you need to quickly ensure that the patient has an open airway and adequate ventilation if the patient has any difficulty breathing begin oxygen therapy and consider inserting an airway adjunct in unresponsive patients have suction available these patients are susceptible to vomiting okay so circulation you need to assess the pulse and skin condition and you will find variations depending on the substance involved okay and then your d of the abcd and that's your transport decision you want to consider prompt transport for patients with obvious alterations to the abcs or for patients who you've determined have a poor general impression okay everyone who is exposed to hazardous material must be thoroughly deconned by the hazmat team before arriving on scene",
        "History Taking": "next is that history taking so moving right down your patient assessment form if you're following along so history taking you want to investigate that chief complaint so if your patient's responsive begin um by the evaluation of the exposure and the sample history um and if your patient is unresponsive attempt to obtain history from other sources the sample history in addition to that sample history ask some questions okay so what substance is involved when did the patient ingest or become exposed to the substance how much did the patient ingest or what was the level of exposure over what period did the patient take or was exposed to the substance and was a patient or a bystander performed any intervention and has the intervention helped and how much does the patient weigh okay",
        "Secondary Assessment": "next is that secondary assessment so you may not have the time to conduct that on scene um or you could you might not have the time to do it in route however if you do physical examinations focus on the area of the body involved with that poison or the route of exposure in general review all of the body systems may not help or may help to identify systemic problems okay a complete set of baseline vitals is important of course and alterations in that level of consciousness pulse respirations blood pressure and skin are the more sensitive indicators that something serious is wrong and then of course your reassessment so continually reassess the adequacy of the patient's abcs repeat vital signs and compare them to that baseline set that you've received and then evaluate the effectiveness of the inventor the interventions that we've performed right and we know that we're going to for every 15 minutes we're going to do the vital signs for a stable patient for an unstable patient or for a patient who has consumed a harmful or lethal dose of something we want to consistently take vital signs every five minutes okay and then the treatment so we're going to support the abcs that's the most important task we're going to contact medical control or a poison center to discuss treatment options manage airborne exposures with oxygen and remove the contact exposures with copious amounts of water or unless it's contraindicated of course and consider activated charcoal for ingested poisons okay and then of course we're going to communication and documentation so we're going to try and report as much information as we have about the poison or chemical to that hospital and if the poison poisoning or exposure occurred in a work setting we want to bring the material data safety sheet to the hospital okay",
        "Emergency Medical Care": "emergency care of course we're going to do the scene secure follow our standard precautions we're going to perform that external decon we want to remove tablets or fragments from the patient's mouth and wash or brush the poisons from the patient's skin and then treatment will focus on support assess and maintain the abcs provide oxygen and perform assistant assisted ventilations if we need to and then of course treat for shock if necessary and transport promptly some ems systems allow emts to give activated charcoal we mentioned that earlier and so what activated charcoal is going to do is it binds to specific toxins and prevents the absorption in the body the toxins are then carried out of the body in the stool activated charcoal is not indicated for certain patients though and so these patients are ones that have ingested some type of alkali poison cyanide ethanol iron lithium methanol mineral acids or organic solvents you cannot use activated charcoal for those also patients who have a decreased level of consciousness they will not be able to perfect protect their own airway so we can't give them anything to drink okay if local protocol permits you will likely carry plastic bottles of this pre-mixed suspension what and it contains 50 grams of activated charcoal the usual dose for an adult or child is one gram of activated charcoal per kilogram of body weight before you give this uh patient-activated charcoal we have to call medical control and obtain per approval okay then you're going to shake that bottle vigorously to mix the suspension you may need to convince the patient to drink it but never force them and then you want to record the time when you administered that activated charcoal if the patient refuses to drink the activated charcoal document the refusal and your attempts to counsel the patient and transport the patient for further evaluation now some of the side effects of activated charcoal are constipation and black stools if the patient has ingested a poison that causes nausea he or she may vomit after taking the activated charcoal and the dose will have to be repeated okay",
        "Specific Poisons": "so now let's talk about specific poisons okay so over time a person who routinely misuses a substance may need increasing amounts to achieve the same result so this is called developing a tolerance for that substance so a person with an addiction has an overwhelming desire to need to continue using that substance at whatever cost with a tendency to increase the dose almost any substance can be abused the importance of safety awareness and standard precautions for caring for patients of drug abuse cannot be overemphasized known drug abusers have a fairly high incidence of serious and undiagnosed infections including hiv and hepatitis expect the unexpected and remember the drug user not the drug can pose the greatest threat so let's talk about these different drugs so alcohol many calls for service have a connection to alcohol use",
        "Alcohol": "alcohol can damage the liver whether through chronic overuse or occasional heavy use we can call this binge drinking now binge use can be more damaging than chronic use and it's depending on the frequency of the binging and the surrounding circumstances alcohol is a powerful central nervous system depressant it is a sedative and a hypnotic in general alcohol dulls the sense of awareness slows reflexes and reduces reaction time it may also cause aggressive and inappropriate behavior and lack of coordination so a person who appears intoxicated may have other medical problems as well so don't forget that so look for signs of head trauma mental illness toxic reactions or uncontrolled diabetes do a bgl blood sugar check okay severe acute alcohol ingestion may cause hypoglycemia so they could go hand in hand alcohol increases the effects of other drugs and is commonly taken with other substances as well if a patient exhibits signs of serious central nervous system depression provide respiratory support if needed depression of the respiratory system can also cause emesis or vomiting okay so patients in alcohol withdrawal may experience frightening hallucinations or delirium tremens and those are those are known as dts delirium tremens okay so dts are characterized delirium tremors are characterized by agitation restlessness fever sweating tremors confusion delusions or even seizures these conditions may develop after a person stops drinking or when alcohol consumption levels are decreased suddenly and what you need to do is you need to provide transport and reassure the patient and provide necessary care and emotional support so withdrawal from alcohol can be just as dangerous as too much alcohol okay we talked about alcohol now let's talk about opiates okay so opiates are and the necrotic narcotic um and it's a drug that produces sleep and altered mental consciousness okay an opiate is a type of narcotic medication used to relieve pain an opiate is a subset of the opiate opioid family and refers to it could either be natural or non-synthetic opiates okay so prescription opiate drugs are among the most commonly abused drugs right now in the united states some people become physically dependent on opioids after taking an approx appropriate medical prescription and then they get they get physically dependent on them okay so it's a named after opium in the poppy seeds from which copedine and morphine are derived okay so um on this slide you're going to see the common opioids or opiates okay 22-2 table prescription opioid drugs are the most commonly abused like i said and these are usually formed by that physical dependence after you are given a medical prescription okay these agents are central nervous system depressants and can cause severe respiratory depression and then of course when you're not breathing you go into cardiac arrest if it's not treated and so what happens is tolerance develops quickly some users may require more doses up to massive doses to experience the same high these drugs often cause nausea and vomiting and may lead to a development of hypotension low blood sugar or low blood pressure although seizures are uncommon they can occur patients appear typically sedated or unconscious and cyanotic with pinpoint pupils so narcan narcan or naloxone is what reverses the effects of opiate or opioid overdoses and they can be given narcan can be given intravenously intramuscularly or intranasally in many ems systems emts administer narcan or naloxone by the i n route so intranasally and it should be used when the patient has agonal respirations or is apneic okay so so when we use narcan is only because of decreased respirations respiration depression as a result of opioids okay in some area lay people are permitted to administer naloxone and find out from bystanders if that patient was given it prior to your arrival next we're going to talk about sedative hypnotic drugs and these drugs are barbiturates or benzodiazepines and they're easily obtained and relatively cheap these drugs are essential nervous system depressants and alter the level of consciousness with similar effects of alcohol the patient may appear drowsy peaceful or intoxicated in general these agents are taken by mouth so orally and occasionally the capsules or and suspensions or dissolved in water or even ejected so iv sedative hypnotic drugs quickly induced tolerance and so the pain the person will require increasingly larger doses these drugs may be given to people as knockout drugs or mickey finn to incapacitate them without their knowledge general generally your treatment is just to ensure the airway is is patent so assist ventilations and then we're going to provide prompt transport get him to the hospital okay so now we're going to move on we're in abused inhalants okay so these agents are inhaled instead of being ingested or injected some are far more common um it includes acetone or um or other inhilants some are found in glue cleaning compounds paint thinners or lacquers okay gasoline and various um hydrocarbons such as freon used uh in aerosols air solar sprays are also abused okay and these are commonly abused by teenagers effects of those inhalants range from mild drowsiness to coma and often cause seizures so hydrocarbon solvents can make the heart hypersensitive to a patient's own adrenaline so try to keep the patients from struggling with you or exerting themselves and use a stretcher to move that patient give them oxygen and transport the patient to the hospital",
        "Hydrogen Sulfide": "all right so hydrogen silified so this is a highly toxic odorless inflammable gas with a distinctive rotten egg odor so when you think of hydrogen sulfide think of that rotten egg odor it affects the organs but it is most impact on the lungs and lungs and central nervous system okay it's used to commit suicide and it's referred to as a chemical or um a detergent suicide okay so if you approach a enclosed vehicle with an unconscious patient inside be alert for warning signs as well as containers buckets or pots okay so if you suspect the presence of a toxic substance please you need to wait for that hazmat team to tell you that the scene is safe signs and symptoms includes nausea and vomiting confusion dypsnia a loss of consciousness seizures shock coma or cardiopulmonary arrest okay so once the patient has been deconned management is largely just supporting them you need to monitor and assist the patient's respiratory and cardiovascular functions and you want to provide rapid transport okay so now we're going to talk about another class and this is a central nervous system stimulant and it mimics the effects of that sympathetic nervous system and so we call them basically sympathy pathomimetic so it mimics the sympathetic nervous system okay they're frequently they frequently cause hypertension tachycardia and dilated pupils it's a stimulant and it produces an excited state so examples of these are amphetamines methamphetamines or designer drugs such as mdna which is also known as ecstasy or mali okay",
        "Sympathomimetics": "cocaine can be taken in a number of different ways and this is a sympathomimetic and it can be absorbed through mucous membranes or even across the skin so immediate effects include excitement and euphoria and lasts less than an hour when you smoke cocaine that's a crack and it produces the most rapid means of absorption and therefore it's the most potent effect okay acute overdose is a genuine emergency because the patients will have high risk of seizures cardiac dysrhythmias and stroke patients may be experiencing hallucinations or paranoia paranoia and placing you at risk so law enforcement officers should restrain the patient if necessary do not leave that patient unattended during transport and patients need prompt transport to the emergency department and give them supplemental oxygen and be ready to provide suctioning the next class we're going to talk about",
        "Synthetic Cathinones": "is the bath salts and this is a synthetic type drug it's an emerging class of drugs and it's similar to mdna it's sold as bath salts to escape the legal restrictions imposed by illicit drugs this uh type of drugs produce euphoria increased mental clarity and sexual hara arousal and basically most users of this drug snort it and the effects reportedly last as long as 48 hours adverse effects include teeth grinding or appetite loss muscle twitching lip smacking confusion gi conditions they could have paranoia headache elevated heart rates and hallucinations so keep the patient calm and transport and consider advanced life support assistance because some of these patients may require a chemical type of restraint to facilitate safe transport okay and then this is next one we're going to talk about is marijuana so marijuana is abused throughout the world it you'll see it written as thc and it's a chemical in the marijuana plant that produces the high inhaling marijuana smoke produces euphoria relaxation and drowsiness it impairs short-term memory and the capacity to do complex thinking and work the euphoria could progress to depression and confusion with very high doses patients may experience hallucinations or become very anxious or paranoid and marijuana is often used as a vehicle to get other drugs into the body okay several states have legalized the restriction recreational use of marijuana and others allow for medical use of marijuana and products that contain the thc edibles are baked goods or candies or other food additives that have been infused with marijuana ingestion can lead to cannabid hyperemesis syndrome and that's characterized by chronic marijuana use and extreme nausea and vomiting that is relieved only by a hot shower or bath synthetic marijuana or spice refers to a variety of herbal incense or smoking blends that resemble thc and produce a similar effect so powerful and unpredictable effects may result ranging from simple euphoria to complete loss of consciousness next class we're going to talk about is the hallucinogens okay so hallucinogens alter the person's sensory perceptions the classic hallucinogen is lsd or you'll hear it acid okay so these agents they cause visual hallucinations intensify vision and hearing generally separate the user from reality so the the patients experiencing a bad trip they could have hypertension tachycardia anxiety or paranoia care is the same as that for patient who has taken a sympathomimetic so we want to do the same things we want to use a calm professional manner provide emotional support we're not going to use restraints unless we have to and only if the patient is in danger okay we're going to watch the patient carefully throughout the transport and we're never going to leave them unattended and we're going to request advanced life support assistance when appropriate next we're going to need to talk about anti-chilergic agents okay so with anticholergic agents these are medicines that have properties that block the parasympathetic nerve the classic picture of a person who has taken too much anti-cholergic medicines is someone who is hot as a hair blind as a bat dry as a bone red as a beet and mad as a hatter okay and these common drugs are stuff like atropine benadryl gypsum weed or some type of elevil okay so it's often difficult to distinguish between anticholeric overdose and a sympathometic overdose but both groups of patients may be agitated and have a high heart rate and dilated pupils okay and then you have tricyclid antidepressants and they are significant anticleric effects so death from these agents can be rapid and the patient can go from appearing normal to a seizure and death within 30 minutes so we want to transport um these immediately and we need to consider calling advanced life support backup okay then you have the clergic agents so not an anticholergic you have a callergic",
        "Cholinergic Agents": "agent and what these do is they over stimulate the normal body functions that are usually controlled by that parasympathetic nerve and these clergic agents can include nerve gas and usually nerve gas is designed for chemical warfare and organophosphate insecticides okay so callergic overdoses are occasionally nerve gases or it could be some type of organophosphate insecticides okay so um the signs and symptoms of a callergic agent are very easy to remember and you could use a mnemonic called dumbbells okay so if you look at the slide you can see um dumbbells uh is the spells at the beginning of each of these words so diarrhea urination meiosis bradycardia emesis lacrimation and seizures we also use an acronym or mnemonic called sludge and this is one that i remember it's sludge m and it stands for salivation lacrimation urination defecation gastric upsets emesis and then muscle twitching okay so these are those cholergic agents and remember the anti-choleric agents do the exact opposite so anti-cholergic it would be you'd be dry instead of salivating right so um you would instead of urinating you'd be dry okay so it's like the exact opposite the most important consideration is to avoid exposure ourselves right so we want to decon that's the priority in many jurisdictions a hazmat team is going to provide that decon okay so just understand that prior to the call your priorities after decon are to decrease the secretions in the mouth and trachea and to provide airway support okay so there are antidote kits for callergic agents and the most common one is called a duode auto injector the kit consists of a single auto-injector and it contains um two separate medicines the it's called a duo so two medicines dote and it contains atropine and proloxidone okay so if a known exposure to nerve agents organophosphates with manifestation of signs and symptoms have occurred we want to use those uh antidote kits okay and often we might need to use them on ourselves",
        "Miscellaneous Drugs": "so miscellaneous drugs too and there are some um examples of some miscellaneous drugs and they're in classifications kind of by themselves and so there could be accidental or intentional overdose with cardiac medicines and just understand that car children may ingest them thinking that they're candy and older adults just may forget that they have taken it already and so they may take second doses of their meds that's pretty common signs and symptoms depend on the medication that has been ingested either way whatever it is we want to contact the poison center or poison control as soon as possible okay um and then aspirin that is a common one that is um ingested okay or poisoned so ingesting too much could result in nausea vomiting hyperventilation you could have ringing in your ears patients with this problem frequently have anxiety confusion tachypnea hyperthermia or danger they're in danger of having seizures okay overdosing with acetaminophen and medications that contain acetaminophen are also common its accidental acetaminophen overdose is a serious as an intentional overdose okay and then some alcohols that contain methyl or ethyl glyco glycol are often more toxic than um than drinking alcohol because both will cause severe tachypnea blindness it could cause renal failure or eventually death okay and one organism that produces direct effects of food poisoning is salmonella bacterium okay salmonella is characterized by severe gi symptoms within 72 hours of ingestion it causes nausea vomiting abdominal pain and diarrhea proper cooking will kill that bacteria and proper cleanliness in the kitchen will prevent the contamination of uncooked foods",
        "Food Poisoning": "the more common cause of food poisoning is the ingestion of a powerful toxins produced by bacteria it that's often in leftovers so the bacterium staphocalis is quick to grow in and produce toxins in food okay so foods left unrefrigerated are common vehicles they result in sudden gi symptoms which includes nausea vomiting and diarrhea and symptoms usually start within two hours after ingestion or it could take as long as 8 to 12 hours the most severe form of toxic ingestion is botulism botulism can result from eating improperly canned foods the spores of bacteria grow and produce a toxin the symptoms are neurologic and it include blurred blurring of vision weakness difficulty speaking and breathing it can be fatal and symptoms may develop within the first 24 hours of ingestion or as long as four days later in general do not try to determine the specific cause of that acute gi problem whether as much history or gather as much history as we can and from the patient and transport him or her promptly to the hospital when two or more persons in the group have the same illness you should take along some of the suspected food if you can and then poisonings there are plant poisonings so there are tens of thousands of cases of plant poisonings annually many household plants are poisonous if you ingest them some can cause local skin irritation and some can cause acute circulatory system or gi tract or central nervous system they could affect okay it's impossible to memorize so we can't memorize every plan or poison let alone their effects what we want to try and do is assess the patient's airway and vital signs notify poison control center for assistance in identifying the plant and then take the plant with you to the emergency department okay so the figure on this slide shows common poison plants all right and so those are different ones and you could see the names of those okay and the figure on this slide shows common poisonous plants different ones okay",
        "Review": "okay so that concludes chapter 22 toxicology lecture let's see what we've learned all right so which of the following questions is the least pertinent for an emt to ask a patient who is intentionally overdosed so we do want to know how much they weigh we would like to know how much they ingested and we would like to know what substance they take and why did you so why did you take the medicine i'm pretty sure that's the least important yep so the why okay a 30 year old male who ingested an unknown substance begins to vomit you should what are we looking for so do you want to collect the vomit and bring it to the hospital give a bag valve mask no we're not going to do that if somebody's vomiting analyze the vomit to try and identify the poison or suction the oral pharynx we know we're not doing that so what we want to do is look for pill fragments um so a so collect the vomit bring it to the hospital okay when caring for a patient with a surface contact poisoning what do we want to do what do we want to do okay so um we want the first thing we've got to do is avoid contaminating ourselves so we want to maybe do the other things but right away if you see avoiding contamination you know that that's what they're looking for okay most poisons occur via the and we know it's ingestion lots and lots eighty percent are ingestion how much activated charcoal should you administer to a 55 pound child who has swallowed a bottle of aspirin so right away um we know that charcoal is per kilogram so what we're going to do is we are going to um change this pounds to kilograms and we know that it is going to be about 25 so pounds is divided by uh 2.2 okay to turn into kilograms and so what we're going to do is 25 it's one gram per kilogram so it's about 25 grams okay and it'll show you in this uh in this basically breakdown so first you convert the patient's weight from pounds to kilograms and that's what we did we divided it by 2.2 so 55 pound child is basically 25 kilograms then it's one gram per kilogram and that's what we got so very good after taking vicodin for two years of chronic pain a 40 year old woman finds that her usual dose is no longer effective it goes to the doctor to try and request a high dose this is a example of and we know this is tolerance right she has dependence she probably has an addiction but we know it's tolerance so that build up over a long period of time which of the following effects does binge drinking not produce all right so i would think it's increased sense of awareness that's not really coming with binge drinking right all right so d increase sense of awareness a 21 year old male is found unconscious in an alley our initial assessment reveals that his respirations are slow and shallow and his pulse is slow and weak further assessment reveals his pupils are constricted so this most consistent with an opioid opioid pinpoint pupils reduce respiratory drive that's an opiate yep and he's going to need narcan the pneumonic dumbbells can be used to recall the signs and symptoms of that clergic drug and the ian dumb mel spell stands for and it's going to be emesis yeah so it's it's uh all things um vomiting lacrimating defecating irritating emesis right all right then finally food poisoning is almost always caused by eating foods that contain and we know it's going to be bacteria right bacteria so that's salmonella okay thank you for joining us tonight with toxicology lecture and if you like this lecture go ahead and subscribe to the channel because we're going to be perf we're going to be doing all the lectures in that 12th edition book thank you and have a good night"
    },
    {
        "Introduction to Obstetrics and Neonatal Care": "hello and welcome to chapter 35 Obstetrics and neonatal care of the emergency care and transportation of the second injured 12th edition if you",
        "National EMS Education Standard Competencies": "complete this chapter and the related coursework you will understand the anatomy and physiology of the female reproductive system as it relates to pregnancy you will learn the assessment and emergency treatment for child birth including stages of labor normal delivery complications of pregnancy and neonatal evaluations and resuscitation okay so let's get started",
        "Childbirth Settings and Decisions": "most child births in the United States occur in a health care setting with trained medical personnel in attendance occasionally the pregnant woman is unable to get to the hospital you must decide whether to assist the delivery on scene or to transport the patient to the",
        "Anatomy and Physiology of the Female Reproductive System": "hospital the ovaries are two glands one on each side of the uterus that are similar in function to the male testes so each ovary contains thousands of follicles and each follicle contains an egg ovulation occurs approximately 2 weeks prior to menstration if fertilize the egg implants in the endometrium which is the lining inside of the uterus if the egg is not feriz within 36 to 48 hours after it is released least it will die and the lining is shed as menstrual flow and this occurs around the 28th day of the woman's cycle the Fallopian tubes extend out laterally from the uterus with one tube associated with each ovary fertilization usually occurs when the egg is inside the fian tube the fertilized egg then continues to the uterus where if implantation occurs it develops into an embryo and then a fetus and grows until the time of delivery the uterus is a muscular organ that encloses and protects the fetus the uterus produces contractions during the labor and ultimately helps to push the fetus through the birth canal the birth canal is made up of the vagina and the lower third of the uterus is called the cervix the figure on this slide shows the anatomic structures of a pregnant woman okay so the vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal it completes the passageway from the uterus to the outside world for the newborn the perineum is the area between the vagina and the anus in a pregnant woman the breast milk um that is produced is carried through small ducts to the nipple to provide n nourishment to the newborn once it is born the placenta is a dis shaped structure attached to the uterine wall that provides nourishment to the fetus keeps the circulation of the woman and fetus separate but allows substances that pass between them anything ingested by the pregnant woman has the potential to affect the fetus the umbilical cord connects the woman and fetus through the placenta the umbilical vein carries oxy oated blood from the placenta to the heart of the fetus and the umbilical artery carries deoxygenated blood from the heart of the fetus to the placenta the umbilical cord is the lifeline of the fetus it connects the woman and the fenus fetus through the placenta and once again the umbilical vein is oxygenated and the umbilical artery is deoxygenated the fetus develops inside the fluid filled bag leg membrane that is called the amniotic sac the sac contains about 500 to 1,000 milliliters of Amic fluid which helps isolate and protects the floating fetus the amniotic fluid is released in a gush when the sac ruptures usually at the beginning of labor so let's talk about some changes",
        "Normal Changes in Pregnancy": "during pregnancy okay so there are some normal changes in pregnancy and during pregnancy the four body systems undergo major changes okay so the four major systems um that undergo changes are the respiratory cardiovascular and the muscular skeletal systems in the reproductive system hormone levels increase to support fetal development and prepare the body for child birth this puts pregnant women at an increased risk for complications from trauma bleeding and other Medical conditions the uterus is displaced out of its normal uh out of its normally well protected position within the pelvic area and this increases the chance of direct fetal injury in trauma rapid uterine growth occurs during the second trimester of pregnancy as the uterus grows it pushes up on the diaphragm and this Dees it from the normal position respiratory capacity changes with increased respiratory rates and de increased minute volumes and then there's overall blood volume which gradually increases throughout the pregnancy and this allows for adequate profusion for the uterus It prepares for the blood loss that will occur during childbirth so blood volume may eventually increase as much as 50% by the end of pregnancy the number of red blood cells also increase and the speed of clotting increases to protect against excessive bleeding during pregnancy by the end of the pregnancy the pregnant patient heart rate will increase up to 20% to accommodate for the increased blood volume and cardiac output is significantly increased the pregnant women um are at an increased risk for gastr sophal reflex nausea vomiting and potential aspiration because the changes that occur with the GI tract and then there's weight gain during pregnancy this is normal the increase in the body weight will eventually challenge the heart and impact the muscular skeletal system certain hormones affect the muscular skeletal system by making the joints looser or less stable in the third trimester the body changes the center of gravity and they're at an increased risk of slips and Falls so let's talk about some",
        "Complications of Pregnancy": "complications in pregnancy most women uh pregnant women are healthy but some may be ill when they conceive or become pregnant so you may um safely use oxygen to treat any heart or lung disease in a pregnant patient without harm to the Fe",
        "Diabetes in Pregnancy": "fetus so diabetes diabetes develops during the second half of pregnancy in many women who have not had diabetes previously this is called gestational diabetes and it resolves in most women after delivery the treatment is the same as for any other patient with",
        "Hypertensive Disorders": "diabetes then there's hypertensive disorders so gestational hypertension is the presence of high blood pressure in the absence of systemic effects defined as a systolic blood pressure higher than 140 and a diastolic pressure higher than 90 it's considered severe when the Sy olic pressure is higher than 160 and the diastolic is higher than 110 preeclampsia or pregnancy induced hypertension can develop after the 20th week of gestation it's characterized by the following signs and symptoms you could have a severe hypertension severe persistent headache visual abnormalities such as seeing spots blurred vision or sensitivity to light swelling in the hands and feet heat upper abdominal or gastric pain dipsia or um retrosternal chest pain anxiety or altered mental status eclampsia is characterized by seizures that occur as a result of the hypertension to treat seizures lay the patient on her side maintain her Airway administer supplemental oxygen if vomiting occurs suction the airway way provide rapid transport and call for advanced life support early if available transporting the patient on their left side can also prevent a thing called supine hypotensive syndrome and this is caused by compression of the descending aorta and the inferior vena by the pregnant uterus when the patient lies",
        "Bleeding in Pregnancy": "supine okay so now let's talk about bleeding so internal bleeding may be the sign of an atopic pregnancy when an embryo develops outside the uterus most often in the fallopian tube s its sudden onset of severe abdominal pain and vaginal bleeding in the first trimester of pregnancy should be considered an atopic pregnancy until proven otherwise consider the possibility of an atopic pregnancy in a woman who has missed a menstrual cycle and complain of sudden severe us usually unilateral pain in the lower abdomen okay so then a hemorrhage from the vagina that occurs before Labor um begins may be very serious in early pregnancy it may be a sign of a spontaneous abortion or a miscarriage in later stages of pregnancy it may indicate two separate things the first is abrupto placenta abrupto placenta is when the placenta separates prematurely from the wall of the uterus and this is most commonly caused by hypertension or trauma okay and then there's placenta Privia and this is when the placenta develops over or covers the uterus any bleeding from the vagina in a pregnant woman is a serious sign and should be treated uh promptly in a hospital what you want to do is treat for shock if the signs are present place a sterile pad or sanitary pad over the vagina and replace it as necessary do not put anything into the vagina to control bleeding the figure on this slide shows the abrupta placenta and the placenta",
        "Abortion and Abuse": "preia next we're going to talk about abortion so a spontaneous abortion is the loss of a pregnancy prior to 20 weeks of gestation without any preceding surgical or medical intervention the term is often used interchangeably with a miscarriage an induced abortion is the elective termination of a pregnancy prior to the time of viability the most serious complications are bleeding and infection if a woman is in shock treat and transport her promptly to the hospital bring any tissue that passes through the vagina to the hospital and never pull any out of the vagina then there is abuse so pregnant women have an increased chance of being victims of domestic violence and abuse abuse during pregnancy increases the chance of spontaneous abortion premature delivery and low birth weight the woman is at risk for bleeding infection and uterine rupture so pay attention to the environment for any signs of abuse pregnant patients who are abused are often scarred and scared and may be uh may not be honest as to how their injuries have occurred so talk to the patient in a private area away from the potential abuser if",
        "Substance Abuse in Pregnancy": "possible and then there's substance abuse the effects of any Addiction on the fetus includes low birth weight prematurity severe respiratory distress or death and then there's fetal alcohol syndrome this describes the condition of infants born to women who have abused alcohol if you are called to handle a delivery of an addicted woman pay special attention to your own safety clues that you're dealing with an addictive patient may include the presence of drug paraphernalia empty wine or liquor bottles statements made by the family or bystanders or by the patient themselves the newborn will probably need a immediate resuscitation okay so let's talk about special considerations for trauma and pregnancy with a trauma call involving a pregnant woman you have two patients to consider you have the woman and The Unborn fetus the pregnant woman also have an increased risk of falling um compared to non- pregant woman hormonal changes also loosens the joints in the muscular skeletal system and the increased weight of the uterus and displacement of abdominal organs can affect the woman's balance as well pregnant women have an increased amount of overall total blood volume and an approximate 20% increase in their heart rate by the third trimester a pregnant trauma patient may experience a significant amount of blood loss before you detect signs of shock the fetus also may have may be in trouble well before signs of shock are present so be alert to additional concerns and ready to assist assess and manage unique types of injuries when responding to a pregnant trauma patient the uterus is usually vulnerable to penetrating trauma and blood injuries the trauma a trauma injury to the pregnant uterus can be life-threatening to a woman and fetus because the uterus has a rich blood supply in most cases the only chance to save the fetus is to adequately resuscitate the woman when a pregnant woman is involved",
        "Trauma and Pregnancy": "of 8) in a motor vehicle crash or a similarly violent mechanism of injury severe Hemorrhage may result in injuries to a pregnant uterus trauma is one of the leading causes of abrupto placenta you should suspect abrupta placenta when the mechanism of injury is blunt trauma to the abdomen and the patient signs and symptoms are suggestive of shock common symptoms include vaginal bleeding and severe abdominal pain improper positioning of a seat belt can result in an injury to a pregnant woman and the fetus if they are involved in a motor vehicle crash carefully assist a pregnant woman's abdomen assess a pregnant woman's abdomen and chest for seat belt marks bruising and obvious trauma if a pregnant trauma patient goes into cardiac arrest your focus is the same as with any other patients in Cardiac Arrest perform CPR and provide transport to the hospital according to local protocols if a woman is in the last month or two of pregnancy compressions may need to be applied higher on the sternum than usual okay so let's talk about um the assessment and management your focus is on assessment and management of the woman uh suspect shock based on the mechanism of injury and be prepared for vomiting and ex uh anticipate the need to manage the airway and protect the patient from aspiring attempt to determine the gestational age to assist you with determining the size of the fetus and the position of the uterus follow these guidelines when treating a pregnant trauma patient so maintain an open Airway be prepared for and anticipate vomiting administer high flow oxygen ensure adequate ventilation if the patient's ventilations are inadequate provide or assist with a bag valve Mass device with 100% oxygen assess circulation control external bleeding maintain a high index of Suspicion for internal bleeding and shock based on mechanism of injury and transport considers consideration so transport the patient on her left side call for advanced life support early and transport to a specialty obstetric or trauma center if one is",
        "Cultural Value Considerations": "available okay so let's talk about some cultural value considerations cultural sensitivity is important when you are assessing and treating a pregnant patient women of some cultures may have a value system that will affect the choice of how they care for themselves during pregnancy and also how they planned the child's birth process some cultures may not per permit a male healthc care provider especially in the prehospital setting to assess or examine a female patient so respect these differences and honor the patients",
        "Teenage Pregnancy": "requests and then there is the teenage pregnancy so the United States has one of the highest teenage pregnancy rates among developed countries pregnant teenagers may not know they are pregnant or may be in denial about it as you begin to assess all female teenagers remember that pregnancy is a possibility and respect the teenager's privacy and the need for",
        "Patient Assessment": "Independence okay so let's start with the patient assessment childbirth is seldom an unexpected event but there are occasions when childbirth becomes an emergency let's talk about the scene size up so of course you're going to take those standard precautions and then consider calling for additional or specialized resources your precautions could be gloves face protection um and uh eye protection at minimum and then a gown uh if time allows and then of course the mechanism of injury um this is going to be a nature of illness so you will encounter pregnant patients who are not in labor so it is important to determine there could be a mechanism of injury all right so uh do not develop tunnel vision during a call and then there's the primary",
        "Primary Assessment": "assessment so you want to form that general impression when the patient is in active labor or whether you have time to assess for immediate or intimate deliver Y and address other possible life threats so perform a rapid exam of the patient and then there's the A and the B so during an uncomplicated birth life-threatening conditions involving the woman's Airway and breathing are not usually an issue however during a motor vehicle crash an assault or any number of medical conditions this may cause a life threat to exist and may result in a complicated delivery if needed provide Airway management and high flow oxygen then there's circulation so blood loss after delivery is expected but significant bleeding is not so quickly assess for any potential life-threatening bleeding and begin treating immediately if signs and symptoms of shock are present control the bleeding give oxygen and keep the patient warm and then there's your D and that's that transport decision so this is complet completely the exact opposite of a normal load and go situation because if delivery is intimate you have to prepare to stay there and deliver at scene so the ideal place to deliver is in the security of your ambulance or the privacy of the woman's home the area should be warm and private with plenty of room to move around if delivery is not intimate prepare the patient for transport and perform the remainder of the assessment and rout to the emergency department women in the second and third trimesters of pregnancy should be transported laying on their left side when possible and then we're going to do that rapid transport for pregnant patients who have significant bleeding and pain are hypertensive are having a seizure or are having an altered mental",
        "History Taking": "status and then there's history taking so obtain a thorough obstetric history including her expected due date any complications if she has been receiving prenatal care or if she expects a um a complicated delivery also get the complete medical history of the patient obtain a sample history also",
        "History Taking Details": "questions related specifically to the prenatal KR identify any complications the patient may have had during during pregnancy or potential complications during determine the due date fetal movement frequency of contractions and a history of previous pregnancies and deliveries and their complications determine whether there is a possibility of multiple bursts and whether the woman has taken any drugs or medication if her water's broken ask whether the water or the fluid looked greenish because green fluid is due to moonium moonium is the feal stool the presence of moonium can indicate newborn distress and it is possible for the feedus to aspirate moonium during delivery and then there's a secondary",
        "Secondary Assessment": "assessment physical examination so if the patient is in labor the physical exam should focus on contractions and possible delivery at any point you suspect that delivery is intimate you should check for crowning if you do not suspect um it's imminent and the patient reports other problems related to delivery you should not visually inspect the vagina then you need to obtain a set a complete set of vital signs and pulseox so be especially alert for tachicardia and hypo or hypertension remember hypertension even Mild May indicate a more serious problem and then of course you're going",
        "Reassessment": "to do that reassessment so repeat the primary assessment with a focus on the patients ABCs and vaginal bleeding particularly after delivery obtain another set of vitals and compare those to the ones obtained earlier and recheck interventions and treatment to see whether they are effective communication and documentation so if delivery is intimate notify the staff at the Receiving Hospital you need to provide an update on the status of the woman and the newborn after delivery if it has happened for pregnant patients with a complaint unrelated to childbirth be sure to include the pregnancy status of the patient in your radio report if delivery occurred in the field you will have two patients uh and two patient care reports to",
        "Stages of Labor": "complete so let's talk about the stages of labor now next and there are three St stages of labor the first is the dilation of the cervix and then the delivery of the fetus is a second and then the third stage is delivery of the placenta the first stage begins when the",
        "First Stage of Labor": "onset of contractions and ends when the cervix is fully dilated the first stage is usually the longest it lasts an average of 16 hours with the first delivery the onset of Labor starts when contractions of the uterus occur other signs of the beginning of labor are bloody show and the uterine rupture of the amniotic sac the frequency and intensity of contractions in true labor increase with time labor is generally longer in a a prima gravada than it is a multigravid and a woman may experience pre-term or false labor when uh or it's called Braxton Hicks contractions and so the table on this slide shows how to distinguish between true labor or false labor um which is the Braxton",
        "First Stage Continued": "Hicks some women experience a premature rupture of the membranes in which the amniotic sac ruptures too early and the fetus is not developed or ready to be born the patient may or may not go into labor and you will need to provide supportive care and transport to the hospital toward the end of the third trimester a head of the fetus normally descends into the woman's pelvis as the fetus positions for delivery this movement down into the pelvis is the Sensation that may accompany The Descent in it's called lightning the second second stage of",
        "Second Stage of Labor": "Labor begins when the fetus begins to encounter the birth canal and ends with the delivery of the newborn the um you need to make the decision about helping the woman to deliver at the scene or providing transport to the hospital uterine contractions are usually closer together and last longer the perum will begin to bulge significantly and the top of the fetus's head should begin to appear at the vaginal opening this is called crowning",
        "Third Stage of Labor": "the third stage of Labor begins with the birth of the newborn and ends with the delivery of the placenta during this stage the placenta Mo must completely separate from the uterine wall this may take up to 30",
        "Preparing for Delivery": "minutes okay so a new normal delivery management when you prepare for the delivery consider delivery at the scene when delivery is intimate and this will occur within few minutes if it is a natural disaster inclement weather or other environmental factors makes it possible um to reach the impossible to reach the hospital you're going to need to prepare for delivery how to determine if delivery is imminent ask the patient the following questions so how long have you been pregnant when are you due is this your first pregnancy how um are you having contractions if so how far apart are they and how long do they last have you had any spotting or bleeding has your water broken do you feel as though you need to have a bow movement and do you feel the need to push to help determine potential complications ask these questions were any of your previous deliveries by cesarian section uh have you had problems in this or any previous pregnancies do you use drugs or alcohol or take any medicines do you know if there's a chance you will have multiple deliveries and does your physician expect any complications if the patient says that she is about to deliver uh says she has to move her bowels or feels the need to push you should immediately prepare for delivery visually inspect the vagina to check for crowning and do not touch the V vaginal area until you have determined that delivery is inate once labor has begun it cannot be slowed or stopped so never attempt to hold the patient's legs together do not let them go to the restroom and instead reassure her that the sensation of needing to move her bows is normal and that this means she's about to deliver if your decision is to deliver deliv on the scene remember that you are only assisting the woman with the delivery your part is just to help guide and support the baby as it's born your emergency vehicle should always be equipped with a sterile emergency obstetric or OB kit and um that's an example on the U slide all right so positioning the patient for that delivery the patient's clothing should be removed or pushed up to her waist in the pants and undergarments undergarments should be removed pressure or preserve the patient's privacy as much as possible place the patient on a firm surface that is padded with blankets folded sheets or towels and Elevate the hips about 2 to 4 in with a pillow or blanket support the head neck and upper back with pillows and blankets and have her key her legs and hips flexed with her feet flat on the surface beneath her and her knee spread apart so when you prepare for delivery in the field put on a protective face shield and gown as time allows Place towels or sheets on the floor around the delivery area to help soak up BL fluids and protect the woman and the newborn open the OB kit carefully so that it it contents remain sterile and use the sterile sheets and drapes from the OB kit to make a sterile delivery field the figure on this slide shows how to prepare the delivery field okay and now let's talk about delivery so your partner should be at the patient's head to comfort soothe and reassure her during the delivery if the patient will allow it administer oxygen it is common for patients to begin to become nauseated during delivery and some will actually vomit so continually check the patient for crowning some patients may experience um uh pre captious labor and birth so position yourself so that you can see the peral area at all times time the patient's contractions remind the patient to take quick short breaths during each contraction but not to strain between contractions encourage the patient to rest and breathe deeply through her mouth you want to follow the steps in skill drill 34-1 to deliver the newborn delivering the head so observe the head as it begins to exit the vagina so that you can provide support as it emerges place your sterile gloved hand over the emerging bony parts of the head to control delivery of the head continue to support the head as it rotates be careful that you do not poke your fingers into the newborn's eyes or into the fontanals okay so an unruptured amniotic sac usually the iotic Sac will rupture at the beginning of labor or during contractions if it has not ruptured by the time the fetal head is crowning it will appear as a fluid filled sack emerging from the vagina the sac will suffocate the fetus if not removed you may puncture the sack with a clamp or tear it by twisting it between your fingers make sure that the puncture site is away from the head of the the Fe us his face and only perform this procedure as the head is crowning clear the newborn's mouth and nose using a bulb syringe if if required by protocols and wipe the mouth and nose with gauze so umbilical cord around the neck as soon as a head is delivered use one finger to feel whether the umbilical cord is wrapped around the neck this is called a nule cord usually you can slip the cord gently over the delivery head delivered head if not you must cut it and then let's talk about the delivery so delivering the body the head is the largest part of the fetus once it's born the body usually delivers very easily so support the head and the upper body as the shoulders deliver do not pull the fetus from the birth canal newborn will be slippery and may be covered with a white cheesy substance and this is called verx quosa post- delivery care so if the",
        "Postdelivery Care": "mother is able and willing hand the newborn to her and place the newborn on her abdomen so skin the skin contact can begin immediately dry off the newborn and wrap him or her in a warm blanket or towel and um ensure the top of the head is covered okay and uh keep the neck of the newborn in a neutral position wipe the newborn's mouth with a sterile go and PAD as needed and clamp and cut the umbilical cord approximately 60 seconds after birth and then you're going to obtain that first minute abgar score so then there's delivery of the placenta the placenta delivers itself usually within a few minutes after birth although it may take as long as 30 minutes after delivery of the placenta and before transport place a sterile pad or sanitary napkin over the vagina and straighten the woman's legs you can help to slow bleeding by gently massaging the woman's abdomen with a firm circular motion uh kneading motion and one hand CED over the top of the fundus and the other above the pubic bone to record the time of birth in your patient care report the following are emergency situations so if more than 30 minutes has elapsed and the placenta has not delivered if there is more than 500 milliliters of bleeding before delivery of the placenta or if there is a significant bleeding after delivery of the placenta if one or more of these events occur transport the woman and the newborn to the hospital promptly",
        "Neonatal Assessment and Resuscitation": "so let's talk about neonatal assessment and resuscitation okay the first minute after birth is often referred to as the golden minute during the first minute of Life perform the following initial steps of the newborn care position um or Airway positioning and suctioning if needed you want to dry you want to warm and tacy stimulate the patient normally the newborn will begin breathing within 30 seconds after breath and the Heart weight rate will be um 100 beats per minute or higher many newborns require some form of stimulation that will encourage them to breathe and begin circulating blood through their lungs so this could include positioning the airway in the normal or sniffing position if necessary suction the mouth and then nose then vigorously dry the head body and back rub the newborn's back and gently flick this or um slap the soles of his or her feet and then tactile stimulation so if signs of good tone and adequate ventilation are not present after performing the initial steps for 30 seconds then positive pressure ventilations with a mask may be necessary the table on this slide shows how to perform resuscitation for a newborn who is not",
        "Additional Resuscitation Efforts": "breathing so when you talk about additional resuscitation efforts you want to observe the newborn for spontaneous respiration skin color and movement of the extremities um evaluate the heart rate by palpating the pulse at the base of the umbilical cord or the brachial AR artery or listening to the newborn's chest with a stethoscope the heart rate is the most important measure in determining the need for further resuscitation if chest compressions are required use the hand circling technique for twers resuscitation perform bag valve Mass ventilation during a pause after every third compression using a compression to ventilation rati IO of 3 to one handson CPR is not as effective as ventilation with CPR and so the figure on this slide shows how to give chest compressions to a newborn using that hand and circling technique if you see moonium in the amniotic fluid or moonium staining on the newborn who is not breathing adequacy consider quickly suctioning the newborn mouth then nose after delivery before providing rescue",
        "The Apgar Score": "ventilations next we're going to talk about the appar score so the appar score is the standard scoring system used to assess the status of a newborn it's assigned in number and the values are zero one or two to five different areas of activity so the five different areas are appearance pulse Grimace or irritability activity or muscle tone and then finally respirations the total of the five numbers is the apgar score and so you calculate the apgar score at 1 minute and five minutes after birth so one more time that's 1 minute and then four minutes later at the fifth minute after birth the highest possible appar score is a 10 the table this slide shows how to calculate the apgar score for Newburn so steps for assessing a newborn you want to quickly calculate the apgar score to establish a baseline of the newborn status stimulation should result in the immediately increase in respiratory respiration rate if not you must begin bag valve Mass ventilations with the BVM if the newborn is breathing well you should check the pulse rate by feeling the bracho pulse or the sensations at the basic of the umbilical cord or oscal osculating the chest with a stethoscope the pulse rate should be at least 100 beats per minute if not you need to begin ventilations with a BVM and then reassess respirations and heart rate at least every 30 seconds assess the newborn's oxygen via pul Sox which is best taken at the right wrist and observed for central cyanosis if pres administer blowby by holding oxygen tubing at high flow close to the newborn's face set oxygen flow rate at 5 lers per minute you want to request a second unit as soon as possible if you determine that a newborn is in any distress and will require resuscitation in situations where assisted ventilation is required you should use a newborn bag valve mask make sure you have a good mask to face seal using gentle pressure make the chest rise with each ventilation if the newborn does not begin breathing on his or her own or does not have an adequate heart rate continue CPR and rapidly transport once CPR is been started do not stop until the newborn responds or is pronounced dead by a physician so let's talk about some",
        "Breech Delivery": "complications okay the first complication of delivery we're going to talk about is breach delivery the presentation is the is the position in which the infant is born or the body part that is delivered first most infants are B born head first this is called The Vortex presentation occasionally the buttocks are delivered and this is called a breach presentation the fetus is at Great risk for Trauma from the delivery and then prolapse cards are more common with a breach delivery breach deliveries usually take longer so you will often have time to transport the pregnant woman to the hospital however if the buttock has already pass through the vagina the delivery has begun preparing for a breach delivery is the same as for normal child birth allow the buttocks to and legs to deliver spontaneously supporting them with your hand to prevent a rapid expulsion let the legs Dangle on either side of your arm while you support the trunk and chest as they are delivered the head is almost always always face down and should be allowed to deliver spontaneously make a V with your glove finger and position them in the vagina to keep the walls of the vagina from compressing the fetus's",
        "Presentation Complications": "airway okay so the next one we're going to talk about is um on rare occasions the present the presenting part of the fetus is either neither the head nor the butto but an arm okay uh leg or foot and this is called a limb presentation an infant with a limb presentation cannot be successfully delivered in the field you need to transport the patient to the hospital immediately if a limb is protruding cover it with a sterile towel never try and push it back in and never pull on it place the patient on her back with her head down and her pelvis elevated and then the there's the prolapsed uh cord so a prolapse of the umbilical cord where the umbilical cord comes out of the vagina before the fetus must be treated in the hospital do not attempt to push the cord back in your job is to try to keep the fetus's head from compressing the cord so you need to carefully insert your gloved hand into the vagina and gently push the fetus's head away from the umbilical cord okay so place the woman supine with the feet foot of the stretcher raised about 6 to 12 in higher than her head with her hips elevated on a pillow or folded sheet alternatively the woman may be placed in the kneel to chest position you can wrap a sterile towel moist and saline around the exposed cord and give the patient high flow oxygen and transport rapidly",
        "Spina Bifida": "and then there's spinabifida so spinabifida is a developmental defect in which a portion of the spinal cord or menes may protrude outside of the vertebrae and possibly outside of the body cover the area of the spinal cord with a sterile moist dressing immediately after birth to prevent um potential fatal infections maintain the newborn's body temperature and it's important when applying moist dressings because the moisture can lower the newborn's body temperature and then you could have",
        "Multiple Gestation": "multiple gestations so twins occur once every 30 births twins are usually smaller than single fetuses and devel a delivery is typically not difficult about 10 minutes after the first birth contractions will Begin Again in the birth process will repeat itself the procedure for delivering twins is the same as that for single fetus however you will need some supplies from additional OB kits clamp and cut the cord of the first newborn as soon as it is born and before the second delivery uh has happened record the time of the birth of each twin separately twins may also be so small that they look premature",
        "Premature Birth": "and then the next thing we're going to talk about is premature births okay so any newborn that delivers before 8 months and that's 36 weeks or weighs less than 5 pounds at Birth is considered premature a premature newborn is smaller and thinner than a full-term newborn and the head is a um proportionately larger in comparison to the rest of the body okay so the verx cassoa will be absent or minimal on a premature newborn and there will also be less body hair premature newborns require special care to survive they often require",
        "Premature Birth Continued": "resuscitation efforts which should be performed unless it is physically impossible with such care premature newborns as small as one pound have survived and de developed",
        "Postterm Pregnancy": "normally and then there's postterm pregnancy and so postterm pregnancy refers to pregnancies lasting longer than 41 weeks postterm fetuses can be larger than a typical 40we fetus and sometimes weighing 10 pounds or more the larger size can lead to problems with the woman and the fetus and it could be a more difficult labor and delivery it could have an increased chance of injury to the fetus increased likelihood of a C-section being required the woman is at an increased risk for paranal tears and infection postern newb Burns have increased risk of meconium aspiration infections and being still born newborns may not have um been able to develop normally because of the restricted size of the feed of the uterus and be prepared to resuscitate the newborn as respiratory and neurologic functions may have been",
        "Fetal Demise": "affected and next we're going to talk about fetal demise so the onset of Labor may be premature but labor will otherwise progress normally in most cases if an inner uterine infection has caused the demise you may note an extremely foul odor the delivered fetus may have skin blisters slothing and a dark discoloration the head will be soft and perhaps grossly formed do not attempt to resuscitate an obviously dead",
        "Postpartum Complications": "neonate then there's postpartum complications so if bleeding exceeds approximately 100 milliliters consider this excessive if bleeding continues after delivery of the placenta you should continue to massage the uterus treat signs and symptoms of shock and excessive bleeding after birth is usually caused by muscles of the uterus not fully Contracting and is potentially life-threatening so cover the vagina with a sterile pad changing the PAD as often as possible consider oxygen if necessary monitor the vital signs frequently and transport the patient immediately to the hospital never hold the woman's legs together or pack anything into the vagina and uh in an attempt to control the bleeding postpartum patients are also at an increased risk of a Venus emilii most commonly a pulmonary emis the pulmonary embolism results from a clot that travels through the bloodstream and becomes Lodge in the pulmonary circulation blocking blood flow to the lungs it is potentially life-threatening this obstruction will block the flow to the lungs if you deliver a newborn in the field and the woman begins to report a sudden difficulty um breathing or shortness of breath consider a pulmonary embolism as a possibility also suspect a pulmonary embolism in patients of childbearing age with respiratory complaints who have recently delivered especially with a sudden onset of difficulty breathing or altered mental step",
        "Review and Conclusion": "status okay so that ends the lecture part of chapter 34 Obstetrics and neonatal care now we're just going to go through the review questions to see what we've learned all right so the first stage of Labor ends when and when do we know that the first stage it ends when the presenting part of the baby is visible all right so a 23-year-old woman who is 24 weeks pregnant with her first baby complains of edema in her hands a headache and visual disturbances o and look at her blood pressure what do we think that she's having and I'm going to say preeclampsia yep because eclampsia is when they are having the actual seizure from the high blood pressure you're transporting a woman who's 8 months pregnant to prevent supine hypotensive syndrome how should we do it and we're supposed to do it always on the left side okay immediately after delivery if um of the new infant's head you should and what should we do we're going to check the position of that umbilical cord the very first thing we want to do is see if there's a nucal cord around the neck upon delivery of the head you should note the umbilical cord is wrapped around the neck what should you do what should we do I think we're going to make one attempt to gently kind of get it off right slide it back over the need for an extent of newborn resuscitation is best on what is based on what and we know that it's going to be pace based on the respiratory effort heart rate and color the one minute appar score of a newborn reveals that the baby has a heart rate of 90 oh that's below 100 so that's a one the body is uh the pink body but blue hands and that's a one but has rapid respirations okay so that is a two and then flick uh and resist attempts to straighten legs two and two all right so I think that's an eight yep an eight we're just subtracting one for the heart rate and one for the body all right the most effective way to prevent cardiopulmonary rest in a newborn is to what do we think ensure adequate oxygenation and ventilation when assessing a woman in labor you realize her vagina are vaginal area and she and you see an arm protruding she tells you she feels the urge to push what should we do all right so this is a limb presentation and we're going to cover that Limb and transport immediately all right the newborn is considered to be term if it's born after how many weeks we know that if it's born in the ranges of 37 weeks um and before 42 weeks it's considered term okay so thank you for uh joining us for the chapter 34 lecture um we hope you've enjoyed"
    },
    {
        "Introduction": "hello and welcome to chapter 18 neurologic emergencies of the emergency care and transportation of the sick and injured 12th edition\ndeath and the leading cause of adult disability in the united states it is common in geriatric patients contributing factors for stroke include family history and race and new treatments are available for stroke seizures and alter mental status may also occur when there is a disorder in the brain now seizures may occur as a result of a recent head injury brain tumors some type of metabolic problem fever or a genetic disposition possible causes of altered mental status include intoxication head injury hypoxia stroke or metabolic disturbances and treatments vary widely",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will understand the significance and characteristics of the following anatomy and physiology of the nervous system common disease processes relating to strokes seizures headaches and altered mental status assessment and basic care management involving patients with a neurologic emergency including performing tests for speech facial movement and arm movement and assistance of the aels provider and managing these neurologic emergencies drogue is the fifth leading cause of",
        "Anatomy and Physiology": "so let's talk about the anatomy and physiology of a neurologic emergency the brain is the body's computer it controls breathing speech and all other body functions there are three major parts this includes the brain stem the cerebellum and the cerebrum now the cerebrum is the largest part the brain stem controls the basic functions such as blood pressure breathing and swallowing also pupil constriction and the cerebellum controls muscle and body coordination the figure on this slide illustrates the three major parts of the brain and you could see the cerebrum the cerebellum and the brainstem okay let's talk a little bit about more about these parts so the cerebrum is located above the cerebellum it's divided into the right and left hemispheres each controls activities on opposite sides of the body the front of the cerebrum controls emotion and thought the middle part controls sensation and movement and the back processes sight\nin most people speech is controlled on the left side of the brain near the middle of the cerebrum messages sent to and from the brain travel through nerves you have 12 cranial nerves and they run directly from the brain to parts of the head the rest of the nerves join in the spinal cord and exit the brain through a large opening in the base of the skull called the forum magnum each vertebrae in the neck back and neck has two nerves which branch out from the spinal cord and carry signals to and from the spinal cord the figure on this slide illustrates the skull and the spinal cord and the intersection of that the spinal cord exits you could see the skull at the four magnum and two nerves branch out of the spinal cord at each vertebra in the neck and back",
        "Pathophysiology": "so let's talk about some of the pathophysiology many different disorders may cause brain dysfunction and may affect the patient's level of consciousness speech and voluntary muscle control the brain is the most sensitive to changes in oxygen glucose and temperature levels a significant change in any of these levels will result in a neurologic damage or change",
        "Headache": "so let's talk about headache first one of the most common complaints you will hear from your patients in terms of pain is a headache headaches can be a symptom of another condition or it can be a neurologic condition on its own only a small percentage of headaches are caused by a serious medical condition tension headaches migraines and sinus headaches are the most common types of headaches let's talk about tension headaches first it's caused by muscle contractions in the head and neck and are contributed to stress the pain is usually described as squeezing dull or an ache usually do not require medical attention\nnext we have migraine headaches and they are thought to be caused by changes in blood pressure uh vessel size in the base of the brain the pain is usually described as pounding throbbing or pulsating and they're often associated with nausea and vomiting and may be preceded by visual warning signs such as flashing lights or partial vision loss migraine headaches can last for several hours two days then you have sinus headaches and they are caused by pressure that is a result of fluid accumulation in the sinus cavities patients may also have cold like signs and symptoms of nasal congestion cough and fever pre-hospital emergency care is usually not required and then there's serious conditions that include headaches such as a hemorrhagic stroke or brain tumor or meningitis so let's start talking about a stroke a stroke which is also known as a cerebral vascular accident or cva is an interruption of blood flow to an area within the brain that results in loss of brain function",
        "Ischemic Stroke": "you have two different types of stroke first we're going to talk about the ischemic stroke and this is the most common it accounts for 87 of all the strokes it results from a thrombus or an emboli and symptoms may range from nothing at all to complete paralysis atherosclerosis in the blood vessels is often the cause\nso this illustration shows an ischemic stroke",
        "Hemorrhagic Stroke": "and then you have a hemorrhagic stroke and this accounts for 13 of all strokes it results from bleeding inside the brain in cerebral hemo hemorrhages are often fatal people at a high risk include those experiencing stress or exertion and people at highest risk are those who have very high blood pressure or long-term elevated pressure that is not treated in this very aneurysm there are also common causes of hemorrhagic strokes in healthy young people and it presents as the worst headache of their life and causes a sub or arachnoid hemorrhage",
        "Transient Ischemic Attack": "then you have a tia and this is a transient ischemic attack and it's stroke-like symptoms that go away on their own within less than 24 hours it may be a warning sign of a larger stroke to come and it's considered an emergency about one-third of patients who have a tia will experience a stroke soon after and all patients with a tia should be evaluated by a physician",
        "Signs and Symptoms of Stroke": "so let's talk about the signs and symptoms of a stroke general signs and symptoms include facial drooping sudden weakness or numbness in the face arm leg or one side of the body you could have decrease or absent movement and sensation on one side of the body lack of muscle coordination or loss of balance\nsudden loss of vision in one eye or blurred or double vision you could have difficulty swallowing decreased level of responsiveness perhaps some speech disorders\naphasia which is difficulty expressing thoughts or inability to use the right words or difficulty understanding spoken words okay slurred speech sudden and severe headache confusion or dizziness you could have weakness combativeness restfulness tongue deviation or coma so if the stroke happens in the",
        "Left Hemisphere": "left hemisphere it may cause aphasia aphasia is the inability to produce or understand speech and speech problems can vary widely strokes that affect the left side of the brain can also cause paralysis of the right side of the body",
        "Right Hemisphere": "then on the right side if you have a stroke on the right side it may affect the brain and it could cause paralysis of the whole left side of the body okay so usually patients will understand language and be able to speak but their words may be slurred and hard to understand and patients may be oblivious to this their problem and also it may affect certain parts of their vision neglect and lack of pain cause many patients to delay seeking help",
        "Bleeding in the Brain": "bleeding in the brain so let's talk about this so patients may have who have very high blood pressure and may cause bleeding and so um when it causes bleeding uh basically this is a compensatory response and so a trend of increasing blood pressures is an important sign as the body may increase the blood pressure to get blood to the brain tissues significant drops in blood pressure may result as the patient's condition worsens",
        "Conditions That May Mimic Stroke": "so conditions that may mimic a stroke are hypoglycemia or low blood sugar postdictal state and that's that state right after you have a seizure or a subdural or epidural bleeding okay so the figure on the slide illustrates intracranial bleeding trauma to the head may result in intracranial bleeding so bleeding outside the dura and under the skull is called epidural bleeding and bleeding beneath the dura but outside of the brain is called subdural bleeding let's talk about seizures so a seizure is a neurologic episode caused by a surge of electrical activity in the brain and in the united states it's estimated that 3.5 million people have epilepsy seizures are caused by two basic groups you have a generalized seizure or a partial seizure now partial seizures are also called focal seizures so let's talk about generalized seizures first you'll hear them referred to as tonic clonic seizures and this is a result from abnormal electrical discharges in large areas of the brain involving both hemispheres typically characterized by unconsciousness and a generalized severe twitching of all the muscles and it lasts usually several minutes or longer",
        "Absence Seizure": "then you have absence seizures and this does not involve any changes in the motor activity they're characterized by brief lapse of consciousness in which the patient seems to stare or not respond",
        "Partial": "then you have focal this is the partial seizure in a focal onset of awareness of a seizure so you might not have a change in the patient's level of consciousness patients may be numb weak dizzy they might have visual problems or an unusual smell and it may cause some twitching or br brief paralysis\nfocal onset so you're going to have an impaired awareness of a seizure the patient has an altered mental status and does not interact normally with his or her environment results from abnormal discharges from the temporal lobe of the brain other characteristics may be lip smacking eye blinking or jerking patients also may experience unpleasant smells and visual hallucinations exhibit uncontrollable fear or perform repetitive physical behavior",
        "Aura": "so patients may experience a warning sign prior to a seizure and this is an aura okay and it could include visual changes or hallucinations people with a history of seizures recognize their auras and they usually take steps to minimize injury such as sitting or laying down auras do not occur prior to every seizure but not all and not all patients with a seizure disorder experience auras",
        "Generalized Seizure": "so a generalized seizure and this is characterized by sudden loss of consciousness followed by chaotic muscle movement and tone and apnea and it may exhibit bilateral muscle movement characterized by a cycle of muscle rigidity and relaxation typically it lasts about five minutes it's followed by a post-ictal state and then you have the absence formerly called a petite maul and this is a seizure that may last for seconds after which the patient fully recovers with only brief lapse of memory of the event",
        "Status Epilepticus": "status epileptis that's a seizure that lasts for more than five minutes and are and they progress um to assass epilepsis so seizures that continue every few minutes without a person regaining consciousness or lasting longer than 30 minutes okay reoccurring or prolonged seizures should be considered immediately life-threatening situations",
        "Causes of Seizures": "all right so on the slide you can see some causes of seizures so these are common causes of seizures you have congenital metabolic or febrile seizure epileptic seizures usually can be controlled with medicines medicines used often to treat seizures include kepra dylan phenobarbital tegritol adepa code topomax and klonopin",
        "The Importance of Recognizing Seizures": "it's important to recognize seizures so recognize a seizure is occurring and whether the episode differs from the previous one recognize the post-ictal state and complications of seizures and identify other problems associated with seizures",
        "The Postictal State": "the post-ictal state is when the seizure has stopped the patient's muscles relax becoming almost flaccid or floppy and the breathing becomes labored okay it may be characterized by hemiparesis or weakness on one side of the body and that might resemble a stroke the postal state is the most commonly characterized by lethargy and confusion and if the patient's condition does not improve you should consider other possible underlying conditions",
        "Syncope": "a syncope so seizures are often mistaken for syncope or fainting and fainting typically occurs while the patient's standing and seizures may occur in any position so fainting is not associated with a post-actual state then let's talk about altered mental status so aside from a stroke and seizure the most common type of neurologic emergency that you will encounter in a patient is an altered mental status",
        "Causes of AMS": "this includes hypoglycemia so low sugar hypoxia intoxication delirium drug overdose or perhaps an unrecognized head injury a brain infection perhaps body temperature abnormalities a brain tumor an overdose or a poisoning",
        "Scene Size-up": "so let's talk about the patient assessment of this these neurologic emergencies okay so first of course you're going to have that scene size up and you need to make an early determination whether it's a medical or trauma situation look for threats to safety and follow standard precautions consider the need for spinal immobilization and call for additional resources early",
        "Primary Assessment": "next is that primary assessment so look for life-threatening conditions perform a rapid exam and establish priorities based on assessment of the patient's level of consciousness and ex-abcs",
        "History Taking": "history taking so if the patient is unresponsive gather any history from the family members or bystanders if no one's around look for explanations for an altered mental status you could look for signs and symptoms that may indicate a patient who has an alter mental status and tried to determine the events which led up to that incident try and obtain a sample history patients with a significant intracranial",
        "Secondary Assessment": "bleeding may have a great deal of pressure in the skull and so when we're taking the vital signs this could cause slow pulse and also respirations can be erratic blood pressure is usually high to compensate for poor perfusion in the brain and unequal pupil size and reactivity indicate significant bleeding and pressure in the brain also when you're doing vital signs make sure you check blood glucose levels okay so let's talk about a stroke assessment so stroke assessments scale um you're going to evaluate the face arms and speech there's an acronym called be fast and that's a mnemonic also the cincinnati pre-hospital stroke scale and the los angeles pre-hospital stroke scales are commonly used so there's a three item stroke severity scale and that's the lag and then the los angeles motor scale that's the lams then you have the glasgow coma scale and that's a score for neurologic assessments\nso this table on the slide displays the b fast mnemonic so you have balance eyes facial droop arm drift speech and time then this table on the slide displays the cincinnati pre-hospital stroke scale you're going to see facial droop so you want to ask the patient to show their teeth arm drift ask the patient to close their eyes hold both arms out with the palms up and then ask the patient to say you can't teach an old dog new tricks the table on this slide displays the los angeles pre-hospital stroke screen so if they have any of those criteria in one through six um it's a probability of a stroke is 97 and then the table on this slide displays the three item stroke severity scale all patients with an altered mental status should also have a glass galcoma score calculated in the table on this slide displays the glass calcoma score and it consists of eye opening best verbal response and best motor response the best score you could have is a 15 and the the lowest score you could have is a three",
        "Reassessment": "okay then we're going to do the reassessment so we're going to focus on reassessing the abcs vital signs and interventions we're going to compare baseline findings with updated information we're going to watch carefully for changes in the pulse blood pressure respirations and glass galcoma scores and we're going to notify the receiving facility of the patient's chief complaint and assessment findings how we're going to treat these patients okay so in general most patients with a suspected stroke physicians in the emergency department need to determine whether there is bleeding in the brain if there's no bleeding the patient may be a candidate for blood clot dissolving medicine if bleeding is present the medicine will increase the bleeding with disastrous consequences so we need to notify the hospital regarding the last time the patient was known to be without their current signs and symptoms of a stroke patients who have had a seizure require definitive evaluation and treatment at the hospital in patients who are having a seizure protect them from harm maintain a clear airway by suctioning provide oxygen as quickly as possible and if a head or neck trauma suspected we need to provide spinal immobilization",
        "Emergency Medical Care": "for patients who continue to have a seizure and this is known as that status epileptis we need to suction the airway we're going to have to provide positive pressure ventilations transport quickly to the hospital and rendezvous with advanced life support if possible",
        "Emergency Medical Care: Headache": "patients with a headache we're going to be concerned if the patient complains of a sudden onset of a severe headache now sudden onset of a headache with a fever seizures or altered mental status following trauma we have to be worried about okay",
        "Emergency Medical Care: Migraine": "so when it comes to emergency medical care for migraine we want to always assess the patient for other signs and symptoms that might indicate a more serious condition we're going to give them high flow too if they can tolerate it we want to darken and quiet the environment and we're not going to use sirens or lights during transport",
        "Emergency Medical Care: Stroke": "emergency medical care for a stroke so we're going to support the abcs and provide rapid transport to the stroke center we're going to maintain a spo2 level of at least 94 percent routine use of oxygen therapy is not recommended unless the patient is experiencing respiratory distress or showing signs of hypoxia fibrolytic therapy and methods of mechanically removing the blood clot may reverse stroke symptoms and even stop the stroke if given within three hours or six hours if possible transport to his designated stroke center okay so",
        "Emergency Medical Care: Seizure 1 of": "when it comes to emergency medical care for seizures the patient may be in a post-dictal state on arrival or the patient may still be actively having the seizure so we want to continue to assess and treat the abcs we want to protect the patient from harm if they're still seizing and if the patient refuses transport after the seizure contact online medical direction and ask them to speak directly with the patient and follow local protocols",
        "Emergency Medical Care: Altered Mental Status": "when it comes to emergency care for altered mental status we need to determine the cause and so we also might need to provide spinal mobilization airway and vent support if indicated okay so transport to the appropriate facility",
        "Review": "all right so that concludes the lecture section for chapter 18 neurologic emergencies next we're just going to go through the review questions to see what we've learned so a 41 year old man presents with slow irregular hypotension and dilated pupils these signs most likely indicate a dysfunction of the all right so respiratory i already i immediately think it's going to be brain stem all right and it is so brain stem is the controls that function for breathing blood pressure and pupil constriction an acute ischemic stroke is caused by now we know rupture is the bleed hemorrhagic increase intracranial pressure usually bleed and let's say a blocked cerebral artery yep a thrombus or an emboli causes a block cerebral artery and that is um that's d 56 year old man experience a sudden severe headache and then became unresponsive he has a history of high blood pressure the most likely cause of this condition is i'm going to say a hemorrhagic stroke because remember that high blood pressure and then that sudden severe headache so he's bleeding somewhere yeah a rupture of the cerebral artery unlike an ischemic stroke a transient ischemic attack is characterized by all of the following except so we know that the symptoms usually resolve within 24 hours and so that means that b the symptoms may persist for longer is incorrect a patient with a suspected stroke presents with slurred speech that has difficult for you to understand this is referred to as okay so what do we think we have three that are very similar so let's take a look at this okay so dis is difficulty okay so difficulty and then we know um that phase that ph is going to be difficulty swallowing um so we know that dysarthria is going to be the answer okay and that's um difficult to understand for us to understand okay so a type of a seizure that's characterized by severe twitching of all the body's muscles and lasts for several minutes or longer is called and this is going to be a generalized seizure yeah so it often lasts for several minutes or longer the most important reason for promptly transporting a stroke patient is to the hospital is and we know that we they could have fibrolytic and you heard it earlier called a clot buster medication and it could reverse that clot which of the following are components of that cincinnati pre-hospital stroke scale we know that it's arm drift facial symmetry arm drift and uh we're going to ask him to smile we're going to ask him to talk and then we're going to ask him to hold the both arms out so so your patient opens his eyes when you say his name is making incomprehensible sounds and withdraws when you pinch his earlobe so we're gonna calculate this okay so let's see opens his eyes when you say his name that's a three incomprehensible sounds that's a two and withdraws when you pinch his earlobe that's a four so i'm thinking we have a glass cow of nine and yes yeah we have a glass cow of nine and this is often difficult to understand and sometimes occasionally you might have to have the chart out in front of you or write the chart down really fast if a patient complains of a severe migraine you should be how should the patient be transported and we know that we don't want it to be in a brightly lit ambulance or with sirens so i think there they want you to do without lights and sirens yeah without lights and sirens you can give them some oxygen if they if it they tolerate it okay so this concludes chapter 18 neurologic emergencies thank you for joining me today and uh i hope you have a great day"
    },
    {
        "Chapter Introduction": "hello and welcome to chapter 33 environmental emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the physiology of environmental injuries you will have learned the proper assessment and management of general and specific types of environmental emergencies including hypothermia local cold injuries such as frostbite and heat exposure illnesses such as heat stroke you will learn the associated signs and symptoms and emergency treatment of drowning diving emergencies high altitude sickness lightning strikes and bites from spiders and marine life snakes scorpions and ticks okay so let's get started environmental",
        "Introduction to Environmental Emergencies": "factors such as temperature and atmospheric pressure can overwhelm the body's ability to cope with its surroundings medical emergencies can result certain populations are at a higher risk and those are children older people people with chronic illnesses young adults who over exert themselves environmental emergencies often accompany other illnesses and injuries that require treatment at the same time environmental emergencies include heat and cold related emergencies water emergencies pressure related injuries caused by diving in high altitude climbing and injuries caused by lightning and venomation caused by bites and stings",
        "Factors Affecting Exposure": "factors affecting exposure so there are four factors that affect how a person deals with heat or cold the factors are physical condition age and nutrition and hydration so first we're going to talk about physical condition so patients who are ill who are in poor physical condition will not tolerate extreme temperatures well then there's age so infants children and older adults are more likely to experience temperature related illnesses infants have a poor thermal regulation at birth and do not have the ability to shiver and generate heat when needed until about 12 to 18 months of age children may not think to or be able to put on extra clothing and then you have older adults there's a loss of subcutaneous tissue which reduces the amount of insulation they have poor circulation also contributes to heat loss and medications can affect the body's thermostat putting a person at an increased risk for temperature related emergencies also high risk of for falls and laying immobile on a hot or cold surface can contribute and then there's nutrition and hydration a lack of food or water will aggravate heat or cold stress and also alcohol will change the body's ability to regulate temperature and then there's environmental conditions so air temperature humidity level and wind can complicate or improve environmental situations extremes in temperature and humidity are not needed to produce heat or cold injuries consider the environment and whether your patient is prepared for that situation",
        "Cold Exposure": "so first we're going to talk about cold exposures if the body or any part of it ex is exposed to cold environments temperature regulatory mechanisms will be overwhelmed cold exposure may cause injuries to the hands and feet ears nose or the whole body there are five ways the body can lose heat the first one we're going to talk about is conduction and that's the transfer of heat from a part of the body to a colder object by direct contact and then there's convection convection is the transfer of heat to circulating air as when the coal air moves across the body there's enviro evaporation and that's that conversion of liquid to gas then radiation so that's a transfer of heat by radiant energy and then of course respiration so body heat loss as warm air in the lungs is exhaled into the atmosphere and cooler air is inhaled the rate and amount of heat loss or gain by the body can be modified in three ways you can increase or decrease in the heat production so shivering and increasing movement when cold will increase heat production and decreasing and limiting movement when hot will decrease heat production also moving to an area where heat loss can be decreased or increase so seek shelter from the wind and cold environments and seek shade in the hot environment and wear the appropriate clothing for the environment so layers of clothing provide good insulation protective clothing traps perspiration and prevents evaporation loosen or remove clothing to cool down",
        "Hypothermia": "so hypothermia cool or core temperature of the body falls below 95 degrees hypothermia occurs the body loses the ability to regulate its temperature and generate body heat so the physiology behind hypothermia is to protect against heat loss the body constricts blood vessels in the skin resulting in blue lips or fingertips the body shivers to generate heat as these mechanisms are overwhelmed body functions begin to slow down and mental status deteriorates eventually key organs such as the heart begins to slow down leading to death so the development of hypothermia it can develop quickly as with cold water immersion or air temperature does not have to be below freezing for hypothermia to occur so there's people who are at higher risk and these are homeless people and those whose homes lack heating or swimmers even in the summer or geriatric patients and ill patients who are less able to adjust to temperature extremes patients with injuries or illness such as burns shock head injury stroke generalized infections injuries to the spinal cord diabetes and hypoglycemia so there's some signs and symptoms and basically they become more severe as the body's core temperature falls hypothermia generally progresses through four stages and so see the table on 33-1 okay so you want to assess the general appearance pull back your glove and place the back of the hand on the patient's abdomen if the abdomen feels cool the patient is likely experiencing a generalized cold emergency a hypothermia thermometer registers body lower body temperatures there's first there's mild hypothermia and this occurs when the core temperature is greater than 93.2 but less than the normal 98 degrees the patient is usually alert and shivering pulse rate and respirations are usually rapid and the skin may appear red or pale or cyanotic then you have moderate hypothermia and that exists when the core temperature is from 86 degrees to 93.2 shivering will stop and muscle activity decreases eventually all muscle activity stops and mental status deteriorates then there's severe hypothermia and this occurs when the core temperature is less than 86 degrees fahrenheit as the core drops towards 85 the patient becomes lethargic and stops fighting the cold the patient appears stiff or rigid if the body temperature continues to fall below 80 degrees the pulse becomes slower and weaker the respirations slow and may become absent and cardiac dysrhythmias can occur at a core temp of less than 80 degrees all cardiopulmonary cardiorespiratory activity may cease pupillary action is slow and the patient may appear dead never assume to that a cold pulseless patient is dead",
        "Local Cold Injuries": "so then there's local cold injuries most injuries from cold are confined to exposed parts of the body when exposed parts of the body become very cold but not frozen injuries such as frost nip and immersion foot or also known as trench foot can result when the parts become frozen though that injury is called frostbite the figure on this slide shows frostbite to the extremities and face important factors in determining the severity of the local injured cold injury are the duration of the exposure temperature to which the body part was exposed and the wind velocity during that exposure consider underlying factors as well so exposure to wet conditions inadequate isolation insulation from colder wind restricted circulation from tight clothing or shoes or circulatory disease and fatigue or poor nutrition alcohol or drug abuse hypothermia diabetes cardiovascular disease and age patients with hypothermia should also be assessed for frostbite and other local cold injuries",
        "Frostnip and Immersion Foot": "frost nip and immersion foot so frost nip after prolonged exposure to a cold to the cold skin may freeze while deeper tissues are unaffected usually affects the ears and nose and fingers and usually not painful so the patient often is unaware that a cold injury has occurred then there's immersion foot and occurs after prolonged exposure to cold water common in hikers and hunters who stand for a long time in the river like signs and symptoms are pale cool skin skin on the foot may look wrinkled but um can also remain soft and loss of feeling and sensation in that injured area",
        "Frostbite": "frostbite the most serious local cold injury because the tissues are actually frozen freezing permanently damages cells and gangrene which is permanent damage or cell death requires surgical removal of that dead tissue the exposed part will become inflamed tender to touch and unable to tolerate exposures to cold signs and symptoms are most frostbitten",
        "Frostbite Details": "parts are hard and waxy the injured part feels firm to frozen as you gently touch it blisters and",
        "Frostbite Severity": "swelling may be present the depth of the",
        "Frostbite Types": "skin damage will vary with superficial frostbite only the skin is frozen but with deep frostbite deeper tissues are often frozen",
        "Scene Size-up": "so let's talk about the assessment of these cold injuries next and we the management of hypothermia in the field regardless of the severity consists of stabilizing the abcs and preventing further heat loss scene size up so note the environmental conditions we need to understand what the wind chill is whether it's wet or dry and then ensure the scene is safe for you and other responders identify safety hazards such as icy roads mud or wet grass and then use appropriate standard precautions look for indicators of that mechanism of injury",
        "Primary Assessment": "and then our primary assessment so of course the first thing we're going to do is form that general impression we're going to perform a rapid scan to determine whether a life threat exists and if so we want to treat that and if the chief complaint is simply being cold quickly assess the patient's core temperature evaluate the patient's mental status quickly using afu scale and then the airway breathing in circulation if you believe the patient is in cardiac arrest proceed directly to the circulation step by providing high quality chest compressions then address airway breathing ensure that the patient has adequate airway and is breathing if your patient's breathing is slow or shallow ventilation with the bvm may be necessary warm humidified oxygen helps warm the patient from the inside out then palpate for the carotid pulse you want to wait for up to 60 seconds to decide if the patient is pulseless the american heart association recommends that cpr to be started on a patient who has no detectable pulse or breathing so perfusion will be compromised based on the degree of cold the patient is experiencing and bleeding may be difficult to find because of the slow moving circulation and thick clothing then there's your transport decision so complications can include cardiac dysrhythmias and blood clotting abnormalities all patients with hypothermia require immediate transport rough handling of hypothermic patients may cause a cold slow or weak heart to fibrillate and the patient to lose any pulse if transportation delayed protect the patient from further heat loss when it comes to the history taking of course we're going to investigate the chief complaint we want to obtain that medical history and be alert for specific signs and symptoms as well as any permanent pertinent negatives sample history so if possible find out how long your patient has been exposed to the environment exposures may be short or prolonged medications and underlying medical problems may have to and may have an impact on the way the cold affects the patient's metabolism the patient's last oil intake and what the patient was doing prior to the exposure will help determine the severity of the cold problem",
        "Secondary Assessment": "then it's our secondary assessment so the physical findings we want to focus on the severity of the hypothermia and assess the areas of the body directly affected by the cold exposure as well as the degree and extent of damage pay special attention to skin temperatures textures and turgor then there's the vital signs it may be altered by the effects of the hypothermia and can be an indicator of its severity respirations may be slow and shallow resulting in low oxygen levels in the body low blood pressure and a slow pulse may indicate moderate to severe hypothermia and evaluate for changes in mental status using the apu scale determine a core body temperature using a hypothermia thermometer and that's based on your local protocol then your reassessment of course you're going to repeat the primary reassess the vitals in chief complaint monitor the patient's level of consciousness and vital signs rewarming can lead to cardiac dysrhythmias and then you're going to communicate all of the information you've gathered to and give it to the receiving facility",
        "General Management of Cold Emergencies": "so let's talk about management of these cold emergencies all right so we want to move the patient from the cold environment to prevent further heat loss and to prevent further damage to the feet do not allow that patient to walk remove any wet clothing and place dried blankets over and under the patient if available give the patient warm humidified oxygen handle the patient gently do not massage extremities do not allow the patient to eat or use any stimulants such as coffee tea soda or tobacco when it comes to mild hypothermia the patient's going to be active and alert and responding appropriately we want treatment it should involve passing rewarming place the patient in a warm environment and remove the wet clothing apply heat packs and water hot water bottles to the groin axillary and cervical regions turn up the heat too high in the patient compartment of the ambulance and give warm fluids by mouth if the patient is able to swallow moderate or severe hypothermia do not try to actively rewarm the patient rewarming may cause a fatal cardiac dysrhythmia local protocols may dictate the appropriate type of rewarming strategies based on the patient's body temperature the goal is to prevent further heat loss you want to remove the patient immediately from that cold environment remove the wet clothing cover the patient with the blanket and transport handle the patient very gently to decrease the risk of ventricular fibrillation if you cannot get the patient out of the cold immediately move the patient out of the wind and away from contact with any object that will conduct heat away from the body place blankets and waterproof protective cover on the patient and cover the head and neck with a towel always remember that even an unresponsive patient may be able to hear you",
        "Emergency Care of Local Cold Injuries": "okay so emergency care for local cold injuries um so this includes the following steps so remove the patient from the cold for their injury handle the injured part gently and protect it from injury and remove any wet or restrictive clothing from the patient especially over the injured part there's if there's no chance of re-injury or if the transport to the ed will be significantly delay delayed consider active rewarming if local protocols allow consult medical control if available with frostnet contact contact with a warm object may be all that is needed immersion foot remove wet shoes boots and socks re-warm the foot gradually protecting it from further cold exposure cover the affected loosely with dry sterile dressing never rub or massage injured tissues rubbing can cause further damage and do not re-expose the injury to cold when it comes to frostbite which is late or deep cold injuries remove the clothing from the injured part cover the injury loosely with dry sterile dressing do not break blisters or rub or massage the area do not apply heat or we re-warm the part and do not allow the patient to stand or walk on a frostbitten foot when you're rewarming in the field if prompt hospital care is not available the medical control and medical control instructs you to begin rewarming in the field use a warm water bath immersion immerse the frostbite part in water with a temperature between 102 to 104 degrees dress the area with sterile dry dressing and including between the injured fingers and toes and expect the patient to report severe pain never attempt to rewarm if there's any chance that the part may freeze again",
        "Cold Exposure and You": "so cold exposure in you you are at risk for hypothermia yourself if you work in a cold environment if cold weather search and rescue is possible in your area then you should receive survival training and precautionary tips stay on top of the weather forecast and make sure proper clothing is available and wear it whenever appropriate so your vehicle must also be properly equipped and maintained",
        "Heat Exposure": "all right so now let's talk about heat exposure and in a hot environment or during vigorous physical activity the body tries to rid itself of heat sweating and dilation of blood vessels removal of clothing and relocation to a cooler environment will help with heat",
        "Heat Exposure Overview": "exposure hyper thermia is a core temperature above at or above 101 degrees fahrenheit risk factors of heat illness include high air temperature and that reduces the radiation high humidity it reduces evaporation lack of accumulation or acclimation to the heat or vigorous exercise and you're going to have loss of fluid and electrolytes with vigorous exercise okay so there's three forms of heat emergencies and that's heat cramps heat exhaustion and heat stroke and also you could have all three forms that may be present in the same patient okay so persons at a greater risk for heat illness are the same ones um basically with the cold illnesses and so we have children especially newborns and infants geriatric patients patients with heart disease copd diabetes dehydration and obesity and patients with limited mobility so alcohol and certain drugs also make a person more susceptible to heat illnesses because they cause dehydration and decrease the ability to sweat",
        "Heat Cramps": "first we're going to talk about the heat cramps and that's a painful muscle spasm that occurs after vigorous exercise do not occur when only when it's hot outside the exact cause is not well understood but occasionally it occurs in leg or in abdominal muscles okay so next",
        "Heat Exhaustion": "we're going to talk about heat exhaustion and it's also called heat collapse so some causes are hypovolemia as a result of the loss of water and electrolytes from heavy sweating also high humidity decreases the amount of evaporation that can occur and exertion in poorly ventilated areas signs and symptoms are dizziness weakness or syncope nausea vomiting and headache cold clammy skin with a ashen pot pallor dry tongue and thirst normal vital signs pulses may be rapid and weak and then normal or",
        "Heat Exhaustion Details": "slightly elevated body temperature such as it could be as high as 104 degrees fahrenheit",
        "Heatstroke": "when it comes to heat stroke that's least common but the most serious cause of heat exposure and it occurs when the body is subjected to more heat than it can handle and more normal mechanisms for getting rid of the excess heat are overwhelmed if left untreated it always results in death typical onset situations so during",
        "Heatstroke Details": "vigorous physical activity or outdoors in a closed poorly vented human space during heat waves in buildings without significant air conditioning or with poor ventilation and children left unattended in a locked car on a hot day signs and symptoms are hot dry flesh skin so the patient may still be sweating even with the heat stroke okay so rapid rise and body temperature up to 106 degrees change in behavior unresponsiveness and seizures and rapid weak pulse that becomes weaker increased respiratory rate and then actually perspiring will stop when we're assessing heat emergencies with the scene size up we want to perform an environmental assessment remember that in a heat emergency it may be secondary to a medical or trauma emergency if the patient's unconscious has an altered mental status or requires intravenous fluids to treat for shock consider calling advanced life support assistance look for indicators of a mechanism of injury protect yourself from the heat or biological hazards and stay hydrated and use appropriate standard precautions including gloves and eye protection",
        "Primary Assessment for Heat Emergencies": "then you're going to do your primary assessment and you're going to start it by forming the general impression you want to observe how the patient interacts with you and the environment a heat emergency may be the primary or secondary condition so perform a rapid scan avoid tunnel vision and assess the patient's mental status using the avpu scale then of course is the airway and breathing and unless the patient is unresponsive the airway should be patent so nausea and vomiting may occur position the patient to protect the airway as necessary the patient's unresponsive be cautious of how you open the airway and consider spinal immobilization if trauma is possible so if the patient's unresponsive insert an oral airway and provide back valve mass ventilations then there's circulation so if adequate assess the for perfusion and bleeding assess the patient's skin condition and treat for shock by removing the patient from the heat and positioning the patient to improve circulation so if the patient's bleeding damage or bandage according to protocol and if the patient has any signs of heat stroke provide rapid transport",
        "History Taking for Heat Emergencies": "next is that history taking so of course investigate the chief complaint and be alert for signs and symptoms then sample history so note the activities conditions or medications that may predispose a patient to dehydration or heat related problems and determine your patient's exposure to heat or humidity and activities prior to the onset of the symptoms",
        "Secondary Assessment for Heat Emergencies": "and then of course there's that secondary assessment the patient is unresponsive perform a secondary assessment on the entire body if the patient is conscious perform an assessment to the specific area of the body assess the patient from muscle cramps or confusion examine the patient's mental status and take vital signs pay special attention to the patient's skin temperature trigger and level of moisture gently pinch the skin on the forehead or back of the hand and perform a careful neurologic examination then of course you want to check the vital signs so patients who are hyperthermic will be tachycardia and to kidney so falling blood pressure indicates that the patient is going into shock in heat exhaustion the skin temperature may be normal or cold and clammy in heat stroke the skin is hot and then use monitoring devices in the secondary assessment so check the patient's temperature with a thermometer depending on your protocol and in patients with a heat related emergency pulse ox is also indicated and then",
        "Reassessment for Heat Emergencies": "we're going to do the reassessment we want to watch carefully for deterioration patients with symptoms of a heat stroke should be transported immediately in a cool ambulance passively cooled with removal of clothing and actively cooled by spraying the patient with water and fanning you want to monitor vital signs at least every five minutes and evaluate the effectiveness of your interventions be careful not to over cool the patient you want to inform the staff at the receiving facility early on that your patient is experiencing a heat stroke because additional resources may be required document environmental conditions and the activities the patient was performing prior to your onset",
        "Management of Heat Emergencies": "then for management of these heat emergencies so when it comes to heat stroke or heat cramps we're going to take the following steps with heat cramps we're going to remove the patient from that hot environment and loosen any tight clothing administer high flow oxygen and have the patient sit or lie down until the cramps subside we want to replace fluids by mouth and cool the patient with water spray or mist and add convection by manually or mechanically fanning the patient when the heat cramps are gone the patient may resume activity the best preventative and treatment strategy is hydration by drinking water so if the cramps do not go away after these measures transport the patient to the hospital when it comes to heat exhaustion we want to treat the patient with heat exhaustion by following the steps and skill drill 33-1 when it comes to heat stroke recovery from heat stroke depends on the speed with which treatment is administered emergency treatment has one objective and that's to lower the body temperature by any means available you want to take the following steps when treating a patient with a heat stroke move the patient out of that hot environment and into the ambulance set the air conditioning to maximum cooling and remove the patient's clothing you want to administer high flow o2 and assist ventilations if indicated you want to provide cold water immersion if possible spray the patient with cool water and fan him or her to quickly evaporate the moisture on the skin aggressively and rapidly fanning the patient exclude other causes of altered mental status and check blood glucose levels if possible transport immediately to the hospital and notify the patient or hospital of the arriving heat stroke patient do not over cool this patient and call for advanced life support assistance if the patient begins to shiver",
        "Drowning": "okay so next we're going to talk about drowning so drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid some agencies may still use the term near drowning to refer to patients who survive at least temporary 24 hours after suffocation in water risk factors include alcohol consumption pre-existing seizure disorders geriatric patients with cardiovascular disease or unsupervised access to water and that's for children drowning is often the last in a cycle of events caused by panic in the water it can happen to anyone who is submerged in water for even a short period of time struggling towards the surface or the shore the person becomes fatigued and exhausted which leads him or her to sink even deeper drowning also occurs in buckets puddles and bathtubs and places where the person is not completely submerged so what happens is the patient will get a laryngospasm so inhaling very small amounts of fresh water or salt water can cause the muscles of the larynx and vocal cords to spasm this is supposed to prevent water from entering the lungs in severe cases progressive hypoxia occurs until the patient becomes unconscious",
        "Spinal Injuries in Submersion Incidents": "spinal injuries and submergent incidents and so we're going to assume that spinal injury exists with the following conditions so anytime there's a submersion has resulted from a diving mishap or significant fall also the patient is unconscious and has no information available to rule out the possibility of a neck injury or if the patient is conscious but complains of weakness paralysis or numbness to the arms or legs most spinal injuries and diving incidents oft affect the cervical spine we want to stabilize the suspected injury while the patient is still in water we need to follow the steps in skill drill 33-2",
        "Safety in Water Rescues": "okay so when it comes to safety we have to ensure the safety of the rescue personnel and request additional resources for a water rescue the basic wool rule of water rescue is reach throw and row and then go do not attempt a swimming rescue unless you're trained and experienced in these techniques if you work in an area near lakes rivers or ocean you should have pre-rage plan for water rescue",
        "Recovery Techniques": "when it comes to recovery techniques if the person is not floating or visible in the water an organized rescue effort is necessary specialized personnel are required in that with a snorkel mask in scuba gear",
        "Resuscitation Efforts": "resuscitation efforts so hypothermia can protect vital organs from lack of oxygen there is the diving reflex and this is the slowing of the heart rate it's caused by submersion in cold water it may indic may cause immediate bradycardia and that's a slow heart rhythm the person may be able to survive for an extended period of time underwater thanks to a lowering of the metabolic rate associated with hypothermia local protocols often dictate that resuscitative efforts continue for up to an hour after submersion while stimul simultaneously rewarming the patient",
        "Descent Emergencies": "when it comes to diving emergencies there are many serious water-related injuries and they're associated with diving with or without dive or scuba gear medical emergencies related to scuba diving techniques and equipment are becoming increasingly common separate them into three phases so when it comes to diving there's the descent emergencies bottom emergencies and then ascent emergencies so first we're going to talk about the descent emergencies and this is caused by a sudden increase in pressure on the body as the person dives deeper into the water the lungs sinus cavities middle ear teeth and the area surrounding by the diving mask are the most commonly affected",
        "Descent Emergencies Details": "usually pain caused by the squeeze problems forces the diver to return to the surface to equalize pressures and the problem clears up by itself now divers who continue pain particularly in the ear after returning to the surface should be transported to the hospital because there could be a peripherated tympanic membrane and that's a ruptured eardrum cold water will enter the middle ear through the ruptured eardrum and the diver may lose his or her balance and orientation the diver may not or may shoot to the surface and run into ascent problems",
        "Emergencies at the Bottom": "so let's talk about some emergencies at the bottom and those rarely occur and they're usually caused by faulty connections in the dive gear such as inadequate mixing of oxygen and carbon monoxide in the air the diver's breathing or accidentally feeding poisonous carbon monoxide into that breeding apparatus it can cause drowning or a rapid ascent required emergency resuscitation and transport",
        "Ascent Emergencies": "are needed so ascent emergencies now these are the most serious injuries and usually require aggressive resuscitation there's a multiple different ones so let's talk about the air embolism first and this is the most dangerous and most common scuba diving emergency so what happens are bubbles of air in blood vessels and you have the problem starts when the diver holds his or her breath during a rapid ascent the air pressure in the lungs remains at a high level within the external pressure of the chest and it decreases so the air inside the lungs expands rapidly causing the alveoli in the lungs to rupture and this may cause a pneumothorax or an air embolism signs and symptoms of an air embolism include blotching which is modeling of the skin froth or pink or bloody um at the nose or mouth severe pain in the muscles joints or abdomen dyspnea or chest pain dizziness nausea and vomiting or dysphagia which is difficulty speaking cough cyanosis difficulty with vision paralysis or coma or irregular pulse and cardiac arrest and then there's decompression sickness and we often hear this called the bends and the bubbles of gas especially nitrogen obstruct blood vessels this results from a rapid ascent from the dive too long of a dive at it too a deep of a depth or repeated dives within a short period of time nitrogen that is being breathed dissolves in blood and tissues complications of the bends include blockage of tiny blood vessels depriving parts of the body of their normal blood supply and severe pain in certain tissues or spaces signs and symptoms inc include abnormal joint pain so severe that the patient doubles up or bends over you may find it difficult to distinguish between an air embolism or decompression sickness so an air embolism generally occurs immediately on return to the symptoms to the surface whereas signs of decompression sickness may not occur for several hours emergency treatment for both of them and it includes basic life support and recompression in a hyperbaric chamber all right so let's talk about the assessment of diving and drowning emergencies scene size up of course scene safety your standard precautions should include gloves and eye protection at a minimum never attempt a water rescue without proper training and equipment call for additional resources early and trauma and spinal immobilization must be considered in recreational settings you have to look for indicators of that mechanism of injury",
        "Primary Assessment for Diving Emergencies": "a primary assessment always form that general impression we're going to pay attention to chest pain dipsnia and complaints of sensory changes when the diving emergency is suspected we want to determine the patient's level of consciousness as always using that apu scale and we need to be suspicious of drugs or alcohol use so airway and breathing of course open the airway and assess the breathing in responsive patients and consider the possibility of spinal trauma and take appropriate actions we need the suction the patient if the patient's vomited and then perform ventilations with a bag valve mass ventilation for inadequate breathing in conduction with an airway adjunct okay if the patient is uh responsive provide high flow oxygen with a non-re-breathing mask auscultation and frequent assessment of breath sounds in drowning patients is a key part of your assessment when it comes to circulation it may be difficult to find a pulse you want to begin cpr and apply your aed l evaluate for shocks and adequate perfusion if the mechanism of injury suggests trauma we have to assess for bleeding and transport appropriately our transport decision so we're always going to transport patients to the hospital inhalation of any amount of fluid can lead to delayed complications lasting for days or weeks decompression sickness and air emboli must be evaluated in and treated in a recompression chamber history taking so we're going to investigate the chief complaint obtain the medical history and we want to be alert for injury-specific signs and symptoms as well as pertinent negatives we need to determine the depth of the dive the length of the time the patient was under water and the time of the signs and symptoms and any previous diving activity",
        "Secondary Assessment for Diving Emergencies": "when it comes to the secondary assessment if the patient's responsive we want to thoroughly examine his or her lungs including breast sounds if unresponsive we have to look for hidden um life threats and possible potential for trauma even if trauma is not suspected for scuba divers look for indicators of decompression sickness or air emboli and check for signs of hypothermia we want to assess peripheral pulses skin color and dis coloration itching pain or paresthesia which is paresthesia's numbness and tingling okay vital signs so we want to check that pulse rate rhythm and quality and it may be difficult to palpate in a hypothermic patient so we want to check for both peripheral and central pulses listen over the chest for the heartbeat if pulses are weak and check for respiratory rate quality and the rhythm and listen for lung cells assess and document pupil size and inactivity or reactivity and oxygen saturation readings may produce a false low reading because of hypoperfusion and or shivering then we want to reassess so we have to repeat the primary drowning patients may deteriorate rapidly due to what happens is the pulmonary injury fluids will shift in the body and this is going to cause cerebral hypoxia and or hypothermia so you could have shifts in the lungs fluid could flood into the lungs okay cause pulmonary edema patients with a pneumo air embolism or decompression sickness may also decom decompensate quickly so we have to assess our patient's mental status constantly assess vital signs every five minutes paying particular attention to respirations and breath sounds and then of course we have to document the circumstances of the drowning we need to know the time the patient was submerged the temperature of the water the clarity of the water and the possibility of spinal injury we want to also bring all dive equipment to the hospital including a dialogue or a dive computer if available",
        "Emergency Care for Drowning or Diving Emergencies": "so when it talks about emergency care for these drowning or diving emergencies we have to do treatment for drowning and it begins with rescue and removal from the water so you have to mobilize and protect the patient's spine when a fall from a significant height or suspected diving injury is possible artificial ventilation should begin as soon as possible even before the patient is removed from the water the patient is not breathing remove any vomit from the airway manually or by suction and assist ventilations with a bvm or a pocket mask provide chest compressions and use the aed if the patient is in cardiac arrest administer oxygen if the patient is breathing spontaneously and treat for hypothermia when treating conscious patients who are suspected of having any air ableism or decompression sickness from scuba diving you want to follow these steps you have to remove the patient from the water and try to keep him or her calm administer oxygen and consider the possibility of a pneumo and monitor breast sounds so provide prompt transport to the emergency department or the nearest recompression facility for treatment based on local protocols",
        "Other Water Hazards": "other water hazards you want to pay close attention to body temperature of the person who's rescued from the cold water and treat hypothermia caused by immersion from cold water the same way you treat hypothermia caused by cold exposure and then there is a thing called breath holding syncope and so this is when a person swimming in shallow water and may experience a loss of consciousness and this is caused by a decreased stimulus for breathing this results in drowning and the patient is the same as that for a drowning patient the treatment is",
        "Prevention of Water Hazards": "okay so prevention so appropriate precautions can prevent most immersion accidents all pull should be surrounded by a fence and most common problem in child drownings is the lack of adult supervision so half of all teenage and adult drownings are associated with the use of alcohol",
        "High Altitude Emergencies": "all right so next we're going to talk about high altitude um issues so you have uh dyspharism injuries and this is caused by difference between the surrounding atmospheric pressure and the total gas pressure in various tissues fluids and cavities of the body and then you have altitude sickness and that occurs when an unacclimated person is exposed to diminished oxygen pressures in high air at high altitudes okay so illness uh illnesses also affect the central nervous system and pulmonary system and will range from acute mountain sickness to high altitude cerebral edema and that is haste h-a-c-e once again high altitude cerebral edema and then high-altitude pulmonary edema and that is hate h-a-p-e acute mountain sickness can occur above 5000 feet and this is caused by diminished oxygen pressure in the high in the air at altitudes above 5000 feet and this results in hypoxia right so this results from ascending too high too fast or not being acclimized to high altitudes signs and symptoms include a headache light-headedness or fatigue loss of appetite nausea difficulty sleeping shortness of breath during physical exertion and possibly a swollen face so treatment primarily consists of stopping the ascent and descending to a lower altitude when it comes to hape that is high altitude pulmonary edema and this can happen above 8 000 feet what happens is fluid collects in the lungs and it hinders the passage of oxygen into the bloodstream signs and symptoms include shortness of breath pink a cough with pink sputum cyanosis and a rapid pulse and then there's haste that's high altitude cerebral edema and this can happen above 12 000 feet may accompany hate and can quickly become life-threatening signs and symptoms are severe constant throbbing headache lack of muscle chlorination and balance extreme fatigue vomiting and loss of consciousness treatment for hate or and haste occur involves descending to that lower altitude providing oxygen rapid transport and for inadequate respirations of course we're going to provide positive pressure ventilation with the bdm cpap may be helpful for a patient with respiratory distress from hate all right so next environmental",
        "Lightning Strikes": "emergency we're going to talk about is lightning",
        "Lightning Strike Details": "there are an estimated 25 million cloud to ground lightning strikes each year in the us lightning is the fifth most common cause of death from an isolated environmental um phenomena targets of direct lightning strikes include people engaged in outdoor activities or anyone in a large open area many individuals are indirectly struck when standing near an object that has been struck by cardiovascular and nervous systems are most commonly injured okay so respiratory and cardio arrest are the most common caused by lightning related deaths the tissue damage pathway usually occurs over the skin rather than through it because the duration of lightning strike is short skin burns are usually superficial categories of lightning strikes include mild loss of consciousness their amnesia confusion tingling or non-specific signs and symptoms or superficial burns and then you have moderate the lightning strikes and seizures respiratory arrest dysrhythmias that spontaneously resolve or superficial burns when it comes to severe cardiopulmonary arrest let's talk about the emergency care and treatment so we want to take measures to protect ourselves from being struck by lightning move the patient to a sheltered area and then we're gonna do uh use a reverse triage so anyone who is in cardiac or respiratory arrest is there is our first try priority other people who may have been struck will not develop cardiac complications so um treatment so we want to stabilize the spine and open the airway with a jaw thrust if the patient is uh if pulses are present and we just need to assist ventilation so if a patient is in cardiac arrest so we want to use the aed as soon as possible control bleeding and transport to the nearest facility okay a patient with signs and symptoms of a lightning strike but no obvious life threats should be transported for evaluation",
        "Spider Bites": "and now we're going to talk about bites and envenomations so we have spider bites spiders are numerous and widespread in the us there are only two spiders the female black widow and the brown recluse spider that deliver serious even life-threatening bites okay so let's",
        "Black Widow Spider": "talk about the black widow first the black widow spider is large measures approximately two inches with the legs extended so usually black with very distinctive bright red orange marking in the shape of an hourglass on its belly his abdomen and they prefer dry dim places around buildings wood piles and among debris the vite bite is sometimes overlooked if the site becomes numb right away the patient may not even recall being bit however most black widow spreader brights cause localized pain and symptoms including agonizing muscle spasms a bite in the abdomen may cause muscle spasms so severe that they resemble an acute abdominal condition the main danger is the venom which can cause nerve tissue damage other systemic signs and symptoms include dizziness sweating nausea vomiting rashes tightness in the chest difficulty breathing and severe cramps generally the signs and symptoms subside over 48 hours a physician can administer a specific antivenom but because of high incidence of side effects its use is reserved for very severe bites older people and younger children younger than five emergency treatment consists of bls care for the patient in respiratory distress transport to the emergency possible department as soon as possible and if possible bring safely bring the spider to the hospital or take a photo of the spider with a cell phone and send it to the hospital ahead of time",
        "Brown Recluse Spider": "okay so the next spider we're going to talk about is the brown recluse spider it's a dull brown in color and about one inch long and the short haired body has a violin shaped mark brown to yellow in color on its back it lives mostly in the southern and central parts of the country but may be found throughout the continental united states they tend to live in dark areas such as corners of old unused buildings under rocks and in wood piles the venom is not neurotoxic but synotoxic it causes severe local tissue damage typically the bite is not painful at first but becomes so within hours the area becomes swollen and tender developing a pale modeled cyanotic center and possibility possibly small blister a scab of dead skin fat and debris will form and dig down into the skin producing a large ulcer that may not heal unless treated promptly transport patients with such symptoms as soon as possible these bites are rarely cause systemic symptoms and signs but when they do the initial treatment is bls and transport to an emergency department if possible safely bring the spider to the hospital or take a photo of the spider with a cell phone and send it to the hospital ahead of time",
        "Hymenoptera Stings": "okay so now we have bees wasps yellow jackets and ants and and these things are painful but not a medical emergency we have to remove the stinger and the venom sac using a firm edged eye item such as a credit card to scrape the stinger and sack off the skin use ice packs to assist in controlling pain from that sting okay so anaphylaxis may occur if the patient's allergic to the venom signs and symptoms include flush skin low blood pressure difficulty breathing wheezes hives or swelling of the throat and tongue and be prepared to assist the patient in administering an epipen auto injector and support the airway and breathing so the next environmental emergency",
        "Snakebites": "we're going to talk about is snake bites so steak snake bite fatalities in the u.s are extremely rare about 15 a year for the entire country and of the approximately 115 different species of snakes native in the us only 19 are venomous so these include rattlesnakes the copperhead the cottonmouth or the water moccasin and then there's the coral snakes okay so the figure on this slide shows different poisonous steaks that are found in the united states snakes usually do not bite unless they're provoked angered or accidentally injured as when they are stepped on except for cottonmouths which are very aggressive so protect yourself from getting bitten use extreme caution on these calls and wear proper protective proper protective equipment for the area okay so only one third of the snakes result in significant local or systemic injuries venomous snakes native to the united states have hollow fangs in the roof of their mouth and that that inject the poison from two sacks uh at the back of their head okay so the classic appearance of these poisonous snake bites is two small puncture wounds usually about a half inch apart with discoloration swelling and pain non-venomous snakes can also bite usually leaving a horseshoe of tooth marks fang marks are clear indications of a poisonous snake bite this is what we're going to talk about is pit vipers okay and so pit vipers are rattlesnakes copperheads and caught mouth and they're all called pit vipers with triangular shaped flat heads they take their name from the small pits located just behind each nostril and in front of each eye the pit is a heat sensing organ okay the fangs are special hollow teeth that act much like a hypodermic needle connected to the sac containing a reserve of venom rattlesnakes they're the most common form of a pit viper and they have patterns of color often with a diamond pattern they can grow up to six feet or more in length then there's copperheads they're usually two to three foot long the red copper color cross with brown and red bands typically inhibit wood piles and abandoned dwellings and they account for most of the venomous snake bites in the eastern united states their bites are almost all never fatal but the venom can cause significant damage to tissues in the extremities and then there's cotton mouths they grow about four feet in length also called water moccasins they're oliver brown with black cross bands and a yellow under surface they are water snakes with an aggressive pattern of behavior fits fatalities from these snake bites are rare but tissue destruction from the venom may be severe the signs of envenomation by a pit viper are severe burning at the site of the injury followed by swelling and a blue discoloration so that echomosis signs are evident within five to ten minutes and they spread over the next 36 hours in addition to destroying tissues locally the venom of a pit viper can also interfere with the body's ability to clot and cause bleeding to at various distant sites okay distinct sites other signs and symptoms may or may not include weakness nausea vomiting sweating fevers and fainting vision problems changes in level of consciousness and shock if swelling has occurred use a pen to mark its edges on the skin when treating a bite from a pit viper you want to take the following steps so calm the patient place the patient in a supine position and explain that staying quiet will slow the spread of any venom through the system locate the bite area and clean it with soap and water apply ice if the bite occurs in an arm or leg consider the use of pressure immobilization bandage of the extremity then place the affected extremity below the level of the heart be alert for an anaphylactic reaction to that venom and treat with an epi auto injector as appropriate do not give them anything by mouth and be alert for vomiting if the patient was bitten on the trunk keep him or her supine and quiet and transport as quickly as possible you want to monitor the vital signs and mark the skin with a pen over the area that has swollen and note whether the swelling is spreading if there are any signs of shock where you're going to treat for it and if the snake has been killed bring it with you alternatively take a picture of the snake with a cell phone and send it to the hospital ahead of time you want to notify the hospital that the patient has been bitten by a snake if possible describe that snake and then transport appropriately if the patient knows the signs of no signs the patient shows no signs of envenomation where you're just going to perform bls as needed and place the patient place a sterile dressing over the suspected bite area and immobilize the injury site all patients with a suspected snake bite should be taken to the emergency department you want to treat the wound as you would any deep puncture wound to prevent infection all right so that was the pit vipers now we're going to talk about the coral snakes and this is a small reptile with a series of bright red yellow and black bands completely and circulating the body okay red on yellow will kill a fellow red on black venom will lack so it injects the venom with its teeth and tiny things by chewing motion leaving puncture or scratch-like wounds because of its small mouth and teeth a limited jaw expansion the coral snake usually bites its victims on a small part of the body such as a finger or toe coral snake venom is a powerful toxin that causes paralysis of the nervous system within a few hours after being bitten a patient will exhibit bizarre behavior following by progressive paralysis of eye movements and respiration successful treatment depends on positive identification of that snake and support of respiration anti-venom is available but most hospitals do not stock it emergency care of a coral snake bites are the same as a pit viper fight okay so the next thing we're gonna talk about is scorpion stings and scorpions are eight-legged arachnoids with a venom gland and a stinger at the end of their tail they are rare and live primarily in the southwestern united states and in deserts with one exception a scorpion sting is usually very painful but not dangerous causing localized swelling and discoloration the figure on this slide shows a scorpion the exception is a specific type of scorpion and the venom of this species may produce a severe systemic reaction that brings about circulatory um collapse severe muscle contractions excessive salivation hypertension convulsions and cardiac failure if you're called to care for a patient with a suspected sting from this type of arachnoid notify medical control as soon as possible administer bls and transfer the patient as rapidly as possible and then there's tick bites so ticks are tiny insects that usually attach themselves directly to the skin they're found most often in brush shrubs trees sand dunes and other animals the bite is not painful but infectious diseases can spread through the tick saliva okay so the figure on this slide shows a tick and the characteristics bullseye rash pattern associated with lyme disease rocky mountain spotted fever this occurs within seven to ten days after a bite and that occur that symptoms are nausea vomiting headache weakness paralysis and cardiorespiratory collapse and then lyme disease so lyme disease is reported in the united states with the exception of hawaii the first symptoms are generally fever flu-like symptoms symptoms um they're associated with that bull's-eye rash that may spread to several parts of the body after more than a after a few days or weeks painful swelling of joints particularly in the knees occur and it may be confused with rheumatoid arthritis and may result in permanent disability if it is recognized and treated promptly with antibiotics the patient may recover completely tick bites occur most commonly during the summer months you want to provide any necessary supportive care and transfer the patient transport the patient for further eval in situations where access to care is delayed remove the tick by using fine tweezers to grasp the tick's head and pull straight out of the skin once the tick is removed cleanse the area with antiseptic and save the tick in a glass jar for identification do not handle the tick with your fingers the patient should follow up with their health care provider as soon as possible and then we're going to talk about injuries from marine animals so basically marine animal envenomations are responsible for more envenomations than any other marine animal you could have fire coral portuguese maniwar sea wasps sea nettles true jellyfish sea anemones and true coral and soft coral figures on this screen show examples of those on jellyfish portuguese man of war and the sea anemone the stinging cells are called neocytes so signs and symptoms very painful red lesions in light-skinned individuals lesions that extend in a line from the sight of the sting headache dizziness muscle cramps and fainting treatment so what do we want to do we want to remove the patient from that water remove the tentacles by scraping them off with an edge of a sharp stiff object such as a credit card not try to manipulate the remaining tentacles on rare occasions a patient may have a systemic allergic reaction so we want to treat such a treat the patient for anaphylactic shock we need to give basic life support and provide immediate transport to the hospital toxins from the spines of sea urchins stingrays and certain spiny fish such as a lionfish scorpion fish or stone fish are heat sensitive the best treatment is to mobilize the effective area and soak it in hot water for 30 minutes the patient still needs to be transported if you work near the ocean you should be familiar with the marine life in your area the emergency treatment of common envenomations consists of the following steps limit further discharge by avoiding fresh water wet sand showers or careless manipulation of the tentacles remove the patient or keep the patient calm and reduce motion of that affected extremity remove the remaining tentacles by scraping them off with the edge of a stiff sharp object immersion in vinegar may also help alleviate the symptoms and then provide transport to the emergency department okay so that concludes the lecture part for chapter 33 environmental emergencies now we're going to go over the review questions to see what we've learned okay so when a person is exposed to a cold temperature and strong winds for an extended period of time he or she may lose heat mostly by and what did we know that is by convection and so if this occurs when the heat is transferred by that circulating air shivering in the presence of hypothermia indicates that the it's going to be c and that's uh that shivering its body is trying to produce heat by generating it through muscle activity right all of the following examples of passive rewarming techniques except all right so it's going to be passive re-warming involves the body's temperature okay so the body and so we know administering fluids in mouth by mouth is not passive a woman with frostbite to both feet walking several miles in the frozen field her feet are white hard and cold to the touch treatment at the scene includes okay so we know we're not going to rub them we're not going to help her walk we want to probably remove the wet clothing and cover her feet in dry sterile dressings yeah because we know we're never going to rub the feet okay 30 year old male who has been playing softball on a all day in a hot environment complains of weakness nausea shortly after experiencing a sinkable episode appropriate treatment for this patient includes all of the following except we want to move them to closer colder environment give them oxygen and so we're going to do everything except for giving them something to drink right right you're assessing a 27 year old woman with a heat related emergency her skin is flushed and hot and moist and her level consciousness is decreased after moving her to cool environment managing her airway and administering oxygen what are we going to do okay so the patient's having a heat stroke after moving her to that environment we are going to cover her with wet sheets and fan her okay it's important to remove a drowning victim from the water before the laryngospasm relaxes and why is this and that is because um it's going to be even small amounts of salt or fresh water might cause that laryngeal spasm and so less water will have entered the patient's lungs if we get them out before a 13 year old is found floating face down in a swimming pool witnesses tell you that the girl was practicing diving after you and your partner safely enter the water what are we going to do and what we're going to do is rotate that body as a unit okay so we're going to rotate the entire upper half of her body as a unit shortly after ascending rapidly to the surface of the water while holding his breath the 27 year old diver begins to cough pink frothy sputum and he's talk complaining of dipsnia and chest pain what are we gonna suspect and we know that uh that's gonna be an air embolism so the signs of an air embolism okay and then finally three ambulances respond to a golf course where a group of six golfers were struck by lightning two of the golfers are conscious and alert and they have some burns the next two golfers have minor fractures and appear confused and then the last two are in cardiac arrest according to the reverse triage which group of golfers should be treated first okay and we knew uh we know that the group in cardiac arrest so c right so that reverse triage where normally um triaging um the while we're doing a triage we know that cardiac arrest is usually normally um the last people but with the reverse triage we're gonna use them first we're gonna do those first okay so this concludes chapter 33 of the environmental emergencies um thank you for listening to the chapter and hope you have a good day"
    },
    {
        "National EMS Education Standard Competencies": "hello and welcome to chapter 28 psychiatric emergencies of the emergency care in the streets lecture upon completion of this chapter and the related course assignments you should be able to recognize behaviors that are associated with risk to providers the patient and others you should be able to discuss the concerns of treatment and transport of a patient having a psychiatric emergency you should also be able to identify situations when where strains may be justified and whether chemical or physical restraint is the preferred method you should also be able to discuss the potential causes of behavioral emergencies and medications that may be used in the treatment of these disorders and finally you should be able to describe the assessment process and safe management of a patient having a psychiatric emergency",
        "Introduction": "so let's get started the mind and body are inseparable parts of the human being illness affects the person's behavior and it also often makes them anxious or depressed changes in mental state influence physical health a depressed person may lose appetite or become more susceptible to bodily disease whenever you examine a patient try to understand both the physical and mental factors contributing to the patient's disease",
        "Definition of Behavioral Emergency": "most experts define behavior as the way people act or perform behavior is all things people do the reason they do these things overt behavior is open and generally understood by those around the person covert behaviors are those that have hidden meanings or intentions that only the person understands almost all disordered behavior represents the person's effort to adapt to stress in most cases the disruptive behavior abates while the person mobilizes his or her physiologic defense mechanism okay so while we're continuing through the definition of a behavioral emergency let's define behavioral emergencies situations in which the patient's presenting problem is some disorder of mood thought or behavior that interferes with activities of daily living adl stands for activities of daily living and that equals normal everyday activities a psychiatric emergency is an abnormal behavior that threatens a person's health or safety or the health and safety of another person most extreme examples are when the person becomes suicidal or homicidal or psychotic in a psychotic episode a patient often experiences delusions or hallucinations and illusions and that's errors and perception so a psychotic episode can have dangerous consequences because of the violent behavior the imperative definition of a behavioral or psychiatric emergency is provided by the person who dials 9-1-1 it can be difficult to perform when you are trying to understand the patient's confused and frayed feelings pre-hospital intervention is possible and often critical in these emergencies",
        "Prevalence": "according to the centers of disease control and prevention the average number of mentally unhealthy days for americans has increased americans reported an average of 2.9 mentally unhealthy days per month in 1993 and in 2008 3.4 days of mentally unhealthy according to a 2014 study published by the u.s department of health and human services an estimated 43.5 million adults age 18 years or older were estimated to have had mental illness in the past year almost 10 million adults age 18 or older are estimated to have had a serious mental illness within the past year and 39.8 million american age 18 years or older are considered current illicit drug users a compounding factor in many mental illnesses serious mental illness is a diagnosis of a psychiatric disorder for example with serious functional impairment",
        "Medicolegal Considerations": "when a person's behavior speech and thoughts are erratic it can be difficult for you to communicate clearly be prepared to spend time with the patient obtain cons consent when possible if the patient refuses continue to talk with him or her about the situation and explain your responsibilities if a patient refuses transport follow your local protocols in standing orders you will often need assistance from law enforcement personnel be clear in your explanations when administering treatments and medications and don't assume that the patient is unable to understand what you're trying to do take time and thoroughly record the call be objective and factual and include comments made by the patient",
        "Causes of Abnormal Behavior": "okay so when it comes to psychiatric emergencies there are four broad categories and we're going to talk about those next so abnormal behavior typically results from a complex interaction of biological or organic causes developmental factors psychological stressors emotional stimuli or social cultural influences these causes can be classified into four broad categories causes that are biologic or organic in nature causes resulting from the person's environment causes resulting from an acute injury or illness or causes that are substance related biologic or organic causes is what we're going to talk about first many patients who present with psychiatric symptoms are affected by biologic or organic factors that interfere with normal cerebral function patients were previously described as having organic brain syndrome so patients with that thought to be non-organic abnormalities do have psychiatric dysfunction in the brain causing their psychiatric illness examples of biological organic causes of abnormal behavior and crew include chronic hypoxia seizure traumatic brain injury chronic alcohol or drug abuse or brain tumors these conditions alter the normal function of the brain and they may cause derangements in behavior and most common offenders are alcohol and drugs dementia and delirium and then there's environmental causes they may include both psychosocial and social cultural influences when people are constantly exposed to stressful psychosocial events or developmental influences they may develop abnormal reactions when a person's basic needs are threatened that person faces a crisis and may cope with it or attempt to alleviate the discomfort by escaping from that stress with alcohol drugs or suicide social psychological factors directly affect biology behavior and response to the stress of emergencies such as assault rape violence or the death of a loved one may produce significant changes in behavior next is injury and illness as causes acute illness can overwhelm a person causing changes in behavior some medical conditions that can cause abnormal behaviors are severe infections electrolyte abnormalities or many types of metabolic disorders an acutely traumatic situation creates stress for the person and those around them post traumatic stress disorder is a severe form of anxiety stemming from a traumatic exposure also substance related causes and the disorders include most often alcohol cigarettes illicit drugs or other substances that change the way the person feels behaves or thinks",
        "Psychiatric Signs and Symptoms": "so when a person's mental health is challenged psychological mechanisms or behaviors mobilize to return the mental state to homeostasis it presents with various types of psychiatric signs symptoms and behaviors it can be grouped according to the systems affected and the psychological functions include consciousness motor activity speech thought it affects the outward expression or of inner feelings their memories orientation and perception psychiatric signs and symptoms include these areas as well as changes in the thought progression thought content mood or intelligence",
        "Patient Assessment": "so differences from other typical methods of patient assessment so when you're assessing disturbed patient you are the diagnostic instrument you must use your thinking processes your perceptions and feelings the assessment of a patient with a behavioral emergency is part of the treatment as soon as you speak to the patient your voice and manner will affect his or her condition listening to the patient describe the issue can also mitigate the problem so assess the patient wherever the emergency occurs",
        "Scene Size-Up": "so let's talk about the patient assessment when it comes to the scene size up situations that have a strong behavioral component are most likely the type of call to present surprises these may appear to be simple calls but the superficial problem may be the result of the patient's own erratic behavior so you have to ensure your safety at the scene this table shows safety guidelines for behavioral emergencies the environment can give clues to the patient's condition or the cause of the emergency so look for the potential clues from the patient's social history general living conditions availability of social and family support activity level medications and overall appearance consider the mechanisms of injury and the nature of illness",
        "Primary Survey": "when it comes to your primary survey clearly identify yourself and tell the patient who you are and what you're trying to do your general impression how much of the assessment you're able to perform will be determined by the patient's overall condition the nature of his or her psychiatric problem you should at least be able to assess your patient's general appearance the airway and breathing so tend to the priority problems first airway breathing and circulatory concerns and assess the airway to make sure it's patent and adequate evaluate the patient's breathing and provide interventions based on your findings when it comes to circulation assess the pulse rate quality and pro and rhythm obtain the systolic and diastolic blood pressures when possible and evaluate for the presence of shock and bleeding and assess the patient's perfusion level by evaluating the skin color temp condition and cap refill so transport decisions what we're going to talk about next and seriously disturb patients should be seen by a physician a conscious adult must consent to be taken to a medical facility so if the patient withholds consent he or she may be taken against his or her will only at express request of the police or the community medical health physician in some jurisdictions the same policy applies to the use of forcible restraint so law enforcement officers should be summoned and every ambulance service should have clearly defined protocols",
        "History Taking": "and then there's history taking part of your assessment so mental status examination or mse is a part of the assessment for a patient experiencing an acute psychiatric emergency check each of the systems of mental function in order using coast map so let's talk about coast map",
        "COASTMAP": "the c stands for consciousness o orientation activity s speech then we're going to talk about the map part so or t is thought m is m memory a is effect and p is perception so let's go through this so consciousness determine the level of consciousness whether the alert confused responds to pain or responsive the orientation is ask what year or month it is activity is restlessness or agitated pacing up and down or experiencing tremors or making any strange movement or repetitive movements s is speech so note the rate volume flow articulation too fast or too slow or too loud or too soft are they using strange words and then thought what is on his or her mind is the patient making sense is there anything unusual about his or her reasoning and then memory recent remote or immediate memories in place of what the patient can or cannot recall an effect in mood is the patient euphoric or sad or is the patient able to talk does the effect seem appropriate to the situation and then the perception ask the patient do you ever hear things that other people cannot",
        "Secondary Assessment": "hear then the secondary assessment so obtain vital signs look for fever or indications of increased intracranial pressure examine skin temperature and moisture inspect the head for evidence of trauma and check the pupils for size equality and reaction to light note any unusual disturbances on the patient's breasts such as poisonings or alcohol or perhaps ketones from diabetic ketoacidosis in examining the extremities look for needle marks tremors or unilateral weakness or loss of sensations",
        "Reassessment": "and then your reassessment so routinely performed during transport monitor patients for sudden changes in thought or behavior and your radio reports of the medical facility should include a report of the medical and mental history medications prescribed and assessment findings also any pertinent information from the medical status examination discuss with the medical facility the need for restraints or medications before instituting these interventions",
        "Emergency Medical Care": "all right so medical care if the erratic behavior might be caused by a medical disorder treat that disorder before assuming the behavior is due to an emotional or psychiatric cause some measures could include oxygen therapy testing blood glucose administrating dextrose or general interventions for hypothermia or shock management",
        "Communication Techniques": "communication techniques so virtually all of the diagnostic information comes from talking with the patient set ground rules for your interview and let the patient know what you expect and what he or she may expect of you allow the patient to tell their story in his or her own way some guidelines include begin with open ending questions let the patients talk and listen and show your listening don't be afraid of silences maintain an attentive and relaxed attitude until the patient resumes the story it is important to be silent when the patient stops speaking because of overwhelming emotion acknowledge and label the patient's feelings do not argue facilitate communication and direct the patient's attention ask questions keep questions as open-ended as possible and avoid avoid yes or no or leading questions and adjust your approach as needed",
        "Crisis Intervention Skills": "so next we're going to talk about some crisis intervention skills be as calm and direct as possible and indicate that you are confident that the patient can maintain control exclude disruptive people and sit down preferably interview the patient while sitting at a 45 degree angle to the patient maintain a non-judgmental attitude and provide honest reassurance and develop a plan of action this step gives the patient the feeling something is being done to help don't present an array of choices but state what you think is best course of action and once the plan is determined and you have begun to carry it out allow the patient to make choices and exercise some control over the situation encourage some motor activity and stay with the patient at all times bring all of the patient's medication to the facility it will help physicians identify the condition for which the patient has is being treated and never assume that it is impossible to talk with any patient until you have tried to do so",
        "Chemical Restraint": "okay so physical restraint use of force and types of restraint so the first one we're going to talk about is physical restraint devices can be improvised from your ambulance materials or commercially made commercial restraints may be applied to wrists and ankles or around the waist or from the front of the patient and may include sleeves to restrain arms be familiar with the strains used by your agencies and make sure you have sufficient personnel before restraining the patient you must have a minimum of at least five trained able-bodied personnel and this includes one for each arm and one for the head a point one leader to direct the team before you begin discuss the plan of action law enforcement should be included when physically restraining violent patients law enforcement might refuse to help restrain a patient in the absence of a warrant for subjects arrest or evidence of evidence of an immediate threat use minimum force necessary and don't immediately move towards the patient give him or her a chance to choose non-violent behavior if the show of force does not calm the patient responders must move quickly to restrained the best position for securing a patient is supine never place your patient face down throughout the process you and your partner should talk to the patient treat the patient with dignity and respect at all times never tie the patient's ankles and wrists together as one hobby tie and that's tied just the feet together and never place a patient face down once restraints are in place do not remove them and don't negate or make d uh deals continuously monitor the patient's airway breathing vomiting airway obstruction and cardiovascular stability and check peripheral circulation every few minutes you want to check radial pulses in the arms and dorsal pedis pulses in the feet be careful if a combative patient suddenly becomes calm and unrecor and cooperative remain vigilant document everything in the patient's chart the reasons you use the restraints examples of the patient's behavior indications of the violence the violent potential number of patients used to subdue the patient the restraining devices used and the status of the patient's airway breathing and peripheral circulations after restraints were applied you may be use reasonable force to defend yourself against an attack having witnesses in attendance can protect you against false accusations to properly restrain a patient using a four-point physical restraint technique refer to your skill drill 28-1 a two-point restraint technique is an option if allowed per protocols so this is performed in the same way as four point except instead of restraining all four extremities to the stationary frame of the stretcher one arm is placed upward towards the head and the other is placed downward towards the waist next we're going to talk about chemical restraint and it's one alternative to physical restraint it uses medication to subdue a patient and this option should be used only with approval of the medical director and by following clearly established local protocols and guidelines not always easier than physical restraint and it has its own hazards so avoid combinations of sedative medicines use physical or chemical restraint only after verbal attempts to de-escalate a patient with excited delirium have failed make the patient comfortable with a blanket or pillow to reduce an anxiety and often accompanies psychosis the medications used most often for chemical restraints include short-acting benzodiazepines antipsychotics disassociative agents and antihistamines many of these medications have not been approved by the fda for chemical restraint though and the fda has issued black box warnings for some of those medications first we're going to talk about benzodiazepines valium ativan or versed so diazepam lorazepam or midazolam is given as either an intramuscular or an iv injection only midazolam and lorazepam have reliable im absorption adverse effects are usually mild easily treated and include drowsiness decreased mental alertness sedation respiratory depression insomnia and agitation usually a safer and effective form of chemical restraint compared to other medicines benzodiazepines are shorter acting such as midazolam and may be given internasally and the onset of the action varies depending on the route of administration antipsychotic medications such as haloperidol or geodon there is a black box warning for doper peridol because of its association with prolonged qt syndromes higher dose and iv administration of heliperidol appears to be associated with the higher risk of the qt prolongation and torsades to points haloperidol is commonly administered using iv administration fda has not approved this route of administration do not administer to patients younger than 14 with those those of a suspected head injury or those who may be pregnant approved for treatment of patients with dementia related psychosis typical antipsychotics may cause seizures or a wider range of symptoms including involuntary movements tremors rigidity muscle contractions restlessness changes in breathing and pulse rate combined with alcohol and other cns depressants it may worsen the cns suppression monitor for hypotension bradycardia and glucose levels next we're going to talk about the antihistamines and specifically benadryl or diphyhydramine have been used for many years into treatment of psychiatric patients they're best known for the sedative properties produces an anti-colorgenic effect that has some effect on the neurotransmitters in the brains that affect behavior it can be used for both adult and pediatric patients",
        "Pathophysiology, Assessment, and Management of Specific Emergencies": "pathophysiology assessment and management of specific emergencies okay so many factors contribute to disturbances of behaviors the causes signed symptoms and management can be grouped into several common areas so let's talk about the pathophysiology",
        "Acute Psychosis": "of acute psychosis state of delusion in which a person is out of touch with reality affected people are turned into their own internal reality of ideas and feelings and reality and fantasy are blurred psychosis and psychiatric episodes occur for many reasons such as biologic or organic mental illness or drug abuse causes relating to the patient's environment or mental illness include intense stress delusional disorders and schizophrenia schizophrenia psychotic episodes can be brief or last a lifetime and disorganization and disorientation are ways in which various conditions may present themselves okay so let's talk about the assessment of the acute psychosis and the most characteristic feature is a profound thought disorder a thorough examination is rarely possible and your principal objective is to transport the patient to the medical facility without trauma coast map outlines common signs and symptoms so consciousness they're awake and alert but may be easily distracted orientation there's disturbances and orientation are more common in organic disorders than in psychosis activity most commonly accelerated with agitation and hyper activity bizarre stereotype movements are common and speech they may be pressured or sound strange because of unusual words the patient has invented they're thought they're disturbed in progression and content and may show any of the following disorders so flight of ideas loosening of associations delusions thought broadcasting and that's when the belief that thoughts can be heard by others or thought insertion and that's when the belief that thoughts are being thrust into the mind by another person also thought withdrawal and that's the belief that thoughts are being removed memory and that can be relatively or entirely intact affect a mood so the mood is likely to be disturbed an effect may result reflect those of interstates or be flat also the perception so auditory hallucinations are common with acute psychosis management so usual methods of reasoning may not work because the patient may have their own rules of logic you are likely to feel uncomfortable in the presence of a psychotic person so the disorganization patient needs structure explain in plain language what is being done and what the patient's role will be direction should be simple consistent and firm and keep oriented creep bring the patient to the time place and the people in the environment and who they are and what they're doing you may have to repeat the information several times and reassure the patient and point out landmarks to help orient him or her when the patient's behavior threatens his or her own well-being or the safety of others you must take an aggressive step to prevent the injury these steps might include physical restraint chemical restraint or both so people experiencing a psychotic episode often do not comply with treatment so employ non-pharmacologic interventions first when these methods fail it may be appropriate to safely restrain the patient and then administer a medication to help the behavior follow medical control direction and standing orders when administering medications",
        "Agitated Delirium": "okay so let's talk about excited delirium next or agitated delirium you'll see it see it worded and so the pathophysiology is its state of global cognitive impairment it's acute and onset and associated with flux fluctuations and mental status and behavior and endorse organized thinking an altered level of consciousness and usually caused by toxic or metabolic problems or infections dementia is the more chronic process that produces severe deficits in memory abstract thinking and non-judgment patients may be agitated and violent when stressors overwhelm them and they are unable to maintain homeostasis common risk factors that may preclude delirium include medical histories of hypertension chronic obstructive pulmonary disease alcohol abuse or smoking so assessment of the excited delirium should first try to reorient the patients to the surroundings and circumstances perform a thorough assessment and management so identify the stressor or metabolic problem and it can help determine the treatments",
        "Suicidal Ideation": "okay so next we're going to talk about suicidal ideation so suicide is any willingful act designed to end one's life it's the second leading cause of death in 10 to 34 year olds and the fourth leading cause of death in 35 to 54 year olds more common among men and risk also high among alcoholics and depressed patients it's estimated that at least one million people in the united states intentionally harm themselves each year attempts typically occur when a person feels that close emotional attachments are endangered has lost someone or something important in life or has feelings characteristics of depression so an assessment the assessment of a depressed person must include an evaluation of the suicidal risk and many paramedics are reluctant to ask about suicidal thoughts because they fear putting the idea in the patient's head approach the subject using a step wise approach so have you ever thought that life wasn't worth living or did you ever feel that you would be better off dead the following patients indicate higher risk who must be evaluated at a medical facility so patients who have made the previous attempts patients who have detailed concrete plans or patients who have a history of suicide among close relatives when a person phones to threaten suicide someone should stay on the line until the rescue squad has reached the patient on arrival survey the area for any instruments the patient might use for self-injury and remove them and be sure to protect your own safety encourage the patient to discuss feelings and ask about the patient's suicidal in ideas and plans whenever you find a patient that is severely depressed or subject suspect a risk of suicide do not leave the patient alone so collect implements of potential self-destruction and bring them with you to the medical facility and acknowledge the patient's feelings encourage transport the patient refuses try to get the people who are close to the patient to help with cooperation it may be necessary to obtain law enforcement assistance when a person has attempted suicide medical treatment is priority if the patient is conscious try to establish communication and ask the patient to talk about the situation",
        "Patterns of Violence, Abuse, and Neglect": "okay so patterns of violence abuse and neglect are what we're going to talk about next and so abuse and neglect so victims and perpetrators of violence and abuse may themselves have a mental illness assess the following for anything that suggests abuse neglect or violence in the patient the environment or the persons involved document your findings and report your concerns according to the local protocols your priorities are safety and management of the acute medical and trauma conditions when it comes to violence aggressive behavior may be the patient's way of dealing with feelings of helplessness most angry patients can be calmed by a trained person who conveys confidence the patient will behave you well ems personnel should be prepared beforehand to deal with hostile or violent behavior preventive action is the best way to ensure no one is harmed stay alert for possible violent encounters and take measures to prevent violence from happening identify situations with the potential for violence preventative action starts with being psychologically prepared for a possible violent encounter so be aware of the possibility during your response to every call and don't rely completely on the information your dispatcher gives you develop survival awareness risk factors for violence so scenarios in which violence is more likely include any situations where there's alcohol or illicit drug use incidents involving large crowds or incidents in which violence has already occurred so people who are more likely to be violent include those intoxicated those experiencing withdrawals those that are psychotic and those who are experiencing delirium from any cause look for the following warning signs so posture if they're sitting intensely at the edge of a chair or gripping at an armrest speech so if they're loud critical or threatening motor activity if they're unable to sit still or pacing back and forth other body language such as cleanse fists or your own feelings management of violent patients include assess the whole situation so are factors in the surroundings contributing to the escalation of violence and can those factors be removed does evidence suggest drug use alcohol use or head injury or diabetes observe your surroundings make sure you have an escape route and place yourself between the patient and the door and don't turn your back on the patient even for a moment and note any furniture potential behaviors or barriers and maintain this safe distance maintain a safety zone of two arm lengths if the patient backs away from you you are too close position yourself at a 45 degree angle with your patient with an escape route unobstructive try verbal interventions first so take a moment to concentrate on your thoughts acknowledge the patient's behavior and restate your willingness to help encourage the patient to talk about what is bothering him or her and show that you are listening ask the patient specifically if he or she might lose control or is carrying a weapon and define your expectations of the patient's behavior if the verbal de-escalation techniques not working back off and get help",
        "Mood Disorders": "all right so next we're going to talk about specific mood disorders and they're formally known as effective disorders it could include manic depressive or major depression and changes in effect are accompanied by other symptoms as well so unipolar mood disorders moods where the mood remains at one only one pole of the depression mania continuum and bipolar is when the mood alternates between mania and depression and then you have manic behavior so patients typically have agitated perceptiveness of joy or euphoria patients are typically awake and alert but easily distracted and fight or flight ideas and delusions of grandeur make it difficult for them to focus on one thing their ideas are often grand duos or unrealistic memory is usually intact but may be disoriented by delusions their effect is agitated and patients have a high probability of getting in some sort of trouble so patients are unlikely to be considered themselves ill and may not agree they need treatment and if the patient refuses transport consult medical control and then a mood order disorder that's common is depression in 2015 an estimated 16.1 million adults aged 18 years or older in the united states reported that they had at least one major depressive episode in the past year that number represents 6.7 of all adults in the united states and they're often identified as a sad expression bouts of crying listlessness expression of worthlessness or guilt wanting to be left alone or and they can occur in episodes with sudden onset and limited duration onsets can also be chronic for diagnosis features of depression use the mnemonic gas pipes okay so it stands for guilt appetite sleep disturbance paying attention interest psychomotor abnormalities energy or suicidal thoughts",
        "Schizophrenia": "next we're going to talk about schizophrenia so schizophrenia 1 in 100 people will be affected in their lifetimes typical onset occurs during early adulthood and contributing influences may include genetics or microbiologic psychological and social influences schizophrenics may include or experience delusions hallucinations apathy a flat effect a lack of interest in pleasure erratic speech or an emotional response or a lack of or extreme motor behavior",
        "Neurotic Disorders": "okay so next we're going to talk about neurotic disorders that's a collection of psychotic or psychiatric disorders without psychotic symptoms so these include anxiety disorders so mental disorders in which dominant moods are fear and apprehension persistent incapacitating anxiety in the absence of external threat us prevalence of adults with an anxiety disorder in the last 12 months is about 18 percent so it's a there's a generalized anxiety a disorder and that's gad or gad it's where the patient worries about everything for no particular reason or worrying prevents patient from deciding what to do about upcoming situations symptoms must be present more days than not for a period of about six months worry must be difficult to turn on and off and it's often treated with both pharmalogic agents and counseling okay so the next neurotic disorder we're going to talk about is phobias and phobic disorders involve an unreasonable fear apprehension or dread of a specific situation or thing simple phobias focus on anxieties onto one class of objects or situations such as a mice or spiders maybe high places or darkness or flying research suggests about seven percent of americans are affected by social anxiety disorders or phobias individuals with social phobias have a fear of everyday social situations when confronted with the feared object or situation the phobic person experiences intolerable anxiety when managing a phobic patient explain each step of the treatment in detail before carrying it out then there's panic disorder and that is a neurotic disorder characterized by sudden unusually unexpected overwhelm feelings of fear and dread women more likely to be affected than men and it attacks usually begin when the patients are in his or her 20s and if allowed to continue panic attacks can cause severe lifestyle restrictions okay a large percent of the signs and symptoms are a consequence of the autonomic nervous system discharge it usually peaks in about 10 minutes and it can last about an hour when you arrive at the scene take the following steps so separate the patient from the panicky bystanders create a calm environment tolerate the patient's disability reassure the patient that he or she is safe and give the patient symptoms a name help the patient regain control a panic attack may mimic a range of physiological disorders in its presentation a patient experiencing a panic attack especially the first time should be fully evaluated at the medical facility hyperventilating patients should not be treated with paper bag therapy try and coach patients to slow their breathing until they regain control",
        "Substance Related Disorders": "okay so let's talk about substance related disorders and so generally they involve over a relatively long period of time ems will typically be called when an acute exacerbation occurs and emergency management typically focus on treating symptomatic complaints and presenting signs and symptoms so substance related disorders include alcohol cigarettes illicit drugs or other substances affecting the way the person feels behaves or things an estimated 9.7 of the u.s population use illicit drugs in 2014 they're grouped into four levels first you have substance use then substance intoxication substance abuse and then substance dependence and that's in addition to the substance determining the most effective treatment requires an intricate approach by examining the following dimensions so social biologic cultural cognitive and the physiological understanding the complex nature of substances related disorders is the first step in providing care",
        "Eating Disorders": "and then there's eating disorders so rapid increase in incidence between 1950s and the 1960s usually women between the ages of 12 and 25 there's two major types of disorders one is bulimia and the next is anorexia severe electrolyte imbalances leading to cardiac conditions or seizures renal failure or erosion of dental enamel or the gland cell of a salivary gland enlargement also anxiety depression and substance abuse disorders as well bulimia is characterized by consumption of large amounts of food and the patients compensate by using purging techniques such as vomiting or laxatives and then there's anorexia and unlike people with bulimia people with anorexia are successful at losing weight the weight loss jeopardizes their health and lives and patients lose weight by exerting extraordinary control over their eating typical patients have decreased body weight and demonstrates intense fear of obesity and experiencing an absence of menstruation",
        "Somatoform Disorders": "okay next we're going to talk about somatoform disorders that's a preoccupation with physical health and appearances that dominates a person's life patients may have multiple complaints but are more concerned with the symptoms than their meaning in conversion disorders a physical condition has no identifiable pathophysiology but results from faking a physical disorder",
        "Factitious Disorders": "then there's factitious disorders and this includes munch and syndrome patients intentionally produce or have physical or psychological signs and symptoms symptoms are under voluntary control patients will typically present at night or on the weekends and factitious disorder by proxy is a parent intentionally making a child sick to garner attention and pity",
        "Impulse Control Disorders": "then impulse control disorders so lack of ability to resist temptations some examples include intermittent intermittent expulsive disorders so acting on aggressive impulses involving destruction of property typically associated with other disorders such as depression or personality disorders or alzheimer's disease this is a group of disorders are rare and treatment at a medical facility relies on cognitive and behavioral interventions to identify underlying triggers and influences",
        "Personality Disorders": "then there's personality disorders so the american psychiatric association a way of thinking feeling and behaving that deviates from expectations of culture causes distress or problems functioning personality disorders is when the ways of relating to others become dysfunctional or cause distress to other people the person with this disorder does not feel any subjective distress and others feel such distress acutely true personality disorders are rare and another psychiatric illness is likely to be present at the same time these patients tend to do poorly during treatment ems providers have difficulty treating personality disorders over the long term so be calm and professional in your patient interactions",
        "Medications for Psychiatric Disorders and Behavioral Emergencies": "so patients with psychiatric problems may be taking any of several types of psychotropic drugs drugs that affect mood thought or behavior and during your assessment identify which medications have been prescribed to the patient and whether they're being taken",
        "Psychiatric Medication Types": "psychiatric medications include anti-depressants and that's prescribed to combat the symptoms of that depressive illness the main types are selective serotonin reuptake inhibitors also serotonin norepi reuptake inhibitors tricyclic antidepressants or oxidase inhibitors so the mechanism of which of the action lies within the ability to alter levels of neurotransmitters in the autonomic nervous system so celexa is the most commonly prescribed antidepressant in the united states it's primarily used to treat major depressive episodes it's also useful in anxiety disorders adverse effects are minimal and but they may include headaches or dizziness or sexual dysfunction nausea or diarrhea and there's also tricyclic and tetracyclic antidepressants that are primarily used for major depression they also are effective in panic disorders or obsessive-compulsive disorders or social phobia examples include sometimes anatriphthalene adverse effects are common and include some anti-choleric effects such as dry mouth or blurred vision and also some non-specific t wave changes or prolonged qt intervals benzodiazepines so they may be prescribed for severe emotional distress they're not a substitute for more formal therapy though short-term medication therapy may be helpful so other uses include muscle relaxantation control of seizures they're contradicted in patients with known hypersensitivity to benzos acute narrow ankle glycoma and first-term ester pregnancy so some benzos have long half-lives and gradually accumulate in the body so they have the greater potential for causing sedation and confusion and then antipsychotics so these were first introduced in the 1950s to treat mental health issues such as schizophrenia newer medication have less risk of adverse effects and are more effective so they're known as atypical psychotrophic drugs and older medications are known as typical antipsychotic drugs so aap agents are often used as a first line therapy to relieve symptoms such as delusions and hallucinations they improve quality of life by reducing symptoms of anxiety and depression and reducing suicidal tendencies they may cause metabolic adverse effects though cardiovascular effects depend on the specific med direc they directly affect the heart and blood vessels um so such meds such as hero parallel may reduce contractility of the heart you may see ecg changes and they may include prolonged prolongation of the qt or pr intervals blunting of t waves or depression of the st segment it may occasionally cause an acute dystonic reaction patients develop muscle spasms of the neck face and back can typically correct by giving diphyhydramine or benadryl 25 to 50 milligrams iv may also cause atropine-like effects so anti-choleric effects such as dry mouth blurred vision or urinary retention and then amphetamine so it's a powerful cns and parasympathetic nervous system stimulant it's prescribed to help with attention deficit disorder and also treat narcolepsy in adults it raises both systolic and diastolic blood pressure so the effects there's a psychological effects depend on the dose the mental state and the personality of the patient results are alertness reduced sense of fatigue elevated mood increased concentration and euphoria",
        "Problems Associated with Medication Noncompliance": "there are problems associated with medication non-compliance so we're going to talk about that next common reasons patients choose to be non-compliant and that means not to stay on their meds include adults or senses slow thinking and also the cost of the medications medication non-compliance often results in frequent confrontation with others when abnormal behaviors develop and when you are obtaining medical history always include the previously prescribed meds and mixed doses",
        "Emergency Use of Medications": "so let's talk about emergency use of medications every call you respond to will have some behavioral component mixed with it the patient's trauma and medical problem in a behavioral crisis it's likely to escalate emergency use of medications may be indicated whether verbal physical or chemical intervention will be necessary is determined by the intensity of the situation the patient's response to you and your protocol before administering medications for chemical restraint complete your assessment a thorough understanding of the chief complaint the attention to allergies and the medications and medical history",
        "The Psychological Effect of War": "the psychological effect of war so next we're going to talk about the returning of combat veterans in 1980 the third edition of the diagnostics and statistical manual of mental disorders introduced the concept that trauma traumatic successful events outside of the individual's control can lead to psychological trauma these events include war torture sexual assault natural disasters airplane crashes and factory explosions",
        "of War": "military personnel who experience combat have a high incidence of ptsd it occurs in up to 20 percent of veterans of the iraq and afghanistan wars 10 of the gulf 30 of the vietnam vets emotional triggers include reminders of their time in the military a 2008 study explored the effects of war on servicemen and service women deployed for opera operation enduring freedom in afghanistan results focused on post-traumatic stress disorder major depression and traumatic brain injury these conditions are often unrecognized and acknowledged by other service members family members and society in general all three conditions are they affect the mood thought and behavior according to the department of veterans affairs ptsd can occur for someone goes through a traumatic event such as combat assault or disaster according to data by the va healthcare from 2002 through 2015 the three most frequent diagnosis of veterans were muscular skeletal ailments mental disorders and signs and symptoms and ill-defined conditions 57 of all patients encountered were for mental health disorders symptoms of ptsd vary in severity but are usually based on four categories intrusive thoughts avoiding reminders negative thoughts and feelings and arousal and reactive symptoms acute stress disorder that's when people experiencing intense distress often develop symptoms within days of the event diagnosis is made within the first month of the appearance of symptoms symptoms differ from those with ptsd in that they are disassociated symptoms such as amnesia or feeling of emotional numbness considered a precursor of ptsd is symptoms persistent evaluation may lead to diagnosis of ptsd an onset of symptoms of ptsd can develop within several months of the event but the onset of symptoms may be delayed even longer paramedics may be caught to situations because ptsd causes significant problems in functioning and the ability to respond normally to everyday situations developing military culture com competency is a specific skill that assists you in identifying sometimes subtle indicators of discharge military personnel military culture beliefs and ideas of defending a nation or national identity are influenced by culture loyalty sacrifice above self and commitment to society and when you encounter military servicemen or military service women experiencing medical or behavioral problems use compassion understanding protocols and acknowledge meant of their cultural background okay so this concludes chapter 28 for joining us today"
    },
    {
        "Introduction to Endocrine Emergencies": "hello and welcome to chapter 23 the endocrine emergencies lecture the endocrine system directly or indirectly influences almost every cell organ and function of the body patients with endocrine disorders often have a broad range of signs and symptoms necessitating a thorough assessment and immediate treatment to advert life-threatening emergencies the endocrine system comprises a network of glands that produce and secrete hormones this chapter provides a thorough discussion of the endocrine system so let's get started the endocrine system influences almost every cell organ and function of the body as i said on the last slide patients with this endocrine disorder often have a broad range of symptoms and signs and you have to do a thorough assessment and immediately treat these life-threatening emergencies",
        "Anatomy and Physiology of the Endocrine System": "so let's talk about the anatomy and the physiology the endocrine system is responsible for control and regulation of all the systems of the in the body disease occurs when normal cell signaling is interrupted",
        "Components of the Endocrine System": "components of the endocrine system include so the major components are the hypothalamus the penal gland the pituitary gland the thyroid gland and the thymus gland the parathyroid gland and the adrenal glands also the pancreas and gonads hormones and chemical messengers that are secreted into the bloodstream by the endocrine glands hormones circulate throughout the body and target organs to maintain homeostasis so the hypothalamus it's a small region of the brain that contains several control centers for body functions and emotions the primary link between the endocrine and nervous systems produces regulatory hormones controlling the release of hormones by the pituitary",
        "The Pituitary Gland": "gland the hypothalamus and the pituitary gland are intimately related through the vascular system the hypothematic pituitary system controls the function of multiple peripheral endocrine organs such as the thyroid the adrenal cortex the gonads and breasts so the pituitary gland six hormones secreted by the pituitary gland control activity of other endocrine glands known as tropic or tropic hormones two other hormones control other body functions so that's adh and oxytocin",
        "Thyroid Gland": "the thyroid gland the thyroid hormones affect metabolism and are secreted in response to stimulation of the thyroid gland by that anterior pituitary gland it secretes thyroxine when bodies metabolic rate decreases so the body's major metabolic hormone it stimulates energy production in the cells cannot be produced without the proper level of iodine intake so production regulated by negative feedback mechanism okay so the thyroid gland secretes calcitonin which helps maintain calcium levels in the blood it stimulates bone building cells to absorb excess calcium and it stimulates kidneys to absorb and secrete excess calcium",
        "Parathyroid Glands": "you have the parathyroid glands they assist in the regulation of calcium the",
        "Parathyroid Hormone": "parathyroid hormone which is known as pth it acts as an antagonist to calcitonin it's secreted when calcium levels are low it stimulates bone dissolving cells to break down bone and release calcium into the bloodstream and it decreases the amount of calcium released in the urine then you have the thymine the thymus gland and that helps",
        "Thymus Gland": "immune system identify and destroy foreign intruders and the pancreas so the digestive gland that is considered both an endocrine gland and an exocrine gland so the exocrine component secretes digestive enzymes into the duodenum via the pancreatic duct",
        "Endocrine Component": "the endocrine component comprises of the islets of langerhans it's a cell group within the pancreas that can act as an organ within an organ so alpha cells secrete glucagon and beta cells secrete insulin delta cells create secrete somostatin when blood glucose levels fall glucagon is secreted to raise it it secretes or stimulates the liver to change glucogen into sugar and secrete it into the bloodstream so when blood glucose levels rise insulin is secreted it transports glucose to the cells stimulates the liver to take in more glucose and store in more glycogen for later use only hormone that decreases the blood glucose levels",
        "Adrenal Glands": "and then you have the adrenal glands they're located on each side of the body on the superior aspect of each kidney it's divided into two distinct sections",
        "Adrenal Cortex and the Adrenal Medulla": "you have the adrenal cortex and the adrenal medulla so the adrenal cortex completely surrounds inner adrenal medulla it secretes aldosterone in response to a drop in blood pressure and decrease in sodium or an increase in potassium so it stimulates kidneys to reabsorb sodium from the urine and excrete potassium when stimulated by the hypothymus thaumas the adrenal medulla secretes small amounts of norepinephrine and large amounts of epi norepinephrine raises blood pressure by causing contraction of the smooth muscle that lines the arterials and relaxation of the smooth muscle that lines the bronchioles epi stimulates sympathetic nervous system receptors and stimulates the liver to convert glycogen to glucose for use as energy in cells the result is increased levels of oxygen and glucose in the blood and faster circulation of blood to the brain heart and muscles and then you have the gonads there the primary function is to promote sexual nutrition and fulfill reproductive needs",
        "Testes": "the testes in men so it's located in the scrotum it produces hormones called adrenal genes it regulate changes associated with puberty such as growth spurts deepening a voice growth official hair muscle growth and strength it's the most important is testosterone so it promotes healthy sperm production determines secondary male sex characteristics such as hair production and stimulates growth it's responsible for secondary characteristics such as increased muscle and bone mass and aggressive behavior and then the ovaries and the women they release eggs they secrete hormones estrogen and progesterone estrogen signals the anterior pituitary gland to secrete the lh hormone when an egg is developing in the um ovarian follicle follicle at puberty estrogen supports development of secondary sex characteristics such as breasts uterine enlargement and fat deposits on the hips and thighs progesterone prepares the uterus for implantation of the fertilized egg okay so that was a little bit of the anatomy and physiology so next we're going to start talking about the actual patient",
        "Patient Assessment": "assessment aspect and treatment so endocrine emergencies tend to affect many organ systems do not take these emergencies lightly the very first part of our patient assessment of course is that scene size up so address hazards and follow standard precautions check the following for medications that give you clues so such as bedside tables or medications or maybe in the refrigerator bring any medication bottles to the hospital with you identify manage life threats immediately and check for medical identification bracelets or necklaces in patients with alter mental status of course check the abcde and that stands for airway breathing circulation disability and exposure form the general impression and if the patient is alert or if they do not have alter mental status um but if there is an unresponsive patient they may be experiencing endogenous crisis such as hypoglycemia or hyperglycemia so diaphoresis is a sign of severe distress and also present with pulmonary edema signs and symptoms of a specific condition so some things such as a buffalo hump or moon face and acne are signs of cushing syndrome model skin is associated with pancreatitis enlarged or upper body parts may occur with edema with syndrome of an inappropriate adrenergic hormone so underweight or overweight may indicate an endocrine dysfunction such as hypo or hyperthyroidism or diabetes and abnormal development may be present in people with some type of pituitary problem",
        "Airway and Breathing": "okay so next is the airway and breathing ensure the airway is patent investigate any abnormal breathing sounds for obstruction maintain airway as needed through suctioning and positioning in basic airways and assess breathing effort so administer oxygen as necessary",
        "Circulation": "next is the circulation so it's a skin color temp and condition obtaining the blood pressure pale cool moist skin may be a sign of shock and hypoglycemia and then hot dry skin is fever or hyperglycemia iv fluid administration or blood replenishment may be necessary and then is your transport decision so many patients with endocrine disorders should be transported to the facility that specializes in these conditions transport the patient rapidly to the closest facility if the patient's condition is unstable and then history taking so especially useful in diabetic emergencies consider the patient's signs and symptoms and any pertinent negative so if the patient's unresponsive you need to obtain that blood glucose level maintain any or manage any abnormalities appropriately use sample to gather that information signs and symptoms of an endocrine disorder in patients with undiagnosed or poorly managed diabetes include polyphasia polyuria and polydipsenia so the following may occur with hyperthyroid so you could have tachycardias premature ventricular contractions premature atrial contractions or an atrial dysrhythmia ascertain any allergies prior to administration medicate administering medicine so all medications the patient is currently taking whether the patient it has been compliant with their regimen and as females of child bearing age about their last menstrual period",
        "Secondary Assessment": "then your secondary assessment so you want to begin the physical exam with observation the general appearance position in which the patient was found where they decorticate or disair but posturing and those are both signs of a serious illness and then you want to identify any atypical findings so focus your assessment on usually is usually not necessary unless it's a trauma patient so full body skin is more appropriate finer abnormalities will help you determine a treatment so the condition of the skin and um like we said earlier if it's cold and clammy it could be shock or hypoglycemia cold and dry could be an overdose or alcohol intoxication and then hot and dry could be hyperglycemia a fever or the possibility of a stroke so there's",
        "Goals": "two goals with the comatose patients you want to determine the patient's level of consciousness and look for signs that might be clues to the source of the coma vital signs you want to look for a combination of hypertension and bradycardia that suggests intracranial pressure be alert for abnormal respiratory pattern remember that cheyenne stokes and that it could be a non-neurogenic source of the coma or couch malls and that's often with patients experiencing dka or diabetic ketoacidosis so look for respiratory related emotions such as sneezing and yawning that require an intact brain stem hiccuping and coughing may indicate brain stem damage and your reassessive reassessment so once you have indicated your treatment plan continuously reassess the patient for changes and document your findings a patient whose gag reflex is absent cannot protect his or her airway so be prepared to suction and then consider innovation if the patient does not regain consciousness with treatment obtain blood specimens early in patients with diabetes okay so administer or address the patient's emotional needs as well and then monitor the cardiac rhythm and during your neuro assessment the most important consideration is the trend shown by several measurements so recheck vital signs pupils and level of consciousness every five minutes unstable patients and every 15 minute and stable and record your findings immediately okay so let's talk about the emergency",
        "Emergency Medical Care": "medical care if a patient has altered mental status you want to establish an iv with normal saline or a saline lock you want to measure the glucose immediately and initiate treatment if the reading is less than 60. give 12 and a half to 25 grams of d50 and some ems systems no longer carry d50 and may use glucagon or d10 and d10 is that 10 dextrose com concentration if the patient's condition does not improve after dextrose and if you have reason to suspect some type of narcotic overdose consider administering naloxone or narcan and then transport for the comatose patient so if the patient is inubated transport supine with a cervical collar in place it decreases the risk of unintentional extubation if the patient is not innovated you may transport the patient in a stable side position unless there is some type of injury and if there are indications of increasing intracranial pressure transport with the head elevated to 30 degrees to 45 degree angle and midline always keep the mouth and pharynx suction free of secretions vomitus and blood okay so let's talk about the management",
        "Management of Glucose Metabolic Derangements": "of glucose metabolic derangements so endocrine disorders are caused by either a hypersecretion or insufficient secretion of the gland hypersecretion presents an overactivity of the organ regulated by the gland and an insufficient secretion of the gland presents an under activity of the organ controlled by the gland so glucose metabolic derangements or disorders are caused by dysfunction of the pancreas it impairs the body's ability to metabolize glucose so effects of the disturbances of the endocrine gland function are determined by the degree of the dysfunction the age insects of the patient most significant endocrine emergencies result in compromise of the abcs improper fluid balance deteriorating mental status and abnormal vital signs and blood glucose levels",
        "Diabetes Mellitus": "so let's talk about diabetes mellitus it's a metabolic disorder encompassing a group of complex diseases with many causes so diabetes mellitus is a disease characterized by the body's inability to sufficiently metabolize glucose gestational diabetes is diabetes that develops during pregnancy hypo and hyperglycemia diabetic ketoacidosis and hypersomaliar hyperglycemic syndrome medically diabetes refers to a metabolic disorder in which the body's ability to metabolize simple carbohydrates is impaired it's characterized by polyphasia which is an increased appetite caused by the inability of the glucose to transported across the cell membrane polydypsnia because it's a sufficient thirst caused by dehydration brought about by the increase in diuresis and polyuria and that's the passage of large quantities of urine containing glucose glucose and which is dextrose is one of the basic sugars of the body along with oxygen it's the primary fuel for cellular metabolism diabetes mellitus is characterized by the body's inability to sufficiency metabo sufficiently metabolize glucose as we said earlier in patients with this disease there are two things so it's either the pancreas does not produce enough insulin or the body cell do not respond to the effects of the insulin that this produced in either case there is an elevated level of glucose in the blood and glucose in the urine glucose builds up and flows out of the body and then cells starve for glucose according to the 2014 national diabetes statistics report 21 or 29.1 million people in the united states that's 9.3 percent of the population has diabetes 8.1 million remain undiagnosed and in 2013 diabetes was the seventh leading cause of death in the united states this figure shows how glucose is unable to enter the cells in a diabetic patient",
        "Life-Altering Complications from Diabetes Include Kidney Failure": "life-altering complications from diabetes include kidney failure diabetes is a principal cause of kidney failure okay and high levels of blood glucose may result in decreased kidney function over time and it causes heart disease so adults with diabetes are two times more likely to die of heart disease or to have a stroke when diabetes is not properly controlled it raises the level of fat in the blood it increase is the risk of atherosclerosis and coronary artery disease",
        "Microscopic Deterioration of the Vessel Walls": "okay so microscopic deterioration of the vessel walls so",
        "Microangelopathy": "microangelopathy is a condition in which swelling of the membranes restricts the flow of blood to organs and tissues and of course ischemia causes neurosis central nervous system damage can also can cause cardiac dysrhythmias and um so what happens is the microangiopathy and the neuropathy contribute to an increased risk for silent myocardial infarct um so an ami should always be assumed until proven otherwise and a 12 lead should be obtained for complaints of sinkable episode fainting weakness fatigue malaise or dipsnia on exertion",
        "Cerebral Vascular Disease Stroke and Hypertension": "and then there's the cerebral vascular disease stroke and hypertension so vessels damaged by the microangiopathy characterize cerebral vascular disease and are associated with the increased incidence of stroke peripheral artery disease impairs circulation to the lower extremities and then hypertension is present in two out of three people with diabetes and eye damage so in adults diabetes is the primary cause of new cases of blindness high blood pressure or high glucose levels damage the vessels of the eye and scar tissue may pull the retina from the eye so that's retinal detachment cataracts form when the fructose and sorbitol are deposited in the lens",
        "Neuropathy": "neuropathy so that's nerve damage that results from the loss of sensation and function it often affects peripheral nerves cause causing diminished sensation and function in the extremities paresthesia can blunt pain perception causing ulcers to go unnoticed until they become seriously infected gangrene may develop in adjacent tissues due to perciculation an infection may spread to the bone which can cause and result in an amputation many conditions associated with diabetes can be delayed or prevented with lifestyle changes and continued management so blood glucose levels are more difficult to control during physical activity and stress but chronic and acute complications are associated with diabetes mellitus more severe in people who require insulin insulin if left untreated diabetes leads to organ system dysfunction wasting of body tissues and death severity of complications create average blood glucose level or it correlates with the average blood glucose level and the age of the onset there's no cure for diabetes treatment is focused on maintaining blood glucose levels with normal range so now let's talk about the two",
        "Types of Diabetes": "different types of diabetes and so type 1 diabetes refers to an insulin dependent diabetic who is or a juvenile diabetic because it generally affects children although hereditary predisposition does exist environmental factors may also be part of the cause so body develops um basically auto antibodies that indirectly identify the body's own tissues or substances as foreign invaders to be destroyed and eventually the pancreatic beta cells become incapable of secreting insulin and regulating intracellular glucose because beta cells are the only source of insulin it must then be administered by injection or with a pump",
        "Autoimmune Diabetes in Adults": "so an autoimmune diabetes in adults is a variant type of type 1 diabetes that occurs in adults older than 30. strict dietary control must be observed and increased activity and alcohol consumption can lead to low blood glucose levels so determine whether your patient is compliant with his management with altered mental status suspect low blood sugar so additional chronic conditions include renal failure chf cad hypertension vision and hearing impairment assess for signs of sores or infection and ask about tingling or numbness or swelling of the extremities vision changes headaches dizziness bleeding sores in the mouth or recent change in bowel or eating habits okay so when it comes to management type 1 diabetes always requires insulin administered by injection or pump insulin cannot be ingested orally because the digestive process will render it inactive some patients use insulin pumps to treat the disease it consists of an abuse infusion set a reservoir for insulin and the pump itself so it's alternative to multiple daily injections the pump is approximately the size of a deck of cards it weighs about three ounces and can be worn on a belt or carried in a pocket insulin is administered through the catheter under the skin the pump is often said to deliver a basal amount of insulin continuously throughout the day alternately the pump can be said to deliver a bolus at specific times such as meal times when blood sugar's levels are high so there are several types of",
        "Types of Insulin": "insulin available in the united states there's rapid acting regular or short acting intermediate intermittent acting and long acting so it differs on onset and action duration and peak time okay so next we're going to talk about",
        "Type 2 Diabetes": "type 2 diabetes and it's the most common form of diabetes it's a condition in which blood glucose levels are elevated because the body cannot produce enough insulin in many cases people with type 2 diabetes the pancreas actually produces enough but the body cannot effectively use it so this condition is known as insulin resistant in some cases an abnormal increase in the production of glucose by the liver causes an increase of blood glucose levels so when the glucose levels remain high excessive amounts of glucose are produced leading to high blood glucose levels approximately 8.5 of the world's population is affected by diabetes mostly type 2. so and approximately 90 of people with diabetes in the united states have type 2 diabetes so it's a development is associated with obesity and physical inactivity so the assessment symptoms include fatigue nausea frequent urination thirst unexplained weight loss blurred vision frequent infections and slow healing wounds and unresponsiveness and seizures symptoms tend to valve gradually and become noticeable in middle age a small percentage of persons do not display symptoms at all okay so management includes weight loss and exercise and a nutritious diet to help control the type 2 diabetes food intake must be spread throughout the day in coordination with many daily medications and insulin injections and also oral medications can be used alone or in combination this table shows oral medications used to treat type 2 diabetes okay and then there's pre-diabetes so it's a condition related to certain risk factors associated with type 2 diabetes it exists when blood glucose levels or hemoglobin levels are above normal levels yet cannot yet not high enough to be diagnosed with diabetes so pre-diabetes affects about one out of every three adults primarily 86 million people and 90 are unaware so within five years with no intervention about 15 to 30 percent of the people with pre-diabetes will develop on type 2 diabetes",
        "Risk Factors": "risk factors are age greater than 45 being overweight family history of diabetes being african-american hispanic or latino american indian pacific islander and or some asian american racial or ethnic backgrounds",
        "Gestational Diabetes": "also gestational diabetes and having given birth to a baby who weighed more than nine pounds interventions affecting two specific factors can help prevent or delay onset of type 2 diabetes by 58 and that's losing 5 to 7 percent of your body weight and getting at least 150 minutes of physical activity per week okay so gestational diabetes and we'll talk about the pathophysiology of that first it's a form of glucose intolerance that occurs during pregnancy it occurs more often in women who are african american or hispanic or native american also if they're die obese or have a family history it increases risk of type 2 diabetes and it usually resolves before delivery for most women and it usually is diagnosed about 28 weeks gestation and peaks in the third trimester the oral glucose tolerance test is used to diagnose gestational diabetes until within 12 weeks of delivery so the management is to stabilize blood glucose levels as soon as possible and includes diet modification exercise and blood glucose testing and insulin injections may be required okay so when it comes to hypoglycemia",
        "Hypoglycemia": "that's low blood glucose levels of 45 millimeters per deciliter or less common problem experienced by patients with both type 1 and type 2 diabetes patients must consider monitoring and intensively controlling their diabetes to prevent long-term complications so hypoglycemia is relatively common and can be treated easily severe hypoglycemia it results in a loss of consciousness or altered mental status and is more common reason to call 9-1-1 and requires intervention and treatment",
        "Pathophysiology of Hypoglycemia": "so pathophysiology of hypoglycemia it often results from too much insulin too little food or both so essential nervous system tissue depends on glucose of course for energy and counter regulation is the body's natural defense ability to maintain blood glucose at an appropriate level so the body's first line of defense against low blood sugar is to redu reduce insulin production by the pancreas and to increase glucagon production by the alpha cells so the second line defense is secretion of catecholamines including epi and norepi by the adrenal glands and so this will effects of the release can be seen in hypoglycemic patient with tachycardia and diaphoresis and the last stimulation of the autonomic nervous system generates signals that allow production of the counter-regulatory hormones to increase so the same stimuli stimulation also triggers symptoms telling the body that blood glucose levels are low in patients with type 1 diabetes the islets of longer helms do not produce insulin the body's first line of defense against hyperglycemia is lost causes of low blood glucose levels in patients with diabetes could be elevated level of the injectable insulin from inaccurate dosings or it could be an intentional overdose or it could be a mismatch with the carbohydrate intake and their injected insulin so patients with type 2 diabetes the pancreas can generate insulin however their bodies may be resistant to the effects of them so they may take may not make enough insulin over time to lower their blood glucose level adequately so medications given to treat the type 2 diabetes so it could act by either stimulating the body's ability to secrete insulin or by improving insulin actions and they can tend to contribute to hypoglycemia some patients who have had type 1 diabetes for years and to a lesser degree patients who have had type 2 diabetes for year years may not have a glycogen glucagon released from the pancreas in response to the hypoglycemia so the body is more dependent on epi to overcome the effects of hypoglycemia yet there may be a lack of responsiveness to epi in diabetes as well prolonged disease can also decrease the patient's ability to recognize having low blood sugar preventing persons from self-treating so your assessment so you wanna patients will tremble have a rapid pulse sweat or feel hungry if the condition persists cerebral dysfunction will progress to permanent brain damage so common signs and symptoms include blood sugar less than 60 hunger agitation altered mentation or confusion nausea weakness tachycardia or cool clammy skin also a headache memory loss slurred speech irritability dilated pupils and seizures and coma in severe cases so when it comes to hypoglycemia it develops rapidly and should be suspected in any patient with diabetes who present with bizarre behavior neurologic signs and a coma hypoglycemic episodes may also be due to alcoholism poisons certain cancers liver disease kidney disease and other conditions persons with diabetes may also experience a head injury stroke seizures meningitis or other traumatic injuries or conditions so management immediately increased blood glucose levels use the least invasive method and measure the patient's blood sugar level administeration of a concentrated glucose with a suspected stroke may exacerbate the cerebral damage so be careful with that and when a comatose patient is 55 or older or the family member gives a history of recent transit ischemic attacks rule out hypoglycemia with a field glucose test take appropriate infection control precautions verify the device is calibrated clean the site to be punctured with alcohol and allow the patient's arm to hang briefly to allow blood flow to the fingertips grasp his finger near the area to be pricked and squeezed for three seconds use a sterile lancet device and quickly prick the side of the fingertip apply adequate pressure to puncture the skin and then properly dispose of the lancet place a sterile dressing on the wound and apply the blood to the test strip read the document results it's a patient's alert able to swallow and has an intact gag reflex encourage him or her to take glucose tablets if not household sources of glucose may be used such as sugar by mouth so an unresponsive patient should never be given oral glucose or anything by mouth because of that risk of aspiration if the patient has an altered level of consciousness or you are potentially unable to manage the airway aspiration may result with administration of other substances so you need to manage the airway and breathing as soon as you would with any other patient",
        "Administer Dextrose to a Patient with Altered Consciousness": "so to administer dextrose to a patient with altered consciousness follow the steps so you want to insert the iv line and assure its patent an 18 gauge catheter is preferred in a large vein due to the viscosity of dextrose if you are using d50 note it is a hypertonic and acidotic so it if there is any type of infiltration it may lead to tissue necrosis so make sure that you administer uh normal saline flush of about 10 to 20 mls to confirm that the line is patent administer 12.5 to 25 grams of dextrose if the coma is caused by hypoglycemia the patient will often wake up rapidly in some cases of severe hypoglycemia another 25 grams of d50 may be required to restore that normal level of consciousness also if the patient has a decreased level of consciousness and you are unable to obtain a patent iv line you can administer glucagon one milligram i am in adults okay so hyperglycemia",
        "Hyperglycemia and Diabetic Ketoacidosis Hyperglycemia": "and diabetic ketoacidosis hyperglycemia is high blood sugar glucose levels and its classic symptom of diabetes it's an early sign including frequent and excessive thirst and urination it occurs when blood sugar levels exceed 120. in patients with diabetes physicians try and maintain glucose levels at at least 160. so it can lead and it can be caused by excessive food intake or infection or illness injury surgery or emotional stress so onset may be rapid or gradual so for hours or days long gradual other causes are hyperglycemia could be the dawn phenomenon it occurs in the hours after waking as the body prepares for the day it releases hormones such as cortisol and catecholamines these hormones trigger the release of glucose from the liver resulting in hyperglycemia some patients with type 2 diabetes can go undiagnosed for years so related episodes of hyperglycemia will cause several physiologic changes that have detrimental long-term effects so hyperglycemia puts undue strain on the cardiovascular system kidneys and other organs that are sensitive to increase viscosity and pressures right so the eventual result is increase of incidence of disorders such as renal failure or chf or coronary artery disease or neuropathy when serum glucose levels rise above tolerable levels other physiologic changes occurs all right so this is pretty important",
        "Diabetic Ketoacidosis": "diabetic ketoacidosis that's when blood levels are greater than 350 and hypersomaliar hyperglycemic syndrome or hhs is when blood glucose levels are greater than approximately 600. okay so untreated hyperglycemia will progress to dka and it is associated predominantly with type 1. it's life-threatening it occurs when certain acids accumulate in the body because of insulin not being available okay and then rising blood glucose levels leads to massive osmotic diuresis and so that's passing of large amounts of urine",
        "Dka": "in dka the deficiency of insulin prevents cells from taking up extra glucose and basically the starving cells prompt a distress signal to go out over the sympathetic nervous system causing the release of various stress hormones so it leads to large quantities of ketone bodies in the bloodstream and this causes a decrease in the blood's ph and results in acidosis the acidosis triggers the body's attempts to buffer the acidity with bicarbonate and the patient in patients with type 2 diabetes dka is rare because insulin is still present at least early on",
        "Hypoglycemia Signs and Symptoms": "so your assessment uh hypoglycemia signs and symptoms you're going to have blurred vision polyuria um polydypsnia and polyphasia so that's that excess of urine output thirst and eating and orthostatic syncope so when they stand up they're going to pass out frequent infections or skin ulcerations so hyperglycemia usually progresses slowly so when the patient's level of consciousness deteriorates gradually the load of glucose in the kidneys results in glucose spilling into the urine causing the body to become hypersomatic so kidneys also help clear ketones from the body's blood and patients lose excessive amounts of sodium potassium and phosphates and the resulting signs and symptoms manifest these factors are polyuria polydipsenia polyphasia remember and nausea and vomiting they have re uh deep rapid respirations and we call those cue smalls respirations they have warm dry um skin and dry mucous membranes beauty fruity odor of ketones on the breath patients usually appear to be thin and dehydrated and have warm dry skin they have orthostatic hypotension fatigue altered mental status with time weight loss from that state and diabetics patients in dk are seldom deeply comatose so if the patient is totally unresponsive look for other sources of the coma such as maybe a head injury or stroke or drug overdose okay so the respiratory rate is usually elevated and tidal volume is increased remember that koosh mall respirations so the table shows the comparison between hypoglycemia and hyperglycemia it's a really good table to get to know so management so the physician will probably order treatment for this and glucose level if it's more than 250. so in most cases insulin therapy should be delivered at the hospital follow the procedure for any comatose patient with regard to airway management of course and be alert for vomiting so start an iv line and infuse up to one liter of normal saline during the first half hour or as suggested by protocol so if a patient's hypotensive rapidly administer isotonic fluids until the systolic pressure is 80. so but be aware for pulmonary edema monitor the cardiac rhythm as well",
        "Hypersomalia Hyperglycemic Syndrome": "okay so hypersomalia hyperglycemic syndrome so hhs you're going to see it written as and this is also called hypersomalia non-chiata coma um so it's a meta metabolic derangement that occurs primarily in patients with type 2 diabetes its key signs and symptoms are hyperglycemia altered mental status severe dehydration or thirst and doc urine or visual and sensory deficits partial paralysis or muscle weakness and also also seizures fewer than 20 percent of patients result in a comatose state so most have severe dehydration and focal or global neurologic deficits so just often develops in patients with diabetes who have a secondary illness that leads to reduced fluid intake so do patients do not experience ketoacidosis an onset can take up to weeks so approximately 30 percent do not have a prior diagnosis of diabetes and so stress response tends to increase hormones that favor elevated glucose levels and that often counter the effects of the insulin and so such as cortisol or catecholamines glucagon or other many others so neurologic changes may be found including drowsiness your delirium or visual disturbances or hemi paralysis or hemiparesis or sensory deficits okay so this table shows a comparison of those hyperglycemic conditions management you're going to do the airway management always as your top priority and cervical spine immobilization should be used for unresponsive large bore iv obtain a blood glucose level a bolus of 500 milliliters of normal saline is appropriate for nearly all adults who are clinically dehydrated and so in patients with a history of congestive heart failure though or renal insufficiency a 250 bolus may be more appropriate and patients may receive up to one or two liters within the first hour okay so now we're done with diabetes and sugar problems and we're going to go",
        "Pancreatitis": "into pancreatitis so it's an inflammation of the pancreas just what it sounds like acute pancreatitis is a medical condition and it can lead to dehydration and hypotension 60 to 80 percent of the cases are caused by gallstones or chronic alcohol abuse other potential causes include certain medications or trauma or some type of pancreatic cancer or a genetic predisposition chronic pancreatitis is a progressive disease eventually leads to the loss of endocrine or exocrine functions and it often causes chronic pain and you could uh diagnose it with a ct so acute pancreatitis may present with flank or epigastric that worsens if the patient is supine tachycardia fever or jaundice so typically an attack is a result of a large heavy meal or excessive drinking the symptoms include nausea and vomiting abdominal distension or muscle spasms less frequently necrosis or organ failure and the laboratory diagnosis um includes determinations of serum levels of lipase or amylase when it comes to management most patients are managed with supportive care patients should not eat until nausea has subsided of course and they patients shouldn't be transported pain management is not always effective but can be considered and patients with chronic pancreatitis lifestyle changes are critical so changes to diet or analgesics are used to control the pain pancreatic enzymes assist with absorption and so surgical intervention may be considered and a patient should be monitored for pancreatic cancers okay so next we're going to move into",
        "Adrenal Insufficiency": "adrenal insufficiency and it's characterized by a decreased function of the adrenal cortex and can consequence under production of cortisol and alidestrone so it's a weakness it results in dehydration or inability to maintain blood pressure cortisol's primary role is to assist with the stress response and so it helps to maintain blood pressure and cardiovascular function it regulates the metabolism of cardio carbohydrates proteins and fats and it allows and slows the inflammatory response so abnormal adrenal cortal function produces abnormalities in the metabolism of carbohydrates and protein and disturbances in salt and water metabolism it's usually well tolerated but may be complicated by factors such as infection or stress affects about four persons per 100 000 in the us",
        "Primary Adrenal Insufficiency": "and then primary adrenal insufficiency is called addison's disease so it's caused by an atrophy or destruction of both of those adrenal glands it leads to deficiency of all the steroid hormones these glands produce it's a rare disease but about one per 100 000 persons in the united states usually results in an idiopathic atrophy and it occurs when at least 90 percent of the adrenal cortex has been destroyed so some causes are tuberculosis or bacterial viral or fungal infection or cancer of those adrenal glands all right so",
        "Chronic Adrenal Insufficiency": "um so chronic adrenal insufficiency may include some type of unexplained weight loss vomiting diarrhea anorexia salt craving or post postural dizziness so increases in pigmentation in the surfaces of the palm creases or oral mucosa so um blood volume and blood pressure may fall and blood potassium may rise and sodium concentration of the blood also falls so management if needed use the coma protocol for glucose thymine and naloxone initiate aggressive fluid replacement using five percent dextrose in normal saline in hydrocortisone 100 milligrams iv is indicated in the acute management of this crisis",
        "Secondary Adrenal Insufficiency": "the secondary adrenal insufficiency so it's character uh recent relatively common it's characterized by a lack of acth secretion from the pituitary gland and basically what this does is it stimulates the adrenal cortex to manufacture and secrete cortisol so it may also occur in patients who abruptly stop taking some type of core steroids",
        "Assessment Signs and Symptoms": "so assessment signs and symptoms may appear slowly um and it may be triggered by an acute exacerbation of the chronic insufficiency so about 25 percent of patients first experience symptoms during an addison crisis chief clinical manifestation is shock so symptoms may also include weakness lethargy confusion or loss of consciousness or low blood pressure elevated temperature or severe pain in lower back or severe vomiting and diarrhea",
        "Management": "when it comes to management um an untreated episodes may be fatal so um of course always we're going to maintain those abcs begin rehydrating the patient and correct electrolyte and acid-base abnormalities so we're going to start that iv and infuse one liter of normal saline check the patient's sugar of course and administer d50 to correct hypoglycemia and then of course we're going to monitor that cardiac rhythm okay now we're going to talk about cushing",
        "Cushing Syndrome": "syndrome and this is one of the other adrenal emergencies it's caused by excessive cortisol production by the adrenal glands okay so an example would be a tumor of the",
        "Tumor of the Pituitary Gland": "pituitary gland or adrenal cortex so um it's a life-threatening illness it's characterized by metabolism of carbohydrates protein and fat it's all disturbed and so what happens is the blood sugar level rises protein synthesis is impaired and the bones become weaker and more susceptible to fractures so it could be signs and symptoms could be weakness and fatigue depression increased thirst and urination high blood sugar levels increase acne or facial hair growth and scalp hair loss in women and sensation sensation of menstrual periods also thinning of skin and easily bruising and darkening of skin in the neck management is always manage and assess the abcs manage the life threats and pre-hospital treatment is just generally supportive but of course obtain that bgl and administer d50 if needed",
        "Adrenal Gland Tumor": "and then there's the adrenal gland tumor it's a rare condition of the adrenal gland in which a tumor usually in the medulla causes excess release of hormones of epi and neuropathy it is less than 10 percent are malignant most common in children adult to mid-adult life combination of symptoms that are frequent but sporadic is common so it may increase the frequency duration and severity",
        "Growth Hormone Pathologies": "and then you have growth hormone pathologies so basically anterior post pituitary gland secretes growth hormone and problems associated with this it could be over secretion or under secretion it's rare it's usually result of a tumor over-secretion results in a condition usually diagnosed in young children and under secretions where and characterized by a delayed development and growth lack of treatment may lead to dwarfism",
        "Hypothyroidism and Hyperthyroidism": "so hypothyroidism and hyperthyroidism approximately 20 percent of the meri of americans have this thyroid disorder um it graves disease is the most common type of hyperthyroidism and it increases the metabolism hypothyroidism is a result of an autoimmune disease which decreases the metabolism hyperthyroidism is a metabolic activity increases oxygen demand and hypothyroidism conditions may result and lead to diminished respiratory effort so graves disease is the most severe and common cause of hyperthyroidism it's 10 times more common in women it tends to follow a chronic course of re-emission and relapse so it's an autoimmune disorder in which the thyroid gland hypertrophies enlarges as it actively as activity increases so it produces a visible mass and that's a goiter in the anterior part of the neck overactive glands increase an excessive amount of thyroxine other signs and symptoms may include increased appetite and marked weight loss polydypsnia or pitting edema of the skin on the interior part of the leg below the knee so hashimoto disease is another rare hypothyroidism it's more common in women results of the infiltration of t lymphocytes and plasma cells it's an autoimmune disorder that affects the thyroid stimulating hormone or tsh receptors and then you have a myoga myoxydema coma and if the supplied to the thyroid hormone becomes inadequate organ tissues do not grow or mature so energy production declines and actions of the hormones are affected okay and so adult hypothyroidism is",
        "Adult Hypothyroidism": "sometimes called my ex edema patients often have localized accumulations of material in their skin and manifest manifestated by a slowing of the metabolic process due to reduction or absence of the thyroid hormone okay so severity is consistent with the degree of the hormone deficiency it includes fatigue or feeling cold weight gain or dry skin or sleeplessness often subtle and can be mistaken for other conditions conditions decrease of hormone levels may lead to this a coma so accompanied by a physiologic decompensation that leads to peripheral vasoconstriction okay a hallmark is deterioration of mental status most cases occur during the winter in women older than 60. all right and this consistent finding is hypothermia so hypothyroidism decreases intestinal motility if not diagnosed and treated immediately the mortality rates are approximately 40 percent administer oxygen and to correct the hypoxia if if it's there an inhibition and ventilation may be indicated monitor the patient's cardiac status okay so treat the hypothermia and with passive rewarming methods so uh aggressive rewarming may lead to vasodilation and hypotension so active rewarming is necessary for the hemodynamic stability um okay so avoid sedatives narcotics and anesthetics okay so the next thing we're going to talk about is a thyroid storm it is rare but it's a life-threatening condition it may occur in patients with that thyroid toxicity it's usually triggered with a stressful event increased volume of the thyroid hormones in the circulation so it may present with the normal signs and symptoms of hyperthyroidism as well as a fever or severe severe tachycardia nausea vomiting altered mental status or heart failure all right hyperparathyroidism",
        "Hyperparathyroidism": "so marked by increased parathyroid hormone level which results in increased levels of blood calcium hyperclic calcimia or decrease phosphate blood levels so primarily causes results from the gland itself secondary causes occur elsewhere in the body and its common cause is a benign some type of neoplasa on the gland so signs and symptoms are fatigue weakness nausea and vomiting confusion and surgery to remove that enlarged gland is um the management of it so patients with mild forms require monitoring of the calcium blood levels manage abcs and provide supportive care so pan hypo pituitarism that's immediate production or inadequate production or absence of the pituitary hormones including aca th cortisol t4 lhfsh or growth hormone or an antidiuretic hormone clinical presentation varies depending on the hormones that are lacking and then you have diabetes",
        "Diabetes": "is sipidus some of the same characteristic characteristics of diabetes mellitus but it's a not a pancreatic pathology so it's when the body's unable to regulate fluid caused by kidneys are unable to respond appropriately so adh causes kidneys to retain the water and so this lac causes increased urination right so one difference in din dm is the amount of glucose present in the urine so when you have di it's very diluted glucose and dm is excessive glucose okay so this table shows a comparison of that diabetes and uh it's table 23-5 in your book okay so thank you for joining us this evening for chapter 23 endocrine emergencies lecture if you like this lecture go ahead and subscribe to our channel because we're going to be releasing the rest of the chapters in the book all right hope you have a great night"
    },
    {
        "National EMS Education Standard Competencies": "hello and welcome to chapter 21 jenna to urinary and renal emergencies upon completion of this chapter and the related course assignments you will be able to describe the anatomy and physiology of the male and female urinary systems as well as the primary and secondary assessments for patients with renal and genitor urinary emergencies",
        "Introduction": "so let's get started the urinary system filters blood and removes metabolic waste it manages concentrations of electrolytes maintains acid-base balance in the bloodstream and regulates fluid volume and blood pressure kidney disease is the most common renal disorder it affects more than 26 million americans approximately 47 000 americans die of kidney disease each year more than 468 000 americans require dialysis and nephrolithiasis which is kidney stone or renal cochlea is the most common acute renal disease affecting roughly 10 percent of the us population another common urinary tract disease is urinary tract infections which are utis and they affect more than 50 percent of all women also non-cancerous enlargement of the prostate and it will develop in about 60 of all men by the age of 50.",
        "Kidneys": "so let's talk about the kidneys in the anatomy and physiology the urinary system consists of kidneys and they filter blood and produce urine the ureters and those transport urine from the kidneys to the bladder the urinary bladder and it stores urine until it's released from the body and then the urethra that's the route by which urine exits the body the urethra is shorter in females than males which increases the susceptibility to infections when we're looking at the kidneys the internal anatomy of the kidney can be divided into three groups there's the cortex the medulla and the renal pelvis and they the renal pelvis drains urine into the ureter nephrons are located in the cortex they're structural and functional units of the kidneys that form the urine okay so each nephron is complete composed of the glomerulus the gamma meruler capsule proximal convoluted tubule the loop of henle the distal convoluted tubular or dct that connects the kidneys and it's the kidneys collecting tubules so here's a better picture of the nephrons of the kidney on this slide",
        "The Male Genital System": "and then you have the male genital system and it's closely related to the urinary system it shares the urethra as the the conduit for urine semen and other secretions the prostate gland surrounds the urethra and along with the seminal vesicles secretes fluid into the urethra during ejaculation testes are located in the scrotum and create the sperm during ejaculation sperm travels from the epididymis into the vas deferens and through the ejaculary ducts it mixes with fluid from the seminal seminal vesicles the glands and the prostate to form semen sperm enter the urethra to exit the body",
        "Scene Size-Up": "okay so let's talk about patient assessments so assessment of a patient with a renal and genital urinary emergency is the same for any other medical patient you're going to do that scene size up ensure that the scene is safe and consider the mechanism of injury assess for hazards and the need for additional help and determine the number of patients you want to take standard precautions to avoid contact with the urine and patients with renal or genital urinary problems may exhibit same many of the same symptoms as a patient with other abdominal injuries for example like nausea and vomiting or constipation or flank pain it is often difficult to determine the source of an abdominal or genital urinary pain denture pain can be many origins so perhaps maybe a bacterial infection so assessment should be intended to detect and prevent life threats and provide supportive care so be sure to make a wide differential diagnosis as you progress through your evaluation",
        "Primary Survey": "after the scene size up of course is that primary survey and we need to form the general impression check for any life threats a patient with a genital urinary or renal problems may exhibit extremity or extremes of activity so check for life threats by assessing the patient's mental status airway breathing and circulation and the um airway breathing and circulation and look for any signs of respiratory distress assess for patients skin color heart rate and blood pressure and look for signs of shock and then make your transport decision use information from the primary survey when making a transport decision of course need to decide if urgent transport is um needed or warranted based on any life threats so is there any testicular torsion or hyperkalemia or maybe uremia and consider how the patient will be moved consider any special equipment needed and also consider the diagnostic and treatment equipment at the receiving facility the transport ride should be as smooth and as gentle as possible",
        "History Taking": "and then when you're taking your history so in these type of patients the history and physical exam will provide the information you need to successfully manage the patient because so many medical diagnostic diagnosis are based on the patient's history you may have to ask the right questions knowing that a patient's pain started and one location has moved to another for example can affect the field diagnosis you sample remember signs and symptoms allergies medications pertinent past medical history last oral intake events leading up to the injury as a guide in obtaining that historical information",
        "Pain": "and the pain so diseases that cause renal and urologic systems range from mild such as a uti to emergent such as acute kidney urgency injury your ability to recognize the signs and symptoms of these conditions is critical to providing patients with the best chance of a possible a positive outcome so understanding the pathophysiology of referred pain is key to determining its origin so first we're going to talk about visceral pain this is deep pain it's caused by activation of pain receptors in internal areas of the body the type of pain most commonly associated with urologic problems it usually occurs when receptors in a hollow structure are stimulated pinpointing the such the source of such pain is very challenging and then you have referred pain so this is pain that originates in one area of the body but is perceived is coming from another part pain assessment finding so use opqrst mnemonic to evaluate the type and severity of pain remember the onset and that's when the pain started and what was the patient doing at that time provocation is to determine what if anything provokes the pain the quality or r is the region or the location radiation or referral and severity is to rate the pain zero from ten keeping in mind that the severity of the pain might not be consistent with the severity of the problem repeat assessment and then the timing was it a sudden or gradual consistent or intermittent",
        "Secondary Assessment": "okay and so the secondary assessment the physical exam can focus on or may move from head to toe depending on the signs and symptoms the abdomen can be divided into four quadrants overlying the internal organs or nine anatomic segments if you cannot be performed on scene do more detailed physical examine route to the hospital assess for flank tenderness which should which could imply kidney infection or distension you usually inspect the genitalia for signs and symptoms of infecting infection swelling or torsion if a male patient reports lower abdominal pain with no clear cause monitor patients vital signs as part of the physical exam and obtain serial vital signs at least every five minutes if renal failure is suspected take prompt action if any deterioration is noted and electrocardiogram monitoring is very important in any patient with a suspected urologic emergency due to the possibility of electrolyte imbalances",
        "Reassessment": "and then your reassessment so patients with urologic emergencies usually especially those with signs and symptoms of renal failure require frequent reassessment electrical light imbalances from toxin buildup can cause rapid deterioration in the functioning of the body's organs especially the heart use the information obtained from the history and physical exam to form field impression and select a treatment plan obtain and document serial vital signs like we said on the last slide on the patient",
        "Emergency Medical Care": "and then pain management so after checking the abcs allow the patient to assume a position of comfort nausea and vomiting are possible so be prepared to suction if needed and establish an iv line um if the patient has nausea or severe pain and consider administering an anti-medic administer an iv bolus of crystalloid fluid to the patient if there are any signs of dehydration or hemodynamic instability and do not withhold pain control for fear of reducing ed diagnostic accuracy by masking symptoms",
        "Urinary Tract Infections": "let's talk about urinary tract infections okay so utis are most common in females after um infancy but increase in men after the age of 50. okay so definitive treatment requires antibiotics and so utis usually develop in the lower urinary tract when bacteria enters the urethra and grows more common in women because of the relatively short urethra and its close proximity to the vagina vagina and rectum utis in the upper urinary tract occur most often when the lower uti is untreated upper utis can lead to abscesses which may lead to sepsis and can be life-threatening so classic uti symptoms are painful urination frequent urges to urinate and difficult urinating it begins as a discomfort and becomes extreme and burning especially during urination um sometimes referred to the shoulder and neck so urine may have a foul odor and may appear cloudy or contain blood patients appear restless and uncomfortable and patients with utis where appear well have normal vital signs and may have some type of tenderness so patients utis are common cause of sepsis in older adults management you're gonna just maintain the abcs and try and make the ride comfortable and be prepared for nausea and vomiting okay",
        "Urinary Catheters": "urinary catheters so many patients who are hospitalized for urinary conditions and other medical diseases receive catheterization with a foley catheter bladder catheterizations introduces a latex or plastic tube through the urethra into the bladder tube is collected to connect it to the drainage bag which is hung below the level of the bladder urine backflow is a concern when transporting a categorized patient so do not lift the drainage bag while handling the patient do not pull out the catheter or kink it if a folded catheter must be removed ensure that the internal balloon is deflated",
        "Urinary Obstruction and Incontinence": "and then a urinary obstruction or incontinence so urinary retention incomplete emptying of the bladder or complete inability to empty the bladder that's the definition of urinary retention and conditions that may cause it are kidney stones acute kidney injuries prostate hypertrophy urinary tract infections or nerve damage so patients with these conditions may present with extreme discomfort and should be transported to the nearest facility for urinary catheter placement urinary incontinence and that is loss of bladder control it's the inability to control the release of urine from the bladder it can occur in anyone but may be a medical problem if it falls into two categories okay so the first is the urge incontinence that's a sudden intense urge to urinate with involuntary urine loss occurring within seconds or minutes urination is frequent and many potential medical causes include urinary intra infection bladder irritants bowel conditions or parkinson's disease alzheimer's or stroke cancers or nervous system damage and overflow incontinence is the next and that's a constant continual slow flow of urine that may have medical causes and this could include damage to the bladder or block urethra also again nerve damage or prostate gland problems in men",
        "Kidney Stones": "okay so next we're going to talk about kidney stones and that's extremely common kidney stones are very very common in the field you'll see them the pathophysiology so what happens is they originate in the renal pelvis and they it form when excessive excess of salts in your uric acid crystallizes in the urine in the united states roughly one in 11 people will experience kidney stones men are affected more often than women and risk factors include diet hydration personal or family history of kidney stones and hypertension the cause of kidney stones varies by type so there's a calcium calcium phosphate stones and those are most common and they may form when concentration of calcium or phosphate becomes too high in the urine and it may have a hereditary component risk factors include patients with a history of gout gastric bypass or surgery and metabolic disorders and then there's struvets stones and they're more common in women than men and they may be associated with chronic utis and then there's uric acid stones those are more common in those with the history of gout and then there is cristine stones and those are associated with a condition that causes large amounts of amino acids and proteins to be excreted in the urine so assessment patients who have kidney stones almost always experience pain usually starts in the flank but it may migrate forward towards the groin as it passes vague discomfort that progresses to intense pain within 30 to 60 seconds and pain is severe often described as the worst pain in the person's life patients may appear agitated and restless others may guard the abdomen vital signs vary based on the pain severity the greater the pain the higher the blood pressure and pulse patients often present with hematuria and if the stone is obstructing urine flow in the ureter flank tenderness so they'll have blood in the urine management so pre-hospital management occurs on pain relief ensure the abcs allow the patient to assume this position of comfort and administer an analgesia if protocol allows so if not allowed contact medical control for pain relief options okay and nitrous oxide is an alternate trans treatment to narcotics so you definitely want to establish an iv line and administer some fluids to hydrate the patient and antibiotics if needed some kidney stones can be treated without surgery and will pass on their own so management is focused on supporting the patient with hydration pain control and anti-medics urologic intervention is required when the uti is present along with the obstructing kidney stone so treatment for persistent stones depends on the size the consistency and the location okay so they'll do a lipotripsy um sometimes and that's a high energy shock wave and it breaks up the stones from outside the body resulting in much smaller stone fragments and the dust that can pass easily sometimes they might have to do a stent placement and that is direct um visualization of the ureter and the urinary systems and so what they do is they do a camera through the urethra into the urinary and a stent can be placed to enlarge the diameter of the urethra and allow the stone to pass okay and then they also could do a percutaneous tube placement and that's a small catheter and it's placed from the outside of the body into the kidney to allow for the drainage of the material that's obstructed by the stone this method is frequently used to depress the kidney and when there is an infection associated with the stone",
        "Acute Kidney Injury": "okay so after kidney stones we're going to talk about next is acute kidney injury and so acute kidney injury which is aki is a sudden decrease in filtration causing toxins to accumulate in the blood so it's basically a loss of function and it may occur over several days most often secondary to another disease process up to 20 percent of critical ill patients develop aki and mortality for these patients may be as high as 70 percent so oliguria is urine output of less than 500 ml a day and a urea is a complete synthesisation of urine production so no urine output at all patients may experience generalized edema and acid buildup and high levels of nitrogen and metabolic waste in the blood can lead to life-threatening volume overload so hyperkalemia uremia metabolic acidosis if left untreated okay and so there are classified in the three types based on where it occurs and you can see the signs and symptoms of these three types so you have the pre-renal you have the intra-renal and then you have the post-renal and those are the three types of classified so the pathophysiology so toxic buildup of nitrogenous waste and salts in the blood associated with aki causes impaired mentation fluid retention tachycardia acid-base imbalances and increased pr and qt intervals associated with hyperkalemia and that's why we say 12 leads and ecg monitoring is really important in these patients pre-renal acute injuries are caused by hypoperfusion of the kidneys so not enough blood is passing into those kidneys for production most common causes are hypovolemia of course trauma shock sepsis and heart failure and this is often reversible if the underlying condition can be treated okay so um intra-renal kidney failure and that involves damage to one of the three areas of the kidney so if the kidney is damaged in the renal intra-renal um that is damage to the small vessels or some type of cells of the tubules or the tubule damage is actually caused and then the third one so the post-renal acute that's caused by obstruction of flow to the kidneys and so a source of the obstruction is often blockage of the urethra by an enlarged prostate and so the blockage raises pressure in the nephrons and eventually shuts them down so presentation of the patient will vary depending on you know if it's pre-renal intra-renal or post-renal so patients with the pre usually it's dehydration shock is happening um and then flank pain could be intra or patients in post renal it could be pain in the supra suprapubic area related to bladder distension or in the penis for obstruction right obstruction and then during the physical exam so fully evaluate the abdomen for other causes of distance of discomfort okay or the presence of ascites so assess flake tenderness and perform ecg to evaluate for dysrhythmias or signs of hyperkalemia and then closely monitor the vital signs management so because metabolic changes caused by the aki can be life-threatening the treatment plan must support the management of the abcs administer an iv bolus if the patient exhibits signs of shock but use caution to prevent pulmonary edema patients with certain concern for rhabdomyosis may benefit from iv fluid boluses and if signs of hyperkalemia are present on the ecg discuss with medical control and treat with iv calcium and bicarb consult medical control if you suspect aki and are transporting a patient with an anabolic or analgesic drips",
        "Chronic Kidney Disease": "okay so acute meaning that sudden onset of kidney injuries versus the chronic kidney disease so over 468 000 people in the united states are on long-term dialysis in the population 65 or older the incidence of chronic kidney disease or ckrd is rapidly growing and it's doubled from 2000 to 2008 in the united states over 20 million people have some form of this condition pathophysiology so chronic kidney disease is progressive and irreversible inadequate kidney function caused by the permanent loss of nephrons it develops over months or years and more than half of the cases are consequence of systemic disease but it can also be caused by a congenital disorder disorder or prolonged some prolonged type of disorder scarring occurs as the damaged nephrons cease to function and as scarring progresses tissues shrink and waste away leading to a loss of nephrons and renal mass uremia which is increased concentrations of ura and other waste products in the blood um happen and systemic complications develop so you you have a high blood pressure heart failure anemia and electrolyte imbalances assessment so patients with ckd have an altered level of consciousness and may also present with lethargy or nausea headaches cramps signs of anemia weakness vomiting anorexia so increased thirst hypertension decreased urine output rusty brown urine pale cool moist skin that may appear jaundice and patients with ckd also can be hypotensive and tachycardic if dehydrated or infected if hyperkalemia develops alterations in waveforms and intervals can be seen on the ecg and paragraph pericarditis and pulmonary edema are also common so you should evaluate and auscultate the chest management so ckd or chronic kidney disease is a chronic condition so management is not performed in the field special considerations when treating a patient with ckd for other complicated complaints though if a fluid bolus is planned remember that patients may be higher risk for pulmonary edema transport the patient in a calm manner to the medical facility talk quietly and calmly and monitor orientation frequently",
        "End-Stage Renal Disease": "then you go from chronic kidney disease to end-stage renal disease and so acute or chronic kidney disease will progress to end-stage renal disease and that's esrd if left untreated kidneys lose the ability to function and toxic waste materials will build up in the patient's blood it's fatal unless treated by dialysis or renal transplant after dialysis patients may appear well but occasionally may be weak or dehydrated and if a patient misses dialysis he or she may present with signs of volume overload as toxins accumulate the following occurs so you're going to have a uremic frost confusion muscle twitching anemia hyperkalemia and as the patients with ckd chest pain should be taken seriously and a full cardiac assessment should be performed untreated esrd may produce seizures or a coma or significant confusion so when we talk about management of end-stage renal disease definitive treatment for patients with this is limited to renal dialysis and kidney transplant so we can though ensure abc stability provide supportive care as needed and for volume overload consider the use of the diuretic if urine is still being produced so that's the key thing if they're able to urinate still then their kidneys are still producing urine for dehydration or shock consider administering a fluid bolus and monitor for signs of pulmonary edema really have to pay attention for pulmonary edema",
        "Renal Dialysis": "okay when it comes to renal dialysis and associated problems may require pre-hospital care and remember renal dialysis is the technique for filtering toxic waste from the blood removing excess fluid and restoring the normal balance of electrolytes there are two types of dialysis there's the peritoneal dialysis and it removes large amounts of  fluid so basically it's a special special formulated dialysis fuel fluids are infused into and then drain from the abdominal cavity and fluid remains in the cavity for about one to two hours it's effective but carries a high risk of peritonitis and so basically it can be performed at home and then there's hemodialysis and that's when the patient's blood circulates through a dialysis machine that functions like normal kidneys patients have a vascular access through either a fistula or an atrial venous av shunt or in emergencies a central venous catheter and a patient with the cardiac or respiratory rest when intraosseous access is difficult or impossible a fistular shunt may be used for iv access the procedure should be performed only in accordance with local protocols and in other instances an iv site in the opposite arm should be selected av shunts should not be used in routine blood draws and blood pressure readings should be taken using the opposite arm you will most likely only encounter dialysis machines if your service transports patients to and from dialysis centers patients requiring dialysis usually undergo the process for about every two or three days for about three to five hours dialysis is done in hospital community dialysis facilities or at home patients undergo home dialysis units have excessive training if a problem with the machine occurs as the patient asks what the patient has done prior to arrival he or she may know a lot more about the machine than you do of course and problems related to dialysis may result from accidental disconnection of the machine or bleeding from the fistula malfunction of the machine rapid shifts of fluids and electrolytes that produce hypotension maybe some potassium imbalances or some maybe an equilibrium syndrome patients who miss dialysis treatment often presents with signs of an electrolyte imbalance remember they could get weakness from the muscles cramping pulmonary edema or a uremic frost other general complications of dialysis include muscle cramping nausea and vomiting or infections at the fistula site hypotension and shock is a sudden drop in blood pressure and it's not uncommon during and or immediately following dialysis treatment patients may feel lightheaded or become confused and dialysis alters the body's chemistry shock secondary debris bleeding is also possible from a number of causes okay potassium imbalance is another problem and so one consequence of renal impairment is the inability to excrete ingested potassium and so hyperkalemia may occur from over aggressive dialysis too and then there's this disequilibrium syndrome and that's a consequence of dialysis so water initially shifts from the bloodstream into the cerebral spinal fluid which mildly increases icp intracranial pressure as a result the patient may experience this syndrome it's characterized by nausea vomiting headache and confusion and symptoms resolve on their own after about a few hours when the fluid is re-um placed between the blood and the cerebral spinal fluid also an air emboli so this results when air enters the system and it could be due to loose fittings or connections in the dialysis system it could be a sudden dipstick is the symptom or hypotension or cyanosis if you suspect an air emboli disconnect the patient from the dialysis machine place the patient in a left lateral recumbent position with about 10 degrees of the head down tilt and transport immediately so this table shows medical emergencies in renal dialysis patients you want to get to know some get to know those medical emergencies that can occur",
        "Male Genital Tract Conditions": "okay so then you have male genital tract conditions and so epididymitis is a complication that occurs uh in the male male uti and it's an affection that causes inflammation of the epididymis along the posterior borders of the testes okay and then you have orchardists and that's when one or both of the testes is infected the infection causes one or both of the testes to become enlarged and tender results in pain and swelling of the scrotum pre-hospital management remember is just supportive and consider administering analgesics so you could have some gangrene and it results from bacteria entering the scrotum or the perineum this causes necrosis of the subcutaneous tissue and the muscle of the scrotum patients will be febrile in the scrotum and the perineum will be tender warm and warm and if unchecked the scrotal tissues will become gray and black a true emergency and prompt transport the hospital is required patients can rapidly become septic and unstable and will require aggressive treatment with iv fluids also a priapism so that's a painful tender persistent erection it can result from sickle cell disease or leukemia a spinal cord injury and certain medications also cause this so antidepressants anti-convulsants and those used to treat erectile dysfunction so maintain the patient's privacy do not make assumptions about the conditions caused and treat the patient with respect also administer analgesics for pain and consider proper immobilization if the spinal cord injury is a suspected okay then benign prostate hypertrophy so bph and that's age-related it can be non-cancerous enlargement of the prostate gland and that occurs in about 50 of men older than 50 and increases with age it may be asymptomatic or may lead to difficulty urine starting the urine flow or weak flow if the prostate becomes infected a condition called prostate alysis occurs and that's inflammation of the prostate gland and presents with symptoms similar to uti as well as fever tremors or urinary obstruction there's also testicular masses and they rarely require treatment but it may be painful or painless and most are benign cyst masses testicular cancer usually presents with a painless solid lump on the testicle and then finally lastly is tectus testicular torsion and that's the twisting of a testicle on the um cord from which it's suspended it's associated with a sudden onset of pain and swelling medical emergency of the twisting of the vessel reduces the blood flow it's usually unilateral occurring in only one and it may occur with or without trauma patients should be carefully and promptly transported to the hospital and allow patient to assume that position of comfort and provide analgesic for pain control if necessary okay so that concludes chapter 21 a jenna to urinary and renal emergencies lecture if you liked it go ahead and subscribe to the channel and we are going to be completing all of the paramedic lectures shortly thank you"
    },
    {
        "Introduction": "hello and welcome to chapter 19 diseases of the Eyes Ears Nose and Throat lecture this chapter provides knowledge of the anatomy physiology epidemiology pathophysiology and psychosocial impact presentations prognosis and management of diseases of the eyes ears nose and throat so let's get started paramedics May respond to calls involving disorders of the Eyes Ears Nose throat eent so a specific number of these calls involve trauma familiarity with the eent conditions will help you when assessing the patient also allows you to educate the patient on prevention or potential care so patients may need to be transported to the emergency department with a access to an eye specialist or an ear nose and throat",
        "The Eyes: Anatomy and Physiology Review": "specialist so let's talk talk about the eyes first so let's do an anatomy and physiology review so connection to the brain by two nerves there's the ocular motor nerve and that's the third cranial nerve it inerts the muscles that cause motion of the eyeballs and upper eyelids and it carries parasympathetic nerve fibers that cause constriction of the pupil and accommodation of the lens and then there's the optic nerve it's the second cranial nerve and it provides the sense of of vision this figure shows the structures of the eyes and this figure shows the lacal system of the tear ducts and",
        "Patient Assessment": "glands okay so the patient assessment so you want to ensure seene safety and keep your patient calm inform the general impression note the environmental Clues at the scene and note the approximate age and sex of the patient assess Airway breathing and rule out life threats do not be distracted by swollen or irritated eye and Mis priorities early transport May improve outcome so cover both eyes to limit damage to the affected eye through the sympathetic movement consider pain management and cardiac monitoring is is recommended so ocular pressure can stimulate the vagal nerve eye drops medications can cause side effects such as low or high blood pressure so provide emotional care and obtain the chief complaintant history and the op CST such as when do the symptoms begin and what symptoms are they experiencing and are both eyes affected so symptoms that may include a serious ocular condition include vision loss that does not improve when the patient blinks double vision of foreign eye pain or foreign body sensation perform a thorough exam and use standard precautions avoid aggravating the affected area so assess for the pain swelling abnormal movement sensation circulatory changes deformity and vision changes and of course Airway compromise and assess for the following visible ocular structures so you want to in the orbital ring you want to check for ecosis swelling lacerations or tend Ness also check in the eyelids for the same and in the corneas for any foreign bodies that you could see in the conjunctiva you're looking for redness plusus in inflammation or foreign bodies and in the globe uh the redness or an abnormal pigmentation or lacerations on the eye surface you're looking for any growth or discoloration and the pupils you want to make sure that the pupils are pea pupils equal round reactive to light and accommodation when assessing ocular function perform the following test and so there's a vision Acuity test and you want to assess the ability to see large and small letters and test each eye separately and document the results and then the peripheral test so test the ability to recognize an object entering the extremities of the visual field also ocular motility so check the ability for the eye eyes to move in all directions and check for paralysis of gaze or discoordination between the movements of the two eyes and that is um the word for that is disconjugate gaze you want to obtain a full set of vitals and reassess every five or 15 minutes depending on the patient's condition and ask the patient how he or she administered any medication he or she has used generally recommended to wait 5 minutes between the first and second drop so eye drops are used for conjunct vtis uh dry or eye itchy eyes eye pain glaucoma eye surgery or herpes simplex corneal abrasions or lubrication and ey drops and lubricants can be applied by gently squeezing the lower eyelid to make it pouch and applying the medication to the lower lid having the patient close the eyes and roll them downward and uh ask the patients would medications they have already taken irrigation may be necessary for chemical or thermal Burns so use sterile water or some type of isotonic saline solution and flush liquid from the inside of the corner to the out I should be seen in the emergency department and um eye injuries may be irreversible so communication is the key to keeping the patient calm and informed um early decisions to transport can improve some outcomes",
        "Contact Lenses": "all right so contact lenses some patients will be wearing them and the only indication for removing the lenses in the prehospital setting is for a chemical burn so there are three types of lenses hard rigid or soft and to remove a hard contact lens use a small suction cup moisten with uh at the end with saline and to remove a soft one just place two drops of saline in the eye and gently pinch the lens between your glove gloved thumb and index finger and lift it off the surface of the eye advise emergency department staff if the patient was wearing contact lenses or if they still",
        "Eye Prosthesis": "are next we're going to talk about eye prosthesis so suspect the patient has an eye prosthesis if the patient does not respond to light or the eye the eye does not move in concert with the other or the eye does not appear quite the same as the opposite the patient says he or she has",
        "Use of Ophthalmoscope": "one okay so um an opalos scope so practitioners in the hospital or Physician's office they may use one of these so they're rarely used by paramedics and they consist of a concave mirror with a battery powered light usually um contained in a the device's handle and a rotating section of the lens and adjustable depth and magnification so their effective evaluation of the eye with this device requires dilation of the patient pupils and significant Diagnostics experience but for steps for use um you could check out the skill drill a",
        "Conjunctivitis": "19-1 okay so let's talk about conjunctivitis conjunctivitis is basically pink eye it's a condition where the conjunctiva and that's the thin layer that lies lines inside the eyelids and the white of the eye becomes inflamed and red most often starts in one ey and sometimes spreads to the other it's most often caused by bacteria viruses allergies or chemicals viral conjunctivitis is often associated with an upper respiratory virus bacterial conjunctivitis is caused by bacterial infection and viral and bacterial forms are highly contagious allergy conjunctivitis is caused by a trigger or an irritating allergen such as pollen and also chlorine and swimming pools and air pollution are potential causes of chemical conjunctivitis if conjunctivitis is due to a foreign body the eye will begin to produce tears in an attempt to flush out the object right you want to perform a general assessment of the patient's Vis Vision including the visual acut and pupil's peripheral vision and N movement viral conjunctivitis normally resolves on its own bacterial conjunctivitis requires a topical antibiotic severe allergic conjunctivitis may need non-steroidal anti-inflammatory drug or an anti-histamine or topical steroid inflammation of the eyelid the",
        "Inflammation of the Eyelid": "uh is what we're going to talk about next and so a protective film of oil glands and oil Ducks cross the eye okay so there's two types of inflammation um a small swollen bump or pstu on the external eyelid formed by blockage and swelling of an oil gland is the first one and the second one is commonly referred to as a sty and that's the infection of an oil gland that produces a red tender lump in the eye or at the lid margin a thorough assessment of vital Science History and transport for physician evaluation is war wared and the patient will usually be asked to apply warm compress compresses for 5 to 10 minutes several times a day and topical or oral antibiotics may be",
        "Glaucoma": "prescribed okay so there's a group of conditions that lead to increase interocular pressure and this is glaucoma it's one of the leading causes of blindness aquous humor the clear watery fluid that fills the eyes anterior chamber maintains intraocular pressure provides nutrients to the inner surface of the eye and helps to bend the light there are several types of glaucoma there's open angle glaucoma and that is when the fluid drains too slowly and pressure builds up within the eye and damages the optic nerve this is the most common type of Glau glaucoma and that's open angle glaucoma then there's normal tension glaucoma it can cause vision changes with no increas and inocular pressure and then there is narrow angle glaucoma that's when the aquous fluid does not drain properly due to narrowing of the drainage Channel and then posterior pressure builds up in the chamber of the eye which pushes the lens forward secondary glaucoma is a result of conditions that damage the drainage channel in the eye such as diabetes or leukemia or Sickle Cell um chances increase with age and usually treated with eye drops to reduce the ocular pressure so the assessment and management if the patient complains may involve loss of field of vision and patients who have an acute attack of narrow angle Glau glaucoma may result severe pain or headache or photophobia blurred vision or Halos uh the cornea may look cloudy and uh pupils often have irregular mark margins and can be fixed in a mid position and dilated so rule out trauma and physical injury and perform a general ey assessment so Central retinal artery occlusion this is a condition in which the blood supply to the retina becomes blocked because of a clot or Emi in the central retinal artery or one of its branches so possible causes include an emis from a coted artery um heart disease drug use or fat embl um perhaps an arterial spasm or oral contraceptive use so may cause partial blindness which may be temporary or permanent so patients with Central retinal arterial occlusion usually seek medical assistance because of the sudden painless loss of vision so vision loss in central retinal vein occlusion May progress over 30 to 120 Minutes immediate transport in a situation in evolving a rapid loss of vision is warranted so next we're going to talk",
        "Iritis": "about iritis and that's inflammation of the iris it's the third leading preventable cause of blindness it can be acute or chronic so acute cause by trauma or irritance and usually affects only one eye uh chronic causes could be autoimmune diseases uh irritable bowel disease or Crohn's disease and infections causes um include Lyme disease or tuberculosis so iritis uh presents as a red area surrounding the iris cloudy vision and usually unusually shaped pupil so the acute usually responds well to topical cortical steroids as long as the cause is not fungal viral or bacterial so 90 different pathogens or autoimmune processes can cause this um so patients should be referred to a specialist",
        "Papilledema": "so Pap edema that's resulting from swelling or inflammation of the optic nerve at or at the rear part of the eye so symptoms are headaches nausea with VI possible vomiting temporary vision loss or narrowing Vision fields or a graying in the field of vision so it could be caused by tumors or an abscess or an inner ear infection Dental infections or menitis fever high blood pressure chronic high blood pressure or the gillon ber syndrome diagnosis will be needed by an opthalmologist or physician so uh prehospital management treating symptoms and transporting and assessing the a uh",
        "Cellulitis of the Orbit": "ABCs next we're going to talk about cellulitis of the orbit and it's a par orbital or orbital cellulitis and so it's more prevalent in children than adults it it's known as uh cellulitis or eyelid cellulitis it presents as a painful red swollen eyelid it's predisposed um insect bites or upper respiratory disorders or trauma and the orbital cellulitis is an infection within the eye socket it's considered a medical emergency the goal of treatment is to avoid the formation of an abscess and there's predisposed risk factors such as sinusitis or tooth infections facial or middle ear infections or trauma or sinus infection so treatment in children is usually IV antibiotics and adults are generally treated with oral antibiotics prehospital management includes ruling out life threats or and obtaining a thorough",
        "Corneal Abrasion": "history okay so the next one we're going to talk about it's pretty common is the corneal abrasion or ulcer so it's when uh the corn that's the transparent outer covering of the eye um it has some type of trauma or foreign body possibly contact lens or exposure to ultraviolet radiation it's the most common eye injury seen in the emergency department it can cause blindness if un uh left untreated so um an ulcer can develop so signs and symptoms are pain redness excessive tearing sensation of having something in a in their eye um and blurred vision or photophobia also headache prehospital management you need to rule out the life threats of course and take a thorough history and then transport",
        "The Ears": "promptly okay so after the eyes we're going to talk about the ears and the primary structures For Hearing and Balance are the ears disorders and injuries can leave a person unable to communicate react and maintain equilibrium changes in ear pressure can cause ear discomfort and tumors on cranial nerves can affect the inner ear balance facial sensation eye movement and facial movement taste and hearing the ear is divided in the three automic parts and so you have the external the middle and the inner and uh you could see the three different parts on the uh slide sound waves travel through the ear and then the internal ear structures form nerve impulses that travel to the brain via the auditory nerve the brain converts these impulses into sound so possible ear injuries include foreign objects or ear infections or blast pressure waves which can burst the eard drum you want to observe the scene to rule out any hazards to EMS personnel and crew and as you approach um try and get the age and sex of the patient environmental conditions uh the patient's degree of distress and whether the patient is wearing a hearing aid and ensure Airway patency breathing adequacy and circulation manage life threats and take a complete history you also want to observe the ears for drainage or excess ear wax inflammation and swelling have the patient rate his or her pain using uh the op Cur and ask the patient about changes in hearing or t tendinitis uh dizziness wound swelling or drainage also look for battle signs and uh that's uh on that mastoid process of the",
        "Use of an Otoscope": "skull an otoscope is used to visualize abnormalities of the internal canal and uh tematic membrane so an oscope consists of a head and a handle and the head contains an electric light source and a low po power magnifying glass the front of the headpiece is an attached for disposable plastic eardrum and the examiner inserts a speculum into the ear and looks through the lens on the rear of the headpiece typically paramedics must work in an expanded scope of practice and receive additional training from their medical director to use this oscope um referred to skill drill 19-2 Okay so another common uh thing",
        "Impacted Cerumen": "that happens is impacted seramin so it's a yellowish oily substance found in the outer ear canal and it's ear wax basically it helps prevent dirt and water from entering the middle ear canal and may protect the ear from bacteria and fungus so it may present as wet uh or a sticky brown color or dry and a grayish flaky substance it can become impacted and cause pressure against that eard drum so there are risk factors and it's more common in older adults abnormal ear canal shape um can cause it an improper use of cotton swabs or Q-tips and so some symptoms are dizziness or pressure or fullness of the ears ringing of the ears or loss of hearing prehospital treatment includes a thorough history and a visual inspection of the ear so treatment is aimed at removing the excess serum and do not attempt to uh extract the material yourself if left untreated infection and irritation can occur so followup is",
        "Labyrinthitis": "necessary okay so next we're going to talk about labyrinthitis and this is the most commonly recognized as a feeling of vertigo or loss of balance after an ear infection or upper respiratory infection it's effect on the nerves of the inner ear and the loss of balance from irritation and swelling of the inner ear so um symptoms are ringing in the ears or dizziness loss of hearing or nause and vomiting prehospital treatment just uh includes reducing the severity of the nausea and vomiting and transporting the position patient in the position of comfort serious disorders will need to be ruled out by CAT scan and an MRI and so um possible treatment includes an antimimetic for nause and vomiting or an antihistamine for swelling or an anti go medicine and diazapam as a sedative",
        "Meniere Disease": "also so next we're going to talk about man's disease and that's a chronic condition of the inner ear characterized by dizziness described as a spinning vertigo or low frequency hearing loss um feeling a fullness in the affected ear it involves the overproduction and defective absorption of fluid which increases the volume and pressure within the Labyrinth of the ear so the mixture disrupts the balance of fluid and electrolytes and damages the vestial and cular hair hair cells the attacks of less than two hours in the early stages altered balance of up to two days as a disease progressives symptoms last hours to days and a permanent tinted us moderate to severe hearing loss and chronic unsteadiness may result so assessment and management so prehospital care includes treating the nause and vomiting with an antiemetic and the physician matri with diuretics and also an",
        "Otitis Externa and Media": "anti-ed so ois externa and media it's an infection that results in the bacterial growth in the ear canal so um you have the externa which is the infection in the outer ear and a media which is the infection in the middle more common in a children than adults and most common bacterial infections so the otus externa may also be an allergic or fungal reaction and the otus media can be virally induced so signs and symptoms are pain itching and uh diminished hearing and inflamed bulging tanic membrane on exam with the otoscope um prehospital treatment should be directed at relieving unbearing able symptoms and in the hospital setting antibiotics may be",
        "The Nose": "administered the nose is what we're going to talk about next and it's susceptible to injury because of the prominent location on the face the nose acts as a filter humidifier and heater for air that enters the body allergens particles and chemicals can cause inflammation infection and injury and there are complications from nasal disorders are very common and the inside of the nose is extremely vascular it's an excellent route for some medicines and faster uh even than intravenous administration so loss of smelling and sensation has many causes aging smoking allergies um polyps flu medications traumatic brain injury and there are some uh smelling disorders um and so anatomy and physiology review so one to two primary entry points for oxygen it warms and humidifies as I said on the last slide as air enters the body contains bony structures and it's connected with the sinuses so uh when you're doing a patient assessment look for environmental Clues and ensure the scene safe determine whether the airway and breathing are sufficient and determine the patient level of Consciousness the vascular nature of the nasal cavities makes them susceptible to bleeding now severe nose and or condition that blocks the airway with swelling or blood is life-threatening so insert an airway adjunct if needed but do not insert the NP or attempt any type of naso tral inhibition in a patient with a suspected nasal fracture or CSF or blood leakage from the nose and inquire about previous history of nose conditions and always consider a hypertensive crisis when an older person has a nose pleed",
        "Epistaxis": "so um we're going to talk about epistasis next and that's the word for nose bleed um it's most common causes digital trauma so picking your nose other causes are dryness and hypertension there are two types of nose bleeds and there are the anterior and then the posterior so anterior is most typically um occurs in in the front area usually self-limiting and can resolve quickly then the posterior is usually more severe often cause blood and drainage to the back of the throat and can cause um some nause and vomiting so when you're talking about the assessment and Management try to estimate the amount of blood loss and place a non- trauma patient in a sitting position leaning forward and pinch his or her nostrils together direct the patient not to sniff or blow his or her nose",
        "Foreign Body": "with a foreign body it's most likely to be seen in pediatric patients and pressure in the nasal passage can cause some tissue necrosis inflammation and swelling so tissue ulceration and epistasis are caused by inflammation and sinusitis caused by nasal blockage so determine if a foreign body pres um presents a life-threatening condition you may be able to see it um any persistent F SW smelling or any discharge from the Nars should lead to suspicion of a foreign body and transport the patient in the position of comfort and pain management or sedation it may be",
        "Rhinitis": "necessary ritis and that's an inflammation in the nasal cavity it may be caused by bacterial viral infections and it can also be caused by certain medications or foreign bodies or irritance in the ear also hormonal uh changes in pregnancy so signs and symptoms are nasal congestion swelling or sneezing itchy runny nose or postnasal drip and keep the patient in the Fowler's position and provide",
        "Sinusitis": "transport sinusitis is a sinus inflammation it occurs when drainage from the sinuses becomes disruptive and sinuses become colonized with nasal bacteria and infected facial pressure pain sore throat nasal congestion tooth AE headache fever chills and muscle aches uh it affects about 29.3 million adults per year according to the CDC young children and older adults are also more susceptible so the condition can be chronic acute or reoccurring prehospital management should include treatment of any respiratory compromise treatment is aimed at reducing inflammation and draining the sinuses so mild to moderate symptoms can be treated with a saline rinse and antibotics are typically prescribed after 7 to 10 days okay next we're going",
        "The Throat": "to talk about disorders of the throat and they could have be acute inflammation and infections chronic inflammation or abnormal growths specific disorders could include vocal cord polyps or nodules contact ulcers or vocal cord paralysis um or cancer so throat infections are common and children and throat problems can be exacerbated by swallowing problems cranial nerve six 7 9 and 12 all play a role in swallowing chronic problems associated with stroke and Trauma can also um make swallowing difficulty in aspiration pneumonia is a life-threatening condition pre Hospital uh treatment of aspiration involves maintaining the paint Airway ensuring adequate breathing and close monitoring of the vital signs and prompt transport for definitive care esophagal disorders can be they can affect the throat the U valve at the end of the esophagus keeps acid stomach contents from coming back up in the throat so in a esophageal reflex the valve only partially closes or opens too much so symptoms include burning sensation ingestion or a change in voice and can cause precancerous condition so um when you talk about anatomy and physiology uh assessment begins at opening the mouth with the teeth and you could see on this slide some of the uh anatomy and",
        "The Mouth": "physiology so when you talk about the um different trigeminal or facial nerve Supply the mouth and its structures and uh you could see on this uh Slide the different nerves that uh Supply the mouth the neck consists of the anterior",
        "The Neck": "and posterior portions the anterior part of the neck includes the thyroid and CID cartilage the trachea and numerous muscles and nerves there's also major blood vessels so the internal and external coted arteries and the internal and external jugular veins and the vertebrae arteries run laterally to the cervical vertebra in the posterior part of the neck and you can see that really good picture on the slide and this figure shows the veins of the neck okay so when you're talking about the patient assessment um patients with swallowing abdali or copious mucus production should be placed in a position that allows drainage so assessing stroke patients must include early recognition of Airway threads for patients who cannot protect their airways and are at risk for aspiration to the lungs innate should be ination should be considered in your assessments you should consider epig glotus epiglottitis if the symptoms are sore throat drooling or forward hanging head and then you have uh Dental",
        "Dentalgia and Dental Abscess": "abscesses and so um a tooth ache B basically can be the start of a dental abscess a dental abscess occurs when bacterial growth spreads directly from the cavity of the gut facial tissue bones or neck and it may have to be drained surgically so infection may have become systemic if the patient has fever chills nausea or vomiting and an absis in the throat neck or under the tongue can affect the ability to breathe so prehospital treatment it's aimed at relieving the symptoms and drainage into the mouth should be rinsed with warm water you should encourage",
        "Diseases of Oral Soft Tissue": "transport next we're going to talk about diseases of the oral soft tissue and it can be a root cause of other health problems so gum disease has been linked to heart disease some common mouth disorders are cold sores or canker sores oral um Candis and that's thrush or Luca plaia and that's caused by excess cell growth in the mouth cheek or gums um also gingivitis that's red swollen guns or bad breath and that's usually linked to plaque or poor oral hygiene so rule out uticaria and allergic reactions for the assessment of management and also thrush so that is a",
        "Oral Candidiasis": "condition in which um you have a fungus that accumulates on the lining of the mouth it's creamy white lesions on the tongue and inner cheeks and it may be painful and it may bleed as they are rubbed or scraped thresh is most likely to be found and babies or patients with compromised immune systems also patients who wear dentures or patients who use inhaled cortical steroids it's um painful and cracking and redness in the corners of the mouth or in lack of taste also a cotney feeling in the mouth in severe cases lesions can move down the esophagus causing the Sensation that food is getting stuck in the throat when swallowing patients have an increased risk um if they have the history of HIV or Aids or cancer diabetes or yeast infections so um treat higher priorities and make the patient comfortable and use standard",
        "Ludwig Angina": "precautions lugwig Ang Gina so this a type of cellulitis caused from bacteria from an infected tooth root or mouth injury it occurs on the floor of the mouth under the tongue and it's rapid swelling and and Airway obstruction redness and swelling of the neck are under under the chin and the tongue may also be swollen an airway through um the nasal passages possibly might be needed so the symptoms are going to be difficulty breathing or difficulty swallowing neck pain neck swelling fever drooling and altered speech sounds prehospital treatment requires aggressive management of the airway in some cases and contact medical control early on remain calm and organized attend the basic ABCs and play part pay particular attention to the condition and smells originating in the",
        "Epiglottitis": "mouth also epiglottitis so that's the inflammation of the epiglottis it blocks the trachea and obstructs the airway it's uh often a result of the type B virus influenza they're going to have fever and a sore throat payro swallowing Strider remember that upper Airway blockage uh resp distress and patients will look sick and anxious and they'll sit up in the classic tripod position or in a sniffing position and usually they'll be drooling uh work of breathing will be increased and cyanosis may be evident you need to transport to the appropriate facility while maintaining that Airway minimize seene time and do not attempt procedures that could agitate the patient and do not attempt to look in the mouth alert receiving Personnel of suspected d diagnosis and patient",
        "Laryngitis": "condition right leitis so this is swelling an inflammation of the lurin Linex associated with heness and loss of voice and it can be a result of overuse most common form caused by a virus though so uh could be caused by pneumonia or irritants or chemicals or also gastrosoph reflex disease or bronchitis allergies and bacterial infections symptoms could include fever heness or swollen lymph nodes or glands in the neck obtain that good history to rule out a evolving upper Airway obstruction or allergic reaction and consider fracture of the hyoid bone have the patient follow up with the physician tracheitis so that's a bit a",
        "Tracheitis": "bacterial infection of the trachea and uh frequently occurs in children following an upper respiratory infection the trachea is easily blocked by swelling so it can be life-threatening um symptoms includes that cro like cough difficulty breathing high fever or high pitch Strider um they'll be in the tripod position with intercostal retractions and they can proceed from respiratory distress to full respiratory failure if not addressed you need to minimize stress and administer a 100% O oxygen use the pulseox and monitor Vital Signs and be prepared for in ination and have the correct ET tube as well as smaller sizes and then transport promptly to the appropriate",
        "Tonsillitis": "facility tonsilitis that's swelling of and inflammation of the tonsils and it's usually caused by a v a viral infection and it can also be caused by bacteria symptoms include swollen tonsils or sore throat and patients will present with the following so red swollen tonsil white or yellow coating or patches on the tonsils fever sore throat pain when swallowing or enlarged or Tender lymph nodes bad breath or headache stiff neck and drooling okay so the next thing",
        "Pharyngitis": "we're going to talk about is the fitis and that's inflammation of the ferx it's often due uh to a rapid onset of a sore throat without discomfort or pain with swallowing symptoms are going to be fever um or headache or a patch yellow gray or white nasal congestion heness cough or ulcers on the soft pallet treatment involves follow-up to the emergency department and a major prehospital concerned is assessment for partial Airway",
        "Peritonsillar Abscess": "obstruction so a collection of infected material around the tonsils is that peritonsillitis abscess and the complication of tonsilitis and of course course one or both of the tonsils are infected the roof of the mouth and the neck and or chest can be infected and there patients are going to have chills difficulty opening their mouth facial swelling or fever drooling or an inability to swallow the saliva headache muffled voice sore throat and tender glands on the jaw in the throat antibiotics in draining the abscess may be needed and Hospital transport in some cases condition may be life-threatening",
        "Temporomandibular Joint Disorders": "the next thing we're going to talk about is TMJ so that's that temporal mobular joint disorder and that's where the um basically the mandible articulates with the temporal Man U membrane bone and it allows movement and um that that when they have this TMJ it's basically arthritis damage so that joints cartilage or jaw injury or jaw muscle fatigue from grinding or clenching teeth okay when it comes to assessment and management of TMJ uh the the symptoms are going to have a headache or jaw pain or aching around the ear an uneven bite or painful bite difficulty chewing and locking of the joint causing difficulty opening or closing their mouth um this is usually managed by the patient's physician or dentist okay so that concludes uh chapter 19 diseases of the eyes ears nose and throat lecture thank you for joining us tonight and if you like this lecture go ahead and subscribe to our Channel we're going to be going through all of the uh different chapters all right have a great night"
    },
    {
        "National EMS Education Standard Competencies": "hello and welcome to chapter 24 hematologic emergencies this chapter provides a basic understanding of the hematopoietic system and that's the blood components and the organs involved in their development and production and hematologic disorders the hematopoietic system consists of organs and tissues primarily bone marrow spleen and lymph nodes involved in the production of blood components",
        "Introduction": "so let's get started hematology is the study of blood it also addresses how its parts are involved in health and disease so the components include red blood cells white blood cells platelets and other proteins involved in bleeding and clotting cascades the hemoplagic system includes organs and tissues involved in the production of blood components hematologic disorders refer to any disorder of the blood so hemolytic disorders are disease process that cause the breakdown of red blood cells and hemostatic disorders is bleeding and clotting abnormalities you should be have a basic understanding of the hemoplegic system and the hemologic disorders and how know how to respond to these kinds of emergencies appropriately",
        "Blood and Plasma": "so let's talk about blood and plasmas anatomy and physiology so connective tissue is composed of cells and cell fragments and it's suspended in plasma and plasma is the liquid portion of blood approximately eight percent of the total body weight and so that's approximately five to six liters the primary function of blood is to supply oxygen and nutrients to the cell transport carbon dioxide and nitrogenous wastes from tissues to lungs and kidneys where waste are removed from the body they carry hormones from the endocrine glands to the target tissues regulate blood temperature it regulates ph through the buffering components in the blood keeps fluid and electrolytes balanced through sodium and potassium proteins also regulates the immune system through the actions of white blood cells and antibodies and forms clots through the action of platelets there are two components you have plasma and formed elements so plasma is 92 water 8 various solutes it accounts for 55 percent of total blood volume and then you have the formed elements so they account for 45 of the total blood volume and it includes red blood cells which are eurythrocytes white blood cells which are leukocytes and the platelets which are the thrombocytes and then 99 red blood cells so this figure shows the components of a blood sample production of red blood cells within stem cells cells that develop into other types of cells are stem cells this production is stimulated by your erythroprotein a protein secreted by the kidneys in response to circulatory need red blood cells may take as long as five days to mature and have an average life of about 120 days within red blood cells iron rich hemoglobin carries oxygen to the tissues oxygen attached to the hemoglobin gives blood its red color there's the bohr effect and that's when oxygen rich red blood cells encounter an environment that contains higher concentrations of carbon dioxide and is more acidic oxygen is then released there are three laboratory blood tests and there is the red blood cell count hemoglobin level and the hematocrit measurement so the red blood cell count measures the number of red blood cells in a blood sample the hemoglobin level identifies the amount of hemoglobin found in the red blood cells and then the hematocrit measurement this gives the overall portion of red blood cells in the in the blood blood is considered balanced if hemoglobin level is one-third of the hematocrit level and the red blood cell count is one-third of the hemoglobin level this table shows red blood cell and platelet counts okay so white blood cells are larger than red blood cells they provide immunity against foreign invaders they are derived from stem cells several types exist and perform a specific task to maintain the immune system certain disease processes are also specific to differential white blood cells immune system responses can be categorized into hormonal immunity and cell mediated immunity this table shows white blood cell count and the differential and then let's talk about platelets so platelets are the smallest of the formed elements approximately two-thirds circulate through the blood the rest are stored in the spleen and they are responsible for clotting and clotting the blood so hemostasis is the process that allows the body to stop bleeding and clots are made of fibrin the clotting cascade is the process by which clotting factors work together to completely form fibrin also called the coagulation cascade it can be initiated through either an intrinsic or an extrinsic pathway okay so blood forming organs and red blood",
        "Blood-Forming Organs and RBC Production": "cell production is what we're going to talk about next the major players in the hematologic system are bone marrow and it's the primary site for cell production it's found in most of the long bones and the pelvis skull and vertebrae and the liver it produces clotting factors found in blood filters the blood removes toxins essential to normal metabolism and homeostasis breaks down old red blood cells in the bile and it's highly vascular and then you have the spleen it's also very vascular it filters and breaks down red blood cells and assists with leukocyte production and helps provide hemostasis and fight infection control and remaining platelets after spleen removal okay so once again this figure shows the major players in the hematologic system the bone marrow liver and the spleen",
        "Patient Assessment": "all right so the patient assessment notation of immediately life-threatening signs and symptoms unusual bleeding or apparently uncontrolled hemorrhage can indicate an underlying pathology ask in-depth and relevant questions about the patient's history and sample history and follow up on the responses a non-judgmental approach is essential to ensure patients they will not be treated differently because of their condition",
        "Scene Size-Up": "scene size up so we have to ensure the scene is safe consider the mechanism of injury determine the number of patients and assess for hazards and the need for additional help gloves and eye protection are the standard minimum precautions",
        "Primary Assessment": "during your primary assessment you need to perform cervical spine stabilization if necessary do not dismiss pain complaint of the spine just because it could be a manifestation of a disease so always perform a thorough careful primary assessment form your general impression and perform a rapid scan of the patient determine the level of consciousness and assess the airway and breathing patients showing signs of adequate breathing or altered mental status should receive appropriate oxygen depending on the severity check circulation so an increased pulse may indicate a compensatory mechanism look for signs of shock manage life-threatening conditions and then provide transport to the appropriate facility if hemophilia is suspected be careful not to wash out clots if fluid resuscitation is necessary all right so watch for signs of acute blood loss and any bleeding of an unknown origin so make your transport decision the decision depends on the severity of the patient's condition and wishes and if a patient is experiencing a sickle cell crisis or uncontrolled bleeding transport to the closest appropriate",
        "History Taking": "facility history taking you may need to be overly inquisited about the patient's history and sample so hematologic disorders may present with multiple symptoms that at the first glance may seem unrelated some examples would be pneumonia in a patient with sickle cell disease or abdominal pain in a patient with some type of polycynemia you must put these pieces together to complete the picture you want to look for changes in level of consciousness or vertigo feelings of fatigue sinkable episodes or dips near chest pain or changes in pulse rate and rhythm maybe coughing up blood or visual disturbances or muscle pain or stiffness determine whether complaints are related as part of the larger disease process or are simply multiple unrelated complaints and ascertain whether pain is isolated or felt throughout the entire body ask if the patient has experienced skin changes or bleeding history of liver problems or pain for unknown reasons or gastrointestinal problems or problems in the genitourinary system",
        "Secondary Assessment": "the secondary assessment may be performed on scene and route or not at all it depends on transport time and patient condition when treating a patient with a blood disorder perform a physical exam you want to systemically examine the patient start at the head and work your way down obtain baseline vital signs",
        "Reassessment": "and then your reassessment so your reassessment frequently to determine if the patient's condition has changed inform hospital staff about the history and situation in your findings and thoroughly document each assessment your findings treatment time of interventions and any changes in the patient's condition",
        "Emergency Medical Care": "so let's talk about emergency care for problems related to a blood disorder they should include oxygen and this could be determined by the severity of the patient's condition and their respiratory status also fluids and ecg transport comfort and pharmacology and physiological support",
        "Sickle Cell Crisis": "let's talk about sickle cell crisis so there is serious and often life-threatening hematologic disorders and the first one is sickle cell so pathophysiology so sickle cell disease is the most common inherited blood disorder it primarily affects african american puerto rican and european populations as of 2016 approximately a hundred thousand people in the us had sickle cell disease average life expectancy is 42 euros old in males and 48 for females it begins with a gene defect of the adult type of hemoglobin it can be inherited from both parents or one parent and when inherited from both there is a high probability offspring will have the disease and carry on the mutation defective red blood cells have an oblong shape instead of a smooth and round shape the shape makes the red blood cells a poor oxygen carrier increasing the risk of hypoxia cells have a much shorter life span increasing risk of anemia and the odd shape can cause red blood cells to lodge in small blood vessels sickle cell disease can lead to an aplastic crisis and that's when the body temporarily stops red blood cell production causing the patient to become easily tired anemic pale and short of breath and then there's a hemolytic crisis and that's acute red blood cell destruction leading to jaundice sickle cell crisis may manifest in several ways so a vaso-occlusive crisis and that's when blood flow to the organ becomes restricted the crisis causes pain ischemia and often organ damage it can last for five to seven days the spleen is frequently affected due to its narrow vessels and function of removing damaged red blood cells an acute syndrome so a vasoclusive crisis associated with pneumonia it's common signs and symptoms include chest pain fever and cough and a vasoclusion in the brain may also result in a stroke so a splematic crisis is sickle cells within the spleen block blood from leaving the spleen this results in painful and acute enlargement of the spleen and hard bloated abdomen so an acute splenic syndrome life-threatening condition in which red blood cells become trapped so it causes a dramatic fall in hemoglobin available in circulation painful acute abdomen and sudden weakness pallor and tachycardia it usually occurs in infants and toddlers so when it comes to the assessment patients are often in a life-threatening crisis characteristic characterizations of sickle cell crisis include shortness of breath signs of pneumonia inadequate profusion of the skin accompanied by hypotension signs of jaundice yellowing in the eye or mild dehydration in acute crisis patients may have significant pain and multiple system involvement pediatric patients typically present with initial pain in the hands and feet and adults typically report back in proximal extremity pain management so you want to administer high levels of oxygen to prevent further destruction from hypoxia rapidly transport the patient to the appropriate facility consider iv fluid therapy if necessary and maintain the patient's body temperature patients may have a high pain threshold and require a higher level of analgesia so recommend that the patient rest during transport",
        "Anemia": "if possible okay after sickle cell we're going to talk about anemia and so what anemia is is it's hemoglobin or your erythrocyte level that is lower than normal it's usually associated with some type of underlying disease process acute or chronic blood loss decreased production or increased destruction of erythrocytes or a pre-existing hematolytic disorder iron deficiency anemia anemia that's the most common type in typical causes include gastrointestinal blood loss or menstrual bleeding or blood loss from frequent donations or diagnostic tests it may be caused by an inherited hematolytic disorder or red blood cells develop rigid or deform membranes such as sickle cell and it may be caused by a hematolytic disorder resulting from deficiency of a glucose 6-phosphate and that's an enzyme product protection of the red blood cells during infections common disruption of red blood cell flow from problems with blood vessel linings or blood clots or autoimmune disorders it affects it effects of smaller number of red blood cells and reduce partial pressure of oxygen at high altitude so your assessment most patients will complain of feeling worn down or having no energy or being unable to catch their breath so patients may also have angina type chest pain related to reduce oxygen to the heart so so assess for pale skin signs and variations in eye conjunctiv conjuctiva inside the lips or creases of their palms management of this you want to check and monitor the airway breathing closely check for vital signs and in cases of chest pain apply a cardiac monitor and get a 12 lead and manage blood pressure and replace fluids as needed allow the patients to assume the position of comfort and transport to the closest appropriate facility consider rapid transport if any of the following develops so if you get hypotension or abrupt change in consequence of consciousness or any other significant perfusion inadequacies",
        "Leukemia": "okay so the next type of blood disorder we're going to talk about is leukemia and leukemia is a cancer that develops in the lymph node system particularly in blood cells they develop abnormally or excessively and leukemia can cause anemia or thrombocytopenia and that's a decrease in platelets so chemotherapy typically leads to leukopenia and patients experience frequent bleeding bruising infections and fevers leukemia can be classified as acute or chronic chronic leukemia develops more frequently in people 65 years or older in chronic leukemia abnormal mature lymph node cells accumulate in the bone marrow lymph nodes spleen and peripheral blood typically found by chance during a routine blood test survival depends on several factors as a what stage of the disease is detected the patient's underlying medical condition and the response to treatment so leukemia is treated with chemotherapy and radiation therapy in most cases treatment results in remission children with acute lymphatic leukemia have a five-year survival rate greater than 85 percent so your assessment use appropriate standard precautions including gloves and masks patients present presentation depends on the stage and the current treatment patients may present with fatigue headaches dipseya signs of some neurologic defects fever bone pain or diaphoresis monitor all basic vital signs and the cardiac rhythm so for management you want to provide airway support and oxygen therapy as needed iv fluid therapy and analgesics may be needed and patients may need constant emotional support so you may be called because the patient's condition has deteriorated and the loved ones are uncertain what to do discuss the situation with medical control and document all findings before leaving be alert to rapid changes in condition and if transport be aware the patient could go into a rest make sure you understand the patient and the family's wishes about what to do",
        "Lymphomas": "okay so lymphomas and so that's a group of malignant diseases that arise within the lymph node system there are two categories non-hodgkin and hodgkin's non-hodgkin lymphoma can occur at any age can be hereditary and may be characterized based on progression so very slow aggressive or highly aggressive in hodgkin's lymphoma its painless progressive enlargement of the lymph node glands most commonly affects the spleen and lymph nodes highly rare form it's suspected to have some hereditary components in incidence at two peaks so 10 through 10 years through 35 years of age and in a late life possible symptoms could be night sweats chills persistent cough swelling of various lymph nodes loss of appetite significant weight loss fatigue and bone pain with treatment disappearance of symptoms for long periods of time can and possibly occur cure can occur so lymphomas require specialized levels of chemotherapy and radiation how well the disease responds to treatment depends on the stage of the disease and the classification so during your assessment ask questions like what type of cancer do you have and what type of treatment are you receiving so management pain management may be needed in treatment treat perfusion with fluid therapy treat any abnormal heart rhythms and if the condition does not improve or deteriorate initiate rapid transport you may be called to offer support but not transport so be supportive and discuss your findings with medical",
        "Polycythemia": "control so polycystemia it is a overabundance or overproduction of red blood cells resulting in increased blood viscosity and volume this can result in congestion of tissues and organs and it's caused by a rare disorder originating in a single stem cell existing disease such as heart failure or hypotension and living in high altitudes for long periods of time it may cause strokes or transited scheming attacks maybe dvts pulmonary emboli myocardial infarcts or headaches clinical treatment usually includes phlebotomy to maintain hematocrit levels so less than 45 percent in men and less than 42 in women so findings may vary widely and include alter level of consciousness or hypoxia respiratory distress or changes in peripheral pulses pulse rate and skin color note the extent and duration of dipsnia and if the patient has experienced uncontrolled itching so has the patient noted changes in skin temperature or obtain a thorough thorough history management so otherwise provide supportive care and transport to the appropriate facility establish oxygen as needed or establish an iv",
        "Disseminated Intravascular Coagulation": "disseminated intravascular coagulation so pathophysiology it may be caused by a number of life-threatening conditions it progresses in two stages so the first stage you have free thrombin and fibrin deposits in the blood and they increase the platelets begin to aggregate and the second stage is an uncontrolled hemorrhage results from reduction in clotting factors it's a high mortality especially in acute cases and up to 65 mortality related to uncontrolled bleeding hypotension and shock so identify signs and symptoms associated with this um so patients will have episodes of respiratory difficulty signs of shock and skin changes you want to maintain the airway give o2 treat for shock and there might be some pharmalogic condition interventions that could include pain management and treatment for abdominal heart abnormal heart rhythms and be optimistic but honest",
        "Hemophilia": "and then we have hemophilia so hemophilia is a bleeding disorder in which clotting does not occur or occurs insufficiently and it's usually classified or associated with an x-linked recessive inheritance pattern so it's classified into two types there's type a and type b and it is primary primarily found in males signs and symptoms are the same in both types and may include acute and chronic bleeding or spontaneous inner cranial bleeding patients with significant acute bleeding episodes may require hospitalization and infusion of factors eight and nine so take care of the abcs and be alert for acute blood loss note any bleeding of unknown origin such as nosebleed or bloody sputum or blood in the urine and watch for signs of hypoxia any patient complaining of respiratory problems should receive high flow o2 you want to note any ecg findings pre-hospital care may include iv therapy analgesics may be appropriate and cover the patients to maintain body temperature if the bleeding stopped before you arrived suggest the patients seek immediate follow-up help",
        "Multiple Myeloma": "so the pathophysiology of a multiple myeloma so the number of plasma cells in the bone marrow increases abnormally and it forms tumors in the bone it impairs normal bone marrow function decreases red blood cells white blood cells and platelet formation so the results in anemia and susceptibility to infection neoplastic cells may also accelerate protein development in the bloodstream this could lead to organ failure the disease occurs mostly in patients older than 40. as the disease progresses progresses patients may have weakness and bones and this could result in spontaneous fractures or pain in the bones and back in advanced cases chemotherapy and other anti-cancer treatment may be given so when you add assessment adhere to appropriate standard precautions including masks and gloves and this is to keep those patients safe so findings depend on the stage of the disease early stage complaints may be fatigue and later could be some unexplained hemorrhages or weight loss or frequent bone fractures and management includes iv fluid therapy pain management supportive care and no assumptions that the patient is ready to or is going to die in definitive care",
        "Transfusion Reactions": "and next let's talk about some transfusion reactions in transfusion reactions occur in approximately 0.2 percent to 10 percent of blood transfusions so reactions are similar to an anaphylaxis reaction because they occur rapidly and can cause severe circulatory collapse monitor the patient receiving a blood transfusion very closely for the first 30 to 60 minutes determine the patient's blood type and type of blood received and transfusion reactions occur when a patient's blood received a blood type different from his or her own the table on this slide shows red blood cells or rh blood types and preferred and alternate donor types so assessment so signs and symptoms may be subtle in an unresponsive or innovative patient in an acute reaction the patient will experience chills fever back pain vomiting tachycardia heightened hypotension and reactions may be delayed up to seven days complications include so the greatest threat to a patient is during the transfusion itself it is primarily caused by the incompatibility between the recipient and donor blood there could also be a febrile reaction most common complication and you want to treat with an antiparetic and observe so an allergic reaction so an anaphylactic reaction to preservatives and or other agents in the product usually occurs within the first few minutes after the transfusion transfusion related lung injury can also occur and treatment of that focuses on supporting the abcs circulatory overload typically occurs in patients with pre-existing cardiomyopathy or ventricular dysfunctions and then a bacterial infection and it's typically a result of poor blood product handling or contamination during the infusion process it can lead to full systemic infections so management the severity of the reaction correlates to the amount of blood volume transfused usually and of course care is going to always center on stopping the transfusion and providing a hemodynamic support care to counteract that shock and then maximizing kidney perfusion a patient with hemodynamically unstable condition requires early inva invasive monitoring vasopressors and dopamine could be helpful uh high flow o2 should be administered an administration of epinephrine and benadryl should be considered okay so this concludes the chapter 24 hematologic emergencies lecture and if you liked it go ahead and subscribe to our channel because we're going to be putting out the rest of the chapters thank you"
    },
    {
        "Introduction": "hello and welcome to chapter 25 immunologic emergencies lecture after you complete this chapter and the National EMS Education Standard Competencies related coursework you will understand the anatomy physiology and pathophysiology of hypersensitivity disorders and anaphylactic reactions additionally you will have the knowledge and skills to recognize and manage hypersensitivity disorders and anaphylactic reactions",
        "Introduction to Allergic Reactions": "okay so let's get started allergic reactions can result in life-threatening anaphylactic reactions the incidence of anaphylaxis is low less than six percent of the u.s population has experienced an anaphylaxis reaction the majority of anaphylactic incidents are due to medications food and insect stings in that order paramedics must be prepared to treat acute airway obstruction and cardiovascular collapse in an allergy related emergency paramedics should be able to distinguish between the body's usual response to a sting or bite and symptoms of an allergic reaction and immune response problems include hypersensitivity allergic reactions anaphylaxis biphasic allergic reactions collagen vascular disease and transplant related disorders",
        "The Normal Immune Response": "so let's talk a little bit about the anatomy and physiology the normal immune response the immune system protects the body from foreign substances and organisms the body protects itself in two types of systems there's cellular immunity and this is a cell mediated immunity in which the body produces t cells to attack and destroy invaders and then there's moral immunity b cell lymphocytes produce antibodies that dissolve in the plasma and lymph to attack foreign organisms the cells that produce immunity are found in lymph nodes the spleen and the gi tract and the goal is to intercept foreign organisms as they enter the body so an immune response it starts with the allergen and the allergen is a substance that produces the allergic symptoms usually harmless and does not pose a threat to others examples are eggs or peanuts antibiotics or insect venom and then an antibody that's a protein produced by the body in response to that antigen this protein otherwise known as goblin also known as immunoglobulin is found in the plasma and the ige antibody is the primary antibody responsible for allergic reactions when the body is exposed to a foreign substance the immune system responds resulting in a localized or systemic reaction so a local reaction is an allergic reaction that is limited to specific area so for example like swelling around an insect bite but a systemic reaction occurs throughout the body and may affect multiple body systems for example swelling and hives all over the body after ingesting an allergen hypersensitivity occurs when a person's immune system reacts with an exaggerated or inappropriate allergic symptoms from a substance that the body perceives to be harmful there's four types of this hypersensitivity there's the allergic reaction anaphylaxis biphasic reaction and a prolonged persistent reaction so let's talk about these four an allergic reaction an abnormal immune response that the body develops when the person has been previously exposed or sensitized to a substance or allergen then anaphylaxis that's an extreme systemic allergic reaction involving two or more body systems then there's the biphasic reaction it it's a two-phase allergic reaction in which the patient's systems improves and then reappear without secondary exposure to the trigger and then there's the prolonged or persistent reaction that's an anaphylaxis symptoms that can that continue over time so 5 to 72 hours so next we're going to talk about the",
        "Routes of Entry for Allergens": "routes for entry of these allergens and substances enter the body through the skin respiratory tract or gi tract invasion is through the skin that may occur by way of an injection and so or absorption so an injection that's the substance when it pierces the skin and deposits the foreign material so for example b or hornet sting and absorption that's the form material is slowly absorbed through the skin including through the vaginal wall inhalation that's exposure occurs when the patient breathes in the allergens through the respiratory tract the foreign substance advanced through the respiratory systems into the lungs so for example cat hair or dander or peanuts and then there's ingestion and that's when the allergens attack via the gi tract no route of entry is determined in up to two-thirds of the patient so people with high sensitivity can be at risk to routes of exposure not commonly associated with an antigen disease-related allergies also referred to as atopic disease include allergic rhinotitis asthma atopic dermatitis and if possible note the route and time of the exposure",
        "Physiology of Immune Responses": "okay so now we're going to talk a little bit about the physiology of the immune responses okay so the body initiates a series of responses to a foreign substance when it enters the body the primary response begins with microfangees and they confront and engulf the invading substance if the body cannot identify the substance the immune cells record the features of the outside of the substance and design specific proteins to match each substance these proteins or antibodies are intended to match the foreign substance which is the antigen and inactivate it the body",
        "Responses": "the body develops sensitivity the ability to recognize the foreign substance when it is encountered again and the body records details to assist the substance identification and distributes them to the rest of the body by placing the antibodies on and there's two things on basophils and that's found in the specific site within the tissue or on the mast cells and that's found in the connective tissue bronchi gastrointestinal mucosa and other border areas the basophils and mast cells produce chemical mediators that contain granules filled with a powerful substance to fight the antigens the granules remain inactive until the body is invaded by a previously identified foreign substance if an antigen enters the body and combines with one of the antibodies the granules are detonated chemical mediators are then released into the surrounding tissue and in the bloodstream the chemical mediator begins and maintains the immune system they summon more white blood cells to the area they increase blood flow by dilating the blood vessels and increasing capillary permeability in that area while useful in a limited area it can be extremely dangerous when one when spread throughout the body systemic effects of a chemical mediator cause the signs and symptoms of allergic and anaphylactic reactions this figure shows the sequence of events of anaphylaxis",
        "Scene Size-up": "okay so let's do the patient assessment and of course we know the patient assessment starts with that scene size up we need to assess the scene for safety issues determine the nature of the illness by checking for potential exposure venules so for example a bee sting in a garden or shellfish and exposure in a seaford restaurant",
        "Primary Assessment": "when you do your primary assessment save to save the patient's life you may have to simultaneously assess the patient identify the problem and intervene within seconds of arrival allergic symptoms are as varied as the allergens themselves so assessment should include evaluations of the level of consciousness the respiratory system the circulatory system the mental status and the skin allergic reactions can be local or systemic allergic reactions are categorized as mild moderate or severe so let's talk about these three categories mild reactions affect a local body area and for example itchy water or a rash or slight congestion moderate reactions beginning with mild symptoms and symptoms that spread to other body parts and these examples are itchy water or itchy eyes and then followed by some trouble breathing or tightness in the chest and then you have severe reactions and these are the anaphylactic reactions and they result in possible life-threatening emergencies these reactions are systemic for example congestion that progresses to respiratory distress and hypotension the onset may be sudden so then you want to form your general impression you need to observe the patient for indications of problem severity is the patient's condition stable if the patient cannot speak assess the airway before assuming a neurologic problem the level of consciousness indicates the severity of the reaction as well as the patient's oxygen and circulatory status so common signs of hypoxia include restlessness confusion anxiety and combativeness immediate airway evaluation and management is needed if there is any change in mental status of an anaphylactic patient so breathing in airway we're going to talk about next and a noisy upper airway may be an early sign of impending airway occlusion due to swelling so check for strider and hoarseness the patient may report tightness or a lump in the throat observe for difficulty breathing a noisy airway tachypnea labored breathing accessory muscle use abnormal retractions or prolonged expiration brass sounds are a predictor of severity initially the patient will present with wheezing as hypoventilation begins there will be diminished lung sounds or silence and this is an ominous finding rich this requires immediate intervention and then circulation so monitor closely for changes in condition evaluate the skin for histamine release or symptoms commonly associated with the anaphylactic reaction now histamine when this histamine re release occurs the symptoms are going to be rashes edema moisture or uticaria note that anaphylaxis can occur without these common skin changes the patient may also show polar or cyanosis a weak thready or absent radial pulse is indicative of potential cardiovascular collapse so ensure early recognition of shock and initiation of immediate treatment and then your transport decision so when completing the primary assessment begin making transport decisions such as remaining on scene or loading the patient beginning immediate transport or calling for air transport also determine which facility the patient should be transported to",
        "History Taking": "so history taking this is a major part of your patient assessment when it comes to allergic reactions the history taking should include investigation of the chief complaint sample and opqrst the history should be directed at the current complaint if a life threat exists some steps can be collected later does the patient have allergies or have they ever had an allergic reaction or an anaphylactic reaction in the past and a severe reaction can occur at the second exposure to the antigen so ask whether any interventions have been taken ask about medications and ask questions regarding the risk factors for severe anaphylaxis such as peanut or tree nut history of allergies pre-existing respiratory or cardiovascular disease asthma delayed administration of epi previous biphasic anaphylactic reactions advanced age or mast cell disease in severe reactions intervention takes precedence over identifying the antigen ask when the symptoms began and direct your assessment to potential life threats ask about feeling of dipsnia to determine any airway concerns determine if any treatment has been administered by the patient or first responders such as an epipen or benadryl or an inhaler inhaler with a beta agonist air sliced epi some epipens have two doses do not discard the second dose ask about less common causes of anaphylaxis such as exercise induced reactions or seminal fluid reactions",
        "Secondary Assessment": "so a secondary assessment physical examinations so anaphylaxis presents with respiratory symptoms and hypotension gastrointestinal symptoms such as abnormal cramping nausea vomiting and diarrhea may be present if symptoms are life-threatening perform secondary assessment after life threats are addressed and you are enrolled to the hospital assessment may direct be direct and should include a systemic head-to-toe focused assessment evaluate the respiratory system through um thoroughly assessing breathing and noting any increased work of breathing use of accessory muscles head bobbing tripod positioning nasal flaring or grunting and then auscultate the trachea in the chest so strider and wheezing may be present remember stride occurs when swelling in the upper airway closes off the airway and can lead to a total obstruction and wheezing occurs when excessive fluid and mucus are secreted into the bronchial passes prolonged respiratory difficult tea may include tachycardia shock respiratory failure and death then assess the circulatory system focus on signs of hemodynamic compromise including blood pressure pulse rate cardiac monitoring and pulse oximetry assess the skin for swelling rash hives and signs and symptoms of the reaction source so the bite sting or contact marks a systemic reaction may present as a rapid spreading rash red hot skin or an altered mental status vital signs you should take of course and assess baseline vitals which include pulse respirations blood pressure skin pupils oxygen set airway obstruction may indicate by rapid labored breathing and respiratory distress or systemic shock are indicated by rapid respiratory and pulse rates and then monitoring devices so you want to use tools such as a cardiac monitor for dysrhythmias and consider 12 lead monitor for elevated end-tidal carbon dioxide levels so monitor for the shark fin waveform on the end tidal monitor so which may be due to bronchial constriction a pulse ox may show low oxygen saturation and oxygen administration should be considered for patients with signs of anaphylaxis or cardiovascular respiratory compromise whether respiratory distress is present or not",
        "Reassessment": "your reassessment should be done and route to the emergency department monitor carefully for rapid and fatal deterioration and focus on the signs of airway compromise including increased work of breathing stridor and wheezing monitor the patient's anxiety as this may be an indicator of a progressing reaction monitor the skin for signs of shock flushing and conduct conduct serial vital signs with an increase in respiratory and pulse rate or decrease in blood pressure noted and continue to reassess the chief complaint so what do we want to recheck we want to recheck the interventions and what was the effect is the patient's condition improving is a second dose needed so a second dose of epi or infusion may be needed if the patient has decreasing mental status increased difficulty breathing or decreased blood pressure identify and treat any changes in that condition and call in the patient report to the receiving facility during transport to give the staff time to prepare by giving them the patient status interventions completed and the patient's response to",
        "Emergency Medical Care": "those okay so emergency medical care first identify how much distress the patient is experiencing early epi administration is a priority for anaphylactic reactions severe reactions require ventilatory support and or fluid resuscitation milder reactions without respiratory and cardiovascular distress may require only supportative care in either situation the patient should be transported to a medical facility for further evaluation",
        "Anaphylactic Reactions": "all right so let's talk about the pathophysiology of an elanaflectic reaction the immune system becomes hypersensitized to one or more substances that should not be identified as harmful immune cells of the allergic person are more sensitive than those of a person without allergies so when invading substance enters the body mast cells release chemical mediators these are the histamine and this causes the local blood vessels to dilate and capillaries to leak leukotrienes they cause additional dilation and leaking white blood cells help engulf and destroy the antigen and platelets begin to collect and clump together in anaphylaxis the effect of the chemical mediators involves more than one body system an initial effect may be followed by secondary effects a few hours later so histamine release and what it causes so histamine causes immediate vasodilation often presenting as marks on the skin and hypotension there's vascular permeability this results in edema fluid secretion and fluid loss so the edema can present as uticaria airway constriction and increased fluids in the airway histamine causes smooth muscle contraction in the respiratory and gi systems resulting in laryngospasms bronchiospasms and abdominal cramping it decrease it in the in inotropic effects on the heart so what this does is when coupled with vasodilation this can lead to profound hypotension and dysrhythmias due to hypoperfusion and hypoxia are very common later responses from leukotrienes compound the effects of histamine and may include respiratory systems to be more dire coronary vasoconstriction contributing to worse cardiac condition and myocardial irritability increased vascular permeability causing further hypo perfusion and other chemical mediators continue to worsen as the signs and symptoms so and the patient may not survive without immediate intervention clinical symptoms of anaphylaxis and uh include skin symptoms and are often the first indicators of anaphylaxis so feeling warm or flushed or pertussis which is issue itching including vasodilation and capillary leaking swelling of the face and tongue so the swelling of the tongue remember that's angioedema and it contributes to airway compromise and edema in the hands and feet and uticaria that's hives from the histamine release respiratory systems are the most common complaints including shortness of breath tightness in the throat and chest and strider or hoarseness it may involve upper airway or lower airway so symptoms may progress slowly or very rapidly and cardiovascular systems are serious complications so histamine and leukotrienes decrease the contractility of the heart the resulting decrease in cardiac output is complicated by that vasodilation and increased capillary permeability so perfusion decreases this leading to ischemia and potential cardiac dysrhythmias and then fluid leaks from the capillaries as much as 50 percent of vascular volume can be lost in 10 minutes of the exposure the blood vessels dilate making vascular volume totally inadequate and causes hypotension in response the heart rate increases so gastrointestinal symptoms may include abdominal cramping nausea bloating vomiting abdominal distension and profound watery diarrhea central nervous system symptoms are headache dizziness confusion anxiety and of course the sense of impending doom if the patient with anaphylaxis experiences three types of shock so they could experience cardiogenic shock and that is due to decreased cardiac output hypovolemic shock and that's due to the leaking fluids and then finally neurogenic shock and that's due to the ill inability of the blood vessels to constrict with your assessment rapidly differentiate between anaphylaxis and other conditions with similar symptoms other similar symptoms may include syncope flushing red man syndrome severe anxiety wheezing transfusion related acute lung injuries or ace inhibitor angioedema if you can't determine another cause of the symptoms and if the patient continues to present with an anaphylactic symptoms do not delay treatment for a more complete diagnosis so people who are having allergic reactions are separated into two groups for management purposes patients who have signs of an allergic reaction but no respiratory distress or dyspnea so the drug of choice with patients with no respiratory distress or dipsnia is benadryl so diethyhydramine continue to monitor for changes in condition most patients in this group will recover with no further problems patients who are not stable initially are and are deteriorating or have no history of deteriorating remove the offending agent when possible separate the patient from the situation involving that antigen and maintain the airway be prepared to assist and assess for the presence of stridor be cautious in changing the position of an anechalactic patient from a supine to an upright use any appropriate oxygen for supplemental oxygen and consider early transport and early administration of epi should be priority okay so administrating fe or administering it i am administering of epi in the anterior lateral thigh is the drug route of choice do not delay administration of epi many patients will require more than one dose of epi to reverse the reaction additional im doses may be repeated every 5 to 15 minutes if needed if there is no response to the im dose administer an iv infusion of epi in conjunction with iv fluid boluses to support the hemodynamic status as needed endotracheal administration may be considered if other routes are not available many patients and emts carry epipens a dose may have already been administered prior to your arrival the patient may have taken their own medications as well so obtain that complete medical history administration of epi with an auto injector involves firmly stabilizing the leg prior to and during administration pushing the auto injector firmly against the anterior latable lateral aspect of the thigh and holding the injector in place for approximately three seconds until the medication is injected and maintain circulation so insert at least one large ib iv catheter to administer an isotonic solution such as lactated ringers or normal saline ideally you should place two ivs and route to the emergency department if iv access is not available use io and be prepared to repeat doses as needed in the hypotensive patient if there is no response consider administering a vasopressor in conjunction with the fluid administration and avoid fluid overload especially in a cardiac patient initiate pharmacologic therapy so administer high flow to epi antihistamines anti-inflammatory and immunosuppressant agents and a vasopressor antihistamine administration should be considered only in a patient with a mild reaction or after epi has been administered antihistamines block the histamine one and histamine two receptor sites so diphehydramine or benadryl is commonly used in the pre-hospital setting following the administration of epi corticosteroids have been used for anaphylaxis as well the time of onset after administration is four to six hours inhaled beta-adrenergic agents such as albuterol or ventalin may be used if bronchiospasms are present so many patients will benefit from the addition of albuterol in conjunction with the epi maintain a supine physician for patients in anaphylaxis with hypotension and with respiratory distress assess lung sounds and consider slight elevation of the head but avoid an upright position emotional support is crucial and be professional and reassuring while focusing on early intervention and transport consider early transport if the patient needs resources you cannot give even if the reaction is stopped and the patient begins to recover the patient should be observed in a medical facility because as many as 20 percent will have symptoms recurrence within eight hours",
        "Autoimmune Disorders and Collagen Vascular Diseases": "autoimmune disorders and collagen vascular diseases so in an autoimmune disorder the immune system inappropriately attacks its own host tissue in collagen vascular disease the body perceives its own collagen tissues as a dangerous invader and attacks the tissues the attack can be chronic causing long-term inflammation or severe enough to result in death the table on this slide shows autoimmune disorders and conditions okay so let's talk about lupus so systemic lupus is a multi-system autoimmune disease that affects the entire body more common in women than men and care should be directed and monitoring for life threats so patients may have immunosuppressive medications and slight changes should alert you to treat aggressively if needed okay the next autoimmune disorder we're going to talk about is scleroderma and this is an autoimmune connective tissue disease that causes changes to the skin blood vessel muscles and internal organs it presents with thickening tightening and scarring of the skin renal damage may result in hypertension and renal crises damage to the heart muscle and major is a major complication and pulmonary complications are the most common cause of death in these patients so rule out life threats with your assessment avoid attributing complaints to chronic conditions and treat treatment may include administration of medications to suppress immune systems and decrease the attack so treat any life threats monitor for causes of infection and determine the patient care according to the effective body system",
        "Organ Transplant Disorders": "and then organ transplant disorders so the body sees the transplanted organ as an invader and the immune system will try and reject it patients are given anti-reaction or medications so these medications put the patient at a greater risk for infection because they cause immune systems to to not recognize the threats so it's important to address priorities in caring for specific transplant organs heart transplants so there are 2 000 of these performed each year in the u.s the recipient's heart is usually removed and replaced by donor heart an ekg may show tachycardia at a rate of 100 to 110 because of the denaturization of the vagal nerve and when they denature as cut off um basically the heart cannot generate that angina pain so chest pain is uncommon and a patient with ischemia tends to show signs of congestive heart failure or dysrhythmias atropine is not indicated because the implanted heart does not have the vagal nerve intervention and will not respond to atropine so um sympa sympathomimetic drugs tend to work well and anti-hypertension medications tend to work for hypertension nor epi and isopropylertnol may have a slightly increased response most reactions or rejections happen in the first three months so signs and symptoms are subtle and may require a biopsy to cons to confirm so dysrhythmias may also have um be re associated with rejection so when looking for indications of infection assess for fever shortness of breath hypotension and poorly controlled hypertension or a new dysrhythmia so next we're going to talk about those organ transplant rejection of the liver and it's the second most common solid organ transplanted the loss of function of the liver rejection causes rapid deterioration and possible death so watch for infection especially opportunistic infections and observe for jaundice and palpate for tenderness over the site patients may present with symptoms that are anywhere from vague to full hepatic failure and monitor for hyperkalemia caused by immunosuppressive drugs kidney transplants those are the most common type of transported or transplant in the u.s infection is a major concern and kidney recipients tend to develop hepatitis c and later liver disease rejection will present as fever tenderness and swelling over the implanted kidney monitor for hypovalemia caused by hypotension and that is common complication up to 50 percent of these patients have hypertension so ask about the normal blood pressure many renal transplant patients are extremely knowledgeable about their condition and can provide valuable information so assessment should include observation of the site for infection auscultation for the development of brute evaluation for other signs of infection and ask whether the patient has had the spleen removed which increases the risk for infection progressing more rapidly and then there's lung transplants so these are performed alone or in conjunction with heart transplants there are three types of lung transplants which are conform which are performed and that's bilateral or unilateral or lobal so signs of rejections include cough dipsnia fever rails ronchi or decreased oxygenation and hemothorax is an early complication of the lung transplant infection presents with the signs and same signs and symptoms of other rejection and requires immediate intervention and then pancreas transplants so there are more complications and a lower survival weight rate at one year than other single organ transplants more are done in diabetics and are often performed with kidney transplants the route to drain the exocrine component must be placed so the bicarbonate produced by the pancreas is drained into the bladder often causing chronic gap acidities patients take bicarbonate substance supplements and infection and rejections are common problems and then so assessment of these patients so be aware of subtle changes and symptoms for infection and rejection signs and symptoms vary according to the transplanted organ and patients who are rejecting a transplant you usually feel ill and have general discomfort consider calling the transplant center for any questions regarding assessment or any other findings the management priorities are for care of the transplant patients including the transplanted organ medications recognition of infection or rejection and transplant to or transport to the most appropriate care facility care depends on the organ transplanted understand how medications will interact with medications the patient is already taking and how they will be metabolized so monitor for signs and symptoms of infection or organ rejection and consider transplant or transport to the transplant facility when possible or consulting that facility when not possible so no matter what type of transplant the patient has received you must understand the anatomic considerations and you must be prepared to identify signs of rejection infection and medication toxicity it is essential that patients have their immunosuppressant medications and drug toxicity is also a problem for transplant patients",
        "Patient Education": "all right so patient education anaphylaxis so educate patients about prevention and self-preservation by discussing the following topics to avoid the antigen so review information on the antigen discuss drugs that may produce a cross reaction remind patients to remain at the facility for monitoring for at least 30 minutes or longer for para internally administered medications so medications administered by mouth food allergies may be difficult to avoid but notify all health personnel of the allergy wear identification tags or bracelets carry an anaphylaxis kit report symptoms early and explain to the patients that they may develop a biphasic reaction so they have to monitor for up to 48 hours after the anaphylaxis incident is recommended and then that collagen vascular disease so education for patients should include encouraging self-monitoring consult a physician and comply with the immunosuppressive regimen and know the signs and symptoms organ transplants so education for these patients with organ transplants include encouraging self-monitoring consult the physician before taking a new medicine and comply with the immunosuppressive regimen and know who to contact okay so this concludes chapter 25 lecture on immunologic emergencies thank you for joining me today and go ahead and subscribe to the channel for more lectures"
    },
    {
        "Introduction to Neurologic Emergencies": "hello and welcome to chapter 18 neurologic emergencies lecture this unit reviews the structures that make up the nervous system it provides a thorough review of anatomy and physiology so students can better understand why a patient may present with neurologic signs and symptoms illness and injuries that can affect the nervous system are also discussed so let's get started the national center for health statistics lists two of the top 10 causes of death in 2015 as neurologic in nature stroke is the fifth leading cause of death in the u.s and alzheimer's disease is the sixth leading cause of death signs and symptoms you find during your assessment may indicate many possible conditions consider the likelihood of the those conditions to help ground your conclusions for example disease occurrence information helps you expect that the patient with dementia is more likely to have alzheimer's disease than crude fell jacob disease patients with neurologic problems may be in danger so many reflexes that protect people who are awake can be inactive when the nervous system is depressed such as eyelids do not blink or the larynx does not it causes gagging and coughing and the body does not speak or seek a positive position of comfort and the tongue can get slack and the airway is at risk all right so let's talk about some anatomy and physiology and let's do a little review so the structures of the",
        "Structures of the Nervous System": "nervous system so the major structure is divided into two categories of course it's the central nervous system and then the peripheral the central is responsible for thought perception and feeling and the autonomic body functions and the peripheral is responsible for communications between the brain and the body and the figure shows the basic",
        "Organization of the Nervous System": "organization of the nervous system okay so the brain an example of a child riding a bike so the lobes images produced by the eyes are transmitted via the optic nerve to the occipital lobe the occipital lobe scans through stored images once an image is recognized a pathway is assessed to the temporal lobe commands from the frontal lobe are sent to the body and signals are sent to the afferent nerves afferent nerves uh send signals of discomfort to the parental lobe and signals are sent from the parental lobe to the frontal lobe okay so next we're going to talk about",
        "Brain": "the brain and you have the diacethalon and the brain stem so the diacethalon divides information into items that need to be managed consciously and those that can be handled unconsciously and the brain stem well the mid brain portion helps regulate level of consciousness and the brainstem frees the cerebral cortex for higher activities the hypothymus and pituitary gland so the lymphatic system generates rage and anger and the hypothalamus controls pleasure thirst in hungary all emotions are mediated in the pre frontal cortex cerebellum is located in the posterior inferior area of the skull and manages complex motor activity and over time learn behaviors transferred to the cerebellum from the frontal lobe",
        "Patient Assessment": "so let's get into the patient assessment the brain this is the most sensitive organ in the body to variable temperatures and fluctuating levels of oxygen and glucose small alterations can affect its function the brain is also resilient to internal environmental changes when assessing a patient for a neurological problem look for gross or obvious changes or subtle and hidden changes you will need to perform all of the general steps of a patient assessment such as scene safety on taking standard precautions considering the mechanisms of injuries and determining whether medications alcohol or other substances were taken a good assessment provides the backbone of patient care so be curious be inquisitive be adaptable and avoid tunnel vision when it comes to the scene size up take standard precautions an assessment of physical environment because begins at dispatch remember take patient symptoms into account when assessing the scene for example if an entire family is reporting headaches consider carbon monoxide poisoning and if the distance to the nearest stroke center is greater than one hour request air medical transport and do it early",
        "Primary Survey": "so the primary survey so when you're forming a general impression determine the following so where is the patient does the patient appear to be in distress what is the what's the position of the patient and is there a patient inside or outside are there obvious injuries what does the environment look like where is there evidence of drug paraphernalia on scene what are the living conditions is the patient able to ambulate on his or her own and is the patient awake and alert is the patient stable or unstable the answers can give you the clues to the functioning of the patient's nervous system because unresponsive patients should be considered unstable and cluttered and disorganized living conditions may be an indicator of a nervous system condition you're assessing level of consciousness",
        "Level of Consciousness": "you want to use the half poo pneumonic and assess the orientation so if they're alert then use glass calcoma score so that's the gcs and remember those parameters of eye opening best verbal response and best motor response this tool is useful in helping you determine how to proceed with patient care what care should be given and where to transport the hospital examine the speed and intensity with which the patient responds and patients may undergo excitation or sedation methods for measuring response to pain so if you announce yourself and the patient does not respond elicit pain but do not cause harm remember for the patient to respond the pain he or she should uh she needs to have a or he needs to have a functioning brain an intact spinal cord and an intact peripheral system so",
        "Methods to Painful Stimuli": "methods to painful stimuli include pressure on the fingernail or pressure to the supraorbital forum so that's that notch near the bridge of the nose okay so observe what happens when you generate that pain response does the patient wake up and does the patient move away from the pain or move in an abnormal fashion remember that disservice posturing which is an abnormal extension is the toes pointed arms extended upwards wrist flexed and a more severe finding than decorticate posturing okay so airway breathing and circulation",
        "Airway Breathing and Circulation": "includes so nerves responsible for airway include the trigeminal nerve the vagal nerve the hypoglosmal nerve so this allows for swallowing controlling the tongue and ensuring the muscles of the hypopharynx are slightly contracted if the patient is unresponsive assess the airway so trespass is tightly clenched teeth it's common presentation it makes it difficult makes it difficult to manage an airway and it can occur in either responsive or unresponsive patients in an unconscious patient it can also include a seizure severe head injury or cerebral hypoxia if tristress is noted determine how effectively the patient can be ventilated with a bvm if ventilation is poor and the patient is still breathing on his or her own a nasotracheal airway can be attempted if it's unsuccessful consider sedation or paralytic agent if sedative and paralytic agents are unavailable a transtracheal airway management is the only other option so routine hyperventilation of neurologic patients can be harmful check the rate and rhythm of the breathing the greater the deviation from normal the more severely affected the nervous system could be and so this table shows common",
        "Respiratory Patterns": "respiratory patterns signs of increased intracranial pressure so evidence of increased intracranial pressure within the cranium so that's icp you could have cushing's reflex and that's a bradycardia bradypenia and systolic hypertension you can have disarabic posturing decorticate posturing biot respirations shine stokes respirations or unresponsive and dilated pupils so as the icp increases blood flow to the brain diminishes the medulla oblongata signals the heart rate to increase contraction force systolic pressure rises and the downward force on the brain stem begin to damage the medulla's ability to send signals and then diastolic pressure falls resulting in widening pulse pressures pressure damages the ability to control the respiratory and pulse rates they both decrease so do the rapid full body scan and consider how to transport complete a rapid body scan which would involve a head to toe or complete the secondary assessment and evaluate only the areas of the patient's complaints a rapid body scan should be performed on any patients with an abnormal assessment or a significant mechanism of injury a secondary assessment based on the chief complaint is appropriate if the patient's stable if you suspect a more complicated condition then quickly perform the secondary assessment covering the entire body",
        "History Taking": "when it comes to history taking to determine the chief complaint of an unresponsive patient look for signs and symptoms of altered mental status or seizure evaluate the patient's speech and ask about over-the-counter medications if the patient has had a seizure and is a post-dictal state look for obvious explanations such as trauma if the patient has a headache try to determine the patient's level of stress or the likelihood of infection or the history of and talk to family and friends about the events leading up to the altered mental status you want to get a sample and that's a history it should be determined whether there is a history of seizures what triggers the seizures and was the episode different from past ones also review the medications so something like phenobarbital it could point towards a seizure disorder if they have anti-seizure meds if the patient has experienced a seizure or if this is their first time a suspected grave condition unfortunately so like a brain tumor or serious infection or maybe icp or an intracranial brain bleeding determine whether the patient takes medications that lower the blood sugar and inquire about drug use and exposure to toxins when you're doing that secondary assessment the head so spend the most time on this so note the symmetry of the face throughout the assessment assess for facial troops",
        "Notable Findings during the Neurological Exam": "notable findings during the neurological exam so any nausea and vomiting are common with some types of headaches urinary and fecal incontinence are common with a seizure or fainting so if incontinence is present the level of consciousness has decreased below that of sleep signs of recent vena puncture marks which may indicate uh recent illicit illicit drug use okay so level of consciousness can vary and the continuum from stable to unstable so a coma is a state in which a",
        "Coma": "person does not respond to either verbal or painful stimuli and it's on the extreme right of the continuum common reality so sensory stimulation that can be confirmed by others so you have hallucinations and those are sensory stimulations that cannot be verified by others or you have delusions and those are thoughts ideas and perceived abilities that are not based in a common reality",
        "Psychosis": "psychosis so that patient cannot determine what is real and what is inside his or her mind patience may be unpredictable so fear anger helplessness are common emotions and ensure your safety when caring for psychotic patients also look at medication management mood and other changes so changes in mood or tempo of the nervous system should alert you to changes in the patient's neurologic system these changes require further evaluation to ensure an appropriate level of care ask the patient how he or she feels and asks the patient how easy it is for him or her to think the corneal reflex all right so a",
        "Protective Reflex": "patient's protective reflex include the cough gag and corneal reflexes the",
        "Corneal Reflexes": "status of the patient's protected reflex relates to the patient's level of consciousness if you tap between the patient's eyes the patient who are asleep or pretending to be responsive will blink reflexively if the patient does not blink or twitch assume that the patient does not have an intact cough or gag reflex",
        "Pupillary Response": "pupillary response so ensure that you are eliciting a response to light not movement approach the patient's eyes from a 45 degree angle and examine the pupils for shape size and response they should be round they should react to light and they should be equal in size shape and response pupillary shape can be changed by trauma glaucoma or increase in your cranial pressure stimulants cause pupillary dilation and depression depressants constrict pupils okay so anything greater than a one millimeter different is worth noting",
        "Blood Glucose": "so when it comes to blood glucose level the brain has no means to store glucose and all patients with a change in level of consciousness should have their glucose level check normal reading is between 60 to 120 and a glucose level fails so does the level of consciousness below 10 is usually fatal below 30 or above 300 is often the cause of confusion and unresponsiveness when it comes to the craving cranial nerve functioning cranial nerves control various portions of the body so look for the ability to respond strength or symmetry and abnormal functioning may occur with a stroke or some type of myosthesia trigeminal neuralgia",
        "Speech": "so speech listen to the quality of the patient's speech also focus on the words a patient chooses aphasia can affect speech so that's the inability to understand speech with ability to speak clearly note if the patient speaks clearly but gives you incorrect answers and patients with speech difficulties often think clearly though so be sensitive and reassure the patient",
        "Body Movement": "body movement so patients with strokes can have weakness or paralysis on one side of the body hemiparesis is a weakness on one side and hemiplegia is paralysis on the one side the patients may have weakness on one side of the body and facial droop on the other examine the function of the cerebellum so if the patients close his or her eyes and hold up his or her hands or arms in front of the body if the patient has had a stroke one arm may drift away from the other so some patients have alterations in their gait and that's the walking",
        "Walking Patterns Ataxia": "patterns ataxia is an alteration of the patient's ability to perform coordinated motion so assess by asking the person to walk several steps posture may be rigid and place one hand on the patient's chest and the other on the patient's back and push the patient should compensate by taking a step to keep from falling in certain disorders such as parkinson's rigidity keeps the patient from compensating bizarre movements may indicate disruption of the nervous system so like dystonia is a part of the body when it contracts and remains contracted also ask does the patient move slow smoothly so rigidity is muscles they do not contract and relax smoothly resulting in a stiffness of motion and tremors is fine auscultating movement involving the motion of joints so a rest",
        "Rest Tremor": "tremor occurs when the patient is at rest intention tremor occurs when the patient is out asked to reach out and grab an object and postural tremor occurs when the body part is placed in a particular position and required to maintain that position for a long period of time so seizures larger less focused movement tonic activity is rigid contracted body posture and clonic activity is rhythmic contraction and relaxation of the muscle groups",
        "Sensation": "sensation so many nervous system conditions can alter the ability to feel pain temperature pressure or light touch paresthesia is a sensation of numbness and and anesthesia is when the patient can feel nothing you want to make sure that you get the vital signs so document the pulse rate rhythm and quality and the respiratory rate rhythm and quality blood pressure skin temp color and condition and the pupil size and reactivity ensure that the patient maintains a systolic pressure of at least 110 to 120 and ensure adequate respiratory rate and pattern ensure effective pulse rate rhythm and if hypothermia or hyperthermia is suspected a thermometer to establish the temperature and then your reassessment so notifying the receiving facility of the patient's complaint and your assessment findings check local protocol regarding stroke alert and be sure to communicate the time the patient was last seen and the findings of your neurologic exam and the time you anticipate arriving at the hospital document the first time of the onset the findings of your stroke skill and any interventions performed any change in the patient during transport and the reason for choice of hospital for patients who have had a seizure document the description by standard complaints onset and duration and evidence of trauma or indications or interventions that you've performed and any history of seizures when you document your interventions record the time of each and how the patient responded and what the findings of the continued reassessments showed all right so let's talk about the",
        "Standard of Care Guideline for the Neurologic": "standard of care guideline for the neurologic patient so you want to focus care for the neurologic patient ensure that the body has the adequate inter internal environment for optimal brain function and so the brain needs of course oxygen glucose and a normal temperature in standard care guidelines should be the foundation on which additional care for specific neurologic conditions is built okay so administration of dextro",
        "Administration of Dextro": "so you want to follow your local protocol revolve regarding what blood glucose reading is considered low and there are two medications available for",
        "Treatment of Hypoglycemia": "pre-hospital treatment of hypoglycemia there's dextrose and glucagon on your slide it shows hyperglycemia but it's hypoglycemia dextrose and glucagon so to administer dextrose an iv line must be established and typically the effects begin within 30 seconds to two minutes if there's no effect ensure adequacy of the iv line and administer a second dose if iv access cannot be obtained administered 0.5 to 1 milligram of glucagon subcutaneously or intramuscularly level of consciousness and blood glucose should increase within about 20 minutes the dosage can be repeated to a maximum of three and there is currently no safe way to decrease blood glucose levels in the pre-hospital setting when administering insulin it is easy to overcorrect and imbalance resulting in hypoglycemic state so rehydration in a severely dehydrated patient with hyperglycemia can dramatically lower the patient's blood glucose if the patient is unresponsive or has a decreased llc and no blood glucose monitor is available administer 12.5 grams of d50 and reassess and proceed with additional dextrose cautiously so when you're treating with narcan",
        "Naloxone": "naloxone is used for the treatment of unresponsive unknown patients who or those with suspected narcotic overdoses so initially is a 0.4 to 2 milligrams intravenously push and can be repeated until you reach 10 milligrams you may also administer neural oxygen using a mucosal atomization device we call it mucosal atomizers bystanders if naloxone has been given prior to arrival and find out how much and when interventions for increased intracranial pressure so if a patient has a sign of increased icp administer normal saline or lactated ringer solution as needed check the patient's blood pressure and pulse if the patient is hypo or hypotensive then support blood pressure to ensure adequate cerebral perfusion pressure or cpp targeted systolic blood pressure of 110 to 120 and perform continuous heart monitoring with an ecg so when you talk about the common",
        "The Common Neurologic Emergency": "neurologic emergency so the patho and assessment and management usually sometimes there could be more than one factor and they call that multifactorial so a disease suspected is often related to a number of causes and how the body system was created during development of the embryo and fetus or how effective the body's defense and repair mechanisms are or how severe prolonged the body's exposure to that pathogen toxin or other depending factors so when it comes to a stroke the serious medical condition in which blood supply to the areas of the brain is interrupted causing ischemia people older than 65 years present most 70 almost 75 percent of the patients so aha reports that the significant number of patients who have had strokes deny or do not understand their symptoms so the goal of treatment is early recognition and rapid intervention okay so one-fifth of the patients with an intracranial hemorrhage will have a significant decrease in their level of consciousness between emergency medical care provided by ems and care upon transfer to the emergency department don't forget that time is brain and so when you talk about the pathophysiology neurologic conditions have can have a vascular origin sudden occurrences are typically the result of an emboli or an aneurysm let's talk about the development of an",
        "Development of an Aneurysm": "aneurysm the process so small tears occur in the arterial wall blood enters between the layers of the artery pressure builds up and initial small tear increases inside size if damage is severe the artery can leak or fail in and it causes intracranial hemorrhaging there are two types of stroke ischemic which makes up 87 in the hemorrhagic that's 13 the pathophysiology of an ex ischemic",
        "Ischemic Stroke": "stroke is as follows so ischemic strokes are also called occlusive strokes in it caused by an occlusion or a blockage blockage can be caused from a thrombose or an emboli in an ischemic stroke the blood vessel becomes blocked causing tissue to beyond it to become ischemic and so tissue will eventually die if the circulation is not restored the severity of the stroke is dictated by the artery artery involved and the portion of the brain being denied oxygen",
        "Pathophysiology of a Hemorrhagic Stroke": "the pathophysiology of a hemorrhagic stroke so they tend to get worse over time because of the bleeding within the cranium the skull is filled with three substances so brain blood and csf or cerebral spinal fluid the ex the exchange of pressure between these substances at the skull is balanced so icp is normally measured between 1 to 20 millimeters of mercury when icp climbs and remains high the following will occur so the brain may become ischemic because of the lack of blood supply portions of the brain may be pushed into different locations causing tissue damage and potentially death the amount of blood available to the brain decreases and cerebral perfusion pressure so cpp begins to fall and so when cpp the pressure of the blood within the cranial volt so normally cpp is about 70 to 90 millimeters of mercury icp changes can constantly so it's constantly um changing the figure shows normal and abnormal intracranial pressure and you could actually see all the way to the right on the abnormal you could see a shift a midline shift of the brain with that increased icp herniation may occur so a shift of the inner cranial contents within the inner cream in the cranial vault or displacement of the contents toward the form magnum so this will eventually compress the brainstem when you are doing your assessment signs",
        "Signs and Symptoms": "and symptoms include a combination of language effects or movement effects so you could have slurred speech aphasia or hemiparesis or hemiplegia arm drifting facial drooper tongue deviation sensory effects such as a headache or sudden blindness cognitive effects such as decrease the level of consciousness or difficulty thinking these seizures use the fast mnemonic to assess for a stroke so facial droop arm drift speech impairment and time it's critical so call 9-1-1 vital signs may indicate intracranial pressure so other signs are posturing or respiratory patterns or on equal pupils",
        "Management": "and management it begins with the standard guide so continuously monitor the patient draw blood for later eval and contact medical control if the patient has a fever and allow the patient to remain supine unless the patient becomes hypoxic administer fluids as needed to patients who are unresponsive and demonstrate other signs of increased icps elevate the patient's head 30 degrees unless you suspect a cervical spine injury ensure the airway is clear watch for seizures and be prepared to administer benzos and monitor the blood pressures closely",
        "Carbon Dioxide Levels": "carbon dioxide levels are important high carbon dioxide levels causes vasodilation of the cerebral arteries and so a diminished level of carbon dioxide lowers icp vasoconstriction decreases blood supply to the brain and that increases ventilation increasing ventilation decreases icp which is good by decreasing the blood supply which is bad the figure shows the adult suspected stroke algorithm from the american heart association so get to know that ems providers need to be involved in educating the community about stroke signs and symptoms all levels of ems providers should be trained to recognize stroke signs and symptoms iv fibrolytic agents must be administered within 3 to 4.5 hours of stroke onset before fibrolytic therapy is administered though the patient has to be evaluated you need to talk to the family and caregivers to gather information all medications allergies and transfer orders standard stroke care includes titrating oxygen to the patient's need so you want to maintain that reading between 94 to 99 and there is currently no aha or american stroke association guideline for the pre-hospital control of hypertension so don't administer aspirin make sure to protect extremities from injury and complete a fibrolytic checklist so the table shows a sample of the pre-hospital fibrolytic checklist for strokes when you make your transport decision you want to make sure you go and transport to the appropriate facility so patients should be transported to stroke centers contact the facility to ensure their ct scan or mri capabilities are operational and if you suspect the hemorrhagic stroke transport consider transporting to a facility that can perform neurosurgery so call ahead to ensure rapid evaluation when it comes to tias these are",
        "Transient Ischemic Attacks": "transient ischemic attacks the pathophysiology of this so episodes of the cerebral ischemia without permanent damage so any presentations associated with stroke can occur but according to aha or asa many tias resolve completely within one hour and they may be a sign of a serious vascular condition though that requires medical evaluation so more than one third of the patients with the tia will have a stroke soon afterwards when it comes to the assessment you want to do the same as for the stroke and management so follow the stroke management guidelines encourage the patient to be transported hypertension is the number one preventable cause of strokes and tia so encourage the patient to talk to his or her physician when it comes to coma we use so this is a decreased level of consciousness but we use the pneumatic a e i o u tips and get to know what this stands for so a is alcohol or acidosis e epilepsy endocrine or electrolytes i is insulin o is opiates or other drugs eu uremia t could be trauma temperature i is infection poisoning is p or psychogenic causes and s could be stroke or syncope or shock maybe a space occupying lesion or a sub arachnoid hemorrhage so you want to continue getting vital history of the present illness because you want to determine when the patient was last seen functioning normally and evaluate the speed and onset of the altered level of consciousness signs and symptoms of diminished lse or in imminent coma include cognitive effects such as decreased level of consciousness and confusion speech effects such as slurred speech or aphasia and movement effects such as aphasia seizures or posturing and then cns effects such as total unresponsiveness of course and that's a coma when you're going to manage these you your support the vital function so you have to secure the abcs gather information about the possible cause so the medical history medications and history of the present illness keep looking for clues and causes so a good assessment is foundation of this patient care medical ids or drug paraphernalia if you cannot find the cause of the patient's llc you want to do the following report to the emergency department staff that you do not know what's wrong and report to them what is not wrong with the patient so pertinent negatives important and positive so patients will routinely need urine and blood analysis or some type of x-rays or ct scans",
        "Management of Seizures": "when it comes to management of seizures or let's talk about the patho first",
        "Seizure": "a seizure is common erratic firing of neurons so patients can experience a wide array of signs and symptoms they could go from muscle spasms to cyanosis and can involve movement of every limb or complete loss of consciousness patients may be aware of the seizure and wake up not knowing if a seizure continues for a long time glucose and oxygen supplies are depleted so the to the cerebral so systemic body-wide changes occur so hypoxia or hypercarbia and blood pressure changes in hypothermia and they can be serious long-term effects including death lethal dysrhythmias are common so try to determine the cause of the seizure medication compliance or whether they have a fever low blood sugar and look at the medications so see if they're compliant with like if they if they're on any type of anti um seizure meds it's like dilantin or ativans maybe tegritol or depakote and so get to know those anti-seizure medicines so there's generalized seizures and",
        "Tonic Clonic Seizures": "these are called tonic clonic seizures the the tonic clonic are formerly called grand mall okay so the patient may travel through each of the following steps or some of them might be skipped but usually there's a loss of consciousness then there's a",
        "Tonic Phase": "tonic phase there's a hypertonic phase",
        "Clonic Phase": "there's a clonic phase and then a post seizure phase so let's talk about these right okay so the tonic phase is when you have rigidity so rigidity hyper is when there's arch back and rigidity and clonic is an intermittent contraction of the muscle groups so i always think clonic is contraction",
        "Post Seizure": "post seizure that's when their muscles are relaxed um their eyes may be posterior and then there's that post icdo it's usually they're confused emotional and tired and sometimes a headache so during the seizure process respirations may be erratic loud and or obviously abnormal or they might stop breathing so if the patient is apneic longer than 30 seconds begin to ventilatory assistance the patient may be incontinent as well pseudoseizures so they're also known as psychogenic non-epileptic seizures generalized neurologic event so may seem no different from a tonic clonic but they're psychiatric in origin so the patient is not intentionally causing the seizure the seizures are also triggered by some emotional event or stress and motion related organized and often a psychiatric history or other medical history exists and then there's absent these were formerly called post mall seizures typically in a child they stop and freeze mid-action usually last no longer than several seconds and may be brought on by flashing lights or hyperventilating",
        "Partial Seizures": "you could also have partial seizures so partial seizures only a limited part of the brain is involved it's a simple partial seizures involve either a movement of one body part which is the frontal lobe or sensations in one part and that's the parental lobe so complete partial involves subtle changes in level of consciousness such as confusion or typically they're not unresponsive so patients with partial seizures tend to experience an aura before the seizure occurs so the table shows the classifications of seizures so you have the generalize and the partial when you're doing your assessment so we'll go through this the assessment part now whether they're generalized or partial most seizures are self-limiting so you want to monitor and protect the patient other important characteristics of your assessment include noting or asking the family member how long did it last and uh what did it look like so describe the seizures as best as possible so does the patient have a history and what does the patient have a recent history of head trauma overdose pregnancy diabetes hypoglycemia or heat exposure was a patient incontinent does the patient have a fever was the patient apnic or cyanotic or vomiting and did the patient experience bowel or bladder incontinence with a thorough assessment the answer the answers to these questions will help the emergency department staff determine the cause when you management aspect begin of course with standard of care determine whether trauma is a concern and don't restrain them remain calm and prevent the patient from striking objects do not place anything in the patient's mouth and correct the hypoglycemia as needed ventilatory support if needed and then emotional support after the seizure was febrile encourage the patient or parents to administer medicines to reduce it consult protocols for appropriate administration of over-the-counter meds and all patients should be transported it can be different difficult to differentiate a seizure from a stroke",
        "A Seizure from a Stroke": "so consider your assessment findings and past medical history when a seizure is caused by a stroke how um it is unlikely that the pattern will be the same as that of a patient's baseline seizures if you're concerned that the patient may have a seizure during transport you could establish an iv and be prepared to give diazepam lorazepam or midazolam and then in hospital management involves determining the cause of course so they're going to do ct scans or mris when it comes to status epilepsis so status epilepsis is a seizure that lasts longer than four to five minutes or consecutive seizures without the return to consciousness in between you want to refer to your local guidelines regarding intervention this is a life-threatening neurologic disorder that should not be taken lightly during a seizure the neurons are in a hyper-metabolic state the goal is to stop the seizure and ensure adequate abcs so assessment is the same for any patient experiencing a seizure be sure to ask bystanders or family if an anti-seizure medication was administered before your arrival follow standard of care guidelines for a neurologic patient ensure the patient does not have hypoglycemia and administer a benzodiazepine so be prepared to control the airway and if the seizure cannot be controlled and the patient cannot be ventilated sedative paralytics may be needed",
        "Syncope Pathophysiology": "when it comes to syncope pathophysiology so syncope is a sudden or temporary loss of consciousness with loss of postural tone so the brain uses a large amount of glucose and has no ability to store it like we said earlier so even a short three to five second interruption of blood flow causes loss of consciousness so you need to determine what caused it if you can when you're doing the assessment the patient is usually in the standing position when syncope occurs vasovagal sympathy or syncope is typically in younger adults and when a patient experiences fear or emotional stress or pain they pass out cardiac dysrhythmia is typically caused in older adults so ventricular attack causes a blood pressure drop and the patient falls down simple as that so the signs and symptoms that precede a disease or condition is a proto so prodomil sign and symptom for syncope include dizziness weakness shortness of breath or chest pain headache or loss of vision and incontinent incontinence is possible so gather information about the history of the present illness to help the emergency department staff they need to determine the cause management so determine if trauma has occurred focus on blood pressure and cardiac issues conduct continuous ecg monitoring and a 12 lead and evaluate blood pressure oxygen and level of oxygen sat and obtain orthostatic blood pressures okay so provide emotional support and transport all right so next we're going to talk",
        "Headaches": "about headaches headaches originate from the nerves within the scalp face blood pressures and muscles of the neck and head muscle tension headaches may be caused by stress the majority of headaches are this type so pain is usually felt on both sides of the head traveling from the back to the front",
        "Migraines": "migraines are complex condition thought to be caused by minor instability within certain clusters of neurons challenges in size of blood vessels at the base of the brain so the patient may report seeing an aura and the pain will be generally unilateral or focused throbbing pounding or pulsating and they have they want to remain in a dark and quiet environment migraine can last several days and then you could have cluster headaches and they are vascular headaches that begin as minor pain around the eye they're sharp and excruciating and intensify and spread to one side of the face they occur in groups that last about 30 to 45 minutes",
        "Sinus Headaches": "so sinus headaches are caused from inflammation or infection within the sinus cavities of the face the pain is located in the superior portions of the face and increases when the patient bends over headaches can indicate a more serious condition so treat for a stroke if other signs are present and ask what medications the patient has taken medications for pain management include toradol or demerol fentanyl or morphine and for nausea and vomiting consider fenegrin or zofran other headaches are rare but they may be caused by there may be some caused by tumors or inflammation stroke or central nervous system infection or hypertension okay so next we're going to talk about",
        "Dementia": "dementia it's a chronic deterioration of memory personality language skills perception and reasoning or judgment changes occur over weeks to years it could be caused by varying things such as vitamin b deficiency when it occurs in patients who are chronically malnourished as well alzheimer's disease is the most common form of dementia it's a progressive organic condition that occurs when neurons die should not be confused with delirium because delirium is a sudden state of confusion or disorientation and delirium is reversible carnicky encephalopathy should be considered it's a confusion and dementia and it's partially reversible so you could administer thymine 100 to 200 milligrams ivp before you give sugar perform ekg and obtain blood chemistries of course in the hospital they're going to do ct scans and mris and blood work",
        "Neoplasms": "neoplasms so neoplasms are growth within the body that serve no useful purpose and are caused by errors during cellular reproduction within the context of the neurologic system neoplasm is a cancer of the brain or spinal cord the primary neoplasms are cancers that arise within the nervous system and metamous tastic neoplasms are tumors that arise elsewhere and are spread to the nervous system so metastasis is the process by which cancer cells move to sites distant from their origin lung and breast cancers are the most common causes of metastasize to the cns",
        "Signs and Symptoms of Brain Tumors": "common signs and symptoms of brain tumors are headaches nausea vomiting seizures ataxia change of mental status and stroke light signs or symptoms common signs and symptoms of a spinal tumor is back weak weakness back pain incontinence or deformity along the spine pre-hospital management is supportive and watch for status epilepsis administer diazepam if needed and protect the limbs from injury so there are similar presentations there's demyelating conditions which occur after damage is done to the myelin sheath surrounding the neuron so degenerating conditions are incurable motor neuron disease are a grouping of conditions that feature destruction of the motor neuron and they are progressive conditions and patients experiences difficulty with speech ambulation and general movement",
        "Multiple Sclerosis": "so we're going to talk about multiple sclerosis all otherwise known as ms and it's an autoimmune condition in which the body attacks the myelin of the brain and spinal cord and of course that results in the demyelation destruction of the myelin the body begins to attack its own cells the myelin coats the axons of the nerve cells a lot and this allows for smooth transition so in multiple sclerosis the body believes the myelin is foreign and attacks it it creates gaps in the isolation insulation it's believed to be caused by an unknown environmental trigger such as a virus so presentation follows a pattern of attacks and remissions common complaints include double vision or blurred vision other signs and symptoms are muscle weakness impairment of pain and impairment of temperature impairment of the sense of touch and in you'll have tremors speech disturbances visual vision disturbances vertigo bladder and bowel incontinence sexual dysfunction and fatigue when it comes to management it's just supportive the condition is typically diagnosed in people ages 20 to 50. signs and symptoms may progress over several hours and in hospital treatment is aimed at controlling the symptoms gillian beret syndrome so this is a syndrome and it's a rare disease in which the immune system attacks portions of the nervous system the cause is unclear patients report having previous minor respiratory or gi infections one theory is that the immune system attacks and damages the myelin some patients recover completely without residual weakness one third of the patients will need respiratory support at some point the condition begins with weakness and tingling sensation in the legs and moves up the arms and attacks the thorax and arms in addition to peripheral motor neuron involvement the autoregulatory system may be involved patients are prone to severe swings in pulse rate and blood pressure closely assess the patient's ability to protect the airway and ventilate and be prepared to administer iv fluids ventilatory support may be necessary and in hospital management includes plasma so plasmaporesis and immunoline goblin injections",
        "Parkinson's Disease": "next we're going to talk about parkinson's disease so this is a neurologic condition in which the environment and genetic factors can cause patients at risk for damage of certain neurons right so dopamine is needed for the muscles to contract smoothly the onset could be months to years initial signs are often unilateral tremors over time the areas of the body more areas are involved genetics plays an important role so classic presentations involve tumor or postural instability rigidity or sometimes depression dementia difficulty swallowing foot and leg contractions and patients in later stages are at risk from aspiration pneumonia falls and complications due to immobility so pre-hospital management is supportive treat the injuries and in-hospital treatment includes levodopa to temporarily restore dopamine levels",
        "Ammotropic Lateral Sclerosis": "ammotropic lateral sclerosis so als it's also known as lou gehrig's disease it's a disease that strikes the voluntary motor neurons the cause is unclear the most common most common is a middle aged men it's an initially subtle and progresses without notice so they it could be fatigue weakness difficulty doing routine activities such as eating writing or dressing progression of signs and symptoms progress of course the inability to walk so average life expectancy is three to five years after diagnosis",
        "Pre-Hospital Management": "pre-hospital management follow standard of care guideline assess the ability to swallow and monitor the airway and the patient may rely on feeding pumps or iv pumps or long-term iv access ports and ventilators in hospital care includes physical therapy and medication to mitigate certain symptoms cranial nerve disorders so they may mimic other conditions involve one or more cranial nerves a good assessment and detailed history taking is necessary so follow the neurologic assessment described earlier test for vertigo and patients who are at risk of a cervical spine trauma or neck disease with hands on either side of the head move the head rapidly from side to side and look or return the head to the neutral position so look to see if the patient's eyes if the patient has vertigo then the nystagmus will be seen so it's mainly supportive management for for nausea and vomiting you could give them fenogram or zofran in most cases and nsaid and opiates are given for the limited benefit managing the pain",
        "Dystonia": "dystonia so dystonias are severe muscle spasms that cause bizarre quotations or repetitive motions or postures dystonia can either be a sign which is occurring within the other condition or the condition itself so patients with dystonia have normal intelligence can think clearly and are not experiencing a seizure dystonias do not impact the patient's level of consciousness and they occur for an unknown reason okay so spasms are involuntary and often painful and you can see on this chart and also on chart or table 18-20 in your book the different types of dystonias and the presentation of those when it comes to management pre-hospital management is focused on ruling out other problems if you suspect the reaction is from this antipsychotic medication administer benadryl or diet dihyphamine at 25 milligrams ivp right okay so next we're going to be talking about",
        "Central Nervous System Infections and Inflammation": "central nervous system infections and inflammation so encephalitis is an inflammation of the brain the meningitis is an inflammation of the meninges and remember the meninges are the outer covering of the central nervous system so infections can cause include bacteria viruses fungi or prisons gaining access to the body and causing damage so damage can be caused by the body's reaction to the infection or the activities of the attacking organisms so the most common sign is a presence of a fever and it allows the immune system to gain control signals the rest of the body that attack is underway and the brain affects uh from high temperatures so eventually the person may have hallucinate hallucinations or become delusional or experience level of consciousness or loss of consciousness and have a febrile seizure damage may also be caused by the destruction of the cells so organisms can produce protein that damage living cells you have endotoxins and those proteins that are released by gram-negative and then exotoxins those are proteins that are secreted by some bacterial and fungi",
        "Assessment": "so assessment both illness begin with flu-like symptoms other symptoms are stiff neck or photophobia or lethargy meningitis malicious uh kernig sign management treatment may be mainly supportive if meningitis is suspected you need to place a mask over your patient and wear a mask if the patient is coughing be prepared for seizures risks include increased icp and sepsis so that indicates infection within the bloodstream the paramedic may need antibiotic treatment and hospital treatment includes decreasing swelling in the brain and spinal cord fighting the infection and supporting the patient's vitals",
        "Abscesses": "okay so abscesses we're going to talk about next and then abscess is caused by an infectious agent within the brain or spinal cord an abscess occurs when the immune system is unable to kill the pathogen and an underlying cause is varied so an abscess is often preceded by an infection of the throat or sinuses or gums or ear you want to look for a high grade fever or persistent headache drowsiness or confusion or generalized focal seizures nausea vomiting or nuclear rigidity or hemiparesis follow your standard care guideline and pay attention to increase icp take seizure precautions and evaluate in high so remove the patient's clothing if there's a high temperature cover with a sheet and turn off the heat and transport promptly in hospital they're going to give them antibiotics and seizure precautions and maybe possibly surgical remover",
        "Poliomolitis and Post Polio Syndrome": "so poliomolitis and post polio syndrome",
        "Poliomyelitis": "so poliomyelitis is a viral infection transmitted by fecal oral route a vaccine was developed after a peak in the 1950s and no cause no cases of wild polio within the united states has occurred since 1979 in the u.s people who contracted the disease typically have not been immune immunized signs and symptoms begin as little as one week after the exposure you could have a sore throat nausea vomiting diarrhea stiff neck management is hydration ventilation and calorie support patients often at risk for problems decades after that infection and so post-polio syndrome may present as difficulty swallowing or fatigue or breathing conditions and it can affect the speed in which the patient decompensates pre-hospital treatment includes managing airway obstructions and in hospital treatment for post-polio patients includes physical therapy and experimental medications",
        "Peripheral Neuropathy": "when we talk about peripheral neuropathy that is a group of conditions in which nerves leaving the spinal cord are damaged signals to and from the brain are distorted so it can cause trauma or causes from trauma or toxins maybe an autoimmune attack or metabolic disorder diabetic neuropathy is the most common form when you're doing your assessment look for sensory or motor impairment a loss of sensation numbness or burning or pain or parasthesia or muscle weakness and we're just given supportive care in the pre-hospital setting but in hospital they're going to give them pain management and help gain better control over the blood sugars probably okay so that concluded chapter 18 the neurologic emergencies lecture if you liked this screencast go ahead and subscribe to our channel we're going to be completing the rest of the chapters from the 8th edition of nancy caroline's emergency care in the streets hope you have a great one thank you"
    },
    {
        "Introduction to Neurologic Emergencies": "chapter 19 neurologic emergencies stroke is the fifth leading cause of death in the United States following heart disease and cancer treatment options depend on the type of stroke which can be either es schic or hemorrhagic approaches to treatment vary from the use of traditional thrombolytic medications to Advanced surgical interventions such as mechanical clot retrieval in cases of cerebral esia including the mercy procedure and the repair of arterovenous malformations additionally seizures and altered mental status can arise due to various brain disorders these seizures may result from recent or previous head injuries brain tumors metabolic imbalances genetic factors scar tissue from a previous stroke or may have an idiopathic origin altered mental status is frequently observed in patients with a broad range of medical conditions common causes include alcohol intoxication head injuries diabetic emergencies and stroke the approach to treatment is contingent upon the specific underlying cause in situations where the nervous system is depressed protective reflexes that typically Safeguard and alert individual may be impaired for instance the eyelids may fail to Blink the ferx may not produce a gag reflex and the the cough reflex might not be triggered by secretions or foreign matter in the airway Additionally the body may not adjust to alleviate pressure on a limb held in an awkward position and the tongue may become flaccid increasing the risk of Airway obstruction.",
        "Overview of the Nervous System": "the nervous system is the most intricate organ system in the human body responsible for coordinating and controlling various bodily functions it is primarily composed of the brain spinal cord and nerves the nervous system is divided into two major components the central nervous system or CNS and the peripheral nervous system or pns the CNS which includes the brain and spinal cord processes information received from the body and commands actions based on this input the pns consisting of the spinal and peripheral nerves acts as the communic ation Network that transmits information between the CNS and the rest of the body it is further divided into the sematic nervous system which controls voluntary muscle movements and the autonomic nervous system which regulates involuntary functions the autonomic nervous system is subdivided into the parasympathetic nervous system which is responsible for rest and digestion and the sympathetic nervous system which prepares the body for fight ORF flight responses the nervous system is responsible for both fundamental and higher level functions in the body it controls basic physiological processes such as breathing heart rate blood pressure and body temperature regulation additionally it manages complex activities like memory understanding communication and thought.",
        "Components of the Nervous System": "the major components of the nervous system are categorized into the central nervous system which includes the brain and spinal cord and the peripheral nervous system which consists of the nerves that Branch out from the CNS to the rest of the body the brain is the central organ responsible for regulating all body functions including breathing speech and other essential activities it's composed of three major parts the brain stem cerebellum and the cerebrum the cerebrum is the largest part of the brain and is involved in higher cognitive functions the brain stem on the other hand is crucial for controlling basic physiological functions such as breathing maintaining blood pressure swallowing and pupil constriction these fundamental activities are essential for sustaining life and are managed automatically by the brain stem the cerebellum is responsible for controlling muscle and body coordination allowing for the smooth execution of complex tasks that require voluntary muscle movement the cerebrum which is the largest part of the brain is divided into two cerebral hemispheres the right and the left each hemisphere controls functions on the opposite side of the body the front of the cerebrum is involved in regulating emotions and thought processes the middle part is responsible for touch and movement and the back of the cerebrum processes visual information in most individuals speech production is managed on the left side of the brain specifically in the area located near the middle of the cerebrum messages transmitted to and from the brain travel via nerves there are 12 cranial nerves that extend directly from the brain to various parts of the head facilitating functions such as sensory perception and muscle movement the remaining nerves converge in the spinal cord and exit the brain through the FMA Magnum connecting the brain to the rest of the body and enabling communication between the central nervous system and the peripheral structures at each vertebrae of the cervical thoracic Lumbar and sacral regions of the spine two spinal nerves Branch out one on each side of the vertebral column these spinal nerves are part of the peripheral nervous system and are critical for transmitting sensory and motor information between the CNS and the rest of the body the spinal nerves carry both a ferent or sensory and eer or motor signals a signals travel from various parts of the body to the spinal cord and then to the brain where they are processed and interpreted allowing us to feel Sensations such as touch pain and temperature eference signals travel from the brain through the spinal cord to the muscles and glands facilitating movement and other bodily functions in addition to their role in Signal transmission each SP nerve is associated with a specific area of skin known as a dermatome dermatomes are regions of the skin that are innervated by sensory fibers from a single spinal nerve root this precise mapping allows clinicians to trace sensory loss or abnormalities to a specific spinal nerve which can be crucial in diagnosing spinal cord injuries nerve compression or other ner NE ological conditions for example if a patient experiences numbness or tingling in a specific area of the armor leg a healthc care provider can determine which spinal nerve might be affected by correlating the area of sensation loss with the corresponding dermatome this understanding of dermatomes is particularly useful in emergency in neurological medicine where quick and accurate localization of nerve damage can significantly impact the management and treatment of patients moreover spinal nerves also contribute to the formation of nerve plexus which are the brachial plexus which supplies the arms and hands and the lumbo sacral plexus which supplies the lower limbs these plexes ensure that motor and sensory signals are distributed to the appropriate regions allowing for coordin ated and effective movement and sensation.",
        "Neurons and Neurotransmitters": "neurons are the fundamental cells of the nervous system and play a central role in transmitting impulses throughout the body each neuron is composed of three primary Parts the cell body the axon and the dendrites the cell body houses the nucleus which contains the cell's genetic material and controls its activities the axon is a long projection that extends from the cell body carrying signals away from the neuron to other cells they may be wrapped in a myelin sheath which is a fatty layer that insulates the axon and enhances the speed of signal transmission the point where two neurons interact is called a synapse which is a junction where the transmission of nerve impulses occur it's important to note that neurons do not physically touch each other instead they communicate across the synapse a synapse exists at the terminal end of a nerve cell connecting it to the next cell in the pathway this connection is facilitated by chemicals known as neurotransmitters which are released by the neuron and travel across the synapse to transmit the signal to the next neuron NE neurotransmitters play a critical role in this process by binding to The receptors on the surface of the adjacent Neuron triggering a response that allows the impulse to continue its Journey Through the nervous system this intricate system of communication enables the brain and body to coordinate a vast array of functions from basic reflexes to complex behaviors ner NE transmitters are essential chemical Messengers that relay electrically conducted signals from one neuron to the next when an electrical impulse reaches the end of a neuron it triggers the release of neurotransmitters into the synapse the small gap between neurons these neurotransmitters then bind to specific receptors on the surface of the adjacent neuron transmitting the signal across the synapse once the neurotransmitter binds to the receptor the receiving neuron responds by either firing an action potential which continues the transmission of the signal or by not firing depending on the type of neurotransmitter and the receptor it binds to this firing or inhibition is what allows the nervous system to regulate and control various bodily functions from muscle contractions to complex cognitive processes this process of signal transmission is fundamental to all neural communication and underlies every action thought and sensation in the body.",
        "Brain Dysfunction and Stroke": "many disorders can lead to brain dysfunction or other neurological symptoms due to the brain's sensitivity to changes in oxygen glucose and temperature even slight deviations in these parameters can trigger significant neurological changes for instance when blood flow to the brain is interrupted the individual May lapse into a coma in a similar fashion A reduced oxygen level in the bloodstream can impact the entire brain leading to symptoms such as anxiety restlessness and confusion in addition to these factors other conditions such as infections and tumors can also cause brain dysfunction these disorders may result in seizures and altered mental status further complicating the clinical picture and requiring prompt intervention to prevent lasting neurological damage a stroke is a sudden Interruption of blood flow to the brain leading to a loss of brain function this Interruption deprives brain cells of oxygen causing them to cease functioning and begin to die this process is known as infarction where cells become damaged if blood flow is not quickly restored prompt medical intervention is vital as the longer a stroke persists the less likely the patient is to achieve a favorable outcome this urgency is encapsulated in the phrase time is brain emphasizing that delays in treatment can lead to more extensive brain damage a significant number of stroke patients either deny their symptoms or simply fail to recognize their seriousness which can lead to delays in seeking treatment recognizing and responding immediately to stroke symptoms is crucial without oxygen the affected brain cells die but if some blood flow persists it may maintain a group of cells known as esic cells which can survive for a time and may recover if blood flow is restored therefore early in aggressive treatment can prevent the death of these cells improving the overall prognosis of the patient if normal blood flow is restored to an esic area of the brain promptly the extent of residual damage can be minimized leading to a better recovery outcome for the patient.",
        "Types of Stroke": "interruptions in cerebral blood flow can occur due to several causes including the formation of a thrombus an arterial rupture or cerebral embolism there are two primary types of stroke hemorrhagic and esic a hemorrhagic stroke occurs when a blood vessel in the brain ruptures causing bleeding within or around the brain tissue this type of stroke is often associated with more severe symptoms and a much higher mortality rate an es schic stroke which is the more common type occurs when a blood BL vessel supplying blood to the brain is obstructed typically by a thrombus or embolism esic Strokes generally develop more slowly than hemorrhagic strokes and may result in less immediate damage but they do require prompt treatment to restore blood flow and minimize injury an es schic stroke occurs when a blood vessel supplying blood to the brain becomes blocked leading to aeia in the tissue dis to the blockage this means that the affected brain tissue is deprived of oxygen and nutrients resulting in cell death if blood flow is not quickly restored a common cause of this blockage is atherosclerosis which is a condition that's characterized by the buildup of calcium and cholesterol within the walls of blood vessels over time this buildup forms plaque which can partially or completely obstruct blood flow the presence of plaque not only Narrows the blood vessel making it difficult for blood to pass through but also reduces the vessel's ability to dilate and adjust to changes in blood flow eventually the plaque can cause complete occlusion of an artery leading to a significant reduction in blood supply to the brain and resulting in an achemical in managing an es schic stroke in order to minimize brain damage and improve outcomes in some cases an atherosclerotic plaque within a cored artery May rupture a crack when this happens a blood clock can form over the disrupted plaque leading to a blockage of blood flow the areas of the brain that are normally supplied by the affected artery become es schemi leading to a potential stroke the symptoms that result from this esea can vary but often include a loss of movement on the side of the body opposite of the blockage also the patient may complain of confusion and difficulty speaking or understanding language known as a fascia in some instances smaller fragments of the clot may break off and travel deeper into the brain or they can cause additional block blockages and exacerbate the es schema condition the extent and severity of symptoms depend on the location and extent of the obstruction within the brain's vasculature depending on where the blockage occurs the patient might experience a wide range of effects from mild symptoms to severe outcomes such as complete paralysis.",
        "Hemorrhagic Stroke": "a hemorrhagic stroke is caused by bleeding within the brain resulting from the rupture of a cerebral blood vessel the severity of this type of stroke is determined by the location and size of the ruptured vessel as blood leaks into the brain tissue intracranial pressure increases compressing the surrounded tissue this compression prevents oxygenated blood from reaching the affected area leading to cell death individuals with iic poorly controlled hypertension are at the highest risk for hemorrhagic Strokes because high blood pressure weakens the blood vessels and the Brain making them prone to rupture proper management of hypertension is critical in preventing long-term damage to these blood vessels and reducing the risk of hemorrhagic stroke unfortunately hemorrhagic Strokes are often fatal due to the rapid deterioration caused by the bleeding and the subsequent increase in intracranial pressure some patients have a congenial weakness in one or more layers of their arterial walls which also increases their risk for hemorrhagic stroke a common cause in these individuals is an aneurysm which develops when a small tear or defect occurs in the artery wall blood infiltrates between these layers causing pressure to build up as the pressure increases the tear enlarges and the artery may eventually rupture leading to an intracranial hemorrhage the symptoms of a hemorrhagic stroke typically include the sudden onset of a severe headache often described as the worst headache of my life and a rapidly decreasing level of Consciousness in young otherwise healthy individuals a hemorrhagic stroke is often due to a saccular aneurysm which resembles a small balloon protruding from a cerebral artery this type of stroke is also known as a subarachnoid hemorrhage in some cases surgical intervention may be possible to repair the aneurysm and stop the bleeding if the bleeding continues the intracranial pressure will continue to rise which can lead to a critical situation known as herniation herniation occurs when the brain is forced out of the cranial Vault through the frame and Magnum due to the excessive pressure this process puts pressure on the medulla oblongata leading to abnormal Vital Signs and other severe neurological findings inoc cranial pressure is not a static value it changes constantly and can fluctuate rapidly a sharp rise in intracranial pressure or a sudden drop in blood pressure can lead to life-threatening complications unfortunately prehospital treatment options are generally ineffective in significantly reducing intracranial pressure making it crucial for patients with suspected elevated intracranial pressure to receive prompt and Specialized Care in a hospital setting the image illustrration Normal and abnormal intracranial conditions in a normal brain the volumes of the brain cerebral spinal fluid and blood are balanced maintaining normal intracranial pressure however in abnormal conditions such as with a brain tumor or hematoma either brain or blood volume increases leading to a compression of the brain blood and CSF which results in elevated intracranial pressure this increase can cause significant neurological damage if not addressed promptly.",
        "Transient Ischemic Attack": "a transient es schic attack or Tia often referred to as a minist stroke occurs when normal bodily processes break down a blood clot in the brain restoring blood flow and allowing the patient to regain function of the affected area the symptoms of a TIA typically resolve on their own within 24 hours and unlike a full stroke no lasting damage to brain tissue occurs despite this every Tia is a medical emergency as it may be a warning of a potential acute stroke in the future therefore all patients who experience a TIA should undergo evaluation by a physician to assess their risk and take preventative measures the signs and symptoms of a stroke or Tia include facial drooping sudden weakness or numbness in the face arm leg or on one side of the body and decreased or absent movement and sensation on one side of the body other symptoms may involve a taxia which is a lack of muscle coordination or a loss of balance and and sudden vision changes such as loss of vision in one eye blurred vision or double vision these symptoms are indicative of neurological impairment and should prompt immediate medical evaluation additional signs and symptoms of a stroke or Tia include dysphasia which is difficulty swallowing a decreased level of responsiveness AP fascia or the inability to speak or understand language and slurred speeech patients may also experience a sudden and severe headache confusion dizziness weakness combativeness and restlessness other symptoms to look for are tongue deviation which can indicate neurological impairment and in severe cases coma these symptoms indicate a significant neurological iCal dysfunction and require immediate medical attention to prevent further brain damage.",
        "Effects of Brain Hemisphere Damage": "problems in the left hemisphere of the brain can result in Aphasia this can manifest in various forms such as receptive aphasia where the patient struggles to comprehend speech but can speak clearly or expressive Aphasia where the patient understands questions but cannot produce the correct sounds to answer additionally left hemisphere damage can lead to Paralysis on the right side of the body conversely right hemisphere issues can cause paralysis on the left side of the body patients with right hemisphere damage typically understand language and can speak but their speech may be slurred and difficult to understand these patients may also exhibit neglect or they are unaware of their problems making it challenging to detect these issues in the field this unawareness combined with a lack of pain often causes delays in seeking medical help bleeding in the brain may present with hypertension which can either be a cause or a response to the bleeding in cases of stroke high blood pressure should not be treated in the field as it is likely a compensatory mechanism as the patient's condition deteriorates significant drops in blood pressure can occur indicating a worsening cerebral profusion rate and an increased risk of severe outcomes.",
        "Stroke Mimics": "certain medical conditions can present with symptoms similar to those of a stroke making accurate diagnosis challenging hypoglycemia with its low blood sugar condition can cause confusion weakness and even neurological deficits that resemble a stroke the postictal state which follows a seizure can also mimic stroke symptoms including the altered level of Consciousness and temporary weakness commonly seen in stroke patients additionally subdural and epidural hematomas which involve bleeding within the brain can present with signs such as headache confusion and motor deficits that closely resemble those of a stroke the images here illustrate the difference between a subdural and epidural hematoma a subdural hematoma occurs when blood collects between the Duram matter and the Brain often due to Venus bleeding in contrast an epidural hematoma involves bleeding between the Duram matter and the skull typically from an arterial Source such as the middle menial artery following a skull fracture understanding the underlying pathophysiology of a subdural and epidural hematoma is important as even though they are both bleeding into the cranium they are not considered a hemorrhagic stroke due to the location of the bleed subdural and epidural bleeding typically result from trauma to the head causing blood to accumulate in areas that exert pressure on the brain the dura a tough leathery membrane covering the brain lies just beneath the skull a skull fracture particularly near the temporal region can cause an artery to rupture and bleed on top of the dura leading to an epidural hematoma symptoms often develop rapidly after the injury due to the arterial nature of the bleed which can quickly increase intracranial pressure and in contrast subdural bleeding which involves venous blood accumulating beneath the dura may present more subtly with stroke-like symptoms that can be less obvious initially both sides of bleeding require immediate medical attention as the increasing pressure on the brain can lead to significant neurological impairment if not promptly treated.",
        "Seizures and Their Classifications": "seizures are characterized by sudden inerratic firings of neurons in the brain leading to a wide range of signs and symptoms the manifestations of a seizure can vary significantly from minor symptoms such as a single hand shaking or a metallic taste in the mouth to more severe presentations involving the movement of all limbs or a complete loss of consciousness the diversity in seizure symptoms reflects different parts of the brain that may be affected during the event seizures are classified into two main types generalized and focal generalized seizures involve the entire brain often resulting in a loss of consciousness and widespread convulsions in contrast focal seizures originate in a specific area of the brain causing localized symptoms such as limb shaking or sensory disturbances and may or may not include a loss of consciousness depending on the extent of brain involvement tonic clonic seizures typically follow a specific pattern though not all patients may experience every step the sequence often begins with an aura a sensation indicating the onset of the seizure followed by a loss of responsiveness the seizure then progresses through the tonic phase where the body becomes rigid and the hypertonic phase characterized by extreme muscle St stiffness the clonic phase involves rhythmic muscle contractions and possible arm leg and heav movements lip smacking biting and teeth clenching after the seizure during the post seizure phase the major muscles relax but nagas may persist and the eyes may remain rolled back finally the post dial phase is a recovery period for the brain which can last from minutes to hours during this phase patients may be aphasic confused emotionally unstable fatigued incontinent or may experience headaches pseudo seizures are generalized neurologic events that can closely resemble generalized seizures making them difficult to distinguish however the root cause of pseudo seizures is psychiatric and nature rather than neurological it's important to note that the patient is not consciously or intentionally causing this Behavior the Motions that occur during a pseudo seizure tend to be relatively organized compared to the more chaotic movements seen in true epileptic seizures.",
        "Absence Seizures": "absent seizures also known as petite M seizures are a form of generalized seizure most commonly observed in children these seizures are characterized by a brief period of sudden disconnection from the surroundings where the child may appear to be staring blankly into space unlike other types of seizures that involve traumatic convulsions or loss of muscle control absent seizures present with minimal physical movement the child May simply stop what they're doing freeze in place and then resume their activity as if nothing happened once the seizure ends the duration of an absent seizure is typically very short usually lasting only a few seconds during this time the child is unresponsive to external stimuli and may not be aware of what is happening however because these seizures are so brief they often go unnoticed or may be mistaken for daydreaming it's important to note that these seizures do not cause the child to fall or lose muscle tone making them less obvious than other types of seizures one of the Hallmark features of absent seizures is the lack of a postal period which is the recovery phase that typically follows other types of seizures after an absent seizure the child does not experience confusion disorientation or drowsiness and they can immediately return to their normal activities absent seizures can be triggered by specific stimuli such as flashing lights or hyperventilation and they can occur multiple times throughout the day while they're generally not harmful on their own frequent absence seizures can interfere with learning and daily activities especially in a school setting if left untreated this may continue into adolescence or adulthood although most children will outgrow them diagnosis of absent seizures typically involves an EEG which can detect the characteristic brain wave patterns associated with the seizures treatment often includes anti-seizure medications that help to reduce the frequency and severity of the seizures allowing the child to maintain a normal lifestyle.",
        "Focal Seizures and Status Epilepticus": "focal seizures also known as partial seizures originate in a specific area of the brain and are categorized into aware and impaired awareness types in aware focal seizures the patient remains conscious and may experience symptoms like numbness weakness visual disturbances unusual smells or motor activity such as muscle twitching that can spread across the body impaired awareness focal seizures involve altered Consciousness where the patient may exhibit automatic behaviors like lip smacking or eye blinking experience unpleasant sensory phenomena or engage in repetitive actions typically without recalling the event afterward status epilepticus is a serious and potentially life-threatening neurological condition characterized by prolonged or repeated seizures it's defined by seizures that last more than four to 5 minutes or by a series of consecutive seizures that occur with without the patient regaining full Consciousness between episodes some medical literature suggests that status epilepticus is only diagnosed after 30 minutes of uninterrupted seizure activity highlighting the critical nature of the condition during a seizure neurons enter a hyper metabolic State meaning they consume energy and resources at an accelerated rate for short durations this hyper metabolic state does not usually result in lasting harm however if a seizure continues for an extended period the body becomes unable to effectively clear metabolic waste products from the brain or maintain the glucose levels necessary for proper neuronal function this deprivation of essential nutrients and the accumulation of harmful byproducts can lead to irreversible damage or death of neurons significantly impacting brain function the goals of prehospital care in a patient experiencing status epilepticus are Urgent and multifaceted the immediate priority is to stop the seizure to prevent further neurological damage this often requires the administration of anti-convulsant medications alongside seizure control it's essential to ensure the patient's Airway remains open breathing is adequate and circulation is stable additionally since the brain is highly dependent on glucose it's important to assess and manage blood glucose levels hypoglycemia can exacerbate the condition or even be the underlying cause of the seizure overall the management requires rapid and decisive intervention to minimize the risk of long-term neurological damage or death prehospital provital play a crucial role in stabilizing the patient and ensuring they receive the necessary treatment as quickly as possible.",
        "Causes of Seizures": "seizures can arise from a variety of causes including congenital disorders diabetic emergencies and fever particularly in infants some disorders such as epilepsy are congenital meaning they're present from birth others may result from high fever structural problems in the brain or metabolic or chemical imbalances in the body body epileptic seizures can typically be managed with medication but patients may experience seizures if they stop taking their medication or simply fail to adhere to the prescribed dosage with non-compliance being a common cause of seizure recurrence feveral seizures which are triggered by sudden high fevers are particularly common in infants and children while generally well tolerated these seizures warrant medical evaluation in a hospital setting as they could indicate underlying conditions such as en sephtis menitis or even brain abscess it is not necessarily the height of the fever that triggers these seizures but rather how quickly the fever spikes recognizing seizures is crucial for providing timely and appropriate care it's important to identify when a seizure is occurring or has occurred and to determine if this episode differs from the patient's previous seizures awareness of the postal state is also essential as complications can arise during this time such as the patient being unable to breathe effectively additionally providers should assess for other issues associated with seizures such as incontinence which is common during generalized tonic clonic seizures the postal state is the period following a seizure during which the patient experiences recovery during this phase muscles relax and breathing may become labored the patient might display hemiparesis a weakness on one side of the body that can mimic the symptoms of a stroke the most common characteristics of the postal State include lethargy and confusion and patients may become combative or appear angry as they regain Consciousness if if the patient's condition does not improve during the postal phase it's important to consider other underlying conditions such as hypoglycemia or an infection which might be contributing to their symptoms.",
        "Altered Mental Status": "altered mental status refers to a condition where a patient is not thinking clearly or is unable to be aroused this can manifest in two primary ways the patient may be completely unresponsive or they may be responsive but exhibit confusion recognizing altered mental status is important as it often indicates underlying medical or neurological issues that require immediate evaluation and treatment altered mental status can result from various underlying causes including hypoglycemia hypoxemia intoxication drug overdose brain t tors glandular abnormalities and poisoning for example hypoglycemia can mimic the symptoms of stroke and seizures but it often presents with a distinctively altered mental status patients may be on medications that lower blood glucose levels and these individuals might not be able to protect their airways if their level of Consciousness is reduced therefore it's important to consider hypoglycemia in patients who've had a seizure particularly if their glucose levels are low or if they simply present with an altered mation following an injury other potential causes of alra Bal status include hypoxia unrecognized head injury severe alcohol or drug intoxication and infections particularly those affecting the brain or bloodstream people with alcoholism may have additional complications like liver dysfunction blood clotting issues and immune system abnormalities which can contribute to altered mental status psychological issues and adverse medication effects may also lead to altered mental status and it's essential to consider that a patient exhibiting psychiatric symptoms could also have an underlying medical condition infections can be life-threatening particularly in the very young very old or the imuno compromised patient and they might not present with typical Vital Signs drug overdoses and poisonings should also be considered with close monitoring for cardiac and respiratory complications.",
        "Syncope": "Syncopy commonly known as fainting is characterized by a sudden and temporary loss of consciousness accompanied by a loss of postural tone meaning the person may collapse or fall while often benign Syncopy can sometimes indicate a life-threatening condition such as a cardiac dysrhythmia stroke or other serious medical issue it primarily affects adults and should always be evaluated to rule out any underlying life-threatening causes meaning that an effort should be made to transport these patients to the most appropriate facility Syncopy can be caused by a varet of underlying issues common causes include problems with cardiac Rhythm or conduction such as arrhythmias which can disrupt the heart's ability to pump blood effectively issues with the cardiac muscle including myocardial infarction can also lead to Syncopy non-cardiac causes include dehydration which reduces blood volume and can lead to a drop in blood pressure as well as hypoglycemia where low blood sugar levels impair brain function additionally a Vasa vagal episode which occurs when the body overreacts to certain triggers like stress or pain can cause a sudden drop in heart rate in blood pressure leading to the patient experiencing a snable episode.",
        "Headaches": "headaches are a common complaint and can be classified into several types with tension headaches migraines and sinus headaches being the most frequent these types of headaches are generally not life-threatening tension headaches are caused by residual muscle contractions within the face and head and are often linked to stress altered cortisol levels or depression this pain is typically described as squeezing dull or aching migraine headaches are believed to result from minor instability within certain clusters of neurons and changes in the size of blood vessels at the base of the brain patients may experience an aura followed by unilateral focused pain that spreads all over the pain is often described as throbbing pounding or pulsating and can be accompanied by nausea or vomiting those suffering from migraines usually prefer dark quiet environments and the headaches can last for several Days Cluster headaches are rare vascular headaches that occur in groups lasting 30 to 45 minutes each with several potentially occurring in a single day these headaches May reoccur for days and then cease entirely the pain typically begins around one eye intensifies and then spreads often causing feelings of anxiety sinus headaches are caused by inflammation or infection within the sinus cavities of the face the pain is located in the superior portions of the face and typically worsens when the person bends forward.",
        "Assessment of Neurological Issues": "when assessing a patient especially in the context of potential neurological issues it's critical to understand that the brain is particularly vulnerable to fluctuations in oxygen glucose and temperature these factors are essential for maintaining normal brain function and even monor viations can lead to significant neurological changes the brain requires a continuous supply of oxygen to function properly hypoxia can quickly lead to an alter mental status confusion loss of consciousness or even permanent brain damage if not corrected promptly during assessment it's vital to evaluate the patient's oxygenation status by checking for adequate Airway breathing and circulation as well as using tools like pulse oxymetry to monitor oxygen levels glucose is the primary energy source for the brain hypoglycemia can cause symptoms ranging from mild confusion to seizures and coma during assessment it's important to measure blood glucose levels particularly in patients presenting with altered mentation seizures or other neurological symptoms the brain's function is also sensitive the body temperature hyperthermia can exacerbate neurological injury while hypothermia can lead to slow mental processes confusion and in severe cases a loss of consciousness the key to identifying a neurologic problem lies in the ability to recognize both obvious and subtle changes in the patient's condition obvious changes might include alterations in Consciousness motor function speech or the presence of seizures subtle changes could involve minor shifts in Behavior mood or cognitive function that might indicate an early or evolving neurological issue during assessment a thorough neurological exam should be conducted this includes assessing the patient's level of Consciousness using tools like the glass galcom scale evaluating cranial nerve function testing motor and sensory responses and observing for any signs of increased intracranial pressure Vital Signs should be closely monitored as changes in heart rate blood pressure and respiratory rate can also provide important clues about the patient's neurological status.",
        "Primary Survey and Neurological Signs": "during the primary survey of a patient forming a general impression is the first step this involves noting the patient's body position and level of consciousness observing for seizure activity is critical as active seizures may require immediate intervention if a seizure is ongoing be particularly vigilant for signs of status epilepticus determining the level of Consciousness is essential as it provides information about the patient's neurological status additionally pay close attention to any abnormal posturing which can indicate severe brain dysfunction decorticate posturing where the patient contracts their arms and curls them towards their chest suggests damage to the brain's corticospinal tract this posture is a concerning sign though not as severe as to separate posturing where the patient extends the arms outward rotates the lower arms in a Palms down manner or pronation and points the toes disate posturing indicates more extensive damage often involving the brain stem and its red nucleus it's also generally associated with poor prognosis recognizing these signs promptly can guide further assessment and intervention in emergency medical care a patient presenting with conditions such as stroke seizure hypoglycemia or hypoxia typically exhibits identifiable signs or symptoms the most most effective treatment begins with a comprehensive assessment of the patient while ensuring that the airway breathing and circulation are maintained for hypoglycemia two primary medications are used in the prehospital setting dextrose and glucagon dextrose is administered only when the patient's blood glucose level is confirmed to be low glucagon serves as an alternative treatment particularly in situations where intravenous access is difficult or when dextrose is unavailable these interventions aim to stabilize the patients condition until further Medical Care can be provided when managing hypoglycemia in the field if you're unable to check the patient's blood glucose level due to an equipment failure administer dextrose with caution adjusting dosages based on the patient's response to previous Administrations it is important to remember that hypoglycemia is more immediately dangerous than hyperglycemia so in cases of uncertainty it's safer to administer glucose when using intravenous dextrose particularly D50 ensure IV access is established with a large bore catheter in a large vessel due to the viscosity of the D50 if vascular access is not possible administer 0. 5 to 1 mgram of glucagon subcutaneously or intramuscularly and if necessary repeat this up to 3 times for patients with decreased levels of consciousness who can still protect their Airway oral glucose is a viable option always take steps to avoid aspiration note that there is no safe method to lower high blood glucose levels in the field therefore provided otal support to both the patient and their family and regularly attempt to reorient the patient as confusion is common in these situations.",
        "Management of Stroke and TIA": "when managing a patient with suspected Tia or stroke always treat them as if they experiencing a stroke administers supplemental oxygen establish IV access and obtain blood samples for analysis transport the patient properly to the nearest appropriate facility for Ev evaluation a CT scan is often necessary to determine if there is bleeding in the brain as this will influence whether clot dissolving medication can be used immediate action is vital especially in unresponsive patients showing signs of increased intracranial pressure administer fluids as needed Elevate the patient's head 30\u00b0 unless spinal injury is a concern and and ensure the airway is clear monitor closely for seizures maintain Vigilant blood pressure control and carefully manage carbon dioxide and oxygen levels avoiding hyperventilation the image on the screen outlines a stroke management protocol it starts with identifying stroke symptoms and activating an emergency response EMS performs initial assessments including checking ABCs glucose levels and using stroke screening tools before transporting the patient to a stroke center in the hospital the stroke team conducts further assessments and brain Imaging if Hemorrhage is detected an intracranial hemorrhage protocol will be initiated if no Hemorrhage is found treatment options include administering outphase or considering EVT the patient is then admitted to an ICU or stroke unit based on their needs a transient es schic attack or Tia is often considered a warning sign of a potential future stroke as it involves temporary disruption of blood flow to the brain while the symptoms of a TIA typically resolve within a few minutes the underlying issue such as a narrowed or blocked artery remains a significant risk factor for a full-blown stroke given the seriousness of this condition the management of a TIA follows the same protocols as that of a stroke this includes providing immediate medical attention and conducting a thorough neurological assessment to evaluate the patient's condition and identify any deficits it's also vital to establish IV access administer supplemental oxygen if needed and prepare for possible transport to a facility equipped to perform brain Imaging studies such as a CT scan or an MRI these Imaging studies help determine if there's any ongoing blockage or other abnormalities in the brain's blood vessels patients should be strongly encouraged to seek immediate transport to a hospital even if their symptoms have subsided educating the patient on the importance of this step is critical as many patients May underestimate the severity of a TIA providers should reinforce that it's not just a minor incident but a serious indicator of possible future Strokes which can lead to permanent disability and even death if not properly managed.",
        "Management of Seizures": "management of seizures requires prompt and thorough evaluation beginning with ensuring that the patient receives definitive Care at a hospital or medic ation levels can be checked and life-threatening conditions ruled out especially for firsttime seizures or those that simply deviate from a patient's usual pattern oxygen should be administered and for recurrent seizures protecting the patient from injury and managing the airway is critical if status epilepticus occurs immediate actions such as suctioning the airway providing positive pressure ventilations and Rapid trans transport are essential paramedic rendevu is advisable if possible and gaining IV access for medication administration is important noting the patients medication history seizure details and responsiveness between seizures is vital for accurate assessment spinal immobilization should also be provided if trauma is suspected an assessment for hypoglycemia is necessary depending on local protocol cause for febrile seizures in children body temperature should be reduced cautiously avoiding actions that might induce shivering when managing a patient who is experience Syncopy one should first assess whether any trauma occurred during the fall and take appropriate cervical spine precautions if needed focus on evaluating the patient's blood glucose level and consider possible cardiac causes obtain orthostatic vital signs to assess changes in blood pressure and heart rate provide supplemental oxygen and establish IV access for fluid administration as needed remember that Syncopy can indicate a potentially life-threatening medical condition so it's important to call for paramedic backup early if the situation warrants it when managing a patient with a headache it's important to recognize that they can sometimes indicate a serious underlying problem provide standard care and inquire about any medications the patient has taken many patients find relief in a darkened quiet environment so if transport is necessary avoid using lights or Sirens to maintain a calm atmosphere.",
        "Conclusion and Summary": "this lecture covered various neurological emergencies if emphasizing the importance of recognizing and managing conditions such as Strokes seizures Syncopy and headaches for stroke management it's critical to assume that a patient with Tia or stroke symptoms is experiencing a stroke and to act promptly by administering oxygen establishing IV access and transporting the patient to an appropriate facility for evaluation the lecture highlighted the import importance of close neurological assessment and the need for timely interventions like CT scans to determine if clot dissolving medication is necessary additionally maintaining Airway patency monitoring blood pressure and controlling oxygen levels are critical steps in managing stroke patients in seizure management patients require definitive evaluation and treatment at the hospital especially if this is their first seizure or if the seizure is atypical oxygen Administration and area protection are vital particularly in recurrent seizures or status epilepticus thorough documentation of the patient medical history and seizure activity is important along with considering hypoglycemia as a potential cause in pediatric patients particularly those with febril seizures body temperature management is advised while ensuring the patient does not shiver as this could exacerbate the condition Syncopy management involves assessing for trauma taking cervical spine precautions and focusing on potential cardiac and glucose related causes orthostatic vital Zs and IV access are recommended with the understanding that Syncopy can indicate life-threatening conditions for patients with headaches while often non-life-threatening it is important important to assess for more serious causes provide standard care and consider the patient's Comfort by minimizing light and noise during transport overall this lecture emphasized the importance of careful assessment prompt action and appropriate interventions in managing neurological emergencies"
    },
    {
        "Introduction to Gastrointestinal and Urologic Emergencies": "chapter 20 gastrointestinal and neurologic emergencies abdominal pain is is a frequent complaint encountered in the field it's important to note that pinpointing the exact cause of this pain can often be challenging this is due to the wide range of potential sources which can include gastrointestinal Geno urinary vascular and even cardiac issues given the complexity of the abdominal region the symptoms presented by the patient can often be non-specific or misleading however your primary responsibility in these scenarios isn't necessarily to diagnose the specific cause of acute abdominal pain on the spot aemts aren't expected to have the diagnostic tools that would allow for a comprehensive evaluation of the underlying cause instead your focus should be on identifying any signs that indicate a potentially life-threatening situ situation such as an abdominal aortic aneurysm ruptured organ or severe infection like peritonitis recognizing these signs involves a thorough assessment of the patient symptoms Vital Signs and medical history pay attention to red flags such as severe sudden onset pain referred pain distension rigidity hypotension or signs of shock these indicators may suggest that the patient is in a time-sensitive condition requiring immediate intervention when such a situation is recognized it's important to act promly to ensure that the patient receives the necessary care this could mean initiating rapid transport to the nearest appropriate medical facility while providing supportive care and Route and insuring ing that the receiving facility is aware of the severity of the patient's condition.",
        "Anatomy and Function of the Abdominal Organs": "the abdominal cavity contains solid and hollow organs from the gastrointestinal genital and urinary systems key solid organs include the liver spleen pancreas kidneys and ovaries these organs are at risk of significant injury from blunt trauma which can lead to internal bleeding and shock in the field be alert for signs of internal bleeding such as a rapid pulse low blood pressure and alra bental Status the gastrointestinal system is responsible for absorbing the products of digestion which provides fuel to the cells throughout the body this system is composed of various organs that work together to break down food absorb nutrients and expel waste starting from the mouth where digestion begins with the help of salivary glands food passes through the ferx and esophagus before reaching the stomach the stomach plays a significant role in breaking down food using acids and enzymes from there The partially digested food moves into the intestines the intestines both small and large are where most Nutri absorption occurs the liver gallbladder and pancreas are accessory organs that contribute to digestion the liver processes nutrients absorbed from the intestines the bladder stores bile to help digest fats and the pancreas produces enzymes to assist in digestion the remaining waste is eventually excreted through the rectum and anus this first image highlights the hollow organs such as the stomach and intestines while the second one shows the solid organs including the liver spleen pancreas and kidneys which are vital in supporting the functions of the GI system.",
        "Digestion Process and Related Complications": "the digestion process which spans 8 to 72 hours begins in the mouth with the secretion of saliva from the salivary glands lubricating food for easier swallowing the food then moves down the esophagus through rhythmic contractions called peristalsis with a cardiac sphincter preventing stomach acid from backing up into the esophagus the veins around the esophagus along with others form the portal vein which is responsible for transporting Venus blood from the GI tract to the liver for nutrient processing if blood flow through the liver is impeded it can lead to a backup of the GI system potentially causing complications like portal hypertension and esophageal varices the stomach plays a critical role in digestion by secreting hydrochloric acid which helps break down food additionally it absorbs water alcohol caffeine and certain medications this process prepares the food for for further digestion and absorption in the intestines the liver is essential for several vital functions including the secretion of bile which AIDS in fat digestion it also filters toxic substances as well as creating glucose stores for energy and producing substances necessary for blood clotting and immune function the gallbladder complements these functions by serving as a res resir for bile releasing it when needed during digestion the dadum the first part of the small intestine is where the pancreas liver and gallbladder connect to the digestive system it plays a vital role in absorbing nutrients and receives digestive enzymes from the pancreas such as amas which helps break down carbohydrates the pan also produces bicarbonate to neutralize stomach acid and Insulin to manage blood sugar levels the small intestine where 90% of nutrient absorption occurs processes Kim into absorbable substances the junam with its extensive surface area is responsible for much of this absorption the ilium the final section absorbs remaining Nutri nutrients including bile acids and vitamin B12 completing the digestive process the large intestine or colon is responsible for processing waste products that are not broken down during digestion its primary function is to reabsorb water thereby solidifying the digested material into feces the colon is also a site of bacterial digestion which AIDS in the final breakdown of Kim and produces gas as a byproduct the rectum is attached to the last portion of the colon and serves as a storage area for feces before they are expelled from the body through the anus this process marks the final stage of digestion and waste elimination.",
        "Role of the Spleen and Reproductive System": "the spleen although located in the abdom adal cavity does not play a role in digestion instead it's part of the lymphatic system and has several important functions related to blood and immune Health the spleen assists in the filtration of blood removing old or damaged red blood cells and other waste it also contributes to the development of red blood cells and serves as a reservoir for blood which can be released during emergencies such as hemorrhage in addition to its role in blood management the spleen is a key player in the immune system it produces antibodies that help the body defend against disease and infection making it a vital organ in maintaining overall health the gital system also known as the reproductive system is divided into male and female components each with specific organs that play roles in reproduction the male reproduction system includes the testicles where sperm is produced and the epidemis where sperm matures the Vasa deferentia are tubes that transport sperm from the epidemis to the seino vesicles which contribute fluid to form semen the prostate gland adds additional fluid to the semen aiding in sperm motility and protection finally the penis is the external organ through which seman is expelled through ejaculation the female reproductive system consists of the ovaries where eggs are produced the Fallopian tubes are the pathways through which eggs travel from the ovaries to the uterus where fertilization typically occurs the uterus is the organ where a fertilized egg implants and develops into a fetus the cervix is the lower part of the uterus that opens into the vagina which is the canal through which child birth occurs and serves as a pathway for menstrual flow and sexual intercourse.",
        "Urinary System Function and Disorders": "the urinary system is responsible for filtering waste products from the blood and expelling them from the body in the form of urine it consists of four main components the kidneys uror urinary bladder and urethra the kidneys filter blood to remove waste products and excess substances forming urine while also helping to regulate blood pressure electrolyte balance and red blood cell production urine then travels from the kidneys to the urinary bladder through the URS the bladder serves as a storage sack holding the urine until it is ready to be expelled when urination occurs urine is discharged from the bladder through the urethra and out of the body the kidneys are vital organs that perform two primary functions that are essential for maintaining the body's internal balance the first function is the regulation of electrolytes water content and acid levels in the blood by managing these components the kidneys ensure that the body's cells and organs function optimally this regulation is crucial for maintaining proper hydration nerve and muscle function and overall pH balance within the body the second function of the kidneys is the removal of metabolic wastes drug metabolites and excess fluids from the bloodstream these waste products and excess substances are filtered out and excreted urine this continuous filtration process is highly efficient with the kidneys filtering about 200 100 lers of blood every day the the kidneys also produce hormones that are vital for generating new red blood cells and assisting the liver in converting glycogen to glucose this is crucial when it comes to maintaining energy levels within the body within the kidneys nephrons which are located in the cortex serve as the structural and functional units that are responsible for forming urine nephrons play a significant role in maintaining homeostasis by eliminating metabolic waste products from the blood ensuring the body's internal environment remains stable however when the kidneys fail the body loses its ability to excrete Ura leading to a dangerous condition known as ureia where waste products build up in the blood once Uranus formed in the nephrons it travels through a series of structures it enters the collecting ducts then moves through the minor and major calluses and finally into the reenal pelvis from there the urine passes through the urer and is stored in the urinary bladder the brain itself controls the urge to void and when appropriate urine is expelled from the bladder through the urethra.",
        "Acute Abdomen and Peritonitis": "the term acute abdomen is used to describe the sudden onset of severe abdominal pain a clinical condition that often signals a significant and potentially life-threatening issue within the abdominal cavity one of the most common underlying causes of an acute abdomen is peritonitis which is an inflammation of the peritoneum the thin layer of tissue that lines the inner wall of the abdomen and covers most of the abdominal organs peritonitis can result from various causes infections are a primary culprit particularly when bacteria or other pathogens invade the peronal cavity this can happen due to a peripher in the GI tract such as from a ruptured appendix a peptic ulcer or diverticulitis in addition to in infections peritonitis may also arise from non-infectious sources such as a penetrating abdominal wound which directly introduces contaminants into the panal space or a blunt trauma severe enough to damage abdominal organs and release their contents into the abdominal cavity diseases like pancreatitis liver disease or pelvic inflammatory disease can also lead to peritonitis the Hallmark symptom of peritonitis is severe diffuse abdominal pain often described by patients as the worst pain they've ever experienced this pain typically worsens with any movement even shallow breathing as the inflamed peritoneum is highly sensitive accompanying the pain clinical signs often include abdominal tenderness upon palp ation guarding involuntarily to protect the inflamed area and distension due to the accumulation of fluids or gas within the abdomen patients may also present with systemic symptoms such as fever chills and teoc cardia reflecting the body's inflammatory response to infection or injury early recognition and prompt management of peritonitis are vital to prevent a progression of sepsis.",
        "Peritoneum and Visceral Pain": "the ponum is a vital structure within the abdominal cavity consisting of two distinct membranes the parial perenium lines the walls of the abdominal cavity and is richly supplied by the same nerves that innervate the skin overlying the abdomen because of this shared nerve Supply the parital par tum is capable of perceiving a wide range of Sensations including pain touch pressure heat and cold this sensitivity makes it a key player in detecting abnormalities within the abdominal cavity in contrast the visceral peritoneum covers the surface of each of the organs within the abdominal cavity unlike the parietal Pars in the visceral ponum is supplied by the autonomic nervous system this part of the nervous system is responsible for involuntary functions and responds primarily to the distinction or contraction of hollow organs activating stretch receptors the stimulation of these receptors typically results in a type of pain known as colic which is characterized by severe intermittent cramping this pain pain is often a sign of underlying issues such as blockages or spasms within the organs when receptors in the affected organs are activated they send impulses through the nerves to the brain where these impulses are interpreted as pain visceral pain which is commonly associated with Urologic problems usually occurs when receptors in Hollow structures such as the uers urinary bladder and urethra are stimulated one of the challenges in managing visceral pain is that it can be difficult to pinpoint its exact source as the pain transmission often involves only a few nerve fibers referred pain occurs when painful Sensations originating from an irritated visceral peritoneum are perceived at a location distant from the actual source of the irritation the phenomenon is due to connections between the body's two separate nervous systems the visceral and submatic nervous system for instance pain originating from the gallbladder might not only be felt in the abdominal region but can also be perceived at a distant point on the body surface such as the shoulder or back the this occurs because the nerves that Supply the visceral organs and those that Supply specific areas of the skin share synapse points in the spinal cord when visceral pain signals are sent to the brain the brain May misinterpret these signals as originating from the skin leading to referred pain the image on the screen illustrates this concept by showing how pain from the gallbladder can be referred to the shoulder area this understanding is important for correctly assessing and diagnosing abdominal pain as the location of the perceived pain may not directly correspond to the underlying issue.",
        "Fluid Loss and Shock in Peritonitis": "one of the major concerns with peritonitis is the loss of fluids into the abdominal cavity which can potentially cause hypothalmic shock due to the significant get fluid shift this condition can be tricky to assess as patients may present with normal vital signs or show signs of shock depending on the severity and progression of the disease fever is another symptom that may or may not be present in parentitis for example fever is commonly seen in patients with diverticulitis or Chic cystitis however in the case of acute appendicitis a patient may maintain a normal temperature until the appendix ruptures and an abscess begins to form this variability in presentation makes it critical for emergency responders to rely on a thorough assessment and consider a wide differential diagnosis this image shows common abdominal conditions and lists various conditions along with their Associated localization of pain each condition is paired with a specific area where pain is typically felt either directly or in a referred pain for example appendicitis often causes pain around the navl which would be referred and in the right lower quadrant which would be direct while chitis causes pain in the right shoulder referred and the upper right right quadrant direct this table also includes conditions like diverticulitis abdominal aortic aneurysm cystitis and peritonitis each with its corresponding pain location to Aid in diagnosis and assessment.",
        "Causes of Acute Abdomen": "an acute abdomen can arise from any condition that allows substances like pus blood feces urine gastric juice intestinal contents bile pancreatic juice Amo fluid or other form material to accumulate within or adjacent to the abdominal cavity this accumulation can lead to peritonitis an inflammation of the peritoneum which is often associated with the acute abdominal pain retr perits NE organs which are located behind the peritoneum can also be involved in conditions leading to acute abdomen eventually almost any type of abdominal problem depending on its severity and nature has the potential to cause an acute abdomen underscoring the importance of careful assessment and prompt monitoring.",
        "Gastrointestinal Hemorrhage": "GI Hemorrhage whether acute or chronic is a symptom indicative of an underlying disease rather than a disease itself and all instances of bleeding should be treated with seriousness GI bleeding can occur in either the upper or lower tract in the upper GI tract sources of bleeding may include conditions such as esophagitis esophago varices or a malerie wise tear often presenting with hemat emesis or Molina due to the partial digestion of blood lower GI trct bleeding commonly associated with conditions like bowel inflammation diverticulosis diverticulitis cancer and hemorrhoids typically presents with bright red blood unless the source is higher in the digestive tract esophagitis the inflammation of the esophagus can be caused by an infectious process reflux of gastric secretions medications chemotherapy or radiation therapy as is often associated with the cils gastro esophageal reflux disease or gird which is also known as acid reflux occurs when the lower esophageal sphincter fails to close properly allowing stomach acid to move superiorly into the esophagus this reflux can cause a burning sensation in the chest commonly referred to as heartburn the risk of developing gird is heightened by factors such as smoking obesity pregnancy consumption of fatty fried foods alcohol and citrus fruits chronic exposure to stomach acid can lead to damage of the esophageal wall making it more susceptible to bleeding patients with gird often present with heartburn which is the primary clinical symptom and may also report increased pain with positional changes coughing or difficulty swallowing in severe cases prolonged damage can result in bleeding leading to hematemesis and Molina.",
        "Peptic Ulcer Disease and Gastritis": "peptic ulcer disease and gastritis are conditions characterized by imbalance between the high levels of acidity present in the stomach and dadum and the protective mucus layers that line these organs when this protective layer erodes the stomach acid begins to damage the underlying tissue leading to the formation of ulcers gastritis on the other hand is a pre-ulcerative inflammatory condition where the stomach lining is inflamed but erosions have not yet occurred peptic ulcers often result from an infection with hpylori or chronic use of ineds or lifestyle factors such as alcohol consumption and smoking which further contribute to the breakdown of the protective mucous layer peptic ulcer disease affects men and women equally but is more commonly seen in older adults in addition to the primary causes foodborn infection and food allergies can also contribute to gastric inflammation patients with PUD typically experience a burning or gnawing pain in the stomach which often subsides or diminishes after eating only to reemerge 2 to 3 hours later this pain is usually localized in the upper abdomen and may be accompanied by nausea vomiting belching and heartburn in cases where the erosion of the stomach lining is severe hematemesis and Molina can occur while some ulcers May heal without intervention complications such as bleeding or perforation can arise necessitating prompt medical attention.",
        "Mallory-Weiss Tear and Boerhaave Syndrome": "a malerie Weiss tear is the condition characterized by tear at the junction between the esophagus and the stomach which can lead to severe bleeding and in some cases potentially be fatal the primary risk factors for developing a malerie wise tear include alcoholism and eating disorders this condition can occur suddenly and affect individuals of any age the most common causes are violent coughing and vomiting in women it may also be associated with severe vomiting related to pregnancy the extent of bleeding can vary from minor to severe in extreme cases patients may present with signs and symptoms of shock upper abdominal pain hematemesis and Molina boreave syndrome is a rare but life-threatening condition characterized by a spontaneous rupture of the esophagus this condition typically occurs as a result of forceful vomiting or wretching which causes a longitudinal tear that extends through the entire wall of the esophagus unlike a malerie wise tear boreave syndrome involves a full thickness rupture making it far more dangerous the rupture allows the contents of the esophagus including Blood air and food to leak into the mediastinum this leakage can lead to severe mediastinitis which is simply an inflammation of the tissues of the mediastinum but can quickly progress to sepsis if not treated promptly this condition is often associated with a high mortality rate if diagnosis and treatment are delayed it occurs more frequently in men and is commonly triggered by excessive eating or drinking particularly in situations where alcohol consumption is involved the classic presentation includes sudden severe chest pain following about a vomiting which may be accompanied by symptoms such as subcutaneous empyema and difficulty breathing immediate medical intervention is crucial in managing boreave syndrome treatment typically involves surgical repair of the esophageal tear along with an aggressive management of any Associated infection and stabilization of the patient's condition due to the high risk of complications prompt recognition and treatment are essential to improve outcomes in patients with this syndrome.",
        "Esophageal Varices": "esophageal vares develop when the pressure within the blood vessels surrounding the esophagus increases typically due to portal hypertension this condition occurs when blood flow is obstructed in the portal vessels leading to the dilation of these vessels and causing the capillary network of the esophagus to begin leaking if the pressure continues to rise The Vessel walls can rupture resulting in massive upper GI bleeding in hemat emesis in industrialized countries the primary cause of portal hypertension is excessive alcohol consumption while in developing nations viral hepatitis is the leading cause of liver damage that leads to this condition the clinical presentation of esophageal varices occurs in two stages initially patients exhibit signs of liver disease which may include fatigue weight loss jaundice anorexia abdominal atis abdominal pain nausea and vomiting this stage of the disease is often gradable taking months or even years before the patient experiences severe discomfort the second stage occurs more abruptly with the rupture of the varaces leading to sudden epigastric or sternal discomfort severe difficulty swallowing and the vomiting of bright red blood this acute presentation is often accompanied by hypotension signs of shock and the presence of hematemesis and Molina the rupture and subsequent bleeding from these vessels are life-threatening and require immediate medical intervention.",
        "Hemorrhoids and Gallstones": "hemorrhoids are a common condition caused by the swelling and inflammation of blood vessels surrounding the rectum this issue affects a significant portion of the population with approximately half of all individuals experiencing hemorrhoids by the age of 50 they often result from factors that increase pressure or irritate the rectum such as pregnancy straining during bowel movements chronic constipation and even diarrhea which can exacerbate irritation the most typical symptom of hemorrhoids is the presence of bright red blood during defecation known as hesia this bleeding is usually minimal and can easily be controlled in addition to bleeding patients may experience itching and notice a small mass or lump around the rectal area which can contribute to discomfort gall stones are crystalline formations that develop within the gallbladder often composed of cholesterol or B Rubin these Stones can obstruct the cystic duct which is the passage way through which bile exits the gallbladder leading to intense pain known as bilary colic this pain typically occurs in the upper right quadrant of the abdomen and may radiate to the back or right shoulder if the blockage persists and the stone does not pass it can lead to kystis an inflammation of the gallbladder kystis is characterized by severe prolonged pain fever and tenderness over the gallbladder and can result in serious complications if not treated promptly in severe cases of gall stones the gallbladder can rupture leading to a life-threatening situation typically the condition presents by a constant severe pain in the right upper mid abdominal region which may radiate to the right upper back shoulder or flank this pain can persist for hours gradually increasing with intensity or it may come and go intermittently symptoms often manifest about 30 minutes after consuming a particularly fatty meal and are more likely to occur at night alongside the pain patients may experience General gastrointestinal distress including nausea vomiting indigestion bloating gas and belching these symptoms indicate significant irritation or inflammation of the gallbladder necessitating prompt medical evaluation and possible intervention to prevent further complications such as rupture or infection.",
        "Pancreatitis": "pancreatitis is an acute or chronic inflammation of the pancreas that can arise from several etiologies most commonly and obstructing gallstone chronic alcohol abuse or other underlying disease such as infections or certain medications the pancreas located behind the stomach plays a role in digestion and blood sugar regulation when inflamed the digestive enzymes are typically inactive within the pancreas and may become activated leading to autodigestion of the pancreatic tissue itself this results in severe abdominal pain typically located in the upper left and right quadrants which often radiate to the back the pain is usually persistent and may be accompanied by other GI symptoms abdominal distension and tenderness are also common due to inflammation and accumulation of fluids in the abdominal cavity in more severe cases the inflammation can progress to systemic complications this condition may lead to sepsis a life-threatening response to infection that can cause widespread organ failure if not promptly treated additionally Hemorrhage within the pancreas or surrounding tissues can occur leading to significant blood loss and further exacerbating the patient's condition given the potential for these severe outcomes pancreatitis is considered a medical emergency that often requires hospitalization aggressive supportive care and sometimes surgical intervention to manage the complications and address the underlying cause.",
        "Appendicitis": "appendicitis is a common cause of acute abdomen a condition characterized by sudden severe abdominal pain it occurs C when the appendix becomes inflamed potentially leading to serious complications such as abscess formation peritonitis or even septic shock if not promptly treated the pain associated with the pendisis typically begins as a generalized dull and diffus discomfort often centered around the umbilical area as the inflammation progresses the pain tends to localize in the right lower quadrant of the abdomen where the appendix is located additionally appendicitis may cause referred pain where discomfort is felt in areas distant from the actual sight of inflammation patients with appendicitis often present with a variety of signs and symptoms including nausea vomiting and anorexia fever and chills are also common as the body responds to the underlying infection r inflammation one of the Hallmark signs of appendicitis is rebound tenderness particularly in the right lower quadrant however this symptom may be less pronounced or even absent in pregnant women making diagnosis more challenging in this population.",
        "Gastroenteritis": "gastroenteritis refers to a group of conditions that primarily involve infection of the GI tract most commonly caused by bacterial or viral organisms that are typically transmitted through contaminated food or water symptoms can develop quickly often within hours to a few days after exposure and include an upset stomach and diarrhea the course of the illness can vary resolving to two to three days or persisting for several weeks although infections are the primary cause gastroenteritis can also result from non-infectious factors such as adverse reactions to medications exposures to toxins or the effects of chemotherapy patients may experience a wide range of symptoms including large volume dumping type diarrhea or frequent small liquid stools the diarrhea may contain blood or even pus and have a foul odor other common symptoms include abdominal cramping nausea vomiting fever anorexia and dehydration given the potential for severe dehydration especially after prolonged cases prompt assessment and supportive care are essential in managing the condition.",
        "Diverticulitis": "D verticulitis was first recognized around 1900 coinciding with significant changes in the types of foods that people consumed as dietary habits shifted particularly with a reduction in the intake of fiber the consistency of stools became more solid this change required stronger and more frequent intestinal contractions to move the stools through the colon leading to increased pressure within the colon over time this elevated pressure contributed to the formation of diverticula small pouches in the colon wall these can become inflamed or infected resulting in the condition known as diverticulitis diverticulitis occurs when bulges in the colonic walls resulting from increased intestinal contractions develop into pouches known as diverticula these pouches can trap fecal matter leading to bacterial growth and causing local ized inflammation and infection the main symptom of diverticulitis is abdominal pain typically localized to the left side of the lower abdomen classic signs accompany this pain include fever Mala body aches chills nausea and vomiting although bleeding is rare in diverticulitis it can occur in some cases as the condition progresses adhes May develop within the colon narrowing its diameter and leading to constipation or even bow obstruction in severe cases the inflamed diverticula can rupture causing perforation of the affected segment of the colon which may lead to more serious complications requiring immediate medical intervention.",
        "Ulcerative Colitis": "alternative colitis is a chronic inflammatory condition primarily affecting the colon characterized by generalized inflammation of the inner lining of the intestine the exact cause of this inflammation remains unclear though genetics stress and autoimmune responses are believed to play significant roles the inflammation associated with ulcerative colitis leads to a thinning of the intestinal wall which can result in a weakened and dilated rectum in the US about 1 million people are affected ected by this condition with a higher prevalence in men compared to women and a strong familial component that suggests a hereditary link patients with ulcerative colitis often present with a gradual onset of symptoms including bloody diarrhea and hesia which may be accompanied by mild to severe abdominal pain additionally joint pain and skin lesions are common extraintestinal manifestations of the disease systemic symptoms such as fever fatigue and loss of appetite further complicate the condition impacting the overall quality of life for those affected.",
        "Irritable Bowel Syndrome": "irritable bowel syndrome is a chronic GI disorder characterized by abdominal pain and alterations in bowel habits a key diagnostic criteria for IBS is the presence of pain at least 3 days per month month for a minimum of 3 months despite its prevalence the exact pathology remains unclear though three primary factors are often observed in patients hyper sensitivity to bowel pain receptors hyperresponsiveness of the smooth muscles in the bowel and a potential connection between psychiatric disorders and IBS problems with bow habits typically begin during childhood and can be triggered by by various factors including stress large meals and certain foods such as wheat Rye chocolate alcohol milk products and caffeinated drinks this condition is marked by episodes of abdominal pain and discomfort which are often relieved by bowel movements additionally patients may experience symptoms such as diarrhea Storia constipation or a sensation of bloating which can significantly impact their quality of life.",
        "Crohn's Disease": "Crohn's disease is a chronic inflammatory condition similar to ulcerative colitis but it can involve any part of the GI tract from the mouth to the anus with the ilum being the most commonly affected area the exact cause remains unknown though it is believed that genetics and family history play a significant role the disease affects hundreds of thousands of Americans most commonly presenting in individuals between the ages of 15 and 35 though incidence has also been noted in older adults Crohn's disease is more prevalent in whites than African-Americans and people of Jewish descent have a notably higher incidence of the condition the disease is characterized by a series of immune system attacks on the GI track all of which involve the layers of the the affected portion this immune response typically results in scarring narrowing stiffening and weakening of the small intestine patients often present with chronic abdominal pain particularly in the lower right quadrant in addition to GI symptoms Cron's disease can manifest with signs and symptoms outside the GI system including rectal bleeding weight loss chronic diarrhea arthritis skin problems and fever The Chronic nature of the disease and its impact on multiple systems makes it a complex condition requiring ongoing management.",
        "Urinary System Pathologies": "the pathophysiology of the urinary system encompasses a wide range of conditions from relatively common urinary tract infections or UTI to more severe and potentially life-threatening acute kidney injuries akis UTI typically involve the lower urinary tract including the bladder and urethra and can cause symptoms such as disera which is painful urination urgency and frequency on the other hand Aki is characterized by a sudden decline in kidney function leading to the accumulation of waste products in the blood and A disruption of fluid electrolyte and acid base balance this condition can result from various causes including dehydration sepsis or direct injury to the kidneys in the prehospital setting care for patients with urinary system conditions is usually supportive this may include managing pain monitoring Vital Signs and ensuring the patient is stable for transport to a medical facility in cases of suspected acute kidney injury rapid transport and early notification to the receiving facility are critical as these patients may require urgent interventions such as fluid resuscitation electrolyte management or even dialysis UTI typically involve inflammation of the bladder known as cystis and are most commonly caused by bacteria entering the lower urinary tract including the urethra and the bladder these infections are more prevalent in women due to anatomical differences if left untreated a lower UTI can Ascend into the upper urinary tract affecting the URS and kidneys as well as leading to more severe conditions such as felin nephritis and abscess formation this progression can ultimately impair kidney function in severe cases especially in the elderly untreated U can lead to sepsis common symptoms of lower UTI include painful urination frequent urges to urinate and then difficulty in urination the pain associated with a lower UTI typically begins as a vague visceral discomfort but can escalate to an intense burning sensation particularly during urination this pain is usually localized to the pelvic region and may be perceived as bladder pain in women or as prate pain in men in some cases the pain can radiate and be referred to the shoulder or neck Additionally the urine in a lower UTI often has a foul odor and may appear cloudy indicating the presence of infection.",
        "Kidney Stones": "kidney stones also known as renal calculi originate in the renal pelvis the funnel-shaped structure at the top of the urer that collects urine from the kidney these stones form when there is an excess of insoluble salts or uric acid in the urine leading to crystallization as these crystals accumulate they can grow into larger stones that may cause significant pain and obstruction as they pass through the urinary tract the development of kidney stones is often influenced by factors such as dehydration diet and genetic predisposition calcium stones are the most common type of kidney stone occurring more frequently in men and often having a hereditary component they are also prevalent in patients with metabolic disorders such as gal or hormonal imbalances individuals with kidney stones typically experience severe pain which usually begins as a vague discomfort in the flank and rapidly intensifies within 30 to 60 Minutes as the stone moves through the urinary tract the pain May migrate toward the groin patients often exhibit restlessness and agitation moving in an attempt to alleviate the pain while Others May remain motionless guarding the abdomen Vital Signs can vary widely depending upon the severity of the pain if the stone becomes lodged in the lower urer symptoms similar to a UTI may occur although fever is typically absent.",
        "Kidney Disease": "kidney disease can be classified as either acute or chronic with chronic kidney disease affecting approximately 14% of the population in the United States acute kidney injury is a condition marked by a rapid decline in renal function which can occur over a few hours or days this abrupt loss of kidney function leads to an impaired ability to filter waste products from the blood resulting in a buildup of toxins and other harmful substances the causes are varied and can include conditions such as severe dehydration sepsis trauma or exposure to nephrotoxic medications the sudden onset of Aki can lead to significant disruptions in the body's hemostasis affecting multiple organ systems one of the earliest signs of Aki is a reduction in urine output known as aligera where the patient produces less than 500 MLS of urine per day in more severe cases the patient may develop anara which would be characterized by complete cessation of urine production these changes in urine output are critical indicators of Ral impairment and are often accompanied by other symptoms such as generalized edema which occurs due to fluid retention as well as metabolic imbalances including acid buildup in the body this of course can lead to metabolic acidosis the accumulation of waste products in the blood including urea and creatinine can have widespread effects patients with a Aki May exhibit symptoms such as confusion lethargy and shortness of breath as the body's normal metabolic processes become disrupted if the underlying cause of Aki is not identified and addressed promptly the condition can escalate leading to life-threatening complications these complications include heart failure as the heart struggles to pump against the increased vascular resistance caused by fluid overload it can also be caused by hypertension which can further exacerbate renal damage additionally metabolic acidosis which is a condition where the blood becomes too acidotic can impair cellular function and lead to further deterioration of the patient's condition early recognition and intervention are critical to managing Aki treatment typically focuses on addressing the underlying cause such as restoring fluid balance treating infections or discontinuing nephrotoxic drugs in some cases renal replacement therapy such as dialysis may be required to support kidney function until recovery occurs.",
        "Chronic Kidney Disease": "chronic kidney disease or CKD is a progressive and irreversible condition has characterized by the gradual loss of kidney function over months or years primarily due to the permanent loss of nephrons which are the functional units of the kidneys this decline in renal function impairs the kidney's ability to filter waste products from the blood effectively this leads to the accumulation of toxins and the disruption of various bodily processes CKD is often the result of systemic diseases such as diabetes malius and hypertension both of which place significant stress on the kidneys over time diabetes can damage the blood vessels in the kidneys leading to diabetic neuropathy while hypertension can cause glomar damage due to increased pressure in the renal blood vessels in addition to these common causes see KD can also arise from congenital disorders prolonged episodes of poly nephritis or a secondary effect of certain infections including strep throat the progressive nature of CKD means that early detection and management of the underlying causes are critical to slowing the progression of the disease and mitigating its impact on overall health as chronic kidney disease progresses the nephrons of the kidneys become increasingly damaged leading to scarring and a gradual loss of function this decline in nefron function results in the buildup of waste products and excess fluids in the bloodstream as the kidneys are no longer able to filter the blood effectively the accumulation of these waste products and fluids can lead to a range of systemic complications hypertension is a common issue as the kidney's ability to regulate blood pressure is compromised Additionally the strain on the cardiovascular system can lead to heart failure anemia is another frequent complication arising from the kidney's decreased ability to produce otein a hormone that stimulates red blood cell production furthermore the disruption of the kidney's role in maintaining electrolyte balance can result in various electrolyte imbalances which then affects multiple body systems further complicating the patient's overall health CKD presents with a variety of signs and symptoms that reflect the body's declining ability to filter and eliminate waste products patients may experience an altered level of Consciousness with seizure es and coma possible in the later stages of the disease common symptoms include Lethy nausea headaches cramps and the typical signs of anemia due to the kidney impaired function the skin may appear pale cool and moist and patients May develop a jaist appearance as waste products accumulate in the body ureic Frost which is the accumulation of uric acid on the skin particularly on the face is another notable sign of CKD as the disease progresses patients may also show signs of bruised skin and experience muscle twitching edema in the extremities and face is common due to fluid retention additionally hypotension and tacac cardia may occur along with complications such as pericarditis the financial burden of managing chronic kidney disease is significant with healthc care expenditures for these patients being notoriously High.",
        "End-Stage Renal Disease": "endstage renal disease or ESRD is a severe condition where the kidneys have lost most of their ability to function as a result toxic waste materials accumulate in the blood leading to potentially fatal complications if not treated the only viable treatments for ESRD are dialysis or renal transplantation without which the condition is inevitably fatal in the progression of endstage renal disease initial symptoms will include confusion shortness of breath peripheral edema bruising chest pain and bone pain as toxins accumulate patients may experience partis nausea vomiting muscle twitching trimmers and hallucinations lethargy headaches muscle cramps and anemia are common with the skin often appearing pale cool and moist Additionally the skin may appear jaundiced or even bruised ureic Frost will devel V around the face and significant edema of the extremities and face is observed patients are typically hypotensive and Tac cardic and may present with pericarditis and pulmonary edema in the late stages seizures and coma may occur.",
        "Gynecologic Emergencies": "gynecologic issues are frequently encountered as causes of acute abdominal pain in women when a woman present presents with lower quadrant abdominal pain and tenderness it is crucial to consider potential problems related to her reproductive organs such as the ovaries Fallopian tubes or uterus these conditions can include ovarian cysts atopic pregnancies or pelvic inflammatory disease all of which can present with similar symptoms and require prompt evaluation and management in addition add to pathological conditions pain in the lower abdomen can also be related to physiologic processes within the female reproductive system for example pain may occur as a result of ovulation known as middle schms which is the release of an egg from an ovary during the normal menstrual cycle this type of pain is generally mild and self-limiting but it is essential to differentiate it from more serious conditions that may require medical intervention pelvic inflammatory disease is an infection that affects the Fallopian tubes and the surrounding tissues within the pelvis this condition is often severe and presents with intense pain in the lower abdomen accompanied by high fever PID is a serious condition that can lead to complications if not not promptly treated including infertility and chronic pelvic pain.",
        "Ectopic Pregnancy": "an atopic pregnancy is a serious and potentially life-threatening condition where a fertilized egg implants outside the uterus with the most common location being the fallopian tube this abnormal implantation occurs in approximately 1 to 2% of all pregnancies the pH iian tube unlike the uterus is not designed to accommodate the growth and development of a fetus and placenta and it can only support this process for approximately 6 to 8 weeks as the pregnancy progresses the growing embryo stretches the fallopian tube which can eventually lead to rupture when this occurs it can cause massive internal bleeding leading to intense localized abdominal pain which is often described as sharp and stabbing particularly on one side of the abdomen this pain is often sudden in onset and may be accompanied by other symptoms such as dizziness fainting and shoulder pain due to referred pain from internal bleeding the significant blood loss from the rupture can rapidly lead to hypothalmic shock a condition where the body loses more than 20% of its blood or fluid Supply making it impossible for the heart to pump sufficient blood to the body signs of shock include a rapid weak pulse low blood pressure cold and clammy skin and confusion without prompt medical intervention an atopic pregnancy is fatal treatment typically involves Sur intervention to remove the atopic tissue and repair the damage to the fallopian tube in some cases where the utopic pregnancy is detected early medical management with Methotrexate which is a medication that stops the growth of the embryo may be possible however in cases of rupture emergency surgery is necessary to control the bleeding and save the patient's life.",
        "Epididymitis and Orchitis": "epidemius and oitis are inflammatory conditions of the male genital tract often arising as complications of UTI epidemius involves inflammation of the epidemis a structure located along the posterior border of the testes where sperm mature oitis refers to inflammation of one or both testes leading to significant enlargement and tenderness with with Associated pain and swelling of the scrotum the infection can cause the affected testes to become acutely painful and the swelling May extend into the groin on the involved side patients with these conditions may experience exacerbated pain during valve movements due to the proximity of the inflamed tissues additionally systemic symptoms such as fever are common and the patient's urine May admit foul odor indicative of ongoing infection the primary approach to managing both of these conditions in the prehospital setting is generally supportive care which includes pain management the monitoring of vital signs and ensuring the patient is comfortable while awaiting further medical evaluation and treatment.",
        "Priapism and Benign Prostatic Hypertrophy": "priapism is a condition characterized by a painful tender and persistent erection that occurs without sexual arousal it can result from various underlying causes including hematologic diseases like leukemia tumors blunt paranal trauma spinal cord injury and the use of substances such as cocaine certain prescription medications or drugs that are specifically designed to treat erect dysfunction when encountering a patient with priapism it's important to maintain their privacy and avoid making assumptions about the cause of the condition this approach helps ensure that the patient receives respectful inappropriate care while addressing the potential medical emergency associated with priapism benign prostrate hypertrophy is an age related non-m maligant enlargement of the prostate gland affecting approximately 50% of men over the age of 60 while some individuals with BPH May remain asymptomatic Others May experience symptoms related to urinary function these symptoms include difficulty starting urine flow a slow or weak urine stream once urination begins incomplete emptying of the bladder increased frequency of urination at night and urinary retention these manifestations can significantly impact the quality of life and may require medical intervention to manage effectively.",
        "Testicular Masses and Torsion": "testicular masses are generally not a condition that requires prehospital treatment and can either be painful or painless if pain is present present it may radiate among the spermatic cord or remain localized to a specific point on the scrotum most testicular masses are benign such as cystic masses or vercelli which is a painful mass of dilated veins located posterior to the testicle however testic cancer is typically indicated by a painless solid lump on the testicle necessitating further medical evaluation testicular torsion involves the twisting of the testicle around the spermatic cord leading to a sudden onset of scrotal pain and swelling this condition is considered a surgical emergency as a twisting constricts blood flow to the affected testes risking permanent damage testicular torsion typically affects only one testicle at a time and can occur with or without preceding trauma the presence of a testicular lump or blood in the semen immediate medical intervention is critical to prevent irreversible injury to the testes.",
        "Aortic Aneurysm": "in older adults the aortic wall can develop weak spots that gradually swell to form an aneurysm this condition is often silent meaning it typically does not present any symptoms unless the aneurysm begins to dissect or rupture aneurysms can grow over time increasing the risk of a life-threatening event particularly in individuals with risk factors such as hypertension atherosclerosis or a family history of aneurysms regular monitoring and Medical Imaging are crucial in identifying an aneurysm before it becomes critical allowing for preventative measures such as lifestyle changes or surgical intervention to reduce the risk of rupture when an aneurysm does rupture or tear it triggers a catastrophic chain of events the rupture leads to massive internal bleeding often causing acute perianal irritation as blood leaks into the abdominal cavity patients May suddenly experience excruciating pain particularly in the back which is a Hallmark of aortic rupture this severe pain is often accompanied by signs of hemorrhagic shock including rapid heartbeat low blood pressure and poar the loss of blood can quickly overwhelm the body's compensatory mechanisms leading to profound shock and potentially fatal outcomes if not treated immediately the emergency surgical repair is usually required to control the bleeding and repair the aorta underscoring the critical nature of the condition.",
        "Hernias": "a hernia occurs when an organ or tissue protrudes through a hole or opening into a body cavity where it does not belong this condition can arise due to various factors including congenital defects such as those around the umbilicus surgical wounds that have not healed properly or natural weaknesses in certain areas of the body such as the groin they do not always present with an obvious mass or lump and in cases of extreme obesity can be particularly challenging to identify in some cases hernas are reducible meaning they can be pushed back into the body cavity without much risk and these typically pose little danger however if the herniated Mass cannot be push back into place it's referred to as an incarcerated hernia these can be very dangerous as they may lead to complications such as strangulation where the blood supply to the protruding tissue is cut off potentially leading to tissue death and requiring emergency surgical intervention signs and symptoms that indicate a serious hernia problem include a formally reducible mass that is no longer longer reducible pain at the sight tenderness upon palpation and red or blue skin discoloration over the hernia these symptoms suggest that the hernia has become incarcerated or strangled which are medical emergencies requiring prompt intervention.",
        "Management of Acute Abdomen": "the signs and symptoms of an acute abdomen signify a significant medical or surgical emergency immediate transport to a medical facility is required and any delay can worsen the patient's condition before initiating transport avoid attempting to diagnose the underlying cause of the acute abdomen as this could divert attention from essential stabilization and transport prioritize ensuring that the patient's air weight is clear and properly maintained to prevent any compromise in oxygenation or ventilation continuous monitoring of the airway is necessary throughout the transport to ensure it remains unobstructed and that adequate respiratory support is provided anticipate that the patient may experience vomiting and place them in the recovery position or a position of comfort to reduce the risk of aspiration administer 100% supplemental oxygen to ensure adequate oxygenation and be prepared to assist with ventilation if the patient shows signs of respiratory distress or inadequate ventilation do not administer anything by mouth to avoid complications such as aspiration or exacerbation of the patient's condition carefully document all relevant information using the opqrst method to assess and communicate the patient condition effectively be vigilant for signs of hypovolemic shock which may develop due to fluid loss or inadequate profusion establish IV access properly and if the patient exhibits signs of hypovolemia administer a 20 ml per kg bolus of an isotonic crystalloid solution to help restore intravascular volume if no signs of hypovolemia are observed administer fluids at a to keep vein open rate to maintain Venus access in patients with a history of UTI or kidney stones and with preserved kidney function administer a bolus of fluid to support renal profusion and function for transport position the patient in a position of comfort typically with the legs flexed towards the abdomen to alleviate Comfort conserve body heat by using blankets or other methods to prevent hypothermia ensure gentle rapid transport to minimize any additional distress and provide psychological support to reassure the patient continuously monitor vital signs to assess the patient's condition and response to treatment evaluate the need for Advanced Care and consider calling a paramedic for backup if the situation warrants additional expertise or resources.",
        "Special Considerations in Abdominal Pain": "acute pelvic inflammatory disease or PID often presents with intense pain and tenderness in the lower abdomen which may be accompanied by a high fever immediate transport of the patient is necessary pneumonia can also cause abdominal pain including pain in the ilium due to the inflammatory response affecting the adjacent abdominal cavity manage and transport patients with pneumonia Who present with abdominal pain in the same manner as other patients with abdominal pain ensuring appropriate treatment and timely transport when a patient presents with both acute abdominal pain and signs of hypemic shock it's important to consider an atopic pregnancy especially in females of childbearing age who display acute abdominal distress and hypotension an acute presentation of abdominal symptoms with accompanying shock could indicate the presence of aneurysm which requires immediate transport to a medical facility for further evaluation and management during the assessment it's crucial to avoid unnecessary or vigorous palpation of the abdomen as excessive manipulation May worsen the patient's condition or contribute to further internal injury intravenous fluid administration should be carefully considered and limited to cases where the patient is hypotensive and exhibiting symptoms of shock ensuring that fluid resuscitation is managed appropriately to address fluid deficits while avoiding potential complications from overresuscitation for any presentation of signs and symptoms that are consistent with the hernia it's important to arrange for prompt transport to the ER hernas can lead to complications such as incarceration or strangulation which require urgent evaluation and intervention conditions like Aki and CKD pose significant risks and can lead to life-threatening emergencies if not properly managed supporting air weight breathing and Circ circulation is essential in these cases to ensure adequate oxygenation and hemodynamic stability be vigilant for signs of hypotension or pulmonary edema which can arise due to fluid imbalances or cardiovascular compromise associated with kidney dysfunction patients may require medications to manage metabolic acidosis and correct electrolyte imbalances along with appropriate fluid resuscitation to stabilize their condition in the acute setting emergency transport coupled with supportive care is generally favored over aggressive therapeutic measures ensuring that the patient receives timely in effective care while minimizing the risk of exacerbating their condition.",
        "Dialysis and Associated Complications": "in the management of patients undergoing chronic dialysis it's important to recognize the potential complications associated with the procedure dialysis is typically performed every 2 to 3 days lasting from 3 to 5 hours per session this frequent and prolonged process is necessary to compensate for the loss of kidney function and to maintain fluid and electrolyte balance during this time patients are particularly vulnerable to issues such as accidental disconnection from the dialysis machine which can lead to Rapid fluid loss and dangerous shifts in blood chemistry machine malfunctions can also occur disrupting the treatment and potentially causing complications if not addressed promptly additionally patients may experience rapid shifts in fluid and electrolyte levels which can contribute to a range of symptoms from hypotension to electrolyte imbalances providers must be aware of these risks and monitor patients closely for any signs of instability or distress in emergency situations it's important to understand that the patients undergoing chronic dialysis may have detailed knowledge about their treatment and the specific operation of their equipment if an issue arises with the dialysis machine the patient may be able to provide valuable information about what is transpired prior to your arrival engaging with the patient to understand their perspective and actions taken can facilitate more effective management and intervention proper care involves not only addressing immediate issues but also providing reassurance and support to mitigate anxiety associated with potential complications ensuring continuity of care and stability in these patients requires a attention to detail in a thorough understanding of the intricacies of dialysis treatment.",
        "Complications During Dialysis": "dialysis can be associated with a range of complications and adverse effects that require careful monitoring and management hypotension is a common issue during dialysis due to the removal of large volumes of fluid which can lead to a decrease in blood pressure patient Pat may also experience muscle cramps as a result of Rapid fluid shifts and electrolyte imbalances nausea and vomiting are frequent symptoms often related to the body's response to changes in fluid and electrolyte levels Hemorrhage especially from the access site can occur posing a risk of significant blood loss infections at the access site are a serious concern requiring Vigilant monitoring for signs of local or systemic infection patients undergoing dialysis may also exhibit altered mentation or a loss of consciousness which can indicate severe complications such as electrolyte imbalances or inadequate cerebral profusion air embolism is a rare but critical complication that can arise if air enters the bloodstream potentially leading to life-threatening conditions electrolyte imbalances can result from inadequate or excessive removal of electrolytes impacting various bodily functions additionally myocardial esea can occur due to Rapid fluid shifts and changes in electrolyte levels potentially leading to cardiac complications it's important to be aware of these potential complications and to respond promptly to any signs of distress in patients who are under going dialysis a sudden drop in blood pressure is not uncommon during or immediately after dialysis and often results from the rapid removal of fluid or other factors related to the process electrolyte imbalances may also develop leading to potential complications such as cardiac dismas therefore given these risks it's important to consider the possibility of serious arrhythmias and the need for ALS backup additionally shock that secondary to bleeding can occur due to various underlying causes necessitating careful assessment and management if a patient misses a scheduled dialysis treatment they may experience a range of complications including increased weakness pulmonary edema and disturbances in electrolyte levels these issues arise due to the accumulation of waste products in fluid that would typically be removed during dialysis monitoring addressing these complications promptly is critical in order to prevent severe outcomes and ensure patient stability when responding to a call involving a patient on dialysis prioritize the assessment and management of the patient's condition using the ABCs provide high flow oxygen if the patient's oxygenation status indicates a need and address any bleeding from the access site promptly to minimize blood loss and prevent further complications if you have to use a tourniquet on the site remember it's better to go high and tight on the extremity than the 2 to 3 Ines above the site as normally seen in injuries not involving a dialysis shot if you encounter a shunt leaking during the dialysis cycle attempt to tighten the connection if possible if the shunt has become disconnected from the vein clamp the canula and disconnect the patient from the machine to prevent further issues in cases where a patient may have deliberately opened the canula during a suicide attempt immediately clamp the canula and apply direct pressure to control the bleeding some dialysis patients may also have urinary catheters in place which should be noted during assessment and transport during the transport unless a life-threatening event occurs make every effort to deliver the patients to a facility equipped with dialysis capabilities to ensure continuity of their treatment.",
        "Disequilibrium Syndrome and Air Embolism": "dis equilibrium syndrome is a complication that can arise during or shortly after dialysis due to the rapid removal of UA and other waste products from the bloodstream this rapid clearance of solutes results in a significant gradient between the concentration of these substances in the blood and their levels in the CSF since the concentration of solutes in the CSF remains High initially water shifts from the bloodstream into the CSF to equalizes gradient this can lead to a mild increase in int cranial pressure contributing to the symptoms associated with the syndrome patients with disequilibrium syndrome may experience a range of symptoms including nausea vomiting headache and confusion these symptoms are due to the changes in fluid balance and pressure within the C Cal nervous system it's important to monitor the patient closely during this period and provide supportive care to manage these symptoms effectively typically the symptoms will improve as the fluid equilibrium between the blood and CSF is reestablished which usually occurs within a few hours following dialysis continued assessment and reassurance are crucial to ensure the patient remains stable and comfortable throughout the process if symptoms persist or worsen further evaluation and intervention should be necessary to address any underlying issues or complications an air embolism can occur in dialysis patients if there are loose fittings or connections within the dialysis system allowing air to enter the bloodstream this can lead to serious complications as the air travels through the vascular system symptoms of anir embolism typically include sudden dnia hypotension and cyanosis if an air embolism is suspected it's important to take immediate action first disconnect the patient from the dialysis machine to stop further air entry then place the patient in a flat suine position to help prevent the air from moving to the brain or heart immediate transport to a medical facility is essential to manage and treat the air embolism effectively.",
        "Conclusion": "this lecture outlines various gastrointestinal urinary and reproductive system pathologies focusing on their causes symptoms and potential complications GI conditions such as diverticulitis peptic ulcer disease and IBS are discussed in detail highlighting how inflammation infection or abnormal organ function can lead to significant abdominal pain altered bowel habits and systemic symptoms specific conditions like Crohn's disease and ulcerative colitis are noted for their chronic inflammatory nature affecting the entire tract in some cases leading to long-term complications such as bowel obstruction or systemic involvement including skin lesions and joint pain the urinary system is addressed with conditions like acute kidney injury chronic kidney disease and urinary tract infections Aki is characterized by a sudden decrease in kidney function leaving to toxin buildup in the blood while CKD involves Progressive and irreversible loss of kidney function UTI particularly common in women can ascend from the lower to the upper urinary tract leading to severe complications like fentis if left untreated we also touch on kidney stones which can cause severe pain as they move through the urinary tract potentially leading to urinary obstruction and infection reproductive system pathologies including conditions like atopic pregnancy pelvic inflammatory disease and epididimitis are also explored these conditions can cause acute pain fever and systemic symptoms often requiring prompt medical intervention we discussed hernas particularly focusing on the risks associated with incarcerated hernas with can lead to strangulation and require Emergency Services overall these conditions underscore the importance of early diagnosis and treatment to prevent severe complications and improve patient outcomes"
    },
    {
        "Introduction to Toxicology": "chapter 23 toxicology Advanced emergency medical technicians free frequently encounter patients who have ingested substances that could be categorized as drugs of abuse these substances can be classified into two main categories legal or ilicit and illegal or ilicit drugs legal drugs such as alcohol and Oxycodone are often abused despite their regulated status and prescribed uses conversely illegal drugs including drugs such as heroin and ecstasy are substances that can be prohibited by law due to their high potential for abuse and lack of accepted medical uses poisons are inherently toxic regardless of the route of entry into the body or the quantity involved this means that any substance classified as a poison can cause harm upon exposure ingestion inhalation or injection no matter the dose in contrast drugs or substances that produce physiological effects would administered in the correct conditions and dosages however when a drug is consumed in excessive amounts it results in an overdose overdose is a toxicologic emergency that requires immediate medical intervention to prevent potentially life-threatening consequences aemts must be prepared to assess and manage the various clinical presentations associated with both lcit and illicit drug use toxicology is a scientific study that focuses on toxic or poisonous substances their effects and how they interact with biological systems.",
        "Toxicologic Emergencies": "toxicologic emergencies are events where exposure to a toxic substance leads to a medical crisis these emergencies can be classified as either intentional or unintentional intentional toxicologic emergencies often involve adults where poisoning is typically a deliberate act on the other hand unintentional toxicologic emergencies frequently occur due to medication dosing errors or accidental poisonings with childhood poisonings being notably common in this category toxicologic emergencies can arise from a variety of sources including natural occupational unintentional and intentional exposures in nature toxic substances such as wild mushrooms can cause poisoning when ingested workplace exposures often go unnoticed until after symptoms manifest with long-term exposure to substances like polychlorinated bipls or pcbs or asbest leading to conditions such as cancer or as best dooses unintentional poisonings frequently result from neglect and oversight posing a significant risk additionally toxicologic emergencies can occur as a result of chemical and biologic Warfare where toxic agents are used deliberately in conflict intentional poisonings or overdoses may also be associated with criminal activities for instance roipnol a drug known for its use in facilitating sexual assault and chlorohydrate known as knockout drops to commit assault are examples of pharmacologic Agents utilized in crimes these agents are also employed in homicides highlighting the deliberate and mil ious use of toxic substances in criminal acts understanding these diverse sources of toxicologic emergencies is essential for prehospital providers.",
        "Routes of Toxin Entry": "toxins exert their effects only after entering the human body where they begin to interfere with physiological functions there are four primary routes through which toxins can enter the body ingestion inhalation injection and absorption each of these methods is distinct in how toxins are absorbed and the rate of absorption varies depending on the entry method the impact of a toxin is determined by the amount introduced into the body and the speed at which it is metabolized this metabolism influences both the intensity of the toxins effects and the rate at which the body can excrete it.",
        "Ingestion Poisoning": "poisoning by ingestion is a common route of exposure often resulting from substances such as medications found around the home or household chemicals the effects of ingested poisons can vary some cause immediate damage to tissues particularly costic substances While others may have delayed effects as they need to be absorbed into the bloodstream indicators of ingestion related poisoning include finding partially chewed plants or missing berries stained fingers lips or tongue empty pill bottles from a recently filled prescription and sudden onset symptoms like stomach cramps nausea vomiting or diarrhea the absorption of toxins through the oral route generally takes longer as little absorption occurs in the stomach with most absorption happening in the small intestine managing ingested poisons typically involve strategies aimed at removing or neutralizing the toxin before it can enter the intestines thereby minimizing the body's absorption of the harmful substance in some Emergency Medical Service systems aemts may be permitted to administer activated charcoal as an alternative treatment for poisoning activ data charcoal is provided as a suspension that binds to the poison in the stomach facilitating its removal from the system it is considered more effective and safer than syrup of epicac which was previously used for similar purposes however it is important to note that the administration of activated charcoal carries a significant risk of severe pulmonary injury if the substance is aspirated into the lungs when assessing a patient who is ingested a potentially harmful substance aemts must focus on the ABCs in cases where the patient has ingested opioids sedatives or barbituates there is a high likelihood that aggressive ventilatory support and CPR may be required ensuring prompt transport to the emergency department is essential for further management and treatment of the poisoning.",
        "Inhalation Poisoning": "poisoning by inhalation typically occurs when toxic substances are presented in the surrounding atmosphere common sources of such poisoning include home medications that can produce harmful fumes when misused or household chemical products that release toxic Vapors inhalation poisoning can only happen if the poison is Airborne creating a hazardous environment in these situations it's critical not to enter the contaminated area without proper precautions instead you should call for resources that have specialized protective equipment to safely manage the situation it's also important to recognize that in toxic environments it's common to encounter multiple patients at the emergency scene requiring careful coordination and management of resources inhaled toxins pose a significant threat as they quickly reach the Alvi providing almost instant access to the circulatory system this rapid onset of symptoms leaves a narrow window for effective treatment the first priority at the scene is ensuring safety specialized Personnel are required to access the patient who may need decontamination after being removed from the toxic environment during this process the patient's clothing should be removed and Emergency Care should not begin until this has been completed inhaled toxins can produce a wide range of symptoms many of which are specific to the substance involved when responding to these incidents it's important to take any containers bottles or labels associated with the toxic substance to the hospital as this can provide valuable information for treatment in some cases patients may use inhal poisons as a means of suicide such as by sitting in a vehicle with an engine running in an enclosed space a newer method known as chemical suicide involves sealing a vehicle and introducing toxic chemicals to create a lethal environment indicators of chemical suicide include taped or sealed windows locked doors posted warning signs a suicide note empty chemical containers and unusual odors the scene often provides clues about the identity of the toxin which along with assistance from poison control centers and direction for medical control guides the treatment plan immediate treatment should focus on addressing hypoxia establishing vascular access and Performing pulse oxymetry.",
        "Injection Poisoning": "poisoning by injection is often associated with drug abuse and can present with a wide range of signs and symptoms injected poisons are particularly dangerous because they are generally impossible to dilute or remove once they enter the body these poisons are rapidly absorbed into the system or cause severe local tissue destruction at the injection site if rapid absorption is suspected it's critical to monitor the patient Airway provide high flow oxygen and remain vigilant for nausea and vomiting swelling at the injection site may require the removal of jewelry to prevent further complications prompt transport to a medical facility is necessary and it's important to bring all related containers bottles and labels to the hospital for further evaluation additionally bites and stings which can also introduce toxins through injection fall under this category of poisoning.",
        "Absorption Poisoning": "poisoning by absorption occurs when toxic substances are absorbed through the skin leading to potentially serious systemic effects Organo phosphates and pesticides are particularly concerning as they are often the most serious agents involved in absorption related poisoning corrosive substances can cause significant damage to the skin mucous membranes or eyes leading to both local and systemic effects other substances once absorbed into the bloodstream through the skin can produce widespread physiological effects it's important to distinguish between injuries caused by contact Burns which result from direct chemical damage and those caused by contact absorption where the toxin enters the bloodstream through the skin signs and symptoms of poisoning by absorption often include a history of exposure to a toxic substance with physical evidence such as liquid or powder present on the patient's skin the patient may also exhibit Burns itching irritation and redness of the skin particularly noticeable in lightskinned individuals additionally there may be odors characteristic of the absorbed substance which can provide important clues for identification and treatment when dealing with poisoning by absorption it's crucial to avoid contaminating yourself or others during the decontamination process the first step is to remove any irritating or corrosive substances from the patient as quickly as possible contaminated clothing should be cut off rather than pulled over the patient's head to prevent further exposure for dry powders thoroughly brush off the powder before flushing the skin with running water followed by washing with soap and water in cases where a large amount of material has been spilled on the patient flooding the affected area for at least 20 minutes may be the most effective treatment if the patient has a chemical agent in their eyes irrigate the eyes quickly and thoroughly to minimize damage chemical burns frequently occur in industrial settings or trained Personnel are often available to assist do not attempt to neutralize the substance with other chemicals as this can cause cause further harm if the material is a solid brush off as much as possible and then immediately wash off the substance with plenty of water it's also important to obtain the material safety data sheet related to the substance and transport them with the patient for reference by medical professionals prompt transport to a medical facility is always necessary during transport continue to irrigate the ected areas and provide oxygen if possible to support the patient's respiratory function.",
        "Understanding Toxidromes": "understanding and using toxidromes is essential for accurately identifying and managing poisoning cases many drugs can produce similar signs and symptoms making it challenging to determine the specific agent involved a toxidrome or toxic syndrome refers to a set of syndrome like symptoms that are characteristic of exposure to a particular poisonous agent recognizing these patterns allows healthc care providers to narrow down the list of potential toxins facilitating more effective and targeted treatment familiarity with common toxidromes is a valuable tool in the rapid assessment and management of patients presenting with signs of poisoning major toxidromes or toxic syndromes are produced by various classes of substances each with its own characteristic set of symptoms these include stimulants opioids sympathomimetics sedatives and hypnotics colonics and anticholinergics each of these categories can include a specific toxidrome helping clinicians identify the type of substance involved in a poisoning case for example stimulants may cause agitation teoc cardia and hypertension while opioids typically result in respiratory depression pinpoint pupils and decreased Consciousness recognizing these patterns is key to effective diagnosis and management.",
        "Substance Abuse Challenges": "the area of medicine that addresses drugs of abuse is notably challenging due to the uncertainty surrounding the prevalence of substance abuse and the continual evolution of new substances substance abuse involves the self-administration of legal or illegal substances in a way that deviates from approved medical or social practices there is also significant cultural variation in what is considered substance abuse making it a complex issue to address universally moreover society's definition of substance abuse does not always correlate with the actual harm a substance may cause for example tobacco which is widely available and unrestricted is known to cause significant cardiovascular and respiratory diseases on the other hand marijuana use which can lead to legal consequences such as fines or imprisonment has been legalized in some states for recreational Andor medical purposes highlighting the discrepancies in societal and legal perspectives on substance abuse these complexities make it imperative for healthc care providers to approach substance abuse with a nuanced understanding of both medical and societal factors.",
        "Basic Terms and Concepts of Drug Use": "understanding basic terms and concepts related to drug use is crucial for effectively addressing substance abuse drug abuse is defined as the use of drugs in a manner that causes harm whether physical psychological economic legal or social this can occur to either the user or others affected by the user's Behavior habituation refers to psychological dependence on a drug which may also include the development of physiological tolerance physical dependence is a state of physiological adaptation to a drug that's characterized by tolerance to its effects and the occurrence of withdrawal symptoms if the drug is abruptly discontinued psychological dependence on the other hand involves an emotional craving for the drug to maintain a sense of well-being tolerance occurs when the body adapts to the effects of a drug requiring increasingly larger doses to achieve the same effect withdrawal syndrome is a predictable set of symptoms often involving changes in CNS activity that occurs when a drug is abruptly stopped or when its usual dosage is rapidly reduced drug addiction is a chronic disorder marked by the compulsive use of a substance despite the physical psychological or social harm that it causes an antagonist is a drug that counteracts the action of another substance by binding to a receptor without activating it thereby preventing the cell from responding potentiation refers to the enhancement of the effect of one drug by another while synergism describes the scenario where the combined effect of two substances is greater than the sum of their individual effects.",
        "Emergency Medical Care for Poisoning": "in providing emergency medical care the first priority is to ensure seen safety this involves taking standard precautions to protect yourself and others from potential hazards external decontamination should be performed as necessary to prevent further exposure to the toxin if the patient has ingested tablets or fragments remove them from the patient's mouth as quickly as possible additionally if the poison has come into contact with the patient's skin it's important to wash or brush it off to prevent further absorption in into the body continuing with emergency medical care it's crucial to assess and maintain the patient's ABCs ensuring that the airway is clear the patient is breathing effectively and circulation is adequate is fundamental to stabilizing the patient if the patient's breathing is compromised provide supplemental oxygen and perform assisted ventilations as necessary to support adequate oxygen ation additionally be vigilant for signs and symptoms of shock such as altered mental status teoc cardia and hypotension and initiate appropriate treatment to prevent further deterioration if local protocols or medical control authorize it administer activated charcoal to the patient as this combined to certain toxins in the GI tract reducing their absorption and mitigating the effects of the poisoning activated charcoal is not indicated for certain patients due to the potential for harm or ineffectiveness specifically it should not be administered to patients who have ingested acids alkaly or petroleum products as these substances can cause more damage if they come into contact with the charcoal or if the patient vomits additionally activated charcoal should not be given to patients with a decreased level of Consciousness who are unable to protect their Airway as this increases the risk of aspiration finally patients who are unable to swallow should not receive activated charcoal as they may choke or aspirate the substance these contraindications must be carefully considered before administering activated charcoal in a poisoning situation the recommended dose of activated charcoal is 1 G per kilogram of body weight for adults this typically amounts to 50 to 100 G for children 25 to 50 g and for infants 10 to 25 G common side effects of activated charcoal include black stools nausea and vomiting additionally because of the potential for Airway complications careful monitoring of the patient is required after Administration these considerations must be weighed carefully when deciding whether to use the activated charcoal in the management of poisoning cases.",
        "Alcohol Abuse and Its Effects": "alcohol is the most widely abused drug both in the United States and globally alcoholism characterized by a state of physical and psychological addiction to alcohol is a major public health concern in the us alcoholism is the fourth leading cause of death reflecting its significant impact on morbidity and mortality individuals who suffer from alcoholism often experience chronic malnutrition due to poor dietary habits and the effects of alcohol on nutrient absorption and Metabolism additionally alcoholics are prone to frequent Falls which can lead to serious injuries the management of alcohol abuse requires addressing both the physical and psychological aspects of addiction along with the associated complications alcohol is a potent CNS depressant that significantly affects neurological function it decreases activity and excitement often leading to a calming or sedative effect alcohol also induces sleep which can sometimes progress to unconsciousness in cases of excessive consumption additionally it dulls the sense of awareness slows reflexes and reduces reaction time making it dangerous for activities that require quick responses such as driving moreover alcohol consumption can lead to aggressive and inappropriate behavior due to its diminishing effects this combined with a lack of coordination increases the risk of accidents and injuries alcoholism is associated with numerous medical problems that can have severe consequences these include head trauma toxic reactions and complications from uncontrolled diabetes one of the most serious risks is death resulting from respiratory depression or the aspiration of vomitus or stomach contents which can lead to choking or L infections alcoholism also leads to physical dependence and withdrawal from alcohol can be dangerous and requires careful medical management individuals with alcoholism are significantly higher risk for a range of serious illnesses and injuries liver damage is the most common issue often manifesting as hepatitis or curosis alcoholism also increases the incidence of pancreatitis a painful and potentially life-threatening inflammation of the pancreas the development of erosive gastritis which causes the stomach lining to become inflamed and eroded is another common complication additionally there is an elevated risk of breast and color rectal cancers among those with chronic alcohol use long-term alcohol abuse can also lead to cerebral atrophy resulting in permanently reduced mental function in managing patients with alcohol related complications the first priority is to always establish and maintain the airway in order to ensure adequate oxygenation and prevent further complications if the patient appears to be in shock it's important to suspect internal bleeding which may require rapid intervention alcohol withdraw is another critical concern particularly because seizures are a common withdrawal symptom typically occurring within 12 to 48 hours after the last alcohol intake in such cases it's essential to call for paramedic backup to administer benzodiazapines which are effective in controlling seizures and preventing further complications when treating a patient experiencing delirium trimens or DTS which is a severe form of alcohol withdrawal key steps should be followed to stabilize the patient and prevent complications first it's essential to keep the patient calm to minimize agitation and reduce the risk of injury administering oxygen helps ensure adequate oxygenation which can be compromised during DS due to respiratory difficulties establishing vascular access is important for managing hypotension which is common in patients with DTS through this access fluids and medications can be administered as needed providers should also regularly assess the patient's breath sounds to monitor respiratory status and detect any emerging complications finally maintaining dialogue with the patient is important this not only helps keep them oriented and calm but also provides ongoing assessment of their mental state effective communication can reduce the severity of symptoms and improve overall outcomes in patients suffering from the DTs.",
        "Opioids and Their Effects": "opioids are a class of drugs that function as CNS depressants reducing the perception of pain and inducing sedation they're categorized into two main divisions opiates which are naturally derived from the Opium poppy plant and synthetic opioids which are chemically manufactured and not derived from opium both opiates and synthetic opioids include lcit therapeutic agents which are prescribed for pain management as well as illicit substances commonly associated with abuse examples of opioids include morphine Codine heroin Fentanyl oxycodone meridine Pro proxen and dextrorphan these substances vary in potency in application ranging from legal prescription medications to illegal drugs with a high potential for addiction and misuse opioids exert their primary effects on the CNS by binding to specific receptor sites located in the brain and other tissues these drugs are readily absorbed from the GI tract but they can also be absorbed through the nasal mucosa or lungs when taken orally the effects of opioids are generally less potent compared to when they are administered par internally such as by injection for example when heroin is metabolized in the liver it converts into acet morphine which continues to exert narcotic effects that May persist even after the administration of nxone Additionally the metabolism of opioids like morphine tends to be slower in older adults prolonging their effects the rare allergic reactions can occur with opioid use drugs like morphine and heroin are known to produce a profound dreamlike State interestingly shortly after injection users may appear to lose Consciousness while remaining quite Lucid internally illustrating the powerful sedation effects of these substances the classic presentation of opioid use includes a variety of signs and symptoms that are indicative of its depressant effects on the CNS patients may experience Euphoria which is often one of the reasons for opioid abuse hypotension or low blood pressure and respiratory depression are also common the latter being particularly dangerous as it can lead to inadequate oxygenation of the body a tail taale sign of opioid use is pinpoint pupils which result from the drugs effects on the autonomic nervous system other symptoms include vomiting and constipation both of which are common with opioid use in severe cases opioid intoxication can lead to coma seizures or even Cardiac Arrest the management of suspected opioid poisoning typically involves checking for responsiveness ensuring the patient's Airway is open administering Naran if available and providing ventilation or CPR as needed Naran is an opioid antagonist that can reverse the effects of opioid overdose it can be administered via IV line IM injection or inasal with a typical dosage ranging from 0.4 to 2 mgram however it is important to note that Naran May precipitate withdrawal symptoms which can result in violent Behavior or seizure activity additionally acute opioid reversal with Naran may lead to vomiting and the risk of aspiration therefore should only be used when the patient exhibits agonal respirations or apnea in cases where the patient goes into cardiac arrest it's critical to follow the appropriate resuscitation algorithm if the patient does not respond to Narcan it's possible that they have experienced a mixed bag overdose where multiple drugs have been ingested some of which may not be opioids and therefore will not respond to Naran in such cases es the patient may require a subsequent dose of Nan it's also important to consider that the patient may have underlying chronic illnesses or conditions such as hepatitis HIV or Aids malnutrition or sepsis which may interact with opioid medications medications taken for these conditions could further complicate the situation accurate documentation is essential including whether the ingestion was intentional or accidental how much of the substance was taken and what was ingested it's also necessary to document whether the patient has vomited since ingestion and to bring any pills or bottles to the hospital for further assessment finally it's important to report all findings to the receiving medical personnel and notify law enforcement about any illicit substances involved in the case this ensures that appropriate measures are taken for both the Patients health and legal considerations.",
        "Stimulants and Their Effects": "stimulants are among the most highly addictive substances with a significant potential for abuse firsttime users can develop an addiction within just a few days and once addiction sets in achieving abstinence is often extremely difficult stimulants can be administered in various ways including orally by smoking or through IV injection clinically the use of stimulants typically presents with symptoms such as excitement delirium teoc cardia and either hyper or hypotension often accompanied by a rapid pulse additionally dilated pupils are a common sign as the use of stimulants reaches toxic levels more sever symptoms can manifest including psychosis hyperpyrexia trimmers seizures and ultimately Cardiac Arrest cocaine is a naturally occurring alkaloid extracted from the leaves of the arthra Zion coca plant it commonly is known by several street names including blow Coke stash nose candy snow and dust cocaine acts as both a local anesthetic and a powerful CNS stimulant its effects make it one of the most if not the most psychologically addictive drugs cocaine is rapidly absorbed across all mucosal membranes and can be applied topically swallowed snorted or injected intravenously it can also be mixed with baking soda and water and then cooked or baked to produce cracked cocaine when snorted nasy the effects of cocaine are felt within 1 to 2 minutes with Peak effects occurring in 20 to 30 minutes smoking cocaine produces a more intense high within 8 to 10 seconds although the effects are shorter lived after the effects of cocaine wear off typically users experience a crash which is characterized by symptoms such as depression irritability sleeplessness and exhaustion this crash phase is often referred to as cocaine wash out syndrome highlighting the severe psychological and physical toll that cocaine use can take on an individual amphetamines Encompass a variety of substances including amphetamine commonly known as ice or crank methyl in diox amphetamine MDA also known as atom and methyl in diox methamphetamine M dma also known as Eve or ecstasy while these drugs are widely abused they also have several legitimate clinical applications for example amphetamines are used as nasal decongestants diet pills and medications for conditions such as narcolepsy and add or ADHD methamphetamine in particular is a lowcost long-acting stimulant with effects lasting up to 12 hours it is extremely addictive and poses a significant public health problem the production of methamphetamine and clanin meth labs is very dangerous and should be treated as a hazardous materials incident due to the volatile chemicals involved synthetic cath Neons often marketed as bath salts are another class of stimulants these substances can contain an active ingredient that is similar to the pseudo edrin reduction drug meth canine or a comparable methamphetamine knockoff users typically snort smoke or ingest these drugs which combine the intense long- lasting effects of methamphetamine with the euphoric effects of crack cocaine however these substances do have serious side effects including severe agitation hallucinations and paranoia which can lead to dangerous and unpredictable Behavior the signs and symptoms of stimulant abuse are often quite pronounced and can include several distinctive features individ idual May exhibit a wild-eyed emancipated appearance commonly described as thin as a rail this is due to the significant weight loss that's associated with chronic stimulant use nervous or jittery movements are also common reflecting the heightened state of arousal and restlessness induced by stimulants stimulant abusers may go on week-long binges without sleep leading to severe exhaustion and a breakdown of physical and mental health this lack of sleep coupled with inadequate nutrition exacerbates their already deteriorating condition as the abuse continues increasing paranoia often develops with the individual becoming suspicious and fearful which can lead to dangerous and erratic Behavior cocaine is associated with several serious complications including lethal cardiac dysrhythmias which can lead to sudden death other severe cardiovascular effects include myocardial infarction seizures stroke apnea and hypothermia crack cocaine users are at an additional risk for developing pneumothorax and pneumomediastinum the clinical presentation of patients abusing amphetamines or Methamphetamine is almost identical to that of cocaine abusers with the key difference being that the effects of amphetamines tend to last much longer the use of synthetic cathon often found in bath salts is associated with severe symptoms such as significant paranoia hallucinations Incredible strength excited delirium and other bizarre behaviors these symptoms can be accompanied by cardia diaphoresis nausea and hypothermia further complicating the clinical management of these patients the treatment of stimulant overdose requires several critical steps to ensure patient safety and stabilization the first priority is to maintain maximum oxygen saturation levels to prevent hypoxia seizures which are a common complication of stimulant overdose should be prevented through adequate sedation continuous monitoring of Serial Vital Signs is essential to track the patient's condition and respond to any changes given the severity of stimulant overdoses it may be necessary to call for paramedic backup to assist in managing the situation establishing vascular access is crucial for administering fluids and medications particularly when managing hypotension the application of a pulse oximeter and intitle capnography is recommended to monitor the patient oxygen levels and carbon dioxide levels continuously patients should be transported to an appropriate medical facility as soon as possible for further care in cases where the patient presents with hypothermia applying ice packs or misting the skin can help lower body temperature it's also important to recognize that patients who have overdosed on stimulants may be emotionally or psychologically unstable with a potential for violent Behavior therefore it's advisable to contact law enforcement for support as soon as there is any suspicion that violence might occur ensuring the safety of both the patient and the medical team.",
        "Marijuana and Synthetic Cannabinoids": "marijuana and cannabis compounds are derived from the harvested and dried leaves and flower buds of the Cannabis Savia plant commonly known by various names such as weed pot dope smoke and Bud marijuana has seen increased legalization over the past decade in many states both for medicinal and in some cases recreational use marijuana is typically smoked though it can be ingested when smoked the onset of effects occurs within minutes while ingestion leads to a delayed onset of several hours users often experience a distorted sense of time and space and some may occasionally feel a sense of unreality smoking marijuana causes Bronco dilation which can ease breathing and it may also result in slight tacac cardia additional signs and symptoms of marijuana use include Euphoria drowsy decreased short-term memory diminished motor coordination increased appetite and bloodshot eyes management of marijuana intoxication primarily involves supportive care addressing any symptoms the patient may be experiencing and ensuring their safety and comfort during the effects of the drug spice refers to a blend of synthetic cannaboids which are chemicals designed to to mimic the effects of THC the active ingredient in cannabis the active substances in spice are typically sprayed into a plant-like material for smoking or are sold as a liquid for use in ecigarettes the use of spice is associated with the range of adverse effects including psychosis hallucinations teac cardia vomiting renal problems and seizures these effects can vary significantly between individuals making it challenging to obtain a thorough assessment and form an appropriate treatment plan management of spice intoxication primarily involves supportive care which includes ensuring adequate fluid intake and maintaining the patient's Airway for patients who experience seizures as a result of using spice benzodiazapines are recommended as a treatment to help control seizure activity the unpredictable nature of synthetic cannaboids like spice underscore the importance of careful monitoring and supportive care in affected individuals.",
        "Hallucinogens and Their Effects": "hallucinogens are substances that alter a person's sensory perception leading to a wide range of experiences that can vary markedly from one individual to another the classic hallucinogen is lysergic acid diolide or LSD which primarily affects the senses rather than changing physiological functions users of LSD may experience Synthesia where the senses overlap such as seeing sounds the effects can last anywhere from 3 to 12 hours depending upon the dose and may include teoc cardia mild hypertension dilated pupils and anxiety attacks psilocybin mushrooms are another frequently used hallucinogen in the United States the onset of symptoms and hallucinogenic effects typically occurs within 30 minutes of ingestion and lasts 4 to 6 hours common signs and symptoms include nausea vomiting dilated pupils tachicardia and hypertension in some cases seizures and hypothermia may also occur PCP also known as angel dust is relatively uncommon among young adults but it's typically smoked snorted or injected PCP use is associated with slurred speech a staggering gate teoc cardia hypertension and a Blank Stare for extended periods muscle rigidity and teeth grinding are also common leading users to often use pacifiers to void jaw eggs Hallmarks of PCP use include Mind Body separation related hallucinations and violent outbreaks with users exhibiting a high tolerance for pain and sometimes seemingly superhuman strength ketamine known as Special K or vitamin K shares a similar chemical structure to PCP most Street ketamine is stolen from from veterinary clinics although it is increasingly used in emergency medicine it's a popular club drug often used in combination with other substances like alcohol and stimulants katamine is colorless and odorless commonly found in powdered form and can be mixed into drinks or snorted it is both physically and psychologically addictive and acts as a dissociative anesthetic users of ketamine often experience mild inebriation lethargy dreamy or erotic thoughts and increased sociability higher doses can lead to pronounce nausea difficulty moving and sensations of entering another reality in extreme cases users may enter the khole involving outof body experiences long-term use of ketamine can result in severe memory problems cognitive impairment and difficulties in speaking or seeing properly masculine derived from the dried flower buttons of the Peyote Cactus has no accepted medicinal use in the United States ingestion of mesculin often results in profound vomiting followed by hallucinations distortions of time and space or outof body experiences the physical effects of masculine include dilated pupils an increased heart rate hypertension and an elevated body temperature the treatment of patients who have used hallucinogens such as PCP ketamine mesculin or psilocybin is primarily supportive this involves limiting sensory stimulation to prevent further agitation or distress during transport it is essential to provide Prov psychological support for the patient for those who have used PCP or ketamine it's important to secure the patient well assess their ABCs and manage any life-threatening conditions administering oxygen therapy and establishing vascular access are critical as long as the patient is receptive in situations where the patient is experiencing significant delirium benzodiazapines may be used to help calm the patient due to the potential for violent and difficult Behavior particularly with PCP use care must be taken to manage the situation safely for users of masculine and psilocybin mushrooms supportive care remains to focus this includes attention to the ABCs administering oxygen monitoring Vital Signs providing positive psychological support and ensuring safe transport to the the appropriate medical facility.",
        "Sedative Hypnotic Drugs": "sedative hypnotic drugs are commonly used in medical practice to reduce anxiety calm agitated patients and induce drowsiness and sleep these drugs are divided into two primary categories sedatives and hypnotics sedatives help to alleviate anxiety and agitation while hypnotics are specifically used to promote sleep sleep barbituates a class of sedative hypnotic drugs are often used as sleep aids anti-anxiety medications and for seizure control however they can be dangerous especially when combined with alcohol symptoms of barbituate use include drowsiness decreased inhibitions a taxia mental confusion and a staggering gate as a dosage increases the patient becomes increasingly lethargic and may eventually become unresponsive abrupt sensation in long-term users can result in withdrawal symptoms which may include anxiety Tremors and in severe cases seizures benzodiazapines are another class of sedative hypnotic drugs commonly used to treat anxiety seizures and alcohol withdrawal these drugs produce sedation reduce anxiety and relax stried muscles however individuals who use benzo Dias aines are often at risk of using other substances including alcohol the clinical effects of benzo dipene may include altered mentation drowsiness confusion slurred speech at taxia and a general lack of coordination withdrawal from benzo a aines can result in teoc cardia Tremors confusion and seizures in managing patients who have overdosed on sedative hypnotic drugs area management should be the first priority it's also important to call for paramedic backup to assist with Advanced interventions High concentration oxygen should be administered and Venus access established to facilitate the administration of fluids or medications in cases of shock rapid infusion of normal saline in 20 ml per kg boluses may be required while ramicon is available for treating benzo aspine overdoses its use in the prehospital setting is rarely warranted.",
        "Cardiac Medications Overdose": "cardiac medications Encompass several major classes including anti-is rythmics beta blockers calcium channel blockers cardiac glycosides and Angiotensin converting enzyme Inhibitors many patients are prescribed a combination of these medications to manage various cardiac conditions overdose of cardiac medications can manifest through a variety of symptoms due to the pharmacological effects of the drugs involved hypotension is a common sign resulting from the decreased cardiac output or peripheral vascular resistance caused by the medication patients may also experience weakness or confusion which can be attributed to reduced cerebral profusion or the Direct effects of the drugs on the CNS GI symptoms such as nausea and vomiting often occur due to the body's reaction to the toxic levels of the drug one of the most critical signs is rhythm disturbances particularly bardia or heart block where the electrical signals that regulate the heartbeat are partially or completely blocked these disturbances can lead to insufficient blood flow to vital organs further complicating the clinical picture patients may also report a headache which can result from changes in blood pressure or as a direct side effect of the drugs difficulty breathing is another serious symptom that may occur due to pulmonary congestion respiratory depression or as a secondary effect of severe bardia leading to poor oxygenation of the blood the combination of these symptoms requires prompt medical attention as the effects of the overdose can lead to life-threatening complications if not managed appropriately treatment often involves stabiliz izing the patient's cardiovascular status addressing any respiratory issues and in some cases administering specific antidotes or conducting decontamination procedures in the management of a cardiac medication overdose is essential to First ensure the patient maintains a patent Airway adequate ventilation and receives high flow supplemental oxygen to support respiratory function and oxygenation establishing vascular access is crucial for administering necessary interventions including potential antidotes if the specific toxic agent has been identified in cases of hypotension administering sequential fluid boluses of normal saline can often help restore blood pressure to an acceptable range if the patient's condition necessitates it paramedic backup should be considered considered particularly for advanced Airway management and the administration of vas oppressors which are medications that can constrict blood vessels and raise blood pressure when fluids alone are insufficient additionally contacting medical control is imperative to ensure the care provided alliance with the latest clinical guidelines and to receive further instructions on managing the overdose.",
        "Erectile Dysfunction Medications and TCA Overdose": "the management of patients who have overdosed on erectile dysfunction medications or tcas requires immediate and comprehensive care erectile dysfunction medications including Viagra Calis and Levitra are particularly hazardous when combined with nitrates prescribed for cardiac conditions as this combination can result in severe hypotention or even cardiovascular collapse in such cases treat involves the administration of repeated boluses of normal saline to elevate blood pressure to acceptable levels tricyclic anti-depressants or tcas are known for their high risk of intentional overdose and present with signs such as altered mentation dysrhythmias dry mouth blurred vision dilated pupils urinary retention constipation and pulmonary edema in more severe cases patients May develop ventricular teoc cardia hypotension respiratory depression and seizures management priorities include maintaining the airway calling for paramedic backup and administering high flow supplemental oxygen vascular access should be established promptly and activated charcoal may be administered under medical controls Direction hypoten ion should be managed with sequential bubbles of normal saline and it's important to assess blood glucose levels rule out head trauma and monitor for agitation or violence.",
        "MAOIs and SSRIs Overdose": "monoamine oxidase Inhibitors or maois are occasionally prescribed for depression but do carry significant risks particularly when consumed in conjunction with triamine containing foods which can precipitate a hypertensive crisis the onset of symptoms is often delayed occurring 6 to 12 hours after ingestion and potentially extending up to 24 hours early symptoms include hyperactivity dysrhythmias hyperventilation and nagas as toxicity increases patients may experience chest pain palpitations hypertension diaphoresis combative Behavior marked hypothermia and hallucinations management should focus on supportive care as no specific antidote exists immediate priorities include establishing a maintaining the airway and administering high flow oxygen vascular access should be established promptly the administration of activated charcoal may be considered if advised selective serotonin reuptake Inhibitors or ssris are commonly used to manage depression and patients may be asymptomatic even after an overdose however toxicity can include nausea vomiting and dysrhythmias along with sedation trimmers and possibly dilated pupils in more severe cases patients may experience agitation blood pressure changes seizures and hallucinations management of SSRI overdose should focus on establishing and maintaining the airway administering high flow supplemental oxygen and establishing vascular access paramedic backup may be necessary especially in severe cases a single dose of activated charcoal may be considered if advised by medical control.",
        "Lithium and NSAIDs Overdose": "lithium commonly used in the the treatment of bipolar disorder poses a significant risk of toxicity due to its slow excretion from the body making overdose a persistent threat clinical manifestations of lithium toxicity include nausea vomiting hand tremors excessive thirst and slurred speech as toxicity progresses patients May exhibit a taxia muscle weakness incoordination blur vision and hyperlexia in severe cases patients may experience seizures or lapse into a coma management is primarily supportive with the main focus on establishing and maintaining the airway administering high flow O2 and ensuring vascular access nonsteroidal anti-inflammatory drugs or ineds are commonly used for pain relief fever control and their anti-inflammatory effects however they can pose significant risks especially with long-term use chronic use of ineds can lead to GI bleeding and kidney dysfunction clinical signs and symptoms of inid toxicity may include headache altered mentation behavioral changes seizures braady dis rhythmia hypotension abdominal pain nausea and vomiting management of inid toxicity is generally supportive beginning with establishing and maintaining the airway administering high flow supplemental oxygen and establishing vascular access in cases of hypotension fluid boluses of normal saline are administered.",
        "Salicylates and Acetaminophen Overdose": "salicylates commonly found in over-the-counter products can can cause significant toxicity patients may present with nausea vomiting abdominal pain diaphoresis hyper apnea and ringing in the ears with severe cases leading to pulmonary edema and acid-based disturbances such as metabolic acidosis or combined respiratory alkalosis metabolic acidosis since there's no specific antidote or antagonist field manager is focused on supportive care this includes establishing and maintaining the airway administering high flow supplemental oxygen establishing vascular access and providing serial boluses of normal saline if hypotention develops the monitoring of carbon dioxide levels with capnography is essential and a single dose of activated charcoal may be administered after Consulting with medical control acetaminophen although generally well tolerated with few side effects requires careful attention to the timing of ingestion in cases of Overdose an antidote should be administered within 8 hours of ingestion to be effective management involves establishing and maintaining the airway high flow supplemental oxygen vascular access and again the administration of activated charcoal with the agreement of medical control.",
        "GHB and Organophosphate Poisoning": "GHB is a colorless odorless liquid often associated with sexual assaults due to its potent hypnotic effects which include dis inhibition severe passivity and anterograde Amnesia it has a salty taste which may go unnoticed when mixed into a drink the treatment of gxb intoxication primarily addresses the CNS depression and is associated with risks of Airway compromise management involves establishing and maintaining the airway closely monitoring the patient's level of Consciousness assisting with breathing as necessary and supplemental high flow O2 establishing vascular access and applying the pulse oximeter are also essential Organo phosphate are a major component in many insecticides and share similar characteristics with compounds used in nerve gases and chemical warfare these substances are classified as coleric agents because they overstimulate normal body functions controlled by the parasympathetic nervous system Organo phosphate poisonings are notably common in cases of suicide attempts and accidental agricultural exposure over stimulation of parasympathetic nerves can lead to severe and potentially life-threatening symptoms making prompt identification and treatment critical Organo phosphate poisoning can present with a variety of symptoms including anxiety restlessness headache dizziness confusion Tremors seizures disia diffuse wheezing respiratory depression and a potential loss of consciousness these signs and symptoms typically appear within the first8 hours following exposure colonic excess a Hallmark of organophosphate toxicity can be identified through the memonic slud or dumbbells slud stands for salivation and sweating lacrimation urination defecation gastric upset emesis and muscle twitching or meosis meaning pinpoint pupils the dumbbells memonic includes diarrhea urination meosis or muscle weakness bardia bronchospasm Bron Oria emesis lacrimation and seizur sweating and salivation when managing a patient exposed to Organo phosphates or nerve agents it's imperative to First decontaminate and remove all contaminated clothing before initiating care or loading the patient into the ambulance the initial steps of care include establishing and maintaining the airway with consideration of an advanced Airway if necessary and Performing suction as needed high flow supplemental oxygen should be administered and Vascular access established paramedic backup should be called and the use of pulso symmetry and entitle CO2 monitoring should be applied immediate transport is crucial the military has developed specific antidotes for nerve agents such as the duodote kit the antidote treatment nerve agent auto injector and the mark1 kit which should be administered if available and indicated these antidotes are typically used in cases of known exposure to nerve agents or Organo phosphates that manifest with signs and symptoms.",
        "Carbon Monoxide and Lead Poisoning": "carbon monoxide is one of the most common causes of fatal poisoning primarily produced during the incomplete combustion of organic fuels poisoning may occur when a flu or ventilation system becomes blocked and it is also a known method of suicide and a major contributor to fatality in house fires carbon monoxide is a colorless odorless and tasteless gas making it difficult to detect without specialized equipment the toxicity of Co arises in its high effinity for hemoglobin in red blood cells where it displaces oxygen and prevents it from being carried to tissues leading to Cellular Suffocation diagnosing Coop poisoning in the field can be challenging due to the variability and non-specific nature of the signs and symptoms which often mimic the early onet of the flu including headache nausea and vomiting in acute cases patients may experience confusion and the inability to think clearly along with complaints of head pressure or roaring in the ears physical examination May reveal bounding pulses dilated pupils and poor or cyanosis with the cherry red color of the skin being a very late sign we should consider Coop poisoning when multiple patients present with similar symptoms after sharing the same environment field treatment for Coop poisoning focuses on providing the highest concentration of oxygen possible to displace the molecules from hemoglobin for patients with symptoms the elimination Hal time of carboxyhemoglobin is approximately 4 hours but can be reduced to an 1 and A2 hours if the patient breathes 100% oxygen Hyperbaric therapy can further decrease the elimination time care involves removing the patient from the exposure environment establishing and maintaining an airway high flow supplemental oxygen and Vascular access it's important to keep the patient quiet and at rest while monitoring their level of Consciousness the patient should be transported to an appropriate facility with preference given to a facility capable of providing Hyperbaric medicine if the patient is unresponsive or show signs of serious Co poisoning lead poisoning is the leading cause of chronic metal poisoning particularly impacting children's intellectual development inorganic lead is primarily absorbed through the respiratory or GI tracts and once inside the body about 90% is stored in the teeth and bones it can also cross the placental barrier affecting fetal development the half-life of lead in the bone is estimated at 30 years most organic lead exposures occur in occupational settings an incopy is a significant cause of mortality and morbidity associated with exposure in the field treatment options are limited focusing on identifying the lead Source maintaining the airway providing supplemental oxygen and establishing vascular access fluid therapy is avoided unless hypotension is present.",
        "Iron and Chlorine Gas Exposure": "iron exposures toxicity is dose dependent with GI symptoms including abdominal pain vomiting and diarrhea while systemic toxicity can lead to hypotension or shock from coagulopathy and vomiting blood this will often result in metabolic acidosis children typically remain asymptomatic with low-level iron exposure exposure to chlorine gas is relatively common due to the widespread use of chlorine compounds in homes and occupational settings initial signs and symptoms include burning Sensations in the Eyes Nose and Throat along with a slight cough more intense exposure can lead to chest tightness choking peroxalate nausea and vomiting diffuse wheezing cyanosis crackles in the chest shock seizures and a potential loss of consciousness the immediate management includes removing the patient from the exposure area quick LLY triaging to prioritize those with difficulty breathing and irrigating any affected eyes or skin with water.",
        "Cyanide and Caustic Substances": "cyanide exposure can occur from fire combustion industrial exposure or ingestion of products containing cyanide this blocks the utilization of oxygen at the cellular level leading to Cellular Suffocation and death which can happen within seconds if inhaled or within minutes or hours if ingested patients may present with an altered mental status headache palpitations and disia the presence of a bitter almond odor on the patient's breath is highly indicative of cyanide poisoning respirations may be rapid and labored early on becoming slow and gasping as the condition progresses along with a rapid and threat pulse vomiting seizures and coma rapid treatment is critical involving the administration of 100% oxygen via a non-ar breathing mask or positive pressure ventilation with the possible administration of sodium Theos sufate under medical control orders CTIC substances including strong acids and alkaly are commonly used in industry Agriculture and homes with most exposures result ing from accidental dermal or ocular contact oral ingestion of CICS is often associated with suicide attempts symptoms include severe pain in the mouth throat or chest with respiratory distress likely due to the soft tissue swelling in the linic epiglottis or vocal cords.",
        "Methyl Alcohol and Hydrocarbons": "methyl alcohol and ethylene glycol are more toxic than ethyl alcohol with methyl alcohol commonly found in dry gas products and Sterno and ethylene glycol found in some antifreeze products these substances cause a drunken feeling and can lead to severe tacac cardia teia blindness renal failure and eventually death there are sometimes used as substitutes by chronic alcoholics who cannot obtain ethyl alcohol and often in suicide side attempts hydrocarbons are found in cleaning and polishing agents glues spot removers lighter fluids paints paint thinner other fuels and pesticides most intentional inhalations of hydrocarbons are recreational although young children may mistakenly ingest them as a beverage inhalation is typically achieved by soaking a rag in the volatile material placing it in a trash bag and inhaling the fumes a process known as huffing or bagging a single hydrocarbon exposure can cause life-threatening toxicity and in some cases sudden death treatment for a patient who has inhaled hydrocarbons includes removing them from the toxic environment administering High concentration supplemental oxygen and promply transporting them to a medical facility if the patient exhibits symptoms such as coughing choking or vomiting shortly after ingestion they may have aspirated the substance and will require immediate attention signs of respiratory distress hypoglycemia and cardiac arrhythmias are danger signals and the patient may also experience severe abdominal pain diarrhea and belching for hours following exposure management includes removing the contaminated clothing decontaminating the patient before transport if possible ensuring Airway patency and adequate ventilation high flow submental oxygen vascular access the administration of normal saline boluses for hypotension and transporting the patient to the appropriate medical facility.",
        "Food Poisoning": "food poisoning should be considered when two or more people become ill simultaneously at at the same location in the US four primary pathogens salmonella Toxoplasma leria and norovirus are the leading causes of food related fatalities colostrum botulism is typically associated with food poisoning resulting from improper storage or canning practices additionally toxin is produced by dof flates during red Tides can contaminate B valve shellfish like oysters clams and muscles leaving to life-threatening or fatal paralytic shellfish poisoning the onset of signs and symptoms varies depending on the toxin ranging from several hours after ingestion to days or even Weeks Later GI complaints including abdominal pain cramping nausea vomiting and diarrhea are the most common symptoms associated with food poisoning prolonged episodes of vomiting or diarrhea can lead to hypotension due to fluid loss and electrolyte imbalance respiratory distress or arrest may occur with botulism or paralytic shellfish poisoning treatment is supportive focusing on establishing and maintaining the airway supplemental oxygen and establishing vascular access.",
        "Plant-Based Toxins": "few plants are poisonous but some of the most common ornamental shrubs and house plants fall into this category most plant related exposures involve children younger than six while some plants cause local irritation of the skin others can affect the circulatory system the GI tract or the CNS dakia nicknamed dumc can result in a person being unable to speak if ingested in severe cases Adema of the tongue and Linex may lead to Airway compromise ingestion is common in children in cats another dangerous plant is the cter bean which contains risen risen exposure causes symptoms such as burning of the mouth and throat nausea vomiting diarrhea severe stomach pains frustration failing vision and kidney failure when dealing with potential plant poisonings gather all the relevant information and consult your Regional poison Center important details include when the patient was digested what exactly was eaten and what signs or symptoms the patient is exhibiting most plant-based exposures require no treatment but any child showing signs and symptoms should be evaluated at an emergency department treatment of dakia poisoning focuses on maintaining an open Airway administering oxygen and transporting the patient promptly.",
        "Conclusion": "in conclusion the various substances discussed pose significant risk to human health often requiring prompt recognition and intervention the tox iic effects of metals like lead and iron as well as compounds like Organo phosphates and carbon monoxide can lead to severe physiological disruptions ranging from respiratory distress to multi-stem organ failure these substances often encountered in occupational or environmental settings demand an understanding of their mechanisms of toxicity and the appropriate prehospital care to mitigate their life-threatening effects equally concerning are the dangers posed by miscellaneous toxic substances including hydrocarbons cosics and foodborn pathogens hydrocarbons commonly found in household and Industrial Products can cause immediate and severe respiratory and systemic effects upon inhalation or ingestion exposure to costic substances and foodborn pathogens can also lead to significant GI and systemic complications necessitating rapid assessment and supportive care to prevent further deterioration of the patient's condition lastly plant-based toxins present unique challenges particularly given their widespread availability and the ease at which they can be ingested or absorbed through the skin from ornamental shrubs like dakia and mistletoe to naturally occurring toxin in plants like poison ivy and Nightshade the potential for accidental poisoning is ever present proper identification of these plants coupled with the knowledge of their toxic effects is essential in guiding effective treatment and ensuring patient safety these substances whether encountered in the home environment or workplace underscore the importance of vigilance and preparedness in emergency medical care"
    },
    {
        "Introduction to Psychiatric Emergencies": "chapter 24 psychiatric emergencies a psychological or behavioral crisis can arise due to a variety of factors these include underlying medical conditions which may contribute to altered mental States or cognitive impairments mental illnesses such as mood disorders anxiety disorders or psychotic disorders are also significant contributors to such crises Additionally the ingestion or influence of mind altering substances such as alcohol drugs or toxins can lead to profound ch changes in behavior and perception lastly stress whether acute or chronic can overwhelm an individual's coping mechanisms leading to psychological distress or behavioral disruptions understanding these potential causes is vital for accurate assessment and appropriate intervention in prehospital care",
        "Misconceptions and Realities of Mental Health": "it's important to recognize that even individuals who are generally healthy May May occasionally exhibit symptoms or signs that resemble those of mental illness a common misconception is that feeling bad or depressed automatically means one is experiencing a mental illness various life events such as divorce job loss or the death of a loved one can lead to feelings of sadness or depression which are natural responses to these stressors however while sadness is an noral reaction to such crises it's important to monitor the duration and intensity of these feelings persistent sadness may suggest the presence of an underlying behavioral issue that requires further evaluation additionally there is widespread belief that individuals with mental health disorders are inherently dangerous violent or unmanageable when in reality only a small percentage of those with mental health conditions exhibit such behaviors while it may be challenging to determine the precise cause of a person's behavioral problem with proper assessment it's sometimes possible to anticipate when a person might become violent this understanding is critical for ensuring appropriate and safe responses in prehospital care",
        "Understanding Behavior and Abnormality": "behavior is the observable aspect of how a person responds to their environment these responses can vary in Clarity sometimes being obvious and other times more ambiguous generally people tend to react to their surroundings in ways that are considered reasonable or expected however in situations where stress levels are exceedingly High the usual coping mechanisms May Fail leading to Temporary changes in Behavior this altered Behavior may not align with what is typically seen as appr or normal there is often debate about what constitutes normal behavior as there is no universally accepted model and perceptions of normaly can vary significantly across different cultural or ethnic groups Society tends to classify Behavior as normal based on what is generally accepted within that context abnormal behavior on the other hand refers to action that deviate from societal norms and expectations such behavior Can interfere with an individual's well-being and ability to function and in some cases it may even pose harm to the person or others around them",
        "Behavioral Crises and Mental Health Patterns": "a behavioral crisis or emergency occurs when an individual's reaction to events interferes with their ability to perform activities of daily living or ADLs or becomes unacceptable to the person their family or the community when disruptions to a person's daily routine become regular the behavior may be indicative of a mental health problem establishing a pattern rather than an isolated incident in contrast isolated short-term Behavior incidents are generally considered normal and not necessarily a cause for concern however if a person exhibits an abnormal or disturbing pattern of behavior for at least a month this warrants attention from a mental health perspective for instance chronic depression characterized by persistent feelings of sadness Despair and discouragement is a medical diagnosis requiring Intervention when an individual is no longer able to respond appropriately to their environment they may be experiencing a psychological or psychiatric eer emergency this can manifest as agitation violence or the potential to harm themselves or others psychiatric emergencies are particularly serious as they involve immediate threats to the person or those around them necessitating urgent intervention to prevent harm",
        "Magnitude and Complexity of Mental Health Disorders": "according to the National Institute of Mental Health nearly one in five Americans will experience some form of Mental Health Health disorder at some point in their lives these disorders are characterized by psychological or behavioral symptoms that can lead to impaired functioning in various aspects of Life the causes of mental health disorders are multifactorial involving a combination of social psychological genetic physical chemical or biological disturbances understanding the magnitude and complexity of these factors s is essential for effectively addressing and managing mental health issues within the population",
        "Pathophysiology of Abnormal Behavior": "the pathophysiology of abnormal behavior involves various factors that can trigger behavioral emergencies abnormal behavior or altered mentation sudden grief often resulting from The Unexpected loss of a loved one can lead to profound emotional responses that may man manest as a behavioral crisis emotional conflicts which involve internal struggles or external relational difficulties can also contribute to abnormal behavior psychological problems such as underlying mental health disorders are significant contributors to altered mentation and behavioral emergencies additionally sudden illness particularly those affected the brain or nervous system can precipitate acute changes in behavior and cognitive function",
        "Impact of Trauma and Substance Use": "continuing from the previous factors recent trauma whether physical or psychological can significantly impact a person's Behavior potentially leading to abnormal responses or a behavioral emergency drug or alcohol intoxication is another common cause as these substances can alter mental status and impair judgment resulting in erratic or dangerous Behavior diseases of the brain such as Alzheimer's are associated with cognitive decline and behavioral disturbances particularly as the disease progresses metabolic disturbances such as hypoglycemia can lead to confusion agitation and other abnormal behaviors hypoxia can also cause cognitive impairment and Behavioral changes as well as exposure to extreme environmental conditions whether it be heat or cold as this can disrupt normal mental functioning and provoke abnormal behavior",
        "Organic Causes of Behavioral Emergencies": "organic causes of Behavioral emergencies often stem from disruptions in the physical or psychological functioning of brain tissue known as organic brain syndrome this condition may be temporary or permanent and can arise from various causes including sudden illness recent head trauma seizure disorders intoxication or withdrawal from drugs and alcohol and diseases affected the brain such as Alzheimer's disease or menitis altered mentation a common presentation in behavioral emergencies can also result from several factors these include hypoglycemia hyp HP oxia inadequate cerebral blood flow and exposure to extreme temperatures such alterations and mental status may also indicate an underlying psychiatric disorder such as bipolarism or an acute medical illness",
        "Environmental and Sociocultural Influences": "environmental factors play a significant role in behavioral emergencies as well continuous exposure to stressful psychosocial events or developmental influences can lead to abnormal reactions when faced with a crisis individuals typically have two options they can either cope by altering the situation or their perception of it or they may attempt to escape the stress entirely sociocultural factors also influence how a person responds biologically and behaviorally to stress injury and illness are additional contributors to to abnormal behavior acute illnesses or traumatic events often create significant stress and conditions such as PTSD are severe forms of anxiety that develop following a traumatic experience lastly substance related causes including the use of alcohol cigarettes illicit drugs and other substances can profoundly alter an individual's Behavior mood and cognitive functions leading to a behavioral emergency",
        "Functional Disorders and Their Impact": "functional disorders are mental health conditions where the etiology cannot be linked to any observable changes in the brain's structure or physiology despite the absence of detectable physical abnormalities these disorders significantly affect a person's thoughts emotions and behavior common examples of functional disorders in include schizophrenia anxiety disorders and depression these conditions are characterized by a range of symptoms that can severely impair an individual's ability to function in daily life even though the underlying cause does not involve structural brain changes",
        "Psychiatric Signs and Symptoms": "psychiatric signs and symptoms represent the body's effort to maintain equilibrium when faced with physical or psychological stress these symptoms are categorized based on the specific systems they impact the primary psychological functions involved include Consciousness motor activity speech thought processes emotional affect memory orientation and perception disruptions in these areas can manifest in various ways affecting an individual's level of awareness physical movements speech patterns cognitive processes mood memory spatial and temporal orientation sensory perceptions and even intelligence understanding these signs and symptoms is crucial for identifying and managing psychiatric conditions in the prehospital setting",
        "Emergency Medical Care and Patient Safety": "in the context of Emergency Medical Care it is Paramount to prioritize the safety of both the patient and yourself when managing a patient ensure that they are securely fastened on a stretcher with the straps fastened and if the situation warrants restrain violent patients to prevent harm it's essential to remain with the patient at all times unless you encounter an unsafe situation that necessitates a temporary departure respecting the patient's personal space is crucial always ask for permission before making physical contact and explain any procedures before carrying them out in order to alleviate the patient's anxiety strive to eliminate or reduce any factors that could distress the patient during care it's also important to maintain a non-judgmental attitude throughout your interaction as judgmental behavior Can exacerbate the patient's distress lastly if there is any indication that the patient may have ingested medication or drugs ensure that any such substances found are brought to the medical facility for proper identification and consideration during treatment this approach helps in providing the most appropriate and effective care for the patient in an emergency setting",
        "Acute Psychosis and Schizophrenia": "acute psychosis is a severe mental state characterized by delusions where an individual loses touch with reality in this condition the boundary between what is real and what is fantasy becomes blurred making it difficult for the person to distinguish between the two various factors can trigger psychotic episodes including the use of mind-altering substances intense stress delusional disorders and psychiatric conditions such as schizophrenia the duration of psychotic episodes can vary significantly some may be brief lasting only a short time while While others can persist throughout a person's life disorganization in thought processes and disorientation are common manifestations in individuals experiencing psychosis these symptoms are often associated with conditions like schizophrenia and organic brain syndromes where cognitive functions are severely impaired leading to a distorted perception of reality",
        "Challenges of Schizophrenia": "schizophrenia is is a complex and challenging mental disorder that is neither easily defined nor readily treated it typically manifests during early adulthood with symptoms gradually intensifying as the condition progresses several factors are believed to contribute to the development of schizophrenia including brain damage genetic predispositions neurobiological influences and psychological and social factors the symptoms of schizophrenia are varied and can be profoundly disruptive to a person's life common symptoms include delusions which are false beliefs that are strongly held despite evidence to the contrary and hallucinations where individuals perceive things that are simply not present apathy or a lack of interest in life's activities and mutism or the refusal to speak are also frequent symptoms additionally individuals with schizophrenia May exhibit a flat affect showing little or no emotional expression and a lack of interest in previously pleasurable activities erratic speech patterns inappropriate or diminished emotional responses and abnormal motor Behavior ranging from a lack of movement to excessive purposeless activity are further characteristic of symptoms of this disorder",
        "Assessing and Managing Psychosis": "assessing a patient experiencing psychosis presents several challenges as these individuals often exhibit incoherent or rambling speech making a thorough examination difficult the primary goal for the aemt is to transport the patient to the hospital safely minimizing any additional trauma the coast map memonic can guide the this assessment if the patient's level of Consciousness fluctuates it may indicate an organic brain syndrome disturbances in orientation are more common in organic disorders than in psychotic episodes typically the patient's activity level is increased with agitation and hyperactivity although it can be diminished often accompanied by bizarre and repetitive movements speech may be be pressured or unusual due to the use of inverted words known as neologisms thought processes are often Disturbed which can manifest as a flight of ideas where the patient rapidly jumps from one thought to another loosening of associations with disconnected orical thoughts and delusions particularly those involving persecution patients may also experience thought broadcasting where they believe others can hear their thoughts or thought insertion and withdrawal where they feel thoughts are being inserted into or removed from their mind memory function in psychosis can remain relatively intact or be entirely unaffected mood and affect are often Disturbed leading to emotional instability perceptual disturbances particularly auditory hallucinations are common in psychotic episodes managing a patient experiencing psychosis requires a specialized approach as traditional methods of reasoning are often ineffective it is important to pay attention to any uncomfortable feelings you may have as these can assist in making attentative diagnosis communication should be clear and straightforward explaining what is being done and what is expected from the patient in plain language directions given to the patient should be simple consistent and firm to reduce confusion continuously Orient the patient to the current time place and the people around them to help them stay grounded offering reassurance and pointing out familiar landmarks can further assist in orienting the patient non-pharmacologic techniques should be prioritized as these can be effective in calming the patient without the use of medication however if the patient is non-compliant imposes a danger to themselves or others it may be necessary to request paramedic backup for the administration of sedative or anti-anxiety medication to ensure the safety of all involved",
        "Depression and Suicide Risk": "depression is the most sign ific Factor contributing to Suicide making it critical to consider the possibility of suicide whenever encountering a patient experiencing depression it's important to recognize that it is a common misconception that individuals who threaten suicide will not follow through in reality a suicide threat or attempt often serves as a cry for help indicating that the person is in crisis and they're unable to manage on their their own immediate intervention is necessary in such cases several warning signs can indicate that a patient may be contemplating suicide these include an air of tearfulness sadness deep despair or hopelessness all of which suggest depression the patient may avoid eye contact speak slowly or haltingly and exhibit a sense of vacancy additionally if the patient appears unable to talk about the future it's important to explore their thoughts on this subject such as by asking about future plans like vacations any mention of suicide or specific plans relating to death should be taken seriously additional risk factors for suicide include the presence of unsafe objects within the patient's reach an unsafe environment evidence of self-destructive behavior and any IM threat to the patient or others it's also essential to consider any underlying medical problems that could be contributing to the patient's Condition it's important to remember that a suicidal patient may also pose a risk of being homicidal necessitating careful assessment and management to ensure the safety of all involved",
        "Agitated Delirium and Its Management": "agitated delirium is a condition characterized by impaired cognitive function often presenting with symptoms such as disorientation hallucinations or delusions agitation in these patients is typically marked by restless and irregular physical activity while patients experiencing delirium are generally not dangerous their agitated Behavior may lead to irrational and potentially harmful actions symptoms of agitated delirium include hyperactive and irrational behavior inattentiveness and Vivid hallucinations which may be accompanied by physical signs such as hypertension teoc cardia diaphoresis and dilated pupils hallucinations are erroneous perceptions of reality and in such cases the patient may perceive you as a threat When approaching a patient with agitated delirium it's important to ensure that can do so safely maintain a calm supportive and empathetic demeanor approach the patient slowly and purposefully respecting their personal space and limit physical contact as much as possible do not leave the patient unattended unless the situation becomes unsafe assessing the patient cognitive functioning requires careful interviewing techniques try to indirectly determine the patient's orientation memory concentration and judgment additionally try to understand what the patient is thinking and pay close attention to their ability to communicate clearly as well as their appearance dress and personal hygiene if it becomes necessary to restrain the patient due to a threat to themselves or others ensure that you have adequate and well-trained Personnel available to assist before taking action action finally if the patient appears to be experiencing an overdose make sure to take all medication bottles or any illegal substances with you to the medical facility for further evaluation and treatment",
        "Mood Disorders and Their Impact": "mood disorders are among the most prevalent mental health conditions with up to 21% of the US population expected to experience a mood disorder or major depression at some point in their lives these disorders involve significant changes in affect accompanied by other symptoms that severely disrupt a person's ability to function patients with unipolar mood disorders experience either depression or Mania while those with bipolar mood disorder alternate between episodes of mania and depression manic behavior is one of the most striking psychiatric conditions characterized by abnormally exaggerated happiness joy or Euphoria often accompanied by hyperactivity and insomnia although patients are awake and alert they are easily distracted markedly hyperactive and have difficulty concentrating the condition often involves a flight of ideas and delusions of grer making it challenging for the patient to focus on a single topic ring thoughts tangental thinking and distorted memory due to underlying delusions are common as are psychotic symptoms such as hallucinations individuals with manic behavior are at a high risk of getting into trouble due to impulsive actions or poor judgment depression another common mood disorder affected more than 7% of us adults or approximately 17.3 million people who experienced at least one major depressive episode in 2017 depression affects women more frequently than men and can occur at any age it is typically identified by sad expression bouts of crying and listless or apathetic Behavior depressive episodes may occur suddenly and last for a limited duration however when symptoms persist for more days than not over a period of at least 2 years the condition may be classified as a dymic disorder which is a chronic form of depression the memonic gas pipes is useful for remembering the diagnostic features of depression guilt appetite changes sleep disturbances impaired ability to concentrate loss of interest in activities psychomotor abnormalities decreased energy and Suicidal Thoughts",
        "Neurotic Disorders and Anxiety": "neurotic disorders are a collection of mental health conditions characterized by the absence of psychotic symptoms and lacking the intense Psychopathology that is seen in other mood disorders these conditions while serious do not involve a loss of contact with reality as is often the case with psychotic disorders however the treatment of neurotic disorders can come at a substantial cost both financially and in terms of the impact on a person's life anxiety disorders are a prominent type of neurotic disorder where the dominant emotional states are fear and apprehension these disorders can significantly affect a person's ability to function even even though they do not present the severe symptoms associated with psychosis or major mood disorders generalized anxiety disorder or Gad is characterized by excessive and uncontrollable worry about various aspects of life without a specific cause this type of worry is often unproductive leaving the person unable to make decisions about upcoming situations and individuals with Gad are typically treated with a combination of pharmacologic agents and counseling to help manage their symptoms phobias another form of anxiety disorder involve an intense and unreasonable fear apprehension or dread of a specific situation or object when confronted with the source of their phobia individuals experience intolerable anxiety which can significantly impair their ability to function it's important to explain each step of treatment to the patient in detail before proceeding to help reduce their anxiety and ensure they understand the process",
        "Panic Disorder and Management": "panic disorder is characterized by sudden and overwhelming feelings of fear and dread that usually occur unexpectedly accompanied by a variety of other symptoms women are most likely to be affected by this condition and most individuals can identify a stressful event that preceded their first panic attack a common related condition is agoraphobia which is the fear of going into public places panic disorder is marked by a discharge of the autonomic nervous system and hyperventilation with symptoms peaking in intensity within about 10 minutes and Lasting about an hour to manage a panic attack of effectively it's important to follow specific steps separate the patient from panicky bystanders provide a calm environment be tolerant of their disability reassure them that the situation is safe give the patients symptoms a name and help the patient regain control panic attacks can mimic a range of physical disorders so it's crucial that any patient patient experiencing a panic attack be fully evaluated in a hospital setting hyperventilation a common symptom of panic attacks is best managed initially by coaching the patient to slow their breathing until they regain control",
        "Legal Considerations in Psychiatric Emergencies": "the medical and legal considerations become more complicated when dealing with a patient undergoing a behavioral crisis or psychiatric emergency legal issues are often mitigated when the patient consents to care making it critical to gain the patient's confidence to ensure cooperation mental incapacity can manifest in various forms such as unresponsiveness due to hypoxia drug use or hypoglycemia as well as temporary but severe stress or depression once it is determined that a patient has impaired mental capacity it's essential to assess whether they require immediate emergency see Medical Care a patient in a mentally unstable condition May resist attempts to provide care and it is important not to leave the patient alone as doing so could expose the caregiver to civil action for abandonment or negligence if the situation escalates it's advisable to request the presence of law enforcement Personnel to handle the patient especially if the patient resists treatment or poses a threat to the Prov fer these considerations are critical to ensure the safety and legal protection of both the patient and the care providers during a behavioral or psychiatric emergency",
        "Consent and Competency Issues": "in situations where a patient is not mentally competent to Grant consent implied consent is generally assumed allowing emergency providers to proceed with the necessary treatment however if the situ situation is not immediately life-threatening emergency medical care or Transportation may need to be delayed until proper consent is obtained to ensure legal compliance when there is uncertainty it's important to contact medical control or follow local protocols to guide the decision-making process it is important to recognize that consent issues are not always straightforward in psychiatric emergencies requiring care F consideration and adherence to legal and ethical guidelines to navigate these complex situations appropriately patients generally have the right to refuse care but this right is subject to limitations especially in the context of mental illness or drug impairment Most states have legal statutes addressing the emergency care of mentally ill and Drug impaired individuals allowing law enforcement Personnel to Place such individuals in protective custody to ensure they receive the necessary care in certain cases medical Direction May order the transport of a patient even if they do not consent a competent adult has the right to refuse treatment including life- saving care however in psychiatric cases a court of law would likely support your decision to provide life-saving care if you have a reasonable belief that the patient might harm themselves or others without your intervention patients who are impaired whether by mental illness medical conditions or intoxication may not be considered competent to refuse treatment or Transportation when faced with uncertainty it's crucial to consult your Superior law enforcement Andor medical control to ensure that your actions are legally and ethically sound in such situations it's advisable to air on the side of providing treatment and transportation to safeguard the patient's well-being and ensure compliance with legal obligations",
        "Use of Restraints in Psychiatric Emergencies": "the use of restraints on a patient must be authorized by a physician a court order or a law enforcement officer this could look like a direct order from medical control over the radio or standing orders in your protocol book if you restrain a person without proper Authority in a non-emergency situation you risk exposing yourself to potential lawsuits and personal danger legal actions that could be taken against you include charges of assault battery false imprisonment and violation of civil rights these legal implications highlight the importance of ensuring that any restraint used on a patient is appropriately authorized and Justified within the legal framework never threaten a patient with restraint as this could be seen as a threat when using restraints it's important to do so only to protect yourself or others from bodily harm or to prevent the patient from committing self harm you should only use the amount of force necessary to control the patient and it's essential to consult medical control and involve law enforcement Personnel when possible especially since different courts May interpret the use of force differently in severe Behavioral or psychiatric crisis law enforcement Personnel should be involved if restraints are necessary and if a patient is restrained by law enforcement they are considered to be in custody whenever possible try to transport a disturbed patient without restraints if restraints are required at least five trained individuals should be present with each person responsible for one extremity before initiating restraint discuss the plan of action and stay outside the patient range of motion during the process always use the minimum force necessary when applying restraints avoid using physical force that could injure the patient and secure their extremities with approved equipment while treating them with dignity and respect monitor the patient for vomiting Airway obstruction and cardiovascular stability and never place the patient face down frequently check circulation in all restrained extremities document the reason for restraint and the technique used and be cautious if a combative patient suddenly becomes calm and Cooperative finally ensure that Witnesses are present during the restraint process and document their presence to protect any potential legal repercussions once the patient is restrained you should not remove restraints unless you are in a vehicle accident and have to move the patient out of the vehicle quickly this comprehensive approach ensures that the use of restraints is conducted safely legally and within the utmost care for the patients's well-being",
        "Post-Traumatic Stress Disorder": "post-traumatic stress disorder or PTSD can develop after an individual is exposed to or injured by a traumatic event this condition can arise from a single traumatic incident or as a result of multiple traumatic experiences accumulated over time PTSD is not uncommon with estimates suggesting that 7 to 8% of the general population will experience signs of PTSD at some point in time in their lives approximately 30 to 35% of EMS Personnel meet the criteria of or have been diagnosed with PTSD at some point in time in their careers the signs and symptoms of PTSD include persistent feelings of helplessness anxiety anger and fear individuals with PTSD may also go to Great Lengths to avoid situations places or objects that remind them of the traumatic event additionally PTSD is often car characterized by heightened nervous system arousal that persists and is difficult to suppress leading to a state of constant vigilance and hyperarousal these symptoms can severely impact the daily lives of those affected particularly returning combat veterans who may experience PTSD as a result of their service in addition to feelings of anxiety fear and anger individuals with PTSD often experience heightened physiological responses these responses can include an increased heart rate pupil dilation elevated systolic blood pressure sharpened senses and heightened mental acuity these patients may also relive their traumatic experiences through intrusive thoughts nightmares or flashbacks which can feel as though they are experiencing the events all over again recent traumatic events May serve as triggers bringing back old memories to the surface and causing the individual to reflexively prepare for the worst in some cases disassociative PTSD can occur where the person attempts to mentally escape from the internal distress caused by the traumatic memories or from a particularly disturbing event along with these responses individuals with PTSD may also experience feelings of guilt shame paranoia hostility and depression all of which can contribute to the overall emotional burden of the condition",
        "Caring for Combat Veterans with PTSD": "caring for combat veterans requires a unique approach due to the specific challenges they face veterans are at a significantly higher risk of self harm or suicidal Behavior compared to the general population additionally combat veterans May develop heart disease earlier than expected for their age have a higher incidence of type 2 diabetes and may experience loss of brain gray matter they are also more likely to have high cholesterol and hypertension a significant concern for combat veterans is the higher incidence of traumatic brain injury or TBI often substained from explosions such as those from improvised explosive devices or ie s unfortunately TBI may go undiagnosed because its symptoms can closely resemble those of PTSD or because the veteran might downplay their symptoms when treating a combat veteran with PTSD it's important to minimize excess noise as this can exacerbate their symptoms always provide explanations before touching the veteran or performing any actions as sudden and unexplained movements can be triggering be aware that even specific triggers like the smell of diesel fumes can invoke strong reactions in combat veterans caring for combat veterans requires a high level of understanding compassion and specialized attention taking the time to establish the patient's history and listen to their concerns is essential approach these patients with sensitivity and respect and be mindful of how you phrase your questions to avoid causing distress or misunderstanding this thoughtful approach is critical in providing effective care and support for our combat veterans",
        "Conclusion: Managing Psychiatric Emergencies": "in conclusion managing patients experiencing Behavioral or psychiatric emergencies requires a thorough understanding of the complexities involved in both their medical and legal care patients in these situations may be mentally incapacitated due to conditions such as hypoxia drug impairment or severe stress necessitating careful consideration of their ability to consent to treatment in such cases implied consent is often assumed but when there is doubt Consulting medical control or following local protocols is essential legal and ethical guid guidelines must be followed closely especially when decisions involve the use of restraints which should only be applied with proper authorization and for the protection of the patient and others the use of restraints must be approached with caution utilizing the minimum force necessary and ensuring that the patient dignity and safety are maintained at all times PTSD particularly among returning combat veterans highlights the need for Specialized Care PTSD can arise from exposure to traumatic events and is characterized by symptoms such as heightened physiological responses intrusive thoughts and avoidance behaviors veterans with PTSD may also suffer from comorbid conditions like TBI which can complicate their clinical presentation providers should approach these patients with a high level level of understanding and sensitivity taking the time to establish their history and address their concerns with respect and care recognizing the specific triggers that might exacerbate their symptoms such as loud noises or certain smells is important in providing effective support ultimately providing care to patients with Behavioral or psychiatric conditions including combat veterans requires a multi-is Ary approach that balances medical treatment with legal and ethical responsibilities practitioners must be prepared to navigate the challenges of mental incapacity the use of restraints and the complexities of PTSD all while maintaining the highest standards of care and compassion by following established protocols involving appropriate authorities when necessary and treating each patient with the respect and dignity they deserve healthc care providers can ensure that they are delivering the best possible care in these difficult situations"
    },
    {
        "Introduction to Gynecologic Emergencies": "chapter 25 gynecologic emergencies occasionally women of reproductive age May encounter substantial gynecologic issues that require immediate medical attention these problems can include menorragia which is characterized by excessive menstrual bleeding which can lead to anemia and other complications if not treated promptly soft tissue injuries in the pelvic area may result from trauma or other causes potentially leading to pain and functional impairment sexually transmitted infections or STI such as chyia gonorrhea and herpes require urgent treatment to prevent further complications and transmission additionally abnormal vaginal discharge which can be indicative of infections or other conditions necessitates prompt evaluation to determine the underlying cause and appropriate treatment while this will be a minority of the calls an AMT will respond to this lecture will focus on gynecologic conditions that one may encounter in the prehospital field",
        "Anatomy of the Female Reproductive System": "the female reproductive system comprises several key structures including the external genitalia uterus vagina Fallopian tubes ovaries and perineum the ovaries which are almond shaped organs situated on either side of the pelvic cavity are responsible for producing OVA as well as the hormones estrogen and progesterone these hormones are secreted by the corpus luteum a small yellow endocrine structure that forms within a ruptured ovarian follicle the Fallopian tubes are paired structures that extend laterally from the uterus and terminate near the ovaries their primary function is to facilitate the transport of an ovom from the ovary to the uterus additionally they play a role in guiding spermatozoa from the uterine cavity toward the ovary which is essential for fertilization the Fallopian tubes are lined with ciliated epithelial cells that help Propel the ovam and spermatozoa along their respective paths the uterus is a hollow muscular organ where implantation and growth of the fertilized egg occur it is responsible for the contractions during labor which are crucial for the expulsion of the fetus through the birth canal the uterus consists of several anatomical components the fundis which is the rounded upper portion the body which is the central part of the uterus the uterine cavity where the embryo implants and develops the endometrium which is the inner lining that changes in response to hormonal fluctuations throughout the menstrual cycle and the myometrium which is the thick muscular layer that facilitates uterine contractions the vagina is the outermost cavity within the female reproductive system forming the lower segment of the birth canal it begins at the cervix the narrow lower portion of the uterus and extends to the external opening of the body this elastic muscular tube is integral to several functions including the passage of menstrual blood the delivery of the fetus during child birth and the reception of spermatazoa during intercourse the cervical Canal a component of this system provides a passageway from the uterine cavity to the vaginal opening enabling the transfer of substances between the uterus and the external environment the vagina structure supports its roles in reproductive health and child birth",
        "External Female Genitalia": "the external female genitalia collectively known as the Volva includes several anatomical structures the mons pubis is a fatty pad located over the pubic symphysis the laia Majora are the outer larger folds of skin that enclose and protect the other external genitalia within the laia Majora are the laia minora which are smaller inner folds that surround the vestibule the ptus a highly sensitive organ located at the anterior Junction of the labia manora plays a key role in sexual arousal the preuse or forkin is the fold of skin that covers the clitorus the vestibule is the area enclosed by the labia manora and contains the opening of the urethra and the vaginal orifice the high is a thin membrane partially covering the vaginal orifice in some individuals the perenium is the area between the vaginal orifice and the anus with the anus being the opening through which feces are expelled from the body",
        "Menstrual Cycle and Hormonal Changes": "each month the increase in hormone levels in females prompts characteristic physiological changes these hormones stimulate the development of os sites in the ovaries and cause the endometrium to thicken in preparation for potential implantation of a fertilized egg if fertilization occurs in the egg implants in the uterus ministration is suspended for the duration of the pregnancy however if no fertilization takes place menstration will begin this involves the cyclical shedding of the uterine lining typically occurring every 28 days lasting for 4 to 6 days with a blood loss of approximately 25 to 60 M the initial onset of menstration known as minarc occurs during puberty menopause marks the cessation of menstration and ovarian function usually occurring between the ages of 45 and 55 years",
        "Premenstrual Syndrome (PMS) and Management": "premenstrual syndrome or PMS is characterized by a range of symptoms that typically emerge 7 to 14 days prior the onset of menstrual flow and generally resolve once menstration commences this condition affects about 20 to 30% of premenopausal women and can significantly impact their daily lives various factors including stress dietary habits alcohol consumption and the use of prescription or over-the-counter medications can exacerbate the severity of PMS symptoms in some cases women may experience reactive hypoglycemia which can contribute to increased feelings of fatigue and weakness in a prehospital setting the management of PMS involves supportive care aimed at alleviating symptoms which may include the administration of oral or intravenous glucose to counteract hypoglycemia and provide symptomatic relief",
        "Mittelschmerz and Amenorrhea": "middle schurtz is a type of abdominal pain and cramping that typically arises about 2 weeks prior to the onset of menstration correlating with the ovulatory phase of the men cycle this discomfort results from the release of an ovom from the ovary and can commence at various times during ovulation the pain is often described as sharp and cramping commonly localized to one side of the lower abdomen corresponding to the ovary releasing the egg while the discomfort is generally transient and can be alleviated with over-the-counter analgesic persistent or unusual pain should be evaluated by a healthc care professional in order to rule out other potential causes such as ovarian cysts or a topic pregnancy which would necessitate further investigation and treatment am manoria is characterized by the absence or cessation of menstrual periods the most prevalent cause is pregnancy which halts the regular menstrual cycle additionally exercise induced amoria is frequently observed in female athletes particularly when intense physical activity leads to a significant reduction in body fat such a decrease in body fat can disrupt hormonal balance and result in the cessation of mes it may also be attributed to emotional factors or severe stress which can affect the hypothalmic pituitary ovarian axis and disrupt the menstrual function in adolescents or young adults this condition may be associated with eating disorders such as anorexia nervosa or bulimia or malnutrition and significant weight loss interfere with the hormonal regulation of the menstrual cycle",
        "Gynecologic Emergencies": "disorders of the female reproductive system can result in gynecologic emergencies that require prompt medical attention these emergencies may include acute or chronic infections which can lead to significant complications if left untreated Hemorrhage either from trauma or internal issues poses a serious risk and necessitates immediate intervention Additionally the rupture of an ovarian cyst can cause sudden and severe abdominal pain while while the rupture of an atopic pregnancy presents a life-threatening situation due to internal bleeding and requires urgent medical care",
        "Pelvic Inflammatory Disease": "pelvic inflammatory disease or PID is an infection that affects the upper reproductive organs in females including the uterus Fallopian tubes and ovaries this condition can manifest as either an acute or chronic infection when PID occurs it often starts in the lower reproductive tract and can extend to the Fallopian tubes and ovaries this can lead to a significant amount of inflammation the primary clinical symptoms of PID include pelvic pain and fever which are indicative of the infection and inflammation present in the pelvic region complications associated with this disease are serious and can have lasting effects on reproductive Health these complications include sepsis abscess formation which involves the development of pus filled Pockets within the reproductive organs and generalized peritonitis an inflammation of the perenium which is the lining of the abdominal cavity infertility is a notable consequence of P due to the scarring and damage to the flu I tubes which can obstruct the passage of eggs to sperm the scarring can also increase the risk of atopic pregnancy where a fertilized egg implants outside the uterus often in the fallopian tube this leads to a potentially life-threatening situation sexually transmitted infections are often the primary cause of p with chlamidia and gonorrhea being the most common pathogens P usually develops as a secondary infection following an STI management includes placing the patient in a comfortable position and providing supportive care to alleviate symptoms and Aid recovery",
        "Bacterial Vaginosis and Chancroid": "bacterial vaginosis is the most prevalent vaginal infection among women aged 15 to 44 this condition occurs with the normal balance of vaginal Flora is disrupted leading to an overgrowth of other bacterial forms symptoms include itching burning or pain often accompanied by a fishy or foul smelling discharge if left untreated especially during pregnancy this can lead to premature birth low birth weight increased susceptibility to more serious infections and progression to PID shanid is a sexually transmitted infection caused by the bacterium hemophilus ducry this infection is highly contagious but can be effectively treated with antibiotics the disease typically presents with painful ulcers or sores on the genitals which can be quite distressing in addition to the genital sword the infection may cause swollen and painful lymph nodes in the groin area known as inguinal bbos these lymph nodes can become significantly enlarged and tender adding to the discomfort notably women with shank croid may not always show symptoms which can complicate diagnosis and increase the risk of unknowingly spreading the infection",
        "Chlamydia and Cytomegalovirus": "lyia is currently the most commonly reported STI in the United States this condition is often asymptomatic or may simply present with mild symptoms making it challenging to detect without routine screening when symptoms do occur they may include lower abdominal pain discomfort in the lower back nausea fever pain during sexual intercourse and bleeding between men periods the absence of symptoms can lead to delayed treatment which poses a risk of the infection progressing to PID cyto megalin virus or CMV is a member of the herpes virus family and is known for its widespread prevalence and ability to persist in the body for years without causing symptoms although there is no cure for CMV the virus can remain dormant and reactivate under certain circumstances when symptomatic CMV infection presents with a range of symptoms including prolonged high fever chills headache General malaise extreme fatigue and splenomegaly certain populations are at an increased risk for serious complications related to CMV individuals with immune disorders such as those with HIV or Aids are particularly vulnerable to severe manifestations chemotherapy patients due to their compromised immune systems also face heighten risks pregnant women are another higher risk group as CMV can be transmitted to the fetus potentially leading to congenital CMV infection newborns who contract CMV may suffer from a variety of conditions including respiratory issues such as pneumonia hematologic abnormalities like thrombos opedia liver problems including hepatitis swollen glands a characteristic rash and poor weight gain the impact of CMV on newborns can be significant and requires careful monitoring and management to address these potential complications",
        "Genital Herpes and Gonorrhea": "genital herpes is an infection affecting the genitals buttocks or anal area and is caused by the herpes simplex virus HSV this virus has two types hsv1 and hsv2 hsv1 is most commonly associated with oral infections such as cold sores or fever blisters but it can also cause genital sores hsv2 is primarily responsible for genital herpes and is more serious though it can also affect the mouth genital herpes is more prevalent among women symptoms of an active infection generally emerge within two weeks of the initial exposure and can persist for several weeks the IAL symptoms often include tingling or Soares at the sight where the virus entered the body other symptoms may include fever muscle aches and pains headache disera vaginal discharge and swollen glands in the groin area the recurrence of symptoms can vary and individuals with genital herpes may experience outbreaks periodically Gara is an infection caused by the bacterium neria goria it affects the cervix uterus and Fallopian tubes in women and the urethra in both women and men in addition to these areas the bacterium can also colonize the mouth throat eyes and anus symptoms of Gonorrhea typically appear 2 to 10 days after exposure with manifestations generally more severe in men women may be asymptomatic or experience mild symptoms for months until the infection advances to other parts of the reproductive system in women common symptoms include disera accompanied by burning or inching yellow or bloody vaginal discharge with a foul o and occult blood related to vaginal intercourse more severe cases may present with cramping and abdominal pain nausea and vomiting as well as bleeding between menstrual periods which can indicate progression to PID rectal infections and infections of the throat are also possible if untreated gonorrhea can lead to systemic spread including to into the brain",
        "Human Papillomavirus (HPV) and Syphilis": "genital warts are caused by the human Pila virus or HPV the presentation varies as some individuals may be asymptomatic While others develop multiple growths in the genital areas HPV is a significant eological factor in the development of cervical vver and anal cancers in pregnant women G warts May grow large enough to obstruct urination or block the birth canal complicating delivery if the virus is transmitted to the fetus during child birth this can lead to lenia papilomatosis a condition where warts develop in the infants linic potentially causing respiratory issues syphilis is an infection caused by the bacterium trepa padium often referred to as the great imitator due to its ability to mimic symptoms of other diseases the disease progresses through three distinct stages primary secondary and tertiary transmission occurs through direct contact with open sorce and individuals may remain asymptomatic for years in the primary stage syphilis is marked by the appearance of a single soore known as a chakra which may be painless small firm and round this sord typically results within 3 to 6 weeks at which point the infection advances to the secondary stage this is characterized by mucous membrane lesions and a rash that may appear on the palms of the hands and the soles of the feet the rash consists of rough red or red brown spots and is generally not itchy additional symptoms during the stage may include fever swollen lymph glands sore throat patchy hair loss headaches weight loss muscle aches and fatigue these symptoms often resolve without treatment but if left untreated the disease progresses to tertiary syphilis in this stage significant internal damage begins to occur affected the brain nerves eyes heart blood vessels liver bones and joints this damage can be asymptomatic for years but may eventually lead to severe manifestations such as paralysis numbness dementia gradual blindness and coordination difficulties pregnant women with syphilis risk having babies who were still born born blind developmentally delayed or who may die shortly after birth",
        "Trichomoniasis and Vaginal Yeast Infections": "tronis is a sexually transmitted infection caused by the protozoan tronus vaginalis this parasite primarily infects the vaginal area in women although it can affect the urethra and other parts of the reproductive system the most common symptoms include a frothy yellow green vaginal discharge that often has a strong unpleasant odor women may also experience irritation and itching in the genital area discomfort during intercourse disera and lower abdominal pain the infection can be asymptomatic in some individuals which can lead to delays in diagnosis and treatment if not treated it poses risks during pregnancy potentially leading to complications such as low birth weight or premature birth moreover if left untreated it can increase an individual's susceptibility to HIV infection as the infection can cause inflammation and damage the genital tract making it easier for HIV to enter the body vaginal yeast infections are caused by the fungus candida albicans under normal conditions the acidic environment of the vagina inhibits the overgrowth of yeast however if this acidity is disrupted the yeast population can increase leading to an infection several factors can alter the vaginal pH and contribute to yeast infections these include the use of oral contraceptives menstration pregnancy diabetes and the use of certain antibiotics additionally moisture and irritation of the vaginal area stress related to lack of sleep illness or poor diet as well as immunosuppressive conditions such as HIV infection or uncontrolled diabetes can also affect the vaginal environment and promote yeast overgrowth symptoms of a vaginal yeast infection include itching burning and soreness in the vagina and around the vulva as well as vvar swelling a characteristic symptom is a thick white vaginal discharge that resembles cottage cheese other symptoms may include pain during sexual intercourse and a burning sensation during urination",
        "Ruptured Ovarian Cyst and Ectopic Pregnancy": "a ruptured ovarian cyst occurs when a fluid filed Sac attached to to the ovary brakes these can sometimes contain a significant amount of fluid while many ruptured cysts resolve on their own without major complications in some cases surgical removal may be necessary especially if the cyst is large or persistent internal bleeding from a ruptured ovarian cyst is fairly uncommon but it does occur in rare cases an atopic pregnancy occurs when a fertilized ovam implants and begins to develop outside the uterine cavity with the fallopian tube being the most frequent site of implantation this condition is significant because it can lead to serious complications the most common initial symptom is vaginal bleeding which may be the only indication of an atopic pregnancy especially in its early stages the rupture of an atopic pregnancy poses a considerable risk of internal hemorrhage into the abdominal cavity which is a leading cause of maternal mortality during the first trimester internal bleeding from a ruptured atopic pregnancy can cause severe abdominal pain and may lead to hypovolemic shock if not properly addressed therefore it's crucial for healthcare providers to consider the possibility of an atopic pregnant y when evaluating women who have missed a menstrual cycle and present with sudden sharp and typically unilateral lower abdominal pain certain risk factors heighten the likelihood of an atopic pregnancy these include a history of PID which can cause scarring of the Fallopian tubes previous tubal liation which might lead to altered tubal function and a history of Prior atopic pregnancies each of these factors can compromise the normal transport of the ovom through the fallopian tube increasing the risk of a topic implantation clinicians should be vigilant in considering atopic pregnancy in any female of reproductive age who presents with abdominal pain early detection and management are essential to prevent the severe consequences associated with this condition prompt evaluation typically involves a combination of History taking physical exam and Diagnostic Imaging such as transvaginal ultrasound in order to confirm the diagnosis and to help guide appropriate treatment",
        "Risk Factors for Ectopic Pregnancy": "several factors can disrupt the normal pathway of the ovom leading to an increased risk of atopic pregnancy previous surgical adhesions often resulting from past abdominal or pelvic surgeries can cause scarring that obstructs or distorts the Fallopian tubes PID is another significant risk factor as it can lead to chronic inflammation and scarring of the reproductive organs particularly in the Fallopian tubes tubo liation a surgical procedure for permanent contraception can some sometimes lead to complications such as tubal occlusion or alterations in tubal function which may increase the risk of atopic pregnancy Additionally the presence of intrauterine devices or an IUD May interfere with the normal migration of the ovam through the Fallopian tubes though this is not very common typically the Fallopian tubes are the primary sites affected by these conditions if an atopic pregnancy does go undiagnosed and untreated the growing embryo can cause the fallopian tube to rupture this rupture represents a critical emergency as it can lead to severe internal bleeding and shock",
        "Vaginal Bleeding in Pregnancy": "vaginal bleeding should never be assumed to be merely a normal ministration when responding to an emergency call it can indicate more serious conditions such as spontaneous abortion or miscarriage especially if bleeding is accompanied by other symptoms in the third trimester of pregnancy any vaginal bleeding is considered a significant emergency and warrants immediate medical attention placenta Privia a condition where the placenta is abnormally positioned over the cervix typically presents with bright red bleeding in contrast abrupt sh placente where the placenta detaches prematurely from the uterine wall is characterized by dark bleeding typically placenta Privia involves substantial bleeding with relatively mild abdominal pain whereas abruptio placente usually presents with minimal bleeding but is associated with moderate and severe abdominal pain in addition to common causes of vaginal bleeding several other factors May contribute to abnormal bleeding the onset of Labor can cause vaginal bleeding as the cervix begins to dilate and the body prepares for delivery a ruptured atopic pregnancy is another serious condition that can result in vaginal bleeding and is often accompanied by a significant amount of abdominal pain and internal hemorrhage PID and other infections may also cause vaginal bleeding due to inflammation and disruption of the reproductive tract trauma such as a physical injury or lesions from previous surgeries or disease processes can further contribute to bleeding traumatic causes of vaginal bleeding include stratal injuries which occur when a person falls or impacts the perineum blows to the perineum from direct trauma or blun Force to the lower ABD such as from an assault or seat belt injury can also result in bleeding insertion of foreign objects into the vagina attempts at abortion or soft tissue injuries can cause significant bleeding each of these conditions requires careful assessment and appropriate medical intervention to address the underlying calls and manage the patient's condition effectively",
        "Endometritis and Endometriosis": "endometria is is an inflammatory condition that affects the endometrium which is the mucosal lining of the uterus this condition is particularly prevalent following child birth or miscarriage due to the potential disruption and exposure of the uterine lining the primary etiology of endometritis is infectious with sexually transmitted infections notably gonorrhea and chlamidia being the most common causitive agent patients with endometritis typically present with a constellation of symptoms including generalized malaise fever and GI disturbances such as constipation or discomfort during bowel movements they may also experience vaginal bleeding or discharge abdominal distension and lower abdominal or pelvic pain treatment generally involves antibo therapy aimed at eradicating the infecting organisms without appropriate treatment IND Demetrius progresses to severe complications such as septic shock or in pregnant patients May contribute to spontaneous abortion endometriosis is a condition characterized by the growth of endometrial tissue outside the uterine cavity this aop tissue can adhere to various structures within the pelvis such as the ovaries Fallopian tubes and the outer surface of the uterus endometriosis is a leading cause of infertility affecting approximately 30 to 50% of women who experience difficulties conceiving many women remain asymptomatic until they encounter problems with fertility at which point endometriosis May may be diagnosed the most prevalent symptom of endometriosis is pelvic pain which is commonly localized to the lower back pelvic region and abdomen patients may experience a range of symptoms including painful intercourse GI discomfort disera and painful bowel movements particularly during menstration additional symptoms include chronic fatigue severe and Progressive menstrual cramping and notably heavy menstrual periods management typically involves providing pain relief through analgesics effective pain management can help alleviate some of the discomfort associated with this condition though treatment strategies may also include hormonal therapies or surgical options depending on the severity and the impact of the symptoms",
        "Postpartum Eclampsia": "postpartum eclampsia is a severe and potentially life-threatening complication that can occur after the birth of a baby although the condition typically presents within the first 24 hours following delivery it can develop as late as 4 weeks postpartum this condition is characterized by the onset of seizures and significantly elevated blood pressure in women who have recently given birth postpartum eclampsia is a continuation of preclampsia a pregnancy related hypertensive disorder women who experienc postpartum eclampsia may have had preclampsia during pregnancy or may develop symptoms for the first time after delivery the seizures associated with postpartum eclampsia can be severe and require immediate medical intervention the elevated blood pressure seen in postpartum eclampsia can lead to complications such as stroke renal failure and cardiovascular issues if not promtly managed it's crucial for the provider to recognize the signs of postpartum eclampsia quickly and provide appropriate treatment to mitigate risks management typically involves stabilizing the patient with medications to control blood pressure and prevent further seizures as well as providing supportive care given the complexity and potential severity of postpartum eclampsia paramedic backup is essential to ensure that the patient receives timely and effective Medical Care immediate transport to an appropriate medical facility is often necessary for comprehensive evaluation and treatment",
        "Sexual Assault and Medical Care": "sexual assault is a traumatic experience with the majority of victims being women although men and children are also affected victims of sexual assault often require immediate and compassionate medical care including psychological assessment and support it is essential to provide empathetic care and ensure the patient is transported to a safe medical facility where they can receive comprehensive treatment victims of sexual assault may present with multiple system trauma which necessitates prompt medical attention to address both physical injuries and potential shock the trauma can Encompass a range of injuries and may require interventions to stabilize the patient and manage the symptoms of shock in addition to physical care a thorough psychological assessment is needed to address the emotional and psychological impact of the assault providing access to mental health support and counseling services is an important aspect of the overall care plan this approach not only addresses the immediate medical needs but also supports the victim's long-term recovery and well-being",
        "Patient Assessment and Scene Safety": "a comprehensive and detailed patient assessment is essential for determining the severity of the patient's condition and deciding on the appropriate interventions this assessment involves evaluating the patient's overall health status identifying the severity of symptoms and recognizing whether immediate life-saving measures are required accurate and thorough evaluation is critical as an incomplete or incorrect diagnosis can lead to fatal consequences for the patient ensuring that all aspects of the patient's condition are thoroughly assessed allows for timely and appropriate treatment decisions which ultimately improves the likelihood of a positive outcome during the scene size up it's essential to adhere to standard precautions to ensure both personal safety and effective patient care gynecologic emergencies often involve significant amounts of blood and body fluids which may be contaminated with communicable diseases utilizing appropriate personal protective equipment and following infection control Protocols are crucial to prevent exposure to these potential hazards the information gathered during the scene size up plays a vital role in assessing the patients overall health and evaluating the safety of the environment understanding the mechanism of injury or the nature of illness provides critical insights into the patient's condition and guides the subsequent assessment and treatment evaluating these factors helps in identifying the specific nature of the emergency which is essential for providing appropriate care and ensuring a safe and effective response to the situation",
        "Emergency Medical Care for Gynecologic Emergencies": "in providing emergency medical care for GH ecologic emergencies maintaining the patient's privacy and modesty is important establish trust by communicating clearly and answering any questions the patient may have honestly use sanitary pads to absorb blood from the external genitalia and avoid tampons as they can interfere with the assessment in management of bleeding if the patient shows signs of shock or has excess vaginal bleeding position her spine and ensure she is kept warm to help stabilize her condition establish at least one IV using a large board catheter inserted in a vein large enough to facilitate effective fluid resuscitation administer a Bolis of 20 MLS per kg of an isotonic crystalloid solution to address potential hypohemia if the patient is not in shock position her her comfortably based on her symptoms and presentation for practical reasons and to enhance communication place the patient on her left side ensuring that she faces you rather than the wall of the ambulance treat any external lacerations abrasions and tears with sterile compresses to minimize the risk of infection and promote healing it's important to avoid packing or placing dressings inside the vagina as this can complicate the situation and potentially exacerbate any underlying issues additionally consider the possibility of pregnancy when assessing the patient as it may influence the management and treatment approach be prepared for the potential occurrence of a miscarriage and ensure that appropriate measures are in place to manage such an event should it take place",
        "Managing Patients with PID and Ruptured Ovarian Cyst": "when assessing and managing a patient with PID look for signs such as lower abdominal pain fever vaginal discharge and painful intercourse patients with PID often present with a distinctive posture walking in a doubled over position and guarding their abdomen due to pain their gate is usually shuffling and they may appear visibly ill position the patient in a manner that provides the most comfort as this can help alleviate some of the discomfort associated with PID ensure that the patient is transported to an appropriate medical facility for further evaluation and treatment as timely intervention is critical for managing this condition effectively in the case of a ruptured ovarian cyst patients typically experience a sudden onset of severe lower abdom adal pain this pain is often unilateral meaning it's localized to one side of the abdomen but may radiate to the lower back additionally there may be some vaginal bleeding associated with the rupture",
        "Ectopic Pregnancy and Shock Management": "in the context of an atopic pregnancy the patient typically presents with signs of hypophil liic shock which may include hypotension teoc cardia and altered mentation the patient often reports severe abdominal pain which may radiate to the back vaginal bleeding can be minimal or even absent despite the possibility of amoria the patient may not be aware of their pregnancy if a rupture occurs bleeding may become significant leading to more pronounced signs and symptoms when assessing this patient gather a detailed history including any previous abdominal surgeries that might indicate surgical adhesions inquire about any history of PID tubal liation the use of an intrauterine device or prior atopic pregnancies as these factors increase the risk of atopic pregnancy monitor the patient closely for signs of impending shock including orthostatic changes in vital signs document the presence and volume of vaginal bleeding given that a rupture to topic pregnancy is a critical medical emergency establish a second IV line if shock is evident and then transport the patient promptly to the nearest appropriate medical facility",
        "Vaginal Bleeding and Trauma": "when managing a patient with vaginal bleeding it's essential to consider that the bleeding may be minasia character ized by heavy vaginal bleeding during the first or second trimester of pregnancy any vaginal bleeding could indicate a spontaneous abortion or miscarriage inquire about any previous episodes of similar bleeding to assess for patterns or recurring issues and provide emotional support to the patient throughout the assessment and treatment process bleeding during the third trimester is particularly concerning and should be treated as a serious emergency as it may indicate conditions such as placenta Privia or bruo placente it's important to inquire about the onset and progression of symptoms to understand the potential severity of the situation if large clots or pieces of tissue are present these should be collected and transported to the emergency department for further analysis additionally patients who have experienced abdominal trauma may present with severe bleeding pain and signs of hypophil liic shock",
        "Handling Sexual Assault Cases": "sexual assault encompasses a range of violations with rape being the most prevalent form during the management of a sexual assault case it's crucial to anticipate the involvement of law enforcement early in the process whenever feasible off for female victims the option to be attended by a female aemt to provide comfort and sensitivity maintaining professionalism tact kindness and sensitivity throughout the care process is essential perform a physical examination judiciously focusing only on identifying life-threatening injuries in order to avoid exacerbating mental TR trauma protecting the patients's privacy and providing them with a sense of control are critical and fostering trust and ensuring their dignity is upheld in the medical treatment of a patient who is experienced a sexual assault the primary concern is to address any immediate medical needs equally important is the psychological care of the patient the provider should not interrogate the patient or attempt to elicit details for law enforcement purposes that being said preservation of evidence is vital avoid cutting through any clothing or discarding items from the scene collect Blood Stained articles in separate paper bags rather than plastic and use evidentiary bags provided by the police if necessary gently advise the patient against cleaning up up using hand sanitizer urinating changing clothes moving her bowels or rinsing out her mouth if the patient insists on these actions respect her decisions while documenting them thoroughly patients May sometimes refuse transport in such cases offer to contact a local Rape Crisis Center for them and adhere to your protocol for for such calls when documenting the incident in the patient care report ensure that it is precise and factual record only what the patient has stated using their own words indicated by quotation marks it is important to refrain from inserting personal opinions or drawing conclusions about the validity of the patient's account you should focus solely on the facts recognizing that rape is a legal term rather than a medical diagnosis",
        "Drugs Used in Sexual Assault and Foreign Bodies": "drugs used to facilitate rape are often undetectable due to their lack of color odor or taste alcohol is a frequently used substance but other drugs may be covertly administered to impair a person's ability to resist or even recall the assault if such drugs remain in the patient system at the time of your assessment symptoms may include hypotension bra cardia respiratory difficulties seizures coma or even death sexual practices involving foreign bodies in the vagina or rectum are considered significant gynecologic emergencies in this case providers should keep the patient calm respect their dignity and ensure appropriate transport avoid attempting to remove any foreign objects from the vagina or anus as this could cause further harm the patient should not be allowed to walk if at all possible practices such as fisting where the closed Fist and wrist are inserted into a bodily orifice for sexual stimulation pose risks of organ rupture and peritonitis Additionally the insertion of live animals into the vagina or rectum including fish eels snakes worms or hamsters require careful handling do not attempt to retrieve such objects transport the patient with their knees flexed and legs together to minimize discomfort and potential injury",
        "Comprehensive Management of Gynecological Emergencies": "in the management of gynecological emergencies it's critical to conduct a comprehensive assessment and prioritize the patients wellbeing initial steps involve ensuring privacy and providing Compassionate Care which includes using sanitary pads to manage bleeding avoiding tampons and administering appropriate treatments for symptoms such as shock establishing IV access with a large board catheter in administering isotonic crystalloid Solutions is essential for patients exhibiting signs of shock for those who are not placing the patient in a position of comfort and monitoring closely is also important immediate and accurate assessment can be life-saving and missing a diagnosis may have severe consequences understanding and recognizing specific emergencies such as PID ruptured ovarian cysts and aop pregnancies is vital remember that P often presents with lower abdominal pain fever and discharge while a ruptured aarian cyst typically causes sudden and severe unilateral abdominal pain with possible vaginal bleeding atopic pregnancy a potentially life-threatening condition may present with signs of hypmic shock severe abdominal pain radiating to the back and minimal vaginal bleeding in cases of sexual assault the focus should be on providing both medical and psychological support evidence preservation is Paramount including avoiding the destruction of clothing or personal items and discouraging actions like cleaning or changing clothes if a patient refuses transport offer alternative support such as contacting a Rape Crisis Center documentation should be precise factual and free of personal opinions additionally awareness of drugs used to facilitate rape and handling foreign bodies and sexual practices are important aspects of care requiring sensitivity and the appropriate non-interventionist approach lastly ensuring a patient's safety and dignity while providing a thorough medical assessment and support is essential for managing these critical situations"
    },
    {
        "Introduction to Endocrine and Hematologic Emergencies": "chapter 21 endocrine and hematologic emergencies the endocrine system plays a significant role in regulating every cell organ and bodily function through the secretion of hormones that influence a wide range of physiological processes disorders of the endocrine system can present with a broad spectrum of signs and symptoms making diagnosis and management complex in addition to endocrine emergencies it's important to recognize the occurrence of hematologic emergencies although these are relatively rare within most EMS systems these emergencies present unique challenges in the prehospital setting as they can be difficult to assess and manage effectively due to the complexity of the underlying conditions and the limitations of available diagnostic tools in the field.",
        "Overview of the Endocrine System": "The endocrine system is composed of a network of glands that produce and secrete hormones which play a pivotal role in regulating various physiological processes the major components of this system include the hypothalamus pineal gland pituitary gland thyroid gland thymus gland parathyroid gland adrenal glands pancreas and gonads hormones are chemical substances synthesized and released by these glands exerting specific regulatory effects on other organs and tissues within the body endocrine glands secrete hormones directly into the bloodstream where they act as Messengers to maintain homeostasis and facilitate long-term structural changes in the body this system's ability to regulate internal balance and adapt to changes is fundamental to the body's overall health and function.",
        "The Pituitary and Thyroid Glands": "The pituitary gland is a key structure located at the base of the brain and is divided into the anterior and posterior regions Each of which has distinct functions the anterior pituitary produces six hormones known as Tropic hormones that stimulate other endocrine glands and to release their hormones these include adrenocorticotropic hormone or act which stimulates the adrenal cortex to secrete cortisol follicle stimulating hormone growth hormone luteinizing hormone prolactin and thyroid stimulating hormone each of these play a role in regulating various physiological processes illustrating the central role of the pituitary gland in coordinating the endocrine systems activities the thyroid gland is stimulated by the anterior pituitary gland to secrete hormones that regulate various metabolic processes one of its primary hormones thyroxine or T4 is released in response to a decrease in the body's metabolic rate thyroxine plays a crucial role in stimulating energy production within cells thereby influencing overall metabolism Additionally the thyroid gland secretes calcitonin a hormone that helps maintain normal calcium levels in the blood calcitonin achieves this by stimulating a bone building cells in the bones to absorb excess calcium and by promoting the kidney's ability to absorb and secrete Surplus calcium thus contributing to calcium homeostasis in the body.",
        "The Pancreas and Glucose Regulation": "The pancreas functions as both an endocrine and an exocrine gland playing dual roles in the body's metabolic processes the exocrine component of the pancreas is responsible for secreting digestive enzymes into the dadum through the pancreatic duct which facilitates the breakdown of nutrients in the digestive system the endocrine component on the other hand consists of specialized cell clusters known as the isolate of langerhans which secrete vital polypeptide hormone including glucagon insulin and somatostatin these hormones are critical in regulating blood sugar levels and other metabolic functions highlighting the pancreases integral role in both digestion and endocrine regulation glucose serves as the primary energy source for the body vital for maintaining cellular function and overall metabolism the brain in particular is highly dependent on glucose as it cannot store its essential nutrient and requires a constant Supply from the bloodstream a lack of glucose or even a significant decrease in glucose levels can lead to Rapid and irreversible damage to brain cells insulin a hormone produced by the pancreas plays a key role in allowing glucose to enter most cells of the body excluding brain cells to be used as fuel for energy production insulin facilitates the removal of glucose from the bloodstream promoting its storage in the form of glycogen fats and proteins this process is essential for maintaining normal blood glucose levels and ensuring that the body has a reserve of energy for future use when blood glucose cells are elevated the isolate of Langer Hons within the pancreas secrete insulin insulin increases the permeability of cell membranes which facilitates the transport of glucose into the cells where it can be used to produce energy through processes such as glycolysis in addition to this insulin stimulates the liver to store excess glucose and promotes the storage of glycogen in skeletal muscles for future use conversely when blood glucose levels decrease the alpha cells of the isolet of langerhans release the hormone glucagon this acts to raise blood glucose levels by stimulating the liver to convert stored glycogen back into glucose which is a process known as glycogenolysis this releases it into the bloodstream for energy use by cells if glycogen stores are depleted the body compensates by metabolizing Fats proteins and other non-carbohydrate sources to produce new glucose through a process called glucogenesis thereby maintaining energy supply to the cells.",
        "Endocrine Disorders and Diabetes Mellitus": "Endocrine disorders arise from either hyp secretion or insufficient secretion of hormones by glands hypers secretion typically leads to overactivity of the target organ regulated by the gland whereas insufficient secretion results in underactivity of the organ two prominent examples of such disorders within the endocrine system are hyperthyroidism and hypothyroidism hyperthyroidism is characterized by excessive thyroid hormone production and leads to an increased metabolic rate while hypothyroidism which is marked by insufficient thyroid hormone production results in a decreased metabolic rate the majority of endocrine emergencies encountered in prehospital settings are often related to diabetic emergencies which stem from abnormal insulin secretion further underscoring the importance of understanding the delicate balance required for proper endocrine function diabetes metis is a metabolic disorder that is now recognized as a group of complex diseases with multiple causes these include conditions such as diabetes malius itself gestational diabetes episodes of hypoglycemia and hyperglycemia diabetic keto acidosis and hyperosmolar hyperglycemic non-ic syndrome the common outcome of these conditions is Hypoglycemia which results from the body's inability to effectively transport glucose into the cells this disorder is characterized by three primary symptoms polyphasia which is an increased appetite due to the inability of glucose to cross the cell membrane polydipsia a substantial thirst caused by dehydration from excessive diuresis and polyurea the passage of large quantities of urine in diabetes the excretion of excess glucose in the urine known as glycose Uria leads to water being drawn out of the body resulting in an increased urine output and further dehydration these symptoms reflect the systemic impact of diabetes on the body's metabolic and fluid balance.",
        "Complications of Diabetes Mellitus": "The in inability of the body to sufficiently metabolize glucose is a Hallmark of diabetes metis leading to a condition where glucose is present in the urine this condition is associated with several life-altering complications over time decreased kidney function can develop along with an increased risk of atherosclerosis and coronary artery disease microscopic deterioration of the vessel walls referred to as microangiopathy causes swelling in the basement membrane cells which contributes to these vascular complications additionally diabetes can lead to a cerebrovascular disease stroke hypertension and peripheral artery disease the small blood vessels in the eyes can also become damaged leading to swelling wall weakness and potential obstruction further compromising Vision peripheral neuropathy a condition affecting the peripheral nerves results in diminished sensation and function in the extremities furthermore any pre-existing medical condition in a diabetic patient will become more challenging to manage due to these extensive systemic effects diabetes mtis is associated with both chronic IC and acute complications affecting various systems throughout the body if left untreated this condition leads to organ system dysfunction Progressive tissue wasting and ultimately death.",
        "Types of Diabetes Mellitus": "There are two primary forms of diabetes militis type one which we previously referred to as juvenile onset diabetes and type two formerly known as adult onset diabet abetes additionally pre-diabetes has been recognized as an early warning sign indicating an increased risk of developing type 2 diabetes if preventative measures are not taken the recognition and management of these forms and stages of diabetes are critical in preventing the severe complications that can arise from the disease type one diabetes metis historically known as insulin dependent or juvenile onset diabetes typically affects children but can also occur in adults this form of diabetes has a hereditary predisposition though environmental factors can contribute it is characterized by the body's development of Auto antibodies that mistakenly Target its own tissues or substances particularly the Bas beta cells in the pancreas which are responsible for insulin production the rate of beta cell destruction varies among individuals leading to differing degrees of insulin deficiency a variant of type 1 diabetes known as latent autoimmune diabetes in adults or Lada occurs in individuals over 30 years old management of type 1 diabetes es requires daily insulin injections and strict dietary control additionally increased physical activity and alcohol consumption can lead to hypoglycemia necessitating careful monitoring of blood glucose levels to prevent complications insulin pumps offer patients with diabetes a more effective means of managing their blood glucose levels leading to improved gly cement control and an enhanced quality of life these devices allow for continuous subcutanous insulin infusion which can be adjusted according to the individual's needs throughout the day by mimicking the body's natural insulin release more closely than multiple daily injections insulin pumps help to reduce blood glucose fluctuations and lower the risk of both hypoglycemia and hypoglycemia for many patients the use of an insulin pump not only provides better medical outcomes but also increases their flexibility and freedom in daily life.",
        "Type 2 Diabetes Mellitus and Pre-Diabetes": "Type 2 diabetes mtis is the most common form of diabetes characterized by the body's resistance to the insulin it produces although it typically develops in middle-aged individuals this condition is increasingly seen in younger populations persistent high levels of glucagon contribute to the over production of glucose resulting in elevated blood glucose levels the development of type 2 diabetes is strongly associated with obesity and physical inactivity both of which are becoming more prevalent in today's society if left untreated type 2 diabetes can manifest with a variety of symptoms including fatigue nausea frequent urination increased thirst unexplained weight loss and blurred vision individuals may also experience frequent infections the slow healing of wounds mood changes such as irritability or confusion and in severe cases unresponsiveness or seizures weight loss plays a significant role in controlling Type 2 Diabetes by improving insulin sensitivity and reducing blood glucose levels in addition to lifestyle modifications such as diet and exercise the medication Metformin is commonly prescribed to manage type 2 diabetes Metformin works by decreasing hepatic glucose production and improving insulin sensitivity making at a foundational treatment for this condition combining weight management with appropriate medication can effectively control blood glucose levels and reduce the risk of complications associated with the disease pre-diabetes is a condition identified in individuals who exhibit certain risk factors associated with type2 diabetes it's characterized by blood glucose levels or hemoglobin A1C levels that are higher than normal but not elevated enough to meet the criteria for diabetes diagnosis managing pre-diabetes is crucial to prevent the progression to type 2 diabetes with a key goal being to maintain an A1C level of 7% or less this management often involves lifestyle modifications such as improved diet increased physical activity ity and weight loss to help normalize blood glucose levels and reduce the risk of developing full-blown diabetes risk factors associated for pre-diabetes and type 2 diabetes include being older than 45 years being overweight having a family history of diabetes and belonging to certain racial or ethnic groups such as africanamerican Hispanic Latino American Indian Pacific Islander and some Asian-American backgrounds additionally a history of gestational diabetes are giving birth to a baby weighing more than 9 PBS increases the risk physical inactivity defined as engaging in fewer than three physical activity sessions per week also contributes to the risk preventative measures such as losing 5 to 7% of body weight and engaging in at least 150 minutes of physical activity per week can significantly reduce the likelihood of progressing from pre-diabetes to type 2 diabetes.",
        "Gestational Diabetes": "Gestational diabetes is a form of glucose intolerance that occurs during pregnancy women who experience gestational diabetes are at a 40 to 60% increased risk of developing type 2 diabetes within a decade after pregnancy fortunately gestational diabetes does resolve before delivery during pregnancy elevated blood glucose levels can cross the placental barrier leading to increased insulin production in the fetus this excess glucose is often converted to Fat which can result in the delivery of large babies known as macrosomia and may necessitate a cerian section despite these concerns the risk of birth defects in gestational diabetes is low management typically involves modifications in diet regular exercise and frequent blood glucose testing to ensure both maternal and Fetal Health.",
        "Hypoglycemia and Its Management": "Hypoglycemia a condition characterized by abnor normally low blood glucose levels often occurs as a result of taking too much insulin consuming too little food or both this can lead to a hypoglycemic crisis also known as insulin shock which is a medical emergency the body has a natural defense mechanism known as counter regulation to maintain blood glucose at appropriate levels the the first line of defense involves reducing insulin production and increasing glucagon production to raise blood glucose levels the second liner defense is the secretion of camines such as adrenaline by the adrenal glands which also works to increase blood glucose and ensure that the body has enough energy to function properly when hypogly IA occurs the autonomic nervous system is stimulated generating signals that increase the production of counterregulatory hormones these hormones trigger the liver to produce new glucose through glucogenesis helping to restore blood glucose levels in type 1 diabetes the isolate of langerhans do not produce insulin while in type 2 diabetes the pancreas retains some ability to produce insulin however a lack of glucagon response makes the body more reliant on epinephrine to counteract hypoglycemia patients experiencing hypoglycemia May exhibit symptoms such as trembling tacac cardia teyia sweating and a sensation of hunger common signs and symptoms include a a blood glucose level of less than 70 hunger agitation or irritability unexplained combative Behavior altered mentation nausea weakness dizziness synful episode and cool clammy skin these symptoms can be present in both type one and type 2 diabetic patients these patients may appear intoxicated due to slow L speech lack of coordination and may display paranoid hostile or aggressive behavior hypoglycemia is easily treated but it's important not to overlook it as a potential cause of altered Consciousness even in patients without a known history of diabetes additionally a diagnosis of diabetes should not prevent consideration of other potential causes of coma in a patient.",
        "Hyperglycemia and Diabetic Ketoacidosis": "Hyperglycemia and diabetic keto acidosis or dka occur when blood glucose levels remain elevated and the body's corrective mechanisms fail hyperglycemia can be triggered by factors such as excessive food intake insufficient insulin dosages infection or illness injury surgery and emotional stress when hypoglycemia is not managed effectively it can lead to a hyperglycemic crisis commonly referred to as a diabetic coma early signs of hypoglycemia include frequent and excessive thirst and urination the onset of symptoms may be Rapid or gradual if hypoglycemia persists it can cause several physiological changes with long-term detrimental effects when blood glucose levels rise significantly Beyond tolerable limits conditions such as dka and hyperosmolar hyperglycemic non-ic syndrome or hhns can develop dka in particular is often precipitated by factors such as infection injury alcohol use emotional stress or acute illnesses like stroke or myocardial infarction the loss of large amounts of water in uncontrolled diabetes leads to the classic symptoms known as the 3ps we discussed this earlier in the lecture but just to review polyurea refers to the excessive production of urine as the body attempts to eliminate excess glucose which also leads to significant water loss polydipsia is the resulting excessive thirst thirst that occurs as the body tries to compensate for the fluid loss caused by the polyura and polyphasia or excessive hunger arises because the body cells are unable to access glucose for energy despite the fact that there are high levels of glucose in the blood these symptoms are indicative of the body's efforts to manage the imbalance caused by uncontrolled blood glucose levels which can then lead to severe complications if not properly addressed when the body uses fat as an immediate energy source ketones and fatty acids are produced as waste products these are difficult for the body to excrete and the accumulation of Ketone bodies in the bloodstream can lead to a decrease in blood pH resulting in metabolic acidosis one of the notable symptoms of dka is a sweet fty odor on the breath caused by the presence of ketones if this is not properly treated with appropriate fluid rehydration and Insulin Administration it can progress to unresponsiveness diabetic coma and eventually death however patients in dka are seldom deeply comos the manifestations of dka include polyurea polydipsia polyphasia nausea vomiting teac cardia deep and Rapid respirations known as KZ M's respirations dry warm skin dry mucous membranes a fruity odor on the breath abdominal pain and sometimes fever respiratory rate is typically elevated and tidal volume increases due to ketonemia acidosis and the body's effort to expel excess carbon dioxide which can result in hypocapnia dka is characterized by both KZ malls respirations and metabolic acidosis in patients with type 2 diabetes dka is rare because insulin production is still present however as the duration of type 2 diabetes increases there may be Progressive loss of pancreatic insulin production which could increase the risk of dka over time this highlights the importance of monitoring and managing diabetes effectively to prevent such severe complications.",
        "Hyperosmolar Hyperglycemic Non-Ketotic Syndrome": "Hyperosmolar hyperglycemic non-ic syndrome syndrome or hhns formerly known as hyperosmolar non-ic coma primarily occurs in patients with type 2 diabetes this condition is characterized by severe hypoglycemia hyperosmolarity which refers to highly concentrated blood due to relative dehydration and an absence of significant ketosis unlike dka these patients do not develop keto acidosis common signs and symptoms include marked hypoglycemia alter mation drowsiness lethargy severe dehydration accompanied by intense thirst dark urine visual or sensory deficits partial paralysis or muscle weakness and seizures the clinical features of hhns and dka can overlap and it's not uncommon to observe these conditions simultaneously in patients hhns develops in patients with diabetes who are experiencing a secondary illness which leads to reduced fluid intake and exacerbates the dehydration in hyperosmolarity because there's no substantial ketosis in hhns patients do not present with the typical acidotic Fe features seen in dka proper identification and management of hhns are essential to prevent severe complications and improve patient outcomes.",
        "Comparison of Diabetic Conditions": "The table provides a comparison between hypoglycemia and two forms of hypoglycemia dka and hhns hypoglycemia typically occurs due to insufficient food intake or excessive insulin dosage it has a rapid onset typically within minutes and presents with pale moist skin thirst is absent but hunger is intense patients may experience irritability confusion seizures or coma with a low blood pressure and Rapid weak pulse blood glucose levels are typically below 60 and treatment with glucose results in an immediate response dka usually results from excessive food intake and insufficient insulin it develops gradually over hours to days with symptoms including warm dry skin intense thirst excessive hunger vomiting and deep rapid respirations known as KZ malls the presence of ketones in the blood leads to a sweet fruity odor on the breath and urine tests will reveal the presence of both sugar and acetone blood glucose levels will exceed 250 and response to treatment is more gradual occurring within 6 to 12 hours following medical intervention hhns also results from excessive food intake and insufficient insulin but it develops more slow SL from days to weeks patients have warm dry skin very intense thirst and excessive hunger but vomiting is typically uncommon respiratory symptoms include tipia rather than kous Ms respirations and there's no fruity breath odor due to the absence of Ketone production blood glucose levels are typically greater than 600 and patients respond grad to treatment similar to dka this table highlights the differences in presentation onset and treatment response between these critical diabetic conditions.",
        "General Management of Endocrine Emergencies": "When managing endocrine emergencies General care should focus on stabilizing the patient and addressing the underlying issue Begin by placing the patient in a position of comfort if the the patient presents with altered mental status establish an intravenous line using normal saline or a saline lock measure the blood glucose level immediately and if the reading is less than 60 initiate appropriate treatment administer 1 mgram of glucagon IM or nasy to patients with hypoglycemia as this can significantly expedite recovery if the patient condition does not improve after administering dextrose and you suspect a narcotic overdose consider administering Naran for unresponsive patients transport them in a Seine or lateral recumbent position to ensure Airway protection and prevent aspiration in cases where there are signs of increasing intracranial pressure transport the patient with the head elevated to a 30 to 45\u00b0 angle while maintaining the head in a midline position to optimize Venus drainage and reduce intracranial pressure it's also important to keep the patient's mouth in fairx suction free of secretions vomitus and blood so that you can maintain Airway patency and prevent aspiration.",
        "Specific Management of Hypoglycemia": "When managing hypoglycemia the primary objective is to increase the patient blood glucose levels immediately if the patient is alert and able to swallow without the risk of aspiration administer sugar orally do not hesitate to provide a sufficient amount of sugar and avoid giving sugar-free drinks or those sweetened with synthetic compounds like saccharine the first line treatment of hypoglycemia is oral glucose which is available able in tablet and gel forms if the patient cannot take oral glucose due to unresponsiveness or the risk of aspiration administer dextrose IV or if not possible glucagon IM after administering glucose frequently reassess the patient's condition monitoring for any Airway problems sudden loss of consciousness or seizures it is important not to delay transport to administer additional oral glucose if the patient's mental status is altered the risk of exacerbating hyperglycemia in this context is minimal if the patient is unresponsive in experiencing seizures it is more likely that they are in a hypoglycemic crisis rather than a hypoglycemic state for patients showing signs of dehydration administer a 20 ml per kg bolus of an isotonic crystalloid solution to support fluid balance administering intravenous dextrose involves several steps to ensure safety and Effectiveness first insert an IV line using the largest catheter in the largest vein available attach an IV bag of isotonic crystalloid solution such as normal saline and carefully check the IV line to ensure its patent and flowing free next inject a test bolus of 10 to 20 MLS of normal saline once the IV line is confirmed to be functioning properly open the line wide crimp the line above the Administration Port and administer 12.5 to 25 G of dextrose slowly over at least 3 minutes ensuring that the plunger is depressed slowly to avoid rupturing the vein when administering D50 draw back on the syringe periodically to check for a blood return especially after half of the dose has been given finally after completing the dextrose Administration flush the IV line by opening it for a few seconds to ensure it's clear and free of any residual medication administering glucagon IM is an option when IV access canot be obtained in the hypoglycemic patient keep in mind though glucagon is only effective when the patient has sufficient glycogen stores to draw from glucagon is supplied in 1 mgram ampules and the standard dosage for an adult is 1 mgram IM which can be repeated after 7 to 10 minutes if necessary for children weighing less than 20 kgs the appropriate dose is 0.5 milligrams while children weighing more than 20 kgs should simply receive the same dose as an adult.",
        "Management of DKA and HHNS": "In the management of hypoglycemia and dka if the glucose level exceeds 250 it's likely that the physician will order treatment for dka the primary goals of prehospital treatment are to initiate rehydration and to address any electrolyte and acidbase abnormalities it's essential to maintain the patient's Airway and administer oxygen as needed be vigilant for signs of vomiting and have suction equipment ready if definitive Airway control is required consider requesting paramedic backup establishing IV access is crucial and a 20 ml per kg bolus of normal saline should be administered if there are signs of De dehydration or if the patient is hypotensive the management of hhns follows a protocol that's similar to addressing dehydration and altered mentation it's essential to complete Advanced Airway management as early as possible especially in unresponsive patients for whom cervical spine immobilization should also be considered obtaining a blood glucose level is a critical step in the man agement process for this patient establish large bore IV access typically with an 18 gauge catheter to facilitate fluid resuscitation that being said in patients with a history of heart failure or renal insufficiency fluids should be administered sparingly to avoid overloading the cardiovascular system it's important to note that fluid deficits in patients with hhn s can be substantial potentially amounting to 10 L or more necessitating careful and judicious fluid replacement.",
        "Introduction to Hematology": "Hematology is the study of blood focusing on how the various components of blood are involved in both health and disease the key components of blood include red blood cells or rbcs which are responsible for oxygen transport white blood cells or wbcs which play a critical role in the immune response and platelets which are essential for blood clotting additionally hematology examines individual proteins that are involved in the bleeding and clotting Cascades as well as the hematopoetic system which is responsible for the production of blood cells understanding these components and their functions is vital to diagnosing and managing hematologic emergencies.",
        "Hematologic Disorders": "A hematologic disorder encompasses any condition affecting the blood within this category hemolytic disorders are characterized by disease processes that lead to the breakdown of rbcs while hemostatic disorders involve abnormalities in the blood's ability to clot and control bleeding understanding these distinctions is important for diagnosing and managing various blood related health issues blood performs several critical functions in the body it transports oxygen from the lungs to the tissues and Carries carbon dioxide from the tissues back to the lungs for exhalation blood also delivers essential nutrients such as glucose proteins and fats from the digestive tract to cells throughout the body additionally it fies metabolic waste products from the cells where they are produced to the excretory organs for elimination blood is responsible for transporting hormones to their target organs and it helps regulate body temperature by transmitting excess internal heat to the body surface for dissipation furthermore blood carries defensive cells and antibodies which of course are essential in protecting the body against foreign organisms and infections.",
        "Components of Blood": "Blood consists of several key components each with specific roles in the body plasma the straw colored fluid makes up 55% of total blood volume and is composed of 92% water and 6 to 7% proteins with the remainder consisting of various elements such as electrolytes clotting factors and glucose plasma serves as the medium through which all formed elements red blood cells white blood cells and platelets are transported throughout the body red blood cells also known as arthr sites make up 99% of the formed elements in the blood these cells contain hemoglobin an iron-rich protein that binds to oxygen allowing rbcs to carry oxygen from the lungs to the tissues and return carbon dioxide from the tissues to the lungs the production of rbcs occurs within stem cells and the oxygen bound to hemoglobin gives blood its characteristic red color white blood cells also known as lucaites play a critical role in the immune system by providing the body with immunity like rbc's wbc's are derived from stem cells and several types of wbcs exist each with specific functions in defending the body against infections and foreign Invaders platelets or thrombocytes are small cell fragments that are responsible for clot formation approximately 2/3 of the platelets circulate in the blood while the rest are stored in the spleen platelets are derived from stem cells and are essential in forming the initial plug at the sight of vascular injury hemostasis is a complex process that allows the body to stop bleeding through mechanisms such as vascular spasm coagulation and platelet plugging when an injury is detected thrombin converts fibrinogen to fiin initiating the clotting process any disruption in the activation or continuation of the clotting Cascade or hemostasis results in a condition known as coagulopathy which can lead to abnormal bleeding or clotting disorders.",
        "Blood Forming Organs": "Blood forming or organs play Vital roles in the production and regulation of blood cells the bone marrow is the primary site for blood cell production including red blood cells white blood cells and platelets bone marrow is found in most long bones as well as in the pelvis skull and vertebrae the liver is another crucial organ in blood formation and function as it reduces the clotting factors that are necessary for blood coagulation filters blood to remove toxins and is essential for metabolism and maintaining homeostasis the liver is also highly vascular reflecting its significant role in the circulatory system the spleen known for being highly vascular is involved in filtering and breaking down old or damaged red blood cells it also AIDS in the production of white blood cells and plays an important role in maintaining homeostasis and controlling infections within the body.",
        "Blood Classification and Transfusion": "Blood classification is critical to ensuring compatibility and preventing complications during blood transfusions the [\u00a0__\u00a0] blood group system is the primary method used to classify red blood cells into types o and a b and ab these classifications are based on the presence of specific antigens found in the plasma membrane of red blood cells additionally blood contains a secondary antigen known as the RH antigen which further refines blood typing transfusion reactions can occur when a patient receives blood that is not compatible with their own it's essential to determine both the patient's blood type and the type of blood they are receiving to avoid these reactions if a patient receives a different blood type a transfusion reaction may occur which can rapidly lead to severe circulatory collapse and potentially death for this reason it's critical to monitor the patient closely during the first 30 to 60 minutes after a transfusion to detect to manage any adverse reactions promptly.",
        "Sickle Cell Disease": "CLE cell disease is the most common inherited blood disorder primarily affecting African-American Puerto Rican and European populations the average life expectancy of men with CLE cell is 42 years while for women it's 48 the disease originates from a genetic defect in adult hemoglobin or a HBA resulting in defective rbcs that are oblong in shape instead of smooth and round making them inefficient oxygen carriers these CLE cells have a much shorter lifespan than normal erythrocytes which leads to anemia their odd shape can cause them to Lodge in small blood vessels leading to thrombosis and they may migrate to the spleen causing it to swell rupture or result in a plastic crisis hemolytic crisis or thrombosis CLE cell crisis can manifest in several ways including vasoocclusive crisis which restricts blood flow to an organ causing pain esea and organ damage and typically lasting between 5 to 7 days this can obstruct circulation to the spleen or cause a stroke if it occurs in the brain acute chest syndrome a vasoocclusive crisis that's associated with pneumonia presents with chest pain fever and cough an aplastic crisis involves a worsening of the patient's Baseline anemia causing teoc cardia poor and fatigue it's often triggered by the parva virus b19 which will impair RBC production hemolytic crisis which is an acute drop in hemoglobin levels due to accelerated RBC breakdown is common in patients with glucose 6 phosphate dehydrogenase deficiency a prevalent enzyme deficiency lastly splenic sequestration crisis is marked by painful acute enlargement of the spleen causing the abdomen to become very hard and Bloated in acute crisis patients with CLE cell disease may experience significant pain due to congested blood vessels that prevent the proper passage of oxygen and nutrients into tissues and Joints this condition can lead to frequent infections which may result in sepsis and death over time as circulation remains impaired various organs may be destroyed and patients may show signs of mild dehydration splendom megal cardiomegaly and other complications those with chronic cyle cell attacks are add an increased risk for severe life-threatening complications.",
        "Complications of Sickle Cell Disease": "Here is an expanded explanation of the potential complications associated with CLE cell disease sickle shaped red blood cells can obstruct blood flow to the brain leading to a stroke strokes and individuals with SCD can occur at a young age and may lead to long-term neurological deficits or death chronic hemalis or the breakdown of red blood cells releases large amounts of B Rubin a byproduct of hemoglobulin breakdown excess bow Rubin can crystallize and form gall stones leading to kystis or inflammation of the gallbladder the rapid destruction of CLE cells releases B Rubin into the bloodstream faster than the liver can process it leading to jaundice the blockage of blood flow to the bones particularly in the hips and shoulders can cause bone tissue to die a condition known as osteonecrosis or a vascular NE necrosis this leads to pain reduced mobility and eventually the need for joint replacement the spleen which filters abnormal red blood cells becomes overburdened in SCD leading to splenic enlargement where large volumes of blood are then trapped within the spleen this condition can lead to splenic infarction and the loss of splenic function making patients more susceptible to infection due to poor blood flow and Bone damage individuals with SCD are at a higher risk of bone infections or osteitis and Joint infections often caused by bacteria such as salmonella chronic pain management in SCD often requires the use of opioids leading to tolerance over time this means that higher doses of opiates are required to achieve the same level of pain relief complicating pain management po circulation combined with chronic inflammation can lead to nonhealing ulcers in the lower legs which are painful and prone to infection the abnormal red blood cells can obstruct the tiny blood vessels in the eyes leading to damage in the retina this condition known as CLE cell retina p pathy can result in vision loss or blindness beyond the acute pain crisis individuals with SCD often experience chronic pain due to ongoing tissue damage and inflammation which requires long-term pain management strategies the blockage of small blood vessels in the lungs can lead to increased pressure in the pulmonary arteries a condition known as pulmonary hypertension which can cause shortness of breath fatigue and heart failure lastly the kidneys are particularly vulnerable to damage from CLE cells leading to a condition called CLE cell neuropathy over time this can progress to chronic renal failure requiring dialysis or kidney transplantation these complications highlight the systemic nature of SCD affecting nearly every organ in the body body and requiring comprehensive multidisiplinary management to improve patient outcomes and quality of life.",
        "Anemia and Other Hematologic Conditions": "Anemia is a condition characterized by a lower than normal level of hemoglobin or red blood cells often associated with an underlying disease process the most common type of anemia is iron deficiency anemia which results from insufficient iron to produce adequate hemoglobin in children anemia is frequently related to premature birth or low birth weight inherited hemolytic disorders such as those involving a deficiency of the enzyme glucose 6 phosphate dehydrogenase can also cause anemia another type of acquired anemia occurs when the flow of red blood cells is disrupted due to issues with blood vessel Linings or the presence of blood clots autoimmune disorders can lead to anemia when the body's own antibodies Target and Destroy rbcs additionally individuals who travel to high altitude areas may experience anemia due to reduced oxygen levels in some cases of anemia patients may experience angina type chest pain due to the reduced availability of oxygen to the heart muscle which can exacerbate cardiovascular strain additionally another hematologic condition such as lucenia which is characterized by a low white blood cell count and thrombos cenia which is defined as a low platelet count are commonly observed in conjunction with or as a consequence of anemia.",
        "Clotting Disorders": "Clotting disorders Encompass various conditions where blood blood clots form in arterial or venous blood vessels leading to symptoms that are specific to the affected part of the vascular system thrombophilia which is a condition that's characterized by a tendency to develop blood clots is a common medical issue that can result in thrombosis within blood vessels or heart chambers pulmonary IMI which are often secondary to deep vein thrombosis are among the leading causes of death in hospitalized patients due to the risks associated with these conditions many patients are prescribed anti-coagulant medications in order to prevent clot formation and as potentially fatal complications risk factors for clotting disorders include recent surgery impaired mobility heart failure cancer respiratory failure infectious diseases age over 40 years and overweight or obesity these factors can increase the likelihood of developing blood clots making it essential for atrisk individuals to be closely monitored and possibly receive preventative treatments such as anti-coagulants additional risk factors for clotting disorders includes smoking the use of oral contraceptives recent trauma and recent longdistance travel such as multi-hour car or plane rides these factors can further Elevate the risk of thrombosis by contributing to conditions like impaired blood flow or increased coagulation Tendencies emphasizing the importance of proactive monitoring and potential intervention in individuals with these risks.",
        "Hemophilia and Disseminated Intravascular Coagulation": "Hemophilia is a genetic bleeding disorder that's characterized by insufficient or absent clotting due to a deficiency in specific clotting factors often involving Von willbrand disease the inability of the body to form spontaneous clots leads to prolonged bleeding times hemophilia primarily affects males and is classified into two main types hemophilia a the most common form which involves low levels of factor 8 and hemophilia B which is characterized by a deficiency in Factor 9 the clinical presentation of both types includes similar symptoms with acute and chronic bleeding episodes that can range from mild to life-threatening spontaneous intracranial bleeding is a significant risk and is a frequent cause of mortality in these patients severe bleeding episodes often necessitate hospitalization for blood transfusions additionally these patients May display signs of hypoxia due to a diminished capacity for oxygen transport in the blood highlighting the systemic impact of this disorder disseminated intravascular coagulation or DIC is a serious and life-threatening condition that can arise from a variety of underlying causes the disorder progresses in two distinct stages initially there's an increase in free thrombin and fibrin deposits within the blood leading to the aggregation of platelets this initial phase is paradoxically followed by a second stage where there is uncontrolled hemorrhage due to a severe reduction in clotting factors the condition is associated with a high mortality rate with the primary causes of death being uncontrolled bleeding hypotension and shock.",
        "Emergency Care for Hematologic Emergencies": "Emergency medical care for hematologic emergencies should include several critical interventions oxygen should be administered as necessary to ensure adequate tissue oxygenation IV fluids should be initiated to replace fluid loss and support circulatory function and timely transport to an appropriate facility is crucial for further management pain management May also be necessary to address discomfort and improve patient outcomes patients should be placed in a position of comfort and covered to maintain body temperature finally providing psychological support is essential as hematologic emergencies can be highly distressing the management of specific hematologic conditions requires tailored interventions for Cle cell disease care may include the administration of analgesics for pain relief antibiotics to prevent or treat infections and blood transfusions as needed to manage severe anemia or other complications in cases of anemia it is crucial to check and monitor the airway breathing ensuring that the patient maintains adequate oxygenation patients reporting chest pain should prompt early paramedic backup to address potential complications such as acute coronary syndromes identifying disseminated intravascular coagulation early is essential for timely treatment which may include blood product Administration and addressing the underlying cause throughout care it's important to maintain an optimistic yet honest communication approach with patients and their families to support them to the treatment process.",
        "Conclusion": "In conclusion the management of endocrine and hematologic emergencies requires a comprehensive understanding of the underlying pathophysiology and the ability to promptly initiate care for endocrine emergencies like diabetes hypoglycemia and diabetic keto acidosis immediate actions such as monitoring blood glucose levels administering glucose or glucagon and ensuring proper hydration is vital understanding the differences between hypo and hyperglycemia along with their respective treatments is critical for Effective intervention on the hematologic side conditions such as anemia CLE cell and clotting disorders including disseminated intravascular coagulation present unique challenges these conditions often require specific treatments such as blood transfusions pain management and careful monitor ing of the patient's Airway and cardiovascular status recognizing early signs of complications providing psychological support and maintaining honest communication with patients and their families are integral to successful outcomes overall the integration of both rapid assessment and targeted treatment strategies is essential in maintaining the complex scenarios that arise in endocrine and hematologic emergency gencies the goal is always to stabilize the patient prevent further deterioration and address the underlying causes to improve the patient's prognosis"
    },
    {
        "Introduction to Immunologic Emergencies": "chapter 22 immunologic emergencies every year more than 50 million Americans experience allergic reactions which can range in severity these reactions may involve acute Airway obstruction and cardiovascular collapse an allergic reaction is defined as an exaggerated immune response to a substance the most severe form of an allergic reaction is anaphylaxis a systemic response involving two or more body systems and often necessitating the administration of epinephrine it's important to differentiate between the body's usual response to an allergen which might involve mild symptoms such as sneezing or a localized rash and anaphylaxis where the immune system's response is exaggerated and can lead to significant life-threatening symptoms.",
        "The Immune System's Defense Mechanisms": "the immune system serves as the body's defense mechanism against foreign substances and organisms you utilizing two primary Protection Systems cellular and humoral immunity cellular immunity involves tea cells specialized white blood cells that identify and Destroy Invaders humoral immunity is mediated by B cell lymphocytes which produce antibodies that Target specific antigens.",
        "Common Allergens and Triggers": "almost any substance has the potential to trigger the immune system leading to an allergic reaction common triggers include animal bites certain foods latex gloves and even semen allergens can be categorized into several General groups insect bites and stings are common triggers as are various medications the reaction to injected medications may be immediate and severe while oral medications May provoke a slower onset of symptoms that can still be significant plants such as dust pollen mold and mildew are other major categories of allergens often leading to respiratory symptoms foods like shellfish and peanuts can also cause reactions that might develop more slowly but remain severe additionally various chemicals including those found in makeup soap hair dye and latex can induce serious allergic reactions.",
        "Pathways for Allergen Entry": "allergens are typically harmless substances that when introduced into the body can trigger an immune response this response involves the production of antibodies which are proteins that are designed to recognize and neutralize antigens these foreign substances can can enter the body through various routes including the skin respiratory tract or GI tract when Invasion occurs through the skin it may be in the form of injection absorption inhalation or ingestion each presenting a potential pathway for allergens to induce an immune  response.",
        "Primary Immune Response": "when a foreign substance invades the body the immune system immediately goes on alert initiating a series of responses aimed at neutralizing the Potential Threat the first encounter with the foreign substance triggers the primary immune response primarily involving white blood cells macrophages play a critical role in determining whether these substances are permissible or harmful if the body cannot recognize the Invader immune cells record its features and design antibodies specifically matched to the antigen to neutralize it through this Primary Response the body developed sensitivity to the foreign substance allowing it to recognize and respond more rapidly upon subsequent encounters.",
        "Role of Basophils and Mast Cells": "specific antibodies are placed on basophils and mass cells which are essential in the immune response basophils and mass cells produce chemical mediators that are stored in granules filled with potent substances which are designed to combat antigens when an antigen binds to one of the antibodies these granules are released through a process known as degranulation where they burst open and discharge their contents this action launches and sustains the immune response summoning more white blood cells and increasing blood flow to the affected area however if these mediators spread throughout the body they can trigger systemic effects leading to anaphylactic reactions which are severe and require immediate medical attention.",
        "Sequence of Events in Anaphylaxis": "the sequence of events in anaphylaxis begins when an antigen such as a be sting is introduced into the body this antigen triggers an immune response where the antigen binds to antibodies present on the surface of mass cells The Binding of the antigen and antibody initiates the release of chemical mediators stored within the mass cells these mediators are then released into the surrounding tissue where they exert their effects on various organs in the lungs they cause bronos spasm and Vaso constriction leading to difficulty breathing in the heart they can decrease output and coronary flow affecting cardiac function blood vessels May undergo vasod dilation and become leaky contributing to a drop in blood pressure in the skin these mediators cause symptoms such as parius ticaria and edema these systemic effects can rapidly progress to a life-threatening condition if not promptly treated.",
        "Vaccines and Acquired Immunity": "vex Vines work by producing immunity against diseases through the controlled stimulation of the immune system when a vaccine is administered the body develops antibodies in response to the antigens present in the vaccine this process allows the immune system to prepare for future encounters with the Disease by producing an immune response that neutralizes the pathogen the development of antibodies through vaccination occurs occurs in a controlled manner ensuring that the body can effectively recognize and respond to the actual virus if it is encountered later upon subsequent exposure to the virus the immune system identifies the pathogen produces antibodies to eliminate it and mounts a secondary more intense response to the invading virus acquired immunity refers to the protection gained through vaccin ation allowing the body to develop antibodies without needing to experience the disease itself and contrast natural immunity is acquired when the body undergos the full immune response after being exposed to the disease experiencing all of its Associated effects.",
        "Pathophysiology of Allergic Reactions": "the image illustrates the skin manifestations that can occur during an immune response highlighting the physical symptoms that may accompany natural immunity as the body fights off an infection pathophysiology involves the study of functional changes in the body that result from disease or injury in the context of allergic reactions the immune system can become hypers sensitive to one or more substances leading to abnormal responses this hypers sensitivity develops when the immune system overreacts to a substance that is typically harmless an allergic reaction occurs when the body has been previously exposed or sensitized to an allergen upon subsequent exposure the immune system recognizes the allergen and mounts a heightened response which can manifest in various symptoms depending on the individual and the severity of the reaction.",
        "Hypersensitivity and Anaphylaxis": "allergic reactions can manifest in various forms ranging from mild localized reactions to more severe systemic responses hypers sensitivity refers to the exaggerated or inappropriate symptoms that occur when the body Peres a substance as harmful even when it may not be these reactions can escalate into anaphylaxis which is a severe and potentially life-threatening condition that should not be confused with other medical emergencies such as heart attacks heat Strokes or similar conditions individuals with a history of allergic diseases like allergic rtis asthma or atopic dermatitis are at a higher risk of experiencing anaphylactic reaction the route of exposure to the allergen and the time interval between exposures also play a significant role in the development and severity of Anapa is anaphylaxis is typically mediated by IG antibodies which are produced in response to the allergen however it is important to note that anaphylactoid reaction which presents similarly to anaphylaxis does not involve IG antibody mediation and can occur without prior exposure to the triggering substance understanding these distinctions is vital for accurately identifying treating allergic reactions and anaphylaxis in a clinical setting.",
        "Chemical Mediators in Allergic Reactions": "the pathophysiologic response to an allergen begins when mass cells recognize a foreign substance as potentially harmful and release chemical mediators to counteract the perceived threat two primary types of chemical mediators are involved in this process histamines and lucrin histamine causes blood vessels in the affected area to dilate and the capillaries to become more permeable leading to leakage of fluids into surrounding tissues lucrin which are more potent than histamines further intensify this response by causing additional dilation and capillary leakage as part of the immune response white blood cells are recruited to the site to engulf and destroy the foreign substance additionally platelets begin to aggregate in the area contributing to the inflammatory response in most cases this overreaction remains localized to the area of exposure but it can lead to significant symptoms especially if the reaction is intense or involves sensitive tissues.",
        "Anaphylaxis: A Severe Multi-System Reaction": "anaphylaxis is a severe multi-stem reaction that occurs when chemical mediators are released in response to an allergen the initial effects are often due to the release of histamines with additional effects developing over the following hours when histamines are released they cause immediate vase of dilation leading to symptoms such as flush skin and hypotension The increased vascular permeability that follows can result in angioedema fluid secretion and fluid loss edema May manifest as aaria Airway constriction and an increase in fluids within the Airways the smooth muscle contraction caused by histamine release particularly affects the respiratory and GI systems leading to lingos spasm bronos spasm and abdominal cramp ing Additionally the anatropin and when combined with vasod dilation can result in profound hypotension lucrin another group of chemical mediators released during anaphylaxis exacerbate the situation by further compromising respiratory function causing coronary Vaso constriction and worsening hypo profusion the persistent action of these and other chemical mediators continues to deteriorate the patient's condition making prompt recognition and treatment of anaphylaxis imperative.",
        "Clinical Symptoms of Anaphylaxis": "clinical symptoms of anaphylaxis often begin with scan manifestations which are typically the first signs of the condition a patient may feel warm and flushed with parius developing due to the Vaso dilation and capillary leakage the area around the eyes is particularly susceptible to this effect angioedema is another common symptom often accompanied by swelling of the hands and feet as well as ticaria respiratory symptoms are the most frequently reported complaints during anaphylaxis these include shortness of breath chest tightness throat tightness Strider and horseness these symptoms are often caused by swelling in the upper Airway particularly in the lenial and epiglottic regions patients may also describe a sensation of a lump in their throat Bronco constriction and increased Airway secretions can exacerbate these respiratory difficulties leading to coughing or sneezing the onset of these symptoms can vary occurring either very slowly or rapidly.",
        "Cardiovascular and GI Symptoms of Anaphylaxis": "cardiovascular symptoms represent more severe complications of anaphylaxis a decrease in cardiac output may occur due to vasod dilation and increased capillary permeability leading to a significant drop in blood pressure this decrease in cardiac output and profusion can result in esema and a heightened risk of cardiac dysrhythmias tachicardia flush skin and hypotension are characteristic signs of anaphylactic shock in anaphylaxis blood volume May shift from the intravascular space to the extravascular space leading to a State of Shock the body cannot tolerate an acute blood loss exceeding 20% of the total blood volume making this shift particularly dangerous GI symptomss often accompany anaphylaxis especially when the antigen is ingested abdominal cramping is a common symptom and patients may also experience nausea bloating vomiting abdominal distension and profuse watery diarrhea CNS symptoms may include headache dizziness confusion and anxiety with the sense of impending doom often reported by patients experiencing severe anaphylaxis this disease can impact multiple body systems simultaneously this systemic involvement can lead to various types of shock cardiogenic shock is due to decreased cardiac output hypmic shock resulting from fluid leakage into tissues and neurogenic shock caused by the inability of blood vessels to constrict.",
        "Patient Assessment and Management": "patient assessment in cases of suspected anaphylaxis requires Swift and accurate identification of symptoms followed by immediate intervention the level of Suspicion for anaphylaxis should be high whenever pertinent symptoms are present as the condition can rapidly become life-threatening the immune response to antigens can occur in a multi-step process beginning with an acute reaction that may be followed by a delayed response acute reactions tend to have a rapid onset and are generally the most severe necessitating Urgent Care delayed reactions on the other hand can take hours or even longer to develop and are generally less severe but still require monitoring in some cases anaphylaxis symptoms May persist for an extended period lasting anywhere from 5 to 72 hours additionally a biphasic response may occur where the patient initially recovers after the first reaction only to experience a recurrence of symptoms later patients who have had an allergic reaction should be strongly encourage to seek medical attention even if they seem to be improving to minimize the risk of a delay or biphasic reaction in emergency medical care distinguishing between anaphylaxis and other conditions with similar symptoms is critical patients with allergic reactions are classified into two groups for treatment purposes the first group consists of those who exhibit signs of an allergic reaction without signs of anaphylaxis and the recommended treatment is dyen hydramine the second group includes patients with signs of anaphylaxis who require the administration of oxygen epinephrine and antihistamines if a patient presents with trouble breathing or signs of shock in conjunction with an allergic reaction epinephrine should be administered immediately.",
        "Emergency Treatment Protocols": "for patients experiencing a severe allergic or anaphylactic reaction several steps should be taken Begin by administering basic life support and promptly transported the patient to the hospital it is essential to remove the patient from the source of the antigen or remove the antigen from the patient maintaining the airway is a priority and high flow oxygen should be administered via nonrebreathing mask at 15 L per minute if the patient is not breathing adequately with preparations to assist ventilations if necessary a high index a suspicion for Airway occlusion due to swelling or edema should be maintained and the patient should be treated for shock circulation should be supported by administering isotonic Solutions at a wide openen rate if the patient does not respond to epinephrine initiate two IV lines in route to the ER and administer 20 MLS per kg of an isotonic fluid rapidly over 15 minutes if the patient does not respond to these interventions consider calling for paramedic backup for the administration of a vasopressor in conjunction with fluid administration it is also important to determine which interventions have already been completed before your arrival and to inform medical control of the patient's condition for further guidance.",
        "Administration of Epinephrine": "administering epinephrine should be a priority in the management of anaphylaxis as early Administration is critical for reversing the severe symptoms associated with this condition the IM route is preferred particularly when the patient shows signs of Airway or respiratory compromise or hypotension when administering epinephrine IM the thigh is the preferred injection site over the deltoid as it allows for more rapid absorption of the medication subcutaneous Administration on the other hand is less predictable and may result in delayed effects especially in the presence of shock making it less than ideal in emergency situations epinephrine is highly effective in quickly reversing the histamine related effects of anaphylaxis underscoring its critical role in treatment it's essential to closely monitor patients who receive epinephrine for any adverse effects if available use a cardiac monitor to watch for dymas and assess the patient's Vital Signs every 5 minutes medical control must be contacted to obtain a direct order for the use or sance with an EpiPen auto injector when using an EpiPen follow the steps outlined in the instructions that come with the kit in life-threatening situations do not delay the administration of epinephrine to expose the thigh as the injection can be administered directly through clothing the injection process takes approximately 3 seconds and Care should be taken to ensure that the patient's leg remains still during Administration after use properly dispose of the injector in a biohazard container and record the time and dose administered the patient's fital signs and the response to the medic ation if there's no improvement within 5 minutes a second dose can be administered other allergy kits may contain oral or intramuscular antihistamines which can work synergistically with epinephrine to combat the effects of allergic reaction common side effects of epinephrine include teoc cardia hypertension anxiety poar dizziness chest pain Headache nausea and vomiting epinephrine should not be administered to patients who do not exhibit signs of respiratory compromise or hypotension and who do not meet the criteria for a diagnosis of anaphylaxis.",
        "Insect Stings and Allergic Reactions": "insect stings are a significant cause of fatalities in the United States accounting for approximately 90 to 100 deaths each year the stinging organ of most bees wasps and hornets is a small Hollow spine that projects from the abdomen the spine is used to inject Venom into the victim which can trigger allergic reactions ranging from mild to life-threatening anaphylaxis signs and symptoms of ant stings particularly from fire ants often include an Abrupt onset of pain localized swelling and heat at the sting site in light-skinned individuals arithma may be observed additionally patients may experience widespread ticaria itching and the formation of a wheel applying ice to the affected area can sometimes alleviate the irritation caused by Wheels if a stinger is present it should be removed by scraping the skin with a sharp stiff object such as a credit card rather than using tweezers or forceps as squeezing May inject additional Venom after removing the Stinger clean the area with soap in water or a mild antiseptic it's also advisable to remove any jewelry from the area before swelling occurs position the injection sight slightly below the level of the heart and apply ice or Cal packs to reduce swelling when treating a patient with a suspected allergic reaction remain vigilant for signs of Airway swelling such as difficulty breathing Strider or aoar voice which may indicate the onset of anaphylaxis other symptoms to watch for include severe hives angu edema or GI distress if you suspect an AIS position the patient in the supplying position to facilitate proper blood flow and prevent potential complications administers supplemental oxygen if the patient exhibits signs of hypoxia or respiratory distress continuously monitor the patient's Vital Signs including heart rate blood pressure and respiratory rate and be prepared to provide additional interventions such as administering epinephrine intravenous fluids or other medications as necessary based on the patient's condition and response to the initial treatment.",
        "Patient Education and Prevention": "effective management of anaphylaxis and allergic reaction hinges on educating patients about prevention and self-care strategies advise patients to avoid known allergens and ensure that all healthc care providers are aware of their allergies encourage the use of identification tags or bracelets to alert others to their condition patients should carry an anaphylaxis kit or EpiPen at all times to quickly address any allergic reactions it's also important to report any symptoms of an allergic reaction as soon as they arise to allow for prompt intervention.",
        "Conclusion and Summary": "in this lecture we cover the critical aspects of identifying and managing allergic reactions and anaphylaxis in the field this lecture begins with an overview of common immunologic emergencies including signs and symptoms such as sudden pain swelling ticaria and arhythmia emphasis is placed on recognizing severe reactions such as Airway swelling and systemic anaphylaxis as well as the import importance of early intervention Key Management strategies include proper techniques for Stinger removal the use of ice to reduce discomfort and positioning the patient appropriately to manage symptoms effectively this lecture highlighted the importance of monitoring Vital Signs and being prepared for further support including administering oxygen and other medications as needed patient education plays a vital role in preventing future emergencies strategies include avoiding known allergens notifying Health Care Providers using identification tags carrying an Anais kit and Reporting science promptly overall this lecture aimed to equi Advanced emergency medical technicians with the Knowledge and Skills to manage immunologic emergency efficiently ensuring patient safety and effective care in prehospital settings"
    },
    {
        "Introduction to Medical Overview": "chapter 16 medical overview in the field of Emergency Medical Services patients typically require assistance due to either medical or trauma emergencies and sometimes even both trauma emergencies refer to injuries that occur as a result of physical forces impacting the body such as blunt force or penetrating trauma on the other hand medical emergencies are associated with illnesses or conditions that arise from diseases or other pathological processes that affect the body understanding the distinction between these types of emergencies is fundamental in determining the appropriate treatment and intervention strategies.",
        "Types of Medical Emergencies": "medical emergencies Encompass a wide range of conditions each affecting different bodily systems respiratory emergencies occur when a patient experiences difficulty breathing or when the oxygen supply to tis tissues is insufficient conditions such as asthma osma and chronic bronchitis are common causes cardiovascular emergencies involve the circulatory system with myocardial infarction and heart failure being typical examples neurologic emergencies affect the brain and can result from seizures Strokes or Syncopy gastrointestinal emergencies include conditions like appendicitis Diverticulitis and pancreatitis while Urologic emergencies may involve kidney stones endocrine emergencies most commonly arise from complications of diabetes malius hematologic emergencies often involve disorders such as CLE cell disease or blood clotting abnormalities such as hemophilia immunologic emergencies occur when the body responds responds inappropriately to foreign substances such as in allergic reactions which can range from mild symptoms to severe Anil axis toxicologic emergencies are related to poisoning or substance abuse leading to various medical complications psychological and behavioral emergencies present a unique challenge as these patients may not exhibit standard signs or symptoms lastly gynecologic conditions can be particularly challenging in the prehospital setting due to a limited treatment option available in the field each type of emergency requires a tailored approach to ensure proper patient care and outcomes.",
        "Patient Assessment in Medical Emergencies": "patient assessment in medical emergencies is comparable to that in trauma cases although the emphasis differs when assessing a medical patient the focus is on determining the nature of the illness or noi identifying symptoms and understanding the patient's cheap complaint information provided by Dispatch before arriving on the scene can be invaluable in shaping expectations and preparing for what may be encountered it's important to recognize that a traumatic emergency may also present as a medical emergency and vice versa the two are not mutually exclusive maintaining a broad perspective during the assessment is crucial as a narrow Focus or tunnel vision can lead to overlooking significant injuries or illnesses the goal is to Gather Comprehensive information to guide appropriate treatment and Care.",
        "Prehospital Management and Treatment": "in managing medical emergencies it's important to recognize that many situations will require treatment beyond what can be provided in the prehospital setting the primary goal of prehospital care is often to manage symptoms rather than address the underlying disease process directly for aemts the administration of medications is typically limited and must be done with caution any medication administered bu an aemt generally requires direct permission for medical control though certain protocols may allow for the administration of specific medications without the need for immediate online medical control it is essential to conduct a comprehensive assessment of the patient before contacting medical control for permission to administer these medications additionally aemts are authorized to use an AED on patients who rep pulses and apnic as this is a critical intervention in cases of sudden cardiac arrest the overall focus in the prehospital setting is to stabilize the patient and prepare for transport to a facility where more definitive care can be provided.",
        "Transport Considerations": "when managing medical emergencies seen time can often be longer for medical patients compared to trauma patients as the nature of the illness may require a more thorough assessment and time spent Gathering information it's important to collect as much relevant data as possible from the scene to relay to the emergency department patients who are in critical condition require a rapid transport to a medical facility this includes individuals with an altered mental status those experiencing Airway or breathing difficulties patients showing signs of circulatory compromise and individuals who are either very old or very young regarding the type of transport if the patient's condition is life-threatening transport should be conducted with lights and Sirens to expedite arrival at the hospital for patients who are not in a critical State non-emergency transport may be more appropriate the decision on the urgency and mode of Transport should be guided by the results of the patient's primary survey ensuring that the patient receives the appropriate level of care during Transit.",
        "Ground and Air Transport": "transportation of patients in emergency medical situations typically falls into one of two categories ground or Air transport ground transport EMS units are usually staffed by Advanced life support providers such as aemts or paramedics along with emergency medical technicians on the other hand air transportation EMS units which may include Critical Care transport units are generally staffed by Critical Care nurses and paramedics providing a higher level of care during transit for patients requiring more intensive medical attention the choice between ground and Air transport depends on the patient's condition the urgency of the situation and the distance to the appropriate medical facility.",
        "Destination Selection for Transport": "When selecting a destination for transport the general rule is to direct the patient to the closest hospital with an emergency department that being said in certain situations it may be more beneficial for the patient to be transported to a hospital that is better equipped to handle their specific condition if a patient goes into cardiac arrest or experiences Cardiac Arrest during transport it's imperative to reroute immediately to the nearest hospital with appropriate emergency facilities if there is any uncertainty regarding the best destination medical control should be contacted for guidance additionally some patients might benefit from receiving on scene treatment provided by paramedics before or during transport depending on their condition and the circumstances.",
        "Infectious Diseases Overview": "infectious diseases are medical conditions resulting from the growth and spread of harmful organisms within the body these diseases can sometimes be communicable meaning they can be transmitted from one person to the next when addressing a patient with an infectious disease it's important to approach them as you would any other medical patient Begin by sizing up the scene and taking standard precautions to protect yourself and others following this perform a primary survey focusing on the ABCs to prioritize transport use the opqrst memonic to thoroughly investigate the patient's Chief complaint which may include symptoms such as fever nausea rash pic chest pain and difficulty breathing additionally collect the sample history and obtain a set of Baseline vital signs to guide your treatment plan and ensure a comprehensive evaluation.",
        "General Management Principles": "when managing a patient it's important to adhere to General management principles to ensure effective and Compassionate Care First prioritize addressing any life-threatening conditions identified during the primary survey maintaining empathy throughout patient inter interactions is vital as it helps build trust and can improve patient outcomes ensure that the patient is placed in a position of comfort on the stretcher and keep them warm to prevent further distress standard precautions must always be followed to minimize the risk of infection transmission this includes adhering to your agency's exposure control plan when cleaning equipment and ensuring that disposable supplies and linens are properly discarded after use.",
        "Epidemics and Pandemics": "when considering epidemic and pandemic situations it's important to understand the definitions and implications of each an epidemic occurs when new cases of a disease in a specific human population substantially exceed what is expected based on recent experience this surge in cases is typically localized but can spread rapidly within the affected area in contrast a pandemic refers to an outbreak that spreads on a global scale affecting multiple countries and populations across the world both scenarios require a heightened awareness and preparedness as they can lead to significant public health challenges and strained medical resources.",
        "HIV and AIDS Overview": "human immuno deficiency virus or HIV and acquired imuno deficiency syndrome AIDS are significant public health concerns first identified in the United States during the 80s according to the CDC over 1.2 million people in the US are currently living with HIV the virus disproportionately affects gay and bisexual men particularly young African-American men within this group HIV is primarily a sexually transmitted infection but it can also be transmitted through blood technically making it a bloodborne pathogen the virus poses a risk only when it comes into contact with mucous membranes or enters directly into the bloodstream transmission can occur from a pregnant woman to her infant during childbirth and the rare due to vigorous testing through blood transfusions once infected the virus attacks and envelops immune cells progressively weakening the immune system this deterioration allows life-threatening opportunistic infections to take hold leading to the progression from HIV infection to AIDS many individuals with HIV May remain asymptomatic for years making the virus particularly Insidious and challenging to detect without testing.",
        "HIV Symptoms and Management": "signs and symptoms of an HIV infection may include an acute febr illness which is characterized by sudden onset of fever other common symptoms include General malaise fatigue and sore throat patients may also experience swelling of the spleen and lymph glands headaches weight loss and in some cases a rash these symptoms are often non-specific and can be mistaken for other illnesses making it important for healthc care providers to consider a patient's risk factors in history when assessing for potential HIV infection acquired imuno deficiency syndrome or Aids represents the final stage of the disease process caused by HIV infection patients with AIDS are highly susceptible to a variety of bacterial viral and fungal infections that typically do not affect individuals with a healthy immune system these opportunistic infections may include pneumonia and infants or individuals with weakened immune systems loss of vision red or purple skin lesions atypical TB and cryptococcal menitis the incubation period for HIV spans the time from initial infection to the development of AIDS it's important to note that the communicable period for HIV begins before AIDS becomes clinically apparent meaning the virus can be transmitted even in the absence of symptoms in the prehospital setting management of patients with HIV and AIDS is primarily supp supportive focusing on stabilization and addressing symptoms currently no vaccine is available to protect against HIV or Aids making prevention early detection and supportive care vital components of managing this disease.",
        "HIV Transmission and Precautions": "in the EMS work setting the transmission of HIV is not easily accomplished the risk of infection is primarily limited to direct exposure to the blood and body fluids of an infected patient because many individuals with HIV may be asymptomatic it's important to always take precautions to prevent infection key precautions include consistently wearing gloves before leaving the ambulance handling and disposing of needles and other sharp objects in a sharp container and ensuring any open wounds you have are properly covered while on the job if you experience any potential exposure it's imperative to seek medical advice as soon as possible to assess the risk and determine the appropriate course of action these preventive measures are essential in minimizing the risk of infection in the prehospital environment.",
        "Influenza Overview": "influenza commonly known as the flu is a contagious respiratory illness it particularly affects individuals with chronic medical conditions compromised immune systems and those who are very young or elderly the virus is primarily transmitted through direct contact with nasal secretions a specific form of influenza the H1N1 virus was initially identified as Swan flu during the 2009 pandemic treatment for the flu generally involves supportive care to alleviate symptoms as there is no real cure for the virus itself flu along with other potentially serious respiratory diseases can be transmitted via the respiratory route emphasizing the importance of prevention measures these include wearing personal protective equipment practicing frequent handwashing and keeping vaccinations up to date for patients with respiratory symptoms placing a surgical mask on them can reduce the spread of the virus during any aerosol generating procedures healthc care providers should wear a HEPA respirator to protect themselves from Airborne particles annual flu shots is strongly recommended particularly for EMS Personnel to protect both themselves and their patients from the flu and its complications.",
        "Hepatitis Overview": "hepatitis refers to the inflammation and often infection of the liver which can result from various viruses and toxins the condition can lead to significant complications including liver scarring liver cancer and ultimately liver failure among the types of viral hepatitis hepatitis C is particularly concerning as it accounts for the greatest number of deaths and has the highest mortality rate in the United States the presentation of hepatitis can vary widely depending on the severity of the disease some patients May remain asymptomatic while Others May exhibit a range of early signs and symptoms these indicators include a loss of appetite vomiting fever fatigue sore throat cough and muscle and joint pain several weeks after the initial symptoms of hepatitis patients May develop jaundice which is characterized by the yellowing of the eyes and skin this is a sign that the liver's ability to process B Rubin is impaired in addition to jaundice patients may experience pain in the right upper quadrant of the abdomen this is where the liver is located and this pain can be indicative of further inflammation or damage to the liver these symptoms suggest a progression of the disease and warrant prompt medical evaluation and intervention.",
        "Hepatitis Management and Transmission": "the management of patients with any type of hepatitis is primarily supportive as there is no definitive treatment or cure for the disease it's important to note there's no reliable method to determine which hepatitis patients are contagious toxin induced hepatitis for example is not contagious but viral hepatitis can be depending on the type and the patient status as a carrier a carrier is an individual who Harbors the Infectious organism possibly without showing symptoms yet still has the potential to spread the infection to others hepatitis A is transmitted orally through fical contamination whereas B C and G are transmitted through other vehicles such as blood or bodily fluids rather than food or water the virulence of a pathogen refers to its ability to produce disease and in the case of hepatitis B it is significantly more contagious and HIV vaccination against Hepatitis B is strongly recommended for amts as well as other prehospital care providers however it's important to understand that not everyone who receives the vaccine will develop immunity therefore it's advisable to seek testing after vaccination to determine your immune status and ensure adequate protection against the virus.",
        "Herpes Simplex and Syphilis": "herpes simplex is a common virus strain that is widely carried by humans many individuals who carry the virus remain asymptomatic meaning they do not exhibit any symptoms however in cases where the infection becomes symptomatic it typically causes eruptions of tiny fluid fil blisters known as vesicles which commonly appear on the lips genitals in certain populations such as the very young very old and imuno compromised herpes simplex can lead to more serious illnesses including pneumonia and menitis the virus is primarily transmitted through close personal contact making it important for healthcare workers to follow standard precautions to prevent the spread of the virus syphilis is often recognized as a sexually transmitted disease but it's important to understand that it's also a bloodborne disease this means there is a small risk of transmission through contaminated needl stick injuries or direct blood-to-blood contact the initial infection of syphilis typically produces a lesion known as a shankri shankri are most commonly found in the genital region and are an early indicator of the disease recognizing these lesions is important for early diagnosis and treatment to prevent further progression of Syphilis.",
        "Meningitis Overview": "menitis is an inflamation of the meni coverings that protect the brain and spinal cord this condition can be severe and requires prompt medical attention common signs and symptoms of menitis include fever headache a stiff neck and altered mental status these symptoms indicate that the inflammation is affecting the central nervous system and immediate evaluation and treatment are necessary to manage the condition and prevent serious complications menitis can be caused by either viruses or bacteria with most forms being non-contagious however menia cocko menitis is an exception and is highly contagious differentiating between various forms of menitis requires Laboratory Testing as the symptoms alone may not be sufficient for a definitive diagnosis it's important to take standard precautions when dealing with suspected cases of menia cocko menitis wearing gloves and a mask is essential to prevent the patient secretions from coming into contact with your nose and mouth reducing the risk of transmission vaccines are available for most types of Menin caucus providing a key preventative measure if the patient is diagnosed with menia menitis they will typically be treated in the emergency department with antibiotics to manage infection after treating a patient with menitis it's important to contact your employer's Health representative this step is crucial because in many states menitis is classified as a reportable disease this means that healthc care providers are required by law to report cases of menitis to Public Health authorities if one of your patients is diagnosed with menitis you may be contacted by public health officials for further information or followup underscoring the importance of proper documentation and communication with your employer's health Team.",
        "Tuberculosis Overview": "tuberculosis is a chronic myobacterium disease that is primarily affecting the lungs many individuals infected with TB remain asymptomatic most of the time however if the disease spreads to the brain or kidneys the patient is generally only slightly contagious TB manifests shortly after infection is known as primary tuberculosis while reactive tuberculosis which occurs after a period of latency is more common and often more challenging to treat this difficulty is exacerbated by the growing resistance to many TB strains of antibiotics patients who were most at risk of spreading TV typically exhibit a persistent cough it is important to recognize that respiratory tuberculosis is the only form of the disease that is contaged through Airborne transmission the primary concern is not the droplets produced by coughing but the droplet nuclei which are the remnants of these droplets after the water is evaporated these nuclei can remain airborne and infectious for extended periods to protect against inhalation of droplet nuclei Healthcare Providers must must wear n95 or HEPA masks for patients experiencing dnia a non-rebreathing mask can be used to oxygenate the patient while also preventing the spread of the Infectious droplets if the patient is not having difficulty breathing then we should place a surgical mask on the patient and a hea mask on yourself to minimize the risk of transmission absolute protection against infection with the tubal bailus bacterium that causes TB is not possible everyone who breathes is potentially at risk of Contracting TB The Who estimates that 1/4 of the global population is actually infected with TB there is a vaccine though it is rarely used in the United States due to its limited Effectiveness and the low incidence of TB in the country Additionally the transmission mechanism is not very efficient which means while the risk exists the likelihood of transmission is somewhat reduced compared to other infectious diseases it is important for individuals especially those in healthare savings to have regular TB skin tests early detection of TB infection before the onset of illness allows for preventative therapy which is almost 100% effective in preventing the progression into active TB but this preventative measure is a key strategy in controlling the spread and impact of the disease.",
        "Pertussis Overview": "pusis commonly known as whooping cough is an airborne disease caused by bacteria that historically affected children under the age of six however it's now becoming more common in adults whose immunity has waned over time particularly those who were vaccinated many years prior the signs and symptoms of pressus include a fever and a characteristic whoop sound which occurs when the patient tries to inhale after a severe coughing attack this whooping sound is caused by the intense effort to Breathe In following a series of Rapid coughs the most effective way to prevent pressus infection is through vaccination with the diptheria tetanus an Anor prusis or Tdap vaccine in addition to vaccination it's recommended to place a mask on both the patient and yourself to prevent the spread of the disease especially in a clinical or prehospital setting.",
        "MRSA Overview": "methylin resistant stafl cacus arus or MRSA is a bacterium known for causing infections that are resistant to most antibiotics in healthcare settings MCA is often associated with nosocomial infections which believed to be transmitted from Patient to Patient primarily through the unwashed hands of healthc care providers studies indicate that between 1 and 5% of Health Care Providers carry MRSA in their Nars which highlights the importance of strict hygiene practices to prevent the transmission of MRSA it's essential to use gloves when handling patients and to practice thorough handwashing techniques several factors can increase the risk of developing a MRSA infection these include undergoing antibiotic therapy having prolonged hospital stays being admitted to an intensive care or Burn Unit and exposure to an infected patient the incubation period for Mera can range from 5 to to 45 days it's important to note that exposure to MRSA will not lead to infection if you come into direct contact with wound drainage but your skin remains intact in the case of true exposure no postexposure treatment is generally recommended but it is essential to document the incident thoroughly as this is crucial for monitoring potential health risks and ensuring that proper Protocols are followed.",
        "Emerging Diseases": "new and emerging diseases such as hirus and westn virus present unique challenges in healthcare hirus is rare but very deadly and is transmitted through contact with rodent urine and droppings it's not directly transmitted from person to person rather it's spread via a vehicle like contaminated food or through a vector such as rodents this makes prevention focused on controlling exposure to rodent carriers the westnile virus is transmitted by mosquitoes which serve as the vector for the disease it affects both humans and birds but is not communicable between humans as a result it poses no direct risk during patient care making standard precautions sufficient when dealing with patients who have westnile virus severe acute Respiratory Syndrome or SARS is a serious and potentially life-threatening viral infection caused by a recently discovered family of viruses the disease typically begins with flu like symptoms which can escalate into pneumonia respiratory failure and in some cases result in death SARS is primarily transmitted through close person-to-person contact or by exposure to respiratory secretions the contagious nature of SARS and its potential severity make it a significant concern in healthc care settings necessitating stringent infection control measures to prevent it spread.",
        "Avian Flu Overview": "Aven flu also known as bird flu is caused by a virus known as the H1 M1 virus and occurs naturally within bird populations this virus is typically carried by the intestinal tract of wild birds where it does not usually cause illness however in domestic bird populations such as chickens ducks and turkeys the virus can be highly contagious if an infected bird is properly cooked and used for food it does not pose a risk for those who consume it human infection with Aven flu generally occurs through close contact with infected Birds importantly no rapid human-to-human transmission of AVM flu has been reported and the overall transmission risk for humans remains low these factors make Aven flu a concern primarily in the context of agricultural settings and those who work closely with birds.",
        "MERS-CoV Overview": "Middle East Respiratory Syndrome Corona virus or Ms KV is a Global health issue primarily associated with bats and camels in the Middle East however cases of human infections have also been reported in other regions including Europe and the United States the symptoms of MS kov infection typically include high fever cough muscle aches vomiting and diarrhea currently there is no cure or vaccination available for this virus if you suspect a patient might have MS KV it's important to place a surgical mask on the patient to reduce the risk of transmission and immediately notify the receiving Health Care Facility to ensure appropriate precautions are taken.",
        "COVID-19 Overview": "Corona virus 19 or covid-19 was first reported in Wuhan China on December 31st 2019 the disease is caused by a novel Corona virus named severe acute respiratory syndrome Corona virus 2 or SARS kv2 which is closely related to the m KV and SARS viruses covid-19 primarily affects the respiratory system leading to severe symptoms respiratory failure and in some cases death on March 11th 2020 the who declared covid-19 a pandemic highlighting the global spread and impact of the virus governments Public Health Systems and Healthcare Delivery Systems worldwide were largely unprepared for the scale and severity of the pandemic covid-19 is a highly contagious respiratory infection with a wide range of symptoms that typically appear 2 to 14 days after exposure common symptoms include fever chills cough shortness of breath body aches headache and loss of taste and smell in addition to respiratory issues the virus can also attack the heart walls blood vessel Linings and kidneys a significant number of individuals infected with the virus May Never develop symptoms but can still transmit the disease to others to mitigate the spread the CDC recommended widespread use of masks in public during the height of the pandemic SARS kv2 primarily spreads through respiratory droplets expelled by an infectious person and maintaining a distance of at least 6 feet from others was advised to reduce the risk of exposure the virus can survive on surfaces for up to a day and longer on some non-pest surfaces transmission can occur if a person touches a contaminated surface and then touches their mouth eyes or NOS those at the highest risk of serious illness from covid-19 include older adults and individuals with underlying medical conditions.",
        "Ebola Overview": "Ebola is a severe viral illness with an incubation period of approximately 6 to 12 days after exposure the symptoms may not appear for as long as 21 days following infection the initial symptoms include watery diarrhea vomiting fever body aches and bleeding which can rapidly progress the fatality rate for Ebola can be as high as 70% if effective supportive treatment is not initiated properly due to the risk associated with the virus if you expect that a patient may have Ebola it is critical to place a surgical mask on the patient and follow strict personal protective equipment precautions ions to prevent transmission.",
        "Zika Virus Overview": "the zika virus is a vector born infection first noted in the United States in mid 2015 it is transmitted primarily by the bite of a mosquito and currently there is no vaccine available for the virus so prevention efforts focus on protecting against mosquito bites according to the CDC most individuals infected with the zika virus exhibit few or no symptoms when symptoms do occur they typically include fever rash joint pain and conjunctivitis other possible symptoms include muscle pain and headache the symptoms are generally mild and last from several days to a week diagnosis of zika can be confirmed through a urine or blood test the most significant complication of zika infection is its impact on pregnant women as the virus poses a serious risk to the fetus including the development of birth defects such as microsopy Beyond mother de fetus transmission the most common human to human transmission of the virus occurs through sexual contact treatment for zika is supportive as there is no specific antiviral Treatment available for healthcare Personnel no special protective equipment is recommended Beyond standard precautions.",
        "Travel Medicine Considerations": "in the field of Travel Medicine patients who acquire an illness from another country can present with a wide range of symptoms which vary depending on the specific illness they have contracted when you encounter a patient who is ill and has a recent history of travel it's important to immediately place a mask on the patient to prevent potential transmission of any communicable disease additionally gather as much information as possible about the patient's travel history and symptoms if you suspect that the patient has a communicable illness it is essential to follow appropriate personal protective equipment precautions to protect yourself and others furthermore promptly notify the receiving facility so that they can prepare and take the ne necessary precautions to manage the patient safely and effectively.",
        "Assessing Patients with Travel History": "when assessing a patient with a recent travel history it's crucial to gather detailed information to help identify potential illnesses Begin by asking where they recently traveled as a geographical location can provide insight into diseases that are endemic to that area inquire whether they received any vac vaccinations before their trip as this can impact their risk of certain diseases it's also important to determine if they were exposed to any infectious diseases during their travels and if anyone else in their travel party is sick as this could indicate a communicable disease additionally ask about the types of food they consumed particularly if it was under cooked or potentially contaminated and what their source of drinking water was since contaminated water can lead to waterborne diseases.",
        "Conclusion on Medical Patient Assessment": "in conclusion the assessment and treatment of medical patients can be particularly challenging unlike trauma patients where the condition is often visible and immediately apparent medical patients may present with conditions that are not as readily observable this requires a careful and thorough evaluation to identify the underlying issues and provide appropriate care the complexity of diagnosing and managing medical conditions underscores the importance of a systematic approach to Patient assessment when managing medical patients the best approach involves several key steps first and foremost it's important to remain calm as a composed demeanor will help you make clear informed decisions decisions utilize your patient assessment skills to Gather Comprehensive information about the patient's condition while treating the patient symptoms maintain a high index of Suspicion for any underlying problems that may not be immediately apparent always report your findings and actions to medical control to ensure that the patient receives appropriate care during transport ensure that the patient is safely taken to the closest and most appropriate facility for their needs lastly remember that patients may have more than one isolated problem so it is essential to consider the possibility of multiple underlying conditions when conducting your assessment and treatment plan"
    },
    {
        "Introduction to Geriatric Emergencies": "chapter 37 geriatric emergencies geriatrics involves the assessment and treatment of diseases and injuries in individuals aged 65 or older physiologically the decline in various body systems begins as early as the late 20s and continues gradually throughout the lifespan this decline affects multiple organ systems altering their functionality and the body's overall ability to respond to injury or illness understanding these age related changes is essential when assessing and treating older adults as it influences the presentation of diseases injury mechanisms and the overall management approach the proportion of older individuals in the population is steadily increasing making geriatric care a significant focus in healthc care in aging bodies the presentation of serious medical conditions can often be masked or atypical complicating diagnosis and treatment physiological changes such as diminished pain perception altered immune response and reduced homeostatic Reserve can obscure the severity of illnesses or injuries requiring a more Vigilant and thorough assessment in this population.",
        "Economic and Social Impact on Geriatric Care": "The Aging population has a notable economic impact particularly in healthcare many older adults Mayes hesitate to seek medical assistance due to concerns about the cost of care leading to delayed treatment and potentially worsening conditions Additionally the high cost of prescriptions can result in some individuals skipping doses or reducing their medication intake which can compromise treatment Effectiveness and lead to poor health outcomes furthermore a significant number of individuals who have reached retirement age continue to participate in the workforce often out of necessity to supplement their income and manage health care expenses contrary to Common assumptions not all older adults reside in nursing homes many live independently and manage their own Affairs in fact some older individuals are the primary caregivers of their own aging parents which in and of itself can present unique challenges in health care situations for these individuals there may be a fear that seeking medical treatment or being hospitalized could result in a permanent loss of Independence leading to anxiety about never returning home most healthy older adults have a strong desire to maintain their independence and this goal often DWS their decisions regarding Medical Care and interventions some older adults do not have family or friends to assist them and are fully self-dependent managing their daily activities and Health Care needs on their own social isolation can increase the risk of self-abuse alcohol abuse or medication misuse as a coping mechanism for loneliness or depression Additionally the stress of caring for a chronically ill- loved one can become overwhelming for older caregivers often leading to caregiver burnout.",
        "Dependent Living and Legal Rights": "Dependent living also referred to as Residential Care encompasses various levels of assistance ranging from minimal support to extensive care depending on the individual's needs and any restrictions imposed by their medical or cognitive conditions these levels of care are carefully tailored to ensure safety and quality of life while addressing specific health or functional limitations mentally competent adults as well as emancipated minors retain the legal right to consent to or decline medical treatment including decisions regarding life sustaining interventions Advanced directives play a significant role in into Life Care guiding health care providers in respecting their patients wishes do not resuscitate DNR or do not attempt resuscitation DN orders are Specific Instructions indicating that no resuscitative efforts should be made in the event of cardiac or respiratory arrest additionally physician orders for life- sustaining treatment or pulst documents outline clear and specific medical orders regarding interventions to be followed as a patient approaches the end of life these orders ensure that treatment aligns with the patient's values and wishes regarding care a health care proxy also known as durable power of attorney for Health Care is a legal document that designates a surrogate to make Health Care decisions on behalf of a patient in the event that they become incapacitated and are unable to make decisions for themselves Hospice Services are designed to provide care and comfort for terminally ill patients often in a homelike setting with a focus on Pala of care rather than Curative treatment additionally some Health Care programs allow patients to receive Medical Care in the comfort of their own homes offering a range of services that include Nursing Care physical therapy and assistance with daily living activities particularly for those with chronic or debilitating conditions.",
        "Effective Communication with Older Patients": "Effective communication with older patients and their spouses requires a thoughtful approach Begin by asking open-ended questions allowing patients to provide detailed information about their condition or concerns follow up with close-ended questions when clarification is needed to ensure accuracy in the patient responses it's important to maintain a professional demeanor avoiding overly familiar language or behavior as this can be perceived as disrespectful or condescending clear respectful communication helps build trust and ensures that patients feel valued and understood during the assessment and treatment process when communicating with older patients it's vital to avoid being judged judgmental as this can negatively impact the patient provider relationship and hinder open communication building patient confidence is key and this can be achieved by demonstrating empathy and professionalism throughout the interaction a slow deliberate approach is recommended allowing the patient time to process information and respond appropriately always explain what you were doing during the assessments or procedures as this helps reduce anxiety and keeps the patient informed after the patient interview it's Ben official to consult with family members or caregivers to clarify any information and ensure that the patient's history and needs are fully understood this collaborative approach enhances the accuracy of the patient's care.",
        "Care in Nursing Homes and Infection Control": "When responding to nursing homes or skilled care facilities the these settings are often where older patients reside and require care before initiating transport it's important to gather key information about the patient including their Chief complaint and admitting diagnosis comparing the patient's current condition with their Baseline prior to the onset of symptoms is also essential in order to assess the severity of the situation additionally obtaining transfer records ensures continuity of care and provides critical medical information infection control must be prioritized in these environments given the increased vulnerability of the patient population to infections especially in communal living situations proper hygiene use of personal protective equipment and adherence to facility Protocols are necessary in order to minimize the risk of spreading infectious diseases.",
        "Leading Causes of Death and Risk Factors": "The leading causes of death in older adults include heart disease cancer chronic lower respiratory disease stroke Alzheimer's disease diabetes trauma and pneumonia the physiological changes that occur with aging make older individuals more vulnerable to these conditions compared to younger populations age related declines in immune function reduced organ Reserve and altered responses to stressors contribute to this increased vulnerability additionally acute illnesses or traumatic events in older patients are more likely to have multi-stem involvement as the body's ability to compensate is diminished often leading to complications that extend beyond the initially affected organ systems other significant risk factors for poor health outcomes in older adults include living alone which can contribute to social isolation and delayed medical intervention and the recent death of a spouse or significant other which can lead to emotional stress and impact physical health immobility whether due to Chronic conditions or injury increases the risk of complications such as pressure ulcers deep vein thrombosis and pneumonia additionally an altered mental status whether from dementia delirium or other cognitive impairments can complicate the recognition in management of medical conditions further increasing the likelihood of adverse outcomes these factors should be carefully considered when assessing and treating older patients.",
        "Physiological Changes with Aging": "As people age their anatomy and physiology naturally undergoes changes which can affect the fun F of various body systems however these changes do not necessarily mean that an individual will experience disease or diminish quality of life it's important to recognize that common stereotypes about older adults such as the assumption that aging always leads to frill or chronic illness are often inaccurate many older individuals remain healthy and active despite the physiological shifts that accompany aging as the body ages several physiological changes occur that impact various systems motor nerves gradually deteriorate leading to a decrease in reaction time and affecting coordination and reflexes blood pressure often increases due to changes in vascular elasticity and arterial stiffness the body's ability to regulate and maintain normal body temperature also declines lines increasing susceptibility to both hypothermia and hypothermia muscles lose flexibility and strength over time contributing to reduced physical function Additionally the efficiency of oxygen and carbon dioxide Exchange in the lungs and at the cellular level declines which can lead to decreased exercise tolerance and respiratory function metabolic rate decreases as well often resulting in weight gain unless adjustments are made to diet and activity levels these changes underscore the importance of tailored healthc care strategies to address the unique needs of the Aging population.",
        "Respiratory System Changes": "As individuals age several changes occur within the respiratory system that reduce overall respiratory capacity the Alvi responsible for gas exchange become enlarged and their elasticity decreases making it more difficult for the lungs to fully expand and contract additionally The receptors that monitor oxygen and carbon dioxide levels in the blood slow in their response reducing the body's ability to regulate breathing effectively these changes combined with altered blood flow distribution within the lungs contribute to a decline in the partial pressure of oxygen in arterial blood leading to lower oxygen levels and reduced respiratory efficiency the respiratory system also becomes slower to react to conditions such as hypoxemia and hypercapnia delaying the body's compensatory responses kyphosis a forward curvature of the spine that's common in older adults May further limit lung volume and maximal inspiratory pressure reducing the capacity for effective breathing Additionally the size and strength of respiratory muscles decrease making breathing more labor intensive and less efficient these factors increase the likelihood of Airway obstructions from secretions or food particles as the cough reflex and clearance mechanisms are often diminished as well chronic lower respiratory diseases including conditions such as COPD and pneumonia are among the leading causes of death in geriatric populations pneumonia particularly infections caused by pumac cacus bacteria remains a significant contributor to morbidity IM mortality in older adults due to their diminished immune response and respiratory capacity pulmonary embolism another potentially life-threatening condition is also a common cause of respiratory distress in older adults and the risk of embolism increases due to factors such as immobility coagulopathies and underlying cardiovascular disease.",
        "Cardiovascular System Changes": "As people age the cardiovascular system undergos several changes that impact overall function cardiac output declines reducing the amount of blood the heart can pump to meet the body's demands Additionally the heart's ability to increase its rate enhance the strength of its contractions and constrict blood vessels in response to stressors is diminished these changes decrease the body's capacity to respond to increased physical or metabolic demands dysrhythmias or irregular heart rhythms also become more common in older adults due to changes in the electrical conduction system of the heart further complicating cardiovascular health older adults are at a high heightened risk for atherosclerosis a buildup of plaque in the arteries which can lead to reduced blood flow and an increased likelihood of cardiovascular events arteriosclerosis the thickening and stiffening of arterial walls further increases the risk of conditions such as stroke heart disease hypertension and bowel infarction in addition aging individuals are at a greater risk for developing annual RMS which are weakened bulging areas in blood vessels one of the most dangerous forms is an abdominal aortic aneurysm or AAA which can rupture and is among the most rapidly fatal conditions requiring immediate intervention these vascular changes necessitate careful monitoring and early detection in older patients to prevent catastrophic outcomes.",
        "Nervous System Changes": "Aging brings about significant changes in the nervous system which are often reflected in neurological exams one notable change is the reduction in brain weight which increases the risk of head trauma as there is more room for the brain to shift within the skull upon impact cognitive functions are also affected with many older adults experiencing short-term memory impairment and slower reflex times the performance of most sensory organs such as Vision hearing and taste declines further impacting their ability to interact with their environment additionally proception or the sense of body position and movement becomes impaired contributing to balance issues and increasing the risk of Falls Vision undergos several changes with aging leading to a decrease in visual Acuity making it more difficult for older adults to see clearly especially fine details night vision becomes impaired reducing the ability to see in low light conditions which increases the risk of accidents cataracts characterized by the clouding of the lens can significantly interfere with vision glaucoma a condition in which intraocular pressure increases to a level that damages the optic nerve can lead to irreversible vision loss if untreated macular degeneration a progressive disease causes vision loss in the central part of the visual field severely affecting the ability to read or recognize faces additionally retinal detachment where the retina separates from the back of the eye can result in permanent vision loss if not promptly treated hearing declines largely due to inner ear changes that make it challenging to detect high frequency sounds this condition known as presbycusis is a progressive form of hearing loss that affects higher pitch sounds making it harder to understand speech especially in noising environments physiological changes also impact the ability to produce speech that is loud clear and well paced further complicating communication for older adults these auditory impairments necessitate adjust UST Ms on how providers and caregivers communicate with older individuals such as speaking more slowly clearly and ensuring proper volume without shouting the sense of taste diminishes due to a reduction in the number and size of taste buds this decrease in taste sensitivity can lead to an inability to distinguish between fresh and spoiled food increasing the risk of food born illness the sense of touch declines as specialized nerve fibers are lost reducing the ability to perceive physical stimuli accurately alterations in pain perception are also common which may cause older adults to overlook or under report injuries or medical conditions delaying necessary medical attention the sense of smell is typically the last of the senses to diminish with age though it can be effective Ed by factors such as upper respiratory infections which may temporarily or even permanently impair old factory function.",
        "Delirium and Dementia": "Disorders affecting mental status such as delirium are also common in older adults delirium is characterized by a sudden change in mental status marked by an inability to focus think logically or maintain attention when assessing for delirium it's important to evaluate potential underlying causes such as hypoxia hypovolemia hypothermia or hypoglycemia as these conditions can often contribute to or exacerbate cognitive disturbances in older patients dementia is a condition marked by a slow Progressive decline in cognitive function characterized by disorientation a shortened attention span and impaired memory unlike delirium which has an acute onset dementia develops gradually over a period of years and is generally irreversible the signs and symptoms of dementia such as memory loss and difficulty with complex tasks often take months to years to become noticeable it's important to differentiate dementia from delirium as dementia is a chronic long-term condition while delirium is an acute reversible condition triggered by an underlying medical issue.",
        "Alzheimer's and Parkinson's Disease": "Alzheimer disease is a progressive neurodegenerative disorder caused by the death of neurons in the brain it begins gradually and worsens over time early symptoms often include confusion changes in personality or judgment and significant challenges in performing daily activities as the disease progresses cognitive decline becomes more pronounced eventually impacting the individual's ability to communicate recognize loved ones and care for themselves Alzheimer's disease is a leading cause of dementia and while there's no cure early diagnosis and intervention can help manage symptoms and improve the quality of life for both patients and caregivers parkon disease is a neurodegenerative disorder that primarily involves the nerve cells in the motor areas of the brain it's caused by insufficient production and action of dopamine a neurotransmitter that's crucial for regulating movement and cordination this deficiency leads to a range of symptoms including discinesia or involuntary movements dementia depression autonomic dysfunction such as Pro problems with blood pressure and digestion and postural instability which in and of itself increases the risk of Falls the progression of Parkinson disease can significantly impair daily functioning and quality of life requiring comprehensive management of both motor and non-motor symptoms.",
        "Depression in Older Adults": "Depression is a medical condition and should not be considered a normal part of the aging process it's both treatable and manageable through medication therapy or a combination of both depression and older adults can be challenging to diagnose as it can mimic symptoms of various other medical conditions such as fatigue cognitive decline or loss of appetite when left untreated depression may become extreme and persistent significantly impacting quality of life treatment for severe depression typically involves olves psychological counseling pharmacotherapy or a combination of these approaches emphasizing the importance of early recognition and intervention to prevent complications such as suicide.",
        "Musculoskeletal Changes and Conditions": "Changes in the muscular skeletal system include a widespread decrease in bone mass in both men and women which increases the risk of fractures and osteoporosis these changes in physical structure and strength can affect an individual's confidence in their Mobility leading to reduced physical activity and an increased risk of Falls additionally degenerative changes in cartilage contribute to the development of arthritis a common condition in older adults that causes joint pain stiffness and reduced range of motion kyphosis a common age related spinal deformity results in an exaggerated forward curvature of the spine particularly at the thoracic level this condition produces flexation at the neck and an interior curling of the spine which can lead to a hunched posture this not only affects the patient's physical appearance but can also reduce lung capacity impair balance and increase the risk of Falls managing kyphosis often involves physical therapy postural exercises and in some cases bracing or surgery depending on its severity and impact on the individual's quality of life osteoporosis is a condition that's characterized by a significant decrease in bone mass leading to a reduction in bone strength and an increased susceptibility to fractures especially in areas like the hip spine and wrists this loss of bone density makes even minor Falls or injuries potentially devastating for older adults osteoarthritis is a progressive joint disease that leads to the destruction of cartilage which cushions the ends of Bones within a joint as the cartilage deteriorates the body attempts to compensate by forming bone spurs which can further restrict movement and contribute to Joint stiffness and pain osteoarthritis commonly affects weightbearing joints such as the knees hips and spine significantly impacting mobility and quality of life both conditions require early identification and management to prevent complications and to preserve function.",
        "Sensory Changes and Nutrition": "A decreased number of taste buds and alterations in old factory receptors can diminish taste and smell impacting diet and dietary choices likewise Dental loss can create significant nutritional and digestive problems making it hard for older adults to consume a balanced diet the production of hydrochloric acid in the stomach tends to decrease with age which can affect digestion and nutrient absorption changes in gastric motility may result in a slower gastric emptying leading to issues such as bloating or constipation that being said the overall function of the small and large bowel changes little with age allowing for relatively stable bowel function in many older adults as individuals age the activity of enzyme systems responsible for the detoxification of drugs and alcohol declines potentially leading to increased sensitivity to medications and a higher risk RK of adverse effects gastrointestinal bleeding can be a possible cause of abdominal pain and shock in older adults necessitating prompt evaluation in management bow obstructions also occur more frequently in this population often due to factors such as decreased bowel motility prior surgeries or the presence of diverticula these obstructions can result in significant complications in including dehydration especially when accompanied by diarrhea older adults are also at a heightened risk for food poisoning due to changes in gastric acid production and immune function which can impair the body's ability to fight off infections.",
        "Renal System Changes": "Aging leads to significant changes in the renal System including a loss of functioning nefron units which diminishes the kidney's ability to filter blood and regulate various bodily functions acute illnesses in older adults are often accompanied by derangements in fluid and electrolyte balance making it critical to monitor renal function closely during these episodes the kidneys also respond more sluggishly to sodium deficiency indicating a reduced capacity to conserve sodium when needed additionally they are less able to excrete a large sodium load due to lower glom filtration rates which further affects fluid balance and blood pressure regulation older adults are particularly susceptible to hyperemia or elevated potassium levels due to the kidney diminished ability to excrete potassium effectively this condition can lead to Serious cardiac complications and requires careful monitoring of potassium levels especially in patients taking medications that affect renal function urinary incontinence is another common issue that can lead to significant complications including skin irritation skin breakdown and urinary tract infections the constant moisture from incontinence can compromise Skin Integrity making older adults more vulnerable to infections in cases of severe urinary retention there's a risk of acute or chronic renal failure as the bladder may become overextended affecting kidney function.",
        "Endocrine System Changes": "Significant changes in the endocrine system result in alterations in hormone levels and production that can impact various bodily functions older adults with diabetes face an increased risk of hypoglycemia which may be particularly dangerous as delirium can sometimes be the only indication of low blood sugar levels additionally hyperosmolar hyperglycemic non-ic syndrome is a serious condition that can occur in individuals with type 2 diabetes and is characterized by an extremely high blood sugar level without the presence of ketosis this condition can lead to severe dehydration electrolyte imbalances and can be life-threatening if not promptly treated physical changes in older adults with hyperosmolar hyperglycemic non-ic syndrome are primarily the result of excessive dehydration and prolonged hypoglycemia these conditions can lead to a range of symptoms including confusion weakness and in severe cases coma thyroid abnormalities become more prevalent with aging and hyperthyroidism can lead to significant cardiovascular issues for instance an overactive thyroid gland increases the risk of atrial fibrillation a condition that's characterized by regular heart beats that can result in complications such as stroke and heart failure.",
        "Infections and Immune Response": "Older adults often manifest infections differently than younger individuals with atypical symptoms or diminished inflammatory responses making diagnosis more challenging in cases a septic shock which can occur as a severe complication of infection older adults may present with signs and symptoms such as fever respiratory distress increased pulse rate generalized weakness and hypotension these manifestations can develop quickly and may not always follow the classic presentation of infection underscoring the need for heightened awareness impr prompt evaluation in older patients presenting with any signs of illness.",
        "Integumentary System Changes": "Changes in the integ matery system system due to aging primarily are characterized by decreasing collagen and elastin which contributes to the loss of skin elasticity and firmness as a result older adults may experience bruising more frequently as the skin becomes thinner and more Fragile the healing process for wounds and injuries also takes longer due to decreased blood flow to the capillaries which can impair nutrient and oxygen delivery that's necessary for repair additionally epidermal cells develop more slowly further delaying the healing of skin lesions consequently there's a higher risk for secondary infections after skin breaks as the compromised Skin Barrier is less effective at preventing microbial Invasion sebaceous glands produce less oil leading to drier skin this reduction in moisture can contribute to skin irritation and an increased risk of skin breakdown Additionally the thinning of subcutaneous fat makes pressure ulcers more common especially in older bedridden patients the decreased cushioning over bony prominences increases susceptibility to pressure injuries which can develop rapidly and lead to serious complications if not addressed promptly preventative measures such as regular repositioning proper nutrition and the use of supportive surfaces manage the risk of pressure ERS in this vulnerable population decubitus ulcers also known as pressure ulcers form when a person remains in the same position for an extended period leading to prolonged pressure on specific areas of the body this condition is exacerbated by fecal and urinary incontinence as moisture can further compromise skin integrity and increase the risk of ulcer formation pressure ulcers are classified into four stages based on their severity ranging from stage one which typically presents as non-blanchable arhythmia to stage four which involves full thickness skin loss and exposure of underlying structures if left untreated these ulcers can lead to significant complications including substantial infection and potentially sepsis underscoring the importance of early detection and intervention to manage and prevent pressure injuries in older adults.",
        "Homeostatic Changes and Toxicity": "A progressive loss of homeostatic capabilities can impact the body's ability to maintain balance and respond effectively to stressors as a result specific illnesses or injuries are more likely to lead to generalized deterioration of older adults making recovery more challenging infections that would typically elicit a high fever May instead produce only a lowgrade fever or either no fever at all in this population complicating diagnosis and treatment furthermore aggressive treatment of moderate hypoglycemia can inadvertently lead to hypoglycemia highlight into delicate balance required in managing blood sugar levels in this population several pathophysiologic changes contribute to the increased susceptibility of older adults to toxicity decreased liver function impairs the body's ability to detoxify blood and eliminate substances which can lead to the accumulation of drugs and their metabolites this issue is further compounded by the prevalence of poly Pharmacy where patients are prescribed multiple medications increasing the risk of drug interactions and adverse effects when evaluating potential non-compliance it's important to check prescription dates and the number of pills available as this can provide insights into the patients adherence to their medication regimen and help identify any potential issues related to toxicity or ineffective treatment.",
        "Emergency Medical Care for Older Adults": "In emergency medical care for older adults key interventions include a appropriate positioning ensuring adequate oxygenation administering glucose when necessary and providing psychological support additional assistance may involve the administration of nitroglycerin aspirin or inhalers depending on the patient's Condition it's important to allow the patient to maintain a position of comfort to facilitate breathing and alleviate distress ventilation support should be provided as needed particularly in cases of respiratory distress when administering oxygen special attention must be paid to monitoring the level of Consciousness in patients with chronic obstructive pulmonary disease as they may be more sensitive to oxygen therapy listening to the patient responding to their needs and providing reassurance are essential components of effective care as this will help reduce anxiety and enhance the overall patient experience during during a medical emergency fluid resuscitation in geriatric patients can be particularly challenging due to the physiological changes associated with aging even modest amounts of blood loss can quickly lead to shock necessitating prompt and careful intervention frequent monitoring of breast sounds is crucial to detect any early signs of fluid overload or respiratory complications which are more prent in older adults when administering fluids it's essential to use them sparingly as excessive fluid can result in adverse effects such as pulmonary edema or heart failure a thoughtful and measured approach to fluid resuscitation is vital to ensure safety and optimize outcomes in this vulnerable population.",
        "Respiratory Emergencies": "In the assessment and management of respiratory emergencies shortness of bre breath is a critical symptom that requires careful evaluation Gathering an accurate medical history including a list of prescribed medications can help determine the underlying plan patients experiencing respiratory distress should receive supplemental oxygen to improve oxygenation additionally ask any questions about medications taken prior to your arrival as this can provide valuable insights into potential causes or exacerbating factors for their condition asthma is relatively common among older adults necessitating careful management due to the potential for complications when asthma coexists with cardiac disease the administration of beta adrenic agents for asthma relief can exacerbate cardiac symptoms such as increased heart rate or arrhythmias in rare cases of life-threatening asthma exacerbations epinephrine may actually be indicated as a rapid acting Bronco dilator to relieve severe Broncos spasm however the risk associated with this use in patients with concurrent cardiac issues must be weighed against the potential benefits careful monitoring and individualized treatment plans are essential for safely managing asthma in older patients particularly those with complex Health profiles pneumonia and older adults can present with atypical symptoms such as delirium a normal temperature and minimal to absent cough which may make diagnosis more challenging patients may also exhibit signs of dehydration highlighting the need for careful assessment of fluid status breath sounds can vary with possible findings including diminish breast sounds wheezing crackles or Ron ey treatment is primarily supportive focusing on maintaining adequate hydration and oxygenation continuous positive of airway pressure May benefit patients with respiratory distress improving oxygenation and reducing work of breathing additionally it's important to reassure the patient and keep them warm to enhance comfort and promote recovery in cases of suspected pulmonary embolism it's important to check for swelling arithma warmth or tenderness in the lower leg as these signs May indicate a deep vein thrombosis which is a common cause of pulmonary embolism handle the affected leg gently to avoid dislodging any potential thrombus and closely monitor the patient for any respiratory changes such as increased respiratory rates or difficulty breathing treatment is primarily supportive with the focus on ensuring adequate Airway and ventilation continuous monitoring and frequent reassessment are essential to identify any changes in the patient's condition promptly and to provide appropriate interventions as needed.",
        "Cardiovascular Emergencies": "In the assessment and management of cardiovascular emergencies Syncopy is considered a life-threatening problem until proven otherwise it's essential to approach any episode of Syncopy in older patients with a thorough evaluation to identify the underlying cause common causes of Syncopy in this population include arthas orthostatic hypotension dehydration medication side effects and cardiovascular conditions a detailed assessment should involve obtaining a comprehensive medical history conducting a physical exam and considering diagnostic tests as needed identifying theology is critical for determining appropriate management and ensuring Public Safety continuous monitoring and supportive care are vital during this evaluation process when assessing chest pain in older patients it's important to recognize that their pain threshold May differ from that of younger individuals potentially leading to atypical presentations utilizing the opqrs memonic can help guide the assessment of chest pain more effectively if the patient has a of angina determine whether this episode feels different from previous events instead of asking directly about pain prompt the patient to describe exactly how it feels which may encourage a more detailed response management of chest pain includes close monitoring of fluids while being cautious to avoid excessive fluid administration which can lead to complications particularly in patients with heart failure or other cardiovascular conditions the classic symptoms of myocardial infarction such as severe chest pain may not be present in this population instead they may exhibit atypical signs and symptoms that can complicate the diagnosis commonly noted symptoms in older adults include shortness of breath fatigue confusion or even GI discomfort rather than the traditional crushing chest pain the table on the screen provides a detailed overview of these atypical presentations emphasizing the need for healthc care providers to maintain a high index of Suspicion for myocardial infarction in this population heart failure becomes increasingly common with age due to the accumulation of associated risk factors such as hypertension coronary arter disease and diabetes prevention strategies focus on Lifestyle Changes including diet modification increased physical activity and smoking sensation which helps reduce the risk of developing heart failure in cases of acute exacerbation patients may experience pulmonary edema leading to symptoms such as shortness of breath wheezing and orthopnea providers should pay close attention to the position in which the patient is found as this can provide insights into the respiratory status for patients who are confined to bed the presence of sacral edema May indicate fluid accumulation and worsening heart failure necessitating prompt assessment and intervention the presentation of heart failure in older adults can be masked by symptoms and signs attributed to aging or shared with other chronic diseases making accurate diagnosis challenging immediate evaluation of entitle carbon dioxide is crucial and it should be monitored throughout transport to assess the patient's respiratory status and effectiveness of ventilation additional treatments should include close monitoring of fluid status to prevent complications associated with fluid overload care should be taken to avoid excessive fluid administration as this can exacerbate heart failure symptoms consideration of CPAP may be been beneficial for patients with respiratory distress due to pulmonary edema in certain cases the potential use of anti-coagulation therapy may be warranted particularly if there is suspicion of coexisting conditions such as atrial fibrillation when administering intravenous fluids it's important to do so judiciously ensuring that the patient's overall fluid balance is maintained while avoiding further complications related to heart failure dysrhythmias in older adults are generally a result of age related changes in the cardiovascular system atrial fibrillation is particularly concerning as it significantly increases the risk of stroke and heart failure due to the potential for thrombus formation in the Atria bardas are more common in older individuals and can be exacerbated by certain medications leading to excessive bardia that may require intervention persistent radoc cardias are often managed with the placement of an internal pacemaker to regulate heart rate and ensure adequate cardiac output controlling hypertension is key for preventing serious complications such as strokes and myocardial infarctions effective management of blood pressure can significantly reduce the risk of these events particularly in older adults who are more SU suceptible to cardiovascular diseases in cases of hypertensive emergencies it's important to achieve a controlled decline in blood pressure to prevent inorgan damage however this controlled reduction is often challenging to achieve in a field setting because of this prehospital providers should focus on stabilization and careful monitoring ensuring that patients are transported to an appropriate medical facility or more intens management can be implemented aneurysms become more common with age posing significant health risks as they can develop in critical areas such as the brain chest or abdomen lifethreatening aneurysms such as aortic or cerebral aneurysms require prompt attention due to their potential for rupture preventative measures focus on controlling risk factors associated with hypertension and athrosclerotic diseases which can help reduce the likelihood of aneurysm formation careful examination of the chest and abdomen is essential for identifying any signs of aneurysms such as pulsatile masses or abnormalities and blood pressure early recognition thorough assessment stabilization of the patient and Rapid transport to an appropriate medical facility help improve outcomes in cases of suspected aneurism traumatic aortic disruption occurs when the inner wall of the artery becomes torn allowing blood to collect between the layers of the arterial wall this condition is life-threatening and requires immediate medical intervention in patients presenting with chest pain obtain blood pressure readings in both arms a difference of 15 or higher in systolic blood pressure between the arms May may suggest a thoracic aortic dissection.",
        "Delirium and Stroke": "In the assessment of any patient presenting with delirium evaluate for recent changes in the patient's level of Consciousness or orientation the deliriums memonic can be a helpful guide for identifying potential underlying causes this includes considering drugs or toxins that may contribute to altered mental status as well as emotional or psychiatric issues issues and electrolyte imbalances that can affect cognition additionally it's important to evaluate for low oxygen levels due to conditions such as carbon monoxide poisoning COPD heart failure acute coronary syndrome or pneumonia signs of infection including pneumonia UTI or sepsis should also be assessed as these can lead to delirium as well retention of stool or urine should be considered as these conditions can cause discomfort and confusion finally recent seizure activity must be evaluated as it can result in post-ictal confusion or altered mation in addition to the previously mentioned causes of delirium undernutrition or under hydration should also be considered as these factors can significantly impact cognitive function metab IC issues related to the thyroid or other endocrine disorders as well as imbalances in electrolytes or kidney function can contribute to altered mentation furthermore the presence of a subdural hematoma which may occur after a fall or head injury can lead to confusion or changes in Consciousness during the assessment monitor vital sounds closely including breast sounds to evaluate the patient's overall condition if the patient is unstable and unable to maintain their Airway the use of Airway adjunct may be necessary to ensure proper ventilation obtaining intravenous access is important for providing a route of fluid resuscitation if needed which further supports the management of any underlying issues contributing to the delirium stroke is a leading cause of death among older adults making its recognition and management critical iCal major risk factors include hypertension diabetes cardiac diseases smoking and a personal or family history of stroke or Tia as well as the presence of brain aneurysms signs and symptoms of a stroke can vary but often include an acute altered level of Consciousness numbness weakness or Paralysis on one side of the body slurge speech and Aphasia patients may also experience visual disturbances headache dizziness incontinence or seizures hemorrhagic Strokes although less common than esic Strokes are more likely to be fatal underscoring the importance of prompt and effective care this includes early recognition of stroke symptoms identifying conditions that may mimic strokes and timely transport to the most appropriate medical facility for treatment utilizing a stroke assessment tool can Aid in the evaluation process with the goal of salvaging as much surrounding brain tissue as possible when assessing the patient it's important to question bystanders about the last time the patient appeared normal and to document this information thoroughly as it can provide critical context for medical professionals transi es schic attacks or tias are characterized by a temporary disturbance of blood supply to the brain and should be treated as if the patient is having a stroke despite their temporary nature TI are a significant warning sign of potential future strokes and require urgent evaluation and management to mitigate long-term risks.",
        "Neuropathy and Altered Mental Status": "Neuropathy is a disorder affecting the nerves of the peripheral nervous system and its symptoms can vary depending on which nerves are affected in their location when motor nerves are involved patients may experience muscle weakness cramps spasms loss of balance and impaired coordination sensory nerves can lead to symptoms such as tingling numbness itching and pain as well as sensations of burning freezing or extreme sensitivity to touch additionally autonomic nerves which control involuntary functions can also be impacted potentially affecting bodily processes such as heart rate blood pressure and digestion management of neuropathy typically involves medications and therapies that are not available in the field setting these may include pain management strategies physical therapy and lifestyle modifications which are essential for improving quality of life and mitigating symptoms associated with the condition altered mental status is a simp symptom rather than a standalone disease and its assessment and management can be complex when evaluating a patient with altered mental status consider potential neurologic causes as well as endocrine changes that may contribute to the condition determining the onset of symptoms is crucial as it can provide insights into the underlying issue additionally understanding what is normal for the patient such as their Baseline cognitive function fun and ascertaining any pertinent medical history is important for identifying potential factors that may be contributing to the altered mental status this comprehensive approach allows for more accurate diagnosis and effective management of the patient's condition vitamins C and D memonic is a useful tool for identifying potential causes of altered mental status as each letter represents a category of conditions to consider during assessment vascular these are issues related to blood flow such as stroke or transient es schic attack inflammation conditions that cause inflammation in the brain or body toxins exposure to harmful substances that can affect cognitive function trauma head injuries or other forms of physical trauma impacting mental status tumors brain tumors or metastatic disease affecting brain function autoimmune autoimmune disorders that may impact neurological function metabolic metabolic imbalances such as electrolyte disturbances or thyroid dysfunction infection infections including menitis or sepsis that can lead to altered mental status narcotics and Other Drugs substance use or withdrawal affecting cognition systemic systemic diseases that can have neurological effects such as liver or kidney failure congenital congenital conditions affecting brain development or function and degenerative degenerative diseases such as Alzheimer's or Parkinson's that impact cognitive abilities.",
        "Diabetic Disorders": "Diabetic disorders can be particularly challenging to manage in older adults especially when other acute diseases are present complicating treatment and increasing the risk of adverse outcomes one significant concern is the heightened risk for hypoglycemia in this population which can arise from several factors confusion about medication doses or usage may lead older adults to mismanage their diabetes medications resulting in an incorrect dose inadequate or irregular dietary intake can further contribute to fluctuations in blood sugar levels as changes and appetite or difficulty preparing meals May hinder consistent food intake additionally cognitive decline can impair the ability to recognize warning signs of hypoglycemia such as shakiness sweating or dizziness aging can blunt the physiological responses to low blood sugar me meaning that typical symptoms may not be as pronounced thus increasing the risk of severe hypoglycemia in older adults delirium may be the only indication of hypoglycemia making it essential for healthcare providers to recognize this subtle presentation symptoms of elevated blood glucose levels can include fatigue poor wound healing blurred vision and frequent infections however the assessment of both hyper and hypoglycemia can be Complicated by age related changes that affect the body's response to glucose levels diaphoresis may be less prominent in older adults due to alterations in regulatory mechanisms and the secretory functions of the skin to ensure effective management it's important to reassess the patient every 15 minutes and monitor for any changes in their condition if available capnography can provide valuable information about the patient's respiratory status careful attention to fluid resuscitation and electrolyte balance is particularly important in this population in order to prevent complications and ensure Optimal Health outcomes hyperosmolar hypoglycemic non-ic syndrome or hhns is more common than diabetic keto acidosis in older adults with infection being the most frequent precipitating cause in hhns the combination of hypoglycemia and hyperosmolarity leads to osmotic diuresis resulting in an osmotic shift of fluid to the intravascular space which can significantly affect fluid balance older patients may be less tolerant of aggressive fluid therapy due to age related physiological changes making care care ful monitoring essential Airway management should be the top priority in these cases with appropriate Airway adjuncts being utilized and if indot tral Innovation is indicated it should be important to call for paramedic backup in order to ensure that advanced Airway support is available in cases of hhns spinal motion restriction should be implemented for all unresponsive patients found lying down to to prevent potential spinal injuries additionally treatment for shock should be administered as indicated ensuring the patient is stabilized establishing large bore IV access is essential for fluid administration and medication delivery it's also important to obtain a blood glucose level to guide treatment decisions in patients with a history of heart failure and or renal insufficiency fluid should be given sparingly and breath sounds should be osculated frequently to monitor for signs a fluid overload if the patient's glucose level is less than 70 and they are symptomatic supplemental dextrose should be administered either orally or intravenously to promptly address hypoglycemia.",
        "Thyroid Disorders": "Thyroid disorders become increasingly prevalent with aging and abnormalities such as hypothyroidism and hyperthyroidism are common in older adults adult hypothyroidism also known as mix EMA is characterized by General slowing of the body's metabolic processes leading to symptoms such as fatigue weight gain and depression older adults may also have a history of Prior thyroid ectomy which can further complicate thyroid management an overactive thyroid gland can induce atrial fibrillation increasing the risk of cardiovascular ular complications both hyperthyroid and hypothyroid patients may require supplemental oxygen particularly if they experience respiratory distress continued decline in hormone levels in patients with hypothyroidism can lead to severe complications such as mix deacom.",
        "Gastrointestinal Emergencies": "In the assessment of GI emergencies abdominal pain is a common complaint that requires careful evaluation while constipation is prevalent in older adults it should not be the initial condition suspected when a patient presents with abdominal discomfort instead providers should investigate causes that have a higher mortality risk first such as abdominal aortic aneurysm or perforated viscera when assessing the patient gather detailed information about their food and fluid intake any history of abdominal issues current bowel and bladder habits and a list of medications and supplements that they may be taking understanding the history of acute versus chronic pain can provide valuable insights acute pain typically indicates a recent onset of a potentially serious condition while chronic pain may suggest ongoing issues that require a different approach this distinction can guide the urgency and nature of further investigation and management using the opqrst memonic and facilitate a thorough assessment of the patients's abdominal pain many abdominal and gastric problems such as appendicitis Chic cystitis and perforated ulcers May ultimately require surgical treatment recognizing the signs and symptoms early is critical as prompt surgical intervention can significantly reduce morbidity and mortality associated with these conditions rapid transport to an appropriate medical facility is essential particularly for conditions requiring surgical evaluation if an abdominal aortic aneurysm is suspected treating the patient for shock is vital if evident this includes monitoring Vital Signs establishing IV access for fluid resuscitation and providing supplemental oxygen since a AAA can lead to catastrophic internal bleeding immediate recognition and management are critical for improving patient outcomes maintaining a high level of Suspicion and acting swiftly can make a significant difference in the management of potentially life-threatening abdominal conditions.",
        "GI Bleeding": "GI bleeding is more common in older adults due to a combination of physiological changes in underlying health conditions one contributing factor is decreased peristalsis which can lead to stagnation of gastric contents and increase the likelihood that irritating substances will damage the gastric whining potentially resulting in bleeding pathologic processes associated with GI bleeding in this population often include the formation of ulcers particularly peptic ulcers and veres peptic ulcers can arise from factors such as chronic use of ineds infection with H pylori and increased gastric acid secretion varices on the other hand are enlarged veins in the esophagus or stomach that can rupture and cause significant bleeding commonly due to portal hypertension associated with liver ceros bleeding from the esophagus is most frequently linked to varices particularly in individuals with the history of alcohol abuse chronic alcohol consumption can lead to liver damage resulting in elevated pressure in the portal Venus system and the development of esophageal varices when these varices rupture they can cause life-threatening Hemorrhage necessitating immediate medical intervention given these factors healthc care providers should maintain a high index of Suspicion for GI bleeding in older patients presenting with symptoms such as Molina hesia or signs of hypovolemia bleeding from the stomach may present as either bright red blood or darker coffee ground emesis depending on the location and the nature of the bleeding coffee ground emesis indicates that the blood has been exposed to gastric acid suggesting a more prolonged bleeding event while bright red blood often indicates active bleeding from a source higher in the GI tract bright red blood in the stool typically originates from the large intestine or rectum common causes for this presentation include diverticulitis which involves inflammation of the diverticula in the colon large ballop structions that can cause esea or pressure anal fissures that result from trauma to the anal canal and hemorrhoids upper GI Hemorrhage occurs from sources within the esophagus stomach or dadum this type of bleeding can result from various conditions including esophageal varices peptic ulcers gastritis or malignancies regular use of incets or alcohol significantly increases the risk of bleeding from the stomach lining or the development of ulcers in heads prohibit the production of prostaglandins which are protective substances in the gastric mucosa when these mechanisms are compromised the stomach lining becomes more susceptible to damage and ulceration chronic alcohol use can also irritate the gastric lining and contribute to ulcer formation given the potential severity of GI bleeding Healthcare Providers should conduct a thorough assessment and prompt intervention for patients presenting with these symptoms lower GI Hemorrhage refers to bleeding from the colon and rectum and it should never be simply attributed to hemorrhoids without a thorough evaluation while hemorrhoids can cause bright red blood in the stool there are numerous other potential causes that must be considered including diverticular disease coloral cancer and inflammatory bowel disease and esic Colitis assessment of a patient with suspected lower GI bleeding should begin with identifying risk factors such as a history of previous lower gab bleeding as well as any symptoms or signs suggestive of other underlying conditions this includes assessing for changes in bowel habits abdominal pain weight loss or any family history of colar rectal disorders severe lower GI bleeding is a medical emergency that requires immediate transport to a health care facility for further evaluation and management patients may present with significant hypovolemia requiring rapid assessment and intervention in cases of lower GI Hemorrhage it's often more important to assess the severity of the bleeding than to determine the precise cause at least initially the focus on severity allows for timely interventions such as fluid resuscitation and stabilization which are critical for improving patient outcomes the treatment of lower GI bleeding is focused on the recognition and management of hypovolemic shock signs of hypovolemic shock may include altered mentation teoc cardia hypotension and a decreased urine output prompt recognition of these symptoms is critical critical for initiating appropriate interventions such as fluid resuscitation and blood transfusions if necessary to stabilize the patient rapid transport to a health care facility is required for further evaluation and treatment during this transport providers should continue monitoring Vital Signs and the patients's overall condition many patients may be on blood thinning medications such as anti-coagulant or antiplatelet agents this can complicate the management of G bleeding these medications increase the risk of bleeding and may require careful consideration when planning treatment strategies because of this providers should review the patients medication history and consult with the medical team regarding the potential need for adjustments or a reversal of anti-coagulation if significant bleeding is present.",
        "Nausea, Vomiting, and Diarrhea": "Nausea vomiting and diarrhea in older patients can be attributed to a variety of conditions both inside and outside the GI tract these symptoms can arise from infections dietary indiscretions medication side effects or even systemic issues such as cardiac events in particular nausea may be a significant symptom during a cardiac episode sometimes overshadowing more typical symptoms like chest pain Rec izing this can help providers evaluate the patient's condition more effectively determining the onset of these symptoms provides valuable Clues to potential underlying causes for example a sudden onset may suggest an acute infectious process while a gradual onset might indicate chronic conditions or medication related issues viral gastroenteritis is a common cause of nausea and diarrhea in older adults adults often resulting in dehydration and electrolyte imbalances that require careful management when assessing a patient providers should inquire about the characteristics of vomiting and diarrhea including the color of the vomit or stool this can help differentiate between various causes such as B stained emesis which indicates obstruction or the presence of blood suggesting a more severe condition additionally providers should prepare for potential episodes of vomiting or diarrhea during assessment and transport this includes having appropriate supplies on hand such as emesis bags and absorbent pads to ensure patient comfort and maintain a hygienic environment.",
        "Bowel Obstruction": "Bowel obstruction is a significant concern in older patients with different causes depending on whether the obstruction is in the large or small bowel large ballot structions are often attributed to conditions such as cancer impacted stool or sigmoid vulas which is a twisting of the bowel that can lead to esea and necrosis if not promply addressed cancer particularly color rectal cancer is a prevalent cause of obstruction in this demographic making early detection and intervention critical small ballop structions can also occur and one common cause in older patients is gallstones which can lead to a condition known as gallstone ilas this type of obstruction occurs when a gallstone passes into the intestinal tract potentially blocking the small intestine the incidence of gallstone related obstructions increases with age due to the higher prevalence of gallstones in older adults additionally both the large and small intestines are at risk for obstruction due to adhesions which are fibrous strands of tissue that can form after abdominal surgery or trauma these adhesions can cause segments of the intestine to stick together leading to obstruction when managing battle obstruction in older patients it's essential to recognize the signs and symptoms which may include abdominal pain distension nausea vomiting and changes in Bow habits prompt assessment and intervention are critical as bow obstructions can lead to serious complications such as perforation and peritonitis treatment most often requires surgical intervention especially in cases where there is a concern for strangulation or bow necrosis.",
        "Biliary Diseases": "Biliary diseases which affect the bile ducts gallbladder and liver can present with a variety of signs and symptoms including jaundice fever right upper quadrant pain and nausea or vomiting jaundice occurs due to the accumulation of B Rubin in the bloodstream often resulting from obstruction or inflammation of the B ducts while these diseases typically cause fever it's important to note that the fibral response may be suppressed in older patients this means that even in the presence of significant infection or inflammation an older adult might not exhibit the expected elevation in body temperature making diagnosis definitely more challenging the pain sensation in older adults may also be altered due to age related changes in the nervous system potentially leading to atypical presentations of pain this can result in Under reporting of symptoms further complicating the assessment and management of bilary diseases caution should be exercised when administering opiates for pain management older adults may be more sensitive to opioids which can lead to an increased risk of respiratory depression or side effects non-opioid analgesics or multimodal pain management strategies should be considered to minimize these risks.",
        "Peptic Ulcer Disease": "Peptic ulcer disease is more prevalent in older patients compared to younger individuals with both gastric and duodenal ulcers becoming common concerns the primary risk factors for developing peptic ulcers in this population include regular use ineds and infections with H pylori a bacterium that can erode the protective lining of the stomach and lead to ulcer formation the main symptom of peptic ulcer disease is dyspepsia which refers to the range of GI discomforts including indigestion bloating and abdominal pain however dyspepsia can often present in ways that mimic other conditions particularly chest pain which can be a significant challenge in older patients symptoms of chest pain due to dyspepsia may be easily confused with chest pain stemming from cardiac issues such as acute myocardial infarction or angina this overlap necessitates careful assessment and a high index of Suspicion when evaluating older patients presenting with chest pain in managing ptic Ulcer Disease in older patients providers should consider the potential for atypical presentations and the significant risks associated with inset use treatment may involve the use of proton pump inhibitors or H2 receptor antagonists to reduce gastric acid secretion as well as addressing any hpylori infection with the appropriate antibiotics.",
        "Urinary Tract Infections": "Urinary tract infections are notably common in the older adult patient population largely due to age related changes in the urinary system and other contributing factors these infections typically developed in the lower urinary tract when normal flora which usually reside in the body without causing harm enter the urethra and proliferate an increase in UTI is particularly observed in men over the age of 50 often related to conditions such as benign static hyperplasia or BPH this can obstruct urinary flow and predispose individuals to infections patients with UTI commonly report symptoms such as painful urination a frequent urge to urinate and difficulty initiating urination these symptoms can significantly impact the quality of life and may lead to further complications if not addressed promptly catheter use is a well-known risk factor for UTI as they can introduce bacteria directly into the urinary tract leading to increased infection rates therefore it's important to assess the catheter's placement condition and the need for continued use later signs and symptoms of a UTI can indicate progression of a more serious condition such as urpis these include hypotension teoc cardia diaphoresis and and pale skin the presence of these signs suggests that the infection may have systemic implications.",
        "Renal Failure": "Renal failure in older adults results from a decrease in the rate of filtration through the gromi which are the tiny filtering udit within the kidneys this decline in renal function can lead to a buildup of waste products and toxins in the bloodstream causing various systemic effects chronic renal failure also known as chronic kidney disease or CKD often progresses to a point where patients may require lifelong dialysis either hemodialysis which filters blood through an artificial kidney or perianal dialysis which uses the lining of the abdominal cavity to filter waste in some cases kidney transplantation may be the most viable option offering the potential for improved quality of life and better long-term outcomes patient Pat who miss a scheduled dialysis treatment can find themselves in an acute life-threatening situation this occurs due to the rapid accumulation of toxins electrolyte imbalances and fluid overload which can lead to complications such as pulmonary edema or even Cardiac Arrest providers must be vigilant in monitoring patients with chronic renal failure and ensure they adhere to their dialysis schedules and promptly address any mistreatments to prevent serious ious Health consequences in the management of Reno failure particularly for patients undergoing dialysis regular monitoring of Vital Signs is used to assess the patient's stability and detect any changes that may indicate complications this includes tracking heart rate respiratory rate temperature and blood pressure to ensure that the patient remains within safe limits when obtaining blood pressure readings avoid using the same arm that has a fistula or a graft for dialysis access this is important to prevent potential damage to the access site which is vital for the patients's ongoing dialysis treatments monitoring breath sounds is also important as changes May indicate fluid overload or pulmonary complications both of which can occur due to renal failure diminished breath sounds or the presence of crackles can signal the need for Urgent intervention if a patient presents with renal failure symptoms or complications related to Mis dialysis they should be transported to a hospital that has hemodialysis capabilities this ensures that they can receive the appropriate care and interventions as quickly as possible additionally administering intravenous fluids may be necessary to manage hydration status especially if the patient is showing signs of hydration or has low blood pressure however fluid administration must be done cautiously as patients with renal failure may have fluid restrictions and excessive fluid can lead to complications such as pulmonary edema.",
        "Toxicologic Emergencies": "In the context of toxicologic emergencies double dosing is the most common therapeutic error this occurs when a patient inadvertently takes an extra dose of medication which can lead to toxicity medication while often beneficial can act as poisons at higher doses highlighting the importance of adherence to prescribed dosages The Beneficial effects of medication are frequently accompanied by side effects which when magnified by overdose can lead to serious health complications non-compliance with medication regimens can also result in emergencies when patients do not take their medications as prescribed what they due to forget fulness misunderstanding or intentional avoidance they may experience exacerbations of their underlying conditions this non-compliance can lead to acute medical crisis necessitating immediate intervention for instance a patient with hypertension who stops taking their anti-hypertensive medication may suffer a hypertensive crisis while a patient with diabetes who neglects their insulin regimen could experience severe hypogly gmia pharmacokinetics the study of how drugs are absorbed distributed metabolized and excreted play a central role in understanding medication Management in older adults one significant concern is that decreases in kidney function and GI absorption with age increase susceptibility to toxicity as renal function declines the body becomes less efficient at eliminating drugs which leads to higher concentrations in the bloodstream and a greater risk for adverse effects in a similar fashion changes in GI absorption can affect how quickly and effectively medications inter circulation potentially altering their intended effects pharmacokinetics may be influenced by various lifestyle factors including diet smoking alcohol consumption and the use of other drugs these factors can interact with medications altering their absorption and Metabolism which may result in unexpected or harmful consequences for instance certain foods can inhibit the metabolism of specific drugs while alcohol can enhance the sedative effects of medications as a result of these age related changes and external influences dosages for older Pat s often need to be reduced to avoid toxicity and ensure safety this necessitates careful consideration when prescribing medications requiring providers to regularly assess renal function monitor for potential drug interactions and adjust dosages accordingly.",
        "Substance Abuse in Older Adults": "Drug and alcohol abuse among older adults often occurs in response to significant life-changing events such as Retirement the loss of a spouse or health declines these transitions can lead individuals to see coping mechanisms sometimes resulting in the misuse of substances the prevalence of alcohol and drug misuse in this population is also attributable to the multiplicity of medications older adults may take combined with the effects of aging on drug metabolism and clearance as pharmacokinetics change the interaction between prescribed medications and alcohol or illicit drugs can heighten the risk of adverse effects and complications recognizing substance abuse in older adults can be challenging this is because symptoms may be massed by the presence of chronic illnesses or even attributed to normal aging processes leading to underdiagnosis and inadequate treatment additionally older adults may be less likely to disclose their substance abuse due to stigma or fear of judgment.",
        "Trauma in Older Adults": "Several factors contribute to the heightened risk of trauma in older adults making them vulnerable to injuries one key aspect is the reduce cardiac reserve and decrease respiratory function which limit the body's ability to respond to stress and recover from injuries impaired renal activity can complicate recovery further as the kidneys may struggle to clear waste products and maintain fluid and electrolyte balance after trauma in effective Vaso constriction diminishes the body's ability to regulate blood pressure and blood flow in response to injury increasing the risk of shock the structural Integrity of older adults vascular and muscular skeletal systems play a significant role in their susceptibility to trauma stiffen blood vessels can lead to reduced elasticity and compromised circulation while fragile tissues are more prone to tearing and bruising upon impact furthermore the presence of brittle demineralized bone increases the likelihood of fractures even with minor Falls or injuries older adults have a decreased ability to Thermo regulate which makes them more susceptible to hypothermia especially in cold environments are during exposure to Thermal extremes their physiological responses to temperature changes are often blunted resulting in an increased risk of temperature related illnesses most trauma cases in the geriatric population are associated with Falls or motor vehicle crashes Falls in particular are a significant concern as they not only lead to physical injuries but are also linked to a higher incidence of anxiety and depression following a fall many older adults may experience a loss of confidence in their Mobility contributing to post-fall syndrome which encompasses a fear of falling reduced activity levels and subsequent physical deconditioning a careful history in assessing trauma cases is needed as it provides insights into the circumstances surrounding the event and any pre-existing conditions that may influence recovery this history can help identify risk factors such as medication use previous Falls or underlying health issues to mitigate the risk of Falls conducting home safety assessments can be invaluable as these assessments involve evaluating the living environment for hazards such as uneven surfaces inadequate lighting or lack of handrails as well as implementing modifications to enhance safety simple changes like removing clutter improving lighting and installing grab bars can significantly reduce the incidence of Falls.",
        "Pathophysiology of Trauma": "The pathophysiology of trauma and older adults is influenced by several age related factors that can compromise the body's ability to compensate for injuries overall physical condition plays a role many older adults may have pre-existing health issues such as cardiovascular disease or pulmonary conditions which can impede their physiological responses to trauma older patients May often exhibit reduced stroke volume meaning their hearts pump less blood with each contraction this reduction can be compounded by potential dismas which may disrupt normal cardiac function and further diminish blood flow decreas respiratory function is common as age related changes in lung mechanics and muscle strength impair gas exchange and oxygen ation decreased chest wall compliance further complicates respiratory function making it harder for older adults to adapt to the increased respiratory demands that often accompany trauma there is also a higher risk of cerebral bleeding following head trauma in older adults factors such as the presence of atrophy in the brain which increases the space around blood vessels as well as the fragility of cerebral vessels themselves eles make older individuals more susceptible to hemorrhagic complications hematomas and older adults can sometimes go unnoticed initially because the blood has a void to fill in the cranial cavity before significant pressure is produced this delayed response can lead to serious complications as the hematoma may continue to expand without immediately presenting clear neurologic symptoms monitoring for subtle changes in Consciousness or behavior following head trauma is critical for early detection female patients especially those who are postmenopausal may experience decreased bone mass and strength due to osteoporosis this condition significantly increases the risk of fractures including those of the spine which can occur with minimal trauma compression fractures of the vertebrae are particularly common in older women and can lead to chronic pain decreased mobility and a further decline in overall health.",
        "Burns and Hydration": "Burns represent a substantial risk for morbidity and mortality in older adults their skin is thinner and more fragile which makes them more susceptible to Burns even from minor injuries the healing process is often slower and complications such as infections can arise more easily easily severe burns can lead to significant fluid loss requiring prompt medical intervention to prevent shock and other serious outcomes after traumatic injury or during periods of illness patients should be monitored for their hydration status this can be assessed by evaluating Vital Signs such as blood pressure and heart rate checking mucous membranes for dryness and measuring urine output these indicators can provide valuable insights into the patient's fluid status and help guide appropriate interventions internal temperature regulation in older adults is often slowed due to age related changes in thermo regulatory mechanisms as a result their ability to recognize fluctuations in temperature becomes delayed which can lead to an increased susceptibility to conditions such as hypothermia most cases of indoor hypothermia deaths involve geriatric patients who have fallen on a hard floor or lolium floor which highlights the need for Vigilant monitoring and protective measures in emergency settings it's important to maintain the patient compartment at a temperature higher than normal to prevent hypothermia during transport ensuring a warm environment can help stabilize body temperature and support the patient's recovery.",
        "Elder Abuse and Neglect": "Trauma can also be caused by abuse which may not always be immediately apparent older adults are vulnerable to physical emotional or even Financial abuse and recognizing the signs is essential for ensuring their safety and well-being careful assessment including history taking and consideration of potential psychosocial factors is crucial for identifying and addressing abuse in geriatric patients reports of elder abuse neglect and related problems are on the rise highlighting a growing concern within Society regarding the treatment of older adults elder abuse encompasses any action or inaction on the part of a family member caregiver or other Associated individual that causes harm or distress to an older person this can include physical abuse emotional or psychological abuse Financial exploitation neglect and sexual abuse neglect is defined as the failure to provide the necessary care services or supervision that an older adult requires this can manifest in various ways such as inadequate assistance with daily activities lack of Medical Care poor hygiene or insufficient nutrition neglect can have serious consequences for an individual's physical and mental well-being the true prevalence of elder abuse is not not fully understood for several reasons firstly elder abuse is largely hidden from society making it difficult to quantify many cases go unreported due to the private nature of family Dynamics as well as a stigma associated with disclosing abuse secondly definitions of abuse and neglect among older adults can vary widely cultural factors individual perspectives and differing interpretations of what con stitutes adequate care can complicate the identification and reporting of abuse victims of elder abuse are often hesitant to report their experiences they may fear retaliation from the abuser worry about losing their independence or feel shame about their situation Financial abuse is one of the most commonly reported forms of elder abuse and includes the unauthorized use of an older person's funds or property this could also include manipulation of financial resources or the exploitation of their financial vulnerability given its prevalence and profound impact it can have on an older person's Quality of Life Financial abuse warrants significant attention from caregivers family members and health care providers recognizing the signs and fostering an environment where older adults feel safe to report concerns helps address and prevent elder abuse and neglect.",
        "Signs of Elder Abuse": "Physical and emotional signs of elder abuse are frequently overlooked or inaccurately identified particularly in a health care setting where symptoms may be attributed to normal aging or chronic conditions this can lead to a lack of recognition and intervention for those in need of help patients with sensory deficits such as hearing or Vision impairments as well as those suffering from cality or other forms of altered mentation may be unable to Port abuse their communication challenges can prevent them from expressing their experiences leaving them vulnerable and without a voice abused individuals are often frail and may have multiple chronic medical conditions which can complicate their situation their health status can make them more dependent on caregivers creating a power Dynamic that may facilitate ongoing abuse the profiles of abusers can vary significantly many abusers of older adults have themselves experienced child abuse which may contribute to their behavior as adults the cycle of abuse can perpetuate a pattern of harmful interactions across Generations abusers themselves May exhibit signs of marked fatigue be unemployed face financial difficulties or struggle with substance abuse and these stressors can exacerbate their capacity for abuse creating an environment where the older adult is at a heightened risk signs of physical abuse in older adults can range from obvious to subtle making recognition challenging for caregivers and health care providers in cases of inflicted bruises these injuries are typically found in specific areas of the body that are not commonly subjected to Accidental trauma common locations include the buttocks and lower back genitals and inner thighs cheeks or ear loes neck upper lip and inside the mouth the presence of bruises in these areas especially if they appear in unusual patterns should raise suspicion for potential abuse pressure bruises caused by the human hand can also provide indicators of physical abuse these may present as oval grab marks pinch marks or distinct handprints on the screen such markings suggest direct physical contact act and may be critical evidence when evaluating potential abuse human bites are a serious form of abuse that can occur in older adults often seen on the upper extremities such as the arms or hands bites can cause significant injury and indicate aggressive behavior from the abuser when assessing for signs of physical abuse in older adults it's important to inspect the ears for indications of twisting pulling or pinching injuries in this area can be a sign of physical aggression and should be carefully evaluated investigating multiple bruises in various states of healing is also crucial this may involve questioning the patient about how the injuries occurred and reviewing their activities of daily living or ADLs to gather context about their living situation and interactions with caregivers discrepancies and explanations are patterns of injury can provide important clues about potential abuse burns are another common form of physical abuse and their presence should not be overlooked the pattern and location of burns can be telling for example burns on the palms or soles May indicate abusive Behavior rather than accidental injuries providers should determine whether the patient appears undernourished or has been unable to gain weight in their current environment signs of malnutrition such as weight loss or a frail appearance can indicate neglect or abuse engaging in a compassionate dialogue with the patient can help uncover underlying issues related to their nutrition and overall care when assessing older adults for signs of abuse it's essential to check for indications of neglect this includes observing for poor hygiene inadequate living condition malnutrition and lack of necessary Medical Care signs of neglect can manifest in various ways such as unclean clothing bed sores or untreated medical conditions and they indicate a failure to provide the required care or Supervision in cases where there are injuries to the generals or rectum with no reported trauma these should be regarded as evidence of potential sexual abuse such injuries require immediate attention and thorough investigation as they may indicate serious underlying issues in the assessment and management of elder abuse healthc care providers should maintain a high level of Suspicion when evaluating potential cases one key indicator is when patients provide answers to questions about the cause of their injuries that are concealed or avoided this evasiveness can suggest that they may be fearful of disclosing the truth or that they are being coerced by an abuser if a patient offers answers that seem unbelievable or inconsistent with the observed injuries this should raise red flags for instance if a patient has significant bruising but attributes it to a minor accident that's just not plausible further investigation is warranted several additional factors can provide insight into possible abuse caregiver apathy about the the patient's condition can be a concerning sign a lack of concern or engagement in the patient's well-being May indicate neglect or abusive Dynamics furthermore if a caregiver exhibits an overly defensive reaction to questions about the patient's care injuries it can suggest that they may be trying to hide something or that they are aware of wrongdoing several additional signs and factors warrant consideration if a caregiver does not allow the patient to cons to answer questions independently this can indicate controlling behavior and potential abuse the Dynamics in which the caregiver speaks for the patient may prevent the individual from disclosing information about their care or any maltreatment repeated visits to the emergency department or clinic may also raise suspicion frequent healthc care encounters could suggest ongoing issues whether related to abuse neglect or simply untreated medical conditions a history of being accident prone can be another indicator as it may point to underlying risks or environmental hazards in the patient's living situation soft tissue injuries such as bruises or lacerations may require closer scrutiny especially if they occur without clear explanations unbelievable vague or inconsistent explanations of injuries can further complicate the assessment process so suggesting that the patient may not feel safe or able to disclose the true circumstances of their injuries psychosomatic issues such as physical symptoms arising from psychological distress may also be present and can mask signs of abuse chronic pain without a medical explanation can be a significant red flag as it may indicate underlying abuse or neglect rather than purely physiological causes additionally self-destructive Behavior eating and sleep disorders and signs of depression or a lack of energy can reflect the emotional toll that abuse takes on an individual's well-being finally a history of substance abuse or sexual abuse should be taken into account as these factors can complicate the assessment of elder abuse and may contribute to the patients vulnerability recognizing these signs is essential before identifying potential abuse providing the necessary support and ensuring the safety of older individuals.",
        "Responding to Suspected Elder Abuse": "In situations where elder abuse is suspected if the patient is in a stable condition but the environment is deemed unsafe assess whether the patient will accept transportation to the hospital ensuring the safety and well-being of the patient should be the top priority even if they do not present with acute medical issues if the patient refuses transport explore alternative Support options in such cases ask if the patient will be willing to accept help from local Adult Protective Services as they can provide resources and interventions to address safety concerns assess the living situation and potentially initiate protective measures if abuse or neglect or confirmed engaging with APS can offer the patient a pathway to safety and support ensuring that they receive the necessary care and protection from potential harm it's vital to approach these discussions with sensitivity respecting the patient's autonomy while prioritizing their safety effective communication and a compassionate demeanor can help build trust and encourage the patient to accept assistance when needed if the situation is immediately unsafe for the patient notify law enforcement Personnel without delay ensuring the safety of the individual is Paramount and law enforcement can provide the necessary intervention to protect the patient from further harm if you choose to remain with the patient ensure that the scene is safe to do so as your safety is also important in effectively managing the situation it's important to note that as a health care provider or caregiver it's not your responsibility to prove the abuse as has occurred Your Role is simply to observe document and report your findings according to established protocols this may include noting signs of abuse inconsistency in the patient story and any relevant information about the caregiver or their living situation.",
        "Conclusion on Geriatric Medicine": "Geriatric medicine focuses on the unique Health needs of individuals age 65 and older emphasis izing the physiological changes that occur with aging as individuals age their body systems gradually decline which can alter the presentation of diseases in the body's response to medications and treatments age related changes include decrease cardiac output reduce pulmonary function and diminish renal function these changes necessitate careful medical evaluation and tailored treatment strategies to effectively manage health conditions and older adults older adults face specific economic and social challenges that can impact their health concerns about the cost of medical care and medications May deter some from seeking timely treatment potentially exacerbating health issues moreover many older patients continue to work Beyond retirement age to support themselves financially which can also affect their Health social factors such as living arrangements and social isolation play a role in the mental and physical health of the elderly and understanding these factors is important for healthcare providers to offer appropriate support and interventions effective communication is vital when dealing with older patients and their families healthc care providers need to employ both open-ended and close-ended questions to Gather Comprehensive information about the patient's condition sensitivity to the patient's Comfort dignity Independence is critical as is respect for their decision making autonomy concerning medical cont treatments including Advanced directives and end of Life Care moreover practitioners must be vigilant about potential signs of elder abuse and neglect ensuring they provide a safe environment and appropriate referrals to Protective Services when needed"
    },
    {
        "Introduction to Obstetrics and Neonatal Care": "chapter 35 Obstetrics and neonatal care most births typically perceived without the need for Advanced Medical intervention with basic measures such as suctioning drying and warming the neonate being sufficient however certain cases may present significant risks to both the mother and the infant necessitating prompt Advanced Medical Care for the aemt responding to a woman in labor can provoke anxiety both for the medical provider and the expected parents this apprehension may be heightened if labor progresses rapidly or if unforeseen complications arise potentially requiring the provider to perform an outof hosp delivery.",
        "Female Reproductive System and Pregnancy": "the female reproductive system consists of several key structures including the ovaries fian tubes uterus cervix vagina and breasts pregnancy is most likely to occur during a specific phase of the menstrual cycle following the maturation of the ovom if fertilization does not take place the IND demetrial lining of the uterus is shed during menstration the external genitalia of the female include the Volva laia manora clitorus preus labia majora and mons pubis all of which play distinct roles in reproductive function gestation refers to the process of fetal development that begins after the fertilization of an ovom fertilization typically occurs in the distal third of the fallopian tube after which the fertilized egg or zgate travels through the fallopian tube towards the uterus from the moment of fertilization until the conclusion of the ninth week of development the developing organism is known as an embryo after the 10th week of gestation it's referred to as a fetus marking the transition to later stages of fetal development this image illustrates the fertilization and subsequent implantation of the embryo in the uterus the process begins with ovulation where a mature oite is released from the ovary into the fallopian tube fertilization typically occurs in the distal third of the fallopian tube following fertilization the zgate undergoes its first mitotic division leading to the formation of a Mula as it travels through the uterine tube the morula further develops into a blasty which eventually implants into the IND demetral lining of the uterus this marks the beginning of embryonic development within the uterus here we also see the surrounding structures including the uterine muscle layer and the corpus luteum in the ovary which produces hormones to support early pregnancy.",
        "Role of the Placenta and Umbilical Cord": "around the fourth week of pregnancy the placenta begins to form and plays a pivotal role in supporting fetal development one of its key functions is acting as an early liver for the fetus synthesizing glycogen and cholesterol metabolizing fatty acids and facilitating the transfer of maternal antibodies to provide early immune protection the placenta also serves as a site for Respiratory gas exchange change allowing oxygen and carbon dioxide to transfer between maternal and Fetal circulations it's responsible for the transport of essential nutrients from the mother to the fetus and the excretion of fetal waste products Additionally the placenta AIDS in the transfer of heat from the woman to the fetus helping to maintain proper thermal regulation it's also involved in hormone production producing hormones like HCG and progesterone which are vital for maintaining pregnancy furthermore the placenta acts as a partial barrier limiting the transfer of certain harmful substances from Eternal circulation to the fetus the umbilical cord serves as the vital connection between the placenta and the fetus attaching to the fetus at the umbilicus it contains an umbilical vein and two umbilical arteries the umbilical vein is responsible for carrying oxygenated nutrient wrench blood from the placenta to the fetus while the umbilical arteries transport deoxygenated nutrient depleted blood from the fetus back to the placenta for waste removal and gas exchange surrounding the fetus is the Amic Sac a membranous structure filled with Amic fluid which provides protection and cushioning throughout gestation during labor the increasing pressure in the ameiotic sac eventually causes it to rupture a process commonly referred to as the water breaking.",
        "Gestational Period and Developmental Milestones": "the gestational period or the time required for the infant to develop in utero typically spans approximately 40 weeks from the last menstrual period to birth the 40 we gestational period referred to as the prenatal period is divided into three Tri trimesters during the first trimester particularly in the embryonic period from weeks 3 through 8 all major fetal organ systems begin to develop marking a critical phase of growth by weeks 17 through 20 fetal heart tones can typically be detected using a fetoscope providing an early indication of the developing cardiovascular systems function these Milestones help monitor the progression of development throughout pregnancy by week 18 of gestation male and female genitalia can typically be distinguished using ultrasonography a newborn is defined as an infant in the first few hours after birth while the term neonate applies to a baby during the first 28 weeks of life after the neonatal period period from the age of 1 month until the first year the child is referred to as an infant these developmental stages are used to guide Medical Care and interventions appropriate to the baby's age and physiological status.",
        "Maternal Physiological Changes During Pregnancy": "during pregnancy several physiological changes occur in the maternal body to support the growth and development of the fetus total blood volume increases by approximately 50% % by the 40th week of gestation while red blood cell Mass expands by around 30% to meet the increased oxygen demands cardiac output Also Rises by 30 to 50% as the cardiovascular system adapts to the increased circulatory load in the second and third trimesters the enlarging gravity uterus May compress the inferior venne Hava when the woman lies in a suine position which can result in reduced Venus return and potential hypotension a condition known as sepine hypotensive syndrome these adaptations are important to consider during both routine care and Emergency Management of pregnant patients the increase in red blood cell production during pregnancy leads to a heightened need for iron to support both maternal and Fetal oxygen transport respiratory adaptations also occur with the respiratory minute volume increasing by approximately 40% by full term to meet the elevated oxygen demands of both the mother and fetus decreased gastrointestinal motility is another common change which may impair the absorption of medications requiring careful consideration in pharmacological management additionally many pregnant women experience edema in their lower extremities due to increased venous pressure and fluid retention particularly in the later stages of pregnancy.",
        "Complications During Pregnancy": "during pregnancy various complications may arise that can pose risks to the health and safety of both the mother and fetus one of the most common emergencies encountered in early pregnancy is vaginal bleeding which can be indicative of several underlying conditions such as miscarriage atopic pregnancy or placental abnormalities prompt assessment and intervention are necessary to manage these complications effectively and minimize potential harm abortion refers to the termination of pregnancy and it can occur spontaneously or be induced most spontaneous abortions or miscarriages take place during the first trimester often before the placenta has fully matured elective abortion on the other hand is a deliberate mechanical procedure to end the pregnancy as healthc care providers it's important to remain dispassionate and professional when addressing cases of elective abortion regardless of personal beliefs to ensure that patients receive unbiased Compassionate Care a threatened abortion refers to a situation where the risk of miscarriage or abortion has not yet occurred but may be impending this condition is typically marked by vaginal bleeding during the first half of pregnancy it may either progress to a miscarriage or abortion or the symptoms May resolve without further complications treatment often includes complete bed rest to reduce the risk of miscarriage and support the continuation of the pregnancy though outcomes can vary depending on the underlying cause an imminent abortion refers to a spontaneous abortion that is impending and cannot be prevented in such cases management focuses on stabilizing the patient's condition maintaining adequate blood pressure and preventing hypovolemia are critical treatment includes administering 250 ml boluses of normal saline to maintain the systolic pressure above 80 and providing 100% supplemental oxygen to achieve an spo2 level greater than 94% emotional support for the patient is also vital along with rapid transport to a medical facility for further care an incomplete abortion occurs when only part of the products of conception are expelled from the uterus with some tissue remaining this is typically accompanied by vaginal bleeding and there is a risk of hemorrhage and infection it's important to monitor for signs and symptoms of shock and an IV line of normal saline should be initiated to maintain profusion if any products of conception are visible or protruding from the vagina is essential to consult medical control for further instructions on how to proceed in contrast a complete abortion has occurred when all of the products of conception have been fully expelled from the uterus usually resulting in the sensation of significant symptoms like heavy bleeding atopic pregnancy occurs when an embryo implants and grows outside the uterine cavity most commonly in the fallopian tube but also potentially in the ovary abdominal cavity peritoneum or cervix A woman with an atopic pregnancy typically experiences lower abdominal pain and cramping bleeding which may be internal or external can range from scant to profuse complicating the diagnosis this condition represents a life-threatening emergency as a developing embryo cannot survive outside the uterus and must be surgically removed to prevent rupture and significant Hemorrhage which is critical to saving the patient's life rapid intervention is necessary to prevent serious complications.",
        "Third Trimester Bleeding and Its Causes": "third trimester bleeding occurs when there is any Detachment of the ovam or embryo from the uterine wall resulting in vaginal bleeding while bleeding during pregnancy is always concerning it becomes particularly dangerous as the pregnancy advances vaginal bleeding during the third trimester presents a significant risk of hemorrhage posing a serious threat to the health of the mother immediate evaluation and intervention are necessary to prevent maternal and Fetal complications making this one of the most critical obstetric emergencies the major causes of substantial Hemorrhage before delivery are abruptio placente and placenta Privia abruptio placente occurs when the placenta prematurely detaches from the uterine wall leading to significant internal or external bleeding and posing serious risks to both mother and fetus placenta Privia on the other hand involves the placenta partially or completely covering the cervical opening leading to painless vaginal bleeding and complicating delivery abio placente is the premature separation of a normally implanted placenta from the uterine wall which can lead to significant maternal and Fetal complications risk factors include hypertension trauma drug or alcohol use diabetes and having multiple pregnancies the patient typically presents with the sudden onset of severe abdominal pain which may radiate to the back along with decreased fetal movement and diminished fetal heart tones in severe cases if the Hemorrhage cannot be controlled after delivery a dctom me may be required to stop the bleeding and save the mother's life placenta Privia occurs when the placenta is implanted low in the uterus either partially or completely covering the cervical Canal this condition presents with a significant risk during pregnancy particularly during the third trimester risk factors for placenta Privia include Advanced paternal age and multiparity the primary clinical presentation is painless bright red vaginal bleeding which can occur without warning immediate medical evaluation is necessary to manage the bleeding and determine the appropriate course of action for delivery this often requires a cerian section to avoid further complications.",
        "Hypertensive Disorders in Pregnancy": "hypertensive disorders during pregnancy pose significant risks to both the mother and fetus chronic hypertension is defined as a persistent blood pressure of 130 over 80 or higher either predating pregnancy or developing early in gestation when diastolic pressures exceed 110 the risk of stroke and other serious cardiovascular complications increases necessitating close monitoring and management to prevent further maternal and Fetal harm gestational hypertension develops after the 20th week of pregnancy in women who previously had normal blood pressure levels and typically resolve spontaneously in the postpartum period preeclampsia a more severe condition also manifests after the 20th week of gestation characterized by elevated blood pressure protina and edema women under the age of 18 experiencing their first pregnancy as well as women of advanced paternal age are at an increased risk for preclampsia additional risk factors include chronic hypertension renal disease and diabetes preeclampsia presents with symptoms such as hypertension severe headaches nausea and vomiting agitation rapid weight gain and visual disturbances if left unmanaged preeclampsia can progress to eclampsia which is characterized by seizures in a pregnant woman with no underlying cause eclampsia is a life-threatening complication that requires immediate intervention additionally postpartum eclampsia can develop up to 4 weeks after childbirth making continued monitoring necessary.",
        "Supine Hypotensive Syndrome and Drug Use in Pregnancy": "sapine hypotensive syndrome occurs when a pregnant woman experiences hypotension while lying sepine due to the compression of the inferior venne Hava by the weight of the uterus this compression reduces Venus return to the heart leading to decreased cardiac output and hypotension if left untreated supine hypotensive syndrome can result in fetal distress due to reduced placental profusion however many women do not develop symptoms of this condition as the body typically compensates by adjusting positioning and circulation when symptoms do occur repositioning the patient to a lateral recumbent position often resolves the issue when pregnant women use drugs these substances cross the placental barrier and inner fetal circulation directly impacting fetal development the potential effects on the fetus include birth defects neonatal addiction premature birth low birth weight and severe respiratory depression these outcomes pose significant risks to the newborn's immediate and long-term Health often requiring specialized neonatal care and interventions to address withdrawal symptoms and other complications.",
        "Fetal Alcohol Syndrome and Isoimmunization": "fetal alcohol syndrome or FAS is a condition that occurs in infants born to women who have abused alcohol during pregnancy in the most severe cases FAS can lead to fetal death alcohol abuse is particularly harmful during the first trimester when key fetal development occurs newborns with FAS may present with distinctive physical characteristics including a small head abnormal facial features such as small WID set eyes a thin upper lip a short upturn nose and smooth skin but between the upper lip and nose other complications include low birth weight and deformities to the extremities management of infants with FAS includes maintaining the air we breathing and circulation with special attention to keeping the newborn warm to prevent hypothermia isoimmunization occurs when an Rh negative woman becomes pregnant by an RH positive man and the fetus inherit the RH positive blood type if fetal blood cells pass into the maternal circulation the mother's immune system can recognize the Rh factor as foreign and produce antibodies against it this response typically does not pose a problem during the first pregnancy as the production of maternal antibodies is slow however in subsequent pregnancies these antibodies can cross the placenta and attack red blood cells of an RH positive fetus leading to hemolytic disease of the newborn in subsequent pregnancies the maternal antibodies produced during isoimmunization can cross the placental barrier and Target the fetal red blood cells which the mother's body recognizes as foreign this immune response can lead to severe complications including hemolytic disease of the newborn where the destruction of fetal red blood cells results in anemia jaundice and even heart failure in most severe cases RH isoimmunization can cause fetal death if left untreated preventative measures such as administering RH immunoglobin are critical to prevent this condition.",
        "Gestational Diabetes and Hyperemesis Gravidarum": "gestational diabetes is a condition in which a pregnant woman develops an inability to properly process carbohydrates leading to elevated blood glucose levels the patient may either be asymptomatic or present with signs commonly seen in diabetes militis such as polyurea polydipsia and polyphasia this condition requires careful management to prevent complications for both the mother and fetus including macrosomia also known as large birth weight and an increased risk of developing type 2 diabetes later in life treatment for gestational diabetes typically involves careful meal planning regular blood glucose monitoring and in some cases insulin therapy patients may experience significant fluctuations in blood glucose levels predisposing them to episodes of hypoglycemia or hypoglycemia uncontrolled hypoglycemia can lead to the fetus growing larger than average which can complicate delivery by making it difficult for the baby to pass through the birth canal fortunately gestational diabetes usually resolve spontaneously after delivery though the mother may have an increased risk of developing type 2 diabetes later in life hyperemesis gravitum is characterized by persistent and severe nausea and vomiting during pregnancy which can lead to dehydration and malnutrition the condition is thought to be caused by increased hormone levels stress and alterations in the GI system symptoms typically include excessive vomiting occurring more than 3 to four times a day treatment involves administering 100% oxygen via a noner breather monitoring blood glucose levels and establishing an IV line with normal saline providing fluid boluses as needed.",
        "Premature Rupture of Membranes and Physical Abuse": "premature rupture of membranes or prom refers to the early rupture of the Amic sack occurring more than 1 hour before the onset of Labor when prom occurs in a pregnancy that has not yet reached 37 weeks of gestation it's classified as pre-term premature rupture of membranes or pprom both POS significant risks due to the loss of the protective Amic fluid which acts as a barrier against infection without this protection bacteria can ascend from the vaginal Canal into the uterine environment increasing the risk of infections which can endanger both mom and fetus additionally pprom is associated with complications such as pre-term labor neonatal respiratory distress and long-term development issues for the newborn providers should reassure the the patient providing emotional support and keeping her calm next the aemt should assess for signs of infection including fever foul smelling vaginal discharge and uterine tenderness in cases of significant fluid loss dehydration should also be monitored while on the scene and during transport avoid unnecessary vaginal examinations as this can actually increase the risk of introducing infection the patient should be transported to a medical facility as soon as possible where further evaluation including ultrasound and monitoring of fetal well-being can be conducted physical abuse often begins or escalates during pregnancy placing both the mother and the fetus at significant risk violence during pregnancy increases the likelihood of complications such as spontaneous abortion premature delivery and low birth weight healthc care providers should maintain a high index of Suspicion for abuse especially when the explanation for an injury seems inconsistent with the observed trauma in these cases it's essential to carefully assess the patients physical and emotional state when responding to a situation involving suspected abuse it's important to prioritize the patients ABCs control any active bleeding stabilize injuries such as fractures and manage the patient for shock if necessary in addition to providing physical care emotional support is critical in these situations providers must also be aware of their mandatory reporting responsibilities in suspected cases of abuse it is legally required to report the incident to the appropriate authorities to ensure that the patient receives further protection care.",
        "Trauma in Pregnancy": "both the pregnant woman and her fetus are particularly vulnerable to trauma due to the anatomical and physiological changes that occur during pregnancy injuries to the pregnant uterus especially in later stages can result in severe hemorrhaging which can compromise both maternal and Fetal health the redistribution of blood volume that occurs during pregnancy complicates trauma management as blood loss may be underestimated due to the increased plasma volume Additionally the shift in women's center of gravity makes her more prone to Falls further increasing the risk of trauma when a pregnant woman presents with a mechanism of injury that's suggestive of shock it's critical to treat her aggressively as maternal shock can severely compromise fetal profusion and oxygenation in cases of substantial maternal bleeding not only does the mother's life hang in the balance but the fetus is also at considerable risk as its survival is closely linked to the mother's hemodynamic stability a pregnant woman who has been involved in a motor vehicle crash fall assault or other traumatic injury must be thoroughly evaluated in the emergency department due to the potential risks to both her and the fetus the management of pregnant women with abdominal trauma follows the same principles as for non-pregnant patients with a focus on maintaining ABCs as the highest priority stabilization of these vital functions is critical to ensuring the well-being of both mom and fetus ensuring adequate oxygenation and profusion as particularly important as compromised maternal circulation can directly impact fetal health during the examination of a pregnant trauma patient findings may include abnormal fetal positioning an easily palpable fetus inability to palpate the fundus of the uterus or vaginal bleeding all of which warrant immediate medical attention given the increased likelihood of domestic abuse during pregnancy it's important to remain vigilant for signs of abuse and act accordingly when transporting the pregnant patient position her on the left side or Elevate her right hip by approximately 6 in this helps prevent compression of the inferior venne Cava key treatment steps include maintaining the open Airway administering high flow oxygen and monitoring and supporting ventilation assess the patient's circulation and if needed initiate IV fluid therapy to support profusion during transport continuously monitor both maternal and Fetal status ensuring the patient is taken to a facility that's equipped to handle both trauma and obstetric Care.",
        "Maternal Cardiac Arrest and Cultural Considerations": "in the event of maternal Cardiac Arrest immediate CPR should be initiated starting with high quality chest compressions the pregnant patient should be positioned toine while another rescuer provides manual left uterine displacement to relieve pressure on the inferior venne Cava and improve Venus return for chest compressions place your hands on the lower half of the sternum using the sternal notch as a reference for proper hand positioning upon arrival at the hospital an emergency cerian section may be necessary to save the fetus especially if Advanced life support measures are unsuccessful uccessful in restoring maternal circulation good quality CPR and ventilatory support are essential in keeping the feed is viable until such a procedure can be performed cultural beliefs and values surrounding pregnancy can vary widely influencing how individuals and families perceive and approach pregnancy in terms of social psychological and emotional aspects as a healthcare provider your primary responsibility is to provide appropriate Medical Care and ensure safe transport of the patient while respecting and acknowledging these cultural differences it's important to honor patient requests and preferences whenever possible maintaining a respectful and non-judgmental approach to their beliefs as long as they do not interfere with Essential Medical Care sensitivity to these cultural values enhances the patient paent provider relationship and supports holistic care.",
        "Teenage Pregnancy and Obstetric Terminology": "in cases of teenage pregnancy some young patients may not be aware of their pregnancy or they may be in denial as a health care provider it's important to respect their privacy and their need for Independence during this sensitive time whenever possible conduct a patient assessment and gather medical history privately away from the parents or Guardians to allow the teenager to speak openly about their condition this approach Fosters trust and encourages honest communication which is essential for providing the appropriate care it is a good idea to be familiar with the laws that govern these issues in your own State and region when child birth is Complicated by trauma or other medical conditions the care you provide to the pregnant patient is vital not only for her health but also for the well-being of the fetus effective management of the mother directly benefits the fetus by maintaining adequate oxygenation circulation and overall stability impatient assessment is essential to understand and use pregnancy related terminology gravida refers to the number of times a woman has been pregnant while Para indicates the number of times she has delivered a viable newborn a primagravida is a woman who is pregnant for the first time and a primipara is a woman who has only had one delivery a multigravida is a woman who has been pregnant two or more times regardless of the outcome of those pregnancies a null aara refers to a woman who has never delivered a viable newborn though she may have experienced pregnancy before a multipara describes a woman who has delivered two or more viable newborns while a grand multipara refers to a woman who has delivered five or more viable newborns these terms are essential for accurately documenting and understanding a patient's obstetric history which can influence the management of current pregnancies and Associated risks.",
        "Assessing Imminent Delivery": "to assess whether delivery is imminent and may occur within a few minutes it's important to observe for crowning and ask the patient key questions these include how many weeks pregnant are you and when is your due date this helps gauge the gestational age and the likelihood of imminent delivery is this your first baby firsttime mothers often experience longer labor while those who have delivered before May progress more quickly are you having contractions how far apart are the contractions and how long do they last this information provides insight into the stage of Labor and how close delivery might be do you feel the urge to move your bowels this sensation can indicate that the baby is moving down the birth canal and delivery is near have you had any spotting or bleeding if so what color was it and how much bleeding could indicate complications such as placental issues so it's important to assess this have you had a rush of fluid from the vagina a sudden gush of fluid May indicate that the Amic Sac is ruptured signaling that labor is progressing these questions help determine the urgency the situation and guide your immediate actions in managing the labor and delivery.",
        "Spontaneous Abortion and Third Trimester Bleeding": "spontaneous abortion or miscarriage is often characterized by vaginal bleeding and abdominal cramping most commonly occurring during the first half of pregnancy in the second half of pregnancy the patient may experience severe abdominal pain due to strong uterine contractions accompanied by significant vaginal bleeding and cervical dilation although there is no specific treatment for spontaneous abortion management focuses on stabilizing the patient condition administer high flow oxygen and if necessary establish a large bore IV with an isotonic crystalloid solution for fluid boluses to maintain circulation emotional support is critical provide reassurance but avoid giving false hope and help the patient remain calm during this distressing event in cases of third trimester bleeding it's crucial to gather as much information as possible about the bleeding's onset in nature key questions include when did the bleeding start what activity was the woman engaging in at the time of onset how much blood has been lost and is she experiencing abdominal pain if pain is present a assess its nature whether it's sharp cramping dull or achy to do this you can utilize the opqrst memonic to evaluate the patient's symptoms assess for any changes in orthostatic vital signs which may indicate significant blood loss also check for signs such as gray Turner sign which is bruising around the flanks or Cullen sign which is bruising around the umbilicus as these can suggest internal hemorrhage regardless of the source of the bleeding prehospital management Remains the Same ensure the ABCs are stable administer high flow oxygen initiate fluid resuscitation if necessary and provide rapid transport to an appropriate facility for further evaluation and management.",
        "Ectopic Pregnancy and Preeclampsia": "in cases of a topic pregnancy the patient often presents with with severe abdominal pain and may be in hypothalmic shock due to internal bleeding treatment should focus on stabilizing the ABCs this includes administering high flow oxygen starting IV fluids to support circulation and ensuring rapid transport to a facility capable of surgical intervention preclampsia is characterized by several key symptoms including headache swelling in the hands face and feet anxiety and nause and vomiting these symptoms often accompany elevated blood pressure after the 20th week of pregnancy and require prompt medical evaluation and intervention to prevent progression to eclampsia which would involve seizures managing preeclampsia involves closely monitoring blood pressure providing supportive care and ensuring a timely trans port to a facility severe preeclampsia presents with more critical symptoms requiring immediate intervention these may include pulmonary edema or shortness of breath which could indicate fluid accumulation in the lungs confusion or altered mental status which suggests severe central nervous system involvement visual disturbances such as blurry vision or seeing spots which are warning signs of impending eclampsia upper abdominal pain typically in the right upper quadrant which may signal liver involvement and myoclonus or hyperactive reflexes as this is a sign of increasing neuromuscular irritability which has often been seen before seizures these symptoms indicate a medical emergency as severe preclampsia can rapidly PR addess to eclampsia as before immediate treatment includes stabilizing the patient's ABCs as well as administering magnesium sulfate to prevent seizures and Rapid transport to a hospital for definitive care.",
        "Supine Hypotensive Syndrome and Gestational Diabetes": "supine hypotensive syndrome the most effective treatment for sapine hypotensive syndrome is to reposition the patient by placing her on her left side as this helps relieve the compression of the inferior venne Cava caused by the uterus this restores proper Venus return and prevents hypotension if it's necessary to immobilize the patient on a long spine board Place blanket rolls or other supports under the right side of the board as this will tilt the patient significantly to the left achieving the same effect gestational diabetes management of gestational diabetes in an emergency setting includes administering high flow oxygen providing IV fluids for hydration and administering dextrose if the patient presents with hypoglycemia for patients experiencing hypoglycemia the primary treatment involves oxygen Administration and IV fluid therapy following local protocols to address dehydration and help St stabilize blood glucose levels.",
        "Stages of Labor and Delivery Preparation": "the process of Labor unfolds in distinct stages labor begins with uterine contractions which gradually increase in intensity and frequency these contractions are the body's mechanism for dilating the cervix and eventually facilitating the delivery of the baby lightning describes the movement of the baby descending into the pelvis in prep preparation for birth this often occurs towards the end of the pregnancy and signals that the baby is getting ready for delivery providing some relief of pressure on the diaphragm but increasing pressure on the bladder and pelvic area these initial phases set the stage for the subsequent progression through Labor and Delivery the three stages of labor are defined as follows the the first stage begins with the onset of regular uterine contractions and continues until the cervix is fully effaced or thinned out and dilated to 10 cm this stage can vary in length especially for firsttime mothers and is crucial for preparing the body for the delivery of the fetus the second stage starts once the cervix is fully effaced and dilated and it continues until the baby is born during this stage stage the mother will experience stronger contractions and the baby moves to the birth canal for delivery the third and final stage begins after the newborn is delivered and ends with the delivery of the placenta this stage usually occurs within 30 minutes of the baby's birth and proper management is important to prevent complications such as postpartum Hemorrhage there are several standard steps to follow when preparing for delivery first ensure that all necessary delivery equipment such as sterile gloves clamps scissors and blankets is ready position the patient on her back with her knees bent and legs apart in a semi-reclining position to facilitate delivery next provide supplemental oxygen to the mother if she is hypoxic or in distress ensuring both maternal and Fetal wellbeing never attempt to hold the woman's legs together as this could obstruct the natural process of childbirth and cause harm your role is to guide and support the newborn as it emerges do not pull on the baby but rather assist its natural movement through the birth canal if delivery becomes imminent during transport safely pull the vehicle over and have your partner or team assists with the delivery to ensure proper care for both mother and baby an emergency vehicle should always be equipped with one or more sterile emergency obstetric kits these kits are essential for assisting in child birth in the field and typically include items such as sterile gloves umbilical cord clamps sterile scissors sterile towels Galls pads a bulb syringe for suctioning and blankets to wrap the newborn having this OB kit readily available ensures that both mother and newborn receive proper care in the event of an outof Hospital delivery the patient should be positioned in an optional way in order to facilitate emergency delivery while preparing for the delivery ensure that the patient's exposure is minimized to maintain her dignity and Comfort covering areas not involved in the delivery process if the emergency delivery is taking place at home or in a non-hospital environment move the patient to a sturdy flat surface such as the floor or a bed which provides better support for the delivery place a pillow or folded blankets under the patient's hips to elevate them about 2 to 4 Ines as this helps facilitate the delivery process by positioning the pelvis more favorably assist the patient into a semi position to provide comfort and improve access for delivery this also helps with the natural progression of Labor and reduces The Strain on the mother arrange clean towels or sheets around the delivery area to catch fluids and protect the environment from contamination helping to maintain a cleaner space for both both mom and newborn open the sterile OB kit with caution to ensure that its contents such as gloves clamps and scissors remain sterile and free from contamination this step is crucial to preventing infection and ensuring a safe delivery for both mom and baby before handling any equipment or assisting with the delivery thoroughly wash your hands using an iodine oral exidine scrub solution to reduce the risk of infection after washing your hands put on sterile gloves goggles and a gown to maintain a sterile environment and protect both yourself and the patient from exposure to blood and bodily fluids utilize the sterile sheets and towels provided in the OB kit to create a sterile field around the delivery area this field will help ensure that the baby is delivered in as clean and sterile an environment as possible though please keep in mind once the delivery starts the field will no longer be sterile your partner should remain at the patient's head throughout the delivery providing Comfort soothing and reassurance this emotional support helps reduce anxiety and promotes a smoother delivery process regularly assess for signs of crowning which occurs when the baby's head becomes visible at the vaginal opening this signals that delivery is imminent and requires careful monitoring do not allow the baby to be delivered too abruptly as this could increase the risk of injury to both baby and mom gently guide the baby's head and body as they emerge stay positioned in a way that allows you to clearly see the peronal area at all times during the delivery this positioning helps you to anticipate and respond to the progression of Labor and manage any complications that may arise between contractions remind the patient to rest and take deep breaths through her mouth this helps conserve energy and maintain proper oxygenation during the delivery process once the baby is delivered immediately wrap the newborn in a clean warm blanket leaving only the face exposed and covering the top of the head to maintain warmth this prevents heat loss and stabilizes the baby's body temperature after suctioning the newborn's Airway if necessary keep the newborn at the same level as the woman's vagina until the umbilical cord is clamped and cut this positioning helps ensure proper blood flow between Mom and baby before the cord is severed the cord should not be severed until it is no longer pulsating.",
        "APGAR Score and Umbilical Cord Care": "the abgar score is a quick assessment tool used to evaluate the adequacy of a newborn's vital functions immediately after birth it measures five key parameters rate respiratory effort muscle tone reflex irritability and color each of these is assigned to score from 0 to two with the assessment taking place at both 1 and 5 minutes after birth a total apgar score of 7 to 10 indicates that most newborns are vigorous and adapting well to life outside the womb however newborns with the score in the 4 to six range are considered moderately depressed and may require resuscitation efforts such as stimulation oxygen and Airway support to help stabilize their condition clamping the umbilical cord should be delayed for 30 seconds after delivery unless the newborn requires immediate resuscitation during this time handle the cord with care once the cord has stopped pulsating apply the first tie or clamp approximately 4 in from the newborn's navl and place a second tie or clamp about 2 in away from the first carefully cut the cord between the two ties or clamps and then examine the cut ends to ensure there's no bleeding afterward wrap the newborn in a dry blanket to maintain warmth once the newborn is stable reassess the mom and prepare for the delivery of the placenta which typically follows shortly after the baby is born the placenta typically delivers on its own within a few minutes after the birth though it may take up to 30 minutes it's important to never pull on the umbilical cord to hasten the delivery of the placenta as this can cause complications such as uterine inversion or cord rupture once the placenta is delivered wrap the entire placenta and umbilical cord in a towel and place them in a plastic bag for transport to the hospital for examination ensuring that no fragments are retained in the uterus which could lead to postpartum Hemorrhage after delivery place a sterile pad or sanitary napkin over the woman's vagina to absorb any postpartum bleeding and gently straighten her legs for Comfort to help slow postpartum bleeding gently massage the uterine fundus using a firm circular kneading motion this encourages uterine contraction which is essential for controlling bleeding and preventing Hemorrhage continuously monitor the woman's condition it ensures she remains stable as the body transitions after delivery massaging the uterus and encouraging the newborn to nurse will help stimulate uterine contractions which can further slow postpartum bleeding it's important to record toward the time of birth and after delivery obtain the woman's vital signs to assess her overall condition additionally closely monitor mom for any signs of postpartum Hemorrhage shock seizure activity or respiratory difficulty as these complications may arise in the postpartum period and will require immediate intervention.",
        "Postpartum Hemorrhage and Cesarean Section": "postpartum Hemorrhage is defined as blood loss exceeding one pint or 500 MLS during the first 24 hours after childbirth it can become an emergency in the following situations one that placenta has not delivered within 30 minutes after birth two more than 500 MLS of blood is lost before the placenta is delivered and three substantial bleeding occurs after the placenta has been delivered in these cases the provider must initiate rapid transport to a medical facility place a sterile pad or sanitary napkin over the vagina to collect blood and if there is external bleeding from paranal tears manage it with firm pressure many complications that arise during abnormal labor or delivery ultimately require cerian section as a definitive treatment to ensure the safety of both the mother and the fetus pre-term labor is any labor that begins after the 20th week but before the 37th week of gestation the primary goal in managing pre-term labor is to prevent it from progressing one of the most effective treatment options it is administering a bolus of isotonic crystalloid solution which helps stabilize the mother and may delay the onset set of Labor giving time for further medical interventions if necessary a newborn delivered before 36 weeks of gestation or weighing less than 5 lbs at Birth is considered premature premature newborns tend to be smaller and thinner than full-term and may lack verx the protective coating on the skin these infants often experience increased alvr surface tension making breathing more difficult to manage a premature newborn administer supplemental Oxygen by placing a ENT or Hood above the newborn's head to maintain proper oxygenation carefully Monitor and prevent bleeding from the umbilical cord as premature infants may be more prone to complications with cord bleeding and lastly take all necessary steps to prevent contamination as premature newborns have underdeveloped immune systems and are at a higher risk of infection maintaining warmth and ensuring a sterile environment are also critical in the care of premature infants.",
        "Postterm Pregnancy and Fetal Distress": "a postterm pregnancy is defined as a pregnancy that extends Beyond 41 completed weeks of gestation they can result in a more difficult labor and delivery due to the increased size of the fetus leading to a higher likelihood of cesarean section additionally there's a greater risk for maternal paranal tears and infection during delivery postterm newborns are at an increased risk for complication including moonium aspiration infection and being stillborn due to the limited space in the uterus some postterm infants may not develop normally which can affect their overall health at Birth Earth it's important to be prepared to resuscitate the newborn as respiratory and neurologic functions may be compromised fetal distress may result from a variety of conditions including hypoxia nucle cord trauma abruptio placente fetal development disabilities and a prolapse cord these conditions can impair the the fetus's oxygenation and overall well-being since their condition cannot be directly assessed in the pre-hospital setting rely on the information provided by Mom particularly regarding fetal development a decrease or absence in fetal movement May indicate distress women at the greatest risk for uterine rupture include those who have had multiple pregnancies and those with a scar on the uterus such as from a previous cerian section this condition can be life-threatening for both mom and fetus a key sign of uterine rupture is a sudden change in the labor pattern mom may initially experience very strong and painful contractions but these contractions May suddenly weaken or stop altogether accompanying this change mom often reports severe abdominal pain while there may be substantial vaginal bleeding it's not always immediately visible making the condition difficult to recognize without a detailed assessment moonium staining occurs when the fetus expels meconium into the Amic fluid often as a result of fetal distress or simply the stresses of Labor and Delivery this poses a significant risk for the newborn as inhaling meconium stained fluid can lead to chemical pneumonia the color of the Amic fluid provides important Clues a yellow tint suggests that meconium has been present in the fluid for some time whereas a green black color with particulate matter indicates recent passage of meconium during delivery be vigilent about the potential need for suctioning to clear the newborn's Airway as meconium aspiration can compromise breathing provider should also call early for paramedic backup if you suspect moonium staining in order to ensure proper care is provided immediately after delivery.",
        "Multiple Gestation and Cephalopelvic Disproportion": "in cases of multiple gestation it's essential to be well prepared which includes ensuring you have a spare OB kit available in your equipment to manage the delivery of more than one newborn consider the possib ility of twins or other multiples if the uterus remains large and firm after the delivery of the first newborn this is a key sign that another baby may still be present requiring further attention and preparation for additional deliveries always be prepared for the extra demands that come with multiple gestations including the need for more resources in careful monitoring of both mom and newborns when delivering more than one fetus follow these guidelines repeat earlier preparations for delivery after the birth of the first newborn ensuring that the delivery field remains as sterile as possible and all necessary equipment is ready once the first newborn is born clamp and cut the umbilical cord approximately 30 seconds after birth ensuring this is done before the second newborn is delivered keep them both warm well oxygenated and maintain as sterile an environment as possible to minimize the risk of infection and ensure stable conditions for both infants identify the first newborn delivered as baby a to distinguish between the siblings record the time of birth for each twin separately to ensure accurate documentation and medical records for both newborns calop pelvic disproportion occurs when the head of the fetus is larger than the maternal pelvis making vaginal delivery difficult or impossible in these cases a cerian section is typically required to prevent maternal and Fetal distress and avoid complications if not addressed calop pelvic disproportion can lead to serious complications including massive Hemorrhage and other postpartum issues which can pose significant risks to both mom and baby early recognition of this condition is critical to ensure timely intervention and reduce the risk of complications.",
        "Intrauterine Fetal Death and Amniotic Fluid Embolism": "complications during labor and delivery can sometimes lead to the unfortunate outcome of intrauterine fetal death in such situations parents are likely to be emotionally distraught and they will require all of your professionalism and support skills to help them cope with their grief if a newborn is obviously dead such as in cases of advanced maceration resuscitation should not be attempted however for normal appearing newborns even in case of uncertainty resuscitation must be ATT tempted to ensure every possible effort is made to support life providing Compassionate Care and clear communication during these difficult moments is essential Amic fluid embolism is a life-threatening but extremely rare condition it occurs when ameiotic fluid and fetal cells enter the maternal pulmonary and circulatory systems through the placenta typically via the umbilical veins several risk factors increase the likelihood of this condition including maternal age over 35 eclampsia abop placente placenta Privia uterine rupture and Fetal distress the signs and symptoms usually present suddenly with the onset of respiratory distress and hypotension being key indicators treatment involves supporting mom's vital systems through measures such as oxygen therapy and IV fluid administration all while ensuring rapid transport to a hospital this may present like anaphylaxis however the utilization of epinephrine will not stop the symptoms from occurring.",
        "Breech Presentation and Limb Presentation": "breach presentation refers to a situation where the fetus's buttocks or feet rather than the head are the presenting part during delivery there are three main types of breach presentations in a Frank breach the hips are flexed and the knees are extended with the buttocks presenting first in an incomplete breach one or both hips and knees may be extended and one or both feet present first with a complete breach both of the hips and knees are flexed with the buttock as the percenting part in breach presentations the newborn is at a higher risk for delivery trauma making it critical to proceed with extreme care always ensure that you have medical control guiding you through the delivery process as breach deliveries can be complex and may require specialized interventions limb presentation is a rare occurrence in which the presenting part of the newborn is a single arm leg or foot in such cases a surgical delivery is required and the newborn must be delivered via cerian section at a hospital as vaginal delivery is not possible or safe if a limb is protruding gently cover it with a sterile towel to protect it from contamination and prevent injury rapid transport to a medical facility is critical and no attempts should be made to deliver the newborn in the field in cases of limb presentation place the patient on her back with her head down and hips elevated this position known as the Trendelenburg position helps reduce pressure on the protruding Limb and prevents further trauma to the newborn that could occur if the mother continued pushing it's a it's essential to transport rapidly to a medical facility as surgical intervention is necessary to safely deliver the newborn avoid any attempts at a field delivery and focus on stabilizing the mother and newborn until hospital care is available.",
        "Shoulder Dystocia and Nuchal Cord": "shoulder dystocia is a complication of delivery that occurs when after the head is delivered the newborn's shoulder becomes lodged behind the mother's symphysis pubis preventing further progress women who have diabetes large fetuses or postterm pregnancies are at an increased risk for this condition the primary concern for the newborn in cases of shoulder dystocia is the risk of injury to the brachial nerve plexus which can lead to nerve damage affecting the arm and shoulder various Maneuvers may be attempted to widen the woman's pelvis or reposition the fetus to facilitate delivery one of the safest and most effective techniques is the McRoberts maneuver which involves hyper flexing the mother's legs tightly around her abdomen to widen the pelvic outlet and allow the shoulder to pass a nucal cord occurs when the umbilical cord is wound tightly around the newborn's neck which can potentially cause asphixiation if not addressed promptly if a ncle cord is present carefully slip your finger under the cord and gently attempt to slip it over the newborn shoulder and head if you are unable to loosen and reposition the cord you must cut the cord before delivery can proceed in cases where the cord is wrapped more than once around the neck you should clamp and cut the cord only once then carefully unwrap it from around the newborn's neck to ensure safe delivery.",
        "Prolapsed Umbilical Cord and Excessive Bleeding": "a prolapsed umbilical cord occurs when the cord emerges from the uterus ahead of the newborn during labor this is a serious emergency as the cord can become compressed between the fetus and the birth canal which may interrupt the blood supply to the newborn leading to hypoxia or even death if not promptly managed to prevent further compression of the umbilical core for and reduce the risk of interrupted blood flow to the newborn it's critical to stop the mother from pushing place the patient sepine with her lower extremities elevated or you could alternatively place the patient in a knee to chest position which helps reduce pressure on the cord after positioning the patient carefully insert a gloved hand into the vagina and gently push the presenting part of the the fetus back to relieve pressure on the cord this helps restore blood flow to the newborn this is a high-risk situation requiring immediate transport to the hospital where surgical intervention typically a cerian section will be necessary to ensure the safety of both mom and baby keep in mind if you're the provider who is inserting your hand into the vagina and relieving pressure on the cord get comfortable you're going to be in that position until the baby is delivered excessive bleeding defined as blood loss exceeding 1,000 MLS is considered high risk for maternal mortality and morbidity the most common cause of such bleeding is the uterus not fully Contracting which can lead to postpartum hemorrage to manage excessive Bleeding cover the vagina with a sterile pad to absorb and monitor ongoing blood loss save blood soaked pads and any tissue that passes from the vagina for examination at the hospital as this information is important for medical assessment administer oxygen is needed and monitor Vital Signs frequently to detect early signs of shock provide rapid transport to a medical facility for further intervention as excessive bleeding requires prompt and aggressive treatment to prevent serious complications.",
        "Uterine Inversion and Pulmonary Embolism": "uterine inversion is a rare but serious complication where the uterus turns inside out as the placenta is being delivered this occurs when the placenta fails to detach properly from the uterine wall and remains adhered during expulsion this condition can result from placing excessive pressure pressure on the uterus during fundal massage or by exerting too much traction on the umbilical cord in an attempt to hasten the delivery of the placenta in the event of uterine inversion make one attempt to replace the uterus by using the palm of your hand to gently push it back inside the body if unsuccessful rapid transport is essential as uterine inversion can lead to severe bleeding and shock never use your fingers to attempt to replace a prolapsed uterus as this can cause further injury and complications only use the palm of your hand for a single attempt administer 100% supplemental oxygen using a non-rebreather to ensure proper oxygenation and help stabilize establish two IV lines with normal saline and titrate the fluid administration based on the patient's vital signs treat for shock which is a common complication of uterine inversion due to the significant blood loss additionally keep the patient warm monitor Vital Signs closely and prepare for Rapid transport to a hospital for definitive care a pulmonary embolism can occur from several sources with a blood clot originating in the pelvic circulation being a frequent cause during the postpartum period if a postpartum woman experiences sudden difficulty breathing teoc cardia or hypotension a PE should be suspected management includes high flow oxygen and arranging for Rapid transport to the hospital.",
        "Spina Bifida and Fetal Transition": "spinal bifida is a condition where a portion of the spinal cord or meninges protrudes outside of the vertebrae typically occurring in the lower third of the back in the lumbar region immediate care after birth includes covering the exposed area of the spinal cord with a sterile moist dressing to protect it from infection and injury it's also crucial to maintain the newborn's body temperature when applying moist dressings as hypothermia can quickly develop in these infants typically the patient will know whether or not not their child will be born with a spinal bifida and sometimes the condition is even corrected in utero in utero a fetus receives oxygen through the placenta with maternal circulation providing the necessary oxygenation as the fetus is delivered a rapid series of events known as fetal transition must occur to enable the newborn to begin independent breathing during this transition the newborn's lungs take over the function of oxygenating the blood and the neonate begins to breathe and oxygenate on its own the image you see on the screen depicts fetal circulation and illustrates how blood flow occurs in the fetus before birth in the womb the fetus relies on the placenta for oxygen exchange rather than its lungs oxygenated blood from the placenta travels through the umbilical vein and bypasses the liver via the ductus venois entering the inferior vena from there it enters the right atrium of the heart in fetal circulation some blood is shunted from the right atrium to the left atrium through the framan ovil bypassing the lungs blood that does reach the right ventricle is pumped into the pulmonary artery but much of it bypasses the lungs via the ductus arteriosis which connects the pulmonary artery to the aorta the oxygenated blood is then distributed to the fetal body through the dorsal aorta at Birth significant changes occur including the closure of the foran ovil and ductus arteriosis allowing blood flow through the newborn's lungs for oxygen exchange these changes are part of the fetal transition necessary for independent breathing and circulation.",
        "Neonatal Distress and Initial Management": "there are several factors that do contribute to delayed transition for newborns and these are reflected on the table on the screen fetal distress in utero is often caused by compromised blood flow in the placenta or umbilical cord which can impair oxygen delivery to the fetus after delivery fetal distress is usually due to Airway or breathing problems leading to inadequate oxygenation clinical findings in neonatal distress include persistent cyanosis and or bardia hypotension respiratory depression or apnea and poor muscle tone these signs necessitate immediate intervention to support the newborn's ABC the initial steps in managing a newborn are focused on stimulating spontaneous effective breathing these steps include drying warming positioning suctioning and gently stimulating the neonate to encourage respiration a rapid initial assessment should be performed simultaneously with these interventions this includes noting the time of delivery and continuously monitoring the newborn's ABCs to ensure proper oxygenation a newborn who has not yet begun to breathe adequately will often appear cyanotic due to a lack of oxygen it is common for newborns to become centrally pink while still having blue hands and feet also known as acrocyanosis this is usually normal in the early minutes after birth if the newborn exhibits a normal breathing pattern and pulse rate greater than 100 beats per minute but continues to show central cyanosis of the trunk or mucus membranes supplemental free flow oxygen should be provided to support proper oxygenation until theosis resolves the first step in neonatal resuscitation is to provide warmth clear the airway if necess necessary and dry and stimulate the newborn to encourage effective breathing position them on a flat surface and ensure the airway is open by positioning the head in a slightly extended position known as the sniffing position in order to facilitate breathing if the newborn does not begin to breathe adequately additional tactile stimulation such as rubbing the back or flicking the soles of the feet should be applied briefly in order to stimulate breathing use the appar score to assess the newborn's overall condition based on the five parameters discussed earlier heart rate respiratory effort muscle tone reflex irritability and color remember to take the score at 1 in 5 minutes Post delivery as this will guide further resuscitation efforts.",
        "Neonatal Resuscitation and Vascular Access": "neonatal resuscitation follows a structured approach to ensure effective care if the newborn is not breathing after the initial steps of dry warm suction stimulate initiate positive pressure ventilation and monitor oxygen saturation to ensure proper oxygenation positive pressure ventilation is the most critical intervention for newborns who are not breathing well or have a low heart rate if the heart rate drops below 60 beats per minute despite adequate ventilation begin chest compressions in conjunction with continued ventilation compressions should be performed at a ratio of 3 to one three compressions to one breath in order to support both circulation and ventilation consider intubation if the newborn's condition does not improve with positive pressure ventilation and chest compressions ensure that these compressions are coordinated with positive pressure ventilation to optimize both ventilation and circulation if the heart rate drops below 60 beats per minute despite these efforts administer IV epinephrine additionally consider potential causes such as hypovolemia or pneuma thorax and treat accordingly the need for resuscitation is determined based on three key parameters respiratory effort heart rate and color assess if the newborn is breathing effectively ensure the heart rate is above 100 beats per minute and if it drops below 60 take immediate action and then evaluate the newborn skin color to check for cyanosis or power this algorithm provides a step-by-step process to support the neonate transition to Independent life ensuring that both oxygenation and circulation are maintained during resuscitation if the newborn appears cyanotic or pale indicating inadequate oxygenation it's important to provide supplemental oxygen to improve oxygen saturation and support breathing the recommended oxygen flow rate is set at 5 L per minute to deliver sufficient free flow o to the newborn ensuring that oxygen levels are optimized without causing respiratory complications bag mask ventilation is indicated for newborns experiencing apnea inadequate respiratory effort or a pulse rate of less than 100 beats per minute but greater than 60 signs that suggest the need for BVM include periodic breathing intercostal retra fractions nasal flaring and grunting on expiration all of which indicate respiratory distress for bag mask ventilation it's important to use the infant siiz bag mask if available to ensure a proper fit for the newborn the face mask should provide an airtight seal fitting over the newborn's mouth and nose extending down the chin but not over the eyes in in order to prevent air leakage and ensure effective ventilation position the newborn in the sniffing position which involves slightly extending the neck to maintain an open Airway and optimize air flow during ventilation assess for bilateral chest rise and breast sounds to confirm that the lungs are inflating properly ventilation should be delivered at a rate of 40 to 60 breaths per minute chest compressions are a vital part of neonatal resuscitation when the newborn's heart rate is critically low there are two main techniques for performing chest compressions on a newborn the first is the thumb technique where both thumbs are placed on the lower third of the sternum while the fingers en Circle the newborn's chest for support the second method is the two finger technique where two fingers are placed just below the zho process between the unimaginary line drawn across the newborn's nipples and compressions are applied to the lower third of the sternum during neonatal resuscitation bag Mass ventilation is performed during a pause after every third compression to ensure the newborn receives sufficient oxygen adequate ventilation is absolutely critical to the success of resuscitation as proper oxygenation is essential for stabilizing the newborn's condition and supporting overall recovery this coordination of compressions and ventilations helps maximize the effectiveness of resuscitation efforts vascular access during neonatal resuscitation can be established through several sites common options include peripheral veins in the anticubital fausa OR sainis veins if these are not accessible intra oous access can be obtained at the proximal tibia to administer medications and fluids rapidly in emergency situations.",
        "Apnea, Bradycardia, and Hypoglycemia in Newborns": "apnea is a condition commonly seen in newborns delivered before 32 weeks of gestation if apnea persists and does not respond to initial stimulation and if further interventions are not initiated it will will lead to hypoxemia and brto cardia apneia and newborns can also follow a period of hypoxia or hypothermia additionally various other factors can contribute to the onset of apnea including maternal or infant narcotic exposure weakness in the airway or respiratory muscles septicemia prolonged or difficult labor in delivery gastro esophagal reflux and central nervous system abnormalities each of these causes may require different management strategies to effectively treat the apnea and support the newborn's respiratory function in primary apnea the newborn has stopped breathing often due to a brief period of hypoxia if this period is relatively short interventions like drying and stimulation may be sufficient to trigger the resumption of breathing however if hypoxia continues during primary apnea without resolution the newborn May begin to gasp and then enter secondary apnea in this phase the newborn will no longer respond to stimulation alone at this point positive pressure ventilation using a BVM is required to restore effective breathing braic cardia in newborns is most often caused by inadequate ventilation and frequently responds well to effective positive pressure ventilation the first step is to assess the patency of the airway to ensure that it is clear and open if bra cardia persists with a heart rate of less than 60 beats per minute despite the 30 seconds of effective positive pressure ventilation chest compressions should be initiated for persistent bra cardia it's important to call for paramedic backup early to allow for the administration of epinephrine and other Advanced resuscitative measures hypoglycemia in newborns is defined as blood glucose levels of less than 45 most newborns will remain asymptomatic until the glucose level drops below 20 for an extended period of time however symptoms can develop and may include cyanosis apnea irritability poor sucking or feeding hypotonia or low muscle tone irregular respirations eye rolling hypothermia and a decreased response to stimuli in cases of suspected hypoglycemia it's important to check the blood gluc glucose level in all sick newborns and thoroughly evaluate their vital signs before directly managing the hypoglycemia ensure that the newborn has adequate oxygenation ventilation and circulation to stabilize her overall condition if the newborn is also hypothermic administering warm IV fluids can assist in rewarming them while addressing both the hypoglycemia and hypothermia hypovolemia in newborns often associated with shock is characterized by a pale appearance and weak pulses the newborn May exhibit persistent Tac cardia or even bra cardia and their cardiovascular function typically does not improve despite effective ventilation chest compressions or cardiac medications in such cases administer 10 MLS per kg of an isotonic crystalloid over 5 to 10 minutes after the initial fluid administration reassess the newborn's condition and provide additional fluids as needed to stabilize the newborn's circulatory status.",
        "Conclusion and Summary": "this lecture covered the essential aspects of pregnancy delivery and newborn care for a EMTs it began with an overview of normal childbirth noting that most deliveries require minimal intervention with basic measures such as suctioning drying and warming the newborn being sufficient however some cases present serious risks to both the mother and baby necessitating Advanced Medical intervention we then reviewed the female reproductive system and the process of fetal development from fertilization to the gestation period highlighting key Milestones such as the formation of the placenta and the role of the umbilical cord in supporting fetal development we addressed normal maternal physiological changes during pregnancy including increased blood volume cardiac output and respiratory minute volume these adaptations are critical for supporting the growing fetus but they also introduce risks such as spine hypotensive syndrome additionally various pregnancy complications such as vagal bleeding preeclampsia and atopic pregnancy are discussed in detail the management strategies for each complication are outlined focusing on stabilization rapid transport and appropriate intervention to protect mom and baby the final sections of the lecture concentrate on delivery related complications such as breach presentation nucle cord and shoulder dystocia along with high-risk conditions like post Hemorrhage and uterine inversion neonatal care including apgar scoring resuscitation techniques and managing newborn conditions such as hypoglycemia and bardia are also covered we concluded by emphasizing The Importance of Being prepared for various obstetric emergencies ensuring that the aemt can respond effectively to both maternal and neonatal needs during out of the hospital deliveries remember women have been giving birth for thousands of years the baby is coming whether you're there or not our job is to make mom as comfortable as possible and prepare for the small percentage of time that the delivery will be difficult"
    },
    {
        "Introduction to Toxicologic Emergencies": "chapter 21 toxicologic emergencies introduction Critical Care transport professionals play a significant role in the transportation of patients experiencing toxicologic emergencies across various scenarios toxic substances present in perilous quantities in homes schools agriculture industry commercial establishments Transportation modes and in the natural environment pose significant risks to individual ual exposure to these toxic substances can occur through accidents carelessness intentional misuse and abuse or deliberate acts of others such as terrorism it is important to acknowledge that toxic exposures have the potential to be lethal underscoring the gravity of these emergencies providers contribute to enhancing patient outcomes by promptly recognizing and effectively treating toxicologic emergencies the Paramount consideration in managing patients who are poisoned or have overdosed is ensuring the safety of the transport team and other health care or emergency responders the unpredictable nature of patients reacting to medication overdoses manifesting in bizarre aggressive or violent Behavior adds complexity to the transport process Additionally the involvement of suicidal individuals in a toxicologic emergency introduces heightened risks as their actions May jeopardize the safety of others during a suicide attempt furthermore patients exposed to hazardous substances not only face health risks but also have the potential to inadvertently expose those providing assistance consequently prioritizing the safety of the transport team and other responders remains a critical imperative in managing toxicologic emergencies in basic care for patients facing toxicologic emergencies priority is given to maintaining a patent Airway supporting respiration and promoting effective circulation these fundamental steps are integral in stabilizing the patient physiologic functions additionally specific measures are implemented to address the complexity of the exposure itself under additional steps protecting the patient from further injury is achieved through de contamination procedures this involves two distinguishable types primary typically performed at the scene or outside a healthcare facility or transport vehicle and secondary decontamination requiring healthc care providers to utilize PPE while focusing on minimizing patient absorption or injury from the toxic substance we will not be discussing decontamination in this lecture preventing the absor absorption of the toxin is a critical aspect of patient care involving measures aimed at halting or reducing the entry of the toxic substance into the body administration of antidotes is another essential step although it is important to note that the term antidote implies a complete reversal of toxicity which is not a common outcome nevertheless the targeted use of antidotes aims to counteract the effects of specific toxins enhancing elimination of of the substance from the body is another facet of care contributing to the overall management strategy General patient safety measures are implemented to ensure the well-being of both the patient and the health care providers involved moreover Comfort measures are integrated to provide relief and support to the patient during the challenging circumstances of a toxicologic",
        "Toxic Syndromes and Medication Reaction Syndromes": "emergency toxic syndrome and medication reaction syndromes exposure to specific classes of chemicals and medications can manifest as a distinct pattern of clinical signs and symptoms referred to as a toxidrome however it is imperative that Critical Care transport paramedics exercise caution and do not Overlook alternative causes when assessing and determining the appropriate course of action for a patient the identification of a toxidrome serves as a valuable diagnostic tool aiding in the prompt and accurate identification of the toxic substance involved it is noteworthy that patients May on occasion exhibit life-threatening reactions even when exposed to medications at therapeutic doses in such instances the Swift recognition of these rare events becomes essential for Effective intervention misdiagnosis in this context holds the potential for lethal consequences the gravity of the situation underscores the need for Precision in diagnosis and treatment Decisions by providers anti-cholinergic syndrome is a clinical condition that manifests following excessive exposure to substances such as antihistamines atropine vrine tcas and certain plants like gemson weed poisoning with these agents leads to muscarinic receptor blockade within the CNS and various other organs resulting in characteristic clinical features the syndrome is categorized by specific characteristics including teac cardia and hypothermia dilated pupils a result of impaired colonic activity contribute to the clinical profile the skin affected by the blockade of sweat glands becomes hot and dry reflecting the anti-cholinergic impact on Thermo regulation GI effects are observed in the form of ilas indicating a functional impairment of the intestines neurologically anti-cholinergic syndrome may present with delirium a state of acute confusion and disturbance in attention and cognition seizures can also occur as well as as hallucinations furthermore urinary retention is a notable feature of anti-cholinergic toxicity on the opposite end of the spectrum colonic syndrome is a clinical condition that arises following exposure to Organo phosphate and carbonate insecticides or certain chemical nerve agents the underlying mechanism involves the inhibition of colon estas enzymes by these toxic substances leading to the accumulation of the neurotransmitter acetylcholine colon estras Inhibitors can affect nicotinic receptors muscarinic receptors or both thereby altering the normal function of acetylcholine in synaptic transmission two distinct patterns of toxicity characterize colonic syndrome with the first being nicotinic receptor toxicity this pattern involves a stimulation of nicotinic receptors resulting in various physiological manifestations teoc cardia is a prominent feature along with hypertension fasiculations contribute to the clinical presentation accompanied by weakness and hypoglycemia dilated pupils which is a consequence of excessive col energic stimulation further delineate the nicmic receptor toxicity associated with coleric syndrome colonic syndrome specifically muscarinic receptor toxicity arises from the excessive stimulation of muscarinic receptors due to exposure to colon estras Inhibitors commonly found in Organo phosphate and carbonate insecticides or certain chemical nerve agents the resulting overactivity of the parasympathetic nervous system leaves to a distinctive set of clinical signs and symptoms encapsulated by the slud and dumbbells mimics under SL sudum the symptoms include salivation lacrimation urination diarrhea gastroenteritis emesis meosis Bronco Coria bronchospasm sweating and brto cardia these manifestations reflect the wide spread effects of coleric over stimulation on various organ systems particularly the GI respiratory and cardiovascular systems dumbbells further categorizes specific symptoms associated with muscarinic receptor toxicity the diaphoresis and diarrhea urinary incontinence meosis bardia bronchospasm Bronco Coria emesis lacrimation and salivation collectively outline the clinical spectrum of coleric toxicity for Health Care Professionals including Critical Care transport providers this detailed understanding of the diverse manifestation of muscarinic receptor toxicity is vital prompt recognition allows for the implementation of appropriate interventions such as the administration of antidotes to counteract the effects of colon estras Inhibitors in cases of severe exposures to coleric syndrome both nicotinic and muscarinic toxicity share common neurological manifestations resulting in Altered mental status coma and seizure activity altered mentation reflects a deviation from normal cognitive functioning including confusion disorientation or unconsciousness coma denotes a profound state of unconsciousness from which the individual cannot be easily aroused while seizure activity involves abnormal electrical discharges in the brain leading to uncontrolled and involuntary movements or changes in Behavior nicotinic toxicity primarily involves the stimulation of nicotinic acetycholine receptors leading to heightened sympathetic activity in severe exposures this can contrib Ute to the development of altered mental status coma and seizure activity on the other hand muscarinic toxicity results from over stimulation of The muscarinic acetycholine receptors affecting parasympathetic functions despite the distinct receptor Pathways involved the shared neurological effects underscore the gravity of the toxic exposure opioid syndrome manifests as a consequence of elicit abuse accidental ingestion or simply adverse reactions to therapeutic use of opioids suspected drugs associated with opioid syndrome include morphine heroin and fentel the clinical presentation of opioid toxicity is characterized by specific signs and symptoms lethargy and sedation are prominent features of opioid syndrome reflecting the central nervous system depressant effects of opioids patients May exhibit a state of drowsiness reduced alertness and decreased responsiveness hypoventilation or apnea a significant concern in opioid toxicity results from the suppression of the respiratory drop by opioids this respiratory depression can lead to inadequate oxygenation and in severe cases respiratory rest one of the Hallmark signs of opioid toxicity is pimple Point pupils known as meosis opioids exert their effects on the pupils by activating the parasympathetic nervous system causing constriction pinpoint pupils are a characteristic finding an opioid overdose and are often used as a diagnostic indicator non-cardiac pulmonary edema is another potential consequence of opioid toxicity although it is less common than the aforementioned symptoms opioids can contribute to the accumulation of fluid in the lungs leading to respiratory distress and compromise gas exchange this complication underscores the complexity and severity of opioid toxicity necessitating prompt recognition and intervention sedative hypnotic syndrome is a clinical condition that arises following exposure to any medication or chemical capable of causing CNS sedation lethargy or coma while various substances can contribute to this syndrome ethanol commonly found in alcoholic beverages stands out as the most frequent cause the signs and symptoms associated with sedative hypnotic syndrome are indicative of the profound CNS depression induced by these substances patients with sedative hypnotic syndrome typically exhibit lethargy reflecting the sedative effects on the CNS sedation further underscores the impact on the central nervous system respiratory depression in the form of hypoventilation and apnea is a critical concern in sedative hypnotic toxicity as this can lead to inadequate oxygenation and in severe cases respiratory arest cardiovascular effects are also evident in sedative hypnotic syndrome with braic cardia and hypotension being common manifestations these cardiovascular changes are typically secondary to the overall CNS depression caused by sedative hypnotic substances sympathomimetic syndrome is characterized by the over stimulation of the adrenic nervous system resulting in a spectrum of clinical signs and symptoms various substances can induce sympathomimetic toxicity including amphetamines caffeine cocaine MDMA or ecstasy or synthetic cannaboids these substances exert their Effects by enhancing the activity of adrenic neuro receptors particularly norepinephrine and epinephrine leading to widespread sympathetic nervous system activation the signs and symptoms of sympathic syndrome involve a range of physiological and behavioral manifestations teoc cardia is a Hallmark feature reflecting the increased sympathetic activity hypertension is another cardiovascular manifestation a sympathomimetic toxicity contributing to the overall hyper stimulation of the ad iic system agitation a state of restlessness and heightened arousal is a common behavioral manifestation seizures may occur due to the intense excitatory effects on the CNS hypothermia is a significant concern as well and can lead to further complications if not promptly addressed ocular effects include dilated pupils a consequence of sympathetic stimulation and diaphoresis the combination of these signs and symptoms reflects the comprehensive impact of sympathomimetic substances on multiple organ systems emphasizing the need for prompt recognition and intervention malignant hypothermia is a rare but potentially life-threatening medication reaction syndrome that occurs following the administration of sual choline or inhaled anesthetic agents particularly in genetically susceptible IND individuals this syndrome is characterized by hyper metabolic response to specific medications leading to a Cascade of physiological changes the signs and symptoms of malignant hypothermia include muscle spasms and profound muscle rigidity reflecting the hyper metabolic State affecting the skeletal muscles metabolic acidosis and imbalance in the body's acidbase status accompanies the syndrome along with hypercarbia contributing to respiratory acidosis hypothermia a marked increase in body temperature is a critical manifestation of malignant hypothermia this is often accompanied by tacac cardia and teyia reflecting the heightened metabolic Demand on the cardiovascular and respiratory systems myoglobin ARA the presence of myoglobin in the urine is a notable consequence of the breakdown of muscle tissue known as rabdom mysis this can result in renal complications emphasizing the systemic impact of the malignant hypothermia hyperemia an elevated level of potassium in the blood further underscores the potential for severe metabolic derangements neuroleptic malignant syndrome or nms is a potentially fatal reaction that can occur in response to anticho and neuroleptic medications this syndrome is characterized by a spectrum of signs and symptoms resulting from an adverse reaction to certain medications particularly those affecting the central nervous system the Hallmark features of nms include hypothermia marked by a significantly elevated body temperature and profound muscular rigidity reflecting the excessive muscle tone associated with the syndrome autonomic dysfunction reflecting the involuntary nervous system contributes to the clinical presentation of nms leading to disturbances in blood pressure heart rate and other autonomic functions metabolic acidosis is a physiological consequence of the syndrome confusion is a cognitive manifestation of in Ms highlighting the impact on mental status in neurologic functioning in severe cases nms can lead to complications such as renal failure emphasizing the systemic repercussions of the syndrome respiratory failure May ensue due to the profound muscular rigidity affecting the respiratory muscles further complicating the clinical course arrhythmias and cardiovascular collapse are severe cardiovascular manifestations that can result in life-threatening consequences serotonin syndrome is an unusual and potentially serious response to medications that alter serotonin levels resulting in hyper serotonergic symptoms this syndrome can occur due to an overdose of Serotonin altering medications or when these medications are combined among the commonly suspected drugs are selective serotonin reuptake Inhibitors or ssris such as proac zolof and paxel other implicated medications include diol monoamine oxidus Inhibitors amphetamines tricyclic antidepressants serotonin and nor epinephrine reuptake Inhibitors as well as lithium the signs and symptoms of serotonin syndrome cover a broad range of neurological and systemic manifestations patients may present with irritability muscle rigidity clonus and myoclonus hypothermia and diaphoresis contribute to the systemic effects of Serotonin excess headaches seizures and in severe cases coma can occur reflecting the impact of Serotonin on the CNS cardiovascular manifestations include tacac cardia hallucinations further highlight the neuros psychiatric aspects of serotonin syndrome the diverse array of signs and symptoms underscores the complexity of ser and toxicity as well as a need for a systematic approach to its recognition and",
        "Gastric Decontamination": "management gastric decontamination gastric decontamination is a medical procedure aimed at reducing the absorption of toxic substances in the stomach orogastric lavage a technique involving the irrigation of the stomach is not typically performed in the transport setting but may be considered for patients who present to a treatment facility within one hour of a life-threatening ingestion the indications for orogastric lavage include highly toxic ingestions where the toxic substance is likely to remain unabsorbed in the stomach substances poorly absorbed by activated charcoal in situations where there is no effective antidote or treatment therapy available despite its potential benefits orogastric lavage has several disadvantages it is a timeconsuming and invasive procedure often requiring the cooperation of awake and alert patients the amount of pills or fragments that can be removed through lavage is limited sedative medications administered for patient cooperation pose a risk of aspiration espe especially if the patient is not fully conscious additionally there is a concern that orogastric lavage May Propel substances further into the digestive tract limiting the effectiveness of other decontamination treatments several contraindications and Associated risks must be carefully considered when contemplating gastric decontamination procedures such as orogastric lavage minimally toxic ingestions may not justify the invasiveness of the procedure and in cases where a significant amount of time has elapsed since ingestion absorption of the toxic substance may have already occurred making lavage less effective the presence of a highly effective antidote for the ingested substance may also negate the need for lavage additionally if the patient is unable to protect their Airway during the procedure the risk of aspiration becomes too significant of a concern making lavage contraindicated the risks associated with orogastric lavage include the potential for aspiration which can lead to Serious respiratory complications there is also a risk of injury to the airway stomach or esophagus during the insertion or manipulation of the lavage tube these risks highlight the importance of carefully evaluating the appropriateness of orogastric lavage on a case-by casee basis it's worth noting that highly toxic liquids can be evacuated from the stomach using a common orogastric or nasogastric tube providing an alternative method for gastric decontamination however the decision to proceed with any decontamination procedure should be guided by a thorough assessment of the patient's condition the nature of the ingested substance and the potential risks and benefits associated with the intervention emesis induced by syrup of epicac once a routine treatment for toxic ingestions is now rarely administered due to concerns about its efficacy and potential comp applications there are specific contraindications that guide the decision-making process regarding the use of syrup of epicac patients who are sedated or obtunded meaning they are in a state of reduced Consciousness or awareness are considered contraindications for emesis induction using syrup of epicac additionally patients with a history of seizure activity or those who have ingested any medication capable of inducing CNS depression or seizures are not suitable candidates for this procedure substances such as hydrocarbons or corrosive agents further contraindicate the use of syrup of epicac the rationale Behind These contraindications lies in the potential risks associated with emesis induction sedated or obtunded patients may not have the protective are reflexes necessary to prevent aspiration during vomiting individuals with the history of seizure activity may be at an increased risk of further seizures triggered by the emetic effects of syrup of epicac ingestions of substances that can depress the CNS or cause seizures could exacerbate these effects making emesis induction inappropriate as epek has become less common in contemporary toxicology management alternative decontamination methods and supportive care measures are often preferred based on the specific circumstances of the toxic exposure activated charcoal is a versatile agent used in the management of certain toxic ingestions it is typically administered orally or through a nasogastric or orogastric tube activated charcoal operates through gut dialysis demonstrating the ability to absorb and remove specific toxic substances from the GI tract the use of activated charcoal is particularly beneficial in reducing the available quantity of certain medications in cases of purely intravenous overdose medications such as theophine fonin carbom menene ciliates and dexin can be effectively targeted by activated charcoal limiting their absorption and distribution within the body administration of activated charcoal is commonly in the form of a single dose for routine ingestions while repeated doses may be considered for severe exposures the indications include the ingestion of a harmful amount of a substance known to be absorbed by activated charcoal within a specific time frame additionally it is employed in cases of unknown substance ingestion or when there is a presumption of toxic ingestions in high-risk patients the mechanism of action of activated charcoal lies in its ability to bind toxins in the GI tract preventing or reducing their absorption into the bloodstream this makes charcoal a valuable adjunct in the early management of certain poisonings Critical Care transport professionals should be familiar with the indications and considerations surrounding the use of charcoal to optimize its Effectiveness in toxicologic emergencies activated charcoal despite its utility in certain toxicologic scenarios is contraindicated in specific situations where its use may be inap appropriate or even harmful sedated patients with unprotected Airways represent a contra indication as the risk of aspiration during Administration May outweigh its potential benefits ensuring that the patient has a protected Airway is essential to prevent complications patients who have ingested CTIC substances which can cause severe damage to the GI tract are also considered contra indications for charcoal the presence of CTIC substances May exacerbate tissue damage during the administration hydrocarbon ingestions present another contraindication as these substances are not well absorbed hydrocarbons such as those found in petroleum based products may lead to complications such as aspiration pneumonia if activated charcoal is administered substances that are poorly absorbed include lithium iron certain heavy metals hydrocarbons and alcohols The Limited efficacy of activated charcoal in binding these substances makes its use less beneficial in cases of ingestion whole bowel irrigation or wbi is a therapeutic approach to toxicology that involves the ingestion or feeding of large quantities of non-absorbable electrolyte balanced liquid this process is designed to propel stomach and intestinal contents through the digestive system facilitating the removal of ingested substances wbi is employed in specific clinical scenarios where its benefits outweigh potential risks primary indications include the significant ingestion of substances that are not well absorbed by activated charcoal such as iron and heavy metals and substances with delay absorption in cases where charcoal is not as effective due to the nature of the ingested substance wbi becomes a valuable alternative for enhanced GI decontamination furthermore it can be utilized in conjunction with activated charcoal in certain situations for instance patients who have ingested large quantities of sustained release or anic coated medications May benefit from the combined use of wbi and activated charcoal this is particularly relevant in cases where the sustained release properties of medications May prolong absorption and increase the risk of toxicity additionally this method is indicated in the management of individuals involving body stuffing or body packing activities where individuals ingest or insert drugs or other substances into their bodies in such cases wbi AIDS in the removal of ingested packets or substances from the GI tract enhanced elimination is a therapeutic strategy that involves replacing or augmenting the body's normal mechanisms for eliminating modifying or breaking down toxic substances this approach is considered in cases where the ordinary route of elimination from the body is impaired by overdose or other pathological conditions additionally enhanced elimination may be indicated if the patient cannot tolerate the adverse effects of poisoning due to pre-existing medical conditions this method is particularly effective against substances that are heavily concentrated in Blood and extracellular fluids however its success is limited in the case of protein bound medications various options exist for enhancing elimination and the choice depends on the specific characteristic of the toxic substance involved multiple dose activated charcoal is one option particularly for substances that undergo in pipa circulation urinary manipulation is another strategy where alization of urinary pH promotes increased excretion of weak acids several modes of dialysis can also be employed for enhanced elimination including perianal hemo hemo profusion and continual renal replacement therapy",
        "Specific Toxicologic Emergencies": "dialysis however it is important to note that these therapies generally need to be discontinued during transport as they require specialized equipment and continuous monitoring which simply is not feasible in a transport setting specific toxicologic emergencies acetam Menan the most frequently overdosed drug poses a challenge due to delayed symptom onset often often complicating timely administration of the antidote acetal cysteine untreated acetominophen toxicity can lead to severe consequences such as liver failure transplantation or even death diagnosis relies on patient history but once toxicity is established future acetaminophen levels do not guide clinical management early signs include nausea vomiting anorexia and dehydration while late symptoms include abdominal pain liver function test elevation hepatomegaly and coagulopathy prolonged exposure may lead to symptom resolution or multiple organ failure in transport management focusing on ABCs using activated charcoal for gastrointestinal decontamination and administering acetylcysteine are key interventions for optimal outcomes in acetamin poisoning amphetamines are both therapeutic medications and elicit stimulants each with distinct implications for overdose therapeutically medications like Concerta adol and dexadrin are used for conditions like ADHD illicit stimulants include MDMA and meth amphetamine commonly abused for their euphoric effects amphetamine overdose is marked by a spectrum of symptoms including hypertension tacac cardia hyperactivity restlessness anxiety diaphoresis Tremors fasiculations rabdom myolysis seizures organ esema and cerebral hemorrhage the stimulant wash out syndrome commonly known as a meth crash follows prolonged amphetamine use where amine stores become depleted this phase is characterized by excessive sleep increased hunger and depression treatment for amphetamine overdose involves managing symptoms and complications benzodiazapines which possess sedative properties and anti-convulsant effects are often employed to mitigate hyperactivity seizures and anxiety associated with amphetamine toxicity additionally phenobarbitol a barbituate with sedative and anti-epileptic properties may be utilized in the treatment regimen benzodiazapines include examples such as Valium Versed and Adavan these drugs are commonly employed for various medical purposes serving as anxiolytics sedatives muscle relaxants and anti-convulsants while benzo aines are generally considered safe when used therapeutically toxicity can occur due to therapeutic errors accidental or intentional ingestion as well as illicit misuse and abuse although death from benzo overdose is rare sedation and respiratory depression May persist for an extended duration posing a challenge in managing affected individuals toxicity is exacerbated when these medications are combined with ethanol opioids or other sedative agents the toxic effects May manifest as hypothermia a taxia and slurred speech notably drug screens for benzodiazapines have limitations as Adavan clopen Xanax and roipnol are not detectable in urine treatment of benzo overdose involves supportive measures with activated charcoal being an option although it is contraindicated individuals with a decreased level of Consciousness rason a selective antagonist of Bodines can be administered in certain situations to reverse the effects however its use in and of itself may lead to an increase seizure activity warranting careful consideration in the treatment approach beta adrenergic blocking agents including drugs like atino la propranol la and moper law manage various cardiovascular conditions by inhibiting the effects of catacol amines particularly norepinephrine and epinephrine however overdose with these medications can result in a spect of symptoms reflecting the pharmacological actions of beta blockers common manifestations of Overdose include hypotension bradicardia hypoglycemia bronchospasm pulmonary edema conduction disturbances tacac cardia mental status depression and seizures the severity of these symptoms depends on factors such as the specific beta blocker involved the dose ingested and individual patient characteristics in the management of an overdose various therapeutic interventions are considered gastric levage may be performed for recent incidents to remove the ingested medication from the stomach activated charcoal is utilized to limit further absorption of the beta blocker in certain cases dialysis may be employed for enhanced elimination glucagon is administered to counteract the cardiovascular effects of beta blockers particularly in cases of severe braac cardia or hypotension calcium channel antagonists known as calcium channel blockers are medications commonly employed in the treatment of hypertension migraines and cardiomyopathy examples of these drugs include lopine cism and Kalen the management of calcium channel blocker overdose is Complicated by the widespread availability of sustained release preparations and any medication beyond the therapeutic dose is considered potentially toxic overdose with the calcium channel antagonist can lead to a range of symptoms reflecting their pharmacological effects these symptoms include hypo attension bradicardia nausea and vomiting metabolic acidosis and hypoglycemia the severity of these manifestations depends on the specific calcium channel blocker involved and the amount ingested in the treatment of calcium channel antagonist overdose several interventions are considered activated charcoal is administered to limit further absorption of the drug and gastric lavage may be employed in certain situations whole bowel irrigation can be considered particularly for sustained release preparation intravenous calcium salts are administered to counteract the calcium channel blocking effects Additionally the use of substances like glucagon and catacol amines may be necessary to support cardiovascular function and mitigate the toxic effects of calcium channel blocker overdose cardiac glycosides are medications utilized for heart rate control treatment of supraventricular arrhythmias and to enhance contractility and heart failure these compounds are naturally occurring and can be found in plants such as Fox Glove Oleander and Lily of the Valley in cases of Overdose severe hyperemia arrhythmias and Ral disease serve as indications for the administration of the antito digifab symptoms of Overdose include nausea and vomiting abdominal pain braic cardia and conduction disturbances additionally hyperemia can occur leading to potential lethargy confusion and weakness the severity of symptoms depends on the specific cardiac glycoside involved the dose ingested and IND individual patient factors management focuses on addressing the toxic effects and supporting cardiac function cocaine is a potent stimulant that is rapidly absorbed by all mucous membranes individuals involved in the illicit handling of cocaine May resort to concealing it internally either by smuggling it or hastily hiding it when a rest is imminent cocaine overdose presents with a spectrum of signs and symptoms including chest pain tacac cardias cerebral hemorrhage or infarction coma anxiety agitation delirium psychosis seizures hypothermia muscle rigidity movement disorders rabdom myolysis acidosis pulmonary edema exacerbation of asthma and skin alter ations the cocaine wash out syndrome is characterized by profound exhaustion due to the depletion of neurotransmitters with affected individuals regaining normal mental status and orientation when aroused in the treatment of cocaine overdose activated charcoal is administered to limit further absorption of the drug and whole bowel irrigation may be considered in certain situations however there is no specific antidote for cocaine toxicity the management of cocaine related complications focuses on supportive measures and addressing specific symptoms given the diverse range of effects associated with cocaine overdose a comprehensive approach is essential to stabilize Vital Signs manage complications and provide appropriate care to affected individuals opioids and opiates widely used for analgesia are also substances frequently abused globally the diagnosis of Overdose is established base on the patient's clinical presentation and is confirmed when symptoms are reversed by an opioid antagonist such as noxin signs and symptoms of opioid overdose include profound CNS and respiratory depression pinpoint pupils Euphoria non-cardiogenic pulmonary edema dermatologic signs of needle marks are subcutaneous ulcerations parius bardia and hypotension the primary focus in the treatment of opioid overdose is on managing the airway breathing and circulation Naran an opioid receptor antagonist is administered to rapidly reverse the opioid induced respiratory depression and other CNS effects activated charcoal may be administered if needed to limit further absorption of the opioid remember the goal is to stabilize the patient's Vital Signs and counteract the life-threatening effects of opioid toxicity through prompt and appropriate interventions which may or may not mean the patient gets Narcan selective serotonin reuptake Inhibitors or ssris such as proac paxel and zolof along with non-cyclic anti-depressants exhibit limited toxicity but severe exposures can lead to seizures serotonin syndrome cardiovascular alterations and potentially fatal outcomes signs and symptoms of Overdose include sedation Axia dizziness coma nausea vomiting diarrhea headache restlessness shivering diaphoresis hypotension QTC prolongation sinus tachicardia muscle rigidity trimmers hyper reflexia and seizures in the management of ssris and non-cyclic antidepres toxicity the primary focus is on the ABCs charcoal may be administered if needed to limit further absorption of the drugs and volume resuscitation is employed to address potential hyp attention IV benzodiazapines are utilized to manage symptoms such as seizures and muscle rigidity contributing to the overall stabilization of the patient toxic alcohols including ethylene glycol and methanol are commonly available substances that may be ingested accidentally due to mislabeling or improper storage in beverage containers with children being particularly attracted to their taste individuals with alcoholism may also consume these substances while seeking an ethanol substitute even small quantities of ethylene glycol or methanol ingestion can lead to profound and potentially lethal metabolic acidosis signs and symptoms of ethylene glycol toxicity include Ataxia slurred speech lethargy nausea vomit in seizures cerebral edema hyperventilation pulmonary edema renal failure and cardiac arrhythmias methanol toxicity presents with similar neurological symptoms gastritis nausea vomiting visual disturbances hypotension seizures respiratory arrest and coma the primary treatment approach involves managing the Airway breathing and circulation ethanol and antisol are administered as antidotes to inhibit metabolism of toxic alcohols preventing the formation of toxic byproducts enhanced elimination through hemodialysis may be employed to further reduce the concentration of toxic substances in the body tricyclic antidepressants prescribed as last resort medications for chronic pain neuropathy and migraines can lead to toxicity either through accidental ingestion or intentional self harm any overdose is considered life-threatening the manifestations of TCA toxicity are dry mouth and skin dilated pupils seizures delirium agitation hallucinations rabdom miysis muscle Tremors hypothermia sinus tachicardia QRS widening indicating conduction disturbances ventricular arrhythmias and hypotension treatment strategies involve addressing the airway breathing and circulation followed by gastric levage and the administration of activated charcoal aggressive supported treatment is essential in managing TCA overdose considering the potential severe cardiovascular and neurological complications associated with toxicity acetycholine estras inhibitor toxicity which includes exposure to substances like Organo phosphates carbamates and chemical warfare nerve agents POS a significant risk due to its interference with the cetto choline estras enzyme this enzyme blockade leads to the accumulation of a cocoline an essential neurotransmitter causing excessive stimulation of very various receptors nicotinic receptors when overactivated produce symptoms such as tacac cardia hypertension fasiculations weakness paralysis and dilated pupils muscarinic receptor stimulation results in distinct syndromes like sludge and dumbbells manifesting as a range of symptoms including bronchospasm diaphoresis and gastrointestinal disturbances severe exposures to acetycholine estras Inhibitors May extend to the CNS causing altered mental status agitation coma and even seizure activity rapid and effective decontamination measures minimize harm this involves thorough washing with soap and water using a diluted sodium hydrochlorate solution and removing contaminated clothing additionally treatment strategies are essential to counteract the toxic effects gastric lavage is employed to remove ingested toxins and activated charcoal Administration helps to prevent further absorption the use of specific antidotes such as atropine and tpam can mitigate the toxic effects of acetycholine estron Inhibitors Prov providing targeted relief to affected individuals blistering agents a category of chemical warfare and terrorist agents induce the formation of blisters and severe tissue damage particularly on the skin and exposed areas such as the eyes inhalation of these agents can lead to Airway and Pulmonary damage effective decontamination measures involve the use of soap and water to mitigate the harmful effects pulmonary agents including chlorine elicit immediate pulmonary irritation and may cause acute or delayed pulmonary edema fos Gene and defos genene although less irritating pose a delayed onset risk of pulmonary edema typically ranging from 2 to 48 hours after exposure incapacitating agents often aerosolized are strategically designed to temporarily hinder individuals from normal functioning emphasizing the need for vigilance and preparedness and addressing diverse chemical threats carbon monoxide toxicity arises from various sources including Motor Vehicles small gasoline engines stoves lanterns burning charcoal and wood gas ranges heating systems enclosed spaces in industrial settings and intentional exposure victims of fires in enclosed spaces are particularly susceptible warranting suspicion of Co poisoning the symptoms of Co toxicity vary in severity mild toxicity manifests as Headache nausea vomiting abdominal pain and dizziness moderate toxicity leads to confusion trouble breathing a taxia teoc cardia and chest pain while severe toxicity is characterized by seizure activity coma Syncopy cardiac arrhythmias hypotension and myocardial esea additionally delayed neurologic signs and symptoms May manifest in up to 20% of coop poison patients effective treatment involves promptly removing patients from the toxic environment Hyperbaric therapy which exposes patients to highpressure oxygen is a critical intervention to enhance Co elimination ABCs should be diligently managed to ensure the patient overall stability caustics and corrosives pose a threat to individuals through occupational or industrial exposure as well as encounters with household chemicals exposure can transpire via inhalation ingestion or dermal and ocular contact potentially leading to systemic toxicity through any of these routes the nature of the injury caused by these substances depends on their acidity or alkalinity acidic substances induce coagulation necrosis limiting the depth and extent of tissue damage while alkalized substances result in liquidation necrosis allowing for more profound tissue penetration to address exposures material safety data sheets provide essential information about chemicals offering guidance on treatments decontamination procedures and recommended personal protective equipment for Rescuers inhalation exposure necessitates immediate transfer to fresh air and symptomatic patients may require inter ventions such as supplemental oxygen Broncho dilator medications humidified oxygen or air or even assisted ventilation in cases of ingestion causitive agents have potential to cause severe injury and the recommended treatment involves providing the patient with milk or water to drink importantly inducing vomiting or attempting neutralization is contraindicated emphasizing the need for cautious and specific specific management strategies for each type of exposure exposure to chlorine ammonia and asfixiate gases can occur in scenarios involving hazardous material releases or unsafe storage practices the toxicity associated with these gases is variable and depends on factors such as the specific gas its concentration the duration of exposure and the pre existing health conditions of affected individuals clinical manifestations of exposure include lacrimation coughing drooling Airway discomfort swelling and irritation as well as labored Rapid or absent breathing wheezing and the potential development of pulmonary edema the treatment approach for individuals exposed to these gases in involves addressing respiratory symptoms and providing supportive care measures such as supplemental oxygen bronchodilator medications and humidified oxygen are implemented to alleviate Airway distress and facilitate adequate breathing in cases of severe respiratory compromise assisted ventilation may be necessary to ensure proper oxygenation the management strategy underscores the importance of tailored interventions based on the specific characteristics of each gas and the unique clinical presentation of affected individuals cyanide extensively utilized in industrial laboratory and Manufacturing settings as well as in chemical warfare agents poses a significant threat due to its potential exposure during combustion of synthetic materials like wood and Plastics the risk of cyanide toxicity it should be considered in individuals exposed to smoke inhalation highlighting the importance of recognizing and managing this life-threatening condition cyanide exposure can occur through multiple routes including inhalation ingestion and transdermal absorption necessitating the adoption of protective measures by Rescuers such as wearing appropriate suits and self-contained breathing apparatus during extrication operations symptoms of cyanide toxicity Encompass the spectrum of manifestations including dizziness weakness headache air hunger and the development of acidosis notably there is no decrease in pulse o symmetry or partial pressure of oxygen underscoring the complexity of C poisoning hyperventilation and respiratory depression further contribute to the clinical picture to address cyanide exposure Rescuers employ skin decontamination ensuring proper decontamination procedures and prioritize ABC's impatient management the cyano kit serves as an antidote in treating cyanide toxicity healthcare workers engaged in patient care must adhere to strict personal protective equipment protocols emphasizing the need for preventative meas measures additionally commercially available cyanide antidote kits play a pivotal role in emergency preparedness and response hydrocarbons compounds consisting solely of hydrogen and carbon find extensive use across various sectors of society their toxicity is most commonly encountered through oral ingestion often as a result of accidental or intentional exposure hydrocarbon poisoning can manifest with a range of symptoms including cough shortness of breath wheezing and hypoxia CNS depression is a notable complication and exposure through dermal or ocular routes may cause local irritation Burns or corneal injury when hydrocarbons are introduced to the lungs individuals may experience dizziness drowsiness slurred speech and an unsteady gate reflecting the systemic impact of these substances in managing hydrocarbon toxicity the approach is mainly supportive treatment strategies focus on addressing respiratory symptoms including the administration of oxygen Bronco dilators and steroids to alleviate Bronco constriction intubation becomes necessary in cases of severe hypox and CNS depression aiming to secure the airway and ensure adequate oxygenation and profusion given the varied sources and potential for exposure providers must be vigilant in recognizing and managing hydrocarbon poisoning tailoring interventions to the specific clinical presentation and severity of symptoms hydropic acid known for its corrosive properties can indu produce rapid onset of symptoms in highly concentrated formulations while symptoms from lower prolonged exposures May manifest several days later the symptoms associated to exposure are diverse and can include vomiting abdominal pain gastritis and a Severe throbbing pain at the site of exposure tissue damage may present late adding to the complexity of the clinical picture moreover exposure is often associated with hypocalcemia which can be severe along with hypom magnesia and hyperemia treatment for exposure involves the administration of a calcium or magnesium containing substance to counteract the effects of the acid it's important to note that calcium chloride should not be used for subcutaneous or intraarterial Administration due to its potential for tissue necrosis the therapeutic approach aims to address the systemic effects of hydrofluoric acid exposure particularly the electrolyte imbalances induced by its corrosive actions providers need to be aware of the potential delayed onset of symptoms and the specificities of managing hydrofluoric acid exposure to ensure effective in timely",
        "Flight Considerations": "intervention flight considerations in the context of managing hazardous material exposures several critical considerations must be addressed when contemplating patient transport via air Medical Services firstly patients should not be placed in transport Vehicles until initial decontamination has been completed this underscores the importance of ensuring that individuals exposed to hazardous materials undergo decontamination procedures before being transported minimizing the risk of further decontamination during Transit secondly helicopters and airplanes commonly employed for air Medical Transport necessitate safe places to land which may not always be readily available on short notice this logistical challenge highlights the need for strategic planning and coordination to identify suitable landing locations ensuring a smooth and efficient transfer of patients to and from Airborne Medical Transport air medical Crews face unique safety concerns particularly the risk of encountering patients or family members exhibiting bizarre aggressive combative or even violent Behavior to address this challenge it's essential to implement thorough screening processes for both patients and their families additionally sedation and restraints may be employed as needed to ensure the safety of air medical Crews and maintain a secure environment during flight operations lastly air medical Crews must be well prepared to anticipate and manage changes that may arise during flight this involves having the necessary equipment medications and train Personnel on board to address any unforeseen medical complications or alterations in the patient's condition"
    },
    {
        "Introduction": "chapter 19 environmental emergencies introduction environmental emergencies Encompass Medical conditions precipitated or exacerbated by meteorological elements geographical features or distinctive atmospheric circumstances these conditions are not confined to specific locals and can manifest anywhere necessitating vigilance by Healthcare Providers across diverse regions among these profession professionals Critical Care transport paramedics play a pivotal role frequently engaging with individuals afflicted by environmental emergencies during the critical care transport process between Health Care Facilities these providers are Adept at managing the complexities associated with such cases ensuring timely and appropriate medical interventions while transitioning patients to higher levels of care their expertise and preparedness are instrumental in optimizing patient outcomes when confronted with environmental challenges during inner facility",
        "Physiology of Environmental Emergencies": "transfers physiology of environmental emergencies environmental emergencies entail a range of risk factors that can significantly impact individuals susceptibility and response to these conditions age stands as is a prominent determinant with both the very young and the elderly exhibiting the highest vulnerability in Pediatrics immature Thermo regulatory mechanisms and limited ability to communicate distress pose particular challenges in contrast the elderly often face diminished Thermo regulatory capacity and reduced awareness of environmental stressors due to age related physiological changes medications repres present another risk factor some drugs can disrupt Thermo regulation alter fluid balance or impair an individual's ability to perceive temperature changes this can include medications like anticholinergics diuretics or beta blockers which can exacerbate susceptibility to environmental emergencies pre-existing medical conditions further Elevate risk with specific diseases amplifying the likelihood of environmental related medic iCal crisis conditions such as diabetes cardiovascular disease restrictive lung disease thyroid disorders and psychiatric illnesses heightened susceptibility individuals with diabetes may experience impaired glycemic control in extreme temperatures while cardiovascular disease can hinder adequate circulation and Thermo regulation restrictive lung diseases reduce respiratory Reserve limiting the capacity to compensate for environmental stressors and thyroid disease can disrupt metabolic functions required for temperature regulation psychiatric illnesses may lead to impaired decision-making and self-care in challenging environmental conditions posing additional risk thermoregulation is an integral aspect of the body's homeostatic process ensuring the maint maintenance of a stable internal temperature which is essential for optimal physiological function this intricate system includes both heat production known as thermogenesis and heat elimination known as thermalsis collectively these are aimed at preserving the body's core temperature which is typically around 98.6 the hypothal hypophysial portal system a vital component of thermal regulation orchestrates this intricate process the hypothalamus a critical region within the brain continuously monitors Core Body temp it communicates with the pituitary gland also known as the hypothesis via this portal system sending stimulating or inhibiting factors that regulate various physiological processes this Dynamic interaction between the hyp hypothalamus in the pituitary gland is termed the hypothalamic pituitary axis the hypothalamus serves as the body's Master thermostat through a sophisticated negative feedback control system when the core body temperature rises the hypothalamus responds by signaling Pathways to reduce thermogenesis and enhance thermalis effectively cooling the body conversely a Dro in core body temperature prompts the hypothalamus to initiate heat production and limit heat elimination mechanisms thereby warming the body when the core body temperature rises due to environmental factors or internal processes the hypothalamus promptly activates signaling Pathways to counteract this increase it accomplishes this by orchestrating a reduction in thermogenesis while concurrently enhancing thermal is these coordinated responses effectively act as a cooling mechanism helping to restore the body's temperature to a desired Point conversely when the core body temperature experiences a decline as can happen in colder environments or during periods of reduced metabolic activity the hypothalamus swiftly adjusts its directives it stimulates heat production mechanisms primarily through shivering and increased metabolic activity to generate warmth concurrently it limits heat elimination Pathways ensuring that less heat is lost to the external environment this synchronized effort serves to raise the core body temperature helping to bring it back within the narrow range necessary for optimal physiological function the effectiveness of the hypothalmus driven negative feedback system in maintaining temperature homeostasis relies heavily on on a collaborative network of complimentary detectors one component of this network is the cold sensors strategically positioned in various locations such as the skin spinal cord and other areas sensitive to the lower end of the temperature Spectrum these sensors detect temperature deviations primarily excess cooling when these cold sensors identify a drop in temperature they initiate a response by trans mitting neural Action potentials to the hypothalamus these action potentials serve as signals to the hypothalamus prompting it to Halt the previously active heat reducing mechanisms that may be contributing to the cooling of the body the negative feedback system which is integral to Thermo regulation includes three major components firstly temperature receptors like the cold sensors mentioned above serve as the ini initial Detectors of temperature fluctuations these receptors are distributed throughout the body ensuring comprehensive coverage and timely detection of temperature changes secondly affector organ systems are responsible for executing the directives issued by the hypothalamus in response to temperature variations these effectors include mechanisms like sweat production shivering and peripheral vasocon rtion or vasod dilation which collectively influence heat generation or dissipation lastly the integrator or controller represented by the hypothalamus serves as the central processing unit of the feedback system it receives input from temperature receptors processes this information and subsequently orchestrates the appropriate responses via the affector organ systems ultimately striving to maintain the body's core temperature temperature within the narrow range that's conducive to normal physiological function temperature receptors key components of the body's Thermo regulatory system are predominantly located within the papillary layer of the dermis the uppermost layer of the skin these receptors are strategically distributed throughout the body and come into two primary types areas of nerves or spots that respond to hot or cold stimuli interestingly the body has a higher abundance of cold sensitive receptors or cold spots compared to those sensitive to heat this distribution aligns with the body's priorization of heat conservation as a survival strategy in response to elevated environmental temperatures or internal heat production the body activates a heat response mechanism to prevent overheating this includes the dilation of blood vessels in the skin particularly the cutaneous Vaso dilation by doing so the body enhances the transfer of heat from the core to the skin surface promoting heat dissipation through radiation and conduction concurrently the body increases perspiration production a process known as diaphoresis to Aid in cooling this can result in up to 10 times the normal rate of perspiration in contrast during periods of excessive cold exposure or when the core body temperature decreases the heat response mechanisms are inhibited muscle activity including shivering is one of the means by which the body generates heat but this response is intentionally subdued to conserve energy and prevent further heat loss when the posterior hypothalamus is stimulated due to a drop in core body temperature it initiates a series of adaptive responses aimed at conserving heat and maintaining thermal equilibrium one key component of this response is the constriction of blood vessels this action reduces blood flow to the Skin's peripheral vessels minimizing heat loss through radiation and conduction by narrowing the vessels the body effectively redirects warm blood away from the skin surface preserving it for Vital internal organs in tandem with phas of constriction the hypothalmic stimulation also results in an increase in muscle activity shivering is a mechanical response that generates heat through Rapid involuntary muscle contractions these contractions demand energy primarily derived from metabolic processes which in turn produces heat as a byproduct Additionally the hypothalmic stimulation during the cold response affects the pyo erector muscles within the skin these tiny muscles contract under the influence of the hypothalamus causing the phenomenon commonly known as Goosebumps when these muscles contract they cause the individual hairs on the skin to stand erect this response often seen in animals as well is an evolutionary Relic that helps trap the layer of air near the skin surface acting as an insulation to minimize heat loss while Goosebumps may not provide substantial insulation in humans due to their limited body hair the response remains an integral part of the cold response mechanism the basil metabolic rate or BMR assists the body's therm regulatory processes particularly when an individual is at rest during periods of rest the primary source of heat production stems from the metabolic processes involved in breaking down and utilizing nutrients BMR is a quantitative measure that quantifies the number of calories metabolized per square inch of body surface area per hour reflecting the minimal energy requirement for an individual to maintain physiological functions while remaining at rest throughout the day for an average adult weighing 154 lbs the typical BMR Falls within the range of 60 to 70 kilo calories per hour this estimate provides a baseline understanding of the minimum energy expenditure required to sustain basic bodily functions such as respiration circulation and cellular metabolism without any additional physical activity it is noteworthy that the ratio of body surface area to body volume has a significant impact on heat loss as this ratio increases the capacity for heat loss Also Rises in Practical terms this means that individuals with a larger surface area relative to their body volume are more suscep a to heat loss for example in a comparison between two individuals of the same weight the shorter person will typically lose heat faster due to their relatively higher surface to area volume ratio this concept is particularly relevant in Pediatrics where children tend to have a high surface area to body volume ratio due to their smaller stature pediatric patients May therefore experience rapid heat loss in C cold environments or during periods of temperature disregulation underscoring the importance of vigilant monitoring and appropriate Thermo regulation interventions in this patient population heat transfer is a fundamental physiological process for maintaining the body's core temperature within a narrow and optimal range the heat generated by metabolism and the breakdown of glycogen warms the body and preserves core body temperature however it is important to eliminate excess heat to prevent overheating there are six primary mechanisms through which heat is transferred from the body to the surrounding environment radiation is one of these mechanisms characterized by the emission of heat in the form of electromagnetic waves this continuous process involves the body radiating Heat heat primarily from its surface into the cooler surrounding environment radiation is responsible for the warmth felt when standing near a heat Source such as a fire or warm Radiator in colder conditions the body May radiate more heat to maintain core temperature conduction is another heat transfer mechanism occurring when the body comes into direct contact with a cooler object or Surface heat is cond Ed away from the body when it touches a cold chair or an icy surface this process can lead to the sensation of cold when a person touches cold objects as heat energy is transferred to the cooler material convection involves the loss of heat through the movement of air or water currents over the body surface when air or water passes over the skin it carries away heat facilitating temperature regulation an example of convection is the cooling effect felt when a breeze blows over the skin or when an individual is immersed in cold water with the moving water carrying heat away from the body evaporation plays a significant role in heat loss especially in hot and dry conditions as the body produces sweat to dissipate excess heat the sweat evaporates from the skin surface taking heat energy with it this cooling mechanism helps prevent overheating during periods of increased physical activity or exposure to high temperatures respiration is another means by which heat loss occurs during breathing warm air from the lungs is exhaled into the atmosphere where it may be cooler than the body's core temperature conversely when cooler air is inh aled it can contribute to temperature regulation this process is particularly evident in cold environments where the temperature difference between inhaled and exhaled air is more pronounced absorption is the final heat transfer mechanism occurring when the surrounding environment is warmer than the body in such instances the body gains heat from the environment assisting in temperature maintenance absorbs is less commonly observed but it does play a role in certain situations where the environment's temperature exceeds that of the body these six mechanisms work in tandem to enable the body to adapt to a wide range of environmental conditions and maintain thermal equilibrium proper functioning of these mechanisms is essential for preserving physiological processes and overall well-being especially especially in situations where the body faces temperature fluctuations or environmental challenges anticipating and effectively managing temperature related emergencies is a fundamental aspect of critical care transport as individuals can encounter such emergencies in any environmental setting providers are well aware that a patient's ability to self-regulate their temperature may become compromised due to various medical conditions exposure to extreme environmental conditions or other factors as a result it's imperative for critical care transport providers to remain Vigilant and proactive in addressing these challenges during patient transport in cases of hypothermia where the body loses heat faster than it can generate providers must take steps to maintain the patient's warmth this may involve providing additional layers of insulation such as blankets or heated blankets and ensuring that the patient is adequately covered to minimize heat loss through radiation and convection providers should monitor the patient core temperature closely and initiate active rewarming techniques when necessary which may include the use of warming devices or heated intravenous fluids conversely in situations where the patient is at risk of overheating providers must Implement strategy to prevent hypothermia this can be particularly relevant in hot and humid environments or when the patient is experiencing a febr illness measures such as ensuring proper ventilation providing cooling measures like fans or cooling blankets and monitoring the patient's Vital Signs and temperature Trends mitigate the risk of",
        "Heat Emergencies": "overheating heat emergencies the escalation of core body temperature due to insufficient thermalis or heat dissipation is a significant Health concern as highlighted by the US Centers for Disease Control and prevention heat related illnesses pose a considerable threat to Public Health and the cdc's data underscores the severity of this issue annually the United States Witnesses a distressing toll of over 700 heat related deaths these fatalities result from the body's inability to adequately manage and dissipate excess Heat leading to hypothermia heat exhaustion or even heat stroke inadequate thermalis can stem from various factors including prolonged exposure to high ambient temperatures high humidity levels and limited access to cooling measures as a result Health Care Providers emergency responders and public health officials play a critical role in raising awareness implementing preventative measures and providing prompt medical intervention to mitigate the risks associated with heat related illnesses and reduce the number of heat related deaths in the United States and Beyond several factors influence how the body responds to heat exposure firstly individuals with pre-existing medical conditions such as cardiovascular diseases respiratory disorders or those with compromised Thermo regulatory mechanisms may be more vulnerable to the adverse effects of heat due to their reduced ability to adapt age is another significant determinant with both the very young and the elderly facing heightened risk pediatric populations May lack fully developed ther regulatory systems making them more susceptible to temperature disregulation conversely aging diminishes the body's therm regulatory capacity impairing the ability to effectively respond to heat stressors and increasing the risk of heat related illnesses in the elderly certain medications can exacerbate susceptibility to heat related conditions medications such as diuretics beta blockers and anti-cholinergic May interfere with Thermo regulation either by affecting fluid balance or inhibiting the body's ability to dissipate heat through sweating the amount of clothing worn by an individual also plays a role as excessive clothing can hinder heat dissipation through evaporation potentially leading to overheating Mobility is a factor that influences heat susceptibility as individuals with limited Mobility may be unable to seek cool cooler environments or just our clothing to regulate temperature effectively finally an individual surroundings are instrumental in heat exposure factors such as the ambient temperature humidity levels and access to shade or cooling resources significantly impact how heat affects the body high temperatures combined with high humidity can limit the body's ability to dissipate heat efficiently through evaporation increasing the risk of heat related illnesses medications can significantly contribute or exacerbate heat related illnesses impacting the body's ability to regulate temperature effectively several classes of drugs have distinct effects on Thermo regulation alcohol and barbituates which are central nervous system presence impair the body's ability to dissipate heat efficiently these substances can lead to diminished awareness of environmental temperature and limit the body's natural responses to heat stress central nervous system depressants including certain sedative medications can induce heat illness or even hypothermia by reducing the body's metabolic rate and impairing its ability to generate heat in response to cold environments on the other end of the spectrum stimulant medications increase thermogenesis enhancing heat production these drugs can lead to elevated Core Body temps especially in individuals exposed to warm environments or engaging in physical exertion sympathomimetic medications Like Cocaine amphetamines and other stimulants may result in hypothermia characterized by excessively high body temperatures these substances stimulate the sympathetic nervous system which can lead to increased heat production and decreased heat dissipation beta blockers calcium channel blockers and diuretics interfere with heat loss mechanisms beta blockers and calcium channel blockers reduce heart rate and may limit blood flow to the skin impacting heat dissipation diuretics by increasing fluid loss through urination reduce the volume of fluid available for evaporative cooling notably impacting the effectiveness of sweating additionally antihistamines tricyclic anti-depressants and anti-cholinergic medications can impair the body's ability to sweat adequately sweating is a vital mechanism for heat dissipation and these drugs can lead to reduced sweating making individual idual more susceptible to heat related illnesses when Thermo regulation mechanisms falter the consequences can be dire with the core body temperature capable of skyrocketing to 106 degrees fah in less than 15 minutes vulnerable populations are at the highest risk of experiencing heat rated illnesses and these groups face specific challenges in thermo regulation older individuals often have reduced Thermo regulatory capacity due to age- related changes in their physiological responses while young children have underdeveloped therm regulatory systems making them more susceptible to temperature disregulation exertional heat stroke a severe Thermo regulatory emergency occurs when individuals engage in physical activity in a warm environment and it is influenced by several key factors the intensity of the ex exercise plays a role as higher levels of exertion generate more metabolic heat placing a greater burden on the body's cooling mechanisms environmental conditions such as high temperatures and humidity levels can exacerbate the risk of heat stroke by limiting the body's ability to dissipate heat effectively clothing and Equipment choices are also critical considerations inadequate clothing choices that limit heat dissipation or excessive gear that impedes air flow and heat transfer can increase the risk of heat stroke finally individual health factors including underlying medical conditions or the use of medications that affect Thermo regulation can further predispose individuals to heat related emergencies exertional heat stroke stands as a prominent and concerting cause of mortality among high school athletes in the United States this condition occurs when individuals engage in strenuous physical activity in hot and humid conditions leading to a dramatic rise in core body temperature high school athletes are at a heightened risk due to their active participation in sports often conducted during the warmer months the combination of intense physical exertion limited heat acclimatization and underdeveloped therm regulatory systems make them part particularly vulnerable exertional heat stroke manifests when the body's Thermo regulatory mechanisms become overwhelmed and The Core Body temp escalates to dangerous levels exceeding 104\u00b0 fah symptoms may include confusion altered mental status nausea vomiting and hot dry skin prompt recognition and immediate intervention are necessary as untreated exertional Heat heat stroke can lead to life-threatening complications including multi-organ dysfunction and CNS damage heat cramps are characterized by involuntary muscle pains typically manifesting in the abdomen or lower extremities these muscle cramps arise primarily due to electrolyte depletion particularly a loss of sodium which occurs as a consequence of profuse sweating during strenuous physical activity in hot environments while heat cramps can affect individuals of any age they most commonly occur in healthy individuals who are overexerting themselves in high temperature settings during vigorous physical exertion in a hot environment the body loses essential electrolytes including sodium through sweating this electrolyte imbalance disrupts normal muscle function leading to painful cramping notably individuals experiencing heat cramps may attempt to alleviate their discomfort by drinking excessive amounts of water in an effort to quench their thirst however this well-intentioned action can inadvertently exacerbate the problem by diluting the remaining sodium levels in the body potentially leading to a condition known as water intoxication or hyponatremia the treatment of he heat cramps typically involves a combination of cooling measures and replenishing lost fluids to address the underlying electrolyte imbalance the following steps help in managing individuals with heat cramps immediate removal from the hot environment prevents further heat stress and minimizes the risk of heat related complications the patient should be relocated to a cooler shaded area in cases where the individual is feeling faint or dizzy placing them in a suine position can help improve blood circulation and alleviate symptoms rehydration is a fundamental aspect of treatment encouraging the patient to drink a salt containing liquid or electrolyte drink replenishes lost sodium and other electrolytes this helps restore the body's electrolyte balance and alleviate muscle cramps in more severe cases where there is significant loss of salts or the presence of hypothermia emergency medical care may be necessary severe hyponatremia can lead to life-threatening complications and hypothermia can escalate into heat exhaustion or heat stroke Critical Care transport professionals should exercise caution when considering the administration of intravenous fluids to correct presumed hyponatremia without a comprehensive patient advice evaluation or laboratory studies administering IV fluids without a thorough understanding of the patient's electrolyte status can potentially worsen the electrolyte imbalance therefore providers need to assess the patient's condition consider their medical history and perform necessary laboratory tests to guide appropriate treatment decisions dilutional hyponatremia often referred to as water intoxication is a medical condition that occurs when the normal balance of sodium in the body is disrupted due to an excessive intake of water sodium is a vital electrolyte for maintaining proper fluid balance and cellular function when an individual consumes an excessive amount of water without an adequate replenishment of sodium the sodium concentration in the body becomes diluted leading to hyponatremia exercise Associated hyponatremia or eah is a specific form of dilutional hyponatremia that is often observed in individuals engaged in sustained physical activity eah is diagnosed when the serum sodium concentration Falls below 135 milles per liter within 24 hours of intense physical exertion this condition is especially prevalent among endurance athletes such as marathon runners and triathletes during extended periods of strenuous exercise individuals may consume large volumes of water to stay hydrated however when sodium losses through sweat are not adequately replaced and excessive water intake continues the sodium concentration in the body decreases resulting in eah the dilution of sodium in the extracellular fluid can lead to neurological symptoms and potentially life-threatening complications as the altered sodium levels disrupt cellular osmotic balance and cause cerebral edema the symptoms of eah when present are generally mild in the early stages and may include weakness dizziness peripheral edema headache lethargy as well as nause and vomiting however a key sign in Hallmark feature is a significant weight gain during the course of the event typically exceeding 6.6 pounds from the start of the activity until its completion this substantial weight gain reflects the excessive retention of water in the body due to the dilutional effect of overhydration and the inadequate replacement of sodium loss through sweat as an athlete consumes excessive amounts of water without concurrent sodium intake during prolonged physical exertion the body attempts to maintain fluid balance by retaining water this water retention leads to peripheral edema causing swelling and may contribute to sensations of weakness and lethargy headaches can result from the cerebral edema caused by the lowered sodium concentration in the extracellular fluid which ALS Alters cellular osmotic balance nausea and vomiting may occur as a result of the body's efforts to eliminate the excess fluid in sodium imbalance the significant weight gain observed in individuals with eah is a critical diagnostic indicator as it signifies the severity of the condition and the degree of dilutional hyponatremia the treatment approach for eah varies depending on the severity of the condition in mild cases the primary goal is to correct the dilutional hyponatremia by restricting the intake of hypotonic fluids and encouraging the consumption of salty oral Solutions this approach helps to normalize the serum sodium levels by reducing water intake and increasing sodium intake thus addressing the underlying electrolyte imbalance mild cases are typically characterized ized by early and relatively mild symptoms such as weakness dizziness and nausea conversely severe cases require more aggressive interventions in these instances IV administration of hypertonic saline or sodium bicarbonate may be necessary to rapidly Elevate serum sodium levels and alleviate potentially a life-threatening symptoms severe cases often manifest with more pronounced neurological symp symptoms such as altered mental status seizures and severe headache one noteworthy aspect is that even a relatively modest increase in serum sodium levels typically in the range of 4 to 6 milles per liter can effectively correct the associated symptoms this highlights the sensitivity of the CNS to changes in serum sodium concentration and underscores the importance of carefully tit treated treatments to avoid overshooting the sodium Target levels heat Syncopy a transient loss of consciousness or near collapse is a common occurrence among individuals who are not acclimatized to high temperatures or prolonged heat exposure this condition typically occurs in non-acclimatized persons often in crowded outdoor settings where people are standing for exterior periods such as outdoor events parades or Gatherings heat Syncopy is primarily attributed to the body's response to heat stress which can result in a sudden drop in blood pressure and reduced cerebral profusion leading to fainting or near fainting episodes the initial steps in treating individuals experiencing heat Syncopy involve immediate intervention to alleviate symptoms and minimize potential complications healthc care providers and bystanders should first place the affected individual in a supply position to facilitate blood flow to the brain and promote recovery moving the patient to a cooler environment with shade or access to fans can help dissipate heat and reduce the risk of further heat related issues encouraging the patient to rehydrate by drinking fluids is essential to address any fluid loss that may have occurred occurred due to sweating however providers should closely monitor the patient's condition as heat Syncopy can sometimes be a precursor to more severe heat related illnesses like heat exhaustion or heat stroke if the patient does not recover quickly or if their symptoms worsen healthc care providers should suspect the possibility of these more serious conditions and initiate appropriate interventions such as aggressive Cooling and fluid resuscitation heat exhaustion is a clinical syndrome that occupies a moderate position on the Continuum of heat related illnesses it typically arises when individuals are exposed to high environmental temperatures and engage in physical exertion challenging the body's ability to regulate its temperature effectively two classic forms of heat exhaustion are recognized based on their underlying mechanisms the first form known as water depleted exhaustion tends to affect older adults active younger workers and athletes who engage in physical activities in hot environments the primary factor contributing to this condition is a deficit in body water resulting from insufficient fluid intake to compensate for the extensive fluid losses through sweating dehydration is a Hallmark feature often compounded by inadequate rehydration practices individuals experiencing water depleted exhaustion may present with symptoms such as excessive thirst fatigue weakness profuse sweating tacac cardia and Mild confusion on the other hand sodium depleted exhaustion results from excessive losses of sodium due to diaphoresis typically observed in individuals who engage in rigorous physical activities or labor these individuals may not adequately replace the sodium loss during their exertion sodium maintains proper electrolyte imbalance and supports normal nerve and muscle function symptoms of sodium depleted heat exhaustion may include nausea vomiting muscle cramps headache and altered mentation it is important to note that sodium depleted exhaustion shares similarities with dilutional hyponatremia but it is distinct as it is not associated with the excessive consumption of hypotonic water in a short period of time heat exhaustion is characterized by a variety of signs and symptoms that manifest when the body body becomes overwhelmed by excessive heat and dehydration these clinical manifestations reflect the body's struggle to regulate its core temperature and maintain adequate fluid balance common signs and symptoms of heat exhaustion involve a range of discomfort weakness is a prominent feature with individuals experiencing a profound sense of physical and mental debility headaches are common and fatigue andt extreme tiredness often accompany these symptoms as the body spends significant energy trying to cool itself down dizziness may occur due to a drop in blood pressure nausea coupled with the sensation of impending vomiting is also a frequent complaint abdominal cramps can be painful and may be attributed to electrolyte imbalances brought on by excessive sweating peruse sweating is a Hallmark sign of heat exhaustion as the body seeks to cool itself self through evaporation the skin may appear pale and feel clammy a result of reduced blood flow to the skin surface as the body prioritizes circulation to vital organs to maintain core temperature the treatment of heat exhaustion encompasses a series of important interventions and monitoring strategies designed to address the underlying fluid and electrolyte imbalances while ensuring the patient's comfort and SA safety firstly the patient is promptly moved to a cooler environment to minimize further heat exposure and encourage heat dissipation excess clothing is removed to facilitate better cooling through sweating and evaporation the patient should be placed in a Supine position with their legs elevated as this helps improve Venus return in blood circulation rehydration is a fundamental aspect of treatment with the patient encouraged to drink fluids to address fluid losses incurred through sweating in some cases especially when the condition is severe or electrolyte imbalances are suspected blood samples may be obtained for laboratory analysis to assess specific electrolyte abnormalities for patients who are severely volume depleted or unable to tolerate oral rehydration Ivy fluids may be administered to rapidly restore fluid balance and electrolyte levels IV fluids are administered cautiously however with the choice of fluids determined by the patient's clinical presentation ECG monitoring is pertinent for patients at risk of electrolyte induced arrhythmias external cooling measures such as cold water immersion sponging or spraying may be considered if the patient is experiencing CNS impairment such as confusion or altered levels of consciousness these measures Aid in reducing core body temperature more rapidly heat stroke is the least common but most life-threatening heat related illness representing a severe disturbance in the body's ability to regulate its core temperature it is characterized by a Core Body temp that exceeds 104\u00b0 Fahrenheit and is often accompanied by CNS dysfunction heat stroke is a medical emergency with a potentially High mortality rate reaching up to 10% in treated patients in cases of heat stroke the body's critical thermal maximum is surpassed when the core body temperature exceeds 109.5 degre F this critical point marks a profound disruption in physiological processes as the body temp Rises beyond the critical thermal maximum cellular respiration becomes severely impaired and this can lead to widespread cellular dysfunction and damage the excessive heat causes cell membranes to become more permeable which can result in the leakage of important cellular contents disrupting the normal functioning of the cell high temperatures introduce protein denaturation a process in which proteins lose their three-dimensional structure and functionality proteins are utilized in numerous biological processes and their denaturation can have devastating effects on cellular function prolonged exposure to elevated core temperatures leads to tissue necrosis in various organs and tissues the severity and extent of which depends on the duration and intensity of the heat exposure classic heat stroke typically occurs during heat waves and is often associated with certain vulnerable populations among those most at risk are the very elderly the very young and individuals who are bedridden or have limited Mobility additionally classic heat stroke is more likely to affect patients with chronic medical conditions people taking specific medications and those with a history of alcoholism during heat waves the extreme environmental heat and hum humidity can overwhelm the body's ability to dissipate Heat leading to a rapid increase in The Core Body temp the impaired Thermo regulation in these vulnerable individuals results in the development of classic heat stroke in contrast exertional heat stroke primarily affects younger healthy individuals who engage in strenuous physical activity in high heat in high humidity conditions this form of heat stroke is often linked to to intense exercise or labor during hot weather where the body's heat production surpasses its capacity for dissipation during vigorous activities increased metabolic heat production coupled with reduced heat loss can lead to a very rapid elevation in Core Body temp thus causing exertional heat stroke heat stroke presents a distinctive array of signs and symptoms that collectively signal a severe disruption in the body's normal Thermo Regulatory and central nervous system functions these clinical manifestations are indicators of the condition and include altered mle status which often manifests as confusion irritability and simply bizarre behavior affected individuals may become disoriented and unable to think clearly some patients May exhibit combativeness reflecting the heightened state of agitation and confusion associated with heat stroke hallucinations both auditory and visual can also occur as a result of the CNS dysfunction a key feature of heat stroke is a significantly elevated Core Body temp exceeding 104\u00b0 F this hypothermia results from the body's inability to effectively dissipate Heat teoc cardia is a response to the body's efforts to circulate blood and dissipate heat through increased cardiac output Topia characterized by rapid breathing is accompanied by a decreased entitle carbon dioxide level indicating heightened respiratory rate and depth as the body seeks to enhance heat loss through the respiratory system heat stroke often presents with hot red skin due to Vaso dilation the skin becomes hot to touch as blood vessels dilate to release heat however blood pressure may be normal or decreased as heat stroke can lead to dehydration and vasive dilation in some cases individuals with heat stroke may experience seizures reflecting the profound CNS disturbance induced by elevated temperature the treatment of heat stroke is a critical and time-sensitive medical intervention focused on rapidly lowering the patient's elevated core body temperature to mitigate the risk of severe complications and improve overall outcomes Central to heat stroke treatment is the urgent need to reduce the dangerously High Core temp the initial assessment of the patient includes a thorough evaluation of their Airway breathing and circulation to ensure that vital functions are adequately maintained once the diagnosis is established immediate measures are taken to initiate cooling this includes removing any excess clothing from the patient and relocating them to a cooler environment the preferred method for Rapid temperature reduction is cold water immersion however sponging and spraying the patient with cool water can be employed if immersion is not immediately available evaporation techniques are continuously applied until the patient Body temp Falls below 102\u00b0 F IV access is established to provide isotonic fluids addressing dehydration and electrolyte imbalances that may have occurred during the heat stroke episode blood samples are also obtained for laboratory analysis to assess the patients metabolic status and electrolyte levels throughout the treatment process provide ERS closely monitor the patient for potential complications particularly pulmonary edema which can arise from the rapid cooling process and the redistribution of fluids continuous monitoring includes Vital Signs ECG and etco2 levels to gauge the patient's response to treatment and promptly detect any signs of arrhythmias or respiratory distress in cases where the patient experiences a seizure providers should prepare to administer a benzoa promptly to control and terminate the seizure",
        "Cold Emergencies": "activity cold emergencies cold related injuries such as frostbite typically affect exposed body parts and are classified in the same manner as burn injuries using a 4 degree system to assess the extent of tissue damage first degree frostbite represents the mildest form is characterized by numbness redness of the skin and capillary leakage which leads to localized edema or swelling at this stage the primary injury affects the superficial layers of the skin and underlying tissues second degree frostbite is marked by the development of superficial blisters on the affected skin these blisters may contain fluid and can be quite painful this degree of frostbite indicates a deeper level of tissue involvement compared to First deegree frostbite third degree frostbite is more severe and involves deep hemorrhagic blistering the term hemorrhagic signifies the presence of bleeding within the blisters and cells which can result from damage to blood vessels within the affected tissue this stage often extends into the deeper layers of the skin and underlying structures fourth degree frostbite is the most severe and extensive form of cold injury it involves damage to deep subcutaneous tissues which may include muscle and even bone this degree of frostbite can lead to the destruction of these deep tissues causing profound damage and potential complications the treatment of severe frostbite hinges on two critical factors the distance to the Receiving Hospital or Burn Center and the degree of tissue thawing that has occurred before arrival at the medical facility when the transport time is less than 1 hour or if the affected body part remains Frozen it is imperative to maintain the part in its frozen state to minimize further damage to achieve this the Frozen part should be paded with dry dressings to provide protection and insulation it is important important to avoid attempting to warm the Frozen tissue during transport as rapid thawing can exacerbate the tissue injury patients should be instructed not to rub or massage the affected area in order to prevent further trauma in cases where the tissue has partially thawed or if transport will exceed 1 hour immediate contact with medical control is necessary to determine the most appropriate course of of action to facilitate the thawing process the affected tissue should be immersed completely in water within the temperature range of 98.6 to 102.2 De F this controlled warming procedure helps gradually and safely thaw the Frozen tissue simultaneously an IV line should be established to administer pain control medication in order to manage the significant pain pain associated with frostbite thawing careful monitoring of the water temperature ensures it will remain within the therapeutic range and patients should be advised not to smoke during this process in order to minimize the risk of further tissue injury once circulation has been successfully restored to the affected area it should be dried thoroughly and dressed in a dry dressing to protect the newly thawed tissue and to prevent infection hypothermia is a medical condition characterized by a decrease in corebody temperature to 95 degrees Fahrenheit or less this potentially life-threatening condition is not confined to a particular season and can occur at any time depending on the environmental conditions and individual circumstances several factors can contribute to the development of hypothermia and providers must recognize po potential risk factors one significant contributing factor to hypothermia is the consumption of alcohol as it has the capacity to impair the body's ability to regulate temperature by dilating blood vessels near the skin surface additionally alcohol can impair judgment and Lead individuals to underestimate the severity of cold exposure certain underlying medical conditions can also predispose individuals to hypothermia hypo thyroidism can slow down metabolism and reduce the body's ability to generate heat making affected individuals more susceptible to hypothermia liver disease and malnutrition can further compromise the body's ability to maintain normal temperature as that impacts metabolic processes and reduces energy reserves in addition to these factors trauma hypovolemia and hypotension can contribute to the development of hypothermia traumatic injuries or severe blood loss can disrupt the body's Thermo regulatory mechanisms and lead to a rapid drop in Core Body temp especially when coupled with exposure to cold environments hypotension can further exacerbate the situation as it impairs the body's ability to redistribute blood flow and maintain vital organ profusion mild hypothermia is characterized by a Core Body temp that falls within the range of 90\u00b0 fah to 95\u00b0 fah in this early stage the body typically initiates compensatory mechanisms to counteract the drop in temperature thermogenesis increases as the body attempts generate more heat additionally thermalsis becomes intermittently interrupted as the Body Works to conserve heat one of the Hallmark signs of mild hypothermia is shivering shivering serves as an Adaptive response to help maintain Core Body temp within a narrow range however as hypothermia progresses shivering can become less effective that muscle coordination May deteriorate in mild hypothermia individuals may exhibit a range of subtle cognitive and motor impairments often summarized as stumbles mumbles fumbles and grumbles these manifestations include an unsteady gate slur speech impaired fine motor skills and clumsiness and changes in Behavior or mood these subtle signs can be indicative of mild hypothermia and may be observed before more severe symptoms become apparent furthermore mild hypothermia can lead to changes in cardiovascular function the heart rate blood pressure and cardiac output may increase as the body attempts to maintain adequate tissue profusion and oxygen delivery these physiological responses are part of the body's efforts to compensate for the cold stress and are characteristic of the early stages of hypothermia moderate hypothermia is a more advanced stage of cold related illness characterized by a Core Body temp that falls within the range of 82\u00b0 F to 90\u00b0 F in this stage the individual mental status is markedly decreased reflecting a significant impairment of cognitive function it is important to note that patients with moderate hypothermia are typically still conscious although their level of alertness and responsiveness may be severely compromised shivering remains present in moderate hypothermia but is generally less vigorous and not as effective as the body temp continues to drop the ability to generate heat through shivering becomes diminished and the Shivering response may become less coordinated and certainly less effective at maintaining body temperature to address hypothermia and prevent further deterioration providers should initiate external warming measures external heat sources such as heated blankets radiant heaters or warm IV fluids may be utilized to raise the patient's core temperature gradually and safely these measures are essential for vering the hypothermic State and restoring normal physiological function active rewarming techniques are typically necessary because passive rewarming such as insulating the individual with blankets alone may not be sufficient to correct moderate hypothermia effectively severe hypothermia represents the most critical and life-threatening stage of cold related illness characterized by a Core Body temp that Falls below 82\u00b0 F in this extreme State profound physiological changes occur and the body's ability to maintain normal function is severely compromised one of the prominent features of severe hypothermia is a significant decrease in heart rate blood pressure and cardiac output the cardiovascular system undergos a marked slowing of activity resulting in reduced blood flow to vital organs and tissues this decrease in blood flow can lead to various complications including impaired tissue profusion and the potential for organ dysfunction a factor contributing to the adverse effects of severe hypothermia is the shift of fluids from the intravascular vessels to the extravascular space this shift of fluids increases the viscosity of the blood making it thicker and more resistance to flow as a result the heart has to work harder to pump this viscous blood further exacerbating the cardiovascular strain shivering will cease at a Core Body temp below 91\u00b0 Fahrenheit and this cessation reflects the body's inability to generate heat through this mechanism and again is a clear sign of severe hypothermia in addition to cardiovascular and therm regulatory changes severe hypothermia can affect the respiratory system tracheobronchial secretions increase potentially leading to Airway obstruction and breathing difficulties bronos spasm may also occur further compromising respiratory function profound hypoventilation is a Hallmark of severe hypothermia with breathing becoming significantly slow and shallow this can result in an adequate oxygen exchange and may contribute to to a decreased oxygen level in the blood cardiac complications are a major concern as braic cardia and cardiac arrhythmias May develop on an ECG an Osborne or j-wave may be observed the presence of these waves on an ECG is a concerning sign as it indicates a high risk of ventricular fibrillation or pess ventricular tardia the treatment of severe hypothermia presents unique challenges primarily due to the profound physiological changes that occur in individuals with core temps well below the normal range several important considerations should be taken into account when managing these cases one critical aspect to Bear to mind is that many Advanced life support medications which are commonly used in resuscitation efforts may be less effective in patients with severe hypothermia the altered physiology associated with severe cold stress can affect drug metabolism and Drug responses as a result it's recommended that ACLS medications be administered at twice the normal intervals for patients with core temps less than 95\u00b0 F in cases where the core body temperature drops below 86\u00b0 fah it's advisable to withhold these medications entirely as this cautious approach helps mitigate the potential risks and uncertainties associated with Drug Administration in hypothermic individuals the primary goal of treatment is to rearm the patient effectively while addressing the associated complications warming the patient is the Cornerstone of therapy and several measures should be implemented to achieve this in the treatment of hypothermia several steps must be taken to effectively rewarm the patient and manage their condition first and foremost providers must remove any cold wet clothing as these can serve as sources of continued cold exposure and prevent the patient from rewarming adequately following this the patient should be carefully wrapped in layers of insulating material designed to retain heat options for this insulation can include dry blankets heated blankets or specialized hypothermia wraps that are specifically engineered to maintain warmth the next critical aspect of treatment is to relocate the patient to a controlled heated environment that is conducive to the rewarming process this may involve transferring the patient to a heated room placing them in an ambulance equipped with a warming unit or transporting them to a medical facility equipped for specialized rewarming procedures intravenous fluid administration plays a vital role in a hypothermia treatment and it is essential to ensure that the fluid is being administered or warmed to temperatures ranging between 102\u00b0 Fahrenheit and 105\u00b0 Fahrenheit this precaution helps prevent further cooling of the patient's core temperature during fluid resuscitation furthermore the provision of warmed oxygen therapy is key delivering oxygen that has been pre-warmed minimizes the risk of heat loss during inhalation and supports the patient's respiratory and circulatory functions in certain scenarios providers May opt for more Advanced rewarming Techniques such as perianal lavage with a potassium chloride free solution or nasogastric orogastric lavage using warm fluids these procedures involve the introduction of warm fluids into the body cavities facilitating heat transfer and aiding in the elevation of the Core Body temp careful monitoring and assessment should accompany all of these interventions to ensure that the rewarming process is gradual controlled and tailored to the specific needs of each",
        "Drowning": "patient drowning drowning is a pressing Public Health concern with approximately 10 individuals losing their lives to unintentional drowning each day this statistic underscores the gravity of the issue as drowning remains a significant cause of preventable death notably among all age groups drowning is particularly concerning for children aged 1 to 4 years where it stands as a leading cause of unintentional injury related to death in the United States this demographic vulnerability emphasizes the importance of effective drowning prevention strategies such as constant supervision and water safety education tailored to young children moreover the impact of drowning extends Beyond fatalities with over 50% of drowning victims who are treated in emergency departments requiring hospitalization and transfer to further Medical Care this statistic highlights severity of drowning related incidents and underscores the need for comprehensive and specialized Health Care interventions hospitalization or transfer for further care is often necessary to address the physiological consequences of drowning including respiratory distress hypoxemia and potential complications such as aspiration pneumonia when it comes to the the treatment of drowning victims healthc care providers must adhere to a systematic approach to address potential complications and ensure the best possible outcomes one critical consideration is spinal motion restriction which should be applied to patients who are observed diving into water or with those with suspected alcohol use ventilation is an immediate priority in drown cases especially when warranted by the patient's clinical condition Swift initiation of ventilation aims to address the potential respiratory distress and hypoxemia commonly associated with drowning to mitigate effects of pulmonary edema and facilitate adequate oxygen exchange positive end expiratory pressure may be employed additionally a nasogastric tube may be utilized as part of the treatment strategy to decompress the stomach reducing the risk of gastric distension and Associated complications bronchospasm and tracho bronchial irritation common Soliloquy of drowning can be managed with a beta 2 adrenic Agonist this medication should help alleviate Broncos spasm and improve Airway function drowning as a traumatic event involving the immersion of the airway in water can lead to several serious complications that demand prompt and specialized medical attention among these complications one of the most critical is acute respiratory distress syndrome or ARS ARS results from the inhalation of water which can cause damage to the delicate Alvi in the lungs this damage leads to increased permeability of the Alvar capillary membrane allowing fluid and proteins to accumulate in the air spaces as a result the the lungs become stiff and non-compliant severely impairing oxygen exchange and causing severe respiratory distress another significant complication associated with drowning is the development of chemical or bacterial pneumonitis when water enters the lungs it may introduce harmful chemicals toxins or bacteria that can trigger an inflammatory response in the lung tissue this inflammation can lead to pneumonitis which manif ests as lung inflammation impaired gas exchange and respiratory symptoms the severity can vary depending on the type and volume of contaminants in the ingested water additionally drowning related complications can extend beyond the respiratory system renal failure is another potential consequence of drowning particularly in cases of prolonged submersion or severe hypoxia the reduced oxygen supply to vital organs incl including the kidneys can result in acute kidney injury or renal failure this condition can further exacerbate the patient overall health status requiring intensive medical management to support renal",
        "Diving Injuries and Decompression Sickness": "function diving injuries and decompression sickness diving accidents can occur even among the most experienced divers due to the unique physiological challenges associated with underwater exploration one critical factor to consider is the increase in pressure as a diver descends into deeper water for every 33.9 ft of depth the pressure on the body increases by one atmosphere equivalent to 14.7 PB per square in or 1 kilogram per square cenm this elevated pressure can have profound effects on the body particularly when it comes to the solubility of gases like nitrogen one of the most common physiological effects of increased pressure during diving is related to nitrogen known as nitrogen Narcosis often referred to as Rapture of the deep this occurs when a diver experiences Euphoria and disorientation due to the narcotic effects of nitrogen at elevated pressures this phenomenon can impair a divers judgment and decision-making abilities furthermore the effects of pressure on nitrogen solubility can result in the formation of nitrogen gas bubbles within the body these bubbles tend to expand as a diver ascends to more shallow depths causing pain when trapped in various anatomical locations the most well-known consequence of these trapped gas bubbles is decompression sickness commonly referred to as the bends decompression sickness can manifest as joint pain and GI discomfort among other symptoms and may require prompt medical attention one of the manifestations of decompression sickness is respiratory disturbances often referred to as chokes when nitrogen gas bubbles form in the lungs or Airways they can cause symptoms such as chest pain difficulty breathing and a feeling of suffocation the respiratory symptoms can be quite distressing and require immediate medical attention another significant aspect of decompression sickness is neurologic impairment often described as staggers nitrogen bubbles that accumulate in the CNS can lead to a range of neurological symptoms divers affected by the bends may experience dizziness confusion weakness loss of coordination and even paralysis additionally decompression sickness can result in skin sensation abnormalities which are commonly referred to as creeps or skin bends as nitrogen bubbles form and expand within the skin and subcutaneous tissues divers may experience Sensations such as itching tingling or a feeling of crawling skin these symptoms can be quite uncomfortable and certainly unsettling barot traumas are a group of medical conditions that can afflict divers during both ascent and descent phases of a dive these conditions are primarily caused by the behavior of gases within the body as pressure changes occur during changes in depth as a diver ascends to a higher elevation the trapped gases within the body expand due to the reduction of of external pressure this expansion can lead to increased pressure within body cavities which can result in barotraumatic injuries conversely during descent the pressure of the surrounding environment surpasses the pressure of gases within the body exerting inward pressure on various bodily structures the areas most susceptible to barotraumatic injury include the lungs ears and the GI tract inadequate Equalization of pressure within these regions can lead to a range of complications including ear barot trauma lung barot trauma and gastric barot trauma barot traumas can vary in severity and may necessitate PR medical evaluation and intervention to alleviate symptoms that prevent further harm to the diver pulmonary overpressurization syndrome or pops is a potentially severe condition that can occur when a diver ascends rapidly to the surface causing gases trapped in the lungs to expand rapidly due to the reduction of external pressure this abrupt expansion of gasin within the lung can lead to various complications one significant risk is the development of Numa thorax here the increased pressure can cause a rupture in the lung tissue allowing air to escape into the plural space surrounding the lungs in some cases this could result in mediastinal or subcutaneous empyema furthermore pops poses the risk of arterial gas embolism a critical condition in which air bubbles escape from ruptured Alvi in inner pulmonary capillaries these bubbles can then travel to the heart and be pumped into the arterial circulation potentially causing acute myocardial infarction or stroke if they block blood flow to vital organs the treatment of diving injuries including decompression sickness requires a multifaceted approach aimed at rapidly addressing the underlying physiological issues first and foremost rapid transport to a medical facility capable of managing diving related injuries is critical upon arrival the administration of 100% oxygen is critical as it helps promote the wash out of nitrogen from the lungs and assists in reducing the size of gas bubbles responsible for decompression sickness the diver alert Network can provide valuable guidance to Critical Care transport professionals when making decisions about the management of these patients continuous monitoring of the patients Vital Signs and clinical status is required even if they initially show signs of recovery as complications can arise later in the course of treatment it is advisable to keep the patient in the supply position to minimize the risk of further complications related to changes in Cabin altitude in addition to oxygen therapy other interventions may be necessary depending on the severity of the diving injury these can include the administration of aspirin to mitigate thrombotic complications the placement of a chest tube if pneuma thorax or other chest related issues are suspected an aggressive IV fluid resuscitation to maintain adequate tissue profusion in cases of profound cardiopulmonary dysfunction following Advanced cardiac life support protocols may also be required to stabilize the patient's condition hyperbaric oxygen therapy is a specialized treatment modality used in in the management of diving injuries and decompression sickness it involves placing the patient inside a specially designed hyper barar chamber where the pressure is elevated above that of the surrounding air within the chamber the patient receives a controlled and precise administration of pure or Blended oxygen either through a mask or an endot tral tube the fundamental goal of Hyperbaric therapy is to facilitate the elimination of inert gas es such as nitrogen from the body's tissues while simultaneously providing the body with a high concentration of oxygen Hyperbaric therapy serves several critical purposes first it helps reduce tissue edema or swelling which is a common consequence of decompression Sickness by delivering oxygen under increased pressure Hyperbaric therapy promotes the disillusion of gas bubbles and accelerates their elimination mitigating the severity of tissue damage Additionally the elevated oxygen levels offset Vaso constriction which can occur in response to decompression injury thereby improving tissue profusion and oxygenation in the context of managing diving injuries and decompression sickness during aeromedical evacuation there are flight considerations that must be adhered to in order to ensure the safety and well-being of the patient firstly aircraft should not Ascend to an altitude exceeding 800 ft unless it is absolutely necessary this limitation is in place to prevent further exposure to reduced atmospheric pressure which could exacerbate the symptoms of decompression sickness Additionally the positioning of the patient within the aircraft is of utmost importance to optimize patient care and minimize the risk of complications the patient should be placed in either a lateral recumbent position or recovery position these positions are chosen for their ability to maintain the patient's Airway patency prevent aspiration and facilitate oxygenation while the aircraft is in",
        "Altitude Illness": "transit altitude illness altitude illness is a condition that can affect both seasoned mountain climbers pushing their physical limits and individuals who travel from lower to higher elevations in their everyday lives this condition arises due to the reduced oxygen availability at higher altitudes which can lead to a range of symptoms and complications several factors can increase the risk of altitude illness among individuals patients with pre-existing medical conditions such as cardiovascular or respiratory diseases are more susceptible to the effects of reduced oxygen levels extremes of age particularly the very young and elderly are also at an increased risk sedentary Lifestyles and poor health choices such as smoking or inadequate hydration can further compound the risk individuals planning to travel to high altitude regions or engage in activities at higher elevations need to be aware of these risk factors and take appropriate precautions to mitigate the potential onset of altitude illness altitude illness is a spectrum of symptoms that can vary widely in severity ranging from subtle signs like imperceptible teyia or mild sleep disturbances to like life-threatening conditions such as pulmonary edema cerebral edema and severe hypoxia these symptoms are primarily a consequence of the reduced oxygen levels at higher altitudes which constrain the body's ability to adapt altitude sickness is most commonly associated with activities like mountain climbing and skiing which often occur at elevations ranging from 3,000 to 8,000 ft above sea level at these Heights the decrease in atmospheric pressure results in lower oxygen levels making individuals more vulnerable to the adverse effects of altitude it is vital for individuals engaging in such activities to be aware of the potential for altitude illness monitor their symptoms closely and seek appropriate medical attention if their symptoms worsen or become severe the Lake Louise criteria are a valuable tool used to assess and categorize the severity of altitude illness particularly acute Mountain sickness or AMS these criteria provide a structured approach to evaluating individuals at high altitudes based on specific symptoms patients are assigned scores depending on the presence and intensity of symptoms associated with altitude sickness those with scores falling between 3 to 5 typically exhibit mild AMS while scores between 6 and 9 suggest moderate AMS a score ranging from 10 to 12 indicates severe AMS the scoring system helps healthc Care Professionals determine the severity of altitude related symptoms and guides decisions regarding further evaluation and management it is an important tool for assessing the degree of impair ment in individuals exposed to high altitudes aiding in appropriate interventions to mitigate the effects of altitude illness high altitude pulmonary edema or Hae is a critical medical condition that arises at very high altitudes typically above 8,000 ft it is characterized by the accumulation of fluid in the lungs resulting in pulmonary edema unlike cardiogenic pulmonary edema Hape is non-cardiogenic in nature meaning it is not primarily caused by heart rated issues Hae usually develops within a relatively short time frame typically 24 to 72 hours after ascending to higher altitudes making it a considerable concern for mountain trekers and travelers to Regions with extreme elevations those who frequently change altitudes such as Prof professional climbers or military personnel are particularly susceptible to hatee symptoms are diverse and may include a persistent cough severe respiratory distress a sensation of chest tightness profound fatigue and sometimes even fever these symptoms can progress rapidly and severely impact an individual's ability to breathe leading to a life-threatening situation in severe cases supplemental oxygen and medications to reduce pulmonary edema may be necessary to stabilize the patient however immediate medical tension and descent to lower altitudes are required for all individuals experiencing Hape very high altitudes typically those above 14,000 ft pose significant physiological challenges to individuals due to the decreased oxygen availability in the thin in air at such elevations there are several implications for the body Alvar hypoxia or oxygen deficiency within the lung's air sacs can lead to pulmonary hypertension a condition characterized by increased blood pressure within the pulmonary arteries this occurs as a response to the body's efforts to enhance oxygen uptake localized inflammation is another concern at very high altitudes the body's tissues and blood vessels may experience irritation and inflammation due to the low oxygen levels and increased workload on the cardiovascular system this can lead to capillary or arterial thrombosis which are blood clot formations within the small vessels in cases where individuals are exposed to very high altitudes and develop altitude related illnesses or complications rapid descent to lower altitudes is the preferred treatment submental oxygen is administered to counteract the effects of hypoxia while certain medications may be used to alleviate symptoms and improve oxygenation additionally portable Hyperbaric bags which simulate a lower altitude environment can Aid in treating altitude related conditions CPAP may also have a role in managing patients who develop respiratory distress at very high altitudes high altitude cerebral edema or haste is a life-threatening condition that demands immediate attention particularly in individuals who have recently ascended to high altitudes this condition is strongly suspected when a patient experiences alterations in mental status or a taxia haste is thought to arise from cerebral vasodilation triggered by the hypoxic conditions prevalent at elevated elevations this vasod dilation can lead to an increase in the permeability of cerebral blood vessels resulting in cuple edema the treatment of Hast involves rapid descent to lower altitudes where oxygen levels are more adequate supplemental oxygen is administered to alleviate hypoxia and mitigate further brain swelling additionally dexamethasone a corticosteroid medication they be administered to help reduce brain inflammation and edema in Flight considerations for critical care transport providers several key factors must be taken into account when performing rescue or evacuation functions in challenging environments these situations often involve locations that may be hazardous for both ground transport vehicles and aircraft to ensure the safety of of both the patient and the medical personnel providers need to carefully evaluate various factors this includes assessing the training and experience of the Personnel involved as well as the capabilities of the transport vehicle itself weather conditions and environmental concerns such as altitude and terrain are also considerations the severity of the patient's illness or injury also plays a significant role in decision-making during trans transport providers must be vigilant in minimizing the impact of environmental conditions on the patient particularly in cases of altitude illness where rapid descent may be required for those with severe manifestations continuous monitoring of devices such as ET tubes and laying geom masks always is essential during both ascent and descent to prevent complications and ensure patient safety furthermore it's important to rec recognize that patients with altitude illness may present with additional issues such as hypothermia dehydration trauma or underlying medical conditions these factors must be taken into account when planning and executing Critical Care transport and challenging environments to provide comprehensive and effective Medical Care to the patient"
    },
    {
        "Introduction": "diseases introduction immunity is a complex system comprising various substances cells and tissues that serve to safeguard the human body from infection this intricate defense mechanism protects individuals from the harmful effects of infectious agents understanding the intricate relationship between humans and infectious diseases is of Paramount importance the mere presence of infectious disease can invoke fear often leading to irrational behaviors and Widespread Panic among populations recent events such as the covid-19 pandemic have underscored the significance of comprehending diseases and their modes of transmission the pandemic served as a stark reminder of how rapidly infectious agents can spread within communities and across borders this heightened awareness has prompted a collective effort to enhance our knowledge of infectious diseases their prevention and treatment medical professionals particularly those involved in critical care and patient Transportation face a heightened risk of exposure to a multitude of pathogens these dedicated individuals need a comprehensive understanding of infectious diseases the body's responses to them and effective methods of mitigating their spread this knowledge equips them with the necessary tools and strategies to protect both themselves and the patients they serve ultimately contributing to the overall Public Health",
        "Fundamental Principles of Infectious Disease": "response fundamental principles of infectious disease the spread of infectious diseases is a multifaceted process that arises from intricate interactions between three fundamental comp components the host the Infectious agent and the environment these elements collectively contribute to the complexity of how diseases are transmitted and their subsequent impact on populations the host in this context refers to the individual who may contract the disease the host susceptibility immune status and overall health assist in determining whether an infection occurs and how severe it becomes factors such as age underlying medical conditions and immune function can significantly influence the host's vulnerability to infectious agents the Infectious agent represents the microorganism responsible for causing the disease which can be a bacterium virus parasite or other pathogen the specific characteristics of the Infectious agent such as its virulence mod of transmission and ability to evade the host's immune defenses greatly impact the likelihood of infection and the severity of the resulting illness the environment includes the external conditions and factors that facilitate or hinder the transmission of infectious agents this includes aspects like climate sanitation population density and healthc Care infrastructure environmental factors can influence fluence the spread of diseases by creating favorable conditions for the survival and transmission of pathogens healthc Care Professionals must recognize and appreciate that the Dynamics of disease transmission do not rigidly adhere to the conventional models used to describe pathogen spread this awareness is vital because the spread of diseases can manifest in ways that challenge established paradigms for instance the classification of diseases as Airborne or Airborne droplet may not Encompass the full spectrum of transmission modes for certain pathogens furthermore the ecological factors surrounding each pathogen are not always fully clear this knowledge Gap can be exemplified by the nipo virus outbreak in India in 2004 initially an unknown disease was linked to the consumption ion of date palm sap however further investigation revealed that fruit bats were contaminating the SAP with NIV shedding light on the ecological aspect of disease transmission moreover the discovery of humano human transmission during the outbreak significantly escalated the threat posed by the disease to the population Carl W's Innovative classification system for microorganisms based on physical properties and cellular components has had a profound impact on our understanding of infectious diseases this classification is not merely an academic exercise but has practical implications for how microorganisms interact with their hosts leading to infections and disease the physical properties and cellular components of microorganisms are instrumental in determining their pathogenic potential these attributes influence their ability to invade host organisms and initiate infection ultimately causing diseases microorganisms possess unique characteristics that distinguish them from their host organisms these differences serve as key factors in the host's immune recognition of foreign Invaders the immune system can detect these disparities triggering an immune response aimed at eliminating the invading microorganisms furthermore these distinctions between microorganisms and their hosts can be harnessed by researchers and medical professionals exploiting these differences has led to the development of agents and therapies designed to combat pathogens researchers have devised strategies to Target and kill microorganisms or inhibit their growth and spread within the host this understanding of the divver diverent properties of microorganisms compared to their hosts is fundamental in the development of vaccines antibiotics and other treatments that manage infectious diseases in the animals of infectious disease history contributions by scientists such as Robert kooch leis past and Paul Erich have shaped our understanding and approach to combating these illnesses Koch and past a were instrumental in substantiating The Germ theory of disease which posits that microorganisms are the causitive Agents of infectious disease their groundbreaking work provided empirical evidence to support this Theory laying the foundation of modern microbiology and epidemiology heich building on the premise that invading microorganisms could be targeted and eliminated to cure disease made significant strides in the early 20th century in 1909 he achieved a remarkable breakthrough where he identified a chemical compound capable of killing tarima padium the organism responsible for syphilis this marked a significant milestone in the development of targeted therapies for infectious disease emphasizing the potential for chemical interventions to combat specific pathogens further advancing the field of infectious disease treatment in 1935 beay introduced sulfanilamide a drug that exhibited some degree of Effectiveness against Staal and streptococcal infections this development marked one of the earliest successes in the Quest for antimicrobial agents Paving the way for the eventual discovery of antibiotics and the revolution in infectious disease management in the realm of Medicine the Magic Bullet archetype persists particularly in the design of antibiotic antiviral and antifungal drugs these Pharmaceuticals are meticulously crafted to selectively Target specific proteins macro molecules cellular organel or enzymatic Pathways critical to the survival or replication of the Infectious agent differentiating them from the host's biology moreover these drugs exploit unique reproductive Strategies employed by the Infectious agent strategies distinct from those of the human Host this precision-based approach minimizes harm to the host while effectively disrupting the pathogen's life cycle reflecting the enduring significance of the Magic Bullet principle in modern Medical Therapeutics for infectious",
        "The Human Immune System": "disease the human immune system system the acquisition of disease hinges on an individual's susceptibility to that particular illness a concept deeply intertwined with various influential factors these factors collectively govern the likelihood of disease manifestation and progression nutritional status is important as an inadequately nourished individual may have a compromised immune system rendering them more susceptible to infection immune status reflecting the strength and functionality of an individual's immune system is another determinant individuals with weakened immune systems such as those with immuno deficiency disorders or under immunosuppressive treatments are particularly vulnerable to infection genetic makeup also exerts a substantial influence on susceptibility generic variations can affect an individual's ability to mount an effective immune response against specific pathogens living conditions incorporating aspects like hygiene sanitation and access to health care assist in determining susceptibility poor living conditions can increase exposure to infectious agents and hinder access to timely Medical Care contributing to a higher susceptibility rate exposure to infection agents either through direct contact or environmental factors significantly impacts disease susceptibility proximity to infected individuals or contaminated environments increases the risk of transmission disease transmission mechanisms involve a spectrum of routes through which infectious agents can enter the human body posing a risk of infection inhalation is one such mode where pathogens are inhaled through the respiratory tract subsequently entering the lungs or upper respiratory passages this route is particularly relevant for Airborne diseases like tuberculosis or respiratory viruses ingestion involves the intake of contaminated substances such as food or water carrying infectious agents the pathogens May then enter the GI tract leading to infection such as food born illnesses or GI viruses direct contact transmission occurs when infectious agents are transferred from an infected source to a susceptible individual through physical touch or contact with bodily fluids this mode is relevant for diseases such as sexually transmitted infections or skin-to-skin contact infections indirect contact transmission involves a transfer of path pathogens from contaminated surfaces or objects to individuals this can occur when an individual touches a contaminated surface and subsequently touches their face mouth or eyes facilitating the entry of the pathogen into the body the Perpetual battle between the host and microbe pits the intricate human immune defenses against the remarkable adaptability ility of microbes in invading these defenses microbes have evolved virulence factors which are adaptions that allow them to effectively counteract the host's immune responses in order for the immune system to fulfill its protective role it must possess the capacity to differentiate between self components or cells and non-self components or cells the immune system must exhibit a delicate balance between specificity and generality on one hand it must be highly specific constantly surveilling for specific antigens that may indicate the presence of pathogens on the other hand it needs to be General enough to respond to a wide array of potential assaults as the immune system encounters various infectious agents over a lifetime moreover the immune system must incorporate diverse cells and mechanisms capable of responding to a multitude of pathogens this diversity ensures that the immune system can effectively combat a wide range of Invaders simultaneously it must possess the ability to distinguish between the body's own cells and those that are nonself to maintain tolerance and prevent harmful autoimmune reactions the human immune system exhibits a remarkable ability to retain a memory of previous encounters with pathogens enabling it to mount a Swift and targeted response upon subsequent exposures to the same agent or similar agents this immunological memory is a fundamental aspect of the Adaptive immune system which consists of specialized cells notably memory B cells and memory T cells that retain a record of previous infections upon the initial encounter with the pathogen the immune system generates a specific immune response leading to the production of antibodies and the activation of cytotoxic tea cells simultaneously memory cells are formed as a result of this encounter these memory cells remember the specific antigens associated with the pathogen preserving a blueprint of the invader's identity when the same pathogen or a closely related one enters the body body again the immune system rapidly recognizes these antigens thanks to the stored memory this recognition triggers a more rapid and efficient immune response preventing the infection from Gaining a foothold and often leading to quicker recovery this ability of the immune system to remember and respond effectively to previous encounters is the basis for vaccination where exposure to harmless or weakened forms of pathogens Prime the immune system's memory cells conferring immunity without causing the disease itself innate immunity constitutes the inherent defense mechanisms that individuals possess from birth serving as the first line of protection against potential pathogens these defenses are primarily manifested through physical and chemical barriers that are always present and are also ready to counter in fading microorganisms the skin forms a formidable mechanical barrier preventing microbes from Gaining entry to the internal environment additionally mucous membranes that line various body surfaces such as those in the respiratory and GI tracts are coated with secretions that contain enzymes and proteins capable of inhibiting microbial growth and attachment innate immunity is non-specific meaning that it responds to a wide range of pathogens without the need for prior exposure or recognition of specific antigens upon Invasion innate immune responses are immediately activated serving as rapid and immediate forms of defense against infection unlike adaptive immunity which improves with repeated exposures to the same pathogen innate immunity does not exhibit a heightened response upon subsequent encounters with the same infectious agent instead it simply remains a constant Baseline level of defense that is essential for the protection of the host from a multitude of potential threats andate immunity functions through several mechanisms each playing a distinct role in defending the host against potential pathogens firstly one of its fundamental roles is to serve as a trigger for the activation of the Adaptive immune response when annate immune components such as macras or dendritic cells detect the presence of microbial Invaders they initiate a Cascade of events that include the presentation of antigens to tea cells this antigen presentation launches the more specific and tailored adaptive immune response where the body generates antigen specific antibodies in cytotoxic tea cells to combat the infection secondly innate immunity serves as a defense line by preventing the entry of microorganisms into the body physical barriers like the skin and mucous membranes combined with the antimicrobial properties of other secretions create formidable obstacles that microbes must overcome to infiltrate the internal environment this prevents the initial establishment of infection and is key in thoring potential threats thirdly innate immunity contributes to the limitation of microbial growth once an infection has begun components of the innate immune system such as phagocytes like neutrophils and macrofagos are Adept at engulfing and digesting invading microorganisms this process called fago cytosis helps control the growth and spread of pathogens within the host tissues preventing the infection from from becoming overwhelming collectively these innate immune mechanisms work synergistically to provide immediate and non-specific defense against pathogens ensuring that the host is protected while the Adaptive immune system is activated and mounted macrofagos are a component of the human immune system belonging to the family of white blood cells serving as phagocytes that ingest and subsequently destroy invading microbes macras are highly Adept at recognizing foreign pathogens and engulfing them through a process known as phagocytosis once internalized the microorganisms are subjected to a series of destructive processes within the microage effectively neutralizing the threat neutrophils on the other hand are the most abundant inate immune cells in the bloodstream like macro ages neutrophils act as fyes rapidly migrating to sites of infection or tissue damage to engulf and eliminate invading microbes their abundance and Swift response make them First Responders to infections where they contribute to the initial containment of pathogens natural killer or ink cells represent another type of white blood cell with a distinctive role in innate immunity these cells are specialized in recognizing and elimin host cells that have become infected with viruses they possess the ability to distinguish between healthy and infected cells launching an immune response against the infected ones while sparing the uninfected ones in addition to these cellular components innate immunity also relies on various proteins to combat infections the compliment system for instance is a group of proteins that initiate a series of events aimed at clearing ing bacterial cells from the body furthermore proteins like transferin play a vital role in sequestering Iron limiting its availability to pathogens as iron is essential for microbial growth and proliferation adaptive immunity also known as acquired immunity is a highly specialized defense system that develops as a result of intricate interactions between components of the immune system and invaded microbes unlike innate immunity adaptive immunity is characterized by its ability to provide increasingly effective protection with repeated exposures to the same or closely related agents a phenomenon known as immunologic memory one of the major branches of adaptive immunity is humoral immunity orchestrated primarily by be cells these cells combat infections by producing antibodies which are specialized proteins designed to Target and neutralize specific antigens present on the surface of pathogens in addition to antibodies the complement system a group of proteins is also involved in humoral immunity it can be activated by antibodies and serves to enhance the immune response by promoting the destruction of the targeted microorganisms cell mediated immunity on the other hand is orchestrated primarily by tea cells these cells are instrumental in directly responding to and eliminating infected or abnormal host cells cellmediated immunity is especially vital in defending against intracellular pathogens such as viruses or certain bacteria where te- cells recognize and Destroy infected cells te- cells also play a regulatory role go in coordinating the immune response and ensuring it is properly controlled active immunity is an essential aspect of the human immune system that involves an ongoing process of developing antibodies and activating te- cells in response to exposure of pathogens or antigens this form of immunity can be acquired through either the natural process of infection or through artificial means such as vaccination when an individual encounters a pathogen naturally their immune system recognizes the invading microorganism and B cells produce antibodies specific to that pathogen likewise t- cells are activated to recognize and Destroy infected cells vaccination which is a form of artificial stimulation involves the introduction of weakened or inactivated forms of pathogens or specific antigens into the body body this prompts the immune system to mount a protective response generating antibodies and memory cells that are tailored to combat the specific pathogen or antigen introduced to the vaccine one notable characteristic of active immunity is its longevity once the immune system has been exposed to a pathogen or antigen it retains memory cells such as memory B cells and memory T cells which remember the pathogen and remain ready to respond quickly and effectively upon reexposure this leads to a long lasting protection against the specific infectious agent however it's important to note that active immunity takes time to develop the initial response to a pathogen or vaccine is slower compared to passive immunity but the enduring protection it provides is a valuable component of the body's immune defenses against infectious diseases passive immunity involves the administration of performed antibodies derived from a donor to an individual one natural form of passive immunity occurs when antibodies are transferred from a mother to her fetus through the placenta providing the newborn with temporary protection against certain infections during the early stages of life in a medical context passive immunity can also be achieved through the administration of specific antibody preparations such as Hepatitis B immunoglobin or hbig to individuals at risk of infection this approach is particularly useful when rapid protection is needed such as during the incubation period following the exposure to a pathogen however passive immunity has a limitation in that it provides immediate effects but does not confer long- lasting protection as the administered antibodies gradually degrade and are not replenished by the recipient's immune system antigens are fundamental components in the realm of Immunology typically consisting of proteins and or sugars anchored into the cell membrane and predominantly displayed on the cell surface these molecular markers serve as identifiers that the immune system relies upon to distinguish itself and non-self entities when an antigen is recognized as foreign or non-self it triggers the immune system to initiate a response aimed at eliminating the perceived threat the response can take one or two major forms the humoral response mediated primarily by B cells and resulting in the production of antibodies targeting the the antigen or the cell mediated response orchestrated by te- cells which leads to the direct destruction of cells displaying the foreign antigen antigens are Central to the immune system's ability to discern Invaders from the body's own cells and tissues serving as the triggers that initiate the precise and coordinated immune responses that are essential for maintaining health and defending against infections the organ and cells of the immune system are intricately organized and categorized based on their anatomic locations distinguishing between central and peripheral components the central immune organs assist in the development and maturation of immune cells while the peripheral immune organs are involved in immune responses and interactions with pathogens the lymphatic system serves as a vital conduit for immune activity consisting of the capillaries vessels Ducks nodes and various organs it functions to produce the transport lymph a clear fluid that contains immune cells and waste products among the central immune organs the thymus is of particular significance it is located within the thymus that tea cells a subset of immune cells undergo differentiation from naive non-specific te- cells into specialized te- cells with distinct functions this differentiation process is essential for te- cells to acquire the specific roles in immune responses enabling them to recognize and combat specific antigens and pathogens the thymus therefore serves as a site for the development of a competent and functional immune system ensuring the generation of tea cells equipped to contribute to immune surveillance and defense against infections the bone marrow is a vital component of the human immune system serving as a site for the synthesis and maturation of various immune cells particularly B cells B cell synthesis occurs within the bone marrow where precursor cells undergo a series of Developmental stages to become mature b cells these mature b cells are equipped with the capability to produce antibodies which are specialized proteins needed for the humoral immune response antibodies are instrumental in recognizing and neutralizing specific antigens and pathogens contributing to the overall defense against infection the spleen another essential immune organ is responsible for a range of immune functions including the encounter and destruction of encapsulated bacteria encap capsulated bacteria possesses a protective outer capsule that makes them resistant to certain immune mechanisms within the spleen specialized immune cells such as macrofagos and dendritic cells are Adept at recognizing and eliminating these bacteria the spleen also functions as a reservoir for blood filters out damaged or old red blood cells and plays a role in immune surveillance notably the removal of the spleen a procedure known as penectomy can have significant implications for the patient's immune function without a functioning spleen individuals may become more susceptible to infection particularly those caused by encapsulated bacteria as the organs roll in their recognition and elimination is compromised the human immune system incorporates several structures and tissues including tonsils intestinal pay patches and lymph nodes each serving distinct roles in immune function tonsils are a set of small oval-shaped structures located in the back of the throat and inside the mouth they form part of the body's first lineer defense against pathogens entering through the oral or nasal passages tonsils contain immune cells such as lymphocytes which help recognize and combat pathogens that may be inhaled or ingested in testinal payers patches are specialized immune structures found in the lining of the small intestine payers patches contain immune cells including B cells and t- cells that monitor the intestinal contents for the presence of pathogens and antigens these immune cells can generate local immune responses when necessary to defend against intestinal infection length nodes on the other hand are distributed network of small beam shaped structures made up of lymphoid tissue located throughout the body they act as filtering stations for the lymphatic system lymph a clear fluid circulates through the lymphatic system carrying immune cells and antigens lymph nodes contain specialized immune cells such as lymphocytes and macras which scrutinize the lymph for foreign Invaders when they are detected the lymph node facilitates immune response such as the production of antibodies or the activation of tea cells to combat the infection t-lymphocytes or te- cells are a subset of immune cells within the human immune system each playing distinct and vital roles in immune responses among t- cells CD4 cells often referred to as helper te- cells hold a central position in regulating immune function helper te- cells serve as coordinators of the immune system playing multifaceted roles they are instrumental in facilitating the development of B cells into plasma cells which are responsible for the production of antibodies required for the humoral immune response additionally CD4 cells activate another subset of te- cells known as cd8 cells which are cytotoxic T lymphocytes cd8 lymphocytes are characterized by their capacity to recognize and eliminate virus infected in tumor cells when these tea cells encounter a cell displaying antigens associated with viral infection or malignancy they launch a direct attack releasing cytotoxic molecules that induce programmed cell death in the infected or abnormal cell furthermore CD4 cells are are also involved in delayed hypers sensitivity reactions contributing to immune responses against certain pathogens or antigens these cells play a multifaceted role in regulating immune reactions aiding the humoral immune response through antibody production and orchestrating cell mediated immune responses via the activation of cytotoxic tea cells collectively CD4 and cd8 T lymphocytes are Central components of the immune system working in concert to orchestrate and execute immune responses against a wide range of threats including infections and malignant cells humoral immunity represents a component of the immune system's defense mechanism and is primarily mediated by antibodies also known as immunoglobins these specialized proteins are produced by B cells in response to the recognition of specific antigens which can be associated with pathogens foreign substances or other Invaders antibodies bind to antigens with high specificity effectively neutralizing or marking them for Destruction they can inhibit the function of pathogens promote their phagocytosis by immune cells or trigger the activation of the complement system leading to the destruction of the targeted microorganisms IGA or imunoglobulin a is a component of humoral immunity with a particular role in mucosal defense this class of antibodies is abundantly found in various secretions including colostrum saliva and tears as well as within the mucosal Linings of the respiratory intestinal and genital tracts IGA plays a significant role in preventing the attachment of bacteria and viruses to mucous membranes when present in these secretions it acts as a first line of defense against potential pathogens by binding them and neutralizing their ability to adhere to the mucosal surfaces this action helps to block the initial steps of infection reducing the likelihood of pathogens establishing themselves Within the host IGM is an important antibody class involved in humoral immunity it plays a significant role in the early stages of the immune response typically being the first antibody produced in the primary immune response against an antigen IGM antibodies are characterized by their penomet structure which allows them to effectively activate the complement system upon encountering an antigen IGM antibodies can rapidly bind to it forming immune complexes that activate the complement Cascade this activation leads to a series of events that enhance the immune response by promoting the clearance of pathogens through mechanisms like opsonization and membrane attack complex formation IGG is a versatile antibody class within humoral immunity IGG antibodies are produced in both primary and secondary immune responses with a more robust production occurring during secondary responses due to the presence of memory B cells one remarkable feature of IGG is its ability to cross the placental barrier making it the only imunoglobulin that can be transferred from a pregnant mother to her fetus providing passive immunity to the newborn IGG antibodies also play a role in complement activation contributing to the immune response against pathogens when these antibodies bind to antigens on the surface of pathogens they can initiate the compliment Cascade leading to various immune activities such as opsonization phagocytosis and membrane attack complex formation IG is a specialized antibody class with distinctive roles in the immune system protecting the host against parasitic infections particularly helmets and worms by binding to their surface antigens and triggering an immune response that aims to expel the parasites from the body however IG is perhaps best known for its involvement in mediating immediate hypers sensitivity reactions such as allergies in response to allergens like pollen or certain foods these antibodies bind to massed cells and basophils leading to their activation this activation results in the Rapid Release of inflammatory mediators such as histamine which produces allergy symptoms like itching swelling and Bronco constriction on the other hand igd serves a different role within the immune system and is primarily found on the surface of B cells where it functions as a receptor when antigens bond to igd on the surface of B cells they activate these cells and Trigger the initiation of immune responses including the production of antibodies igd's role in activating these cells is fundamental for the immune system's ability to recognize and respond to a wide range of pathogens and antigens ultimately contributing to the development of adaptive immune responses humoral immunity serves to protect against infection by employing various mechanisms one of its primary functions is the neutralization of toxins and viruses antibodies produced during humoral immune responses can bind the toxins or the surface proteins of viruses rendering them inactive and preventing them from causing harm to the host additionally humoral immunity plays a crucial role in opsonization a process where antibodies coat pathogens making them easily recognizable and fos sized by immune cells such as macrofagos and neutrophils this response is particularly effective against agents that produce toxins bacteria encased in capsules and certain viral infections notably the primary immune response initiated by humor oral immunity typically takes 7 to 10 days to develop but subsequent infections with the same or similar pathogens trigger a faster and more efficient immune response due to the presence of memory B cells cell mediated immunity is a vital arm of the immune system responsible for defending against intracellular infections including tuberculosis gonorrhea viral infections fungal infections parasitic diseases and tumors it relies on a variety of specialized immune cells to execute its protective functions one key player is the CD4 helper T cell which serves as a central orchestrator of immune responses CD4 helper te cells assist in antigen recognition and the immune response by facilitating the activation of other immune cells C including cd8 cytotoxic tea cells that directly Target and Destroy infected or abnormal cells B cells involved in antibody production and macras is responsible for the phagocytosis and antigen presentation another subset of te- cells known as regulatory te- cells or treg previously referred to as suppressor te- cells controls and modulates the immune response tag cells help regulate the intensity and duration of immune reactions preventing excessive immune activity that could lead to autoimmune disorders or immune mediated tissue damage cd8 cytotoxic te- cells are effectors of cell mediated immunity with a primary role in targeting and eliminating infected or endogenous cells these specialized te cells possess a a potent arsenal of mechanisms to carry out their function effectively one key mechanism involves the production of perorin which are specialized proteins that are capable of creating holes or pores in the membranes of target cells these pores disrupt the Integrity of the cell membrane compromising its structural integrity and leading to the influx of ions and molecules subsequently cd8 cells introduce apos is a programmed cell death process in the Target cell apotosis is a highly regulated and controlled form of cell death that ensures the orderly disposal of the infected or damaged cell without causing excessive inflammation or tissue damage macrofagos are key players in cell mediated immunity serving as versatile immune cells with multifaceted functions these immune cells are Adept at ingesting and destroying foreign cells viruses or cellular debris through a process known as phagocytosis moreover macrofagos process and present antigens from engulfed pathogens on their cell surface these antigen presentations activate te- cells particularly the CD4 cell which recognizes foreign antigens that are bound to Major his compatibility complexes on the macroasia surface in response to the recognition of foreign antigens macrofagos also produce various cyto kindes including interlukin one or il1 and tumor necrosis factor or tnf these cyto kindes act as signaling molecules that help coordinate and amplify the immune response by recruiting other immune cells enhancing inflammation and regulating the immune system's overall activity micras thus serve as Central mediators in cell mediated immune responses linking the initial detection of pathogens to the activation of specific tea cells and the orchestration of immune reactions against infections enk cells are a unique subset of immune cells within cell mediator immunity characterized by their distinctive features and functions these large granular lymphocytes differ from te- cells in that they do not express te- cell antigen receptors instead these cells assist in recognizing and eliminating abnormal cells such as tumor cells or virus infected cells by distinguishing them from healthy host cells based on the absence of self markers a process known as missing self recognition ink cells are regulated by various proteins in the immune response ensuring precise control over their activity what sets ink cells apart is their ability to rapidly respond to target cells without requiring specific activation when Incas cells encounter a Target they can release perorin and granzymes which induce either apotosis or necrosis in the abnormal cell ultimately leading to its destruction cyto kindes are essential proteins produced by various immune cells playing a fundamental role in the regulation and modification of the immune response within cell mediated immunity these signaling molecules Ser as key messagers that orchestrate immune reactions influencing the behavior in function of other immune cells among the various types of cyto kindes chemokines represent a subgroup that is particularly involved in directing immune cells to specific locations within the body Chemin attract cells such as macras and neutrophils to the site of infection or inflammation their precise localization at the infection site ensures the rapid response of immune cells to combat evading pathogens or clear away cellular debris by facilitating the movement and positioning of immune cells cyto including chemokines contribute to the overall effectiveness of the immune response allowing for a coordinated and targeted reaction against infections and other immune challenges monoclonal antibodies represent a specialized class of antibodies distinct from the common polyclonal antibodies produced by various B lymphocytes while polyclonal antibodies exhibit diverse specificities for different Target antigens monoclonal antibodies are characterized by their uniformity as they are generated in large quantities from a single B cell clone this singular specificity allows for Precision in targeting particular pathogens or antigens monoclonal antibodies have found extensive applications in medicine and have been designed as drugs recognizable by their names ending with the suffix MB these antibodies are engineered to Target specific antigens and are employed for various therapeutic purposes including the treatment of immunological diseases cancer and the reversal of drug effects their use is particularly significant in addressing active diseases and providing prophylaxis for individuals who have not been vaccinated but do require protection against specific pathogens such as covid-19 the Ebola virus or even the zika virus hyp sensitivity reactions refer to immune responses that are characterized whether in appropriateness or exaggeration in reaction to typically harmless substances which lead to various clinical manifestations these reactions can occur after the initial exposure to an allergen during which the person becomes sensitized and develops an immune response in this process the immune system recognizes the allergen as foreign and mounts an antibody response often producing antibodies of the IG class these antibodies then bind to mass cells and basophils upon subsequent exposures to the same same allergen the sensitized individual experiences an exaggerated immune response the allergen binds to the IG antibodies on the mass cells and basophils triggering the release of inflammatory mediators such as histamine that lead to the characteristic symptoms of hypers sensitivity including itching swelling Bronco constriction or other types of allergic reactions hypers sensitivity reactions are classified into four types based on their underlying mechanisms and they can manifest in various clinical conditions ranging from mild allergies to severe autoimmune diseases hyper sensitivity reactions type one also known as immediate hypers sensitivity reactions are characterized by an excessive production of IG antibodies which then bind to mass cells or basofil in the body upon subsequent exposure to the allergen cross- linking of IG molecules on the surface of these cells leads to their activation and the release of various inflammatory mediators these mediators include histamine lucrin and tryptase as well as a stimulation of cyto production these released substances contribute to the Cascade of physiological response such as the contraction of smooth muscles and the induction of hypotension leading to the typical symptoms of type 1 hypers sensitivity reactions in localized reactions referred to as atopy patients may experience conditions like ticaria however type 1 hypers sensitivity reactions can also manifest systemically leading to a severe and potentially light life-threatening condition known as anaphylaxis anaphylaxis is characterized by widespread effects on the body including respiratory distress and circulatory collapse and can be triggered by various substances including Foods medications insect Venom and environmental agents like latex hypers sensitivity reactions type two known as cytotoxic hypers sensitivity reactions are characterized by the presence of antibodies directed against antigens found on the surface of host cell membranes these antibodies typically of the IGM or IGG class recognize these antigens as foreign or abnormal and initiate immune responses that lead to Cellular damage one of the mechanisms involved is the activation of the complement system which results in the formation of membrane attack complexes that create pores in the cell membrane this litic and osmotic damage disrupts the Integrity of the host cells leading to their destruction these reactions are observed in various clinical scenarios including transfusion Reactions where blood transfusions with incompatible antigens can trigger a rapid immune response and himalis of transfused red blood cells additionally these reactions are implicated in conditions such as hemolytic disease of the newborn where maternal antibodies directed against fetal red blood cell antigens cause destruction of the fetal red blood cells and in certain autoimmune diseases where the immune system mistakingly targets self antigens on the host cell leading to tissue damage and inflammation hyper sensitivity reactions type 3 also refer referred to as immune complex mediated hypers sensitivity reactions involve the desposition of circulating antigen antibody complexes on various tissues or on the endothelium of blood vessels this triggers a Cascade of immune responses that lead to tissue damage upon desposition these complexes activate the complement system resulting in the production of complement proteins and the formation of membrane attack complexes Additionally the activation of compliment releases chemotactic factors that attract other immune cells to the affected area the immune cells primarily nutrifil become activated and contribute to the inflammatory response further exacerbating tissue damage type three reactions are associated with a range of clinical conditions including cluding serum sickness polyarteritis nodosa glomular nephritis and systemic lupus in lupus for instance the accumulation of immune complexes in various tissues can lead to a wide array of symptoms and organ involvement highlighting the diverse and systemic nature of type 3 hypers sensitivity reactions hypers sensitivity reactions Type 4 also known as delayed type hypers sensitivity reactions are characterized by delayed onset of immune responses that typically occur days after exposure to the triggering antigen unlike the immediate hypers sensitivity reactions seen in type 1 type four reactions involve cell mediated immunity and are not antibody dependent in type four reactions tissue damage primarily results from the excessive activation of macras upon reexposure to the antigen synthetized T cells specifically CD4 t- hoper cells and cd8 cytotoxic tea cells recognize and respond to the antigen leading to the Recruitment and activation of macras at the site of contact these activated macras release inflammatory cyto and cytotoxic molecules causing tissue inflammation and damage a classic example of type four reactions is the skin rash associated with poison ivy and poison oak exposure in these cases contact with the plant's allergenic compounds sensitizes the individual and a delayed skin reaction occurs upon reexposure characterized typically by itching redness and even blister formation due to the inflammatory response orchestrated by the activated macras immuno deficiency refers to a state where the immune systems normal functioning is compromised due to dysfunction in one or more of its components this dysfunction can be attributed to various factors including genetic mutations that impair immune system function or environmental factors medical intervention underlying diseases like HIV or Aids or malignancies that disrupt the immune system's normal operation the specific component of the immune system that is affected can vary but the common outcome is that the patient becomes more susceptible to infections and diseases in critically ill patients whose immune systems are already under stress any additional compromise in immune function can be particularly detrimental as they have limited Reserve to fight off infections several factors associated with chronic illness such as stress Mal nutrition invasive medical procedures the loss of physical barriers pathogenic bacterial overgrowth or bacterial colonization of normally sterile tissues can further weaken immunity and increase the risk of infection patients undergoing immunosuppress of therapy either to manage autoimmune diseases or prevent organ transplant rejection face an elevated risk of infections and certain malignancies due to the deliberate suppression of their immune responses immuno modular medications such as corticosteroids or specific immunosuppressant are commonly used to dampen the immune system's activity in these clinical settings while these therapies are vital for controlling autoimmune reactions or ensuring graft acceptance they also diminish the body's ability to mount effective immune responses against pathogens or midate cells consequently patients on immunosuppressive regimens are more susceptible to infection caused by bacteria viruses fungi and parasites as their immune defenses are compromised Additionally the weakened immune surveillance can increase the risk of developing cancers particularly those related to viral infections such as certain lymphomas or skin cancers effectively managing transplant patients during Critical Care transports is a significant and specialized aspect of Health Care it is imperative to engage in thorough discussions with the transplant team a for initiating transport as a typical management strategy for various illnesses and injuries may become complex in the context of transplant patients this complexity arises from two main factors firstly the administration of immunosuppressive medications a Cornerstone of posttransplant care can introduce a range of side effects and interactions that need careful consideration secondly the patient's immunosuppressed condition a necessary consequence of transplantation to prevent organ rejection places them at an increased risk of infection and malignancy when transporting transplant patients certain considerations become Paramount to ensure their well-being firstly the management of surgical complications and the early recognition and intervention of cases in acute graph rejection are of utmost importance transplant recipients May develop surgical complications related to the transplantation procedure or the transplanted organ such as vascular issues bleeding or graph dysfunction which require prompt assessment and management secondly due to their immunosuppressed state these patients are particularly vulnerable to infection preventing infections through strict infection control measures is vital additionally Vigilant monitoring for any signs or symptoms of infection is imperative and even mild symptoms that might be overlooked in routine transports could signify serious conditions in transplant patients immunosuppression is a prevalent concern in patients receiving treatment in Rheumatology and oncology a demographic that surpasses even transplant recipients in numbers these patients often face a significant degree of immunosuppression as a consequence of their therapeutic regimens in Rheumatology patients with conditions like rheumatoid arthritis vasculitis or lupus are frequently prescribed immunosuppressive medications including steroids like prazone in order to manage their symptoms and control autoimmune responses likewise cancer Therapeutics such as chemotherapy and targeted therapies can profoundly impact the immune system leading to immune deficiencies in these immunosuppressed individuals infections May manifest more subtly than in their healthy counterparts often lacking the typical signs and symptoms this heightened susceptibility to infection underscores the importance of vigilant monitoring early detection and proactive infection prevention strategies in the care of Rheumatology in cancer patients as their compromised immune defenses demand a specialized and attentive approach to",
        "Pathogenicity": "healthare pathogenicity the vast majority of bacteria inhabiting the human body are either beneficial or have a neutral impact on our health these normal bacterial residents that colonize various niches in and on the body help to prevent disease non-pathogenic bacteria contribute to the body's defense mechanisms in several ways firstly they assist the immune system by preventing the overgrowth of pathogenic strains through mechanisms like competitive exclusion by utilizing available nutrients they limit the resources available for pathogenic bacteria effectively curbing their proliferation secondly normal bacteria help maintain a balanced pH level in their respective environments which can be inhospitable to certain pathogens furthermore they produce bacteri oins which are antibacterial toxins that can selectively Target and inhibit the growth of harmful bacteria opportunistic bacteria are agents that typically do not cause disease in individuals with normally functioning immune systems but can become pathogen and patients with compromised immune responses in these immunocompromised individuals the delicate equilibrium between the host and the microb is disrupted leading to an increased susceptibility to infection the immuno compromised State can arise from various factors including genetic defects that impair immune function the use of immunosuppressive medications like corticosteroids or chemotherapy or the presence of chronic diseases that weaken the immune system's defenses opportunistic infections can manifest in a range of clinical settings from hospital acquired infections to Chronic conditions like HIV or Aids where the immune system is progressively compromised the ability of these opportunistic bacteria to cause disease highlights the importance of understanding and addressing the unique vulnerabilities of imuno compromised individuals to minimize the risk and severity of infections in this patient population in individuals with acquired immuno deficiency syndrome certain indicator conditions which are clinical diseases that are typically rare or not seen in people with a healthy immune system become prevalent due to severe immune dysfunction providers must be acutely aware of the the heightened vulnerability of patients with compromised immune systems as these individuals can be inadvertently exposed to pathogens during the transportation process to mitigate the risk of infection transmission it is imperative for critical care transport providers to adhere to strict infection control practices pathogenic bacteria are microorganisms characterized by their ability to cause disease in their host organisms these mechanisms through which these pathogenic organisms induce disease are multifaceted and often involve a combination of virulence factors these factors can include attributes that facilitate their entry into the host body the colonization of specific host tissues the capacity to overcome host defense mechanisms the production of toxins capable of causing cytopathic effects or even the infliction of mechanical damage to host tissues in their quest to establish infection some pathogens employee strategies to invade the immune system surveillance and destruction this evasion can take various forms such as the production of capsules slime layers or specialized cell walls that make them less recognizable to the immune system additionally certain pathogens employ preemptive counter measures like disrupting fomes or inhibiting phagocytosis in order to enhance their survival and persistence within the host violence factors Encompass a spectrum of characteristics and mechanisms that collectively determine the degree of pathogenicity referred to as virulence exhibited by a microorganism these factors enhance the organism's ability to establish and propagate infection within a host several key factors significantly influence virulence including host and tissue specificity which dictates the microorganism's capacity to gain entry into the host body and Target specific tissues adherence to host cells is another Factor as it allows the microorganism to establish a foothold within the host while invasion of host tissues enables it to infiltrate and colonize evasion of host defenses involves tactics employed by the microorganism to circumvent the immune system surveillance and destruction Additionally the production of toxins contributes to the microorganism's pathogenicity in some cases microorganisms develop a protective polysaccharide capsule a process known as encapsulation which can enhance their virulence virulence is Quantified through two key measures the ineffective dose which reflects the number of microorganisms required to initiate infection in 50% of exposed individuals and the lethal dose which signifies the amount needed to cause the death of 50% of those infected host and tissue specificity in the context of virulence factors are key determinants of how pathogens interact with their hosts and the diseases they could potentially cause the portal of entry where a pathogen gains access to the host body shapes the course of infection and the specific disease manifestations different pathogens exhibit varying degrees of host and tissue specificity for example certain bacteria like staf cacus have a broad spectrum of tissue tropism allowing them to infect multiple tissues and induce various diseases in the host conversely some pathogens are highly specific in their host and tissue preferences causing infections only when they gain entry through particular routes or conditions this host and tissue specificity can profoundly influence the pathogenesis of infectious diseases and guide the clinical presentation observed in infected individuals adherence is a fundamental virulence factor that enables pathogenic organisms to initiate the process of infection within a host to establish infection and reproduce these organisms must first adhere to specific host cells this adhesion is often facilitated by specialized structures that extend outward from the bacterial cell wall known as peely or femry these structures enable bacteria to interact and attach to specific receptors on host cell surfaces creating a stable connection once adherence occurs many pathogenic organisms can immediately initiate the process of reproduction within the host tissue this step sets the stage for the subsequent stages of infection and disease development the ability to adhere to host cells is a fundamental aspect of the pathogen host interaction and is Central to the virulence of many infectious agents invasion is a virulence Factor employed by many pathogens to establish and propagate infection within a host once these microorganisms have gained entry into the host body they multiply within host cells exploiting the intracellular environment to their advantage some pathogens have the remarkable ability to invade a neighboring cells efficiently often utilizing specialized pores that connect adjacent cells this cellto cell infection not only facilitates their dissemination but also serves as a strategy to evade immune system surveillance and destruction as the pathogen can hide within host cells sheltered from the host's immune responses additionally some microbes utilize enzimatic mechanisms to break down the modular bonds that hold cells together thereby invading host tissues and spreading the infection toxicity is a virulence factor in the pathogenicity of bacteria with toxins categorized into two main types exotoxins and endotoxins exotoxins are proteins produced by certain bacteria and are typically secreted into the surrounding tissue or fluids these toxins exhibit High specificity in various modes of action often affecting different tissues exotoxins are generally specified by the genetic information carried on plasmids or bacteria phases and are predominantly produced by gr positive bacteria in contrast endotoxins are structural components of the bacterial cell wall and remain bound to the bacterium until it is destroyed at which point they are released exotoxins represent a significant category of bacterial toxins with unique characteristics and mechanisms of action these toxins are synthesized within bacterial cells and subsequently secreted into the surrounding tissues or fluids the genetic information specifying exotoxin production is typically carried on plasmids or bacteria fages exotoxins are renowned for for their High specificity often targeting specific tissues or cells and they exhibit diverse modes of action which contribute to their virence gr positive bacteria are the primary producers of exotoxins the classification is based on the types of tissues they affect leading to the categorization of neurotoxins which cause paralysis Intero toxins responsible for digestive tract damage etheric toxins targeting capill iies and cytotoxins capable of destroying various tissues neurotoxins or exotoxins that specifically Target the nervous system by interfering with neurotransmission or neural function they can lead to symptoms ranging from muscle weakness to paralysis diseases like botulism are known for their neurotoxin mediated paralysis inot toxins primarily affect the digestive tract they can disrupt normal intestinal function leading to symptoms like diarrhea and vomiting various bacterial species such as stacus Arius produce inter toxins that are responsible for food poisoning and GI infections aeic toxins are exotoxins that Target capillaries causing damage to small blood vessels this can result in the characteristic red rash in conditions like scarlet fever caused by streptococus pyes the toxins contribute to the systemic symptoms seen in these infections cytotoxins represent a broad category that have the capacity to damage various host tissues these toxins can affect multiple organs and systems leading to a wide array of clinical presentations endotoxins are an essential component of the cell walls of certain gram negative bacteria and they possess distinctive properties compared to exotoxins unlike exotoxins endotoxins are structural components of the bacterial cell wall specifically found in the outer membrane of gram negative bacteria these toxic molecules are not actively secreted by the bacteria during their growth or replication but are instead released when the bacterial cell wall is disrupted or destroyed such as when the bacterium dies this release of endotoxins can occur during bacterial infections or treatments like antibiotic therapy leading to various pathological effects several well-known bacteria produce medically important endotoxins examples include salmona and ecoli as well as many other gram negative pathogens when these bacteria are killed or liced they their endotoxins can be released into the surrounding tissues or bloodstream contributing to the inflammatory response and symptoms associated with bacterial infections the presence of endotoxins can trigger a Cascade of immune responses leading to Fever inflammation and potentially life-threatening conditions such as sepsis encapsulation is a virulence Factor employed by certain microorganisms to enhance their survival and pathogenicity some bacteria produce protective and polysaccharide layers which serve as capsules or slime layers that surround their cell walls these capsules have evolved to inactivate proteins essential for the immune system's aiic mechanism rendering the pathogens less susceptible to engulfment and destruction by fiic cells such as macrofagos this defensive strategy has two significant consequences first it makes it nearly impossible for macrofagos to ingest the pathogen and second it provides some bacteria with a safe haven to initiate reproduction within the protected environment of macras or length nodes in addition to encapsulation certain microbes have developed another protective mechanism known as biofilm formation biofilm are complex",
        "Epidemiology": "communities of bacteria and other microorganisms that aggregate on Surface such as Mechanical Devices or tissues within the body these biofilm structures are highly resistant to antibiotics and the host immune system they offer the bacteria shelter from immune surveillance and create a conducive environment for the exchange of genetic material facilitating the acquisition of antibiotic resistant genes epidemiology epidemiology is a field of study focused on understanding how diseases are distributed within populations it serves several specific objectives to Public Health First it aims to identify the iology or the underlying causes of diseases which is fundamental for developing effective prevention and treatment strategies second epidemiologists work to determine the extent of disease within a given Community providing valuable data for healthc care planning and resource allocation lastly the field seeks to understand the natural history of diseases including their progression and outcomes helping healthc Care Professionals anticipate and manage cases better moreover epidemiology evaluates the effectiveness of therapeutic methods and interventions it helps in identifying sources of disease outbreaks tracking the origins and spread of infections and recognizing the modes of disease transmission this knowledge is essential for implementing control measures and mitigating the impact of outbreaks ultimately epidemiologists work towards the development of methods for disease prevention including vaccination programs Public Health campaigns and sanitation improvements with the overarching goal of safeguarding the health of communities and populations epidemiology relies on two essential Concepts incidence and prevalence in order to gain insights into the occurrence and impact of diseases within populations incidents defined as a number of new cases of a disease within a specific population over a defin period serves as a viable metric when assessing how quickly a disease is spreading in a community it helps epidemiologists track the rate of disease emergence and identify potential outbreaks or surges in cases on the other hand prevalence incorporates the total number of cases of a disease within a population considering both old and new cases this metric provides a comprehensive view of the overall burden of disease on a population it takes into account the accumulated cases over time shedding light on the disease's persistence within a community both incidence and prevalence play roles in epidemiology they aid in understanding the patterns of disease occurrence facilitating the planning and allocation of health services and Facilities based on the population's needs additionally these Concepts and form decisions related to the training of future health care providers ensuring that Healthcare professionals are equipped to address the prevalent health issues in their communities effectively epidemiology provides a framework for understanding the various patterns of disease occurrence within populations when a disease occurs sporadically it means that it appears infrequently unpredictably in contrast endemic diseases are consistently present in a community with a number of cases expected and predictable over time an epidemic occurs when there is a clear and significant increase in the number of disease cases within a specific time or geographic area surpassing a predefined threshold on a global scale a pandemic describes a worldwide epidemic highlighting the widespread nature of the the disease to detect emerging or reemerging infectious diseases systematic data collection and continuous surveillance of disease incidents are essential organizations like the Centers for Disease Control and prevention monitors and tracks the incidence of contagious diseases allowing for timely interventions and public health responses in epidemiology infectious diseases are categorized based on their transmitt ability a communicable disease is one that can be transmitted from one person to another often through various modes of transmission such as direct contact respiratory droplets or vectors like insects on the other hand non-communicable diseases cannot be transmitted from person to person and are typically the result of factors such as genetics life lifestyle or environmental exposures contagious diseases represent a subset of communicable diseases and are characterized by their high level of transmitt ability often leaded to Rapid and widespread outbreaks for providers the nature of their workplaces put them at risk of Contracting infectious diseases as they are regularly transporting patients who may have these communicable diseases reservoirs of infection play a role in the persistence and transmission of microorganisms to establish and perpetuate an infection microorganisms require suitable conditions for survival and replication these reservoirs provide a continuous supply of nutrients and an environmental Niche that enables the long-term survival of the microorganism some micro organisms have evolved mechanisms to withstand adverse conditions and maintain their viability for extended periods for instance Spore forming bacteria are particularly resilient they can form spores a dormant and highly resistant form of the microorganism which can endure harsh environmental conditions such as drying and low nutrient availability in the soil these spores can persist for decades waiting for the right condition to return to their active infectious State encapsulated bacteria have developed a protective mechanism that enhances their resilience to hostile environments one notable feature of encapsulated bacteria is their resistance to changes in PH which means they can survive in a wide range of acidic or alkaline conditions moving on to reservoirs of infection both wild and domestic domestic animals can serve as significant sources of various infectious diseases these animals can Harbor microorganisms that are pathogenic to humans without displaying any symptoms themselves when such diseases are transmitted from animals to humans they are referred to as xenosis xonotic diseases pose a significant Public Health concern as they can lead to outbreaks and epidemics if not properly controlled influenza is a well-known example of xenosis where the influenza virus can be transmitted from birds or other animals to humans leading to flu outbreaks with the potential for severe consequences in epidemiology individuals who are colonized by pathogenic microorganisms but do not exhibit any symptoms of the disease are termed asymptomatic or latent carriers these carriers can unknowingly host and transmit diseases making them an important epidemiological consideration asymptomatic carriers can be responsible for the transmission of various infectious diseases including diptheria AIDS hepatitis gonorrhea and Amic dentary for instance individuals carrying the HIV virus without displaying symptoms can still transmit the virus to others through activities such as unprotected sexual contact it is essential to recognize that Healthcare environments such as Hospitals and Clinics can potentially serve as reservoirs of infection this phenomenon is particularly concerning as Healthcare settings are meant to be places of healing and Recovery one of the reasons for this is that medical equipment despite being subjected to anti antimicrobial cleaning and disinfection procedures can still Harbor bacteria for extended periods ranging from days to weeks this Persistence of bacteria on medical equipment can pose significant risk to patients especially those with compromised immune systems or who are undergoing invasive medical procedures inadequate cleaning improper disinfection techniques or the development of antibiotic resistant strains of bacteria all contribute to the proc istence of pathogens within Healthcare",
        "Selected Diseases": "environments selected diseases menitis is a medical condition characterized by the inflammation of the leptomeninges which are the protective membranes surrounding the spinal cord and brain this inflammation can result from infections caused by various pathogens including bacteria viruses parasites or fungi due to the potentially severe and life-threatening nature of bacterial menitis all cases of menitis are typically treated as if they have bacteria origin until this possibility has been ruled out this precaution is essential because bacterial menitis can progress rapidly and lead to significant neurological complications if not promptly diagnosed and treated with appropriate antibiotics bacterial menitis poses a significant medical challenge as it can lead to fatal outcomes in up to 30% of patients even among those who survive approximately 10% may experience permanent neurological impairments such as cognitive deficits hearing loss or motor dysfunction which underscore the devastating consequences of this condition while the classic clinical presentation of bacterial menitis includes a Triad of SYM symptoms comprising fever nucal rigidity and alter Bal status it is essential to note that fewer than half of those affected individuals exhibit all three components however almost all patients with bacterial menitis present with a fever which is typically greater than 10.4 Dees fah and at least one of the other classic Triad symptoms additionally patients may experience other symptoms such as severe headache photophobia and skin manifestations such as petii or Pera further adding to the clinical complexity of the disease given the high morbidity and mortality associated with this disease rapid diagnosis and immediate initiation of appropriate antibiotic therapy are Paramount to improve patient outcomes and minimize complications bacterial menitis can lead to various neurological comp complications and among them seizures and neurologic deficits are notable seizures can occur in a significant proportion of patients affecting approximately 30% of those with bacterial menitis these seizures can manifest as sudden uncontrolled episodes of abnormal electrical activity in the brain and are often associated with an altered mental state additionally ocular motor nerve pusies which involve dysfunction of the cranial nerves responsible for eye movement can be observed in a substantial number of cases clinical signs such as the Briny sign and keric sign are important diagnostic tools in the assessment of bacterial menitis the brazinsky sign is considered positive when there's an involuntary flexation of the patient's hips upon passive Flex flexation of the neck conversely the keric sign is deemed positive if the patient is unable to fully extend their knees when the hips are flexed suggesting resistance due to menial irritation in cases where bacterial menitis is suspected a diagnostic step is the performance of a lumbar puncture to obtain CSF this procedure involves the insertion of a needle into the subarachnoid space to collect a sample of CSF for analysis extremely important to note that the collection should not be delayed as prompt diagnosis and treatment are vital in bacterial menitis in fact antibiotics should not be withheld pending the results of the CSF as any delay in treatment can have serious consequences to determine the specific bacterial organism responsible for the infection clinicians take into consideration various factors including the patient's age medical history immune status and and they're presenting symptoms bacterial menitis is a condition predominant observed in adults and can be attributed to a range of bacterial species the most common culprits being neria menitis streptococus pneumoni and hemophilus influenza neria meningitis is often referred to as menia cauas is notorious for causing menia cocko menitis and as a leading cause of bacterial menitis in young adults especially in college dories streptococus manoni is a common respiratory pathogen and can also invade the CNS resulting in numac menitis which tends to affect older adults and individuals with underlying health conditions additionally hemophilus influenza primarily typ type B has been a significant cause of bacterial menitis in children however widespread vaccination has significantly reduce its incidents viral menitis characterized by inflammation of the menes due to viral infection is a condition commonly encountered in young adults unlike bacterial menitis viral menitis tends to have a less severe clinical course this condition can manifest acutely subacutely or even as a relapsing illness various viruses can be responsible for viral menitis including caxi A and B viruses echovirus adreno virus lymphocytic virus cyto Megalo virus poliovirus and Epstein bar virus many of these are transmitted through the feal oral route emphasizing the importance of proper hygiene and sanitation in preventing their spread viral menitis typically originates from structures in close proximity to the brain such as the middle ear sinuses or respiratory tract which can become colonized by pathogenic viral species this colonization May subsequently lead to the spread of the virus to the meninges resulting in inflammation and the characteristic symptoms of viral menitis although it is a serious medical condition it often follows a milder course compared to its bacterial counterpart patients with the disease typically present with symptoms such as fever nucal rigidity and a severe headache they may also experience nausea vomiting photophobia and a general sense of malaise despite its seriousness virro menitis usually resolves within 7 to 10 days and most patients recover without the need for specific antiviral treatments cellulitis is a skin condition characterized by the presentation of an area of skin with distinct borders often accompanied by rhythma edema and warmth it is most commonly observed in middle-aged and older adults the leading cause of cellulitis is infection with beta hematic strepto COI which can enter the skin through wounds or breaks in the Skin's barrier on the other hand an abscess is a localized collection of pus within the dermis or subcutaneous base it can develop as a result of various factors including infections forign bodies or obstruction of oil or sweat glands risk factors for both cellulitis and skin abscess include traumatic disruption of the Skin Barrier skin inflammation and edema due to impaired lymphatic drainage or Venus insufficiency as well as obesity imuno supression skin breaks between the toes pre-existing skin infections and close contact with individuals infected with or carrying Mera these risk factors increase the susceptibility to skin infections and prompt diagnosis and treatment are essential in managing cellulitis and preventing complications necrotizing fasciitis is a severe and potentially life-threatening soft tissue infection that primarily affects the subcutaneous tissues fat and fascia this condition is characterized by rapid tissue destruction and can progress quickly interestingly necrotizing fasciitis typically spares the skin and muscle in its initial stages which can make diagnosis challenging however prompt diagnosis and immediate intervention are fundamental for reducing mortality rates associated with this condition treatment typically involves a combination of broadspectrum antibiotics to Target the causitive bacteria and surgical de bment to remove infected and necrotic tissue given the highly contagious nature of some pathogens that can cause NE izing fasciitis Critical Care transport professionals must exercise Extreme Caution when handling and transporting these patients taking necessary precautions to protect themselves and prevent the spread of infection there are two types of necrotizing fasciitis type one which is polymicrobial and often involves both aerobic and anerobic bacteria and type two which is typically caused by group a streptococus as is often referred to as the flesh eating bacteria necrotizing fitis type 1 is a severe self tissue infection characterized by the involvement of a mixture of aerobic and anerobic microorganisms this type is often encountered in post-operative patients especially those with underlying medical conditions such as diabetes or peripheral vascular disease the causitive Agents of type one can vary but commonly include a combination of bacteria such as staf cacus orius stafl cacus species ocus species eoli Pepto streptococus species bacteroid species vibro vulnificus and claustrum species the polymicrobial nature of this infection contributes to its aggressiveness and challenging clinical management type two is primarily caused by the bacterium group a streptococus this type of necrotizing fasciitis typically arises when there is a breach in the Skin Barrier often occurring during surgery which provides it with an entry point into the deeper tissues the initial symptoms may include localized warmth redness or edema at the site of infection typic Al affecting an extremity as the infection progresses more severe systemic symptoms can develop such as fever tachicardia and hypotension indicating the severity of the condition within the subcutaneous tissues the bacteria proliferates rapidly leading to extensive tissue destruction it's important to note that treatment with antibiotics alone is not sufficient to combat type two and it is is associated with an extremely high fality rate if not promptly addressed through surgical intervention such as surgical debent to remove affected tissue nosocomial pneumonia is a severe and potentially life-threatening condition characterized by infection of the lung parima often caused by various pathologic bacteria and sometimes involving polymicrobial infections this type of pneumonia is most commonly associated with patients in healthc care settings hence its name nosocomial pneumonia includes several distinct subtypes including Hospital acquired pneumonia ventilator Associated pneumonia and Healthcare Associated pneumonia each with its specific criteria Hospital acquired pneumonia occurs when patients develop pneumonia 48 hours or more after admission to a hospital and its mortality rate is alarmingly high reaching about 50% ventilator Associated pneumonia on the other hand affects ventilated patients within 48 hours after indot tracheal intubation adding to the complexity of managing these critically ill individuals lastly Hospital Associated pneumonia is diagnosed in non-hospitalized patients who have had contact with Health Care Facilities or personnel highlighting the risk of acquiring infections even outside traditional Hospital settings fungal diseases have shown an alarming increase in incidents over the past two decades particularly among individuals with compromised immune systems unlike many bacterial and viral infections fungal diseases are generally not contagious to healthy individuals and are usually a result of opportunistic pathogens taking advantage of weakened immune defenses the rising prevalence of fungal diseases can serve as an important indicator of serious immunosuppression making early diagnosis and treatment critical for affected patients when transporting individuals with fungal infections providers must exercise caution and follow strict infection control protocols to prevent the potential spread of these pathogens this includes thorough decontamination of your equipment proper hand hygiene and adherence to personal protective measures to safeguard both the patient and healthc care providers from further complications herpes viruses are a family of viruses known for their ability to establish latent infections following an initial acute viral syndrome during which they cause symptoms there are six main types of herpy viruses each with its own unique characteristics these include herpes simplex types 1 and two known as hsv1 and hsv2 vercillo roster virus cyto megala virus Epstein bar virus in human herpes virus 8 two members of this family Epstein bar and human herp virus 8 are notably associated with the development of certain cancers such as burket lymphoma and kosi saroma hsv1 and two are responsible for causing lesions hsv1 is typically transmitted through saliva often leading to oral herpes while hsv2 primarily spreads through sexual contact resulting in general herpes these viruses can cause painful and recurrent outbreaks of lesions on the affected area with periods of latency between episodes it's important to note that herpes viruses can remain dormant within the body and reactivate at a later time leading to the recurrence of symptoms this ability to establish latent infections and periodically reactivate makes herpes viruses a unique and clinically significant group of viruses in the field of infectious diseases viral hepatitis is a condition characterized by inflammation of the liver which can result from various causes including infectious agents toxins or drugs this inflammatory process can lead to a wide range of symptoms from mild malays and subclinical symptoms to more severe manifestations such as jaundice hepatomegalia abnormalities in blood clotting alter mental status and even multiple organ failure in severe cases there are six known viruses that can cause hepatitis namely hepatitis A B C D E and G each with its own unique characteristics in modes of transmission we can further categorize hepatitis into two main types based on the duration of symptoms acute hepatitis is defined by the presence of symptoms of liver inflammation for a duration of 6 months or less chronic hepatitis is defined by symptoms of liver inflammation lasting 6 months or more the severity and progression of hepatitis are often evaluated by assessing histologic and pathologic findings allowing for grading and staging of the disease hepatitis A is primarily transmitted through the fcal oral route typically via contaminated food or water the virus has an incubation period of 2 to 6 weeks before symptoms manifest large scale outbreaks can occur when contaminated food or drinking water sources are widespread however in recent years there has been a significant increase in the incidence of person-to-person outbreaks of hepatitis A leading to a higher number of cases in 2018 there were a reported 12,474 cases of hepatitis A in the United States but this figure likely underrepresents the true number as many cases were asymptomatic and thus unreported symptoms of hepatitis A can include jaundice fatigue abdominal pain loss of appetite intermittent nausea and diara fortunately it is preventable through vaccination which is recommended for for various groups including children starting at age one and up also individuals planning to travel to Regions with a high prevalence of hepatitis A as well as those residing in endemic areas as well as children and caregivers at daycare centers all should have the hepatitis A vaccine additionally immune globulin can be administered before or after known exposures to provide a temporary protection Hepatitis B is primarily transmitted through various routes including shearing needles sexual contact or accidental exposure in health care settings the virus can be found in all body fluids and has an incubation period ranging from 1 to 6 months in the United States there were 3,322 reported cases of acute hepatitis B in infections in 2018 but again the actual number is estimated to be higher with an approximate figure of 21,600 cases accounting for Under reporting symptoms are similar to those of hepatitis A they may include jaundice sclero ioris fatigue abdominal pain loss of appeti and intermittent episodes of nausea and vomiting Hepatitis B can lead to various disease States including acute hepatitis fulminant hepatitis and chronic hepatitis fulminant hepatitis is characterized by severe liver inflammation rapid destruction of liver tissue and often resulting in liver failure patients may also experience inyopools and cerebral EMA necessitating transplantation to save their lives chronic hepatitis b is another outcome where individuals may remain asymptomatic carriers capable of infecting others without evident liver damage in 2015 an estimated 257 million people worldwide were carriers of chronic Hepatitis B chronic Hepatitis B of infection can manifest as chronic persistent hbv a low-grade infection from which the patient eventually recovers or as chronic active hepatitis where the patient remains in an active hepatitis State without recovery for more than 6 months patients at the highest risk of hepatitis B infection include individuals engaging in highrisk behaviors such as IV drug use unprotected sexual activity with multiple partners ERS and men who have sex with men people living in or traveling to Regions where the disease is endemic intervenous drug users heterosexuals with multiple sexual partners and individuals of low socioeconomic status are also at elevated risk additionally children born to immigrants from Hepatitis B endemic areas infants born to infected mothers hemodialysis patients and Healthcare work workers who may be exposed to infected blood or body fluids are considered high-risk populations hepatitis C is responsible for both acute and non-acute or chronic hepatitis is primarily transmitted through exposure of inflected blood often associated with shearing needles during drug use and can also be transmitted through sexual activity although the rate of sexual transmission is lower compared to that of of hepatitis B its incubation period ranges from 2 weeks to 6 months in 2018 there were 3,621 reported cases in the United States but as with hepatitis B the actual number of cases is estimated to be much higher exceeding 50,000 hepatitis C infection is often a symptomatic in its early stages making it challenging to diagnose without proper screening Additionally the interval from initial affection to the development of therosis can extend beyond 30 years further complicating disease assessment and management infection can lead to sosis a condition observed in 5 to 25% of affected individuals making it a significant medical concern it stands as the primary cause behind the need for liver transplantation further emphasiz izing its clinical revalence key risk factors for transmission include IV drug use in a history of blood transfusions prior to 1990 additionally individuals undergoing hemodialysis Health Care Professionals sexual partners of infected individuals hemophiliacs and neonates born to hepatitis C infected mothers are all susceptible to Contracting the virus the necessitating a comprehensive approach to prevention and management recent advances in the field of hepatitis C virus treatment have led to the development of curated therapies for the disease caused by genotypes 1 and four which Mark a significant breakthrough however it is imperative to note that despite these therapeutic breakthroughs there remains an absence of preventative vaccines against hepati I itis C the primary objective of treatment is to mitigate the progression of the disease with the focus on averting the onset of therosis and liver failure as these represent severe and potentially life-threatening complications associated with chronic hcv infection hepatitis D is an RNA virus with a unique characteristic as it can only replicate in the presence of the hepatitis B virus this interdependence makes it particularly challenging to manage and treat as it often occurs concurrently with hepatitis B infection leading to more severe liver related complications it is predominantly endemic in regions such as the Mediterranean Middle East and parts of South America where the prevalence of both infections is notably high transmission primarily occurs to the exchange of contaminated blood products especially through unscreened blood transfusions and IV drug use highlighting the significance of stringent blood safety measurements and harm reduction strategies in curtailing its spread Hepatitis E is relatively uncommon in the US with the majority of cases being reported among individuals who have traveled to Regions considered indemic including India southeast Asia Africa and Mexico the transmission and clinical course are akin to hepatitis A often occurring through contaminated food and water sources however a distinctive and concerning feature is its notably High fatality rate in pregnant women making it a particularly Public Health concern in regions where it is endemic pregnant women infected with Hepatitis E face an increased risk of severe complications and mortality underscoring the importance of preventative measures and vaccination for vulnerable populations hepatitis G primarily transmitted through parental routes such as blood transfusions IV drug use and needl stick injuries is frequently identified in individuals with chronic liver disease however despite its prevalence in this population a definitive causitive link between hgv and chronic liver disease remains elusive the exact role of hepatitis G in liver pathology remains unclear and has not been conclusively established as a sole causitive agent for chronic liver disease therefore further research is needed to explain the intricate relationship between hepatitis G and liver disease riet seal diseases a group of infectious illnesses caused by bacteria of the Ricket sea genus are primarily transmitted through tick bites marking the vector responsible for their dissemination among these diseases three major entities fall under the classification of tick born Ricket seal diseases namely Rocky mounted Spotted Fever air liosis and ooplasm notably Rocky mountet Spotted Fever presents the highest mortality rate among these conditions posing a more severe clinical threat this potentially life-threatening disease is characterized by symptoms such as fever rash and various systemic manifestations early signs and symptoms of tick born diseases are typically mild and lack specificity posing a diagnostic challenge in individuals with suspected or known tick exposure Rocky Manus Spotted Fever should be considered when fever is present the onset of symptoms in these diseases is acute characterized by fever often accompanied by severe headache rash muscle aches nausea vomiting and Mala to prevent these diseases effective strategies include the application of insect repellants containing DEET and wearing light colored clothing long sleeves and long pants to minimize tick contact after outdoor activities the body should be thoroughly inspected for ticks and if any are found they should be carefully removed using tweezers and gloves to prevent tickborne infections importantly one should avoid crushing or squeezing The Tick during removal post extraction the bite area should be cleaned with soap water and rubbing alcohol to minimize the risk of infection transmission",
        "Strategies for the Treatment of Infectious Disease": "strategies for the treatment of infectious disease antibiotics a category of antimicrobial agents can be broadly classified into two main groups based on their mechanism of action bacteriostatic antibiotics work by inhibiting the growth of bacteria thereby preventing their replication and spread in contrast bacteria cdal antibiotics have a more direct and lethal effect as they actively kill bacteria disrupting essential cellular processes or structures what unifies all antibacterial agents is their specificity for targeting proteins processes or cellular components that are distinct from those found in human cells this selectivity is essential for minimizing harm to the host while effectively combating bacterial infections by targeting microbial elements unique to bacteria antibiotics can exert their therapeutic effects ultimately aiding in the eradication or containment of bacterial pathogens within the human body viruses posed a substantial Global Health burden contributing to millions of severe illnesses annually notably seasonal influenza viruses alone account for a staggering 3 to 5 million severe cases and result in 290,000 to 650,000 deaths due to respiratory illnesses each year in response to these viral threats the primary objective of antiviral medications is to impede the replication of the virus within the host body however a significant challenge in combating viral infections is that Viral replication often OCC occurs during an incubation period when the patient is asymptomatic making early intervention and diagnosis key furthermore once a virus has entered a latent state within the host cells it becomes exceedingly difficult if not impossible to completely eradicate necessitating long-term management strategies for certain viral infections antiviral agents Encompass three distinct class tailored to Target viral infections first nucleoside analoges function by mimicking nucleotides the building blocks of DNA and RNA thereby disrupting viral genome replication second enzyme Inhibitors act on specific viral enzymes required for viral replication inhibiting their activity and impeding the virus's life cycle lastly interference arons exemplified by Alpha an Aeron serve as signaling proteins that activate the host immune response against viral Invaders while these antiviral therapies play an essential role in managing affections it is vital to emphasize that the most effective means of prevention against many viral diseases remains vaccination vaccinations stimulate the immune system to produce proactive antibodies or immune memory cells offering long-term immunity and reducing the risk of infection often serving as a Frontline defense in public health initiatives against various viral pathogens the development of effective anti-fungal agents poses a unique challenge due to the shared eukaryotic nature of human and fungal cells both human and fungal cells share a common cellular characteristic making it difficult to find agents that selectively ly Target fungal cells without causing harm to human cells to address this challenge anti-fungal medications are designed to selectively Target Pathways or enzymes that are specific to fungal cells by focusing on these distinct fungal components anti-fungal agents can interfere with critical cellular processes unique to fungi such as cell wall synthesis or ergosterol biosynthesis while sparing human cells which lack these specific fungal  features"
    },
    {
        "Introduction": "chapter 22 obstetric and gynecologic emergencies introduction management of pregnant patients poses significant challenges for critical care paramedics due to several key factors that demand careful consideration firstly the provider must strike a delicate balance between addressing the health concerns of both the pregnant woman and the developing fetus this dual focus is vital as interventions or treatments aimed at improving the mother's condition should not jeopardize the well-being of The Unborn Child secondly the physiologic changes introduced by pregnancy add complexity to patient management pregnancy leads to various alterations in the cardiovascular respiratory and endocrine systems these changes can influence the presentation of symptoms and the body's response to emergencies making it crucial for providers to be well versed in the unique physiology ol of pregnancy thirdly pregnant patients may present with potentially life-threatening pathologic conditions specific to pregnancy or exacerbated by it these conditions could include preeclampsia placental abruption or topic pregnancies recognizing these emergencies promptly and taking appropriate actions is vital to ensuring the safety of both the mother and the fetus in this context this chapter serves as an invaluable resource offering an overview of the physiologic changes that occur during pregnancy additionally it delves into specific emergency conditions associated with pregnancy child birth and postpartum care understanding the anatomic and physiologic changes that transpire throughout pregnancy is fundamental for critical care transport professionals as it forms the foundation of delivering Optimal Care in obstetric and gyne ologic emergencies by being well informed and prepared to address the unique challenges presented by pregnant patients providers can contribute significantly to improved outcomes for both mother and baby during critical",
        "Anatomy and Physiology of the Female Reproductive System": "situations anatomy and physiology of the female reproductive system the female reproductive system operates on a 28-day a menstrual cycle characterized by a series of precise hormonal secretions during this cycle the uterine wall undergos a process in which it sheds its inner lining known as the endometrium as a result mucosal tissues blood are discharged through the vagina typically referred to as menstration in the context of conception and gestation if fertilization has occurred through the union of sperm and egg the resulting zet or fertilized egg undergos implantation in the receptive endometrium of the uterus this critical step marks the initiation of pregnancy where the developing embryo receives essential nutrients and support from the maternal body for further growth and development the placenta is firmly attached to the uterine wall its primary role encompasses several vital functions firstly it serves as a conduit for supplying the fetus with the central oxygen and nutrients required for growth and development facilitating the exchange of these substances between maternal and Fetal bloodstreams secondly the placenta plays a key role in removing waste products notably carbon dioxide from fetal circulation ensuring the elimination of metabolic byproducts Additionally the placenta functions as an endocrine organ secreting progesterone which is essential for maintaining the Integrity of the swollen endometrium and sustaining the ongoing pregnancy importantly the placenta has the remarkable ability to grow in tandem with the developing fetus adapting to the increasing demands for oxygen and nutrients as pregnancy progresses the placenta is also equipped with a thin membrane that separates fetal blood from maternal blood while this barrier provides protection and separation between the two circulations it is not entirely impermeable some nutrients and medications can pass through this membrane allowing for a selective transfer of substances necessary for fetal well-being or therapeutic interventions as required overall the placenta multifaceted functions are essential for ensuring the health and V ability of the developing fetus throughout pregnancy the umbilical cord is a vital structure in fetal development consisting of two arteries and one vein this arrangement provides a conduit for the exchange of oxygen and nutrients between the developing fetus and the placenta which is needed for the fetus's growth and substance the umbilical cord serves as a life line connecting the fetus to the placenta where oxygen and nutrients are received from the maternal bloodstream while waste products including carbon dioxide are transported away for elimination this critical connection ensures the fetus's well-being throughout pregnancy and highlights the importance of careful monitoring and preservation of the umbilical cord during obstetric and gynecological emergencies pregnancy is a dynamic physiological process characterized by several key factors in the initial 12 weeks the growing fetus is situated within the pelvis offering some protection to the developing uterus however as the pregnancy progresses and the uterus expands upward into the abdominal cavity the risk of injury to the fetus becomes more pronounced due to its placement and increased vulnerability one method used to gauge the progression of pregnancy is McDonald's rule a clinically relevant guideline according to this rule the fundle height measured in centimeters from the pubic symphysis to the top of the uterine fundus is proportionate to the number of weeks gestation this measurement can be applied effectively from the 12th to the 38th week of pregnancy offering Healthcare Providers a valuable tool to estimate the stage of gestation and monitor fetal growth by understanding these aspects of Pregnancy healthc Care Professionals can better assess and manage obstetric and gynecologic emergencies ensuring the well-being of both the pregnant woman and the",
        "Physiologic Changes During Pregnancy": "fetus physiologic changes during pregnancy pregnancy exerts a profound influence on the typical physiological functions of females impacting nearly every organ system within the body these alterations can introduce complexities in clinical assessment as they have the potential to obscure well recognized signs or symptoms of underlying diseases furthermore some of these pregnancy induced changes can mimic pathological conditions making it challenging to differentiate between normal physiolog iCal adaptations and actual health issues in light of these considerations providers must possess a functional understanding of the various physiological changes that accompany pregnancy this knowledge is indispensible for accurately assessing and managing pregnant patients as it enables the differentiation between normal pregnancy related variations and potential medical concerns the cardiovascular system undergoes significant changes during pregnancy to support the growing demands of the developing fetus one notable adaptation is the increase in normal cardiac output which Rises by approximately 20 to 30% within the first 10 weeks of pregnancy this augmented cardiac output can be attributed to several factors including an expansion in plasma volume or reduction in vascular resistance and an increment in heart rate by approximately 10 beats per minute these adjustments ensure an adequate blood supply to meet the increased metabolic needs of both the mother and developing fetus additionally there is a notable increase in blood flow directed toward the uterus to facilitate optimal field development the elevated position of the diaphragm due to the enlarging uterus can lead to the displacement of the heart within the chest cavity this anatomical shift May alter the way the heart functions and is positioned within the chest potentially influencing cardiac output and the overall cardiovascular Dynamics during pregnancy these cardiovascular adaptations are essential in sustaining a healthy pregnancy and warrant careful consideration in the evaluation and management of pregnant patients blood pressure regulation undergo significant changes throughout pregnancy which Critical Care paramedics must consider when assessing and managing pregnant patients in mid pregancy blood pressure often experiences a decrease due to the influence of progesterone a hormone that relaxes the walls of blood vessels this decrease is most pronounced during the second trimester when blood pressure reaches its lowest point dropping by approximately 5 to 10 millim of mercury systolic and 10 to 15 millime of mercury diastolic however as pregnancy progresses to term blood pressure gradually returns to levels near those observed before pregnancy providers should be mindful of these fluctuations as they can impact the assessment of a pregnant Pat patient cardiovascular status patients may present with lower blood pressure levels than their Baseline complicating the differentiation between physiologic and pathologic hypotension body position plays a role in blood pressure and cardiac output regulation particularly during the third trimester in a Supine position the enlarged uterus May compress the vnea leading to a condition known as sepine hypotensive syndrome resulting in hypotension displacement of the uterus off the venne Hava by repositioning the patient can help restore blood pressure for patients secure to a long spine board it is important to tilt the backboard to alleviate pressure on the venne Cava placing materials underneath the backboard rather than under the patient helps maintain proper positioning and circulation minimizing the risk of supine hypotensive syndrome and ensuring Optimal Care for the patient Venus pressure in the lower extremities undergo significant alterations during the later stages of pregnancy this phenomenon is primarily attributed to the compression exerted on the inferior vnea and pelvic veins by the enlarging uterus as a result peripheral Venus pressure in the lower limbs progresses ly Rises creating a series of clinical implications one notable consequence of elevated Venus pressure is the potential for increased bleeding from minor wounds or injuries to the lower extremities this height and pressure within the veins can impede the normal hematic mechanisms leading to more significant blood loss than expected moreover the heightened Venus pressure in the lower limbs poses additional risks to the pregnant patient it can contribute to the development of legadema a condition characterized by the accumulation of excess fluid in the lower extremities there is an increased susceptibility to the formation of hemorrhoids varicose veins and DVT hemorrhoids result from the dilation of rectal veins due to elevated pressure while vericose veins manifest as swollen and twisted veins in the legs DVT is a potentially life-threatening condition in which blood clots form in the Deep veins posing a risk of imization blood volume and composition undergo substantial changes during pregnancy reflecting a complex interplay of physiological adaptations to support both the mother and the developing fetus circulating blood volume expands significantly increasing by an average of 40 to 45% this expansion serves several critical purposes including providing an adequate blood supply to the developing fetus and compensating for factors such as impaired Venus return to the maternal heart and potential blood loss during labor one notable effect of this increase in blood volume is the development of dilutional anema where the rise in plasma volume outpaces the increase in hemoglobin levels leading to to a relative reduction in red blood cell concentration Additionally the Lucas cell count Rises although their function may be somewhat depressed platelet counts on the other hand remain relatively stable the coagulation system undergos modifications as well with increased levels of coagulation factors and a substantial elevation in fibrogen levels nearly doubling by the time of delivery these changes heighten the risk of thrombotic events making pregnant women predisposed to conditions such as DVT and Pulmonary embolism in clinical practice these alterations have critical implications pregnant patients with active bleeding may experience significant blood loss before exhibiting overt clinical signs including changes in Vital Signs consequently healthc care providers must maintain a high index of Suspicion and closely monitor pregnant patients especially those involved in traumatic incidents even while hemodynamically stable pregnant patients with blunt trauma should be considered at risk for internal bleeding necessitating thorough evaluation and appropriate interventions to ensure their safety and the well-being of the developing fetus pregnancy exerts significant effects on the respiratory system with several key adaptations and considerations that Healthcare Providers must be aware of when managing pregnant patients ventilation increases due to an elevation in tidal volume allowing for a greater exchange of oxygen and carbon dioxide to meet the heightened metabolic demands of both the mother and the growing fetus while the respiratory rate may increase slightly the primary mechanism for accommodating increased oxygen demand is through changes in tital volume rather than a substantial rise in breathing frequency the body compensates for the alkaline shift in PH that often accompanies pregnancy by creating a state of metabolic acidosis this adjustment helps maintain the acidbase balance necessary for optimal physiologic functioning the growing fetus places greater demands on oxygen supply reducing the oxygen Reserve available to the pregnant patient this reduced Reserve increases the susceptibility of pregnant patients to hypoxia in situations where oxygenation is compromised pregnant patients in respiratory distress face challenges in using accessory respiratory muscles effectively because the diaphragm is displaced due to the enlarging uterus and abdominal muscles may be weakened these anatomical changes can limit the patient's ability to compensate for Respiratory difficulties patients in respiratory arrest experience hypoxia more rapidly than non-pregnant patients due to the reduced oxygen reserve and compromised respiratory mechanics prompt intervention must occur to prevent severe oxygen deprivation early oxygenation and aggressive Airway management including ination if necessary should be primary considerations when managing pregnant patients in respiratory distress orrest ensuring adequate oxygen delivery is essential for the well-being of both the mother and the developing fetus healthc care providers should be prepared to address these unique respiratory challenges to optimize patient outcomes during Critical Care situations pregnancy induces significant GI changes with clinical relevance for providers during obstetric and gynecologic emergencies the enlarging uterus displaces abdominal organs raising the risk of nausea and vomiting especially in later pregnancy stages delayed gastric emptying and reduced gastro esophageal sphincter tone contribute to Gastro esophagal reflux a common issue in pregnant women which can potentially lead to aspiration chronic nausea vomiting and dehydration are also common during pregnancy due to hormonal shifts in organ displacement necessitating careful fluid and electrolyte management given the heightened risk of aspiration providers should consider early intubation to secure the airway the renal and endocrine systems undergo significant change es during pregnancy each with its own set of clinical implications the renal system experiences notable adaptations during pregnancy glomular filtration rate increases by approximately 30% to meet the heightened demands of waste elimination and fluid regulation this increase is accompanied by the enlargement of the kidneys and relative obstruction of the URS due to the expanding uterus potentially leading to hydro urer nephrosis these conditions manifest as frequent urination in flank Paine commonly referred to as kidney pain pregnant patients are also more susceptible to urinary tract infections which if left untreated can lead to a severe kidney infection in cases of chronic renal failure patients may require dialysis as needed to manage renal function and fluid balance effectively the endocrine system undergos significant changes from the moment of conception the pituitary and thyroid glands enlarge contributing to an increase in the production of several hormones including estrogen progesterone cortisol and thyroxine these elevated hormone levels can lead to insulin resistance resulting in elevated blood glucose levels and the develop vment of gestational diabetes thyroid conditions if present may not only affect maternal Health but can also impact fetal development and potentially lead to fetal distress underscoring the importance of monitoring and addressing endocrine related concerns during pregnancy pregnancy induces various dermatologic changes each with its distinct characteristics ICS and potential impact on maternal well-being firstly increased acne can occur due to hormonal fluctuations particularly elevated Androgen levels secondly the development of a lenina Negra a darkened line extending from the naval to the pupus is a common pigmentation change during pregnancy primarily attributed to a melany stimulating hormone production third thirdly clisma characterized by darkened skin patches on the cheeks and forehead results from increased melanin production often triggered by hormonal changes and sunlight exposure in some cases late term pregnant patients may present with puic ertical papules and plaques of pregnancy or P PPP an itchy rash that can be localized to one area or spread widely across the body the exact cause remains unclear but it's thought to be related to immune system changes during",
        "Fetal Assessment and Monitoring": "pregnancy fetal assessment and monitoring fetal circulation and oxygenation are essential processes that ensure the developing fetus receives the necessary oxygen and nutrients for growth and survival these processes are facilitated through the umbilical vein and umbilical arteries which form the umbilical cord connecting the fetus to the placenta the oxygen content in fetal blood is lower than that of maternal blood underscoring the need for efficient oxygen transfer the developing fetus relies on the exchange of oxygen and nutrients across the placental barrier obtaining oxygen from the maternal bloodstream despite this Reliance the fetus possesses a limited reserve of oxygen typically lasting for about 1 to two minutes in case the maternal oxygen supply is temporarily disrupted as might occur during contractions in labor during labor oxygen supply to the fetus is replenished between contractions when uterine blood flow is restored however the fetal heart rate is highly sensitive to changes in oxygen supply any disruptions or reductions in oxygen delivery can lead to fetal distress highlighting the importance of closely monitoring fetal heart rate and promptly addressing any signs of compromised oxygenation during labor and delivery fetal assessment is a fundamental aspect of prenatal care and Labor Management just as all patient assessments begin with the evaluation of ABCs fetal assessment also involves assessing the fetal ABCs which present unique challenges to assess fetal well-being pregnant patients are encouraged to monitor fetal movements aiming for a minimum of 10 kicks every two hours providers may use a Doppler or fetal stethoscope to detect and evaluate the fetal heartbeat which is typically within the normal range of 110 to 160 beats per minute in cases where there is an insufficient fetal movement count or a non-reassuring fetal heart rate further detailed evaluation is warranted this may involve additional tests such as a non-stress test or a biophysical profile these assessments provide a more comprehensive picture of fetal health and help healthc care providers make informed decisions regarding the management of pregnancy and potential interventions to ensure the well-being of both a pregnant patient and the developing fetus electronic fetal monitoring is a critical tool in the assessment of fetal well-being particularly during high-risk inner facility transports this monitoring can be conducted externally and involves the use of specialized equipment to gather essential data external fetal monitoring typically entails the application of an ultrasonic transducer to the pregnant patient's abdomen the equipment required for this process includes a fetal monitor conducting gel tracing paper an ultrasonographic Doppler and an external uterine activity detector known as a Toco dynamer the primary purpose of electronic fetal monitoring is to assess the fetal oxygenation during labor providing valuable insights into the well-being of the developing fetus the interpretation involves the assessment of uterine contractions along with the analysis of five key fetal heart rate components the Baseline heart rate Baseline variability accelerations de acceleration ations and changes or Trends observed over time uterine contractions alert the provider to the progress of Labor and the well-being of both the pregnant patient and the developing fetus these contractions are typically measured by assessing their frequency and pattern over a designated time frame specifically contractions present in a 10-minute interval are averaged over 30 minutes to establish the contraction pattern to externally detect uterine contractions the Toco Dynam meter is employed which assesses the abdominal pressure and Contour changes resulting from uterine contractions in normal labor the contraction pattern typically consists of five or fewer contractions in a 10-minute window averaged over 30 minutes when contractions occur more frequently exceeding five contractions in a 10-minute interval averaged over 30 minutes it is termed tachis cyly which may have clinical implications and require careful monitoring once uterine contractions are assessed and Quantified they are categorized as a category one two or three based on their characteristics with each category signifying a different level of concern and potential impact on fetal well-being this classification system AIDS healthcare providers in making informed decisions regarding the management of Labor and the safety of both the pregnant patient and the fetus during childbirth early pregnancy loss also known as miscarriage or spontaneous abortion is a relatively common occurrence in the early stages of pregnancy affecting approximately 30% of all pregnancies before reaching the 20th week Mark the majority of these losses roughly 80% transpired during the first trimester chromosomal abnormalities in the developing fetus contribute to approximately half of these early pregnancy losses patients typically present with symptoms such as vaginal bleeding and cramping prompting early clinical evaluation during assessment the primary focus is to differentiate between an early pregnancy loss and other potential complications such as an atopic pregnancy providers should remain vigilant for signs of excessive bleeding defined as soaking more than one pad per hour which necessitates immediate attention additionally hypotension if observed should be addressed promptly through isotonic fluid replacement to maintain hemodynamic stability treatment primarily involves providing comfort and emotional support to the patient during this challenging time in some cases a medical procedure known as dilation and cutter or a DNC may be required to remove all the products of conception ensuring complete complete resolution Critical Care transport providers should be attentive to signs of infection in patients who have undergone a DNC monitoring for symptoms such as fever chills pelvic discomfort Topia and lethargy which may indicate post-procedural complications at topic pregnancy is a critical obstetric condition characterized by the implantation of a fertilized egg outside of the uterus most commonly within the fallopian tube this condition poses a life-threatening risk to the pregnant woman as it can lead to severe Hemorrhage and other complications if not promptly addressed healthc care providers should maintain a high index of Suspicion for a topic pregnancy in all women of childbearing age Who present with sudden onset of abominal pain or unusual vaginal bleeding as these symptoms can be indicative of this condition early detection ensures timely intervention and minimizes potential harm to the patient treatment options for a topic pregnancy include both medical and surgical approaches medical management often involves the administration of medications such as methyl trexate to Halt the growth of the atopic pregnancy and facilitate its reabsorption by the body surgical intervention may be necessary when the atopic pregnancy poses an immediate threat to the patient's health or if medical management is unsuccessful surgical options include laparoscopy to remove the atopic pregnancy or in severe cases laparotomy from more extensive surgical intervention vaginal bleeding in the second and third trimesters of pregnancy is a concerning symptom often associated with pathologic conditions that can pose life-threatening risks to both the pregnant woman and the developing fetus among the three major causes of such life-threatening bleeding are brop placente placenta Privia and uterine rupture any episode of vaginal bleeding during the third trimester must be treated as a dire medical Emer Mercy until proven otherwise to address this critical situation specific steps are taken the patient should be placed on her left side in a recumbent position to optimize blood flow and reduce the risk of further complications oxygen should be administered to improve oxygenation for both the woman and the fetus IV access should be established with lactated ringer solution or normal saline to address any potential hypo Almia abruptio placente is a serious obstetric condition characterized by the premature separation of the normally implanted placenta from the uterine wall before delivery this separation can occur spontaneously or as a result of trauma including even minor traumatic events such as a fall from standing position several risk factors increase the likelihood of abruptio placente including tobacco use cocaine use chronic hypertension preclampsia thrombophilia and a history of previous abruption in a prior pregnancy regardless of the underlying cause this condition typically presents with common signs and symptoms including vaginal bleeding abdominal pain back back pain and uterine tenderness it is worth noting that the separation of the placenta from the uterine wall can occur in a way that results in the containment of bleeding by the portion of the placenta still attached to the uterine wall a physical examination of a patient may reveal abdominal tenderness and the uterus may feel rigid upon palpation vaginal bleeding associated with this condition can vary in appearance ranging from bright red to dark and may be mixed with Amic fluid in some cases patients May spontaneously go into labor as a result of uterine contractions triggered by the condition prompt recognition and intervention are critical in managing these patients in order to mitigate potential complications and ensure the best possible outcomes for both both the pregnant patient and the fetus placenta Privia is an obstetric condition where the placenta is abnormally implanted low in the uterus partially or completely covering the cervical Canal this condition is estimated to be present in approximately 4% of ultrasonographic studies conducted between 20 to 24 weeks of gestation a characteristic and often concerning symptom associated with placenta Privia is bright red vaginal bleeding which is the usual presenting complaint in affected patients importantly the bleeding implent a Privia remains typically painless and the uterus retains its soft and non-contracting state in managing placenta Privia the primary focus is on hemodynamic management to address potential blood loss and stabilize the patient's condition Hemorrhage can be severe necessitating careful and prompt intervention and treatment should be conducted with minimal movement to avoid exacerbating bleeding or causing further complications the goal of treatment is to ensure the well-being of both the pregnant patient and the developing fetus by addressing the immediate hemodynamic concerns associated with placenta Privia uterine rupture is a rare but critical obstetric emergency characterized by the tearing of the uterine wall leading to catastrophic bleeding this condition carries a grim prognosis with almost 100% fetal mortality and a maternal mortality rate of approximately 10% clinical suspicion of uterine rupture AR Rises when a pregnant patient exhibits specific signs and symptoms these include the loss of palpable uterine Contour making the fetus easily palpable and typically severe abdominal pain this condition can occur spontaneously often associated with labor and does not necessarily require external trauma patients at the highest risk for uterine rupture are those who have undergone previous uterine surgy iies including cerian sections incomplete uterine ruptures are often diagnosed at the time of cerian section as an incidental finding the signs and symptoms of uterine rupture Encompass abnormal maternal Vital Signs sudden or worsening abdominal pain abnormal fetal heart rate patterns loss of fetal station abnormal uterine contraction vaginal bleeding and even hamat ARA treatment of uterine rupture primarily involves volume resuscitation to address a significant blood loss and the provision of oxygen to support maternal and Fetal oxygenation providers should prepare the patient for surgical Intervention which is often necessary to repair the uterine rupture and prevent further",
        "Medical Conditions During Pregnancy": "complications medical conditions during pregnancy hypertensive disorders of pregnancy including gestational hypertension preeclampsia without severe features preclampsia with severe features eclampsia and help syndrome are characterized by elevated blood pressure during pregnancy and contribute significantly to maternal and Fetal morbidity and mortality gestational hypertension entails new onset high blood pressure after 20 weeks of gestation preeclampsia marked by hypertension and significant prua may or may not exhibit severe features indicating end organ damage eclampsia involves seizures in pregnant women with no history of epilepsy and poses severe risks help syndrome characterized by hemolysis liver enzyme elevation and low platelet counts is a life-threatening preeclamptic variant these disorders necessitate Vigilant monitoring prompt intervention and often consideration of pre-term delivery to mitigate risks to both mother and fetus just gational hypertension is a medical condition characterized by the development of elevated blood pressure typically defined as a blood pressure reading of 140 over 90 or higher after the 20th week of gestation in a previously normal tensive patient one key feature of gestational hypertension is that blood pressure tends to return to normal levels after the delivery of the baby it is noteworthy that the management of gestational hypertens ion closely mirrors that of preeclampsia which involves Vigilant monitoring assessing for signs of end organ dysfunction and considering the possibility of pre-term delivery in severe cases notably approximately 50% of women diagnosed with gestational hypertension will progress to develop preeclampsia hence close monitoring and early intervention are essential preclampsia is a serious hypertensive disorder of pregnancy that comes in two forms characterized based on the presence or absence of severe features this condition is characterized by the onset of new hypertension in combination with protina or hypertension with thrombos yenia preclampsia most commonly manifests after the 20th week of gestation but can also occur earlier in some cases notably patients with preeclampsia who exhibit severe features are at a higher risk of progressing to eclampsia which is considered a life-threatening complication the signs and symptoms of preeclampsia Encompass hypertension edema or pathologic edema proteinuria headache visual disturbances such as blurred vision or seeing spots and abdominal pain these clinical manifestations require close monitoring and medical management to assess for signs of end organ dysfunction and to mitigate the risks associated with preclampsia which can be severe for both the pregnant patient and developing fetus eclampsia is a severe and life-threatening complication of pregnancy defined by the occurrence of new onset seizures in a woman who is beyond 20 weeks gestation and usually has a pre-existing hypertensive disorder of pregnancy importantly eclampsia can occur even without a prior diagnosis of preeclampsia or help syndrome it is a condition that can manifest before during or after the delivery of the baby the campsa often begins with impaired development and function of the placenta in preclampsia and eclampsia the placenta may not adequately establish and maintain the Maternal Fetal circulation leading to inadequate oxygen or nutrient supply to the developing fetus eclampsia is also associated with widespread vasospasm particularly in the small blood vessels throughout the body this Vaso constriction contributes to increased blood pressure which is a Hallmark of preclampsia and eclampsia vasospasms and other factors can damage the endothelium which is the inner lining of blood vessels this endothelial dysfunction results in the release of vasoactive substances and the activation of clotting factors which contribute to hypertension and increase the risk of blood clot formation eclampsia is associated with an inflammatory response in the body with increased production of inflammatory markers this can further damage the vascular endothelium and cause vascular permeability resulting in protein leakage into the urine and organ dysfunction as the blood vessels narrow and become less compliant due to vasospasm the blood supply to various organs including brain liver kidneys and placenta may be compromised reduced organ profusion results in organ dysfunction and failure lastly the pathophysiology of eclampsia in relation to seizures involves cerebral edema increased intracranial pressure and changes in cerebral blood flow the exact mechanisms leading to seizures are not fully understood but are believed to be related to changes in the brain's excitability in neuronal function the primary focus of treating a clamps is to prevent and manage these seizures in order to ensure the safety of both the pregnant patient and developing fetus magnesium sulfate is the primary medication of choice for preventing seizures and its Administration should be coordinated in the consultation with the medical center in cases where mag sulfate is unavailable diazapam or other benzo diazines may be administered as an alternative however if they are to be utilized the provider must report this treatment to the receiving medical providers due to potential neonatal respiratory depression as a side effect of these medications neonates born to mothers treated with these drugs may require additional support at the time of delivery to mitigate any Associated complications help syndrome is a severe and potentially life-threatening condition that typically manifests after the 20th week of pregnancy help stands for hemalis elevated liver enzymes and low platelet count help syndrome often starts with abnormalities in the placenta similar to other hypertensive disorders of pregnancy like preclampsia and it's thought that inadequate placental profusion and oxygenation May trigger the development placental dysfunction can lead to the release of factors into the maternal bloodstream that activate endothelial cells lining the blood vessels triggering inflammation and clotting Within these blood vessels hemalis refers to the destruction of red blood cells and in help syndrome the activated endothelial cells damage red blood cells as they pass through the narrowed blood vessels leading to their premature destruction this results in anemia and the release of hemoglobin into the bloodstream liver involvement in help is not fully understood but it is likely related to a combination of factors including inflammation and compromise blood flow within the liver elevated liver enzymes such as a and ALT are indicative of liver cell damage platelets are involved in blood clotting and preventing bleeding and in help syndrome platelet consumption and destruction occur due to their activation within the damaged blood vessels leading to a decrease in platelet count which can result in an increased risk of bleeding the combination of hemolysis liver involvement and low platelet count has widespread systemic effects including hypertension edema and proera as well as damage to various organs although the precise cause of help syndrome remains unclear Some risk factors have been identified these include first pregnancies multiple pregnancies a history of preclampsia and a maternal age over 25 the definitive treatment involves the delivery of the fetus given the potential for severe complications including organ failure and maternal morbidity prompt medical attention and timely delivery are essential to ensure the best possible outcomes for both the pregnant patient and the developing",
        "Complications During Labor": "fetus complications during labor the transition of fetal circulation at Birth is a complex physiological process that is critical to the survival of the newborn prior to birth the fetal lung is in a collapsed State and filled with Amic fluid as a fetus does not breathe in utero however within seconds of birth the newborn's lungs must rapidly expand with air in this expansion triggers a series of changes in the circulatory system as the baby's lungs fill with air pulmonary vascular resistance decreases while systemic vascular resistance increases this shift and resistance allows blood to flow into the lungs where it can pick up oxygen from the inhaled air simultaneously the change in pulmonary pressure prompts the closure of the frame and oval a small opening between the Atria of the heart that allows blood to bypass the fetal lungs this closure is essential for the redirection of blood flow into the pulmonary circulation in order to receive oxygen this transition must occur promptly as any delay in the decline of pulmonary pressure can result in hypoxia for the newborn this can lead to serious complications therefore the successful transition of feudal circulation at Birth becomes a critical process that requires close monitoring and intervention when necessary to ensure the newborn's well-being and oxygenation pre-term labor represents a significant Health Care concern and is the leading cause of neonatal mortality in the United States this condition is defined as the onset of Labor occurring between 20 and 37 weeks of gestation well before the typical 40we full-term pregnancy duration one of the treatment approaches for pre-term labor involves the use of tocolytics which are medications designed to stop uterine contractions the administration of tocolytics serves multiple purposes including allowing for the administration of corticosteroids and magnesium sulfate which can benefit the developing fetus and enhances Readiness for transport to a tertiary Care Facility where specialized neonatal care may be available in the case of pre-term Labor knowledgeable Critical Care paramedics play a pivotal role as a critical link between the local hospital and the tertiary Care Facility their expertise ensures that the pregnant patient receives appropriate care and timely transportation to the facility that's equipped to handle the specific needs of both the mother and the preterm infant furthermore pre-term labor May progress rapidly resulting in a precipitous delivery defined as delivery occurring in less than 3 hours from the offset of regular contractions patients presenting with potential pre-term labor should be asked about the frequency and duration of contractions as well as the presence of vaginal leakage of blood fluid or mucus as these signs May indicate imminent delivery premature pre-labor rupture of membranes or prom is another concern related to pre-term labor where the Amic Sac ruptures before the onset of Labor and pregnancies of less than 37 weeks most women will deliver within 7 Days of membrane rupture emphasizing the need for expedited care and transport support to manage both maternal and Fetal well-being it is essential to recognize that all prehospital deliveries especially those involving pre-term labor are considered emergencies and are inherently high-risk situations necessitating prompt and appropriate medical attention to optimize outcomes for both mother and",
        "Delivery": "child delivery the vertex presentation is considered the ideal fetal presentation during child birth in this position the baby's head is the presenting part and it is aligned with the birth canal with the oxop put positioned closest to the maternal symphysis pubis this alignment allows for smooth progress during labor and delivery as the baby's head is well positioned to navigate the birth canal when a Vertex presentation is observed crowning is typically observed as well which means that the widest part of the baby's head has passed through the mother's cervix and is visible at the vaginal opening at this stage the role of the provider is to ensure that delivery proceeds without complications and this involves closely monitoring both mom and baby's Vital Signs assisting with the delivery process as needed and providing emotional support to the mother remember women have been giving birth for thousands of years the baby is coming regardless of whether or not you were there while a Vertex presentation is considered the most favorable form of vaginal delivery complications can still come up and the provider must be prepared to respond to any emergent situations promptly Mal presentations such as breach present presentation represent variations in fetal positioning during child birth breach presentations occur in approximately 4% of all deliveries and are characterized by the baby's buttocks or lower extremities presenting first rather than the ideal head first presentation this atypical positioning can increase the risk of complications including fetal asphyxia and Fetal mortality making them an obvious concern during childbirth breach presentation are more commonly observed in premature infants or low birth weight infants there are several types of breach presentations each with distinct characteristics the first type is the Frank breach presentation in which both of the infant's hips are flexed and their feet are positioned near the head another variant is the complete breach presentation where the baby's hips are flexed and their legs are also flexed at the knees with the buttocks presenting first along with the legs flexed alongside the buttocks an incomplete breach presentation is similar to the complete breach but with one foot extending into the birth canal making it an intermediate presentation lastly the footling breach presentation involves both of the baby's feet extending into the birth canal creating a potentially complex delivery scenario the delivery of a baby in a breach presentation can present unique challenges and the approach may vary depending on the specific type of breach presentation encountered in cases of a Frank breach or complete breach presentation vaginal delivery can often be accomplished though Special Care must be taken to ensure the delivery is safe in contrast when the baby is in an incomplete breach or footling breach presentation the delivery process becomes more complex in such cases a foot can protrude through an incompletely dilated cervix but the rest of the fetus will not deliver naturally fetal positioning like this necessitates a cerian section for delivery to ensure the safety of both mom and baby the provider's responsibility in these instances is to facilitate timely transport to a facility equipped to perform a cerian section as this intervention is urgently needed to avoid potential complications umbilical cord prolapse is a critical obstetric emergency that occurs when the umbilical cord presents first in the birth canal before the baby's head or body this presentation poses a significant risk to the developing fetus as the cord can become compressed between the baby's head and the walls of the birth canal or pelvis this compression leads to reduction in blood flow through the umbilical cord resulting in fetal hypoxia immediate in appropriate management of umbilical cord prolapse mitigates the potential harm to the fetus one essential step in managing this emergency is positioning the patient to alleviate cord compression the preferred position for a patient with umbilical cord prolapse is the knee chest position where the patient is placed on their elbows and knees this position helps relieve pressure on the cord by Shifting the baby's head away from it however it is essential to note that not all patients May tolerate the knee chest position and in such cases an alternative approach is a trendelenberg position in the trendelenberg position the baby's head is lowered and their feet are elevated which can also help alleviate core compression and improve blood flow to the fetus shoulder dystocia is a critical obstetric complication that arises when the infant's head passes through the birth canal but then becomes trapped behind the mother's pelvic bone due to its larger size this situation can be recognized by the turtle sign where the the fetal head protrudes during delivery but then retracts back indicating a challenging birth recognition of shoulder dystocia is vital as it is a true obstetric emergency and requires immediate intervention to ensure a favorable outcome for both mom and baby one of the primary Maneuvers used to managed shoulder dystocia is the McRoberts maneuver in this technique the patient is instru Ed to flex their legs against her abdomen which effectively increases the functional size of the pelvis with the next contraction the patient is encouraged to push while direct pressure is applied just above the pubic synthesis to move the anterior shoulder of the infant underneath the pubic bone it's essential to avoid applying fundle pressure or traction to the baby's head during this maneuver if the McRoberts maneuver does not resolve the dystocia additional measures may be necessary a glof hand can be inserted underneath the infant identifying the humorous and sweeping it across the trunk and face creating more room for the anterior shoulder to pass underneath the pubic bone in cases where shoulder dystocia persists the gasa maneuver or in more severe cases the zavanelli maneuver follows by a cerian section may be performed by Obstetricians we will now demonstrate the gasan or all fours maneuver this maneuver can be done primarily or secondarily after other Maneuvers have failed this usually requires that the mother have minimal or no anesthesia so she can assume the hands and knees or all fource position the delivering attendant in this maneuver should then try to deliver the posterior shoulder which is now in the anterior position sometimes s the simple change in maternal position realigns the structures inside the pelvis with reference to the fetal shoulders and simple downward traction results in delivery of the fetus in the event that downward traction does not result in delivery of the fetus alternative Maneuvers can be performed such as posterior arm extraction in this case the posterior arm which Now lies anterior can be grasped by inserting the hand inside the vagina tracing the humoral shaft locating the wrist and extracting the arm the fetus is then delivered in the standard manner multiple births such as twins can present unique challenges during delivery in some cases twins may share a placenta or gestational sack which requires specialized management after the delivery of the first twin it is essential to double clamp the infant's cord to prevent any complications related to cord entanglement or interference between the Twins one of the complexities of multiple births is the variable timing of delivery for the second Twin this interval can vary widely and during this delay transport should continue without unnecessary Interruption only if the second infant begins to emerge should transport be momentarily paused to address the imminent delivery it is vital to recognize that each infant in a multiple birth situation may experience distinct complications or requirements therefore the provider must be prepared to manage and address the individual needs of both infants in cases of multiple births it's essential to adhere to specific protocols and guidelines one critical guideline is to not attempt to deliver the placenta of the first twin before the second Twin has been safely delivered this ensures that both infants receive proper care and that complications related to the second Twin's delivery are minimized the delivery of the placenta also known as the third stage of Labor is a critical phase in the child birth process and active management of this stage has been demonstrated to reduce the risk of postpartum Hemorrhage one aspect of active management involves the administration of oxytocin a hormone that plays a key role in uterine contraction and prevents excessive bleeding oxytocin is administered at a dose of 20 to 40 units in one liter of IV saline solution over a period of 20 to 40 minutes it is important not to give this drug via IV push as this can lead to profound hypotension compromising the patient's hemodynamic stability additionally during the delivery of the placenta gentle traction is applied to the umbilical cord to facilitate the separation of the placenta from the uterine wall this process is aided by the contraction of the uterus which also helps expel the placenta simultaneously fundal massage is performed to stimulate uterine contraction and to control bleeding the provider applies gentle consistent pressure to the fundus of the uterus located just above the pubic bone this massage assists in ensuring the uterus contracts effectively as the placenta begins to separate from the uterine wall there may be a small gush of blood and a lengthening of the umbilical cord this indicates that the placenta is in the process of being expelled marking the successful completion of the third stage of Labor post- delivery care is essential for Mom and newborn as it focuses on ensuring their well-being and addresses any potential complications here are a few key aspects of post- delivery care first the newborn's vital signs including their ABCs should be promptly assessed the apgar score which is a quick assessment tool used to evaluate the physical condition of the newborn should also be determined to assess their overall health and response to the delivery process simultaneously attention should be given to Mom's perineum particularly if she experienced tearing during the delivery large tears that are actively bleeding require immediate intervention and direct pressure should be applied to control the bleeding in some cases identifying the exact source of bleeding may be challenging so additional measures may be necessary uterine massage is also a key component of post- delary care as discussed previously the uterus should be gently massaged to stimulate uterine contraction which helps control bleeding by compressing blood vessels during this process you if not already done so establish one or two large bore IV lines through which a crystalloid solution can be administered to maintain mom's fluid balance additionally high flow oxygen should also be administered as needed to ensure proper oxygenation regarding the newborn after delivery the infant should be thoroughly dried wrapped in warm blankets and placed on the mother's chest for skin-to-skin contact if possible be advised you should not transport the patient in this position as any patient should be properly secured this practice however does support bonding and helps regulate the newborn's body",
        "Postdelivery Complications": "temperature post- delivery complications postpartum Hemorrhage is a significant concern in the post-d delivery period and can result from various causes commonly referred to as the Ford T's these include tone trauma tissue and thrombin tone postpartum Hemorrhage can occur due to the inability of the uterus to contract adequately leading to prolonged bleeding this lack of uterine tone can result from factors such as uterine atony where the uterine muscle fails to contract effectively to compress blood vessels trauma traumatic causes of postpartum Hemorrhage involve physical damage to the birth canal or uterine rupture lacerations hematomas and uterine rupture can lead to significant bleeding tissue retained placental tisue tissue can obstruct the uterine cavity and prevent effective uterine contraction resulting in postpartum Hemorrhage ensuring complete removal of placental fragments is crucial to prevent this cause of bleeding thrombin coagulopathy can contribute to postpartum Hemorrhage throbin abnormalities can lead to excessive bleeding as the blood's ability to clot is compromised in managing postpartum Hemorrhage various treatment strategies are employed funel massage involves massaging the uterus to stimulate uterine contractions improving tone and aiding in hemostasis by compressing blood vessels uterotonic agents are medications that are administered to promote uterine contractions and tone common agents include oxytocin which is given intravenously to enhance uterine contractions emotic fluid embolism or AF is a rare but life-threatening obstetric emergency that occurs when fetal cells Amic fluid or other debris cross the placental barrier and enter the maternal circulation this event can take place in various situations including any disruption of the Maternal Fetal barrier such as trauma or attempts to manipulate the fetus within the uterus AF has significant clinical implications leading to a Cascade of events that result in severe maternal morbidity and mortality AFE initiates a series of physiologic responses notably the development of right- side heart failure and subsequent left-sided heart failure this Cascade leads to pulmonary edema which manifests as severe respiratory distress simultaneously systemic hypotension ensues contributing to hemodynamic instability the clinical course of AF can rapidly evolve and its severity can vary widely with mortality rates ranging from 24 to 80% in developed countries symptoms of AF typically present abruptly and dramatically the affected patient may experience sudden onset shortness of breath often accompanied by profound hypotension additional signs and symptoms include chest pain restlessness anxiety coughing vomiting pulmonary edema a sense of impending doom shivering seizures altered mental status rigor and in severe cases cardiac arrest uterine inversion is a rare but potentially life-threatening obstetric emergency that occurs when the uterus inverts or turns inside out after child birth this phenomenon typically happens when the placenta remains attached to the uterine wall and the uterus attempts to expel the placenta during this process the uterine fundus becomes inverted and protrudes into the vaginal Canal or even partially outside the vag vagina the immediate treatment for uterine inversion is uterine replacement a procedure where the inverted uterus is manually repositioned into its normal anatomical State it's important to note that uterine replacement is a highly specialized procedure that falls beyond the scope of practice for a critical care transport paramedic and requires the expertise of an obstetrician or other skilled medical provider with the necessary equipment surgical intervention is typically necessary following uterine inversion to address any potential complications or Associated injuries this intervention may involve repairing any damage to the uterine tissue managing excessive bleeding and ensuring the proper repositioning of the",
        "Gynecologic Emergencies": "uterus gynecologic emergencies pelvic inflammatory disease or PID is a condition characterized by inflammation of the female reproductive tract including the uterus Fallopian tubes and ovaries this response can result in significant damage to these organs and is most commonly caused by STI particularly gonorrhea and chyia when left untreated P ID can lead to the formation of scar tissue known as adhesions on the reproductive organs which in turn result in various complications including chronic pelvic pain infertility and an increased risk of an atopic pregnancy symptoms of PID can vary in severity but include back and abdominal pain vaginal discharge that is pertinent or foul smelling abnormal vaginal bleeding pain with intercourse painful urination and occasionally a low-grade Fe fever diagnosis is typically based on clinical evaluation but may involve a pelvic exam Laboratory Testing and imaging studies the primary treatment for p is the administration of antibiotics often delivered intravenously in more severe cases to ensure prompt and effective resolution of the infection it's important for providers to be aware of the specific an I biotics prescribed and any potential drug interactions when transporting patients receiving IV antibiotic therapy toxic shock syndrome or TSS is a rare but potentially life-threatening medical condition that typically occurs following infections with bacteria while there can be various underlying causes TSS has historically been associated with the use of tampons particular particularly those made of Highly absorbent materials symptoms can develop rapidly and may include high fever profound malaise vomiting diarrhea skin shedding and a diffuse body rash resembling sunburn along with a severe headache and hypotension the combination of these symptoms can lead to multi-stem organ dysfunction and failure making early recognition and intervention critical the treatment of TSS involves several essential components Airway management and supportive care including fluid resuscitation are Paramount to stabilize the patient's condition identifying and controlling the source of infection is required to prevent ongoing toxin production this may include removing foreign bodies such as tampons or nasal packing and Performing Surgical procedures as needed additionally TSS is typically treated with highd does intravenous antibiotics to Target the underlying bacterial infection ruptured ovarian cysts can lead to a spectrum of clinical presentations ranging from mild discomfort to severe Hemorrhage and shock these cysts which are fluid filled sacks located on or within the ovary can rupture spontaneously or due to trauma or physical stress when a cyst ruptures it can cause several distinct symptoms and complications the most common symptom of a ruptured ovarian cyst is an Abrupt and often severe lower abdominal or pelvic pain this pain may be localized to one side depending on which ovary the cyst is associated with additionally vaginal bleeding can occur as a result of the cyst's rupture in severe cases is the Hemorrhage from a ruptured cyst can lead to hypohemia a significant loss of blood volume that can result in shock treatment for a ruptured aarian cyst primarily involves addressing immediate life-threatening issues this includes shock management through aggressive fluid resuscitation and hemodynamic support if the patient's condition is unstable surgical intervention may be required as an emergent measure to control bleeding and stable the patient laparoscopic surgery is often used in such cases allowing for the identification and management of the ruptured cyst hemostasis and the removal of the cyst or its remnants ovarian torsion is a medical condition characterized by the rotation of the ovary around its axis which can lead to significant lower abdominal pain and complications if not promptly addressed Dred it often presents with symptoms that can mimic other abdominal emergencies such as appendicitis or atopic pregnancy making it a diagnostic challenge the primary cause of aarian torsion is the presence of aarian cysts which can predispose the ovary to twisting upon itself pregnancy particularly when the enlarged uterus causes changes in pelvic Anatomy is also considered an independent risk factor for ovarian torsion when this occurs the twisting of the ovarian blood vessels can result in impaired blood flow to the ovary itself if left untreated this esea can lead to serious complications including ovarian infarction which is tissue death due to insufficient blood supply necrosis and the irreversible death of the tissue itself"
    },
    {
        "Introduction to Endocrine Emergencies": "chapter 18 endocrine emergencies introdu ction endocrine emergencies Encompass a wide range of clinical presentations from subtle to overt signs and symptoms these conditions result from disruptions in hormone production or action a comprehensive diagnosis relies on a thorough understanding of the patient's medical history current illness or injury and a detailed physical examination Critical Care transport providers must remain vigilant for these emergencies during patient assessment as they can often masquerade as other medical conditions timely recognition and appropriate transport to specialized medical facilities are key for improving patient outcomes in endocrine",
        "Anatomy and Physiology of the Endocrine System": "emergencies anatomy and physiology the endocrine system is a complex network of glands and organs responsible for producing and regulating hormones which are chemical Messengers that control various bodily functions key components of the endocrine system include glands such as the pituitary thyroid adrenal and pancreas as well as hormone secreting tissues like the ovaries and testies these glands release hormones directly into the bloodstream allowing them to travel throughout the body and exert their effects on target tissues and organs the endocrine system plays a critical role in regulating processes such as metabolism growth and development immune function and the body's response to stress hormones produced by the endocrine system act as powerful Regulators of homeostasis helping to maintain the body's internal balance these chemical Messengers bond to specific receptors and target cells triggering a Cascade of physiological responses for example insulin which is produced by the pancreas regulates blood glucose levels by promoting the uptake of glucose into cells the hypothalamus pituitary axis serves as a control center orchestrating the release of hormones from various glands dysfunction in the endocrine system can lead to a wide range of disorders from diabetes and thyroid diseases to adrenal insufficiency underscoring the importance of understanding its anatomy and physiology in healthcare the thyroid gland situated in the neck holds the distinction of being the largest gland in this region its primary role within the endocrine system is the regulation of metabolism achieved through the secretion of thyroxine or T4 when the body's metabolic rate decreases thyroxine recognized as the principal metabolic hormone in the human body plays a pivotal role in stimulating energy production within cells it's worth noting that iodine is an essential component of thyroxine underscoring the significance of dietary iodine intake in maintaining thyroid function in addition to thyroxine the thyroid gland releases calcitonin another hormone that serves a distinct purpose calcitonin travels to the bones where it stimulates bone building cells and AIDS in the absorption of excess calcium from the bloodstream into bone tissue this regulation of calcium levels help maintain the delicate balance required for numerous physiological processes it is important to note that the thyroid gland is highly vascular making it susceptible to profuse Hemorrhage if accidentally nicked or injured emphasizing the need for caution during surgical procedures or interventions involving the gland the parathyroid glands are a set of small ovoid glands positioned in the posterior surfaces of the thyroid gland typically consisting of four glands each approximately the size of a grain of rice despite their diminutive size these glands play a vital role in maintaining calcium and phosphate homeostasis in the body the primary hormone they secrete is known as parathyroid hormone or pth which exerts profound effects on calcium and phosphate levels in the bloodstream pth acts as a regulator of calcium balance within the body when calcium levels in the blood drop the parathyroid glands respond by releasing pth this hormone stimulates various mechanisms to increase blood calcium level levels pth enhances calcium absorption from the intestines promotes the release of calcium from bone and encourages the kidneys to reabsorb calcium while excreting phosphate this orchestrated response ensures that the bloodstream maintains the necessary calcium concentrations for necessary physiological functions including muscle contraction nerve transmission and blood clotting however when there's an over production of pth by the parathyroid glands a condition known as Hyper parathyroidism ensues this condition can lead to excessive calcium release from the bones elevated blood calcium levels and an array of associated health problems such as kidney stones and weak bones understanding the function and location of the parathyroid glands is central for healthcare professionals to diagnose and manage disorders related to calcium and phosphate metabolism effectively the adrenal glands situated on top of each kidney produce a variety of hormones that influence numerous physiological processes these glands consist of two distinct Parts the outer adrenal cortex and the inner Adrenal medulla the the adrenal cortex is responsible for synthesizing corticosteroids a group of hormones with wide ranging effects on metabolism immune system function and sexual function additionally corticosteroids are integral in regulating the balance of salt and water within the body the hypothalamus releases adrenocorticotropic hormone or act which in turn targets the adrenal cortex prompting the the secretion of cortisol cortisol is a primary stress hormone that helps the body cope with stress and maintains various metabolic processes furthermore the adrenal cortex releases aldosterone in response to a sudden drop in blood pressure aldosterone regulates the amount of sodium and potassium excreted in the urine contributing to blood pressure regulation and electrolyte balance the inner part of the adrenal glands known as the Adrenal medulla responds during the body's fight ORF flight response in a high stress situation it secretes nor epinephrine and epinephrine epinephrine has a profound effect on the sympathetic nervous system stimulating increased heart rate heightened alertness and enhanced liver function the liver converts stored glycogen into glucose providing a rapid energy source for the body's response to stress aldosterone is a vital hormone produced by the adrenal cortex specifically within the Zona gomula regulating electrolyte balance and blood pressure in the body one of its primary functions is to prompt the kidneys to reabsorb sodium from the urine while facilitating the excretion of potassium this intricate process maintains the delicate equilibrium of sodium and potassium levels in the bloodstream by promoting sodium retention aldosterone indirectly influences water retention leading to increased blood volume and blood pressure while aldosterone's role in regulating electrolytes and blood pressure is indispensable for normal physiological function abnormal overproduction of this hormone does have severe consequences conditions such as primary hyperaldosteronism often caused by an adrenal gland tumor can result in excessive aldosterone secretion this leads to an abnormal accumulation of sodium and water in the body causing hypertension low pottassium levels and Associated complications if left untreated this disease can have life-threatening consequences including cardiac arrhythmias heart failure and eventually death consequently the precise regulation and balance of aldosterone is critical for maintaining overall health and preventing the serious repercussions associated with its abnormal overproduction the pancreas is a multi-functional organ situated behind the stomach serving both exocrine and endocrine roles within the body its exocrine component is responsible for the secretion of digestive enzymes which are released into the small intestine to Aid in the breakdown of carbohydrates fats and proteins during the digestive process the integr component of the pan consists of specialized clusters of cells known as the isolet of linger Hons these house different types of cells including alpha cells that secrete glucagon and beta cells that release insulin the balance between these two hormones is integral to the regulation of blood glucose levels in the body insulin plays essential role in maintaining blood glucose homeostasis when blood glucose levels rise after consuming food insulin is responsible for facilitating the uptake and storage of glucose in various tissues including the liver muscles and adapost tissue it also promotes the conversion of excess glucose into glycogen fats and proteins for storage conversely glucagon secreted by alpha cells act to raise glucose levels by stimulating the breakdown of stored glycogen in the liver and the release of glucose into the",
        "Diabetes and Its Management": "bloodstream diabetes diabetes is a metabolic disorder characterized by impaired glucose metabolism in the pancreas leading to either a lack of insulin production or the decrease ined sensitivity of cells to insulin within the pancreas the iset of langerhans are responsible for producing hormones including insulin omlin glucagon and somatostatin insulin and glucagon work in concert to maintain blood glucose levels within the narrow range of 70 to 100 milligrams per deciliter in diabetes this delicate balance is disrupted resulting in abnormally elevated blood glucose concentrations consequently individuals with diabetes experience polyurea passing large volumes of urine containing glucose along with increased thirst polydipsia and compromised immune function normally excess glucose not immediately used for energy is stored in the liver and muscles as glycogen or simply converted to Fat the pain pancreas secretes insulin in response to high blood glucose levels prompting a glucose uptake by cells for energy and storage conversely when levels drop the pancreas secretes glucagon stimulating the release of stored glucose to raise blood sugar levels type 1 diabetes formerly known as juvenile diabetes but recognized to manifest in adulthood as well is primarily car cized by an autoimmune mediated destruction of pancreatic beta cells leading to an absolute deficiency of insulin production while there is a hereditary predisposition for developing type 1 diabetes environmental factors such as viral infections may also contribute to its onset individuals with type 1 diabetes are unable to produce indigenous insulin necessitating external sources typically it ministered through injections or pumps additionally dietary management is a critical component of glycemic control managing type 1 diabetes can be especially challenging for children high performance athletes individuals with alcoholism and those with multiple medical comorbidities as it requires Vigilant monitoring precise insulin dosage adjustments and careful attention to diet and lifestyle to achieve optimal glucose control and prevent complications associated with chronic hypoglycemia type 2 diabetes previously known as adult onset diabetes is the most prevalent form characterized by a combination of insulin resistance and in some cases insufficient insulin production by the pancreas in individuals with type 2 diabetes the pancreas continues to produce insulin but the body's cells become less responsive to its effects a phenomenon we know as insulin resistance this resistance hampers the ability of glucose to Inner cells leading to elevated blood glucose levels over time the pancreas may also experience a decline in its insulin producing capacity while the exact cause is multifactoral it is often associated with lifestyle factors such as obesity physical inactivity and poor dietary choices all which can exacerbate insulin resistance management typically involves a combination of lifestyle modifications along with medications to improve insulin sensitivity and promote adequate glucose control hypoglycemia is a critical concern for patients with diabetes it can be triggered by various factors including an excessive dose of diabetes medication inadequate food intake Intense or unforeseen physical exertion disease or alcohol consumption hypoglycemia demands prompt attention because if left unaddressed it can lead to severe complications notably brain brain damage due to the brain's dependence on glucose for energy Health Care Providers should be particularly vigilant for hypoglycemia in patients presenting with altered mentation or new neurological deficits as these can mimic other medical conditions and pose a significant threat to the patient's well-being early recognition and prompt intervention often involving the administration of of glucose or carbohydrate Foods restores normal blood glucose levels and prevents potential complications associated with hypoglycemia hypoglycemia stands as a primary and defining characteristic of diabetes metis serving as a primary diagnostic cerion for the disease Physicians utilize various methods to diagn hypoglycemia which in turn AIDS in identifying and managing the disease these diagnostic criteria include a fasting blood glucose level of 126 milligram per deciliter or higher an elevated hemoglobin A1c measurement of 6.5% or greater or a random blood glucose level exceeding 200 mg per deciliter accompanied by noticeable symptoms of hypoglycemia these parameters help healthc Care Professionals establish the presence and severity of hypoglycemia which is critical for diagnosing diabetes and guiding treatment decisions hyperglycemia when persistently elevated can lead to a range of complications and is a key Target for intervention in the management of diabetes to prevent the onset of more severe conditions such as diabetic keto acidosis hyperglycemia and the subsequent development of diabetic keto acidosis or dka can be triggered by various factors and underlying causes in individuals with diabetes these contributing factors Encompass excessive fluid intake which leads to an imbalance between insulin availability and glucose utilization likewise insufficient or improper administration of medications such as insulin can result in uncontrolled blood glucose levels infection or illness can also Drive hypoglycemia as the body's stress response elevates blood sugar to provide energy for immune system functions additionally trauma or injury can induce a surge in stress hormones contributing to elevated blood glucose levels surgical procedures due to the associated physiological stress and changes in medication regimen can disrupt glycemic control essentially various physiological stressors including emotional stress severe illness or certain medications can all exacerbate hyperglycemia untreated hypoglycemia can and progress to a life-threatening condition known as diabetic keto acidosis or dka in dka the body's inability to effectively utilize excess glucose leads to a Cascade of severe metabolic disturbances this condition is often more commonly observed in younger individuals particularly those with type 1 diabetes though it has been known to occur in individuals with type Ty two diabetes under certain circumstances dka is characterized by distinct fruity odor on the breath resulting from the production of ketones as the body resorts to using fats for energy due to the lack of glucose uptake additionally dka is associated with the passage of large volumes of urine a condition known as polyurea if left untreated dka can progress rapidly culminating in shock loss of consciousness and potentially death hyperosmolar hyperglycemic state or HHS also referred to as hyperosmolar hypoglycemic non-ic syndrome or hhns is a severe hyperglycemic crisis characterized by markedly elevated blood glucose levels and increased blood osmolarity leading to osmotic diuresis and a shift of fluid into the intravascular space although most individuals affected by HHS have a prior history of diabetes typically type two approximately 30% may not have a known diabetes diagnosis the clinical presentation of patients with HHS is similar to that of diabetic keto acidosis with symptoms such as excessive thirst frequent urination and increased appetite however a distinguishing feature of HHS is the absence of Keto acidosis this critical condition often occurs in older adults and is precipitated by factors such as infection medication non-compliance or underlying medical conditions during the transport of patients with suspected hypoglycemia or hyperglycemia providers should perform timely laboratory assessments to Aid in the diagnosis and guide appropriate management utilizing a portable glucose monitor providers can measure glucose levels in either the capillaries or veins ensuring accurate interpretation by adhering to the glucometer instructions and understanding its upper and lower measurement limits in cases involving dka Venus blood gas monitoring is indispensable suspected metabolic acidosis can be confirmed by observing specific parameters such as a pH below 7.3 bicarbonate levels less than 15 mil equivalents per liter and a paac CO2 below 30 millim of Mercury additionally providers May perform urine and or serum Ketone tests to assess the presence and severity of ketosis before initiating transport a hemoglobin A1c may be conducted to assess a long-term glycemic control in the management of patients with hypoglycemia stabilization before transport is Paramount potentially requiring the maintenance of Ivy access and continuous cardiac monitoring during transport Airway management and ventilation assistance may be necessary and for monitoring urine output the insertion of an indwelling catheter may be indicated continual assessment of the patient's neurologic status is indicated and in the Intensive Care setting providers can anticipate encountering continuous insulin infusions for patients requiring close glycemic control these laboratory assessments and management strategies are components of effective prehosp care for patients with glucose related",
        "Pituitary Disorders and Their Impact": "emergencies pituitary disorders pituitary disorders can often present with symptoms that mimic various other medical conditions making an accurate diagnosis challenging without a comprehensive medical history in thorough physical exam while these conditions are typically not immediately life-threatening untreated pituitary disorders can lead to significant morbidity and mortality over time emphasizing the importance of a timely diagnosis and appropriate management the pituitary gland often referred to as the master gland plays a central role in the endocrine system by secreting hormones that regulate the function of other glands throughout the body situated just below the hypothalamus in the brain it is anatomically divided into the anterior and posterior pituitary lobes the anterior lobe produces and secretes a range of hormones including growth hormone thyroid stimulating hormone adrenocorticotropic hormone and three gonadotropic hormones these have far-reaching effects on growth metabolism adrenal gland function and reproductive Health conversely the posterior pituitary primarily releases anti-diuretic hormone also known as vasopressin which regulates water balance and oxytocin which plays a central role in uterine contractions during child birth and lactation Central diabetes incipit is a condition that arises when the posterior part of the pituitary gland no longer synthesizes and releases antidiuretic hormone ADH regulates water balance in the body by promoting the reabsorption of water in the kidneys thereby reducing urine output in the absence of ADH individuals with Central diabetes and citus experience a profound disruption in water homeostasis this leads to excessive dilute urine production and subsequent free water loss resulting in severe dehydration and an increase in serum sodium levels a condition known as hypernia the imbalance in water and sodium manifests with symptoms such as extreme thirst excessive urination dry mucus membranes and potential neurological manifestations underscoring the critical need for early diagnosis and management to prevent life-threatening complications associated with Central diabetes and citus pituitary lesions Encompass a spectrum of abnormalities that can affect the pituitary gland structure and function approximately 30% of these lesions fall under the category of non-functioning adenomas which are tumors originating from the pituitary gland but that do not secrete hormones themselves the remaining 70% of pituitary lesions are categorized as functioning adomas where the tumors secrete specific hormones leading to various endocrine disorders among these act secreting adenomas are associated with Cushing's disease characterized by excessive production of act that leads to hyper cortisol ISM growth hormones secreting adomas are linked to acromegaly marked by the abnormal overgrowth of Bones and tissues and giantism when it occurs in children lastly prolactin secreting adomas lead to excessive prolactin production which can result in reproductive disorders such as infertility and menstrual irregularities acromegaly and gigantism are disorders characterized by excessive secretion of growth hormone by the pituitary gland but manifest at different stages in life due to the timing of GH overproduction acromegaly typically occurs in middle-age adults when the epical plates which are responsible for longitudinal bone growth have already closed as a result the excessive GH primarily leads to the thickening and enlargement of bones and soft tissues often resulting in disfigurement and various systemic complications while acromegaly can significantly impact a person's appearance in overall health it is rarely life-threatening but can lead to complications that affect the patient's quality of life on the other hand giantism is a condition that arises in childhood or adolescence before the epical plates have closed during this period of rapid growth excessive GH secretion leads to excessive linear bone growth causing affected individuals to grow to abnormally tall Heights unlike acromegaly giantism presents unique challenges related to skeletal development and can significantly impact the child's physical and psychological well-being both diseases are almost exclusively caused by Ben non pituitary tumors typically adomas effective management of these conditions often involves surgical removal are medical interventions to regulate GH secretion and prevent further complications assessing individuals suspected of having acromegaly or giantism involves a thorough and systematic approach to gather information and conduct diagnostic tests a comprehensive medical history is vital with particular attention given to any rapid growth and unexplained weight gain these are Hallmark symptoms of these conditions additionally providers should assess for Associated signs and symptoms such as changes in facial features joint pain and visual disturbances which are often indicative of excessive growth hormone secretion laboratory results frequently reveal elevated levels of certain biomarkers specifically creatine levels exceeding 1.2 milligrams per deciliter and GH levels surpassing 18 milligrams per deciliter are commonly observed in patients with acromegaly and giantism supporting this diagnosis in terms of management several treatment modalities are available in addressing the underlying GH over production bromocryptine is utilized to decrease GH secretion by targeting the pituitary gland while synthetic analoges of semat Statin can also be used to inhibit production and secretion of GH these medications are employed to effectively halt the excessive production and can be utilized to block the action of endogenous GH molecules at the receptor level effectively counteracting their",
        "Adrenal Abnormalities and Related Conditions": "effects adrenal abnormalities adrenal abnormalities Encompass a wide range of conditions affecting the adrenal glands each characterized by distinct pathophysiological mechanisms and clinical presentations these abnormalities can be broadly categorized into three main groups hereditary disorders steroid resistant syndromes and hypers sensitivity conditions hereditary adrenal disorders include a group of genetic conditions that affect the structure or function of the adrenal gland these mutations can lead to adrenal insufficiency congenital adrenal hyperplasia or other disorders depending on the specific genes and Pathways involved hereditary adrenal conditions are typically present from birth and may result in hormonal imbalances affecting various bodily functions that are regulated by the adrenal hormones steroid resistant syndromes involve a reduced or impaired responsiveness of Target tissues to adrenal steroids such as cortisol these conditions lead to a range of symptoms and may be associated with autoimmune or genetic factors steroid resistance can affect the body's ability to manage stress and regulate inflammation potentially resulting in chronic health issues lastly hypers sensitivity conditions refer to situations in which the adrenal glands respond excessively to certain stimuli or triggers for example in conditions like Cushing syndrome the adrenal glands produce cortisol in response to chronic stress or an underlying medical condition the successive cortisol production can lead to a range of metabolic and hormonal abnormalities pseudo Cushing States represent a group of conditions that mimic the symptoms and laboratory findings of Cushing syndrome including increased cortisol production without actually stiming from an underlying adrenal or pituitary disorder instead these states are triggered by various extrinsic factors that lead to elevated cortisol levels in the body common causes of pseudo Cushing states include the physiological stress associated with surgery severe illness and emotional stress as well as intense aerobic exercise caloric restriction and alcoholism the abrupt cessation of alcohol intake known as alcohol withdrawal syndrome can also invoke cortisol elevation additionally certain medical conditions such as diabetes militis and obesity can contribute to pseudo Cushing States in these conditions the body's stress response mechanisms become activated leading to the release of cortisol from the adrenal glands distinguishing between true Cushing syndrome and pseudo Cushing States is essential as the management and underlying causes differ significantly endocrine hypertension refers to a subset of high blood pressure conditions that are primarily driven by hormonal imbalances unlike essential hypertension which often lacks a clear underlying cause endocrine hypertension results from specific hormonal disorders this can include conditions where hormones such as aldosterone or cortisol are overproduced due to various factors most commonly the presence of a tumor for example con syndrome arises from the excessive secretion of aldosterone by the adrenal glands typically due to an adrenal adenoma likewise conditions like Cushing syndrome result from excessive cortisol often triggered by an adrenal tumor or a pituitary adoma the Hallmark of endocrine hypertension is that it is secondary to an identifiable hormone disturbance the management of endocrine hypertension typically involves addressing the underlying hormonal disorder in some cases surgical intervention to remove the responsible tumor may be necessary alternative anti-hypertensive therapy may be employed to control blood pressure and mitigate the cardiovascular risks associated with hypertension while underlying hormonal issues may be managed adrenal insufficiency is a medical condition characterized by the underproduction of two critical hormones cortisol and aldosterone primarily due to decreased functioning of the adrenal cortex this insufficiency can result from various underlying causes with autoimmune disorders such as Hashimoto's disease being a common primary cause an autoimmune adrenal insufficiency of the body's immune system mistakenly targets and damages the adrenal glands impairing their ability to produce hormones other primary causes of AI include acute illness or increased stress genetic disorders affecting the adrenal glands renal injuries that disrupt hormonal regulation radiation therapy that damages adrenal tissue and surgical procedures involving the removal of adrenal tissue additionally infections affecting the adrenal glands as well as lesions within the pituitaria or hypothalamus can disrupt the normal functioning of the adrenal cortex leading to adrenal insufficiency permanent adrenal insufficiency or AI encompasses a group of conditions in which the underproduction of adrenal hormones primarily cortisol and aldosterone is enduring and not expected to resolve spontaneously Addison's disease is one of the most recognized causes of permanent AI characterized by the autoimmune destruction of the adrenal cortex in Addison's disease the immune system mistakenly targets and damages the adrenal glands resulting in a lifelong deficiency of cortisol and aldosterone congenital adrenal hyperplasia or cah is another condition leading to permanent AI often caused by genetic mutations affecting enzymes involved in cortis all synthesis this inherited disorder typically presents in childhood and necessitates lifelong hormone replacement therapy surgical removal of the pituitary or adrenal glands known as adrenalectomy or hypo visectomy can also result in permanent AI if the entirety or significant portion of these glands is excised in such cases the loss ofal iCal hormon producing tissue disrupts the body's ability to regulate cortisol and aldosterone levels necessitating lifelong hormone replacement therapy to maintain hormonal balance temporary AI is a transient condition in which the adrenal glands temporarily fail to produce adequate levels of cortisol and in some cases aldosterone this occurs due to various external factors and stressors that disrupt the normal functioning of the adrenal glands physical stress such as severe illness injury or trauma can overwhelm the adrenal gland's capacity to produce cortisol resulting in temporary AI infections particularly those involving the adrenal glands can also lead to a temporary disruption in adrenal hormone production surgical procedures such as those involving the adrenal gland can temporarily impair adrenal function as well additionally medication non-compliance especially in patients who are reliant on exogenous corticosteroids can lead to a sudden drop in cortisol levels resulting in a transient AI episode this is often reversible once the underlying stressor or trigger is addressed or resolved treatment may involve supportive care such such as administering corticosteroids to bridge the gap until adrenal function returns to normal the adisan crisis also known as an adrenal crisis is a life-threatening medical emergency that occurs in individuals with adrenal insufficiency particularly in cases of acute severe adrenal hormone deficiency this crisis is marked by a rapid and severe deterioration in Health with a range of alarming symptoms and complications patients experiencing an addisonian crisis often present with symptoms such as shock which is characterized by hypotension teoc cardia and an altered mental status due to the profound drop in blood pressure these patients May exhibit extreme weakness altered mental status and hyperthermia severe pain in the lower back legs or or abdomen may also occur often accompanied by severe vomiting and diarrhea leading to fluid and electrolyte imbalances and dehydration an addisonian crisis requires immediate medical attention usually involving hospitalization in the administration of intravenous fluids corticosteroids and the correction of any underlying triggers or stressors failure to promptly manage an addisonian crisis can result in severe complications including circulatory collapse and organ failure which underscores the critical importance of early recognition and intervention in individuals with adrenal insufficiency Addison's disease also known as primary adrenal insufficiency is a chronic hormonal or endocrine disorder characterized by deficiency of cortisol and in some cases aldosterone production due to damage or dysfunction of the adrenal glands this results in a range of clinical manifestations including weakness fatigue hypotension unexplained weight loss and the darkening of the skin particularly in areas exposed to sunlight or friction a phenomenon known as hyperpigmentation the Hallmark symptoms of Addison's disease often result from the decreased cortisol levels regulating metabolism stress response and immune function while Addison's disease is a manageable chronic condition in adults with appropriate hormone replacement therapy it can be potentially lethal in children if not promptly diagnosed and treated the condition can be caused by autoimmune destruction of the adrenal cortex infections genetic mutations or underlying factors management typically involves lifelong hormone replacement therapy to maintain adequate cortisol and aldosterone levels regular monitoring and awareness of stressors that may require dose adjustments Cushing syndrome is a rare medical condition characterized by the prolonged exposure of the body to elevated levels of hormone cortis it can result from various underlying causes including adrenal tumors pituitary tumors that produce excessive adrenocorticotropic hormone or the long-term use of high do glucocorticoid medications several risk factors can contribute to the development of Cushing syndrome including obesity poorly controlled type 2 diabetes hypertension and the use of glucocorticoid medications for conditions such as autoimmune disorders or chronic inflammation the signs and symptoms of Cushing syndrome are diverse and often reflect the impact of excess cortisol on various bodily systems this can include weakness and fatigue mood disturbances such as depression and mood swings increased thirst and urination and significant weight gain particularly in the abdominal facial neck and upper back regions skin changes may include thinning easy bruising and the appearance of pink or purple stretch marks on the abdomen thighs breasts or shoulders other notable features can Encompass increased acne facial hair growth in women and scalp hair loss women with Cushing syndrome may also experience menstrual irregularities additionally darkening of the skin on the neck may occur in children Cushing syndrome can lead to obesity and restricted growth due to the interference of excess cortisol with normal growth processes early diagnosis and identification of the underlying cause are vital in managing this syndrome as it can lead to a range of systemic complications if left untreated treatment strategies typically involve addressing the underlying cause surgical removal of tumors when applicable and the gradual reduction of corticosteroid medications if they are deemed to be the cause theia chromosoma is a tumor characterized by the excessive production of catacol amines including epinephrine norepinephrine and dopamine by the chromaffin cells located in the Adrenal medulla these tumors can occur sporadically or is part of a genetic syndrome and can either be benign or malignant the overproduction of catacol amines Bia chromos cyas can lead to significant physiological effects the catac colomines stimulate Alpha adrenic receptors resulting in hypertension increased cardiac contractility glycogenolysis glucogenesis and intestinal relaxation Additionally the stimulation of beta a generic receptors by catacol amines can lead to an increase in heart rate and contractility the excessive release of these hormones results in a hypertensive crisis characterized by severe headaches diaphoresis visual disturbances palpitations epistaxis Ami heart failure and even stroke prompt diagnosis and treatment are essential in managing theoc chromosoma fortunately this condition is treatable in approximately 90% of cases and the primary approach is a surgical removal of the tumor if left untreated this can be fatal due to uncontrolled and severe hypertension and the associated cardiovascular and neurological complications aldosteronism is a medical condition characterized by hypertension and low potassium levels primarily resulting from an excess production of the hormone aldosterone there are two main forms of aldosteronism primary and secondary primary often referred to as con syndrome is usually caused by a tumor typically benign found in a single adrenal gland these tumors overproduce aldosterone leading to an imbalance in the regulation of sodium and potassium in the body this hormonal imbalance contributes to hypertension and the subsequent loss of potassium which can lead to symptoms such as muscle weakness fatigue and abnormal heart rhythms secondary aldosteronism on the other hand is not directly associated with adrenal gland tumors but rather occurs due to various other underlying factors these factors can include obstructive renal artery disease which reduces blood flow to the kidneys and prompts the release of aldosterone as a compensatory mechanism renov Vaso constriction and certain emis disorders can also trigger secondary aldosteronism by affecting the body's regulatory mechanisms for aldosterone release accurate diagnosis and differentiation between primary and secondary are crucial as treatment strategies may vary management often includes addressing the underlying cause medication for the control of blood pressure and potassium levels and sometimes surgical intervention to remove adrenal tumors in cases of primary aldosteronism idos is a group of diseases characterized by the abnormal accumulation of protein deposits known as amloid in various tissues throughout the body this condition can result in significant damage to affected tissues and organs potentially leading to organ failure in cases of systemic amloid dois there are two main types of amiloidosis primary and secondary primary is the most common form and mainly affects tissues such as the heart kidneys tongue nerves and intestines it is often associated with the presence of multiple Myoma a type of bone marrow cancer in primary amiloidosis the abnormal accumulation of amid proteins is not secondary to another underlying illness or condition in contrast secondary amitosis occurs as a consequence of another under lying disease or condition such as chronic infections or chronic inflammatory diseases like rheumatoid arthritis it typically affects tissues including the kidneys liver spleen and lymph nodes currently there is no known cure and treatment primarily focuses on managing the symptoms and complications associated with the condition therapeutic approaches may include addressing the underlying cause managing organ dysfunction and in some cases medications or therapies aimed at reducing the production of amid proteins early diagnosis and management are essential in improving the prognosis and quality of life for individuals with amitosis in the assessment of patients healthc Care Professionals must remain Vigilant about the potential presence of adrenal complications in the differential diagnosis this involves a thorough evaluation of clinical signs and symptoms which can vary depending on the specific adrenal disorder in question for instance Cushing syndrome and Cushing disease typically necessitate Laboratory Testing for definitive diagnosis symptoms may include weight gain moon face buffalo hump and muscle weakness in contrast theoc chromosoma may present with symptoms such as hypertension teoc cardia diaphoresis chest pain upper abdominal pain and anxiety primary aldosteronism can manifest with signs like hypokalemia metabolic alkalosis muscular weakness polyurea polydipsia and hypertension while secondary aldosteronism may be associated with edema States heart failure hepatic curosis and malignant hypertension amoosed symptoms including pedal edema weight loss shortness of breath weakness diarrhea fatigue and cardiac arrhythmias lab assessment assists in definitively diagnosing these underlying health conditions specific tests such as the ACT stimulation test and cortisol test are employed in the diagnosis of Addison disease which is characterized by adrenal insufficiency in a healthy individual these tests typically result in a significant rise in blood in urine cortisol levels in contrast a patient with adrenal insufficiency May exhibit a minimal increase or no increase in cortisol levels indicating a dysfunctional adrenal response normal cortisol levels in adults typically fall within the range of 5 to 25 adstone levels on the other hand typically range from 2 to 9 in adults the management of adrenal complications primarily revolves around addressing the hormonal imbalances caused by the adrenal glands dysfunction in cases of adrenal insufficiency where the adrenal glands are not producing sufficient cortisol and aldosterone treatment typically involves hormone replacement or substitution therapy this aims to restore the body's hormonal equilibrium and alleviate symptoms associated with adrenal insufficiency for individuals experiencing an acute Ute adrenal crisis the immediate priority is to correct hypmic shock this is accomplished through aggressive fluid resuscitation which helps restore blood volume and stabilizes blood pressure in addition to fluid replacement the administration of intravenous corticosteroids addresses the cortisol deficiency quickly adequate steroid replacement therapy is vital to prevent further complications and support the body during dur the stressful",
        "Thyroid Abnormalities and Emergencies": "crisis thyroid abnormalities thyroid emergencies typically do not necessitate Critical Care transport as they can often be managed effectively in a non-emergency medical setting nevertheless understanding the pathophysiology of thyroid emergencies is critical for healthc care providers to recognize and address these conditions appropriately the thyroid gland serves as the primary controller of the body's metabolism playing a central role in regulating various physiological processes it produces two essential hormones triodine or T3 and thyroxine or T4 which are responsible for stimulating increased organ function throughout the body these thyroid hormones act on target tissues and cells to enhance metabolic rate energy production and heat generation they also play a critical role in regulating heart rate respiratory rate and body temperature imbalances in thyroid hormone levels whether due to excessive production or insufficient production can lead to thyroid emergencies impacting multiple organ systems and and potentially causing life-threatening complications hypothyroidism is a rare medical condition characterized by deficiency in the thyroid hormones T3 and T4 which are required for regulating various metabolic processes the signs and symptoms of hypothyroidism are diverse and can affect multiple organ systems patients with hypothyroidism often exper exp erience a decrease in body temperature which may manifest as intolerance for cold temperatures gradual weight gain is a common symptom along with lethargy fatigue and a general feeling of weakness GI symptoms include constipation while muscle aches and joint pain stiffness and swelling can lead to discomfort and reduced Mobility facial swelling particularly around the eyes may occur and individuals with hypothyroidism often exhibit pale dry skin brittle fingernails and hair heness of voice may be present and patients may also experience depressive symptoms recognizing these clinical signs and symptoms helps healthc care providers to initiate proper diagnostic testing and treatment for hypothyroidism which typically involves hormone or replacement therapy with synthetic thyroid hormones like levothyroxine to restore hormonal imbalance and eleviate these distressing symptoms hyperthyroidism is a medical condition characterized by an over production of the thyroid hormones T3 and T4 which play a vital role in regulating the body's metabolism as a result of the increased thyroid hormone level individuals with hyperthyroidism often exhibit a distinct set of signs and symptoms a notable feature is an elevation in body temperature and patients May frequently complain of feeling warm or experiencing heat intolerance contrary to hypothyroidism hyper thyroidism often leads to unintended and gradual weight loss despite an increased appetite the cardiovascular system is significantly affected with patients experiencing an elevated and sometimes irregular heartbeat and hypertension excessive sweating is common and individuals with hyper thyroidism May report feelings of restlessness and irritability which can be attributed to the heightened metabolic State thyroid toxicosis and thyroid storm are rare yet extremely severe in life-threatening complications that can develop in patients with untreated or undertreated hyperthyroidism although the precise mechanisms triggering these conditions are not fully understood they pose a significant risk to affected individuals with mortality rates ranging from 10 to 20% patients experiencing thyroid toxicosis or thyroid storm manifest grossly severe symptoms of hyperthyroidism indicating a profound disruption in thyroid hormone regulation these symptoms include hyperpyrexia where the body attempt often exceeds 103\u00b0 fah and can reach as high as 104 to 106\u00b0 fah altered mental status is a common feature reflecting the systemic impact of thyroid hormone excess myocardial depression characterized by impaired cardiac function is a critical concern in these cases patients frequently present with significant teoc cardias in atrial fibrillation further underscoring the gravity of these conditions mexicoma is a rare and life-threatening condition that occurs in individuals with long-standing severe and treated hypothyroidism the condition is characterized by an underactive thyroid gland that fails to produce adequate thyroid hormones this medical emergency is marked by constellation of severe symptoms that necessitate immediate medical attention patients with my XD micoma typically present with altered mental status and lethargy reflecting the profound impact of thyroid hormone deficiency on the central nervous system these patients appear confused disoriented or even comos the altered mental state can be accompanied by significant weakness and fatigue one of the defining features of this disease is the failure of the body's Thermo regulatory system this leads to hypothermia and the body's temperature drops to dangerously low levels in severe cases Body temp can fall below 95\u00b0 F despite the presence of infectious diseases or other illnesses that would typically trigger a fever response in the body patients with memac coma often do not exhibit a fever this paradoxical lack of fever is a key diagnostic clue and can help differentiate memac coma from other conditions mxd Moma can be precipitated by various events or medical conditions including cold exposure infections certain medications trauma Strokes heart failure GI bleeding and other critical medical illnesses these precipitating factors can exacerbate the underlying hypothyroidism leading to a rapid deterioration in the patient's Health given its life-threatening nature early recog I condition and prompt intervention are Paramount for patients with memac coma treatment typically involves hormone replacement therapy with thyroid hormones such as intravenous levothyroxine to rapidly restore thyroid hormone levels additionally addressing the underlying cause or precipitating event such as managing infections or providing supportive care is essential to stabilize the patient's overall condition Hashimoto's disease often referred to as chronic lymphocytic thyroiditis is a chronic autoimmune disorder characterized by the immune system's attack on the thyroid gland this response results in chronic inflammation and damage to the thyroid tissue leading to a reduction in the gland's ability to produce thyroid hormones Hashimoto is recognized as one of the primary causes of hypothyroid ISM Hashimoto's disease predominantly affects women with the higher incidence observed in individuals between the ages of 30 and 50 years though it can occur at any age the precise trigger for the autoimmune response in Hashimoto's disease is not entirely understood but it is believed to involve a combination of genetic predisposition and environmental factors over time the persistent immune attack on the thyroid gland can lead to thyroid enlargement known as a goiter and a gradual decline in thyroid function patients with Hashimoto disease often present with symptoms of hypothyroidism including fatigue weight gain cold intolerance dry skin brittle hair and constipation the management of Hashimoto's disease typically involves thyroid hormone replacement therapy with synthetic thyroid hormon hormones in order to replace the deficient hormones and restore normal thyroid function assessing a patient with a thyroid related condition involves a comprehensive evaluation to identify potential signs and symptoms related to thyroid dysfunction patients with thyroid disorders may present with a range of clinical manifestations which can vary depending on whether they have hypothyroidism or hyperthyroidism hypothyroidism can manifest with General weakness cold intolerance and an overall sense of lethargy altered mental status which can include confusion or cognitive impairment may also be observed abdominal pain can occasionally occur though it is less common and should not be overlooked as it could be a sign of associated complications or conditions in contrast hyperthyroidism often presents with heart rated complications such as tacac cardia heart failure atrial fibrillation and hypertension these cardiovascular symptoms can have significant impact on the patient's overall health and may require immediate attention during physical exam providers may also perform a thyroid assessment to evaluate the gland size and texture enlargement of the thyroid gland seen here on this slide as a goer can be palpated or visualized during the exam the presence of a goer can provide important diagnostic clues about the underlying thyroid condition and guide further evaluation and treatment laboratory assessment allows Healthcare Providers to evaluate the levels of thyroid hormones and thyroid stimulating hormone in the patient's blood the main laboratory tests conducted for thyroid assessment include measurements of TSH T3 and T4 these tests provide valuable information about the functioning of the thyroid gland and help differentiate between hypo and hyper thyroidism in normal thyroid function the hypothalamus pituitary thyroid axis regulates the secretion of thyroid hormones TSH is produced by the pituitary gland and stimulates the thyroid gland to release T3 and T4 the normal range for TSH levels typically Falls within the range of 0.4 to 4.2 Milli international units per liter deviations from this range indicate thyroid dysfunction common labor testing for thyroid disorders involves measuring these hormone levels in the patient's blood TSH levels often indicate primary hypothyroidism where the thyroid gland fails to produce sufficient T3 and T4 conversely decreased TSH levels suggest primary hyperthyroidism which would be characterized by an excessive production of T3 and T4 the management of thyroid related conditions requires a tailored approach depending on whether the patient is dealing with hyperthyroidism or hypothyroidism in cases of hyperthyroidism the primary goals of management are to control the excessive production of thyroid hormones and alleviate symptoms this can be achieved through various means including the use of anti-thyroid medications to inhibit the thyroids hormone production radioactive iodine therapy to reduce the thyroids activity or the surgical removal of the thyroid gland itself however it is essential to note that patients which undergo surgery or receive radioactive iodine will require lifelong hormone replacement therapy to maintain thyroid function within a normal range conversely hypothyroidism is managed through hormone replacement therapy typically involving the administration of synthetic thyroid hormones this treatment aims to supplement the deficient thyroid hormones and restore them to normal levels in the body the dosing of hun replacement therapy is carefully adjusted to achieve optimal thyroid function and alleviate hypothyroidism related symptoms lipid disorders Encompass a range of conditions that involve alterations in the reduction or utilization of cholesterol within the body while these disorders can significantly increase the risk of atherosclerosis and cardiovascular diseases like heart disease they typically do not constitute a medical emergency in and of themselves one specific lipid related condition is something known as APS which is an autoimmune disorder in APS the body's immune system produces antibodies that obstruct specific phospholipid binding proteins disrupting their normal function of preventing excessive coagulation initially observed in patients with SLE APS can lead to increased risk of blood clots and related complications another lipid related issue is metabolic syndrome which comprises a cluster of risk factors that collectively heighten the likelihood of developing coronary arter disease stroke and type two diabetes these risk factors typically include obesity high blood pressure elevated blood sugar levels abnormal lipid profiles and insulin resistance metabolic syndrome underscores the intricate relationship between lipid disorders insulin resistance and cardiovascular help effective management of lipid disorders and metabolic syndrome often involve life style modifications such as dietary changes exercise and medications to mitigate the risk of cardiovascular events and improve overall metabolic  health"
    },
    {
        "Introduction to Gastrointestinal and Genitourinary Emergencies": "chapter 17 gastrointestinal and Geno urinary emergencies Introduction introduction homeostasis relies on the intricate metabolic functions of the GI and the GU systems various issues can disrupt these processes giving rise to manifestations such as pain alter mutation and shock it is essential for critical care paramedics to recognize and address disruptions in the GI and gu systems promptly as they assist in maintaining the body's equilibrium understanding the potential challenges associated with these systems is essential for Effective emergency response and patient",
        "Anatomy and Physiology of Gastrointestinal Abnormalities": "care anatomy and physiology epidemiology and pathopysiology play integral roles in understanding gastrointestin abnormalities disturbance of the mucosa can expose mesenteric vasculature nerves lymph and inner tissue layers to the extreme changes in PH levels and digestive enzymes in the GI Lumen consequently common symptoms of GI abnormalities such as abdominal pain tenderness and bleeding arise due to this exposure upper GI bleeding originates proximal to the ligaments of triot supporting the junction of the dadum and the gunum bleeding Beyond this point is categorized as lower GI bleeding extrinsic factors including alcohol and tobacco use dietary habits and inid usage are identified contributors to increased incident of upper GI bleeding recent surgery and illness further Elevate the risk lower GI bleeding May manifest with bright red blood at the rectum while upper GI bleeding typically presents with dark or tar stools however brisk upper GI bleeding can also exhibit bright red blood endoscopy stands as the preferred method for locating the bleeding Source moving to conditions affecting the upper GI track gastritis characterized by inflammation of the gastric mucosa serves as a a precursor to upper GI bleeding hydrochloric acid and pepsin in gastric juice assale the mucosa while protective mechanisms such as mucin producing cells bicarbonate secretion prostaglandins and Rapid cell turnover work in concert to Shield it from drainage recognizing the epidemiological factors and underlying pathophysiology of these conditions is essential for a comprehensive understanding and effective Management in critical care paramedicine acute gastritis is defined by the Swift onset of mucosal inflammation or the abrupt breakdown of protective barriers often resulting in upper GI bleeding notably the ingestion of corrosive chemicals has the potential to rapidly burn the epithelial lining of the GI tract exacerbating the severity of the the condition furthermore it's important to recognize that many instances of acute gastritis represent an escalation of an underlying chronic GI condition for example individuals with chronic alcoholism exhibit extensive tissue damage in approximately 20% of all cases understanding the eological factors including chemical exposures and the connection between acute exacerbation and chronic conditions is needed for Effective management and intervention in cases of acute gastritis that are encountered in the realm of critical care H pylori is identified as a causitive agent of acute gastritis particularly during the primary phase of infection this bacterium contributes to the initiation of inflammatory processes affecting the gastric mucosa the beyond the acute phase long-term histopath changes in the gastric lining can give rise to conditions such as chronic atropic gastritis in instances of chronic atrophic gastritis enduring alterations to the histological structure of the gastric mucosa occur importantly this chronic condition is linked to potential complications with pernicious anemia being one of the notable consequences the development of pernicious anemia in the context of chronic atrophic gastritis underscores the systemic impact of prolonged hpylori infection on the body's hematologic status understanding the association between hpylori induced acute gastritis and the subsequent progression to Chronic atrophic gastritis and pricious anemia allows for comprehensive Management in the field reactive gastritis is characterized by chronic irritation of the stomach lining commonly induced by the prolonged use of ineds alcohol consumption and exposure to bile the persistent irritation leads to inflammatory changes in the gastric mucosa notably patients undergoing abdominal radiation therapy May encounter a distinct form known as radiation gastritis this condition closely mimics the symptoms of acute gastroenteritis and typically manifests within days of initiating radiation treatment the correlation between chronic irritants such as ineds alcohol and bile and the development of reactive gastritis underscores the importance of identifying and managing causitive factors to alleviate symptoms and prevent further mucosal damage likewise recognizing the unique manifestation of gastritis induced by abdominal radiation therapy provides targeted care to patients undergoing such treatments in the realm of critical care peptic ulcers stand as the primary causitive factor behind upper GI bleeding representing a significant concern these ulcers are characterized by the erosion of the mucosal lining within the GI tract with a occurrences observed in either the stomach which would be referred to as gastric ulcers or the dadum known as duodenal ulcers two major risk factors associated with the development of peptic ulcers are the presence of H pylori infection and the use of ineds H pylori is particularly noteworthy in its association with increased incident rates of peptic ulcer disease patients infected with this bacteria exhibit a 6 to 10-fold heightened likelihood of developing these ulcers compared to their uninfected counterparts the detrimental impact of ineds and H pylori on the mucosal defenses is rooted in their ability to hinder the production of protic Landin which are essential hormones that mediate the inflammatory response in tissues ineds exert their effect by inhibiting prostag glandon synthesis simultaneously hpylori infection further disrupts the delicate balance by interfering with the normal physiological functions of the gastric mucosa this inhibition of prostaglandins compromises the mucosal defenses against irritation rendering the GI tract more susceptible to damage in addition to in says in H pylori alcohol and tobacco use emerge as independent risk factors for peptic ulcer disease the deleterious effects of alcohol and tobacco extend to the mucosal barrier exacerbating the vulnerability of the GI tract these substances contribute to the erosion of the protected layers increasing the likelihood of mucosal damage and the subsequent development of peptic ulcers esophago varices the second most common cause of upper gii bleeding result from the swelling of the esophageal veins known as esophageal varices which protrude into the Lumen of the esophagus and have the potential to rupture these varaces are a consequence of increased pressure within the portal Venus system often associated with liver sorosis in cerotic conditions the normal blood blood flow through the liver is obstructed leading to portal hypertension and the development of collateral vessels including esophageal veraces the swelling and intrusion of these varices into the esophageal Lumen create a vulnerable site that's susceptible to rupture which can then result in severe and life-threatening upper GI bleeding understanding the underlying pathophysiology of esophago varices allows for prompt recognition and intervention that are essential in managing patients with liver curosis and Associated complications the potential for rupture and subsequent upper G bleeding underscores the significance of addressing the root cause and mitigating factors contributing to portal hypertension in the comprehensive care of individuals with this disease esophagitis a frequent contributor to upper GI bleeding is often associated with severe gastroesophageal reflux disease and alcohol abuse this condition involves inflammation of the esophageal lining and its prevalence as a cause of upper GI blading underscores his clinical significance in cases of gird The Chronic exposure of the esophagus to stomach acid leads to the irritation and inflammation of the esophagus potenti culminating in esophagitis alcohol abuse further exacerbates this susceptibility adding to the likelihood of further GI complications however it can also result from alternative factors including irritation caused by pills a condition known as pill esophagitis or infectious agents pill esophagitis occurs when certain medications particularly those that are acidic or irritant lead to localized inflammation additionally infections affecting the esophagus can contribute to its development malerie Weiss syndrome is characterized by Tears in the esophagus specifically at the gastro esophageal Junction these tears are a consequence of repeated alterations of local pressure typically occurring during episodes of severe wretching or vomiting The increased pressure in the esophagus during these events leads to Mechanical stress on the gastro esophageal Junction resulting in tears or lacerations several risk factors are associated with malerie wise syndrome further emphasizing its clinical relevance hial hernas conditions where a portion of the stomach protrudes to the diaphragm into the chest cavity are ident identified as potential risk factors bulimia a disorder characterized by recurrent episodes of overeating followed by compensatory behaviors such as vomiting poses an increased risk of malerie wise tears due to the repetitive nature of induced vomiting chronic alcohol use which can lead to a weakened esophageal muscle and increased susceptibility to tears is also recognized as a risk factor additionally advancing age is considered a contributing factor to the development of malerie Weiss syndrome boreave syndrome is characterized by the spontaneous rupture of the esophagus often induced by forceful vomiting this rupture can lead to perforations of the esophageal wall posing a severe and potentially life-threatening condition notably the forceful nature of vomiting is a primary contributor to the occurrence of this syndrome in addition to forceful vomiting perforations leading to borov syndrome may also result from CTIC ingestion or pill esophagitis intriguingly in about half of all cases endoscopy or stricture dilation procedures contribute to the development of these perforations several other factors are associated with the onset of borof syndrome foreign body ingestion most commonly in children is also observed in adults particularly in association with eating esophageal impaction frequently occurring in individuals with psychiatric illness or alcohol intoxication represents another potential cause patients with pre-existing conditions such such as severe obstruction underlying strictures or tumors May necessitate endoscopic intervention to address the risk of borof syndrome diverticulosis a prevalent condition in older adults affects the lower GI tract characterized by the formation of small pouches known as diverticula this condition predominantly manifests in the descending colon and sigmoid colon the emergence of diverticula is attributed to robust contractions of the hostal muses exerting pressure on weaken mucosa that commonly occurs with aging despite being generally painless diverticula are commonly observed in a substantial percentage of individuals aged 80 years or older with prevalence ranging from 50 to 70% contri ruting factors to the development of diverticulosis include a low fiber diet chronic constipation sedentary lifestyle and smoking diverticulitis characterized by inflammation of the diverticulum is a complication that arises in up to 15% of diverticulosis cases this inflammation is thought to result from either microscopic or macros opic perforations in the diverticulum triggered by focal inflammation the occurrence of diverticular bleeding which is observed in about 15% of patients with diverticulosis is a significant concern with onethird of these cases presenting as massive GI bleeding angio dysplasia is characterized by the Mal formation of submucosal blood vessels within the GI tract while this condition can manifest anywhere along the alementary canal a significant majority of cases exceeding about 34s are observed in the seeum and ascending colon the distinctive feature of angio dysplasia lies in the thin walled winding nature of the affected vessels rendering them highly susceptible to rupture this vulnerability to rupture can lead to GI bleeding making angio dysplasia a notable cause of a cult or overt lower GI bleeding appendicitis arises when the appendix a blind pouch extending from the seeum becomes inflamed and infected the classic presentation of appendicitis is characterized by a relatively rapid onset of pain primarily located in the right lower quadrant or per umbilical region this pain is often accompanied by symptoms such as nausea vomiting and fever collectively indicative of the inflammatory process affecting the appendix recognized as one of the most common reasons for emergency abdominal surgery in the United States appendicitis affects up to 8% of the population over the course of their lifetime the prevalent of this condition underscores its clinical significance and the need for prompt intervention in advanced cases the inflammatory process May progress to complications such as perforation peritonitis and sepsis perforation of the appendix can result in the release of infectious contents into the abdominal cavity leading to peritonitis a severe inflammation of the abdominal lining the systemic effects of advanced appendicitis such as sepsis pose significant risks to the overall health of the patient inflammatory bowel disease or IBD encompasses a range of pathologies collectively responsible for approximately 10% of cases involving lower GI bleeding two prominent forms are ulcerative colitis and Crohn's disease each characterized by distinct patterns of inflammation within the G trct ulcerative colitis specifically involves inflammation of the rectal mucosal and sub mucosal tissues this localized inflammation contributes to symptoms such as abdominal pain diarrhea and rectal bleeding in contrast Crohn's disease represents a less organized inflammation affecting various segments of the GI tract with potential involvement of all layers of the mucosa The Irregular and patchy nature of the inflammation of Crohn's Disease distinguishes it from the more localized presentation of ulcerative colitis individuals with crohn's disease may experience a broader spectrum of symptoms including abdominal pain diarrhea weight loss or fatigue as both ulcerative colitis and Crohn's disease progress to Chronic stages the inflammatory process can lead to scar tissue formation causing the thickening of the mucosa this thickening contributes to the development of complications such as ball structions which can impede the normal passage of digestive contents through the affected segments of the GI tract gastroenteritis is an illness resulting from infections caused by bacteria viruses or parasites characterized by symptoms such as vomiting and diarrhea this condition predominantly affects the GI tract in immunocompetent individuals infections leading to gastroenteritis are often self-limited and the primary approach to management involves supportive care particularly oral rehydration therapy to address fluid and electrolyte imbalances induced by the frequent vomiting and diarrhea despite being generally self-limiting in individuals with intact immune systems gastroenteritis is associated with considerable morbidity and mortality particularly in low and middle income countries where resources for adequate Health Care may be limited in particular children are vulnerable to the severe consequences in these settings the rapid loss of fluids and electrolytes due to the vomiting and diarrhea can lead to dehydration requiring prompt intervention to prevent complications es schic colitis represents a potentially life-threatening form of colitis that arises due to a reduction in blood flow to the GI tract the causes vary ranging from arterial obstruction often associated with embolic events in patients with aib to significant vessel narrowing in individuals with vascular occlusive diseases or traumatic injuries the classical presentation of a patient experiencing an intestinal infar involves severe abdominal pain that is notably disproportionate to the clinical examination despite the severity of pain the the patient may not exhibit signs of systemic distress and the abdomen may not demonstrate the inspected level of tenderness based on the reported pain if left untreated es schic colitis can lead to critical complications including bow necrosis perforation sepsis shock and ultimately death the progression of a schic colitis to bow necrosis is a consequence of inadequate blood supply which deprives the affected portions of the intestine of oxygen nutrients resulting in tissue damage the risk of perforation further increases the potential for sepsis and shock underscoring the urgency of recognizing and promptly addressing es schic colitis in the realm of critical care param medicine to prevent these life-threatening complications other types of colitis include distinct pathologies with unique etiologies and manifestations radiation colitis for instance manifests in approximately 75% of patients who have undergone radiation therapy with doses of 4,000 Rad or more to the abdomen or pelvis this form of citis is characterized by chronic mucosal thickening resulting from radiation therapy attributing to structural changes within the colon additionally ulcerations throughout the colon may occur as a consequence of radiation induced damage immun mediated colitis represents another variant commonly associated with adverse effects of immune checkpoint Inhibitors these Inhibitors monoclonal antibodies designed to enhance the immune system's anti-cancer response may lead to unintended consequences including immune mediated colitis typically affecting the lower giat trct this form of colitis highlights the delicate balance that is required for modulating immune responses in cancer therapy assessing the conditions of the G trct involves a comprehensive evaluation of various signs and symptoms that may indicate underlying issues black tari appearing stool known as Molina is a significant indicator of upper GI bleeding suggesting the presence of digested blood diffuse abdominal discomfort often described as chronic stomach ache or non-specific Burning Sensations can be indicative of a range of GI conditions necessitating further investigation emesis containing blood known as hemat emesis is a critical symptom signaling potential bleeding within the upper GI tract weight loss anemia and malnutrition May accompany chronic GI conditions reflecting the systemic impact of ongoing issues affecting the digestive system symptoms such as dizziness and Syncopy may be associated with significant blood loss or dehydration emphasizing the importance of assessing the patient's overall hemodynamic status fever can be indicative of infectious inflammatory processes affecting the GI tract while diarrhea and dehydration may suggest a range of GI disorders hypotension and hemodynamic instability are critical signs requiring prompt attention as they may indicate severe bleeding or shock the presence of blood in the stool known as hesia can be associated with lower GI bleeding and its identification AIDS in determining the location and severity of the issue notably pressure ulcers are often associated with prolonged immobility or chronic conditions affecting the GI tract serving as potential indicators of the patient's overall health status Laboratory Testing and monitoring can provide valuable insights into the patient's overall health and the severity of the bleeding hemoglobin and hematocrit levels are fundamental indicators that Aid in assessing the extent of blood loss a decrease in these values may suggest anemia helping healthc care providers gauge the severity of the bleeding and guide appropriate interventions monitoring the coagulation profile which includes parameters such as Prothrombin time and activated partial thromboplastin time is essential for evaluating the patient's clotting function abnormalities in the coagulation profile can be indicative of potential coagulopathies or complications related to bleeding disorders blood Ura nitrogen levels provide insights into the renal response to GI bleeding elevated bu levels May signify increased absorption of blood or products of blood breakdown in the GI tract reflecting the severity of the bleeding and potential complications such as hyp emia Imaging localizes the origin of GI bleeding allowing for accurate diagnosis and targeted intervention the most effective method for mucosal exploration is through endoscopy specifically through a process known as EGD which can visualize more than 90% of the upper GI tract endoscopists can employ various therapeutic inter interventions through EGD to stop bleeding including cauterization local application of hematic material and vasoconstricting injections colonoscopy focusing on the lower GI mucosa is a valuable Imaging modality as well although it is more intricate than EGD due to the nature of the lower GI Anatomy CT angiography has emerged as an increased ly convenient diagnostic tool for active GI bleeding this Imaging technique enables the rapid localization of bleeding Legions anywhere in the GI tract offering a non-invasive approach to identifying the source of bleeding technum 99m labeled red blood cell synct graphy once a commonly used method involving the identification of blood cells attached to Isotopes is gradually being abandoned in favor of CT angiography due to its enhanced diagnostic capabilities and efficiency the management of GI bleeding necessitates a systematic and comprehensive approach to stabilize the patient and address the underlying cause of bleeding initiation of care begins with attending to the ABCs ensuring the patient essential physiological functions are maintained in conscious andert patients supplemental oxygen should be administered to maintain oxygen saturation levels of 92% or greater simultaneously all patients should be designated as NPO to prevent further complications the placement of two large bore IV catheters anything larger than an 18 is a priority facilitating prompt fluid resuscitation in patients who may be exhibiting signs of shock fluid resuscitation consisting of 500 mL boluses aims to maintain a mean arterial pressure of 60 mm of mercury blood samples should be drawn to ascertain a type and Cross Match complete blood count errly levels Momin time and partial thromboplastin time values guiding further interventions blood Administration is withheld until the patient's hemoglobin drops below 7 gram per deciliter and transfusion decisions are made based on clinical features of shock particularly in cases of ongoing bleeding continuous monitoring of blood pressure and pulo symmetry is imperative to evaluate the patient's response to fluid resuscitation efforts in hemodynamically unstable Pat patients arterial line placement provides real-time visualization of their hemodynamic status continuous ECG monitoring is equally essential enabling the observation of potential arhythmia secondary to electrolyte imbalances or hypoxia this systematic and well-coordinated approach ensures that Critical Care paramedics can effectively manage GI bleeding addressing both the immediate resuscitative needs and ongoing monitoring required for optimal patient care upper GI bleeding is managed through a comprehensive approach nasogastric or orogastric tube placement facilitates blood and gastric content clearance although it is no longer routinely done during transport endoscopy perform when the patient is stable identifies and treat treats bleeding sources including injection sclerotherapy and verical band liation vasoactive medications like vasopressin effectively stop bleeding mechanical obstruction through devices like the sing stocken Blakemore tube or Minnesota esophagogastric tanod tube can control Hemorrhage trans jugular intrahepatic protoy systemic shunt placement is employed for veral bleeding and proton pump inhibitors are administered to reduce gastric acidity offering a comprehensive strategy for upper GI bleeding management the management of lower GI bleeding shares similarities with that of upper GI bleeding emphasizing comprehensive care for patients experiencing Hemorrhage from the lower GI tract attention must be devoted to fluid loss through water shifts in the colon addressing Associated dehydration and potential electrolyte abnormalities that may arise endoscopic methods including cauterization and coagulation with argon plasma are utilized to terminate lower G bleeding offering targeted interventions in cases of diverticular bleeds the first line treatment involves local infiltration with vasoconstrictive medication and clip placement aiming to control bleeding at the source for patients presenting with acute Hemorrhage the administration of blood and blood products is essential to address coagulopathy and stabilize the patient trans catheter embolization of bleeding vessels stands as an effective alternative approach providing a minimally invasive means of achieving hemostasis",
        "Intestinal Obstructions": "intestinal obstructions the epidemiology and pathophysiology of intestinal obstructions involve diverse etiologies with postoperative adhesions emerging as a significant cause these adhesions which are bands of connective tissue formed post surgery have the potential to distort the normal anatomy of the abdomen leading to Mechanical obstruction additionally other common causes of intestinal obstructions include tumors hernas Crohn's disease vilus and insception mechanical obstruction can arise from both extrinsic and intrinsic factors extrinsic causes involve adhesions hernas volvulus and masses adhesions as I mentioned earlier result from post most operative changes and can lead to constriction of the intestine Heria is Manifest as a protrusion of an organ from its tissue lining contributing to an obstruction vulas characterized by the twisting of the intestine onto itself often results in strangulation further exacerbating the obstruction intrinsic causes might include diverticula neoplasms and interception interception involves a prolapse of one segment of the intestine into an adjacent segment contributing to blockage intraluminal obstructions can result from ingested foreign bodies or fecal impactions causing constriction and hindering the normal flow of intestinal contents ilas is characterized by the lack of movement of the GI content through the intestines occurring in the absence of mechanical obstruction this condition disrupts the normal peristaltic activity of the intestines leading to a functional impairment in the movement of intestinal contents the causes of ilas can be categorized into primary and other contributing factors the primary cause often includes post-operative and idiopathic instances where disruptions in Bow function occur without an apparent mechanical blockage other contributing causes of ilas include a range of conditions such as abdominal inflammation peritonitis heavy metal poisoning metabolic abnormalities and spinal cord injury abdominal inflammation in peritonitis can induce a state of decreased bow motility as part of the body's response to inflammation heavy metal poisoning and metabolic abnormalities may affect the neuromuscular function of the intestines contributing to ilas spinal cord injury particularly affecting the nerves responsible for intestinal motility can also lead to impaired GI movement assessment of intestinal obstruction involves recognizing Key signs and symptoms moderate to severe abdominal pain and distension near the obstruction are prominent bad breath and foul smelling vomit possibly containing b or even feces signify the stasis and decomposition of intestinal contents fever May indicate complications such as infection while shock can develop in severe cases reflecting on the systemic impact of the obstruction on vital",
        "Liver Disease": "functions liver disease epidemiology and pathophysiology of liver disease es comprise diverse conditions each with its distinct characteristics hepatitis serves as a physiological consequence of various liver diseases viral infections particularly Hep B and C contribute to 90% of hepatitis Associated fatalities the remaining 10% of cases result from factors such as excessive alcohol consumption autoimmune disorders toxins and drugs fulminate hepatic failure emerges as a consequence of a sudden and significant insult to the liver Acetaminophen Toxicity stands as the leading cause accounting for 46% of cases followed by idiosyncratic drug reactions and hepatitis B non-alcoholic fatty liver disease is the most prevalent liver disorder in Western industrialized countries with Rising incident linked to risk factors like central obesity type 2 diabetes metis D lipidemia and metabolic syndrome non-alcoholic fatty liver disease has the potential to progress to therosis highlighting the importance of early intervention and management sosis is characterized by irreversible structural damages to the liver which impair its normal functioning the course of liver disease involves a Cascade of events initiated by inflammation of liver tissue leading to damage to various functional cells including hepatocytes and cuper cells as these cells are progressively destroyed the fundamental acar framework responsible for blood detoxification and bowel production becomes disarranged inflammation extends to liver sinusoids and bile drainage canals resulting in increased resistance to both portal blood flow and B passage the initial blood backup can lead to a splen omegal diminishing the spleen Effectiveness in metabolic processes simultaneously the accumulation of B Rubin in the blood occurs as the normal conjugation and excretion process by hepatocytes is impaired resulting in jaundice additionally damaged hepatocytes May compromise proper nitrogen fixation leading to elevated concentrations of blood ammonia in alcoholic liver disease liver cells undergo the distension due to fat accumulation disrupting their normal function therosis represents the advanced stage of liver disease emerging as hocy damage and destruction become widespread enough to cause local areas of necrotic tissue this intricate progression underscores the complexity of liver diseases necessitating a nuanced understanding for Effective medical management and intervention signs and symptoms of liver disease are a spectrum of manifestations reflecting the intricate impact on various physiological systems in early acute hepatitis General malaise and fatigue emerge as the most prominent symptoms portal hypertension a consequence of liver disease gives rise to aites marked by abdominal fluid retention leading to significant distension and a distinctive fluid wave the combination of decreased hepatic synthesis of coagulation factors and collateral blood flow poses a risk of dangerous bleeding especially in the GI tract impair diaphragmatic expansion can result in chronic shortness of breath splenic and systemic vasod dilation continue to decrease cardiac afterload manifesting as hypotension and tardia spontaneous bacterial peritonitis stemming from infection of acidic fluid presents with generalized abdominal tenderness and fever common secondary features of liver disease include hair loss and and gomasa hepatorenal syndrome characterized by renal injury and failure in patients with curosis represents a severe complication as well the diverse array of signs and symptoms highlights the multi-stem impact of liver disease necessitating comprehensive assessment and management strategies laboratory data and imaging focuses on the evaluation of synthesized products and cellular enzymes within the blood key key indicators of liver function include albumin and serum levels of B Rubin the presence of a prolonged proin time and an elevated INR suggest a decrease in clotting Factor synthesis by the liver the model for instage liver disease score or meld is a validated prognostic tool that provides valuable insights into predicting mortality among patients with liver disease the release of specific enzymes from hepatocytes into the bloodstream serves as a marker for the Existence and progression of liver disease notable enzymes include a alt ggt or ggtp monitoring these enzyme levels AIDS in diagnosing liver pathology and assessing the severity of aat cellular damage integrating laboratory data including both functional markers and enzyme profiles enhances the diagnostic precision and informs the management strategies for individuals with liver disease management of liver disease is a multifaceted approach tailored to address specific conditions and mitigate complications in cases of hepatitis the primary focus of treatment revolves around preventing progression to curosis antiviral and interferon drugs play a key role in managing infectious hepatitis aiming to suppress viral replication and modulate the immune response supportive care constitutes a substantial component to liver disease management emphasizing the prevention and correction of complications ECG monitoring is essential to detect arhythmia resulting from electro imbalances particularly hypokalemia Vigilant monitoring for evidence of GI bleeding Reno failure and incopy is imperative to promptly address emerging complications patients with therosis often require preventative measures to manage aites involving a low sodium diet fluid restriction and diuretics despite comprehensive management strategies it's important to acknowledge that there is no cure for Hepatitis or curosis apart from a liver transplant this serves as a definitive intervention for inst stage liver disease offering a chance for improved quality of life and long-term survival the management Paradigm underscores the importance of a holistic and individualized approach to address the diverse challenges associated with liver",
        "Biliary Tract Obstructions": "disease bilary tract obstructions bilary tract obstructions notably the presence of gallstones in the gallbladder pose a significant Health concern affecting approximately 10% of Americans annually these Stones can originate from the accumulation of excess cholesterol in the bile leading to cholesterol stones or from an excess of B Rubin and calcium salt resulting in pigment stones the presence of gall stones can extend beyond the gallbladder contributing to the distension and inflammation of the gallbladder itself a condition referred to as colio cystitis the presence of stones within the biliary ducts introduces additional complications the movement of stones within the biliary system particularly into the cystic duck can result in lacerations of the inner walls adding to the complexity of the condition notably these stones have a propensity to large either in the cystic duck or the distal common bod duck causing further obstruction and potential complications understanding the epidemiology and pathopysiology of bilary tract obstructions including the various manifestations associated with gallstone is critical for accurate diagnosis and effective management of these conditions assessment of biliary track obstructions involves a comprehensive analysis of signs symptoms laboratory data and imaging modalities to accurately diagnose and characterize the condition in cases of chiotis patients commonly experience kicy pain localized in the right upper quadrant of the abdomen conversely gallstones in the biliary duck manifests with a distinct clinical presentation known as the sharot Triad including fever jaundice and upper right quadrant pain additionally a positive Murphy sign marked by the sudden arrest of inspiration upon applying constant pressure to the right upper quadrant is indicative of this condition elevated serum values reflecting block secretions from the gallbladder to the pancreas provide other key diagnostic insights the comprehensive management AB bilary track obstructions involves a systematic approach to provide immediate relief of symptoms and address the underlying cause following the initial interventions for pain management in outpatient settings definitive treatment is pursued upon hospital admission ercp is a central Diagnostic and therapeutic tool serving both to confirm the diagnosis and to facilitate the removal of stones this procedure allows for direct visualization of the billary ducts and when needed the extraction of stones using various techniques for larger Stones lithotripsy becomes a valuable intervention this technique de loys external vibrations to break down the stones into smaller more manageable fragments sphincter ectomy a surgical procedure involving the incision of the sphincter muscle is often performed to widen the passage and enable the stones to pass into the dadum once in the dadum stones could be retrieved using specialized instruments such as baskets or catheters cystectomy the surgical removal of the gallbladder is commonly recommended especially in cases of Chio cystitis or to prevent the recurrence of gallbladder biliary duct Stones this surgical intervention aims to eliminate the source of gall stones and prevent further complications by combining immediate relief measures with targeted interventions for stone removal and addressing underlying issues the management approach ensures a comprehensive an effective strategy for individuals with biliary track obstructions offering both symptomatic relief and long-term",
        "Pancreatic Disease": "resolution pancreatic disease pancreatic disease specifically pancreatitis poses a significant threat to gastrointestinal physiology and his impact varies based on severity and underlying causes the primary culprits for pancreatitis include gallstones accounting for 40 to 70% of cases and alcohol abuse contributing to 25 to 35% of cases other etiologies Encompass idiosyncratic drug reactions ercp tumors hypercalcemia and congenital defects notably approximately 20% of patients progress to severe acute pain pancreatitis marked by systemic inflammatory response syndrome and organ dysfunction chronic pancreatitis signifies an advanced stage characterized by irreversible anatomical alterations within the pancreas coupled with a degree of functional impairment the inflammatory Cascade in pancreatitis arises from the self-digestion of pancreatic tissue reflecting a complex interplay of factors contributing to the pathological process additionally complications such as pancreatic ptoy May develop as a consequence of acute pancreatitis representing accumulations of cellular debris and extracellular pancreatic enzymes understanding the epidemiology and pathophysiology of pancreatic disease is needed for Effective diagnosis and management considering its diverse eological factors and potential progression to severe forms assessment of pancreatic disease involves a thorough examination of signs symptoms laboratory data and imaging to establish a comprehensive understanding of the condition the primary symptom is upper abdominal pain often accompanied by abdominal guarding and rigidity in the presence of peritonitis nausea vomiting and fever are common manifestations reflecting the body's immune response against infectious complications severe cases May exhibit specific discolorations such as Turner sign and Cullen sign indicating potential complications liver function testing including alt a AP ggt and serum B Rubin helps assess the impact on the biliary system Imaging techniques such as contrast enhanced CT scan MRCP and ercp provide visual insights into the pancreas and surrounding structures the combined use of abdominal ultrasonography and endoscopy enhances visualization aiding in a comprehensive assessment of the disease the management of pancreatic disease particularly pancreatitis involves a multifaceted approach aimed at providing supportive care and addressing specific clinical needs General treatment strategies involve supportive measures such as supplemental oxygen Administration analgesia and ECG monitoring prioritizing fluid repl placement is essential especially in patients exhibiting signs of hypotension and tacac cardia to address potential dehydration and maintain hemodynamic stability a key component of the management protocol for pancreatitis is the implementation of noo restrictions for all patients this dietary restriction aims to minimize pancreatic stimulation allowing the inflamed pancreas to rest and reducing the risk of exacerbating symptoms additionally effective pain management is an important aspect of care often involving the administration of intravenous opioids or the use of patient controlled analgesia devices to deliver adequate pain relief while closely monitoring and adjusting medication dosages as needed by combining these measures healthc care practitioners can provide comprehensive care to individuals with pain I etic disease addressing immediate needs and promoting the overall well-being of the",
        "Urinary System Conditions": "patient urinary system conditions acute kidney injury is characterized by a sudden decline in glomular filtration in individuals without pre-existing renal dysfunction reflecting a rapid and often reversible impairment of kidney function this condition is classified based on its location within the renal system differentiating between prerenal intrarenal and post-renal causes pre-renal constituting the majority of cases which is proximately 2/3 arises from factors external to the kidney that diminish renal profusion in contrast intrarenal or intrinsic involves structural damage to the kidney itself affecting the neurons and impairing their function this category includes various etiologies including ischemic injury and toxic insults to renal tissue lastly postrenal occurs due to obstructed urine flow beyond the nephrons often stemming from conditions such as urinary tract obstruction or bladder Outlet obstruction understanding the classification of Aki based on its location a is essential for targeted interventions and management strategies as the underlying causes and mechanisms can vary significantly by delineating Aki into pre-renal intrarenal and post-renal categories Healthcare practitioners can approach diagnosis and treatment with more precise and tailored approaches to address the specific pathophysiological factors that are involved assessing acute kidney injury involves recognizing Key signs and symptoms as well as utilizing relevant laboratory data and imaging techniques for comprehensive evaluation signs of Aki often manifest as abnormalities in urine production oliguria defined as decreased urine output is a common manifestation though an increase in urine output can occur if the nefron urine concentration mechanisms become ineffective dehydration a frequent precipitating factor for Aki contributes to symptoms such as dizziness poor skin turg thirst flat neck veins dry mucous membranes tachicardia and orthostatic blood pressure changes in specific cases of Aki caused by urinary tract infection additional symptoms may include low back pain suprapubic pain and fever these clinical manif a provide valuable clues for identifying the underlying etiology of Aki evaluation involves assessing the retention of wastes in the bloodstream due to decreased glomular filtration rates Ur analysis AIDS in examining the composition and characteristics of urine while renal ultrasonography is employed as a non-invasive Imaging method to visualize the kidneys and identify potential structural abnormalities contributing to Aki this comprehensive approach to assessment allows Healthcare professionals to diagnose and manage Aki effectively by addressing both clinical manifestations and underlying pathophysiological factors the management of acute kidney injury requires a strategic approach aimed at maintaining vital functions and enhancing glomular filtration rate initial treatment involves prioritizing the patients's ABCs along with maintaining blood pressure at a sufficient level to ensure adequate profusion of vital organs the primary focus of management is to increase GFR the key parameter reflecting renal function renal replacement therapy becomes a critical intervention in cases where Aki has led to significant physiologic disruption and hasn't responded to less invasive measures the choice of rrt modality is a subject of debate with options including intermittent hemodialysis continuous venovenous hemofiltration and perianal dialysis the selection depends on various factors including the severity of the Aki patient characteristics and institutional resources while controversies persist regarding the optimal rrt modality the overall goal remains to support renal function and restore electrolyte and fluid balance urinary tract infections arise when bacteria Flora typically residing symbiotically within the GI system gain entry into the urinary system leading to potential damage the initiation point for UTI is commonly the urethra where bacterial colonization Begins the incidence of UT TI is notably higher in females than in males a distinction attributed to anatomical differences in the urethra proximity to the anus additionally patients facing challenges in urination due to obstructions or nervous system disruptions are predisposed to UTI notably individuals with bladder catheters are at an elevated risk of infection due to the direct access provided to bacteria lower UTI such as urethritis and cystitis affecting the urethra and urinary bladder respectively are prevalent manifestations of UTI ecoli bacteria are responsible for about 90% of these infections the inflammatory response triggered by the infection induces a burning pain intensified during urination accompanied by malodorous urine in contrast an upper presents more severe symptoms including fever chills low back pain flank pain and nausea with or without vomiting despite the discomfort associated with UTI the majority respond well to antibotic treatment successful therapy effectively targets the causitive bacteria resolving the infection and alleviating symptoms prompt and appropriate management can prevent complications and ensure a favorable outcome in individuals affected by UTI nephrol liasis commonly known as kidney stones arises from the accumulation of minerals in the renal pelvis leading to the formulation of calculi within the kidneys with an approximate lifetime risk of 10% Roc calculi are more prevalent in males who are twice as likely to develop this condition compared to females a family or personal history of kidney stones should raise suspicion for their diagnosis as there may be a genetic predisposition to their formation While most pass through the urinary tract and are excreted without significant complications their movement can cause excruciating pain the Hallmark presentation is cicy flank pain often accompanied by symptoms such as nausea vomiting and radiation of pain into the groin the clinical manifestation of kidney stones is distinctive aiding in the diagnosis of this condition ultrasonography stands out as the optimal diagnostic test allowing for visualization of the stones and assessment of their size and location additionally non-contrast CT proves to be another effective diagnostic modality offering detailed Imaging of the urinary tract to confirm from the presence of renal calculi these diagnostic tools contribute to Accurate identification and characterization of kidney zones enabling providers to formulate appropriate management strategies based on the size and location testicular torsion is a critical medical condition characterized by the rotation of one or both testes to the extent that their blood supply becomes obstructed this rotation typically occurs around the spermatic cord leading to a compromised blood flow to the affected testes the occlusion of blood vessels triggers a rapid onset of severe pain which is a Hallmark symptom of testicular torsion the pain is often intense and sudden prompting individuals with this condition to seek immediate medical attention immediate surgical intervention is imperative in cases to salvage the affected testes and prevent necrosis which can occur rapidly if the blood supply is not restored promptly the urgency in management is to preserve testicular function and avoid long-term complications surgical techniques involve detorsion of the testes securing it in the correct anatomical position and fixing it to prevent further occurrences of torsion the time sensitive nature of this intervention underscores the significance of prompt diagnosis and treatment in some instances patients may not only experience testicular pain but also present with Associated symptoms such as nausea vomiting and abdominal pain these additional symptoms can be attributed to the severe pain and physiological stress induced by the compromised blood supply to the testes priapism is a medical condition characterized by a prolonged and often painfully direction of the penis posing a risk of damage to surrounding tissues there are two main types of priapism high flow and low flow high flow is rare and typically results from penal injury leading to excessive arterial blood flow to a persistent erection on the other hand low flow known for its increaseed pain is more commonly associated with conditions such as CLE cell disease and certain medications use the initial treatment approach involves the application of a coal pack followed by intracavernosal aspiration and the administration of a sympathomimetic drug this intervention aims to alleviate the prolonged erection and prevent potential complications associated with tissue damage penal fracture is a condition that arises from blunt injury to the penis typically occurring during an erection and most commonly associated with sexual intercourse the trauma leads to the rupture of the tuna alnia a fibrous membrane surrounding the penal kapora cavernosa in such cases cold compresses are recommended to mitigate swelling and alleviate pain at the sight of Injury Care should be taken when managing these cases especially when considering interventions such as catherization if there is evidence of blood at the meus or suspicion of urethal injury inserting a urinary catheter should be avoided to prevent further harm and",
        "Maintenance Tubes": "complications maintenance tubes feeding tubes provide interal nutrition to incapacitated patients following challenges with swallowing the inability to swallow is a significant obstacle to food intake in such individual uals in short-term situations a simple nasogastric tube can be employed to overcome this obstacle however for more extended nutritional support G tubes are utilized with the peg tube being a common variant alternatively in situations where direct access to the dunum is preferred a j tube can be inserted known as a peg J the peg J tube procedure has gained popularity due to its reduced complication risk and decreased aspiration complications associated with feeding tube insertions include the most common risk of aspiration where the ingested material enters the Airways bleeding at the insertion site is another potential complication particularly if the peg tube is abruptly pulled or traumatically removed infection around the insertion site poses a risk manifesting as local rening or swelling addressing complications promtly is essential to ensure the well-being of the patient if the feeding tube becomes clogged a solution involves administering sterile warm water of about 30 to 50 MLS to clear the blockage efficiently total parental nutrition or TPM serves as an alternative feeding method when the GI tract fails to function adequately in tpn all essential nutrients including carbohydrates proteins fats vitamins and minerals are delivered intravenously to the patient bypassing the digestive system this method is critical for patients who cannot tolerate interal nutrition or have conditions that hinder proper absorption in the GI tract despite its benefits tpn comes with inherent risks patients undergoing tpn are particularly susceptible to complications such as air embolism and thrombosis an ath embolis a potential serious complication is most likely to occur during line changing or if an unexpected disruption in the infusion system occurs therefore meticulous atten to the administration process is essential to prevent these complications nutritious monitoring is a fundamental aspect of managing patients receiving tpn regular assessments are necessary to detect and address any potential metabolic abnormalities or electrolyte imbalances ostomies constitute surgical procedures aimed at creating an opening in the GI tract through the abdominal wall serving as an alternative route for Waste elimination these openings are diverse classified according to their origin and specific purpose an IL ostomy for instance is established in the ilum of the small intestine allowing for the diversion of feal material and providing an essential solution for patients with compromised lower bowel function on the other hand a colostomy can be crafted at various points along the large intestine offering flexibility in addressing different clinical scenarios both ostomies and colostomies assist in the management of conditions such as inflammatory bowel disease colar rectal cancer or traumatic injuries providing patients with improved bow function and a means to maintain essential bodily processes despite challenges in the normal gastrointestinal pathway these surgical interventions contribute significantly to the overall care and quality of life for individuals facing complex GI health issues additionally ostomies are designed to drain urine directly from the urinary tract the decision to perform an ostomy is driven by specific indications such as bowel or bladder disease or injury as well as congenital anomalies ostomies and colostomies divert in reroute bodily waste when the normal physiological route is compromised for instance in cases of severe bowel disease or injury an ostomy or colonos may be implemented to allow for the elimination of fecal matter through an alternative route urostomy serve a similar purpose for individuals with urinary tract issues ensuring the direct drainage of urine when conventional pathways are dysfunctional management of ostomies involve vigilance for poti potential complications that may arise post surgery these complications include but are not limited to obstruction constipation diarrhea dehydration leakage tissue necrosis Detachment prolapse and infection regular monitoring is essential to detect signs of tissue necrosis and infection ensuring prompt intervention a standard assessment for an osty patient involves exam in the insertion site for pain-free characteristics and the absence of redness or swelling complications like Detachment or prolapse May necessitate bleeding control eclusive dressings and surgical reconstruction to manage ostomies effectively appropriate equipment is essential this includes a stom measuring guide or pattern scissors a new pouch a soft washcloth soap and water for cleansing a razor for abdominal hair shaving waste collection containers toilet paper rubber ears for Odor Control and biohazard bags for disposing of soiled pouches a comprehensive approach to ostomy care involves regular assessments patient communication regarding functionality and the use of the proper equipment needed to address these complications and maintain op opal hygiene specific drainage tubes serve critical roles in postoperative care aiding in the removal of accumulated fluids and blood within the abdominal cavity one such system is the Jackson Pratt drain commonly utilized after surgical procedures the patient plays an active role in managing the strain by employing a bulb which when squeezed induces suction and facilit itates the draining process additionally surgical draining tubes like the hemovac and Daval drains share similar functions effectively addressing post-operative fluid accumulations in the context of liver transplant surgery A specialized drainage tube known as the t- tube is strategically placed to monitor the drainage of bile from the gallbladder this ensures effective surveillance of the bile post surgery allowing healthc Care Professionals to assess the functioning of the biliary system and detect any potential complications each of these drainage tubes is carefully selected and placed based on specific requirements of the surgical procedure contributing to the overall management and optimal recovery of patients undergoing abdominal",
        "Metabolic Regulation of Acid\u2013Base Status": "surgeries metabolic regulation of acidbase status the metabolic regulation of acidbase status is a highly intricate process tightly orchestrated by various organs receptors and buffer systems within the human body this complex system plays a pivotal role in maintaining the delicate balance of pH levels essential for normal cellular tissue and organ function any disfunction or disruption in this tightly controlled mechanism has the potential to compromise the overall physiological homeostasis and functionality of cells tissues and organs the significance of maintaining a precise acid base balance is underscored by its direct impact on cellular process enatic activities and overall metabolic functions therefore an intricate interplay of physiological components Works cohesively to ensure the stability of acidbase status highlighting the the critical nature of this regulatory process in supporting fundamental cellular and organ functions in acidbase physiology the Dynamics of hydrogen ions play a central role in maintaining the delicate balance of pH levels in the body these ions released as single protons from hydrogen atoms Define acids which are solutions containing hydrogen ions on the other end bases also referred to as basic or alkaline substances have the ability to accept free hydrogen the equilibrium between acids and bases is reflected in the pH value representing the concentration of free hydrogen in the body's extracellular fluid with a normal range of 7.35 to 7.45 the pH value value serves as a critical indicator of acidbase balance and deviations from the normal range can have profound consequences an increase in free hydrogen concentration leads to a decrease in PH which would be acidosis while a decrease in free hydrogen concentration results in an increase in PH which is alkalosis maintaining this delicate balance is essential as deviations from normal PH range can impair cell protein activity when the pH fall belows 6.8 or rises above 7.8 cell Death Becomes a significant concern emphasizing the critical importance of AET based regulation in preserving cellular function and preventing detrimental effects to the overall physiological process the human body employs various chemical buffer system systems to counteract the impact of acid and Alkali loads maintaining the delicate balance of pH crucial for physiological processes buffers which are substances capable of either binding or releasing hydrogen ions play a pivotal role in preventing abrupt shifts in acidity or alkalinity among these the bicarbonate carbonic acid buffer system stands out as the primary extracellular buffer operating in both the lungs and kidneys this system helps regulate PH by either accepting or donating hydrogen ions aiding in the body's acid base equilibrium another essential buffer system is the phosphate buffer system primarily active in urine it facilitates the conversion of strong acids or bases into weaker forms allowing for gradual pH adjustments following significant variations in free hydrogen this system contributes to the body's ability to respond to and neutralize acidic or alkaline challenges maintaining a relatively stable pH environment additionally various proteins such as hemoglobin albumin and specific bone tissues serve as chemical buffers within the body these proteins have the capacity to absorb or release free hydrogen contributing to the overall buffering capacity of the system the multifaceted nature of these chemical buffer systems highlights the intricate mechanisms in place to ensure the precise regulation of acidbase balance that is essential for sustaining optimal cellular tissue in organ function carbon dioxide is involved in determining acid base balance exerting a significant influence on the intricate balance of pH within the body the concentration of carbon dioxide exhibits a direct correlation with hydrogen ion concentration and an inverse relationship with extracellular fluid pH this relationship is a fundamental aspect of the respiratory influence on acidbase equilibrium during acidic States the body employs a dynamic response mechanism automatic elevation of alvr ventilation this physiological adjustment serves to increase the elimination of carbon dioxide leading to a subsequent decrease in hydrogen concentrations and a rise in PH the heightened Alvar ventilation acts as a compensatory mechanism actively working to counterbalance the acidic conditions and restore the delicate acidbase equilibrium notably any escalation in alv ventilation Beyond Baseline levels contributes to a further elevation of pH and a reduction in the concentration of free hydrogen this intricate interplay underscores the finely tuned respiratory control over acidbase status emphasizing the body's ability to regulate PH through the modulation of carbon dioxide levels and lvlr ventilation the kidneys play a critical role in maintaining the body's acidbase equilibrium serving as the ultimate defense against the consequences of substantial acid or base loads positioned at the body's last line of defense the renal system actively responds to deviations in PH providing a key regulatory mechanism in instances of metabolic or respiratory alkalosis the kidneys execute a strategic response by int intensifying the excretion of bicarbonate this process serves a dual purpose first it increases the availability of free hydrogen ions in circulation and second it lowers the pH effectively counteracting the alkalotic conditions conversely when faced with acidic States the kidneys orchestrate a series of intricate Maneuvers to rectify the imbalance the response involves the reversal of transmembrane ion flow to address excess hydrogen ions in cases where an excess of hydrogen ions is present the kidneys excrete hydrogen directly into the urine simultaneously the kidneys have the capacity to reabsorb bicarbonate which was previously filtered and return it to circulation this reabsorbed bicarbonate acts as a valuable buffer binding with excess hydrogen ions and in the process correcting or mitigating the acidosis the liver renowned as the most metabolically active organ in the body exerts a profound influence on the delicate balance of hydrogen ions in the systemic circulation thereby contributing significantly to the regulation of pH as a key player in the digestive process the hepatic tissue with its dual blood supply serves as both the source and a SN for hydrogen ions the energy intensive digestion of food is a prime generator of acids within the liver the oxidation of ingested carbohydrates and fats produces carbon dioxide which subsequently splits into hydrogen and bicarbonate ions in fasting States the liver undergos the oxidation of fatty acids and the formation of ketones processes that also yield hydrogen ions notably the liver plays a role in the conversion of ammonium to Ura further contributing to the release of hydrogen ions Additionally the liers multifaced functions extend to the production of alumin a phytoplasma protein with buffering capabilities for carbon dioxide and fixed acids laboratory analysis particularly blood gas analysis serves as a pivotal tool in assessing acidbase status and unraveling key variables within the extracellular fluid both arterial blood gas and Venus blood gas samples offer insights into the concentration of free hydrogen ions and other critical parameters interpretation of blood gas results is integral for Discerning the presence and nature of acidosis or alkalosis ABG sample results provide a wealth of information with a pH below 7.35 indicative of acidosis and a pH above 7.5 signaling alkalosis these conditions can further be classified as primary metabolic primary respiratory or mixed metabolic acidosis manifests with a pH below 7.35 and decrease by carbonate levels while respiratory acidos is exhibits a decreased pH and an increased pco2 level conversely metabolic alkalosis is characterized by a pH greater than 7.45 and elevated bicarbonate levels while respiratory alkalosis involves a pH greater than 7.45 and decreased PC2 levels mixed acidosis or alkalosis presents with a combination of these par parameters highlighting the complexity of acidbase disturbances indirect measurements of acidbase status such as total blood carbon dioxide levels provide valuable insights during routine blood work a normal plasma bicarbonate value falling within the range of 23 to 30 serves as a reference point elevated bicarbonate values may indicate chronic respiratory acidosis or metabolic alkal is while low bicarbonate values may suggest metabolic acidosis or respiratory alkalosis in the assessment of acidosis the annion gap or AG proves to be a valuable tool providing insights into the potential origin of the disturbance the normal anion gap Falls within the range of 8 to 12 mil equivalents per liter an elevated an ion Gap suggests the presence of an underlying acidosis often associated with specific conditions elevated lactic acid levels resulting from trauma shock seizures hypoxia or exposure to toxic substances contribute to an increased anion gap additionally alcoholic keto acidosis and diabetic keto acidosis are known causes of elevated annion Gap acid dosis serum lactate levels exceeding 4.0 Mill per liter serve as an indicator of lactic acidosis further supporting the diagnostic utility of the anion gap it is important to recognize that an acidosis with a normal anion gap is classified as hyperchloremic acidosis this distinction is valuable in Discerning different ideologies of acid-based dis disorders aiding clinicians in accurately identifying and addressing the underlying cause metabolic alkalosis can be classified as chloride resistant or chloride responsive based on urine chloride concentration a common eyology involves vomiting or gastric suction leading to a loss of gastric acid and subsequent alkalosis additional causes include placing a patient with a previously compensated respiratory acidosis on aggressive ventilation or administering sodium bicarbonate excessively clinical manifestations often involve concominant electrolyte abnormalities with potential for seizures altered mental status refractory arrhythmias and weakness urgent intervention is warranted when the bicarbonate level exceeds 40 milles a liter or the pH surpasses 7.55 management of metabolic alkalosis necessitates volume resuscitation and electrolyte repletion with close monitoring specific interventions may include surgical management of conditions like pyloric stenosis or addressing underlying factors such as emesis obstruction or discontinuation of gastric suction devices in severe cases pharmacological options are available for targeted treatment metabolic acidosis characterized by a decreased serum pH accompanied by A reduced bicarbonate concentration of less than 22 Mill per liter can result from three potential mechanisms first the kidneys may be unable to excrete sufficient hydrogen ions produced or absorbed secondly an increased amounts of hydrogen may be present due to exogenous loading or Ultram metabolism lastly excessive renal or GI bicarbonate excretion can also cause an imbalance renom metabolic acidosis may stem from various kidney dysfunctions ureic States arising from the accumulation of cellular waste products can contribute to metabolic acidosis additionally inadequate renal ammonium production or decrease by carbonate secretion may be implicated distinct types of renal tubular acidosis further deluminate the mechanisms involved type one impairs the kidney's ability to excrete hydrogen while type two involves impaired bicarbonate reabsorption leading to increased renob bicarbonate excretion type four results results from impaired renin Liberation or altered synthesis excretion or response to aldosterone by the kidneys or adrenal glands type three is a rare classification with characteristics of type one and type two and is not clinically relevant clinical features of metabolic acidosis are rarely isolated occurrences often presenting with additional symptoms kousal respirations are characteristic reflecting the body's compensatory mechanism treatment approaches vary emphasizing caution in administering IV sodium bicarbonate for every metabolic acidosis case specific types of RTA may require targeted interventions such as sodium bicarbonate or sodium citrate over extended periods close monitoring and repletion of electrolytes including calcium and potassium are essential components of managing metabolic  acidosis he"
    },
    {
        "Introduction to Neurologic Emergencies": "chapter 12 neurologic emergencies introduction Critical Care patients with neurologic complications pose unique challenges for critical care transport professionals during The crucial process of patient transport neurologic complications Encompass a broad spectrum ranging from traumatic brain injuries to acute Strokes requiring specialized attention and skill from providers the assessment of these patients involves not only monitoring vital signs but also a thorough evaluation of neurological status including cognitive function motor responses and sensory perception managing such patients during transport Demands a nuanced understanding of the intricacies of neurocritical care as alterations in in cranial pressure seizures and fluctuations in neurological status may occur the provider must navigate these challenges while ensuring the continuity of critical care interventions such as neuroprotective measures adequate sedation and careful monitoring of any neurologic specific interventions timely and effective communication with receiving facilities is Paramount as the intricate nature of neurologic complications requires seamless coordination between prehospital and hospital-based Care team teams for the critical care transport professional a comprehensive comprehension of the foundational principles governing neurologic structure function and dysfunction is fundamental in steering effective Critical Care Management delving into the particulars of neuroanatomy and neurophysiology equips the provider with the knowled needed to navigate neurologic injuries during transport understanding the nervous system lays the groundwork for anticipating potential challenges and tailoring interventions to the specific needs of the patients with neurologic complications furthermore an awareness of the diverse types of neurologic injuries coupled with a deep grasp of their underlying path of physiology forms the Cornerstone for evidence-based management staying on top of current trends and advancements in neurocritical care is essential for the provider to implement the most up-to-date and effective interventions ultimately contributing to Optimal patient outcomes this knowledge not only guides the immediate care provided during transport but also facilitates seamless communication with the receiving medical team ensuring a Continuum of Care that is rooted in a solid understanding of neurologic principles anatomy and physiology",
        "The Nervous System": "the nervous system stands as a Marvel of complexity in organization within the human body representing a highly sophisticated Network that orchestrates communication and coordination it's Inc Es are so extensive that it is considered one of the most diverse organ systems a key aspect of this organization lies in the classification of its various components based on either their physical location or their specific functions this dual classification system allows for a comprehensive understanding of the nervous systems structure and purpose the nervous system is primarily dived divided into two major components the central nervous system or CNS and the peripheral nervous system or pns the central nervous system comprising the brain and spinal cord serves as the command center responsible for processing information and initiating responses on the other hand the periperal nervous system extends beyond the confines of the CNS encompassing both both spinal and cranial nerves that extend throughout the body these nerves act as conduits transmitting signals between the CNS and the rest of the body enabling sensory perception and motor function this division into the central nervous system provides a fundamental framework for understanding the roles and interactions of different components within the nervous system forming the basis for exploring these intricate functions and responses the peripheral nervous system further refines its organization based on the nature of information transmitted through specific fibers contributing to the nuanced orchestration of sensory and motor functions",
        "Sensory and Motor Functions": "the peripheral nervous system is intricately involved in mediating various activities driven by sensory stimulation with the stimuli often detected by specialized receptors dedicated into specific senses such as Vision hearing or touch this initial sensory input sets off a chain of events orchestrated by afferent Pathways also known as ascending Pathways which carry these sensory impulses toward the central nervous system these Pathways Serv as conduits for the transmission of information we laying signals from the periphery to the brain and spinal cord for processing once the central nervous system has processed and integrated the sensory information eent Pathways or descending Pathways come into play these Pathways carry the processed impulses away from the central nervous system directing them towards affector organs these affector organs which which can include muscles both smooth and skeletal or glands then respond to the signals by executing appropriate actions this interplay between AER and eer Pathways ensures that the nervous system cannot only perceive and interpret sensory stimuli but also generate precise and coordinated motor responses facilitating a wide array of physiological activities for maintaining homeostasis and responding into the external environment",
        "Voluntary and Involuntary Functions": "physiologically the nervous system displays a remarkable organization characterized by distinct divisions that govern both voluntary and involuntary functions the voluntary component known as the sematic nervous system plays a pivotal role in connecting the central nervous system with skeletal muscles and and the skin this network of nervous system fibers facilitates conscious control over muscle movements and sensory perception allowing individuals to interact purposefully with their external environment in contrast the involuntary division of the nervous system termed the autonomic nervous system oversees activities that occur Beyond conscious control the autonomic nervous system is further divided into the sympathetic and parasympathetic branches each finely tuned to regulate specific physiological responses nervous system fibers within the autonomic division establish connections between the central nervous system and smooth muscles cardiac muscles and glands the sympathetic branch is associated with the fight ORF flight response mobilizing the body's resources for heightened activity and increased alertness in response to stressors conversely the parasympathetic branch is instrumental in promoting a rest and digest State fostering relaxation and restoration by slowing down bodily functions and conserving energy this duality of the nervous system encompassing both voluntary and involuntary aspects underscores its adaptability and ability to navigate a diverse array of physiological demands whether consciously orchestrating movements through the sematic nervous system or unconsciously regulating vital functions via the autonomic nervous system this physiological framework allows for the intricate coordination of bodily activities essential for maintaining equilibrium and responding dynamic dynamically to internal and external stimuli",
        "Cranial Anatomy": "cranial Anatomy is a Marvel of design serving as a protective Fortress for the vital organ that is the brain the skull or Cranium is divided into two main components the neurocranium often referred to as the brain box and and the visero cranium which constitutes the facial skeleton composed of 14 Bones the neurocranium takes center stage in safeguarding the brain with eight distinct bones that contribute to its robust structure these include the frontal bone the paired parial bones paired temporal bones an occipital bone a sphenoid bone and an ethmoid bone each of these elements play a role in providing a secure enclosure for the neural tissue a key feature of cranial Anatomy is the presence of for Amina at the base of the skull these openings serve as gateways allowing the passage of cranial nerves and blood vessels into an out of the cranial cavity the for Amina are essential conduits that facilitate communication between the brain and the rest of the body enabling the nerves and vessels to Traverse the protective confines of the skull this network is essential for maintaining the functionality of various systems including sensory perception motor control and the vascular support apply to the brain understanding cranial Anatomy not only unveils the physical framework that Shields the brain but also elucidates the pathways through which essential neural and Vascular elements navigate the design of the skull with his distinct components and formina underscores the delicate balance between protection and connectivity highlighting the Precision with which the cranial Anatomy ensures the brain security while facilitating its vital interactions with the broader physiological landscape",
        "The Meninges": "enveloping the central nervous system is a protective Trio of membranes collectively referred to as the meninges specifically addressing the the brain the cranial meninges constitute a shield that not only guards this essential organ but also provides structural support for the intricate network of arteries veins and Venus sinuses that Traverse the cranial cavity the three layers that comprise the cranial meninges are the Duram matter arachnoid matter and the Pia matter the outermost layer the Duram matter is a tough and durable membrane that acts as a protective barrier forming a resilient enclosure around the brain it serves as a physical barrier against external trauma helping to Shield the delicate neuro tisue within beneath the Duram matter lies the arachnoid matter a webike membrane that contributes to the menual architecture the arachnoid matter plays a role in supporting the blood vessels that course through the cranial cavity the innermost layer the pomatter adheres closely to the Contours of the brain providing a thin and highly vascular interface that intimately interacts with the neural tissue collectively these three layers of the cranial meninges form a dynamic and protective system that not only acts as a barrier against potential harm but also facilitates circulation of cerebral spinal fluid which is important for maintaining the brain's buoyancy and providing essential nutrients",
        "The Dura Mater": "let's take a look at each of these three a little more closely the Duram matter is a critical component of the cranial meninges and Exhibits a complex and multi-layered structure contributing significantly to the protective enclosure of the central nervous system adhering closely to the internal surface of the cranium the Duram matter manifests as a two layered membrane with distinct functions the outer layer serves a dual role acting as the periostium for the cranial bones and forming the direct connection to the internal surface of the calvaria providing a robust Shield against external forces the inner menial layer of the dura extends into the cranial space demonstrating continuity at the frame and Magnum with the dura that envelops the spinal cord this seamless integration underscores the unified nature of the menial system in safeguarding the entire Central nervous system both within the cranium and along the spinal column notably the Duram matter presents four extensions or folds that contribute to its architecture the fals cerebri one of these folds stands out as a double layer that traverses the longitudinal fissure of the brain effectively dividing the cerebrum into distinct right and left hemispheres the fal cerebri serves a pivotal role in maintaining structural integrity and preventing excessive movement within the cranial cavity this detailed organization and specific structural features of the Duram matter showcase the Precision with which it supports and protects the delicate neural structures within the cranium",
        "The Arachnoid Mater": "the arachnoid matter a delicate layer within the cranial meninges contributes significantly to the environment that envelops and protects the brain characterized by its extreme thinness the arachnoid matter forms a loose enclosure around the brain situated between the Duram matter and the Pia matter the proximity between the arachnoid matter and the ual layer of the dura is maintained by the circulating cerebral spinal fluid beneath the arachnoid layer this interaction underscores the dynamic nature of the venal system where the aroid matter plays a crucial role in mediating the balance between protection and fluid dynamics within the cranial cavity within the arachnoid matter a network of webike structures called arachnoid tracula extends forming small protrusions of connective tissue that pass between the arachnoid and the patter these trebay contribute to the overall structural Integrity of the menal layers and play a role in supporting the delicate architecture of the brain contrary to the common notion that the brain simply floats freely in C spinal fluid it's more accurate to describe the brain as being suspended within the cerebral spinal fluid filled sub arachnoid space by these arachnoid trebay this suspension system created by the arachnoid truc provides crucial support and buoyancy preventing direct contact between the brain and the rigid structures of the skull while facilitating the circulation and absorption of cereal spinal fluid",
        "The Pia Mater": "the pomatter represents a highly vascularized membrane intimately associated with the brain surface this thin and delicate layer follows the Contours of the brain closely adhering to its topography the Pam Matter's primary role lies in its vasular richness hosting an extensive network of small blood vessels that supply a significant volume of arterial blood to the cerebral tissues this vascular Supply is essential for nourishing the demanding metabolic needs of the brain highlighting the P Matter's contribution to the overall well-being of the central nervous system in addition to its vascular functions understanding menul spaces further illuminates the protective mechanisms surrounding the brain the extradural space or epidural space is not a true space but rather a potential one situated between the cranial bones in the periostal layer of the dura matter the dura arachnoid Junction often referred to as a subdural space is typically only a potential space but may become an actual space if a head injury causes bleeding into the area this potential for transformation underscores the dynamic nature of the menial spaces in response to traumatic events",
        "The Ventricular System and CSF": "the ventricular system and cerebral spinal fluid together form a central component of the brain's anatomy and physiology ological regulation the ventricular system serves as the central core of the brain filled with CSF that plays essential roles in cushioning nourishing and protecting the delicate neural tissue within this system there are two lateral ventricles and midline third and fourth ventricles interconnected by the cerebral Aqueduct each cerebral hemisphere has houses one lateral ventricle and these ventricles extend from the frontal lobe to the occipital lobe notably the lateral ventricle feature horns that extend from the main ventricular chamber contributing to the overall intricate architecture these lateral ventricles are more than anatomical structures they are are significant in clinical contexts such as intracranial pressure monitoring CSF drainage or the placement of a CSF shunt the monitoring of intracranial pressure is important in the management of various neurological conditions ensuring timely intervention in cases of abnormal pressure within the cranial cavity moreover the drainage of Cs F or the placement of a shunt can be instrumental in managing conditions where CSF circulation is disrupted preventing the potential buildup of pressure that could lead to adverse neurological outcomes the lateral ventricles with their horns extending across different loes showcase the extensive connectivity within the ventricular system emphasizing its integral role in facilitating fluid exchange and maintaining homeostasis in summary the ventricular system and CSF collectively form a sophisticated Network for the brain's structural support metabolic balance and the regulation of intracranial pressure",
        "CSF Circulation": "cerebros spinal fluid circulation is fac facilitated by the interconnected ventricular system which serves vital functions in supporting and protecting the central nervous system the fan of Monroe stands out as a key conduit linking two lateral ventricles to the third ventricle this connection is strategically positioned between the thalmic structures in the deylon emphasizing the importance of precise communication Within in the brain's core the cerebral Aqueduct further extends this network providing a passage for communication with the fourth ventricle situated between the brain stem and the cerebellum the fourth ventricle significance is underscored by two openings at its base the fan of lushka and the fan of magandi these openings play a role in connecting the ventricular system to the subarachnoid space ensuring a proper flow of cerebral spinal fluid this flow is important for maintaining the fluid balance within the brain and spinal cord facilitating the removal of waste products and participating in the absorption of minor mechanical forces integral to the production of cerebral spinal fluid is the choid plexus located in the lateral third and fourth ventricles through a process involving active transport and diffusion the choid plexus produces more than 70% of the cerebral spinal fluid at a rate of approximately 500 MLS per day this constantly secreted fluid fills the ventricular system and envelops the Brain and spinal cord in the subarachnoid space the cerebral spinal fluid acts as a dynamic protective mechanism serving as a shock absorber against minor acceleration and de acceleration incidents moreover the csfs unique osmolarity slightly lower than that of serum facilitates the transport of small molecules metabolic products and drugs from the surrounding brain tissue into the cerebral spinal fluid this osmotic gradient contributes to the brain's homeostasis and the efficient removal of waste",
        "The Cerebrum": "the cerebrum constituting the largest and most prominent part of the brain is a complex structure that governs higher cognitive functions accounting for a staggering 80% of the brain's total weight it is composed of two cerebral hemispheres each contributing distinctively to cognitive and motor function the cerebral hemispheres are separated by the cerebral fissure a deep Clift that extends across the cerebrum at the base of this fissure lies the Corpus colossum a a significant structure comprised of transverse fibers that facilitate communication between the two hemispheres enabling the integration of sensory and motor information positioned above the brain stem and cerebellum and separated by the transverse cerebral fissure the cerebrum surface is characterized by intricate convolutions known as gyri these gyri increase the surface area of the cerebrum accommodating the vast number of neurons that are critical for complex cognitive processes the gyri are separated by grooves called sulai which serve to organize and demarcate different functional regions of the cerebrum deeper and more substantial grooves are referred to as fissures further enhancing the structural complexity of the cerebrum the convoluted surface of the cerebrum is not merely an anatomic feature it actually plays a vital role in supporting the extensive neural networks that underly cognitive abilities such as perception memory and decisionmaking the intricate arrangement of gyri sulai and fissures ensure an OP able balance between structural compactness and functional specialization in essence the cerebrums organization reflects its role as the epicenter of higher brain functions orchestrating complex neural processes that Define human cognition and behavior",
        "The Cerebral Cortex": "the cerebral cortex the outermost layer of the cerebrum is a remarkably thin yet immensely complex structure measuring between 2 to 5 mm in thickness despite its modest Dimensions the cerebral cortex plays an important role in coordinating numerous cognitive functions composed of billions of unmyelinated cell bodies dendrites and neurons this layer is commonly referred ref to as gray matter due to its distinctive coloration it is within the cerebral cortex that the majority of information processing sensory perception and motor coordination take place essentially making it the epicenter of higher cognitive functions beneath the cerebral cortex lies the white matter characterized by melinated tracks that serve as communication Pathways these tracks facilitate the transmission of neural impulses from the cerebral cortex to various regions within the brain the myelin sheaths surrounding these tracks enhance the efficiency of signal transmission allowing for rapid and coordinated communication between different brain areas this itri interplay between gray matter in the cerebral cortex and white matter tracks is fundamental to the integration and execution of complex cognitive processes the organization of the cerebral hemispheres is a key feature of the cerebral cortex the hemispheres are divided into four paired loes each delineated by specific fissures the frontal loes parial loes temporal loes loes and occipital loes each lobe is associated with distinct functions contributing to the overall specialization and efficiency of the cerebral cortex the frontal loes for instance are involved in executive functions and motor control while the parietal loes play a crucial role in sensory processing and spatial",
        "Lobes of the Brain": "Anatomy and Physiology awareness the temporal loes are associated with auditory processing and memory while the occipital loes are primarily responsible for visual processing the cerebral cortex represents the Nexus of cognitive complexity within the brain its structure combining gray and white matter in an organized fashion enables the diverse array of functions that characterize human cognition and behav Behavior the division of the cerebral hemispheres into loes further emphasizes the specialization and functional diversity embedded within the cerebral cortex highlighting its significance in the orchestration of higher brain functions now we'll take a look at each of the different loes of the brain the frontal constituting a remarkable 1/3 of the total cortical tissue is a dynamic region nestled beneath the frontal bone of the skull it is demarcated posteriorly from the parital lobe by the central fissure and inferiorly from the temporal lobe by the lateral fissure within the frontal lobe the prefrontal area emerges as a hub for a ton of higher cognitive functions this multifaceted region exercises control over thought processes concentration depth perception abstract thinking memory and even autonomic nervous system responses showcasing its integrative role in complex cognitive operations adjacent to the prefrontal area is the premotor area positioned alongside the motor area these regions are interconnected by various cranial nerves including cranial nerves 3 4 6 9 10 and 12 facilitating the coordination of specific movements the motor area assumes governance of voluntary motor functions on the opposite side of the body this Arrangement highlights the frontal lob's involvement in the precise regulation of motor activities and its coordination with various cranial nerves an integral component of the frontal lobe is the broka area situated at the inferior lateral gyrus this associative area plays a role in the formulation of words contributing to the expressive aspects of language damage to the broka area can result in expressive Aphasia a condition characterized by difficulty in articulating words and constructing grammatically correct sentences the frontal lobe with its diverse and specialized functions is thus a Lynch pin in the orchestration of higher cognitive processes motor control and language expression showcasing the interplay of neural circuits within this region of the cerebrum the parial lobe situated directly posterior to the frontal lobe and lateral to the central fissure is essential for sensory processing and integration this region is involved in a multitude of sensory functions emphasizing its significance in the overall cognitive and perceptual framework one of the primary responsibilities of the parietal load is the integration of sensory information where various sensory inputs from the environment and the body are synthesized to create a cohesive perceptual experience the parietal lobe contributes to our awareness of body parts and their spatial relationships it is responsible for the interpretation of tactile Sensations such as touch pressure and pain providing us with a profound sense of our physical selves and the external World Additionally the parietal lobe is responsible for the recognition of object characteristics including clud size shape and texture this function is vital for our ability to navigate and interact with the surrounding environment enabling us to distinguish between different objects and understand their physical attributes the neural circuits within the parietal lobe highlight its role as a central hub for the processing and interpretation of sensory inputs through its involvement in body awareness tactile perception and object recognition the parietal lobe contributes significantly to our overall sensory experience and the construction of a coherent mental representation of the world around us the seamless integration of sensory information within the parietal lobe is a testament to its complex functions and its indispensible role in shaping our perception and interaction with the external environment the occipital lobe positioned at the posterior region of the cerebral cortex stands as the primary receptive area for vision making it a hub for visual processing within the brain its specialized function in visual perception underscores its significance in the network of sensory processing with within the occipital lobe visual information collected by the eyes is precisely processed allowing for the interpretation of shapes colors movements and other visual stimuli the primary visual cortex located in the occipital lobe serves as the initial destination for visual input this area is characterized by a complex arrangement of neurons and neural circuits that respond to various features of visual stimuli as visual signals Traverse through the layers of the occipital lobe they undergo sophisticated processing leading to the perception of coherent and meaningful visual experiences the occipital loes role in shaping our visual World extends Beyond basic image processing as it contributes to our buil ility to recognize faces discern objects and navigate our surroundings damage or dysfunction to the occipital lobe can have profound effects on visual perception leading to conditions such as visual agnosia color blindness and visual field defects understanding the occipital lob's specialized function provides valuable insights into the mechanisms that underly our ability to see and interpret the visual world the occipital lob's designation as the primary receptive area for vision highlights its role in the interplay of sensory processing contributing significantly to our overall cognitive experience and understanding of the visual environment the temporal lobe situated in the lateral portion of the cerebrum is a multifaceted region with diverse functions that span auditory processing speech behavior and even memory this lobe is vital to our ability to perceive and interpret auditory stimuli making it a central hub for the processing of sound information within the temporal lobe primary auditory receptive areas play a key role in receiving sound impulses and contribute to our capacity to determine the source of sounds and interpret their meaning this auditory processing within the temporal lobe is fundamental to our overall ability to engage with the auditory World recognizing and comprehending various sounds in our environment one of the notable areas within the temporal lobe is W's area which AIDS in language comprehension War's area is responsible for understanding both written and spoken words making it a Lynch pin in our ability to comprehend and derive meaning from language damage to War's area can result in receptive aphasia where individuals may struggle to understand language despite uent in articulate speech production the interplay between auditory processing and language comprehension within the temporal lobe emphasizes its significance in our cognitive and communicative abilities furthermore the temporal lobe is intricately involved in aspects of behavior and memory its connections with other regions of the brain contribute to emotional processing as well as well as forming and recalling memories the temporal Lo's involvement in memory functions is particularly evident in cases where damage to this region can lead to difficulties in forming new memories or recalling past events the limic lobe known as the reen sephylon forms a border along the lateral ventricles and is home to sever structures including the hippocampus uncus primary olfactory cortex and the amygdaloid nucleus this region of the brain is Central to a range of fundamental functions associated with emotions memory and all faction at the core of the lyic lobe the hippocampus plays a role in memory formation and retrieval especially in the context of short-term memory consolidation its involvement is essential in converting recent experiences into more uring memories contributing significantly to our ability to learn and remember the uncus situated within the lyic lobe is closely linked to the lyic system's role in regulating primitive behaviors and self-preservation instincts this region is implicated in various functions including emotions and the integration of sensory information with emotional responses Additionally the primary olfactory cortex Associated within the lyic lobe is instrumental in processing and interpreting smells emphasizing the lyic lob's significance in olfactory perception one of the lyic lob's most renowned components is the amygdaloid nucleus which assist assists with emotional processing and responses the amydala is involved in the evaluation of stimuli for emotional significance contributing to the generation of emotional responses and the regulation of mood these connections with other brain regions make it a key player in fear conditioning emotional memory and social behaviors collectively the functions of the lyic loobe Encompass a broad spectrum of activities crucial for The Human Experience from self-preservation instincts to the regulation of moods emotions and short-term memory the limic lobe serves as a Nexus for various cognitive and emotional processes its network of structures highlights the complex interplay between emotions memory and sensory experiences underscoring the limic lob's central role in shaping our emotional and cognitive landscape Apes",
        "The Diencephalon": "the deylon a significant division of the cerebrum is a complex structure that plays a central role in the integration and relay of sensory information as well as the regulation of various autonomic functions this vital component is further subdivided into four distinct regions each with its own specialized function the thalamus the largest region of the dlon acts as a relay station for sensory information directing signals from various sensory modalities such as Vision hearing and touch to the corresponding areas of the cerebral cortex its role in sensory integration and distribution makes the thalamus a hub for perceptual awareness the hypothalamus positioned below the thalamus is a key regulator of homeostasis and plays a pivotal role in controlling autonomic functions endocrine secretion and various behavioral patterns its influence extends to the regulation of body temperature hunger thirst and circadian rhythms Additionally the hypothalamus is instrumental in connecting the nervous system and endocrine systems serving as a control center for the release of hormones that influence growth metabolism and stress responses the subthalamus which is a smaller region situated beneath the thalamus is primarily associated with motor control and movement it houses the subthalamic nucleus which forms part of the basil ganglia circuitry involved in motor coordination and control the epithalamus the smallest region encompasses the pineal gland which secretes melatonin and is involved in the regulation of circadian rhythms and sleep wake Cycles the pineal gland synthesis of melatonin helps synchronize biological processes with the natural light dark cycle contributing to the maintenance of a balanced sleep wake pattern let's take a closer look at the four components of the deylon the phalus situated at the core of the deylon functions as a multifaceted relay station playing a role in the transmission and integration of neural signals its involvement spans a broad spectrum encompassing motor and sensory activities basic neuronal processes and higher order cognitive functions in terms of sensory and motor activity the thalma serves as a Gateway for incoming sensory information directing it to the appropriate areas of the cupal cortex for further processing simultaneously the thalmus is engaged in basic neuronal activity contributing to the intricate processing of brain activity that underlies our conscious experiences Beyond these foundational roles the thalmus actively participates in memory formation thought processes emotional responses and the orchestration of complex behaviors this multifunctional capacity underscores the thalamus significance as a central node in the neural circuitry that governs our perception cognition and emotional experience the hypothalamus forming the floor and interior walls of the third ventricle occupies a strategic position within the deylon this region is a regulatory Powerhouse overseeing a myriad of physiological processes essential for maintaining internal homeostasis its anatomical connection to the third ventricle underscores its Central role in coordinating and modulating various autonomic functions including temperature regulation thirst hunger and circadian rhythms beneath the hypothalamus the pituitary gland resides in the cellot Tura and is intricately connected to the hypothalamus by the pituitary stock this connection enables the hypothalamus to exert control over over the pituitary gland's hormone secretion thereby influencing diverse physiological processes such as growth metabolism and stress responses moreover the hypothalamus is integral to the complex interplay between the neural and emotional aspects of the brain its connections to the lyic system facilitate the generation of physical responses to emotions illustrating the hypothalamus role in translating emotional experiences into tangible physiological reactions the subthalamus positioned beneath the phalus emerges as a component of the deylon closely associated with the basil ganglia in terms of function this region though relatively small plac plays a significant role in motor control and movement regulation its connections with the basil ganglia a group of nuclei involved in motor coordination contribute to the modulation of voluntary motor movements dysfunction in the sub thalmus is implicated in movement disorders such as those seen in Parkinson's disease highlighting its importance in maintaining the delicate balance of motor control in contrast the epithalamus a region within the deylon houses the pineal gland an endocrine structure with implications for both physical growth and sexual development the Pineo gland is particularly noteworthy for its role in the secretion of melatonin a hormone that regulates circadian rhythms and sleep wake Cycles melatonin production by the Pineo gland is influenced by environmental light cues and its release helps synchronize biological processes with the natural light dark cycle Beyond its circadian rhythm regulation melatonin is also thought to initiate the onset of puberty and sexual maturation making the epithalamus a key player in the interplay between endocrine regulation and developmental processes in essence the the subthalamus and epithalamus though distinct in their functions contribute significantly to the broader spectrum of physiological regulation within the deylon the subthalamus involvement in motor control particularly through its connections with the basil ganglia highlight its importance in orchestrating coordinated movements meanwhile the epithalamus housing the pineal gland contribute to the delicate regulation of circadian rhythms and the hormonal environment needed for growth and sexual development",
        "The Basal Ganglia": "the basil ganglia situated deep within the cerebral hemispheres represent a complex network of nuclei for motor control and coordination comprising several masses of nuclei including the St atom Globus platus and the substantia Negra the basil ganglia collaborate with other brain regions to modulate motor functions particularly those involving fine control such as movements in the hands and lower extremities these nuclei work in concert receiving signals from the cortex and sending refined instructions to the thalmus and brain stem contributing to the precise regulation of voluntary movements the internal capsule facilitates communication between various subdivisions of the brain and the spinal cord this neural highway is a massive bundle of both eer and aarant fibers forming a dense track that traverses through the brain it acts as a conduit for motor and sensory information connecting different regions of the cerebral cortex with the brain stem and spinal cord the efferent fibers within the internal capsule carry motor signals from the cortex to the spinal cord and other subcortical structures influencing voluntary movement conversely aparent fibers transmit sensory information from the periphery to the sensory regions of the cortex and enabling the brain to receive and process information about the external environment",
        "The Brain Stem": "the brain stem is a critical component of the central nervous system and serves as a vital Bridge connecting the cerebral hemispheres with the spinal cord positioned at the base of the brain the brain stem acts as an essential conduit for communication between higher brain structures and the rest of the body comprised of three main regions the medulla oblongata the ponds and the midbrain the brain stem plays a fundamental role in regulating basic life sustaining functions including breathing heart rate and blood pressure the midbrain a pivotal region within the brain stem houses several important structures that collectively contribute to a range of functions both motor and sensory key anatomical features within the midbrain include the cerebral Aqueduct which serves as a conduit for cerebral spinal fluid connecting the third and fourth ventricles Additionally the superior culi and inferior calculi located on the dorsal surface of the midbrain are critical for processing Visual and auditory stimuli respectively these calculi play a vital role in organ the head and eyes forward relevant sensory information and coordinating reflex responses to visual and auditory stimuli the midbrain is home to cranial nerves three or the ocular motor and four the trolear which play essential roles in eye movement and coordination the ocular motor nerve controls the movement of most eye muscles including those responsible for constriction of the pupil and adjusting the lens shape for near or far Vision the trolear nerve inates of muscle that aids in downward and inward eye movements together these cranial nerves contribute significantly to the intricate control of eye movements and visual processes a functional aspect of the midbrain is its involvement in relaying stimuli related to voluntary motor movement through its connections with other brain regions and the spinal cord the midbrain serves as a central hub for coordinating and transmitting signals that initiate and regulate purposeful body movements this function is particularly evident in the midb brain's role in the control of posture balance and certain aspects of motor coordination within the midbrain lies the Edinger Westfall nucleus which is responsible for mediating autonomic reflex centers involved in pupilary accommodation to light this nucleus Reg Cal Ates the size of the pupil in response to changes in ambient light levels ensuring optimal visual Acuity under varying lighting conditions the midbrain is a dynamic region housing the structures involved in sensory processing cranial nerve function and the coordination of voluntary motor movements its diverse functions underscore its significance in coordinating various aspects of both sensory and motor integration with the central nervous system",
        "The Pons": "the ponds is a component of the brain stem situated above the medulla and below the midbrain serving as a vital relay station for information traveling between the brain and spinal cord along fiber tracks its Central role in facilitating communication makes it a key Nexus for various sensory and motor pathways within the central nervous system notably the ponds assists in respiratory control hosting two essential respiratory centers the austic center and the pneumotoxic center the apneustic center is responsible for stimulating and producing sustained respirations regulating the depth and duration of the breathing breathing cycle the activation of the ABN mustic Center results in prolonged inhalations contributing to the maintenance of adequate oxygen levels in the body in contrast the pneumotaxic center serves as an antagonist to the austic center by inhibiting inspiration and is involved in fine-tuning the respiratory system preventing excessive inhalation and promoting a smoother transition between inhalation and exhalation this Dynamic interplay between the apneustic and pneumotaxic centers contributes to the finally orchestrated regulation of breathing patterns Additionally the pwns is also the site of origin for several cranial nerves including the cranial nerves five or trigeminal six or abducens seven or facial and eight acoustic these cranial nerves play diverse roles in functions such as facial sensation eye movements facial expression and hearing their origin in the ponds highlights the significance of this brain stem region in controlling and coordinating various sensory andoor functions underscoring its integral role in the over all functioning of the central nervous system",
        "The Medulla Oblongata": "the medulla oblongata situated at the base of the brain stem is a vital structure that serves as the connection point between the spinal cord and the Brain linking with the spinal cord at the fan Magnum this anatomical location is important as it allows for the transmission of neural signals between the brain and the peripheral nervous system Additionally the medulla is a site where neural fibers from one side of the body cross over to the opposite side below this point stimuli from the left side of the brain control voluntary movements on the right side of the body and vice versa highlighting the intricate cross functional wiring of the nervous system Beyond its role and motor control the medulla houses groups of neurons that govern a variety of involuntary functions that are important for survival these functions include the regulation of basic physiological processes such as swallowing vomiting coughing vasoconstriction and respiration this ensures the protection of the airway expulsion of harmful substances and maintenance of cardiovascular homeostasis the medulla serves as the origin of the particular formation a network of neurons involved in regulating arousal attention and Consciousness cranial nerves nine or glossop feral 10 or Vegas 11 or spinal accessory and 12 hyp glossal emerg from the medulla further emphasizing its significance in controlling functions related to the throat neck and tongue the glossop feral nerve is involved in taste sensation and the control of swallowing while the vagus nerve plays a key role in autonomic functions such as heart rate and digestion the spinal accessory nerve is responsible for controlling Sur neck muscles while the hypoglossal nerve inates the muscles of the tongue",
        "The Cerebellum": "the cerebellum positioned just Superior and posterior to the medulla oblongata is a highly organized structure with distinct parts that contribute to its functions in motor coordination structurally it consists of the cortex the gray outer covering responsible for the processing of sensory information and white matter which forms connections between the cerebellum and other parts of the central nervous system Additionally the cerebellum features four pairs of deep cerebellar nuclei contributing to its neural architecture the primary function of the cerebellum is the coordination of voluntary movement a role that involves intricate control over various aspects of motor activity the vermis a central region within the cerebellum is particularly responsible for trunk control maintaining stability and coordination in movements involving the core muscles which helps contribute to posture imbalance further delineating its responsibilities the three loes of the cerebellar hemispheres control the upper and lower extremities these loes which include the anterior posterior and focular nodular loes are integral to the regulation of anti-gravity muscles proprioception which is the awareness of body position in space tactile impulses motor tone facilitation volitional braks in movement Synergy of movement and equilibrium the cerebellum fine-tunes motor commands from the cerebral cortex ensuring precise and coordinated movements and additionally modulates muscle tone refining the execution of Complex Motor tasks and facilitating smooth purposeful movements in essence the sarabellum serves as a neural conductor for the Symphony of voluntary movements contributing to the Precision and fluidity of motor actions its involvement in various aspects of motor control from trunk stability to extremity coordination underscores its indispensable role in the overall coordination and execution of purposeful movements in daily life",
        "The Reticular Formation": "the reticular formation a complex set of neurons extending from the upper level of the spinal cord through the medulla ponds and midbrain into the thalamus and cerebral cortex is a component of the brain stem with far-reaching connections to various brain regions its interplay with the basil ganglia thalmus cerebellum and cerebral cortex underscore its function in regulating a spectrum of physiological and cognitive functions the descending component of the reticular formation is primarily tasked with maintaining a delicate balance between excitatory and inhibitory stimuli essential for the maintenance of normal muscle tone this function is instrumental in supporting the body against gravity and ensuring coordinated movements the descending reticular formation is closely linked to the functions of the basil ganglia which play a role in modulating motor activity and the cerebellum this helps to regulate muscle tone preventing excessive rigidity or floppiness and contributing to the overall Precision of voluntary movement on the ascending front the reticular formation is indispensable for functions related to arousal attention and perceptual Association the ascending reticular formation contributes to the overall state of wakefulness and attentiveness regulating the level of Consciousness it forms connections within the phalus a central relay station for sensory information and the cerebral cortex the seat of higher cognitive function by influencing the level of arousal and attention the the ascending reticular formation contributes to the modulation of sensory perception and the integration of sensory information into conscious experience",
        "The Reticular Activating System": "the reticular activating system or Ras is a diffused network of neurons extending from the lower brain stem to the cerebral cortex playing a fundamental role go in regulating arousal wakefulness and attention the lower portion of the RAS deeply rooted in the brain stem holds a key responsibility for the control of sleep wakefulness cycles and Consciousness this region of the RAS integrates sensory information and internal States in order to modulate the overall level of arousal and alertness it acts as a sentinel for external stimuli and internal cues contributing to organization of the sleep wake cycle and the transitions between states of Consciousness in contrast the upper portion of the RAS located in the thalmus directs attention this part of the reticular activating system is intricately involved in the modulation of selective attention allowing the individual to focus on specific tasks or stimuli while filtering out irrelevant information by influencing the flow of sensory information to the cerebral cortex the upper Ras facilitates the prioritization of stimuli contributing to cognitive processes such as concentration perception and task performance",
        "Cerebral Circulation": "cerebral circulation is a vital aspect of the circulatory system that ensures the brain a highly metabolically active organ receives a continuous and adequate blood supply to meet its demanding metabolic needs the brain's remarkable metabolic rate accounts for approximately 15 to 20% of the total cardiac output and consumes a staggering 40% of the oxygen carried by the blood this high demand for oxygen and nutrients is a reflection of the brain's essential role in governing the body's functions and maintaining homeostasis the predominant metabolic process occurring in the brain is the oxidation of glucose to produce energy this intricate energy demanding process is crucial for supporting the diverse functions of neurons and maintaining the electrochemical gradients necessary for nerve impulse transmission the brain's Reliance on a constant and efficient supply of oxygen in glucose highlights the critical nature of cerebral circulation in sustaining its physiological processes cerebral circulation is primarily facilitated by two pairs of arteries the vertebral arteries and the internal cored arteries the vertebral arteries Ascend along the spinal column and merge at the base of the brain to form the basil artery while the internal kateed arteries originate in the neck and Ascend to the base of the skull these arteries deliver oxygenated blood to the brain ensuring a constant supply of nutrients and removing metabolic byproducts The Circle of Willis serves as a vascular Hub at the base of the skull ensuring a redundant and collateral blood supply to the brain comprising a circular arrange of arteries The Circle of Willis is strategically positioned to provide alternate Pathways for blood flow mitigating the risk of compromised circulation in case of arterial blockages or disruptions this circulatory pathway is divided into anterior and posterior circulation branches forming an interconnected Network that facilitates the distribution of oxygenated blood to various regions of the brain arteries that contribute to the structure are primarily the internal cored and Basler arteries the internal cored arteries originating in the neck Ascend to the base of the skull and Branch into the anterior cerebral arteries and middle cerebral arteries on the other hand the vertebral arteries Ascend along the spinal column converge and form the Basler artery and then subsequently give rise to the posterior cerebral arteries these create a vascular safety net that ensures continuous blood supply to the brain even if one of the contributing arteries faces obstruction or compromise which helps maintain cerebral profusion and protects against es schic events on the occasion of a blockage or stenosis in one of the arteries blood can be rerouted through collateral Pathways within the circle preserving oxygen delivery to critical brain regions this adaptive mechanism is particularly significant in preventing the development of neurological deficits that may arise from compromised blood flow",
        "The Vertebral Arteries": "the vertebral arteries components of the posterior circulation are critical vessels that play a central role in supplying oxygenated blood to the posterior part of the brain originating from the subclavian arteries these arteries Ascend along the cervical spine entering the skull through the framan Magnum a key anatomical landmark along the course of the vertebral arteries is the ponds at this point the two arteries unite and form the Basler artery the joining of these arteries creates a vital convergence Point establishing a unified pathway for blood flow that sets the stage for the subsequent distribution of oxygenated blood to different regions of the brain the Basler artery becomes a central conduit that further underscores the significance of the vertebral arteries in posterior cerebral circulation continuing this journey the Basler artery extends along the midline of the brain stem and at the level of the midbrain under goes division to give rise to the paired posterior cerebral arteries these arteries fan out to supply the posterior part of the brain contributing to the vascular support of critical structures involved in sensory processing memory and other higher cognitive functions",
        "The Internal Carotid Arteries": "the internal cored arteries Supply oxygenated blood to the frontal loes and other vital structures in the anterior part of the brain originating from the common kateed arteries which arise from the aortic Arch the internal and cided arteries Ascend along the sides of the neck traversing the kateed sheath as they reach the base of the skull they penetrate into the cranium through the cored canals gaining access into the intracranial space upon entering the cranium the internal cored arteries become integral participants of the circle of will this anatomical structure acts as a dynamic vascular Hub facilitating the distribution of oxygenated blood to different regions of the brain and provides a collateral Network this connection ensures redundancy and adaptability in cerebral circulation minimizing the risk of compromised blood flow due to potential blockages or disruptions in any one one arterial pathway within the intracranial space the internal cored arteries further Branch into two major arteries the interior cerebral artery and the middle cerebral artery the anterior cerebral artery supplies the medial and Superior portions of the frontal loes contributing to motor control personality and executive functions the middle cerebral artery on the other hand distributes blood to the lateral convexity of the cerebral hemispheres influencing sensory and motor functions as well as language and higher cognitive processes",
        "Venous Drainage": "Venus drainage in the brain is a critical component of the circulatory system responsible for returning deoxygenated blood and waste products away from the brain tissues the veins of the brain intricately navigate through the cerebral structures and eventually converge into Dural Venus sinuses which are specialized channels located between the layers of the Duram matter the superior sagittal sinus is a major Venus channel that receives drainage from cerebral veins on the paril lateral surfaces of the brain this large midline sinus runs along the superior aspect of the brain and plays a crucial role in collecting Venus blood from the frontal and parietal loes channeling blood towards the Dural Venus sinuses for subsequent drainage into larger veins on the postero inferior aspect of the brain cerebral veins have a different drainage route they Channel deoxygenated blood into sinuses such as the straight sinus transverse sinus and Superior petal sinuses these sinuses are strategically positioned within the cranial cavity providing an efficient pathway for the collection and transport of Venus blood from the posterior and inferior regions of the brain the straight sign sinus runs along the junction of the fo cere and the tentorium cerebelli connecting to both the superior sagittal sinus and the transverse sinuses ultimately the Dural venous sinuses serve as a convergent point for Venus drainage from various regions of the brain the blood collected in these sinuses is then directed towards larger EX cranial veins primarily the internal jugular veins the internal jugular veins are major vessels in the neck that receive deoxygenated blood from the brain and transport it back to the heart completing the Venus circuit and ensuring continuous blood flow for optimal brain function",
        "The Blood-Brain Barrier": "the blood brain barrier is a highly specialized ized network of endothelial cells and astrocytes a type of neuroglia that envelop cerebral capillaries forming a protective barrier between the bloodstream and the central nervous system this barrier acts as an interface regulating the transport of various substances such as nutrients ions water drugs and waste products maintaining the optimal micro environment for the brain's proper functioning the selective permeability of the blood brain barrier is a fundamental aspect of its functionality some molecules can easily Traverse the endothelial cells in the barrier ensuring the passage of essential substances required for brain function simultaneously though the bloodb brain barrier Acts as a formidable defense against potentially harmful compounds by blocking the entry of toxic substances pathogens or large molecules that could compromise the delicate balance within the central nervous system several factors determine the passage of substances through the barrier including particle size lipid solubility chemical breakdown and protein bind ing potential smaller lipid soluble molecules with stable physiologic pH profiles are more likely to cross the barrier efficiently this selective permeability is vital for protecting the brain from potentially harmful agents while allowing the entry of essential substances required for neurological processes the barrier is notably permeable to certain substances crucial for brain function such as water oxygen carbon dioxide and glucose these essential components can readily Traverse the barrier ensuring the brain receives the necessary resources for energy metabolism and cellular activities additionally most drugs or compounds that are lipid soluble and stable at a physiologic pH can rapidly cross the barrier influencing the efficacy of pharmaceutical interventions in neurological disorders",
        "The Vertebral Column": "the vertebral column is the fundamental structural component of the human skeletal system providing support stability and protection to the spinal cord while allowing for a wide range of movements the vertebral body serving as the anterior weightbearing structure is composed of bone that contributes to the overall stability of the spine shared components of most vertebrae include the body lamina pedicles and spinous processes each playing a specific role in the structural integrity and function of the spine the intervertebral Forin situated in the middle of each vertebrae is a vital space that facilitates the exit of peripheral nerve roots and spinal veins while allowing the entrance of spinal arteries on both sides of each vertebral Junction this anatomical feature is crucial for the passage of neural and vascular structures supporting the intricate Network that that connects the central nervous system to the peripheral tissues the cervical spine incompasses the first seven vertebrae and their supporting structures beyond safeguarding the vital cervical spinal cord the cervical spine Bears the weight of the head and permits a high degree of mobility in multiple planes allowing for essential movements such as flexation EXT tension and rotation the thoracic spine typically comprises 12 vertebrae each associated with rib attachments that contribute to its stability this region of the vertebral column plays a role in protecting the thoracic organs and providing support for the rib cage the lumbar spine consisting of the five largest vertebrae carries a substantial portion of the upper body weight this weightbearing capacity makes the lumbar spine particularly susceptible to injury and it requires robust support from surrounding muscles and ligaments the sacrum formed by the fusion of five vertebrae serves as the posterior plate of the pelvis contributing to its structural Integrity the coxics composed of 3 to five small fused vertebrae represents the terminal portion of the vertebral column intervertebral discs positioned between each vertebrae Serv as cushions that limit bone wear and act as shock absorbers these discs are essential for maintaining flexibility in the spine while providing protection to the neural and vascular structures passing through the intervertebral foramina together these components of the vertebral column form a complex yet highly functional structure that balances support flexibility and protection",
        "The Spinal Cord": "the spinal cord serves as a conduit for transmitting sensory and motor signals between the brain and the rest of the body originating at the base of the brain the spinal cord is a continuation of the central nervous system and its structure is integral to the overall functionality of the nervous system emerging from the frame in Magnum the spinal cord extends down the vertebral column reaching as far as the second lumbar vertebrae or L2 at this level the the spinal cord undergo a significant anatomical transformation known as the C aenna this term which translates to horse's tail in Latin describes the bundle of nerve roots and fibers that continue beyond the spinal cords formal termination 31 pairs of spinal nerves arise from distinct segments along the length of the spinal cord these spinal nerves are classified into different regions based on their originating spinal segments eight cervical 12 thoracic five lumbar five sacral and one coxal each spinal nerve is responsible for specific sensory and motor functions in the corresponding region of the body the SP chal cord relays information between the brain and peripheral tissues sensory signals from various body parts are transmitted to the brain for interpretation while motor commands originating in the brain are conveyed through the spinal cord to initiate appropriate responses in muscles and glands this by directional communication is essential for coordinating voluntary and involuntary movement as well as maintaining sensory perception and reflex actions the spinal cord when examined in cross-section reveals a distinctive butterfly-shaped Central core of gray matter that plays a fundamental role in neural processing composed of neural cell bodies and synapses this gray matter is strategic rically organized into distinct regions the posterior or dorsal horns position towards the back of the spinal cord primarily carry sensory input signals from the peripheral nervous system to the central nervous system in contrast the anterior or ventral horns located at the front inate the motor nerves of the corresponding segment facilitating the initiation of motor commands surrounding the gray matter on each side are three columns of peripheral white matter composed of melinated ascending and descending fiber Pathways these fiber tracks form the communication highways of the spinal cord transmitting information between different levels of the CNS and facilitating the relay of sensory and motor signals the myelination of these fibers enhances the speed and efficiency of signal transmission contributing to the rapid and coordinated response of the nervous system the brain stem which serves as a critical Bridge connecting the spinal cord to the rest of the brain further extends the neural Pathways all but two of the 12 cranial nerves exit from the brain stem highlighting its significance in orchestrating essential functions such as breathing heartbeat and other autonomic processes this integration of spinal cord and brain stem activities forms the basis for complex physiological and behavioral responses",
        "The Peripheral Nervous System": "the peripheral nervous system facilitates communication between the central nervous system and the rest of the body one essential component of the system is the network of spinal nerves emerging in 31 pairs from each side of the spinal cord these nerves are named based on the specific vertebral region and level from which they arise the spinal nerves serve as conduits for sensory information entering the CN s and motor commands exiting the CNS to various regions of the body an intriguing feature of the spinal nerves is the occasional convergence of nerve Roots into clusters known as plexuses these plexus enable the peripheral nerve roots to rejoin and function collectively as a group The plexus are needed for the coordination and distribution of nerve fibers to specific body regions the most well-known include the cervical plexus brachial plexus lumbar plexus and sacral plexus each of these serve specific anatomical areas allowing for more efficient and organized intervation of muscles and sensory structures for instance the cervical plexus arises from the upper cervical nerves and contributes to the ination of the neck and parts of the head the brachial plexus formed by the lower cervical and upper thoracic nerves supplies nerves to the upper limbs the lumbar plexus originating from the lumbar spinal nerves is associated with the lower abdomen and interior thighs lastly the sacral plexus formed by the lower lumbar and upper sacral nerves innervates the posterior thigh and most of the leg the existence of plexus enhances the adaptability and resilience of the peripheral nervous system injuries or damaged to individual spinal nerves may be mitigated by the redundancy in overlap provided by these nerve clusters Additionally the arrangement of these plexus allows for more efficient communication and coordination between the spinal nerves contributing to the precise and coordinated control of movement and sensation throughout the body",
        "The Sympathetic Nervous System": "the sympathetic nervous system a division of the autonomic nervous system is primarily regulated by the hypothalamus in the brain and controls the body's response to stress often referred to as the fight or flight response the hypothalamus serving as a control center integrates signals from various sources including emotional stimuli and environmental cues to activate the sympathetic nervous system when necessary in information from the brain is transmitted through the brain stem to the cervical spinal cord these neurop Pathways facilitate the communication between the higher brain centers and the sympathetic ganglia which are clusters of nerve cell bodies which transmit signals to Target structures the sympathetic nervous system exhibits a unique anatomical Arrangement where the preganglionic neurons emerge from the thoracic and Lumbar levels of the spinal cord forming what is commonly known as the thoro lumbar outflow upon exiting the spinal cord the preganglionic neurons synapse with post ganglionic neurons in sympathetic ganglia located near the spinal cord from these ganglia the postganglionic neurons project to various Target structures including organs glands and blood vessels throughout the body the neurotransmitter norepinephrine is released at these synapses contributing to the activation of a generic receptors on the target cells and eliciting a rapid and coordinated physiological response the sympathetic nervous system's functions are diverse and include increasing heart rate rate dilating Airways redirecting blood flow to vital organs and mobilizing energy stores these responses collectively prepare the body to confront or escape from a perceived threat a mechanism that has evolved to enhance survival in challenging situations",
        "The Thoracolumbar System": "the thoro lumbar system provides sympathetic stimulation to peripheral tissues through the activation of Alpha and beta receptors and originates from the thoracic and Lumbar regions of the spinal cord giving rise to preganglionic neurons that extend to sympathetic ganglia upon reaching these ganglia the preganglionic neurons synapse with postganglionic neurons in initiating the release of neurotransmitters that react with Alpha and beta receptors on the target cells in the context of sympathetic stimulation Alpha receptors are particularly significant when Alpha receptors are activated they induce smooth muscle contraction in blood vessels and bronchioli this physiological response is part of the sympathetic nervous systems broader mechanism to prepare the body for a fight or flight situation the contraction of smooth muscle in blood vessels known as Vaso constriction leads to a reduction in the diameter of the vessels consequently increasing blood pressure this effect is instrumental in redirecting blood flow to essential organs and tissues during times of stress or perceived Danger additionally Alpha receptor stimulation causes Bronco constriction narrowing the Airways in the bronchioles this response enhances the efficiency of oxygen intake by redirecting air flow to the primary air passages while this Bronco constrictive effect is advantous in acute stress situations prolonged activation of alpha recept ctors can contribute to respiratory challenges especially in individuals with pre-existing respiratory conditions beta receptors elicit relaxation of smooth muscles in both blood vessels and bronchioles this effect is significant in the context of blood vessel dilation leading to an increase in blood flow moreover beta receptors exert chronotropic and inotropic effects on myocardial cells influencing both the heart rate and the force of cardiac contractions however disruptions in the normal sympathetic communication can occur particularly in cases a spinal cord injury a spin cord injury at or above the level of T6 which corresponds to the thoracic region May impede the flow of sympathetic signals resulting in Altered anomic function this disruption can lead to a loss of sympathetic control over certain physiological processes potentially affecting blood pressure regulation heart rate and respiratory Function One notable consequence of a spinal cord injury especially above the T6 level is the risk of autonomic disres flexia autonomic dis reflexia is a condition characterized by an exaggerated sympathetic response in individuals with spinal cord injuries stimulation of sympathetic nerves in the absence of proper parasympathetic input can lead to a state of sympathetic overdrive this uncontrolled activation of the sympathetic nervous system may result in a rapid increase in blood pressure headaches perus sweating and other autonomic disturbances autonomic dis reflexia is a medical emergency requiring prompt attention to alleviate the excessive sympathetic activity and prevent potentially life-threatening complications",
        "The Parasympathetic Nervous System": "the parasympathetic nervous system often referred to as the rest and digest system promotes relaxation and maintaining homeostasis in the body this system consists of fibers originating from the brain stem and upper spinal cord specifically the cranos sacral region these fibers carry signals to various organs including those in the abdomen heart lungs and the skin above the waist the parasympathetic nervous system functions in opposition to the sympathetic nervous system aiming to conserve and rest store energy when activated it promotes activities such as digestion slowing the heart rate and enhancing nutrient absorption the parasympathetic system helps maintain internal balance during non-stressful situations allowing the body to recover and recuperate disruption of the lower parasympathetic nerves particularly those in the sacral region can have profound effects on bodily functions the sacral parasympathetic nerves are crucial for regulating bowel and bladder tone as well as sexual function in cases where these lower parasympathetic nerves are compromised individuals may experience a loss of control over bowel and bladder functions leaving to incontinence furthermore disruptions in sacral parasympathetic ination can impact sexual function potentially causing difficulties in arousal and reproductive processes",
        "Axonal Transport": "axonal transport is a fundamental process in the intricate Machinery of neuronal function ensuring the efficient movement of essential proteins and organel within the complex structure of neurons this intracellular transport mechanism is particularly crucial for neurons giving their unique elongated morphology and the requirement for precise delivery of cellular components to specific sites along the extensive axonal and dendritic processes the key feature enabling this precise delivery is a long range microt tual based transport system comprising two essential components this system involves molecular Motors that act as the driving force for the movement of cellular materials and microtubules that serve as the tracks or highways directing these components to their designated locations within the neuron microtubules are Dynamic structures made up of tubulin subunits forming a network that extends throughout the length of the neuron providing structural support and serving as the framework for the axonal transport system the molecular Motors responsible for axonal transport are typically motor proteins such as kinin and Dinan kinin move cellular components towards the distal end of the neuron known as anterograde transport while dians facilitate movement toward the cell body known as retrograde transport these molecular Motors utilize adinis Trio phosphate as an energy source to power their movement along the microt tual tracts ensuring the precise delivery of cargo to synapses dendrites and other subcellular compartments this highly organized and regulated axonal transport system is critical for the maintenance function and survival of neurons disregulation of axonal Transport has been been implicated in various neurodegenerative disorders including Alzheimer's and Parkinson's diseases emphasizing the significance of this process in normal neuronal physiology",
        "Axonal Transport Dynamics": "the direction and speed of axonal Transport within neurons are intricately regulated processes and these Dynamics are largely dictated by the specific molecular Motors involved either kinin or dians the choice of molecular motor depends on the cargo being transported the specific cellular destination and the direction it is headed one way to categorize AAL transport is based on the speed of the bulk cargo movement in this distin distinction is particularly relevant for understanding the transport of different cellular components fast axonal transport is characterized by the Swift movement of cargo such as vesicles and mitochondria along the microt tual tracks this rapid transport is essential for supplying synaptic terminals with neurotransmitters energy producing mitochondria and other vital cellular materials that are required for efficient neuronal function in contrast slow axonal transport involves the more gradual movement of cytoskeletal components along the microtubules this form of Transport is responsible for the steady delivery of structural proteins such as tubulin and neurofilaments which contribute to the maintenance and renewal of the neurons structural Integrity slow axonal transport ensures that the cytoskeleton is continuously updated and provides the necessary support for the neuron structure and function over time when the finally tuned process of axonal Transport is disrupted it can have profound impc ations for neuronal health contributing to the pathogenesis of various neurodegenerative diseases",
        "Neurodegenerative Disorders": "one Hallmark pathology observed in numerous human neurodegenerative disorders including Alzheimer's Parkinson's disease and anatrophic lateral sclerosis is the accumulation of organel and proteins within the axons and cell bodies of neurons in conditions like Alzheimer's abnormal accumulations of proteins such as beta amloid and towel are formed within neurons these accumulations known as plaques and Tangles disrupt normal cellular function and contribute to the degeneration of synaptic connections and neuronal loss the transport of essential materials including neurotransmitters and organel is impaired leading to synaptic dysfunction and cognitive decline Parkinson's disease is characterized by the accumulation of misfolded alpha culine protein forming louisi bodies within neurons the disruption of axonal transport mechanisms contributes to the impaired delivery of mitochondria which which are needed for energy production resulting in the generation of dopaminergic neurons and the characteristic motor symptoms associated with the disease in amyotrophic lateral sclerosis disruptions in axonal transport are implicated in the accumulation of abnormal protein aggregates including tdp43 these Aggregates contribute to the degeneration of motor neurons leading to muscle weakness and eventual paralysis therapeutic strategies aimed at preserving or restoring proper exal transport May hold promise in mitigating the progression of these disorders investigating the molecular and cellular events associated with disrupted axonal transport and neurodegenerative diseases is an active area of research offering potential avenues for targeted interventions and the development of Novel treatments to address these devastating",
        "Neurologic Examination": "conditions neurologic examination critical patients with neurologic complications pose distinctive challenges during both care and transport necessitating a meticulous and specialized approach to their examination and management the neurologic examination serves as the starting point for the entire patient management process this examination is a comprehensive assessment aimed at evaluating the function and integrity of the nervous system encompassing the brain spinal cord and peripheral nerves the critical care team must adeptly navigate the complexities associated with neurologic dysfunction as it requires a nuanced understanding of the patient's presentation underlying pathophysiology and any potential complications the neurologic exam typically involves a thorough assessment of various components in including mental status cranial nerve function motor function sensory function coordination and reflexes in critical care scenarios where patients may be acutely ill or have altered levels of consciousness assessing mental status becomes Paramount for gauging the severity of neurologic compromise cranial nerve examination provides insights into potential intracranial pathology while evaluating motor and sensory function helps identifi deficits and localize the neurologic lesion coordination assessments contribute to understanding cerebellar function and reflex testing provides information about the Integrity of the spinal cord and the peripheral nerves the execution of specific neurologic tests is contingent upon several factors including the patient's condition the nature of the inner facility transport and the assessments conducted during the initial Hospital evaluation for inner facility transports it is common for a comprehensive set of neurologic tests to have already been performed as part of the patient's initial assessment at the hospital these assessments may include but are certainly not limited to the evaluation of mental status cranial nerve function motor and sensory function coordination and reflexes the decision regarding which neurologic evaluation is to perform during Critical Care transport is highly individualized and certainly hinges on the patient's evolving clinical status if additional or repeat evaluations are deemed necessary based on changes in the patient's condition or simply the need for ongoing monitoring the provider will perform them as appropriate this may involve reassessing mental status re-evaluating motor and sensory functions or conducting specific tests relevant to the patient's neurologic presentation importantly transport team members must possess a thorough understanding of how to interpret the findings from neurologic tests and more critically how to adapt their care strategies based on these results this requires a nuanced comprehension of neuroanatomy pathophysiology and the potential implications of neurologic abnormalities in the patient's overall health the ability to dynamically adjust care plans based on neurologic assessment is important in the fluid and sometimes unpredictable context of critical care transport",
        "Mental and Emotional Status": "in the realm of physical examination the assessment of mental and emotional status serves as a critical component delving into various aspects of cognitive and emotional function specific areas targeted within this component Encompass the patient's level of Consciousness General behavior and thought processes including memory attention and concentration abstract thought and judgment the examination of mental and emotional status provides invaluable insights into the patient neurologic well-being and overall cognitive function the evaluation of level of Consciousness is a foundational element that should be systematically assessed in all patients we come in contact with as it gauges the patients responsiveness and awareness of their surroundings ranging from Full alertness to various degrees of altered Consciousness assessing General Behavior involves observing the patient's demeanor interactions and responses to stimuli contributing to the overall understanding of their current mental state testing thought processes provides a more nuanced examination of cognitive function memory assessments explore the patient's ability to recall information while attention and concentration tests delve into their focus and ability to sustain attention the evaluation of abstract thought and judgment offers insights into the patient higher cognitive functions including problem solving abilities and decision-making skills in the critical care setting the assessment of mental and emotional status is particularly vital as it can reveal early signs of neurologic deterioration delirium or other cognitive disturbances changes in mental status may be indicative of underlying pathologies or complications that require prompt attention the results of this examination guide the critical care team in tailoring interventions and adapting care plans to address specific cognitive or emotional challenges",
        "Level of Consciousness": "in the assessment of a patient's level of Consciousness arousal and awareness emerge as Paramount qualitative markers crucial for gauging the patient's overall neurologic function the evaluation of arousal in particular serves as a direct examination of the patient's particular activating system and its intricate connection with both the phalus and the cerebral cortex arousal which we Define as a state of being awake and reactive to stimuli provides profound insights into the Integrity of these neural circuits which play a pivotal role in regulating weightfull and awareness are imperative in the critical cure setting arousal is not a static attribute but can fluctuate in response to various factors including medications interventions and the patient's underlying condition repeated assessments allow Health Care Professionals to track changes over time identifying trends that may indicate Improvement or even deterioration in neurologic status the evaluation of arousal involves assessing the patient's responsiveness to stimuli such as verbal commands tactile stimuli or even painful stimuli this exam aims to determine the patient's ability to wake from sleep follow commands and exhibit purposeful responses the reticular activating system which again is a network of neurons extending from the brain stem to the thalmus acts as a regulator of these arousal responses furthermore the connection between the reticular activating system thalmus and cerebral cortex is vital for maintaining a state of awareness and processing sensory information disruptions in this pathway can result in Altered Consciousness or impaired awareness warranting prompt attention and intervention by scrutinizing the patients arousal and awareness levels healthc care providers can swiftly identify signs of neurologic compromise allowing for targeted interventions and the adjustment of treatment plans to optimize outcomes arousal assessment serves as a fundamental component of neurologic examinations and various scales are employed to describe and quantify the patient's level of consciousness two commonly used scales for this purpose are the avoo scale standing for awake verbal painful and unresponsive as well as the glass scal Coma Scale or GCS the GCS in particular offers a comprehensive approach to documenting and trending a patient's level of arousal based on three parameters eye opening verbalization and movement movement in the evaluation of awareness or orientation attention is directed toward the patients ability to comprehend and respond appropriately to their surroundings this involves assessing their understanding of time place and person disorientation often manifests as a predictable sequence with the patient losing awareness of time first followed by place and then person recognizing these patterns AIDS in identifying cognitive impairment or neurologic dysfunction guiding further assessment and intervention Beyond arousal and awareness the assessment of General Behavior provides valuable insights into a patient's neurologic status this involves Keen observation of gestures facial expressions mood affect and posture changes in Behavior can be indicative of neurologic deterioration as well as pain discomfort or emotional distress regular monitoring of General Behavior allows healthc Care Professionals to detect subtle nuances and variations that may signify underlying issues prompting targeted interventions the many mental state examination or mmse is an additional tool designed to assess higher cognitive functions systematically developed for its Simplicity and ease of application the mmse evaluates aspects such as orientation memory attention calculation language and Visos spatial abilities this comprehensive examination AIDS in detecting cognitive impairments and provides a standardized means of tracking changes over time in the critical care setting where rapid and accurate assessments are essential the choice of assessment tools depends on the specific needs of the patient and the clinical Conta regular use of these tools enables Health Care Providers to not only gauge the patients's neurologic status accurately but also to identify subtle changes promptly this proactive approach ensures that appropriate interventions can be implemented to address evolving neurologic challenges and optimize patient outcomes",
        "Speech Function Assessment": "speech function assessment plays a role in the neurologic examination particularly for critical care transport professionals as abnormalities in speech can serve as early indicators of underlying neurologic issues recognizing and addressing speech related issues promptly is essential as they may interfere with the provider's ability to accurately assess other highlevel neurologic function functions abnormalities in speech Encompass a range of conditions that can reflect dysfunction in various components or processes of communication these include deafness aasia dysphonia and dysarthia deafness involves the inability to hear which can impact the patient's ability to understand and respond to verbal communic communication Aphasia on the other hand is a central focus in the assessment of speech function as it is commonly associated with acute neurologic processes aasia refers to a language disorder that can affect a person's ability to express themselves through speech understand spoken or written language and sometimes even both providers pay particular attention to Aphasia because it often indicates an acute neurologic event such as a stroke or traumatic brain injury it is important to note that the patients experiencing AP fascia may still be capable of hearing and comprehending spoken language even if they struggle to express themselves verbally",
        "Cranial Nerve Assessment": "the assessment of cranial nerves is a critical component of the neurologic examination and while many cranial nerve tests involve active patient participation certain nerves are more commonly assessed in critically ill or injured patients one such nerve is the olfactory nerve designated as cn1 the evaluation of cn1 is particularly important in patients who have experienced head trauma where there is suspicion of pathology at the base of the skull or in those with altered mental status the assessment involves the use of familiar odors to gauge the patients Al Factory function commonly employed scents include coffee vanilla soap or even lemon oil the AL Factory examination aims to determine the patient's ability to detect and identify specific odors providing valuable insight into the Integrity of the olfactory nerve patients who have sustained head trauma may be at risk for injury to the olfactory nerve or Associated structures at the base of the skull an altered mental status can also signal potential neurologic dysfunction making the assessment of the cn1 crucial in such cases by using familiar and easily recognizable odors The Examiner can elicit responses that help assess the patient's ability to detect and differentiate between smells contributing to a comprehensive evaluation of cranial nerve function the optic nerve designated as cn2 is a component of the neurologic examination as it plays a role in visual function originating from cells in the retina the optic nerve passes into the orbit and its assessment involves an individual evaluation of each eye several tests are imployed to comprehensively assess the optic nerve including evaluations of visual ual Acuity visual fields and the fundi through fundoscopy Visual acuity testing is performed to determine the patient's ability to discern details of visual stimuli assessment of visual Fields involves evaluating the extent of peripheral vision with a normal visual field extending 60\u00b0 nasally 100\u00b0 tempor corally and 130\u00b0 vertically fundoscopy allows visualization of the optic disc macula and blood vessels on the back wall of the internal eyeball aiding in the detection of abnormalities associated with the optic nerve the ocular trolear trigeminal and abducens nerves denoted as cn3 three four and six are often examined as a group due to their Collective role in eye movement and the control of ocular muscles to maintain parallel eye alignment parameters observed during this assessment include the positions of the eyeball and the upper eyelid in the context of an unconscious patient certain reflex tests may be employed the o oculos falic reflex commonly known as the doll's eye test involves moving the patient's head to observe reflex movement of the eyeball the oculo vestibular reflex assessed through the caloric test involves introducing warm or cold water into the ear to elicit reflex eye movements the facial nerve designated as cn7 is a complex cranial nerve encompassing motor sensory and parasympathetic fibers its motor component inates the muscles responsible for facial expression and its function can be assessed through various tests patients are instructed to perform tasks such as wrinkling the forehead closing the eyelids tightly smiling or grimacing to show the teeth and whistling these actions help evaluate the Integrity of the facial nerves motor function providing valuable information about potential neurologic issues the vestibulo coclear nerve or cn8 is a cranial nerve involved in both Hearing and Balance it consists of two divisions the clear division responsible for hearing and the vestibular division which contributes to balance assessment of the vestibular division involves using rotational and caloric stimuli to induce changes in the indol lymph current within the semicircular canals patients experiencing vestibular dysfunction may present with with symptoms like vertigo nausea vomiting and difficulties with balance the caloric test is commonly used to assess vestibular function however it is contraindicated in patients with ruptured tanic membranes in the unconscious patient the dolls eye test or oculos falic reflex test is performed by rap rapidly rotating the head from side to side observing the eye movement the absence of doll's eyes where the eyes move in the same direction as the head is turned indicates an abnormal response and signifies severe brain stem dysfunction the glossop feral and Vagas nerves or the cn9 and CN tin nerves respectively are often evaluated in conjunction due to their anatomical proximity in shared functions the glossop faren geal nerve contributes sensory components to various structures including the ferx tonsils soft pallet and the posterior third of the tongue meanwhile the vagus nerve has a broad range of functions including both sensory and motor intervation to the heart lungs digestive tract and linic to assess the glossop farang gal and vagus nerves a common method is to instruct the patient to open their mouth and say ah this action helps evaluate the motor function of these nerves particularly in relation to the muscles involved in fation and swallowing Additionally the provider May stimulate the gag reflex during the examination this gag reflex is elicited by gently touching the posterior fenial wall with a tongue depressor observing the appropriate response the stimulation of the gag reflex provides valuable information about the Integrity of the glossop faral and Vagas nerves which play crucial roles in both sensory and motor functions associated with the throat and other vital structures in the body the spinal accessory nerve or cn1 and the hypoglossal nerve or cn12 are evaluated to assess motor functions associated with specific muscles the spinal ACC accessory nerve is tested in two segments to evaluate its Integrity first the trapezius muscle is examined by palpating while the patient shrugs their shoulders against resistance this action tests the motor function of the spinal accessory nerve in controlling the trapezius muscle which is responsible for shoulder movement in the second segment of the test the patient turns her head to one one side and pushes the chin against the examiner's hand during this maneuver The Examiner should also palpate the Sterno ceto mastoid muscle for tone and strength the combined assessment of these movements provides valuable information about the functionality of the spinal accessory nerve the hypoglossal nerve which is responsible for the ination of the tongue's muscul is evaluated by observing specific aspects of tongue function the provider should look for signs such as fasiculations atrophy strength and the ability of the tongue to protrude fasiculations and atrophy May indicate underlying neurological issues affecting the hypoglossal nerve because of this the provider should assess the strength of the tongue by checking the patient's ability to resist resistance during tongue movements",
        "Motor Function Assessment": "the assessment of motor function involves the evaluation of muscle tone and strength the examination typically proceedes systematically from the upper limbs to the neck and trunk and finally to the lower extremities ensuring a thorough evaluation of motor capabilities across the body a key aspect of this assessment is the comparison of symmetry between the two sides of the body which AIDS in identifying any asymmetries or abnormalities that may indicate underlying neurological issues muscle tone the resistance encountered when a muscle is passively stretched is assessed by the provider through GLE manipulation of the patient's limbs abnormalities in muscle tone such as hypertonia or increased tone and hypotonia or decrease tone can provide valuable information about the Integrity of the motor pathways and potential neurological dysfunction strength assessment involves evaluating the force exerted by muscles during voluntary movements here the provider systematically assesses the strength of various muscle groups considering both proximal and distal muscles this evaluation not only helps in identifying weakness or paresis but also provides insights into the specific nerve routes or Pathways that have been affected during the neurologic examination the assessment of muscles extends Beyond strength evaluation and includes palpation through the normal range of motion palpation helps in detecting abnormalities in muscle tone and response to passive lengthening providing valuable insights into the underlying neurologic conditions abnormalities in muscle tone are indicators of neurological dysfunction spicity characterized by undue resistance of muscles during passive lengthening due to injury to the corticospinal system often results in stiff and jerky movements this abnormality can arise from conditions such as upper motor neuron lesions stroke or traumatic brain injury affecting the normal functioning of the corticospinal tracts rigidity on the other hand involves a more constant state of resistance and is associated with dysfunction in the extra predial motor system this system which includes the basil ganglia plays a role in regulating involuntary motor movements rigidity can be observed in conditions like Parkinson's disease where there is disruption in the normal balance of neurotransmitters within the extra peridial system fluidity indicating decreased muscle tone or hypotonia is another noteworthy abnormality it can result from lower motor neuron lesions or damage to the peripheral nerves hypotonia leads to a lack of resistance in the muscles and can manifest as weakness and diminish reflexes the assessment of sensory function helps evaluate the patient's ability to perceive different types of Sensations when their eyes are closed this examination assesses the Integrity of sensory receptors and the conduction tracks within the nervous system during the examination the provider systematically evaluates the patient's response to various stimuli including pain temperature and touch assessing these Sensations helps to identify potential abnormalities or deficits in sensory perception which can be indicative of underlying neurologic conditions pain perception is evaluated by applying a controlled stimulus such as a pin prick to different areas of the body the patient's ability to discriminate between sharp and dull Sensations provides insights into the Integrity of pain receptors and the associated neural Pathways temperature sensation is also assessed often using a cold or warm object to identify any discrepancies in the patient's ability to perceive temperature changes touch sensation evaluation involves assessing the patient's response to light touch or pressure on specific areas of the body this helps in identifying abnormalities related to the tactile sensory Pathways accurate documentation of the sensory examination findings helped to establish a Baseline for monitoring changes over time reflex testing provides valuable insights into the Integrity of the spinal nerves and can indicate the presence of brain stem or spinal cord lesions the exam primarily focuses on deep tendon reflexes which are automatic involuntary responses to a specific stimuli these reflexes involve the stretching of a muscle tendon activating sensory receptors which in turn stimulate motor neurons to cause a rapid contraction of the muscle tendon reflexes are commonly tested in the upper and lower extremities including the biceps triceps patellar and achilles reflexes the exam involves tapping the corresponding tendon with a reflex Hammer eliciting a quick muscle contraction the interpretation of reflex responses assists in differentiating between upper motor neuron and lower motor neuron lesions in cases of upper motor neuron lesions such as those affecting the brain or spinal cord tendon reflexes tend to be increased or exaggerated this heightened reflex activity is the result of the disruption of inhibitory signals from the central nervous system leading to an overactive response conversely lower motor neuron lesions which typically involve damage to the peripheral nerves or the nerve Roots result in decreased or absent reflexes in these cases the interruption of the neural circuit prevents the normal reflex arc leading to a diminished response pathologic reflexes are abnormal responses that can be elicited during the neurologic exam providing insights into potential neurological dysfunction among these reflexes the plantar reflex is a commonly assessed component in this test the provider uses a blunt object such as the back of a PIN to rapidly stroke the lateral aspect of the sole of the foot from heel to the ball the normal response involves toe flexation however an abnormal response known as the Pinsky sign occurs when there is toe extension indicative of potential upper motor neuron dysfunction other pathologic reflexes include the oppenheim sign which involves eliciting an extensor response by stroking the anterior medial tibial muscle the Gordon sign is another pathologic reflex that results in an extensor response triggered by firmly squeezing the gastron neous muscle these signs when present suggest abnormalities in the neural Pathways controlling motor responses the Hoffman sign is a distinctive reflex observed when flicking the distal phalance of the index or middle finger a positive Hoffman sign manifests as a sudden clawing of the fingers and thumb indicating an exaggerated reflex in the upper extremities this response is particularly associated with upper motor neuron Le lesions that can be indicative of spinal cord or brain pathology the grasp reflex is a neurological test performed during the examination of patients especially those with potential neurological impairments in this test the provider instructs the patient to grasp their index finger creating a voluntary grip then gently pulls the patient's hand away instructing them to release the grasp a normal response to this test is observed when the patient can willingly let go of their hand demonstrating intact voluntary control over the gripping action however an abnormal response is characterized by the involuntary flexation of the fingers indicating an exaggerated or retained grasp reflex this abnormal finding may suggest dysfunction in the neural Pathways responsible for coordinating motor responses particularly in relation to hand movements superficial reflexes play a role in assessing the Integrity of specific neural Pathways and motor responses providing valuable information during neurological exams one such reflex The chromic Reflex can be assessed in men by gently stroking the inner aspect of the upper thigh downward the expected response involves the elevation or movement of the testicle in the scrotum typically this reflex is more relevant in the assessment of neonatal in pediatric patients than in adults during Critical Care trans Port the application of this test to assess adult patients is less common the reflex is associated with the motor intervation of the chaster muscle which is connected to the testicle while the reflex may be elicited in male adults it is often not routinely tested during transport unless specific clinical indications or concerns warrant its evaluation evaluation of menal irritation is useful when investigating potential infections caused by various agents such as bacteria viruses fungi parasites or toxins each type of causitive agent leads to distinct pathophysiological processes clinical manifestations and treatment strategies menal irritation occurs when the causitive agent acts as an irritant triggering an inflammatory reaction around the meninges located in the arachnoid space cereal spinal fluid and ventricles this inflammatory response results in hyperemia and increased permeability of the Menin vessels contributing to the characteristic symptoms associated with menal irritation common symptoms include a throbbing headache that tends to progress in severity heightened sensitivity to light nucle rigidity kerig sign and rudinsky sign the generalized throbbing headache is often a primary complaint reflecting the increased pressure within the menial space photophobia is a typical symptom due to the irritation of the meninges nucle rigidity refers to the stiffness of the neck muscles and can be assessed by attempting to flex the neck forward keric sign is a positive finding when there is resistance and pain to the hamstrings when the knee is extended with the hip flexed brinsky sign is observed when passive neck flexation induces flexation of the patient's hip and knee these signs collectively Aid in the clinical diagnosis of menial irritation the lomite phenomenon is a distinctive neurological symptom characterized by the experience of an electric shock-like Sensation that occurs when an individual flexes their neck forward this sensation typically travels down the spine or radiates into the limbs the presence of the lomite phenomenon is indicative of cervical pathology particularly involving the cervical spine or nerve Roots this phenomenon is often associated with dementing conditions affecting the central nervous system such as multiple sclerosis in these cases the protective covering of nerve fibers known as myelin becomes damaged leading to abnormal signaling along the nerves when the neck is flexed the altered transmission of signals results in the characteristic shock-like sensation the Lite phenomenon serves as a clinical sign that neurologists and healthc Care Professionals consider during the evaluation of Pat patients especially those with suspected or known neurological disorders it is essential in the diagnostic process to understand the context and the overall clinical presentation of the patient as the Lite phenomenon alone is not specific to a particular condition but rather serves as a potential indicator of underlying cervical pathology as an integral component of the neurologic examination during Critical Care transport obtaining Vital Signs is fundamental for assessing and monitoring a patient's overall health in neurologic status the brain stem houses centers that control vital functions making it a key regulator of essential processes like respiration and cardiac activity monitoring Vital Signs such as heart rate blood pressure respiratory rate and temperature allows the provider to gather real-time information about the patient's neurologic condition any deviations from Baseline values or alterations in Vital Signs can provide invaluable insights into the patient's neurologic status and guide the provider in making prompt clinical decisions for instance changes in breathing patterns or disruptions in cardiac function can signal potential issues within the system prompting the need for immediate attention and intervention blood pressure is a critical parameter monitored during neurologic assessment especially in the context of neurologic injury and Rising intracranial pressure hypertension is a common effect on blood pressure associated with neurologic injury particularly when there is elevation in intracranial pressure this hypertension is often observed in conjunction with other symptoms forming the classic Cushing Triad which includes braic cardia abnormal respiratory patterns and elevated blood pressure the Cushing Triad reflects the body's compensatory response to increased intracranial pressure where the slowing heart rate and changes in breathing aim to maintain cerebral profusion under elevated pressure conditions conversely cerebral injury rarely causes hypotension except in the advanced stages of injury monitoring blood pressure in neurologic patients is critical as it provides insights into the Dynamics of intracranial pressure and cerebral profusion the provider may also observe changes in pulse pressure specifically a widening of pulse pressure greater than 40 mm of mercury which can be indicative of increasing intracranial pressure body temperature regulation can be significantly impacted by neurologic injury especially when the hypothalamus the body's Central thermostat is involved neurogenic fever is a phenomenon observed in patients with traumatic brain injury where an elevated body temperature occurs without an Associated infection initially considered relatively uncommon more recent data suggest that neurog enic fever may occur in as many as onethird of patients with severe traumatic brain injury the underlying mechanism is thought to involve the disruption of the hypothalmic temperature set point leading to an abnormal increase in body temperature neurologic Diagnostics help in evaluating and understanding abnormalities in the central nervous system computed tomography or CT is a widely used imaging technology that provides detailed cross-sectional views of the body including the brain this involves passing intersecting x-ray beams through the area of interest and measuring the density of substances as they pass through in a normal CT scan of the head different tissues appear with distinct Shades such as bone in white blood in off-white brain tissue in Gray cerebral spinal fluid in off black and Air in Black CT scans can be performed with or without IV contrast medium non-contrast CT is often employed to assess intracranial conditions like Hemorrhage intracerebral edema or structural displacements computed tomography angiography or CTA enhances the diagnostic capability by introducing an IV contrast agent for better visualization of vascular lesions which is very important in stroke Imaging protocols post administration of tissue plasmagen activator magnetic resonance imaging or MRI is another powerful diagnostic tool offering Superior image detail compared to CT this technique involves placing a patient in a strong magnetic field and introducing radio frequency waves that cause Resonance of protons in the body a computer then uses the generated resonance to create highly detailed images non-iodine containing contrast mediums are typically administered through an IV infusion before the MRI procedure to enhance visualization MRI is especially valuable for examining soft tissues providing detailed insights into brain structures tumors and other abnormalities cerebral angiography is a diagnostic technique that provides a detailed visualization of the Lumen of blood vessels offering critical information about patency size irregularities or occlusions this procedure is commonly employed in the diagnosis and treatment of cerebral aneurysms arterovenous malformations and cored artery disease to perform the the procedure a catheter is inserted into the femoral artery and threaded through the aorta into the origin of cerebral circulation once in position a radiopaque contrast medium is injected enabling the visualization of blood circulation through serial radiologic Imaging while this procedure is valuable potential complications include hypers sensitivity to the contrast medium and renal dysfunction trans cranial Doppler or tcd ultrasonography is a non-invasive technology used to monitor cerebral blood flow through inner areas of the skull such as the temporal bone the eye and the FMA Magnum the Doppler ultrasonography probe can measure blood flow velocities in various cerebral arteries including the anterior middle and posterior cerebral arteries as well as a vertebral and Basler arteries depending on the angle of the probe this procedure is valuable particularly in monitoring patients following the rupture of intracranial aneurysms to assess for vasospasm identifying intracranial lesions after stroke and detecting changes associated with in increase intracranial pressure transcranial Doppler ultrasonography provides essential insights into cerebral hemodynamics aiding in the management and treatment of various neurologic conditions electroen graphy or EEG is a diagnostic technique that involves recording the electrical impulses is generated by the brain to localize abnormal electrical activity this technology is commonly employed in patients with suspected seizure activity cerebral infarcts metabolic andypath altered Consciousness infectious diseases some head injuries and to confirm brain death during an EEG electron are placed on the patient's head to transfer electrical impulses to a recording unit different types of brain waves are observed delta waves these are normally seen in adults during sleep and are also normal in infants theta waves these are associated with young children drowsy older children drowsy adults and sometimes seen in meditation Alpha Waves these are normal when relaxing or closing the eyes but are also associated with coma beta waves these are normal when a person is active working or anxious they may also appear following the use of benzo aspenes and gamma waves these are normal and associated with performing cognitive motor functions lumbar puncture involves entering the subarachnoid space in the lumbar region of the vertebral column to obtain diagnostic information or provide therapeutic intervention this procedure is valuable in assessing cerebral spinal fluid for varying conditions such as in infections bleeding and certain neurological disorders lumbar puncture allows healthc care providers to analyze the composition of cerebral spinal fluid which surrounds the brain and spinal cord providing essential insights into neurological conditions and guiding appropriate treatment strategies laboratory assessment plays a critical role in the comprehensive evaluation of neurologic emergencies complementing routine blood studies biopsies and cerebral spinal fluid analysis traditionally laboratory studies Beyond these standard assessments were not extensively utilized in neurologic emergencies but recent advances in medical Diagnostics have expanded the scope of laboratory investigations in this field for most patients presenting with neurologic emergencies a baseline set of laboratory tests is recommended this typically includes a complete blood count which provides information about the cellular components of blood such as red blood cells white blood cells and platelets a basic chemistry panel is essential to assess electrolyte levels kidney function and glucose levels coagulation studies including tests like proin time and activated partial thromboplastin time help evaluate the blood's clotting ability which is critical in cases of intracranial hemorrhage or other bleeding disorders additionally cardiac biomarkers such as troponin and creatine canes MB may be measured to assess cardiac involvement in certain neurologic",
        "Traumatic Brain Injury": "emergencies traumatic brain injury primary brain injury encompasses the initial stage that occurs directly as the result of the traumatic event this form of injury can be categorized by two main cont ceps contact phenomena injuries and acceleration de acceleration injuries contact phenomena injuries occur when there is direct trauma to the Head this can result from various incidents such as Falls blows or penetrating injuries the impact on the head whether from a collision fall or other forceful encounter directly causes damage to the brain tissue at the side of impact the severity of the injury can vary depending on the force location and nature of the trauma acceleration de acceleration injuries on the other hand can occur due to sudden changes in velocity when the head experiences rapid acceleration or de acceleration the brain inside the skull May lag behind or collide with the interior bony structures this movement can lead to sheer forces and rotational stress on the brain causing injury these types of injuries are commonly associated with motor vehicle collisions sports related incidents or any scenario involving sudden changes in motion the likelihood of brain injury is closely associated with the anatomy of the skull and the impact of forces involved certain areas of the brain particularly those adjacent to rough portions of the skull such as the frontal and temporal loes are more susceptible to injury this increased vulnerability is due to the proximity of these brain regions to bony prominences on the inner surface of the skull the frontal and temporal loes being situated near the forehead and sides of the head are more prone to injuries resulting from traumatic events conversely areas of the brain associated with smoother surfaces let the occipital lobe located at the back of the head generally have a lower incidence of injury Contra injury is a specific phenomenon that occurs when the impact force is applied to one side of the head causing the brain to move within the skull and collide with the opposite side the secondary impact occurring in a region distant from the initial trauma site results from the brain's momentum and movement inside the cranial cavity Contra injuries often lead to additional damage in the brain tissue opposite the primary impact site secondary brain injury encompasses delayed mechanisms that contribute to additional damage following the initial traumatic event these mechanisms are broadly categorized as systemic or intracranial and involve processes that unfold over time exacerbating the impact of the primary injury the failure of normal protective mechanisms after a brain injury is a key factor in the development of secondary injuries systemic secondary injuries involve issues that affect the entire body such as falling profusion pressure which is the force driving blood delivery to the tissues this reduction in profusion pressure can lead to inadequate oxygen and nutrient supply to the brain exacerbating the damage caused by the primary injury intracranial secondary injuries manifest within the confines of the skull and include phenomena like neuronal swelling edema and cerebral hyperemia resulting from carbon dioxide retention neuronal swelling and cerebral edema contribute to an increase in intracranial pressure adding further stress to the already compromised brain tissue cerebral hyperemia an increase in blood flow to the brain can compound these issues creating a challenging environment for the injured brain to function optimally one critical parameter affected by secondary brain injury is cerebral profusion pressure or CPP CPP is determined by the difference between mean arterial pressure and intracranial pressure in the context of brain injury when Auto regulation the brain's ability to regulate blood flow in response to changes in systemic blood pressure is impaired CPP becomes a primary determinant of blood flow to Injured brain tissue a decrease in CPP can exacerbate aeia contributing to ongoing damage and complicating the recovery process",
        "Specific Neurologic Injuries": "specific neurologic injuries scalp injuries Encompass a range of traumatic conditions affecting the outermost layer of the head common types include abrasions contusions lacerations and avulsions abrasions involve The Superficial layer of the scalp or the skin may be rubbed away due to friction or abrasion minor bleeding may occur and the injury typically affects the epidermis causing a raw appearance to the affected area contusions manifest as bruises on the scalp often accompanied by the accumulation of blood in the subcutaneous layer the area may present as swollen and discolored due to the leakage of blood from damaged blood vessels into the surrounding tissue lacerations represent more severe scalp injuries involving the tearing of the tissue resulting in a jagged opening lacerations can extend through multiple layers of tissue potentially reaching down to the skull itself aulions occur when there is forceful partial or complete tearing away or separation of the scalp tissue resembling a flap these can be particularly traumatic often involving the tearing of blood vessels nerves and other structures within the scalp skull fractures occur as a result of a direct High Force impact to the cranium and they are a common consequence of severe traumatic brain injuries present in more than 50% of affected patients these fractures pose a significant risk as they can lead to various complications including damage to large blood vessels located between the skull and the dura potentially resulting in hemorrhaging within the brain linear skull fractures are a specific type of fracture char cized by a single fracture line they are often discovered incidentally on computed tomography scans emphasizing the importance of thorough Imaging in cases of suspected head trauma the occurrence of linear skull fractures is typically associated with the separation of two or more bones of the skull at the sutur line which is the fibrous joint connecting these bones linear lar stellate fractures are a subtype of linear fractures that exhibit a distinctive pattern in this subtype multiple linear fractures radiate from the impact site resembling a star-like pattern the term stellate is derived from the Latin word stellatus meaning star diastatic stellate fractures represent another subtype of linear stellate fractures in this variation there is a separation or dislodgment of an eposis related to a Central site of impact an eposis refers to the end portion of a bone that forms a joint with another bone the term diastatic implies the separation of these bone components this type of fracture signifies not only the linear fractures radiating from the impact site but also the specific discoloration or separation of a bone component a depressed skull fracture is a type of skull fracture characterized by the displacement of a portion of the skull inward towards the brain and the scalp and or Dura may or may not be torn this type of fracture often results from a high impact Force to the head and clinical signs may include soft tissue swelling over the trauma site along with a palpable step off or depression in the Bony structure these fractures are further classified into open or closed depending upon whether there is a breach in the Duram matter in an open depressed skull fracture there's a communication between the fracture site and the external environment potentially exposing the brain to infection closed depressed skull fractures on the other hand do not involve a breach of the Duram matter and the displaced bone is not in contact with the external environment several subtypes of depressed skull fractures exist true fractures the most common subtype in involve the depressed segment in direct contact with the cranial Vault flat fractures in contrast feature a depressed segment without any connection to the cranial Vault and are less common the ping pong ball fracture is a specific subti seen in pediatric patients characterized as a green stick fracture of the skull resembling the deformity scene when a pingpong ball is pressed comminuted skull fractures represent a severe type of skull injury characterized by the splintering or shattering of the skull into multiple pieces unlike linear fractures where there is a single fracture line communed fractures involve the breaking of the skull bone into numerous fragments this type of fracture is often associated with high impact trauma such as blows to the Head Falls from significant Heights or traumatic accidents the communed nature of these fractures poses unique challenges for medical professionals in terms of diagnosis and management the complexity of the fracture pattern makes it essential to conduct thorough Imaging studies such as CT scans to precisely assess the extent and distribution of the fractured bone fragments understanding the specific characteristics of communed fractures is important for determining the severity of the injury as well as for determining potential complications and the most appropriate treatment strategy these patients may experience a range of symptoms depending upon the extent of the injury including severe pain swelling and in some cases visible deformities or depressions at the side of the fracture basil skull fractures represent a specific category of skull injuries involving fractures along the base of the skull these fractures typically occur due to a significant impact to the parietal temporal or occipital regions of the skull with the temporal region being the most commonly affected the diagnos NOC features associated with basor skull fractures carry important clinical implications for Health Care Professionals managing head trauma cases one characteristic sign associated with Basler skull fractures is the Halo test which is conducted to detect leaking cerebral spinal fluid fractures involving the auditory canal and lower lateral areas of the skull may lead to specific clinical manifestations for example blood migration into the mastoid region situated posterior and slightly inferior to the ear can result in discoloration known as retroarc ecosis or battle sign additionally fractures involving the orbital region may lead to hring into the surrounding tissue presenting as periorbital ecosis or roniz it is estimated that as many as 60% of patients with significant facial injuries also suffer trauma to other vital structures fractures involving the facial bones are often intensely painful necessitating substantial analgesia to ensure patient Comfort when faced with focal injuries Airway control becomes the foremost priority of the initial assessment proper evaluation and stabilization of the airway are important to prevent respiratory compromise and secure the patient ability to breathe effectively among facial fractures maxillary fractures are particularly serious and are classified using the lefor criteria these fractures result from high energy forces applied to the face the lefor classific ification system characterizes maxillary fractures into distinct types each associated with specific anatomical features and clinical considerations lefor one fractures involve a Traverse pattern that separates the hard pallet from its bony frame despite slight instability to the maxill there is no Associated displacement lefor 2 fractures manifest as a peridial fracture involving the Central maxill and pallet extending through both the maxill and nasal Bones the for three fractures represent A cranofacial disruption extending from the frontozygomatic sutures orbits and nasoethmoidal regions these fractures are unstable and often lead to problems with oral and nasal patency importantly these fractures can result in leakage of cerebral spinal fluid highlighting the potential severity of associated complications lefor 4 fractures essentially combine the characteristics of lefor 3 fractures with a concurrent frontal bone fracture this complex pattern further underscores the need for a thorough understanding of facial anatomy and a multi-disciplinary approach to manage these intricate injuries brain injuries Encompass a spectrum of conditions and among them focal injuries such as Cal contusions present specific challenges in diagnosis and management a cerebral contusion refers to bruising of brain tissue often resulting from traumatic head injuries these injuries frequently occur in situations involving rapid de acceleration notably contusions tend to manifest at the tips of the frontal and temporal loes areas where the irregular shape of the skull base makes the brain more susceptible to injury upon sudden de acceleration lacerations that penetrate the cranium pose a significant risk as they can lead to tearing of the cortical surface of the brain such injuries can result from various traumatic incidents including Falls accidents or penetrating injuries an epidural hematoma also known as an extradural hematoma is a specific type of traumatic brain injury characterized by the accumulation of blood between the inner periosteum and the Duram matter this condition often arises due to a traumatic incident such as a blo of the head patients with epidural hematoma may present with a distinctive clinical course the history often includes a brief period of unconsciousness immediately following the event followed by a lucid interval that can last for minutes or several hours this Lucid interval during which the patient appears conscious and alert can be misleading as it may create a false sense of improvement in the patient's condition however large hematomas associated with epidural hematomas can exert a mass effect acting as a space occupying lesion within the cranial Vault this Mass Effect contributes to increased int cranial pressure which can lead to compression of the surrounding brain tissue brain stem herniation is a life-threaten in complication that can occur in the context of increased cranial pressure due to various neurologic injuries this dangerous phenomenon occurs when the expanding blood exerts pressure on the brain forcing it downward through the fan Magnum when the brain herniates through this opening it can lead to a shearing type force on the brain stem because the brain stem is responsible for Vital functions such as breathing heart rate regulation and Consciousness compression or injury to the brain stem can result in severe neurological deficits and in some cases may be incompatible with sustaining life subdural hematoma is another form of traumatic brain injury that arises from bleeding within the brain's protective coverings specifically the results from the disruption of the bridging veins located over the crest of the brain these veins Traverse the subdural space when trauma causes these veins to tear blood accumulates in the subdural space forming a hematoma the clinical presentation of a subdural hematoma can vary and symptoms may not manifest immediately the accumulation of blood within the subdural space can exert pressure on the brain leading to neurological symptoms such as headache altered mental status focal neurological deficits and in severe cases coma intracerebral hemorrhages are characterized by bleeding within the brain tissue itself this condition often results from the rupture of small blood vessels within the brain leading to the accumulation of blood in the surrounding tissues these injuries can be caused by various factors including hypertension arterovenous malformations or trauma with the clinical presentation varying based on the location and extent of bleeding symptoms include severe headache neurological deficits altered Consciousness and in severe cases life-threatening complications delayed traumatic intracranial hemorrhage refers to bleeding within the brain that occurs after a certain period following the traumatic injury this delayed onset of bleeding can complicate the clinical course of patients who initially appear stable after trauma while the exact mechanisms are not fully understood it is thought to involve the delayed rupture of blood vessels or the progression of microscopic bleeding into more significant hemorrhages monitoring and repeated neuroimaging are often necessary in patients with head trauma to detect and manage this condition properly subarachnoid hemorrhage is characterized by bleeding into the subarachnoid space the most common cause is the rupture of an intracranial aneurysm although other causes such as head trauma or vascular Mal formations can also contribute subarachnoid hemorrhage is a medical emergency often presenting with a sudden and severe headache neck stiffness and altered mentation the diagnosis is typically confirmed through neuroimaging such as CT scan or lumbar puncture concussion often referred to to as a mild traumatic brain injury represents a traumatically induced physiological disruption of brain function without the presence of structural damage this type of diffuse injury results from a direct Blow To The Head face neck or somewhere else on the body with an impulsive Force that's transmitted to the head unlike more severe traumatic brain injuries concussions do not typically involve detectable structural abnormalities on neuroimaging studies like CT scans or MRIs instead the impact leads to Temporary dysfunction of neuronal activity and metabolic processes in the brain symptoms of concussion can vary widely and may include headache dizziness confusion memory loss and altered Consciousness While most concussion questions are self-limiting and resolved with time and rest it is important to manage these injuries carefully especially in cases of repeated concussions to prevent potential long-term complications and ensure the individual's safe return to normal activities concussions manifest through a range of signs and symptoms that providers carefully assess to gauge the extent of neurological disruption loss of consciousness is a prominent indicator and its duration provides insights into the severity of the concussion additionally patients may experience retrograde amnesia causing a loss of memory for events immediately preceding the injury and anterograde Amnesia impacting memory function for events following the traumatic incident alterations in mental status are common during a concussion with patients reporting feelings of being dazed disoriented irritable drowsy giddy or confused these cognitive and emotional changes are critical in diagnosing and managing concussions effectively focal neurologic deficits which refer to impairments in specific neurological functions are noteworthy it's important to emphasize that if unconsciousness persists for less than 30 minutes and the patient achieves a class galcom scale score of between 13 and 15 focal neurologic deficits may still be present indicating the need for ongoing monitoring and Care a diffuse axonal injury or Dai is a traumatic brain injury that occurs deep within the brain and is characterized by widespread damage to the axons the long projections that allow nerve cells to communicate the mechanism is typically associated with rapid acceleration de acceleration forces often resulting from highed accidents or violent shaking remarkably da accounts for approximately 50% of all primary brain injuries and contributes to 35% of all traumatic brain injury related deaths the severity is graded based on histologic evidence and the location of the damage in Dai grade 1 there's evidence of axonal damage in the white matter of the cerebral hemispheres Corpus colossum brain stem and less commonly the cerebellum grade two involves additional lesions in the Corpus colossum while grade three extends to include lesions in the dorsolateral quadrant of the rostral brain stem mild daai is categorized by a coma lasting from 6 to 24 hours with patients typically beginning to obey commands by 24 hours although death is rare with mild da cognitive and neurological deficits are common in survivors moderate dii is associated with the coma lasting longer than 24 hours but notable brain stem signs are absent patients who survive moderate de often experience an incomplete recovery severe Dei is marked by a contracted coma and the presence of prominent brain stem signs such as decoration cerebration and abnormal respiratory patterns unfortunately individuals with severe dii usually face a grim prognosis with a high likelihood of death or severe disability the grading system for Dai helps clinicians understand the extent of injury and guides appropriate interventions for these challenging",
        "Intracranial Pressure": "cases int cranial pressure in the realm of neurophysiology intracranial pressure or ICP represents the pressure within the skull and its Associated contents in a healthy adult the normal range of ICP is between 5 to 15 mm of mercury it's important to recognize though that ICP is not a static parameter rather it is subject to Dynamic changes influenced by various physiological factors one factor influencing ICP is cardiac syy which involves the contraction of the heart muscle during this phase there is distinction of the intracranial vascular tree contributing to fluctuations in pressure within the cranial cavity additionally respiration a fundamental physiological process exerts a slower change in pressure the act of breathing particularly the expansion and contraction of the chest cavity can influence ICP Dynamics another consideration is the impact of straining and compression of the neck veins changes in pressure within the neck veins can be transmitted to the intracranial compartment affecting ICP this interaction underscores the interconnectedness of various physiological processes in the regulation of intracranial pressure the Monro Kelly Doctrine is a concept in neurology that revolves around the idea that the volume within the skull is relatively fixed and consists of three main components the brain and medulla spinalis including the meninges the blood vessels and blood and the cerebral spinal fluid space according to this Doctrine any expansion of one of these compartments occurs at the expense of the other two the brain in the medulla spine finis surrounded by the meninges constitute a significant portion of the intracranial space Additionally the blood vessels and blood within the cranial cavity along with the CSF space contribute to the overall int cranial volume equilibrium among these compartments is important for maintaining stable intracranial pressure cerebral spinal fluid plays an important role in the doine it is continuously secreted within the brain and after circulating around the brain and spinal cord is absorbed at a rate equal to the rate at which it was produced this Dynamic circulation helps maintain a balance within the intracranial compartments however disruptions in this equilibrium can lead to an increase in ICP for instance obstruction to Venus outflow such as in cases of blood vessel compression or clot formation results in a buildup of blood volume within the intracranial space this increased blood volume contributes to heightened intracranial pressure further emphasizing the interdependence of the three compartments described in the Monro Kelly Doctrine one important aspect of of ICP physiology involves the relationship between ICP and cerebral Venus pressure as ICP increases the cerebral Venus pressure Also Rises typically remaining 2 to 5 millimet of mercury higher than the ICP this phenomenon is essential to prevent the collapse of the Venus system within the brain the cerebral veins responsible for draining blood from the brain need to maintain a pressure gradient relative to the intracranial pressure to ensure efficient blood return to the Heart by keeping the cerebral Venus pressure slightly higher than ICP the veins remain patent and functional preventing Venus collapse that could impede blood flow increased intracranial pressure can result from various physiological changes within the cranial cavity these changes include alterations in cerebral spinal fluid cerebral edema the presence of expandable masses such as tumors and changes in vessel size cerebral blood flow ensures a continuous supply of oxygen and nutrients necessary for proper neural function several key factors contribute to to the regulation and maintenance first cardiac output and oxygen consumption despite accounting for only 2% of total body weight the brain receives a remarkable 15% of resting cardiac output underlining its high metabolic demand second volume of blood utilized the brain utilizes an astonish 1,000 L of blood over a 24-hour period third maintaining constant blood flow cerebral blood flow is carefully regulated to remain constant within a specific range of profusion pressures the auto regulatory mechanisms of the cerebral vasculature ensure that blood flow is maintained between 60 and 150 millimeters of mercury of profusion pressure and fourth the effect of pco2 on cerebral blood flow the partial pressure of carbon dioxide or pco2 has a profound impact on cerebral blood flow even moderate alterations and levels can significantly affect blood flow an increase in pco2 known as hypercapnia causes vasod dilation of cerebral blood vessels leading to an increase in blood flow conversely if one were to decrease the patient's pco2 levels resulting in hypocapnia the result would be Vaso constriction and decrease blood flow this sensitivity to pco2 Highlights the intricate mechanisms that regulate cerebral profusion to maintain an optimal environment for neural function various physiologic factors can influence or alter cerebral blood flow notably conditions such as hypoxia or hypercapnia can lead to an increase in cerebral blood flow while this may initially serve as a compensatory mechanism to enhance oxygen delivery sustained increases in blood flow can contribute to elevated intracranial pressure once normal compensatory mechanisms are exhausted the provider must recognize the delicate balance between optimizing oxygen delivery and avoiding detrimental increases in ICP especially in patients with compromised neurologic function poor Airway management or inadequate ventilation can contribute to hypoxia hypercapnia and hyp hension exacerbating the critical condition of the brain cerebral profusion pressure is determined by the difference between the mean arterial pressure and intracranial pressure expressed as CPP equals map minus ICP in essence cerebral profusion pressure represents the driving force responsible for moving blood through the cerebral vessels the brain possesses a remarkable ability to Auto regulate its blood flow ensuring a relatively constant supply of oxygen and nutrients despite fluctuations in systemic blood pressure Auto regulation involves adjusting the resistance of cerebral blood vessels in response to changes in blood pressure this process allows the brain to maintain a stable cerebral profusion pressure within a certain range typically between 60 and 100 mimers of mercury in order to ensure adequate profusion without causing damage if pressure Falls below the lower limit of Auto regulation cerebral blood flow may become compromised leading to esia and potential neurological deterioration conversely excessively High cerebral profusion pressures May contribute to increased intracranial pressure posing a risk of brain injury the provider must carefully assess and optimize factors influencing cerebral profusion pressure including map and ICP to support adequate cerebral profusion while avoiding complications associated with imbalances of pressure homeostatic mechanisms are often disrupted after head trauma particularly in cases of severe injury for the critical care transport paramedic recognizing and addressing these disruptions is vital for optimizing patient outcomes maintaining an adequate cerebral profusion pressure is associated with reduced mortality in severe head injuries the target for optimal outcome is typically set between 70 and 90 mm of mercury this range mitigates the risk of poor outcomes in patients with increased intracranial pressure a common occurrence after head trauma systemic hypotension defined by a systolic blood pressure less than 90 is strongly associated with a poor prognosis emphasizing the need to address and correct low blood pressure promptly the pathophysiology of increased intracranial pressure revolves around the principle that any change leading to an increase in volume within the confined space of the skull will subsequently Elevate ICP several conditions and events can contribute to this physiological disturbance with some of the most prevalent causes being cerebral hemorrhage tumors hydris and traumatic brain injuries within the intracranial compartment the tissue itself is challenging to manipulate without surgical intervention primarily due to the rigid constraints imposed by the skull consequently any factor that introduces additional volume into this limited space can result in a Cascade of complications related to increased ICP clinically increased ICP is defined as a sustained elevation and pressure above 20 mm of mercury this threshold serves as a critical point of reference for health care providers indicating a situation where the pressure within the cranial Vault has exceeded normal physiological limits Beyond this point the delicate balance within the in cranial space is disrupted potentially leading to a myriad of detrimental effects on cerebral profusion tissue oxygenation and neurological function the human body employs a series of compensatory mechanisms to maintain intracranial pressure within a normal physiological range ensuring the delicate balance within the intracranial compartment these mechanisms help to make changes in volume and pressure preventing undue stress on the delicate brain tissue one of these compensatory mechanisms involves the shunting of cerebral spinal fluid into the spinal subarachnoid Space by redistributing CSF to the spinal sub renoid space the body can mitigate increases in intracranial volume helping to maintain a more stable pressure environment increased cerebral spinal fluid absorption is another compensatory mechanism employed to manage changes in intracranial pressure the absorption occurs primarily through the arachnoid Vil structures responsible for draining excess fluid by enhancing the absorption the body can reduce the volume within the intracranial compartment thereby exerting a compensatory effect on ICP in in addition the body can modulate intracranial pressure by decreasing the production of CSF the choid plexus located within the ventricles of the brain is responsible for CSF production by reducing the rate of production the body can further regulate the overall volume within the inter cranial space contributing to the maintenance of a balanced intracranial pressure furthermore shunting a Venus blood out of the skull is a compensatory mechanism that aids in managing intracranial pressure Venus blood is important for the transport of deoxygenated blood away from the brain by shunting blood away from the cranial Vault the body can influence the overall in cranial volume and pressure Dynamics when intracranial pressure escalates to the point of equaling the arterial pressure a critical Cascade of events known as Cushing's Triad is initiated marking a severe and potentially irreversible condition within the cranial cavity Cushing Triad manifests as a specific combination of physiological responses including an elevation and systolic blood pressure coupled with a simultaneous decrease in diastolic blood pressure accompanied vibr cardia the Triads components serve as indicators of an extreme rise in intracranial pressure suggesting that the delicate balance within the cranial compartment is severely disrupted the increase in systolic blood pressure reflects the body's attempt to maintain profusion pressure in the face of heightened intracranial pressure simultaneously a decline in diastolic blood pressure occurs potentially due to compromise cerebral profusion and impaired Auto regulation mechanisms bardia is another element of Cushing Triad and reflects the body's response to the critical state of intracranial hypertension clinically the Triad is often considered an ominous sign indicating severe brain injury or trauma its presence suggests that the compensatory mechanisms to manage intracranial pressure are overwhelmed and the brain is under significant duress if ICP continues to rise unabated reaching levels equivalent to systemic arterial pressure it can lead to termination of cerebral circulation this cessation of cerebral blood flow if not promptly addressed can result in irreversible brain damage and ultimately brain death in cases where there is an increase in ICP due to factors like intracranial temperature or obstructive hydris the effects may be minimal or even absent this is attributed to the brain being structurally normal and auto regulation remains intact in such instances the gradual onset of increased ICP allows compensatory mechanisms to come into play preventing severe logical consequences conversely compromised cerebral blood flow can occur even with relatively low intracranial pressure especially in the presence of lesions such as tumors hematomas or contusions these lesions can induce brain shifting and disrupt the normal Auto regulatory mechanisms leading to inadequate blood flow and perfusion this emphasizes that the absolute value of ICP is not the sole determinant of cerebral profusion the underlying pathology and its impact on auto regulation are equally crucial the rapid onset of acute hydris poses a unique challenge as it allows minimal time for compens or mechanisms to come into play unlike more gradual increases in ICP acute hydril leads to a swift deterioration as the brain has limited time to adapt the rapid accumulation of Cal spinal fluid in the ventricles or the sectoid space results in increased pressure within the cranium overwhelming the compensatory capacity of the brain as ICP continues to rise there is a risk of herniation as brain structures are displaced from their usual anatomical locations trans tentorial herniation involves the downward displacement of brain structures through the tentorial notch alternatively herniation through the fom Magnum occurs when brain structures are forced to the opening at the base of the skull these can lead to selective compression and esea of the brain stem trans tentorial herniation can result in clinical deterioration even if cerebral blood flow remains adequate this is particularly true in cases where there is Uncle herniation characterized by the displacement of the uncus a part of the temporal lobe across the tentorium a temporal Mass such as a tumor or hematoma they cause Uncle herniation without a significant rise in ICP likewise a frontal Mass can lead to axial Distortion compromising brain stem profusion and contributing to clinical  deterioration the clinical features associated with increased intracranial pressure are commonly encapsulated in Cushing Triad the classic symptoms that include arterial hypertension braic cardia and respiratory changes these alterations in Vital Signs represent the body's attempt to respond to the escalating pressure within the skull arterial hypertension arises as a compensatory mechanism to maintain cerebral profusion while bra cardia reflects the increased pressure on the brain stem triggering a reflexive decrease in heart rate the respiratory changes of observed in the context of increased intracranial pressure depend on the specific level of brain stem involvement if the midbrain is affected Shane Stokes respirations May ensue characterized by a cyclical pattern of gradually increasing and decreasing respiratory rates in cases where both the midbrain and the ponds are involved sustained hyperventilation can also occur when when the upper medulla is affected patients May exhibit rapid and shallow respirations progressing to axic breathing in the final stages beyond the neurological manifestations increased ICP can have repercussions on pulmonary function contributing to conditions such as pulmonary edema the physiological interplay between intracranial and systemic pressures may lead to fluid shifts and compromise the Integrity of the blood brain barrier allowing for the development of pulmonary edema this pulmonary involvement underscores the systemic impact of elevated ICP with potential consequences extending beyond the confines of the central nervous system a comprehensive Baseline monitoring setup is essential for managed patients with severe brain injuries this includes continuous monitoring of oxygen saturation electrocardiography mean arterial pressure intital carbon dioxide Central Venus pressure and urine output monitoring ICP in blood pressure is Paramount as it provides the most reliable means of determining cerebral profusion pressure as stated before c DPP is calculated as a difference between map and ICP and as a critical parameter in assessing cerebral blood flow for patients with severe brain injuries maintaining an optimal CPP is essential to prevent cerebral hypo profusion in cases where standard methods alone may be insufficient to maintain ICP and CPP within the desired range multimodality monitoring becomes crucial this Advanced approach involves the incorporation of additional parameters such as jugular Venus oxygen saturation brain tissue oxygen tension and transcranial Doppler ultrasonography jugular Venus oxygen saturation provides insights into the balance between cerebral oxygen supply and demand while brain tissue oxygen tension directly measures brain tissue oxygen levels lastly transcranial Doppler allows real-time assessment of cerebral blood flow velocity in critical care settings the decision to monitor intracranial pressure is based on specific indications that reflect the potential risk and severity of neurological will compromise the following indications highlight scenarios in which ICP monitoring is particularly warranted severe traumatic brain injury patients with severe TBI are at a heightened risk of elevated ICP due to the trauma-induced disruption of normal in cranial Dynamics monitoring in these cases allows for timely intervention to prevent secondary brain brain injury and optimize cerebral profusion intracranial hemorrhage patients with intracranial hemorrhage whether it be subarachnoid subdural or epidural are prone to increase ICP monitoring becomes essential to gauge the impact of bleeding on intracranial Dynamics and guide interventions to mitigate further damage cerebral edema conditions leading to cerebral edema such as severe head injuries es schic Strokes or inflammatory processes can result in increased ICP monitoring provides critical information for managing these patients and avoiding complications associated with elevated pressure prior craniotomy individuals with the history of craniotomy may be monitored for ICP especially if there is a concern concern about post-operative complications recurrent bleeding or edema that could compromise neurological function space occupying lesions various space occupying lesions including epidural and subdural hematomas tumors abscesses or aneurysms that obstruct the CSF pathway can lead to an increase in ICP continuous monitoring helps assess the impact of these lesions on in cranial Dynamics Ray syndrome patients with Ray syndrome who develop coma abnormal posturing and atypical responses to stimuli May benefit from ICP monitoring to manage the neurological aspects of this rare but serious condition in cyop from from lead ingestion hypertensive crisis or hepatic failure conditions causing incopy such as lead ingestion hypertensive crisis or hepatic failure can contribute to increased ICP monitoring is crucial for assessing the neurological impact and guiding appropriate interventions menitis or incilius inflammatory conditions affecting the meninges and brain may result in the malabsorption of CSF leading to an increase in ICP monitoring assists in managing these cases and preventing complications associated with elevated pressure Glascow Coma Scale score of less than eight or a positive CT patient patients with a GCS score below eight or positive findings on a CT scan indicative of brain hemorrhage or conditions predisposing to Hemorrhage are candidates for ICP monitoring this helps in tailoring interventions based on real-time assessment of intracranial Dynamics while intracranial pressure monitoring is a valuable tool in managing certain neurological conditions there are contraindications that need to be considered to ensure patient safety and prevent potential complications the following are contraindications to ICP monitoring CNS infection patients with an active infection such as menitis or en sephtis pose a risk of introducing pathogens into the intracranial space during the insertion of monitoring devices infection control is a priority and the risk of exacerbating the infection May outweigh the benefits of ICP monitoring coagulation defects individuals with coagulation defects or disorders are at an increased risk of bleeding complications associated with the insertion of ICP monitoring devices coagulation defects can Le to uncontrolled bleeding hematoma formation and compromise the safety of the procedure coagulopathy similar to coagulation defects patients with coagulopathy whether due to underlying medical conditions or medications affecting clotting factors are at an elevated risk of bleeding complications during ICP monitoring the potential for uncontrolled bleeding May out outweigh the benefits in these cases scalp infection active infection of the scalp including skin and soft tissues at the insertion site is a contraindication for ICP monitoring inserting monitoring devices through infected tissue can introduce pathogens into the intracranial space leading to serious complications severe midline shift resulting in ventricular displacement in cases where there is severe midline shift with displacement of the ventricles the anatomy may be distorted to the extent that safe insertion of the monitoring device becomes challenging attempting the procedure under such circumstances May pose risk of injury to the surrounding structures cerebral edema resulting in ventricular collapse in situations where cerebral edema is severe and leads to ventricular collapse the normal anatomical landmarks may be altered inserting monitoring devices under these conditions may not only be technically challenging but could also pose a risk of misplacement or damage to structures in cranial pressure monitoring is a viable tool in the management of various neurological conditions but like any medical intervention it comes with potential complications that healthc care providers must be vigilant about the following are some complications associated with ICP monitoring one of the most significant complications is the risk of intracranial infection the insertion of monitoring devices creates a potential pathway way for pathogens to enter the intracranial space leading to infections such as menitis strict adherence to aseptic techniques during the procedure will minimize this risk the insertion of monitoring devices can cause trauma to blood vessels potentially resulting in intracerebral Hemorrhage this complication can lead to additional neurological damage and compromise the patient's overall condition accidental introduction of air into the ventricles or subarachnoid space during the insertion process can also lead to complications air embolisms in these areas will disrupt normal cerebral blood flow and contribute to neurological dysfunction improper placement or damage to the monitoring device can cause leakage of CSF this may lead to complic ation such as persistent cerebral spinal fluid drainage risking infection and altering intracranial Dynamics in some cases overd drainage of CSF may occur leading to ventricular collapse and herniation this complication can be a consequence of mismanagement of the drainage system or inadequate monitoring of CSF Dynamics the catheter used for ICP monitoring may become uded with brain tissue or blood compromising the accuracy of pressure findings regular monitoring and appropriate maintenance of the system are essential to prevent this complication technical issues such as dampened waveforms electromechanical failure or operator error can lead to inaccurate ICP readings misinterpretation of these readings may result in inappropriate therapeutic interventions or a delayed response to genuine changes in intracranial Dynamics non-invasive methods for assessing ICP involve clinical evaluation without direct penetration of the intracranial space Healthcare Providers monitor for signs and symptoms of increased ICP including changes in mental status Headache nausea vomiting and alterations in Vital Signs Imaging studies such as CT scans can provide indirect evidence of elevated ICP while noninvasive this approach lacks the Precision and immediacy of quantitative measurements invasive methods offer a more direct cor and quantitative assessment of ICP providing real-time data for prompt intervention two commonly used devices are the intraventricular catheter or IVC and the subarachnoid screw the IVC involves the insertion of a catheter into the ventricles of the brain this allows for direct measurement of ICP and the potential for CSF drainage the C ceter is connected to an external monitoring system enabling continuous monitoring of ICP fluctuations the subarachnoid screw is another invasive method that involves placing a screw into the subarachnoid space like the IVC this method provides direct measurements of ICP the screw is attached to a transducer allowing continuous monitoring and real-time assessment of intracranial Dynamics there are several advantages of using an IVC one significant advantage of using an IVC is the ability to drain cerebral spinal fluid providing a therapeutic option to lower elevated ICP which helps manage conditions such as traumatic brain injury hydris or cerebral edema the IVC allows for the collection of cfsf samples facilitating the assessment of potential infections within the central nervous system the direct placement of the catheter into the ventricles of the brain provides a more accurate and immediate measurement of ICP allowing providers to promptly respond to changes optimizing patient care additionally ivcs are known for their accuracy and reliability in continuously monitoring ICP there are risks however one of the primary risks associated with IVC is the potential for infection strict aseptic techniques during insertion and maintenance are important to mitigate this risk insertion of the IVC poses a risk of injury to the brain tissues themselves which is why careful placement by skilled healthc Care Professionals is essential the presence of the catheter in the ventricles can contribute to clot formation increasing the risk of thrombotic events regular monitoring and appropriate anti-coagulation measures should be implemented to prevent this complication the insertion of the catheter may lead to Hemorrhage particularly if there is vascular compromise or fragility the provider should monitor for signs of bleeding Ing and ensure proper homeostasis during the procedure CSF drainage while beneficial in reducing ICP can lead to the collapse of ventricles therefore monitoring the volume of drained CSF is critical to prevent excessive drainage and subsequent ventricular collapse placement of an IVC may be technically challenging or even impossible in certain cases especially when there is ventricular compression due to trauma or cerebral edema this limitation emphasizes the importance of considering alternative monitoring methods based on individual patient conditions intrarenal devices offer a lower risk of infection or Hemorrhage less than 1% compared to intraventricular catheters or or ivc's however they do not allow for CSF drainage limiting their therapeutic capabilities the accuracy of these devices tends to drift over time since they cannot be recalibrated after insertion this may necessitate periodic adjustments to maintain reliability the complex design of these devices increases the risk of failure their intricate structure May be susceptible to malfunctions emphasizing the need for careful monitoring and maintenance epidural catheters offer advantages such as decreased rate of infection compared to ivc's and a lower risk of brain injury during placement while they do have their benefits they cannot be used for CSF drainage additionally their measurements may be less reliable in comparison as they are often and less accurate and their use may require careful consideration of their limitations subarachnoid screws and bolts are less invasive than ivc's resulting in a lower rate of infection they also cause less injury to the brain during placement and are easier to insert however they too have their limitations as they provide less accurate monitoring cannot be used for drainage and require a closed intact skull for proper functioning additionally subarachnoid screws and vaults may be prone to becoming clogged with debris rendering their readings unreliable over time fiber optic transducer tip probes provide an alternative method for ICP monitoring utilizing fiber optic technology for accurate measurements devices such as cardio search pneumatic sensors and electronic devices offer mechanically coupled surface monitoring of ICP the Amaya Reservoir a fluid filed catheter connected to an arterial pressure monitoring system and the lad device are additional ICP monitoring options with specific applications each ICP monitoring device comes with its set of advantages and limitations requiring careful consideration based on the clinical context and patient characteristics the ICP wave form serves as a valuable tool for clinicians offering insights into cerebral hemodynamics and potential pathology typically exhibiting an amplitude of 1 to 4 mm of mercury the ICP waveform mirrors the arterial pulse in a healthy waveform three distinct Peaks P1 P2 and P3 are observed with P2 having a smaller amplitude than P1 an altered waveform where P2 surpasses P1 signifies reduced intracranial compliance the dichroic wave or P3 indicates pressure transmitted through the Venus system from aortic valve closure its occurrence aligns with the dicrotic notch on an arterial pulse waveform a keen understanding of these waveform features is important for clinicians in interpreting ICP data pathologic changes in the ICP waveform service indicators as the ICP arises the waveform amplitude increases in more advanced stages P2 amplitude surpasses P1 and P3 becoming the dominant wave lunberg a waves marked by sharp ICP spikes lasting 5 to 10 minutes are associated with cerebral esea and impending herniation lunberg B waves rhythmic elevations lasting 1 to two minutes suggest ongoing cerebral injury and a gradual rise in Baseline ICP notably these pathologic changes May precede a significant elevation in average ICP therefore a proactive approach to management is facilitated by close attention to the ICP waveform enabling timely interventions clinicians must be Adept at recognizing these waveform patterns to tailor intervention itions and mitigate potential complications emphasizing the importance of continuous ICP waveform monitoring in neurocritical care settings performing intracranial pressure monitoring is a critical aspect of neurocritical care requiring specialized equipment and a meticulous approach to ensure accuracy and patient safety the following equipment is essential for the procedure external drainage system with mounting card this system serves as the interface between the patient and the monitoring equipment it includes the catheter which is inserted into the interc cranial space and a mounting card to secure and stabilize the catheter pressure transducer with a 48 in pressure tubing the pressure transducer is a key component component that converts the pressure exerted on the catheter into an electrical signal the 48 in pressure tubing facilitates the connection between the transducer and the catheter sterile sodium chloride with sterile 20 ml syringe sterile saline is used to calibrate the pressure inducer and ensure accurate pressure readings the syringe is employed in this calibr process pressure monitoring cable this cable connects the pressure transducer to the monitoring system allowing real-time visualization of intracranial pressure IV tubing IV tubing is utilized to connect the external drainage system to the pressure transducer and monitoring system manual resuscitator mask and 100% oxygen source these are essential for maintaining oxygenation and ventilation during the procedure ensuring adequate oxygen supply is crucial for patients undergoing ICP monitoring cardiopulmonary monitor this monitor provides continuous tracking of the patient's Vital Signs including heart rate blood pressure and oxygen saturation offering comprehensive data during the monitoring process body substance isolation compliant attire infection control is Paramount during any invasive procedure healthc Care Professionals performing ICP monitoring must adhere to body surface isolation protocols including wearing appropriate protective attire such as gloves gowns and masks intracranial pressure monitoring is a delicate procedure that demands strict adherence to precautions to safeguard both the patient and the accuracy of the measurements here are key precautions to consider aseptic technique is Paramount during ICP monitoring to minimize the risk of infections providers must rigorously follow sterile procedures when handling both the patient and the monitoring equipment accurate ICP readings depend on the proper leveling and zeroing of the monitoring equipment ensuring that the equipment is correctly positioned at the level of the patient's skull and zeroed appropriately is crucial any deviation from this could lead to inaccuracies in pressure readings when positioning and turning the patient utmost care must be exercised to prevent accidental de de canulation or disconnection of the tubing the catheter must remain securely in place to maintain the Integrity of the ICP monitoring system Additionally the risk of complications such as bleeding or infection can be minimized through gentle handling of the patient to prevent an increase in ICP providers should refrain from inducing flexation and hyperextension of the patient's neck during monitoring these movements can potentially exacerbate intracranial pressure and the patient should be positioned in a manner that minimizes stress on the cervical spine activating the high ICP alarm is a critical precautionary measure as this alarm serves as an early warning system alerting providers to any significant in increase in pressure that could be detrimental to the patient the ICP monitoring system incorporates a filter to safeguard against contamination it's imperative to prevent the filter from becoming wet as moisture can compromise its Effectiveness wet filters May impede the accurate transmission of pressure signals and potentially lead to erroneous readings when conducting pressure monitor ing ensure that the stopcock to the drainage system is closed this precaution prevents unintended drainage of CSF during the monitoring process maintaining the stability of pressure ratings if CSF drainage is deemed necessary providers must adhere to strict limit to prevent excessive fluid laws training only a small amount of CSF not to exceed 3 MLS at at a time this restriction helps maintain the delicate balance of intracranial volume and pressure while preventing potential complications associated with excessive CSF removal effective management of adverse reactions during ICP monitoring is Paramount to ensure patient safety and reliability of the recorded data providers should be vigilant in recognizing potential issues and implementing timely interventions if blood is observed in the pressure tubing promptly notify the physician as the presence of blood May indicate vascular injury or other complication necessitating immediate attention and potential adjustments to the monitoring system if a satisfactory waveform or accurate ICP reading cannot be obtained a systematic approach is necessary flushing the monitoring system can help address potential obstructions or issues hindering the proper signal transmission this intervention aims to optimize the system's functionality and enhance the accuracy of ICP measurements an acutely low ICP May signal acute decomposition often associated with CSF leakage or overd drain AG notify the physician when such a scenario is identified addressing the cause of the decompression is crucial to prevent further complications and ensure appropriate Management in the event of acute decompensation characterized by sustained ICP levels greater or equal to 15 millim of mercury hyperventilation may be considered as an initial intervention this is because hyperventilation helps reduce ICP by inducing Vaso constriction and decreasing cerebral blood flow however this intervention should be used judiciously and the physician should be notified immediately to guide further Management in the realm of neurocritical care the focus on cerebral blood flow and oxygen content of the blood is Paramount emphasizing the need for advanced monitoring techniques multimodality monitoring emerges as a comprehensive approach delving into various parameters to gain a nuanced understanding of cerebral circulation and oxygen utilization Central to this approach is the assessment of the oxygen extraction fraction or OE a critical metric that gain enges the amount of oxygen available to support essential brain functions the thick principle employed to determine cardiac output underlies the equilibrium between oxygen uptake through the lungs and the concentration difference between mixed Venus and arterial blood multimodality monitoring incorporates a combination of sophisticated Technologies including jugular Venus bul oxm brain tissue oxygen tension assessment and transcranial Doppler ultrasonography this integration allows clinicians to glean insights into cerebral circulation and oxygen consumption providing a comprehensive picture of neurophysiological Dynamics it is important to note that while these monitoring techniques assess oxygen delivery and extraction by the brain none directly measure cerebral activity for a more holistic evaluation of brain function cerebral function monitors and cerebral function analysis monitors come into play offering summed averaged and analyzed outputs that contribute to understanding the General State of brain activity in the context of severe traumatic brain injury standard monitoring protocol include assessing oxygen saturation ECG map and urine output in situations where continuous entitle carbon dioxide monitoring faces limitations the inclusion of an intraarterial catheter becomes imperative for determining arterial blood gases effectively managing increased intracranial pressure demands a nuanced approach that addresses the root cause while ensuring optimal patient care the primary intervention revolves around the removal of the causative lesion underscoring the critical role of identifying and treating underlying pathologies debates persist within the medical community regarding whether increased ICP is the cause or consequence of brain damage emphasizing the intricate relationship between two phenomena stratifying treatment into first line and second line approaches allows for a systematic and comprehensive response to this complex clinical scenario firstline management involves General measures aimed at ensuring patient comfort and addressing trauma Management's foundational aspects encapsulated by the ABCs on the other hand second line management Ventures into induced cerebral Vaso constriction strategies this includes interventions such as hyperventilation hyperosmolar therapy administration of barbituates or corticosteroids surgical interventions and therapies like hyperbaric oxygen and hypothermia Within These therapeutic options specific measures may play pivotal roles maintaining the elevation of the head of the stretcher at a 30 to 45\u00b0 angle and aligning the patient's head and neck in a neutral position contribute to optimizing cerebral profusion intubation and mechanical ventilation become important components of the strategy to manage respiratory parameters effectively consideration of osmotic diuretics such as administering hyperosmolar agents A AIDS in reducing cerebral edema anti-inflammatory agents like dexamethasone or methanol predone may be employed to control inflammation and swelling systolic pressures are carefully regulated to stay below 150 millim of mercury to prevent the exacerbation of ICP in cases where a surgical drain is in place cerebral spinal fluid damage becomes a targeted intervention if ICP surpasses 20 mm of mercury for patients with intracranial hemorrhage especially those on anti-coagulants like aarin the administration of plasma or platelets in route becomes a critical consideration to mitigate the risk of",
        "Brain Herniation": "bleeding brain herniation brain herniation stands as a critical manifestation of increased inter cranial pressure where a segment of the brain undergos displacement due to heightened pressure within the cranial Vault this phenomenon is frequently associated with brain swelling also known as cerebral edema The increased pressure within the closed comines of the skull forces a portion of the brain to move from its normal position leading to potentially severe consequences while head injuries are a prevalent cause of brain herniation other underlying factors can contribute to this condition hemorrhagic stroke characterized by bleeding within the brain and the presence of space occupying lesions such as brain tumors are among the diverse etiologies that can lead to brain herniation in these cases the added mass or the impact of bleeding exacerbates intracranial pressure triggering the displacement of brain tissue brain herniation manifests in various forms each carrying significant implications for patient outcomes among the most common types is Uncle herniation where a portion of the temporal lobe displaces through the the tentorium a structure within the brain Uncle herniation leads to a state of coma and respiratory arrest emphasizing the critical nature of this neurological emergency tons herniation represents another pivotal subtype of brain herniation characterized by the displacement of part of the cerebellum through the fan Magnum this displacement exerts pressure on the brain stem resulting in the compromise of vital functions this in turn leads to apnea decreased profusion and ultimately death from a transport perspective the management of brain herniation involves a multi-dimensional approach key interventions include the intubation of the patient and the utilization of mechanical ventilation with the focus on hyperventilation to maintain carbon dioxide levels within a specific range typically 25 to 35 millim of mercury osmotic diuretics like manitol also play a role in reducing cerebral edema while corticosteroids such as dexamethasone may be administered particularly in cases involving brain tumors rapid transport to a Neurosurgical facility is imperative underscoring the urgency and complexity of managing brain herniation to optimize patient",
        "Spinal Cord Injuries": "outcomes spinal cord injuries flexation extension injuries a significant category within the spectrum of spinal cord injuries are typically triggered by rapid de acceleration or a direct blow to the oxop put these injuries primarily involve the cervical region with the potential for concurrent damage to the spinal cord due to compression within the spinal canal the mechanism involves hyperextension of the head and neck leading to a range of traumatic outcomes including fractures and ligamentous injuries the vul unability of specific spinal levels is noteworthy with the C5 C6 level being particularly susceptible to flexation extension injuries this susceptibility is attributed to the biomechanics of the cervical spine and the distribution of forces during traumatic incidents the intricate interplay between flexation and extension forces in the cervical region underscores the potential for damage to the spinal cord ligaments and supporting structures clinically flexation extension injuries pose unique challenges in terms of diagnosis treatment and Rehabilitation management strategies should Encompass a thorough understanding of the injury mechanism enabling providers to tailor interventions that address the specific nuances of flexation extension injuries and mitigate their impact on spinal cord function and overall patient well-being vertical compression injuries a distinct class of traumatic incidents arise from either a direct blow to the crown or rapid de acceleration typically occurring when an individual falls through the feet legs and pelvis these injuries exhibit a predilection for the thoro lumbar Junction indicating a region commonly affected during such traumatic events in the context of Falls the lower cervical spine frequently becomes involved in vertical compression injuries this involvement results from the transmission of axial loads along the vertebral column creating a Cascade of forces that impact the lower cervical spine the dynamic interplay of biomechanical forces during vertical compression contributes to the complexity of these injuries influencing the specific patterns of damage observed in the cervical spine understanding the mechanism of vertical compression injuries is Paramount for accurate diagnosis effective treatment and comprehensive rehabilitation providers must consider the distinct characteristics of injuries resulting from direct blows to the crown versus rapid de acceleration tailoring their approach to address the intricacies of each scenario rotation flexation injuries represent a distinctive class of trauma that predominantly manifests in the thoro lumbar interface these injuries typically result from a combination of rotational and flexation forces acting on the spine in the context of rotation and flexation injuries the thoro lumbar Junction becomes a critical focal point the interplay of rotational and flexation forces in this region can induce complex patterns of damage to the vertebral column depending on the severity and direction of these forces the spine May sustain staple fractures where the spine Integrity is preserved despite the injury or unstable fractures and dislocations where the structural stability of the spine is compromised the clinical implications of rotation flexation injuries underscore the importance of accurate diagnosis and appropriate management providers must carefully assess the extent and nature of the injury considering factors as such as stability and Alignment this detailed evaluation informs treatment strategies ranging from conservative measures for stable fractures to more aggressive interventions such as surgical stabilization for unstable fractures and dislocations primary spinal cord injury is a direct outcome of the initial trauma experienced by the spinal cord encompassing a spectrum of injuries resulting from both penetrating and blunt mechanisms penetrating trauma poses a unique set of challenges as it can lead to either a trans section of neural elements or cause concussive injury to the spinal cord in cases of penetrating trauma the severity of injury can vary manifesting as either complete or incomplete injuries based on the extent of neuro disruption blunt trauma on the other hand induces primary spinal cord injury through a different set of mechanisms it may involve the displacement of ligaments in bone fragments leading to the compression of specific points along the spinal cord this compression can result in an incomplete dislocation of the vertebral body further contributing to the complexity of primary spinal cord injury the consequences of blunt trauma on the spinal cord are multifaceted involving structural damage inflammation and disruption of neural pathways in the intricate landscape of primary spinal cord injury hypo profusion and esema emerge as critical factors particularly when the spine vasculature succumbs to the trauma this type of injury often triggers the Cascade of events compromising the blood supply to the spinal cord hypoperfusion characterized by inadequate blood flow and eskee contributes significantly to the overall damage sustained during primary spinal cord injury contusions represent another facet of primary spinal cord injury pathology arising from various traumatic scenarios fractures dislocations or direct trauma inflict contusions on the spinal cord creating localized areas of bruising and tissue damage these contusions not only disrupt the structural Integrity of the spinal cord but also set the stage for secondary complications that may exacerbate the initial injury cord laceration occurs when a penetrating Force such as a projectile or bone fragment enters the spinal cord this intrusive event results in the tearing and laceration of neural tissues introducing a unique set of challenges in terms of diagnosis and management secondary spinal cord injury unfolds as a consequential progression stemming from the initial trauma introducing a multifaceted challenge in the realm of spinal cord care following the primary spinal cord injury a Cascade of inflammatory responses is set in motion contributing to the amplification of tissue damage and neurological compromise this secondary phase of injury represents a critical juncture in the clinical trajectory demanding careful consideration and targeted interventions to mitigate further deterioration the inflammatory response is triggered by the primary spinal cord injury can lead to various deleterious effects including edema oxidative stress and immune Cell Activation edema characterized by the accumulation of fluid in the spinal cord tissues exacerbates the compression and impairs blood flow oxidative stress adds another layer of complexity as reactive oxygen species contribute to Cellular damage and hinder the regenerative capacities of neural tissues immune Cell Activation while integral to the body's defense mechanisms May inadvertently intensify inflammation within the already compromised spinal cord while some aspects of secondary spinal cord injury may be inevitable providers play a pivotal role in minimizing further injury through effective stabilization measures spinal motion restriction and maintaining neural alignment become key elements in the early care of individuals with spinal cord injury in the realm of secondary care specific imperatives revolve around minimizing heat loss and M maintaining optimal oxygenation the delicate balance of these factors AIDS in creating an environment conducive to healing and Recovery effective management during the secondary phase involves not only addressing the immediate consequences of inflamation but also laying the groundwork for a comprehensive rehabilitation strategy aimed at optimizing long-term outcomes for individuals navigating the complexities of secondary spinal cord injury within the intricate landscape a spinal cord injuries the classification into complete and incomplete injuries serves as a crucial determinant of the ensuing clinical picture and prognostic implications a complete spinal cord injury represents a profound and comprehensive disruption where all tracks of the spinal cord face a total severance the consequence is a stark absence of sensory and motor function more than three segments below the designated level of injury the Hallmark of a complete spinal cord injury lies in its unequivocal and encompassing impact on neural Pathways this comprehensive disruption translates into a profound loss leaving no room for residual function beyond the demarcated three segment threshold this categorization underscores the severity of the injury reflecting a scenario where the spinal cords integrative functions are abruptly and entirely halted complete spinal cord injuries often manifest with an absence of voluntary motor function and sensory perception below the injury site the neurological deficit is not only extensive but also pervasive emphasizing the global impact on the spinal cords intricate Network Rehabilitation and management strategies for complete spinal cord injuries necessitate a nuanced approach acknowledging the formidable challenges posed by the absence of residual function and the imperative to optimize the individual's quality of life Within These constraints incomplete spinal cord injuries constitute a dynamic landscape within the realm of neurological trauma presenting a spectrum of retained function below the level of injury in such cases patients retain some degree of core mediated function beyond the demarcated three segment threshold opening avenues for potential recovery and Rehabilitation the diverse manifestations of incomplete spinal cord injuries are classified in into several syndromes each with distinct etiologies and clinical presentations interior cord syndrome unfolds as a consequence of bony fragments displacing into the anterior portion of the spinal cord typically arising from flexation injuries or fractures this syndrome underscores the vulnerability of the spinal cord to Mechanical insults leading to a specific pattern of neurological deficits in contrast Central cord syndrome emerges from hyperextension injuries from the cervical area resulting in Hemorrhage or edema within the central cervical segments this syndrome presents a unique challenge as the impact is concentrated in the central region of the spinal cord contributing to a distinct clinical picture characterized by a specific set of sensory and motor deficits Brown scard syndrome is the outcome of penetrating trauma accompanied by hemisection of the cord this results in complete damage to all spinal tracts on the involved side delineating A syndrome with a clinical manifestations reflect the specific anatomy and functional roles of the separate tract finally posterior cord syndrome associated with extension injuries highlights the susceptibility of the spinal cord to trauma in distinct orientations this syndrome underscores the intricate interplay between injury mechanisms and resultant neurological deficits emphasizing the need for a nuanced understanding to guide tailored therapeutic approaches the exploration of incomplete spinal cord injuries and their various syndromes not only enriches our comprehension of spinal cord pathology but also informs the development of targeted interventions to optimize recovery and improve the quality of life for individuals navigating the intricate terrain of incomplete spinal cord injuries in the aftermath of spinal trauma the body grapples with a Cascade of neurologic responses that give rise to distinct conditions namely spinal shock and neurogenic shock spinal shock manifests as a temporary impairment of reflex arcs at and below the sight of the spinal injury this phase is characterized by a spectrum of neurologic deficits ranging from flaccid paralysis and and sphincter to absent reflexes sensory function below the level of injury is compromised during this acute stage contributing to the complex clinical presentation neurogenic shock on the other hand ensues from the transient loss of sympathetic tone at and below the level of the spinal injury the ensuing unbridled parasympathetic stimulation precipitates profound cardiovascular repercussions marking a distinctive clinical Triad this Triad comprises hypotension ricardia and skim that is warm and flushed the hemodynamic and systemic effects are consequential underscoring the intricate interplay between the sympathetic and parasympathetic divisions of the autonomic nervous system when faced with a potential spinal cord injury the provider plays a pivotal role in conducting a meticulous assessment to guide subsequent care a thorough neurologic examination is indispensable during the initial assessment and before embarking on the Journey of Transportation this examination entails a systematic evaluation of sensory and motor functions reflexes and any discernable signs of neurologic compromise this comprehensive approach ensures that the provider captures a nuanced understanding of the extent and nature of the spinal trauma laying the foundation for tailored interventions visual scrutiny of the neck is a step in the assessment process the provider meticulously inspects for any deformities that may signify spinal trauma and the hands are employed to palpate the region Discerning the presence of crepitus or eliciting signs of pain this Keen observation AIDS in identifying potential cervical spine injuries and contributes to the overall assessment of the patient's condition prior to initiating transport a judicious evaluation of the airway assumes Paramount importance given the intricate relationship between spinal injuries and compromised Airway management assessing for any impediments or challenges is vital the critical care transport paramedic ensures the Airways Integrity taking preemptive measures to address any identified issues and guaranteeing a secure pathway for ventilation during Transportation assessing the patient's back adds another layer of diagnostic Insight the provider conducts a systematic evaluation for tenderness and deformity seeking indicators that may further elucidate the nature and extent of the spinal trauma this examination is fundamental in identifying potential fractures dislocations or other injuries to the spinal column contributing to a comprehensive understanding of the patient's condition in the nuanced landscape of spinal cord injury assessment the critical care transport provider delves into additional layers of scrutiny to unravel the intricacies of the patient's condition the palpation of the spine becomes a pivotal step in this comprehensive evaluation aiming to uncover subtle signs of injury that may elude casual observation the provider systematically explores the spine Discerning areas of tenderness and deformity that may serve as point poent indicators of underlying trauma this tactile examination contributes valuable data to the overall assessment forming a mosaic that informs subsequent interventions and care strategies assessment of neurologic function extends beyond the immediate visual inspection in palpation encompassing a meticulous evaluation of the patient's strength in both upper and lower extremities and the presence of sensation this Hands-On examination serves as a dynamic component of the overall neurologic assessment offering insights into the Integrity of motor pathways and sensory responsiveness the critical care transport paramedic systematically engages with the patient gauging their ability to generate force and perceive stimuli thereby painting a more intricate portrait of the neural NE ologic status as the provider embarks on the Journey of transporting a patient with a spinal cord injury the commitment to ongoing assessment remains unwavering this vigilance is particularly directed towards pulse motor and sensory function continuous monitoring of these vital parameters allows the provider to detect any Dynamic changes in the patient's condition facilitating prompt inter ventions in response to evolving neurologic status this Dynamic approach ensures the transport team remains attuned to the patient's physiologic responses creating a responsive and adaptive framework for the Continuum of Care during transit in navigating the complexities of spinal cord injury assessment the provider armed with a systematic and thorough approach strives to uncover the subtleties of spinal trauma the integration of palpation neurologic function assessment and ongoing vigilance establishes a robust foundation for tailored interventions and patient Centric Care throughout the critical transport journey in the management of spinal cord injury the critical care transport professional must provide rapid in comprehensive interventions the inherent urgency of these injuries propels the provider to swiftly initiate a multifaceted approach aimed at assessment treatment and ultimately transportation to the most suitable medical facility this effort operates within the framework of maintaining spinal motion restriction recognizing its critical role in preventing an exacerbation of spinal trauma trauma as the patient is transitioned into the transport setting the provider meticulously tailers their approach to minimize movement recognizing the importance of preventing further injury this conscientious execution involves employing specialized techniques and equipment to ensure that the patient spine remains stable throughout the journey the commitment to spinal motion restriction extends beyond the procedural mandate it embodies a profound understanding of the delicate balance between urgency and Precision in spinal cord injury management simultaneously the provider casts a Vigilant eye on the patient's hemodynamic parameters identifying and aggressively managing hypotension and hypoxia this proactive stance is not merely a response to immediate threats but a strategic Endeavor to prevent anoxic injury to the spinal cord recognizing the relationship between systemic profusion and spinal cord Integrity the provider strives to maintain optimal oxygenation and blood pressure mitigating the risk of secondary damage and fostering an environment conducive to neurologic Recovery in the management of spinal cord injury the critical care transport provider utilizes set priorities aimed at Swift intervention and optimal stabilization foremost among these priorities is the rapid identification and correction of life-threatening problems a foundational step that sets the stage for subsequent interventions the management of the airway assumes particular prominence especially in cases involving higher level cervical fractures here the provider employs a strategic and Vigilant approach to secure and manage the airway effectively recognizing its role in ensuring adequate oxygenation and preventing further complications this emphasis on Airway management underscores the provider's commitment to addressing the unique challenges posed by these types of injuries where respiratory compromise can have profound implications for patient outcomes additionally continuous monitoring of blood pressure is essential whether through non-invasive means or the implementation of arterial lines during transport the provider remains Vigilant serving as a sentinel for hypotension this realtime monitoring allows for prompt and targeted interventions aligning with the overarching goal of optimizing profusion and minimizing secondary injury in the realm of fluid resuscitation the provider should execute a judicious and tailored approach for patients with multiple injuries the administration of appropriate intravenous fluids and blood component therapy is orchestrated with Precision recognizing the delicate balance between volume resuscitation and potential complications this multifaceted strategy aligns with the provider's commitment to holistic patient care acknowledging the inner connectic nature of injuries and the need for comprehensive resuscitative measures recognizing the impact of temperature on patient outcomes the providers should extend their focus to temperature control for those requiring monitoring to maintain normothermia this will involve the provision of warm intravenous fluids blankets and other temperature regulating measures by addressing the multifactoral aspects of spinal cord injury management the critical care transport professional Endeavors to create an environment conducive for optimal recovery encapsulating the essence of their role in the critical care continuum in the realm of pharmacotherapy for spinal cord injuries the provider employs a nuanced approach to address the multifaceted needs of the patient IV opiates emerge as valuable allies in managing the complex pain Dynamics associated with Transportation movement and the injury itself fentel a short acting synthetic opiate assumes a prominent role characterized by its efficacy in pain management coupled with a lesser impact on blood pressure as a firstline therapy fitel becomes a Cornerstone in the provider's Arsenal strategically deployed to alleviate pain while minimizing potential hemodynamic effects following the establishment of pain control and the exclusion of hypoxia the provider judiciously integrates sedative into the regimen versed or Adavan offer a delicate balance between effective sedation and the imperative to maintain respiratory stability this approach underscores the provider's commitment for patient safety and the meticulous titration of pharmacological interventions a paradigm shift in the use of corticosteroids marks a pivotal point in in spinal cord injury pharmacotherapy the once common practice of employing corticosteroids in the acute phase of injury has been reassessed and is now no longer recommended this reflects a dynamic nature of medical knowledge and the provider's dedication to evidence-based practices neurogenic shock a potential complication introduces the need for vasoactive medications to support blood pressure the provider should manage this challenge by incorporating targeted pharmacological interventions tailored to the unique hemodynamic considerations of each patient Additionally the nuan nature of neurogenic shock may be accompanied by braic cardia prompting the use of atropine to bolster heart rate in blood pressure there are often complications when dealing with spinal cord injuries necessitating Vigilant monitoring and ProActive Management by the provider in the acute phase the risk of aspiration or respiratory rest is significant underlying the imperative of closely attending to Airway integrity and respiratory function Swift and effective interventions are Paramount in mitigating these risks you mobilization a common facet of management brings its own set of challenges with deep vein thrombosis and Pulmonary embolism emerging as potential life-threatening complications the provider should be cognizant of the heightened risk associated with immobility employing preventative measures and Keen surveillance to detect and address these vascular complications promptly pressure ulcers another significant CERN in the acute phase underscore the importance of meticulous patient care immobility places individuals with spinal cord injury at an increased risk of developing these skin lesions emphasizing the need for the provider to implement preventive measures such as frequent repositioning and skin inspections to mitigate this potential complication the avoidance of Foley catheters stands out as a critical element of the provider's approach to spinal cord injury management particularly in mitigating the risk of urinary tract infections by adopting alternative strategies for urinary drainage the provider contributes to the reduction of complications associated with invasive catherization autonomic dysreflexia a condition that may arise post spinal cord injury demands acute attention due to its potential for severe consequences including stroke seizures and even death unraveling the underlying triggers and addressing them is Paramount in managing autonomic dysreflexia the provider equipped with a nuanced understanding of this condition employs vasodilators judiciously to mitigate blood pressure surges and avert the associ",
        "Stroke": "complications stroke the mechanism of injury in a stroke also known as a cerebrovascular accident or CVA is characterized by disruption of blood flow to the brain leading to a persistent neurologic deficit lasting for more than 20 24 hours this disruption can occur through various mechanisms including es schic or hemorrhagic events esemicolonr Strokes result from bleeding within the brain in the context of an es schic stroke the timely initiation of care is important to restore proper blood flow and minimize the L loss of normal neurologic function rapid intervention is essential in the acute phase to prevent further damage to brain tissue esemicolonr medications like tissue plasmagen activator or TPA or indiv vascular procedures to remove or break down the clot transient es schic attacks or tias in contrast represent a temporary disruption of blood flow to the brain where neurologic deficits completely resolve within 24 hours while tias do not cause permanent damage they serve as warning signs indicating an increased risk of subsequent more severe Strokes medical attention following a TIA is crucial to assess and manage risk factors potentially preventing a full-blown stroke the mechanism of injury and stroke underscores the critical importance of timely and effective intervention to mitigate the impact of neurologic function whether ischemic or hemorrhagic Strokes demand Swift medical attention and a comprehensive approach to reduce the risk of disability and improve overall outcomes for affected individuals hemorrhagic Strokes manifest when there's bleeding within the brain leading to direct or secondary damage to cerebral tissue two primary subtypes are intracerebral Hemorrhage and subarachnoid hemorrhage with intracerebral Hemorrhage bleeding occurs within the brain's paranal tissue often due to the rupture of small blood vessels this bleed results in the accumulation of blood in the intra paranal space leading to compression and damage to the surrounding tissue subarachnoid hemorrhage on the other hand involves bleeding into the subarachnoid space surrounding the brain this type is frequently associated with the rupture of an aneurysm or arteria venous malformation causing blood to leak into the cerebral spinal fluid filled space hemorrhagic Strokes are characterized by the sudden onset of severe symptoms and require specialized management strategies es schic Strokes on the contrary occur when there is a decrease in cerebral blood flow due to the occlusion of a blood vessel this occlusion can result from a thrombus or embolis leading to inadequate blood supply to a specific area of the brain these Strokes are more prevalent accounting for the majority of stroke cases rapid intervention is necessary in treating esic Strokes to restore blood flow and minimize damage to brain tissue thrombolytic medications such as tissue plasmagen activator or endovascular procedures are often employed to achieve reperfusion and Salvage ischemic brain regions thrombotic strokes and embolic strokes represent two specific subtypes of esic Strokes each with distinct underlying mechanisms and clinical implications thrombotic Strokes result from the gradual accumulation of atherosclerotic plaque within cerebral blood vessels over time these plaques can narrow the vessel's Lumen restricting blood flow to the brain thrombotic strokes often occur in areas where atherosclerosis have been progressively developing and the plaques rupture or a complete occlusion of the vessel leads to a sudden reduction in blood supply to the affected brain region common risk factors include hypertension diabetes and Hyper lipidemia which contribute to to the formation and progression of these plaques in contrast embolic Strokes are characterized by the lodging of an imis a detached clot or other material in a smaller cerebral vessel the embolis typically originates from the heart or in a different part of the circulatory system and travels to the brain where it becomes lodged causing an Abrupt blockage of blood flow cardiac conditions such as atrial fibrillation valvular heart disease or recent myocardial infarction can predispose individuals to the formation of imali the nature of embolic Strokes often leads to more rapid and severe clinical presentations compared to thrombotic Strokes focal es schic Strokes and Global esic Strokes represent distinct categories of cerebral esea each with unique characteristics and underlying causes focal esic Strokes occur when a specific region of the brain experiences reduced blood flow leading to the development of an esic penumbra which is a zone of tissue with marginal profusion that surrounds a core of esic cells the penumbra is a critical Concept in es schic stroke pathology as it represents an area where brain cells are at risk of irreversible damage but may be salvageable if blood flow is promptly restored common causes include thrombotic or embolic events that result in the occlusion of a cerebral blood vessel leading to localized deprivation of oxygen and nutrients to the effective brain region rapid intervention such as thrombolytic therapy or mechanical thrombectomy is crucial in salvaging the esic penumbra and minimizing permanent neurological deficits on the other hand Global esic Strokes occur when there is a widespread and severe reduction in blood flow to all areas of the brain this can be a consequence of systemic issues such as severe hypotension or cardiac r where the heart's ability to pump blood is compromised in cases of cardiac arrest the lack of oxygenated blood reaching the brain can result in a global esemicolonr which are often caused by localized vascular events global management of these Strokes necessitates addressing the underlying cause such as restoring blood pressure or addressing cardiac issues as well as providing supportive care to mitigate secondary brain injury assessment of stroke is a critical aspect of prehospital care and recognizing the Hallmark signs of a stroke is essential for Timely intervention the primary indicator of a stroke is the sudden onset of focal neurologic signs which can manifest as a variety of symptoms such as facial droop arm weakness and slurred speech the combination of these signs indicates a potential disruption of blood flow to a specific area of the brain to assist in the rapid identification of stroke symptoms the provider can utilize abbreviated prehospital tools that are designed to be efficient and effective in the field two commonly used tools are the Cincinnati prehospital Stroke Scale and the Los Angeles prehospital stroke screen the Cincinnati prehosp Stroke Scale involves a quick assessment of three key indicators f facial droop arm drift and abnormal speech if any of these signs are present it raises suspicion for a stroke prompting the need for further evaluation and appropriate intervention the Los Angeles prehospital stroke screen is a tool designed to quickly assess potential stroke patients it involves checking for facial droop arm weakness and speech abnormalities a positive finding on any of these components triggers a more comprehensive stroke assessment in the assessment of stroke obtaining a non-contrast CT scan is a crucial diagnostic for the provider this Imaging modality helps to determine the underlying cause of the patient symptoms distinguishing between es schic and hemorrhagic Strokes non-contrast CT scanning is particularly effective in identifying the presence of an occlusion or bleeding within the brain which guides subsequent treatment decisions in the case of es schic Strokes the CT scan can reveal early signs of infarction aiding in the determination of eligibility for time sensitive interventions like thrombolytic therapy however it's important for the provider to consider the possibility of stroke mimics during the assessment several medical conditions and disorders can present with symptoms similar to those of a stroke leading to potential misdiagnosis some common stroke mimics include hypoglycemia seizures migraines hyponatremia and other metabolic derangements given the importance of time sensitive interventions in stroke cases accurately identifying stroke mimics is critical to avoid unnecessary delays in appropriate care thorough clinical assessment consideration of the patient's history and when available collaboration with medical control or consultation with a stroke specialist can contribute to a more accurate diagnosis and ensure that the patients receive the most appropriate care for their specific condition complications following a stroke can significantly impact patient outcomes and the provider should be vigilant in recognizing and managing these potential issues cerebral edema is a notable complication occurring in 10 to 20% of patients with a schic stroke this swelling can lead to clinical deterioration that may result in increased intracranial pressure monitoring neurological status and Vital Signs along with prompt intervention if signs of increased ICP are detected is critical to prevent further damage hemorrhagic conversion is another complication that can occur especially in es schic strokes this process involves the transformation of an initially es schic area into a hemorrhagic one further complicating the patient's condition the provider should be alert to signs of worsening symptoms or neurological deficits as they would indicate hemorrhagic conversion early recognition and coordination with the receiving medical facility are essential for appr appropriate treatment seizure activity is also a potential complication following a stroke particularly in areas of the brain that have been damaged the provider should be prepared to manage seizures properly and consider the patient's history as anticeptic medications may be necessary when stroke is suspected the provider should prioritize determining the time of symptom onset as time is a critical factor in the administration of certain interventions this information helps determine eligibility for time sensitive treatments such as thrombolytic therapy supporting the patient's cardiopulmonary function is a key aspect of stroke management the critical care transport professional should closely monitor Vital Signs particularly focusing on Main maintaining normal blood pressure levels chemodynamic status is Vital Information and blood pressure targets may vary based on the clinical situation controlling blood pressure is crucial to prevent complications such as hemorragic transformation in esic Strokes or increased bleeding in hemorrhagic Strokes neurological monitoring is essential throughout transport with particular attention to any changes in the patient condition patients with stroke are at risk of respiratory compromise due to factors like aspiration upper Airway obstruction or hypoventilation maintaining normal blood glucose levels is another consideration in stroke management hypoglycemia can mimic stroke symptoms and hyperglycemia has been associated with worse outcomes in stroke patients regular monitoring of blood glucose levels and appropriate interventions if necessary contribute to comprehensive stroke care in the management of stroke fiber linic therapy can be a crucial intervention to restore a circulation to es schic brain tissue and potentially improve patient outcomes the primary fibr linic agent used for the treatment of a schemi stroke is tissue plasmagen activator or TPA however before initiating this therapy it's essential for the provider to carefully review the inclusion and exclusion criteria as outlined by the American Heart Association this is because exclusion criteria play a role in determining the eligibility of a patient for fibr linic therapy conditions that may preclude the use of TPA include a history of intracranial neoplasm arterovenous malformation or aneurysms as these conditions can increase the risk of bleeding complications patients with current bleeding or bleeding disorders are also excluded from this therapy due to the heightened risk of uncontrollable bleeding a history of stroke recent non-compressible vascular puncture and major surgery or trauma within the past three months are additional exclusion criteria elevated systolic blood pressure specifically greater than 180 millimet of mercury is considered a contraindication and careful blood pressure management is necessary before considering therapy pregnancy and the postpartum period up to one month are also excl inclusion criteria due to the potential risks to the fetus endovascular interventions have emerged as valuable therapeutic options for patients experiencing Strokes particularly those caused by proximal or large vessel occlusions these interventions play a crucial role in the comprehensive approach to stroke management offering potential benefit benefits in cases where traditional treatments may be limited in situations where IV fibrinolysis is contraindicated or simply not feasible intraarterial thrombo represents an alternative for a subset of patients this approach involves a targeted delivery of thrombolitic Agents directly to the sight of the occlusion through catherization this method allows for a more local localized and concentrated administration of the clot dissolving medication mechanical thrombectomy stands out as a significant advancement in endovascular interventions for stroke this procedure involves the use of specialized devices such as stin retrievers or aspiration catheters to physically remove or disrupt the obstructing blood clot within the affected blood vessel mechanical thrombectomy has demonstrated clear advantages over fibr linic therapy alone especially in cases involving large vessel occlusions Studies have shown that mechanical thrombectomy leads to more effective and Rapid revascularization resulting in improved clinical outcomes for patients with large vessel occlusions this approach has become a standard of care for eligible stroke patients and is often considered alongside or as an alternative to intravenous fiis the success of endovascular interventions underscores the importance of a multidisiplinary approach to stroke care involving neurologists Interventional Radiologists and Emergency Medical Teams to optimize outcomes and minimize the long-term impact of stroke a well organized stroke system of care is critical for minimizing stroke morbidity and mortality necessitating a comprehensive plan that addresses various components to ensure efficient and effective management this plan should be implemented at the regional level considering the collaboration of healthcare institutions Emergency Medical Services and Rehabilitation centers public education plays a vital role in stroke systems of care aiming to raise awareness about the signs and symptoms of stroke the importance of seeking immediate medical attention and the available resources within the community this educational strategy can contribute significantly to reducing the time between symptom onset and treatment a critical factor in improving stroke outcomes the coordination between EMS providers primary stroke centers comprehensive stroke centers and Rehabilitation Facilities is Paramount dispatch instructions and triage strategies should be well defined to ensure that patients with suspected Strokes are rapidly identified and transported to the most appropriate facility based on the severity and type of stroke EMS protocols and training must align with the latest evidence-based guidelines to optimize prehospital care for stroke patients continuous quality improvement is an essential aspect of stroke systems of care regular evaluation and feedback mechanisms should be established to assess the effectiveness of the system identify areas for improvement and Implement changes accordingly this process ensures that the stroke Care Network remains responsive to emerging best practices and evolving Health Care standards the regional plan should also establish clear criteria for activating the stroke system and determining the appropriate transport destination for stroke patients this involves defining the roles and responsibilities of each component in the system streamlining communication channels and fostering a collaborative environment that prioritizes the timely and coordinated delivery of stroke care overall an integrated and well-coordinated stroke system of care enhances the likelihood of positive outcomes for stroke patients while optimizing the use of available resources within a given region",
        "Intracerebral Hemorrhage": "intracerebral Hemorrhage intracerebral Hemorrhage represents a severe and often life-threatening neurological condition characterized by bleeding directly into cerebral tissue leading to cerebral tissue destruction cerebral edema and increased intracranial pressure this condition poses sign ific challenges due to its potential for Rapid neurological deterioration and The Limited treatment options available the primary culprit behind spontaneous intracerebral Hemorrhage is often hypertension induced vessel rupture the sustained high blood pressure weakens the Integrity of the small arteries within the brain ultimately causing them to rupture and bleed into the surrounding cerebral tissue this vascular rupture results in the release of blood into the brain parena initiating a Cascade of events that contribute to the clinical manifestations associated with intracerebral Hemorrhage the consequences extend beyond the immediate physical damage caused by bleeding encompassing secondary effects such as cerebral edema and the subsequent elevation of intracranial pressure understanding the etiology pathophysiology and clinical implications of intracerebral hemorrhage is important for timely diagnosis and the implementation of appropriate interventions to mitigate its impact on neurological function and overall patient outcomes the symptoms of intracerebral hemorrhage typically commence as local ized neurologic dysfunction directly related to the specific area of the brain where the vessel has ruptured it may manifest as focal neurological deficits such as weakness sensory abnormalities or visual disturbances depending on the affected region as the bleeding progresses leading to an increase in in cranial pressure the patient may experience a decline in Consciousness the rate and extent of clinical deterioration are closely tied to the quantity and speed of the bleeding rapid and substantial bleeding can result in a swift decline in neurological function emphasizing the need for prompt recognition and intervention the critical care transport provider plays a pivotal role in managing cardiopulmonary function given the potential for systemic complications arising from intracerebral hemorage maintaining optimal oxygenation and ventilation is key to support cerebral profusion and mitigate secondary brain injury Additionally the provider should monitor and manage blood pressure within appropriate parameters as hypertension can exacerbate bleeding and contribute to increased ICP a thorough understanding of the evolving symptoms and the ability to provide timely and effective cardiopulmonary support are essential aspects of the care of patients with intracerebral",
        "Subarachnoid Hemorrhage": "Hemorrhage subarachnoid hemorrhage subarachnoid hemorrhage refers to the occurrence of bleeding into the subarachnoid space and this type of hemorrhage is typically of arterial origin the majority of cases are attributed to the rupture of a cerebral aneurysm or arterovenous malformation an aneurysm is characterized by the outpouching of the blood vessel wall resulting from a weakening of the vessel's structural Integrity the weakened area becomes susceptible to rupture leading to the release of blood into the subarachnoid space surrounding the brain arterovenous malformations represent another common cause of subarachnoid hemorrhage arterovenous malformations are intricate clusters of abnormal blood vessels characterized by a tangle of arteries and veins that create a direct shunt from arteries to veins without traversing the normal capillary Network the abnormal Anatomy increases the risk of vessel rupture contributing to subarachnoid bleeding both cerebral aneurysms and arterio venous Mal formations are critical eological factors in subarachnoid hemorrhage and the identification and management of these underlying vascular abnormalities are Paramount in the overall approach to treating patients with subarachnoid Hemorrhage subarachnoid hemorrage presents with distinctive clinical features that Aid in its assessment one of the Hallmark symptoms is the sudden and severe onset of a headache this headache is often described as Thunderclap in nature and is recognized as one of the most intense headaches a person can experience alongs aside this headache patients May exhibit symptoms such as a loss of consciousness nausea vomiting and photophobia focal neurologic deficits may also be present reflecting the specific area of the brain affected by the Hemorrhage as intracranial pressure continues to rise due to the accumulating blood in the subarachnoid space more severe manifestations can occur nual rigidity May develop indicating irritation of the meninges in some cases the patient's level of Consciousness May deteriorate leading to coma and in severe instances death emergency medical personnel must recognize these signs and symptoms promptly as subar noid Hemorrhage as a medical emergency that requires urgent intervention and Specialized Care to mitigate complications and improve outcomes in the management of subarachnoid hemorrhage the primary focus is on maintaining cardiopulmonary function as the patient's level of Consciousness declines and the risk of vomiting increases Airway management and ventilatory support become critical to prevent Airway compromise adequate attemp ention should be given to securing the airway ensuring proper ventilation and addressing any respiratory distress promptly preventing a rise in intracranial pressure is another key aspect of subarachnoid hemorrhage management this involves measures to control and manage ICP such as maintaining head elevation ensuring proper fluid balance and avoiding factors that could contribute to increased pressure within the intracranial space early interventions to stabilize ICP contribute to better outcomes and can help mitigate the risk of complications the complications associated with subarachnoid hemorrhage include rebleeding which can occur in the initial hours to days following the Hemorrhage and poses a significant threat to the patient's well-being cerebral vasospasm is another potential complication characterized by the narrowing of blood vessels in the brain leading to reduced blood flow and potential of these patients the hormonal response triggered by the Hemorrhage can lead to abnormal fluid balance and close monitoring and appropriate interventions are necessary to maintain electrolyte equilibrium hydris the accumulation of cerebral spinal fluid within the brain is another potential complication this can contribute to increased intracranial pressure and may require interventions such as drainage procedures to manage fluid",
        "Acute Guillain-Barr\u00e9 Syndrome": "accumulation acute gilan Beret syndrome gilan Beret syndrome or GBS is a collection of immun related poly neuropathies characterized by their shared features often triggered by an antient infection this syndrome is considered an autoimmune response where the immune system mistakenly targets the peripheral nerves leading to inflammation and subsequent nerve damage the most common infection associated with GBS include respiratory or GI infections with caloor Juni being a frequently identified culprit individ idual with acute GPS can experience a rapid onset of symptoms and in severe cases they may require transportation to referral centers equipped to manage the complexities of this condition one Hallmark feature is ascending paralysis which may progress from the lower extremities to involve the upper Limbs and in some cases affect the muscles responsible for respiration and facial movements the progression of paralysis can be Swift and patients May develop respiratory distress necessitating urgent medical attention and potential respiratory support respiratory involvement is a critical aspect of GBS and some patients may experience respiratory muscle weakness or paralysis this compromise can lead to difficulties in maintaining adequate oxygenation and ventilation requiring careful monitoring and intervention in severe cases mechanical ventilation may be necessary to support respiratory function until the acute phase of GPS resolves the initial diagnosis of GBS relies on the clinical presentation characterized by the progressive onset of mostly bilateral and symmetric muscle weakness accompanied by depressed or absent deep tendon reflexes this pattern of weakness typically ascends from the lower extremities to involve the upper Limbs and in some cases may affect respiratory and facial muscles the Hallmark feature of absent or diminished deep tendon reflexes such as the Achilles reflex is a key diagnostic Criterion clinicians often use additional tests such as nerve conduction studies and lumbar puncture to further support the diagnosis and assess the extent of nerve damage during transport the management of GPS is primarily supportive given that the disease is an immune mediated disorder specific treat treatments aim to modulate the immune response and reduce inflammation however these interventions are typically initiated in a hospital setting under the supervision of Neurology and Critical Care Specialists therefore during transport the focus should be on providing supportive care to address the evolving clinical manifestations these supportive measures typically include adequate oxygen and ventilation especially in cases where respiratory muscles are affected close monitoring of Vital Signs including respiratory rate and effort is important in severe cases where respiratory compromise is evident Advanced Airway management and mechanical ventilation may be necessary to maintain adequate oxygen levels IV fluids may be administered to maintain hydration and support blood pressure pain management and strategies to prevent complications associated with immobility such as pressure ulcers are also essential aspects of supportive care while definitive treatment often involves immunomodulatory therapies such as intravenous immunoglobin or plasma exchange these interventions are typically initiated upon arrival at the hospital the prehospital and transport phase focuses on recognizing and addressing immediate concerns stabilizing the patient and facilitating timely transfer to a medical facility equipped to manage the complexities of",
        "Seizure and Epilepsy": "GBS seizure and epilepsy seizures and epilepsy are neurological conditions characterized by AB normal electrical activity in the brain leading to episodes of involuntary movements altered Consciousness or other unusual Sensations the underlying mechanism involves disruptions in the balance between excitatory and inhibitory neurotransmitters within the brain overactivity of excitatory neurotransmitters or underactivity of inhibitory neurotransmitters can precipitate a seizure this imbalance can result from various factors affecting the intricate network of neurons in the brain one common cause is a sudden change in excitatory neurotransmitters particularly glutamate which leads to an uncontrolled and excessive firing of neurons several factors can contribute to the occurrence of seizures fever especially in young children is a common trigger leading to fibral seizures imbalances in glucose levels such as hypoglycemia or hyperglycemia can also provoke seizures electrolyte imbalances involving essential minerals like sodium potassium and calcium May disrupt the electrical signals in the brain potentially leading to seizure activity traumatic events such as head injuries concussions or hemorrhagic Strokes can cause structural damage to the brain and tricker seizures additionally exposure to certain toxins or substances including drugs or alcohol withdraw May induce seizure activity by interfering with normal brain function epilepsy is a chronic neurological iCal condition and individuals diagnosed with epilepsy may experience recurrent seizures throughout their lives in managing these patients the initial focus should be on ensuring their safety and well-being the first priority is maintaining an open Airway to ensure adequate oxygenation during a seizure individuals may lose control of their muscles including those responsible for breathing this can lead to respiratory compromise because of this providers should be prepared to assist with Airway management potentially using techniques such as the recovery position to prevent Airway obstruction protecting the patient from injury during a seizure is another critical aspect of management seizures can cause uncontrolled movements and altered Consciousness putting the individual at risk for Falls and injuries clearing the immediate surroundings of any potential hazards and providing a safe environment can help prevent injuries during a seizure episode while seizures are often brief and self-limiting it's crucial to monitor the duration and characteristics of the seizure if it persists for an extended period such as in status epilepticus or if the patient has difficulty breathing or sustaining normal oxygen levels then medical intervention is necessary in such cases providing supplemental oxygen and if needed administering anti-epileptic medications may be part of the management strategy it is generally advised not to attempt to restraint a patient who is actively seizing as these attempts at physical restraint may lead to injury for both the patient and the provider instead focus should be directed towards creating a safe environment such as removing potential hazards and ensuring the patient's Airway remains open establishing IV access is an important step in the management of seizures this allows for the administration of medications monitoring of the patient's cardiac status and obtaining blood samples for essential laboratory tests monitoring the patient's glucose level is particularly important as hypoglycemia can sometimes trigger seizures or exacerbate existing seizure disorders if indicated glucose should be administered to correct any glucose imbalance in cases of actively seizing patients the administration of anti-convulsive medications is a critical intervention commonly used drugs during transports include lorazapam diazapam and melum patients with a known history of epilepsy may already be taking anti-epileptic medications maalum has demonstrated superiority in the prehospital setting and is considered the firstline drug of choice for stopping prolonged seizures its ease of administration and Rapid onset of action make it particularly suitable for use in the field the timely and appropriate administration of anti-convulsive medications aims to terminate the seizure activity prevent status epilepticus and contribute to the overall well-being of the patient during the phase of",
        "Transport Considerations": "care transport considerations prior to transporting a patient with a neurologic emergency it's important to ensure that all the necessary diagnostic tests and surgical procedures have been completed whenever possible this helps in obtaining a comprehensive understanding of the patient's condition and facilitates more informed decision-making during transport Critical Care transport involving neurologic emergencies may involve various types of equipment that require careful monitoring and troubleshooting to ensure their optimal function throughout the journey one critical piece of equipment is the cardiac monitor before transport check for sufficient battery power proper charging General functionality and ensure proper waveform capnography which provides valuable information about the patient's ventilation status ventilators equipped with waveform capnography are utilized to Monitor and control ventilation prior to transport providers need to check the ventilator for adequate oxygen and gas supply inspect ventilator tubing verify oxygen and circuit connections and ensure proper capnography hookup to monitor entitle carbon dioxide levels infusion pumps play a vital role at administering medications during Critical Care transport providers should refer to the manufacturer's troubleshooting chart to address any issues related to the infusion pumps in cases where in cranial pressure monitoring or cerebral function monitoring is implemented specific attention is required ICP monitoring devices must be checked for stability and the fluid level needs to be maintained as per the manufacturer's guidelines likewise cerebral function monitoring which is used to assess sedation monitor brain wave activity predict and monitor seizure activity and assess the onset and effectiveness of paralytics may require troubleshooting as per the manufacturer's recommendations typically when this type of monitoring is in use patients are on a ventilator connected to a cardiac Monitor and receive medications administered through an intravenous pump the comprehensive eval valuation and troubleshooting of these equipment components before transport contribute to the safe and effective management of neurologic emergencies during Critical Care transport when considering the scene in inter hosp transport for a patient with a head injury several factors come into play to ensure the safety and wellbeing of the individual the four most risks in the early stages of head injur injury are hypoxia and hypertension emphasizing the need to prioritize the ABCs during assessment and intervention the patient with a severe closed head injury is often presumed to have an elevated intracranial pressure underscoring the importance of careful management to prevent further complications some systems advocate for additional protective measures me such as the use of ear and eye protection for the patient this is done to mitigate potential spikes in intracranial pressure that could result from exposure to loud aircraft noise or Sirens during transport minimizing external stimuli and maintaining a controlled environment are important considerations the minimum requirements for monitoring patients during transport include continuous EC CG pulse oxymetry and intermittent measurements of blood pressure respiratory rate and pulse rate these parameters offer essential insights into the patient's cardiovascular and respiratory status enabling timely interventions if needed complications reported during transport are at times attributed to equipment malfunctions therefore it's imper that the provider is ultimately familiar with all equipment and monitoring devices in use this familiarity ensures not only optimal patient outcomes but also helps in averting complications that may arise from equipment misuse or malfunction this particular focus should be placed on the ability to measure major ventilation parameters such as tital volume or minute ventilation providing the critical care transport professional with Comprehensive data to assess and manage the patient's respiratory needs effectively by addressing these considerations the transport team can enhance the safety and quality of care for patients with head injuries during both scene response and Inter hosp transport flight considerations for transporting patients with neurologic emergencies particularly those with head injuries involve several measures to ensure the safety and well-being of the individual during Air transport firstly when planning the flight efforts should be made to have the pilot fly at altitudes where cabin pressure can be maintained as close to the original departure pressure as possible this is essential to minimize changes in atmospheric pressure that could impact the patient's condition particularly in cases of elevated intracranial pressure if the patient is intubated adjustments to the indot tral cuff pressure become important with changes in altitude decreasing the cuff pressure at higher altitudes helps prevent damage to the trachea while reinf lating it during descent prevents leakage these measures are critical to maintaining optimal Airway management throughout the flight for patients with indwelling catheters and colostomy bags adjustments to the pressure inside these devices are necessary to prevent breakage considering the variations in cabin pressure during flight in cases where a patient has a drain and ICP is being monitored it is imperative to ensure that the ICP remains below 20 mm of mercury this may involve draining off excess fluids to manage ICP within the desired range during flight continuous monitoring of the patient is Paramount and any changes in respiratory rate pattern or cardiac function must be promptly addressed these changes could be indicative of herniation a critical condition requiring immediate intervention in such cases the aircraft should Ascend to an altitude of the patient's condition is manageable emphasizing the need for real-time assessment and decision making during Air transport by addressing these flight considerations the transport team can optimize the conditions for patients with neurologic emergencies ensuring their safety and stability throughout their journey in this comprehensive lecture we delved into the intricate Realms of anatomy and physiology unraveling the complexities of the nervous system the neurologic examination a Cornerstone of our diagnostic approach was explored in detail enhancing our Proficiency in assessing patients with diverse neurological presentations traumatic brain injuries a common challenge in prehospital care were dissected to understand their varied manifestations and the nuances of effective management specific neurologic injuries including spinal cord injuries provided insights into the intricacies of stabilizing and transporting patients with these critical conditions our journey continued into the realm of intracranial pressure brain stem herniation and the complexity surrounding their monitoring and intervention stroke encompassing es schic and hemorrhagic episodes was also a focal point highlighting the significance of timely recognition and tailored interventions the lecture concluded by unraveling the mysteries of intracerebral and subarachnoid hemorrhages as well as seizures equipping us with a comprehensive understanding to navigate the intricate landscape of neurologic emergencies with precision and expertise"
    },
    {
        "Introduction to Medical and Obstetrics/Gynecology Fundamentals": "In This Chapter Surveying the structures and functions of each body system Encountering emergency medical conditions Being a medical detective to better understand how to treat your patient To understand how the body works, you have to look at it as a series of systems that interact to create the state known as homeostasis \u2014 life, in balance. Every moment of every day, your body tries to keep itself in a constant state of homeostasis. Each system has a very specific series of structures and functions that, under most conditions, are very complementary with each other. When something goes wrong somewhere in the body, the systems work to compensate and then combat the issue. For example, think about an infection. The body normally does a great job in keeping foreign invaders like viruses and bacteria at bay. But on occasion, one gets through and takes hold somewhere. It multiplies quickly. The body fights back by increasing its metabolism rate and creating a fever to kill the infection. White blood cells in your blood look for and destroy the foreign cells. If the infection is in your gastrointestinal tract, your body speeds up the process of moving food through it, causing you to have diarrhea. As you can imagine, this battle takes a toll on your body. Other systems also spring into action. Your vasculature dilates, causing blood to pool at the surface of the skin to help dissipate excess heat. Your sweat glands begin to secrete fluid, causing you to perspire as more heat is removed. Your brain triggers your thirst mechanism so that you drink more fluids to replace the loss. This is a simple example of how the body\u2019s organ systems interact with one another. Understanding this interaction helps you better think about what may be causing your patient\u2019s signs and symptoms. In fact, you might not look at someone quite the same way as you once did! This chapter describes the body\u2019s main systems, lists medical conditions you may encounter, and explains treatments.",
        "Introducing the Body\u2019s Main Systems": "You need to review several organ systems for the EMT exam. Each is comprised of a series of organs and structures, which in turn has a unique series of functions. As an EMT, you should be knowledgeable about a few structures. Table 11-1 provides an overview of each system. I cover each one in more detail in the rest of this chapter. Note: The respiratory and cardiovascular systems are so important that they are covered in separate chapters (Chapters 9 and 10, respectively). You may want to take a moment to review them now.",
        "The Nervous System": "Simplistically, the nervous system serves a command and control purpose, primarily by receiving signals from nerves throughout the body, passing them through the spinal cord, processing those signals in the brain, and communicating some type of change in response. Figure 11-1 shows the main structures of the nervous system. Of course, we\u2019re much more than just a bunch of signals moving back and forth. The human brain \u2014 which gives us the ability to have conscious thought and engage with our environment in a purposeful, deliberate way \u2014 is what makes us stand out from most of the animal kingdom. The human brain is much bigger proportionally to the body compared to most other mammals. It requires a lot of oxygen and nutrients, such as glucose, to function effectively. That\u2019s the reason why EMTs evaluate mental status early and often \u2014 even simply being sleepy may be an early indication of an oxygenation, ventilation, or circulation issue. The brain is also sensitive to changes in chemistry, ranging from disease processes like hyperglycemia that causes increased acidity in the blood (diabetic ketoacidosis) to recreational drugs such as alcohol, marijuana, and 3-4 methylenedioxymethamphetamine (MDMA, also known as Ecstasy or Molly). Checking for orientation status \u2014 awareness of person, place, time, and event \u2014 gives you a more precise understanding of how affected the brain is in these situations.",
        "The Gastrointestinal System": "The abdomen contains most of the major structures and organs of digestion. In general, they\u2019re divided into two categories: hollow organs such as the stomach, gallbladder, and intestines, and solid organs such as the liver, kidneys, and pancreas. If injured or breached, hollow organs tend to spill their contents into the abdominal cavity, possibly causing infection and cell tissue damage. Solid organs contain a lot of blood vessels and tend to bleed if injured. Food is mechanically broken down by the teeth and chemically taken apart by stomach acid. It eventually becomes a slurry that is moved slowly through the small and large intestines through rhythmical motions known as peristalsis. Nutrients and water are absorbed by the walls of the intestines and circulated throughout the body. Eventually all that is left are feces \u2014 waste products that the body doesn\u2019t need or can\u2019t use. They\u2019re excreted out the rectum through the anus. Figure 11-2 shows the main structures of the gastrointestinal system.",
        "The Immune System": "The immune system is key to your ability to ward off foreign bodies that can make you sick \u2014 bacteria, viruses, and other organisms, as well as proteins that can be irritating to the inside of your body, such as pollen. The following sections describe allergic reactions, anaphylaxis, and infections.",
        "The Endocrine System": "As in Aesop\u2019s fable, the endocrine system can be compared to the nervous system as the tortoise to the hare. They both perform the same general function \u2014 control \u2014 but unlike the zippiness of the nervous system, the endocrine system is a much slower but longer-lasting control system. That\u2019s good, because the endocrine system controls processes that are longer in duration, such as overall growth, and continuous processes, such as balancing blood sugar levels. Several organs contain glands that make up the endocrine system (see Figure 11-3). Each secretes a hormone that travels through the bloodstream and causes an effect somewhere else in the body. Hormones cause their effects by connecting with receptors that are found on cell membranes. A specific receptor interacts only with a specific hormone, just as a specific key fits a specific lock.",
        "The Hematologic System (Blood)": "Your blood performs several amazing functions. The red blood cells carry most of your oxygen quite efficiently, picking it up only at the alveoli, where it\u2019s most abundant, and dropping it off only at the cells, where the concentration is lowest. White blood cells come in different types, but they work in concert to combat infection. Platelets are cells that initiate the clotting process. All of these cells, along with proteins, nutrients, and waste, are carried in plasma, the watery part of blood.",
        "The Urinary System": "Located in the retroperitoneal space in the flanks, kidneys are the body\u2019s main filters. They primarily regulate the balance of water and various electrolytes within the body, as well as remove certain toxins, which helps to control the body\u2019s blood pressure. Urine is formed as these substances are filtered out of the bloodstream, which passes through ureters into the urinary bladder. When the bladder becomes full, it triggers the reflex that makes you urinate. The urine is released from the bladder and travels out of the body via the urethra. (Figure 11-5 shows the main structures of the urinary system.)",
        "Obstetrics and Gynecology": "Obstetrics studies the pregnancy process, from fertilization to delivery. Gynecology is the study of diseases that can affect the reproductive system. Together, they represent a variety of conditions specific to the female. The female reproductive system consists of several organs (see Figure 11-6). A pair of ovaries are the primary organs, generating the hormones that are involved with pregnancy and secondary sex characteristics, and generating eggs. During a menstrual cycle, hormone levels begin to rise, causing an egg to mature and be released roughly halfway through the cycle. The egg is swept into the fallopian tube where, if a viable sperm is present, it may be fertilized and become an embryo. This process is called conception.",
        "The Musculoskeletal System": "You should be familiar with the basic structure of bone; I review the musculoskeletal system in more depth in Chapter 12. Bone is a living tissue, made of the protein collagen, which forms a soft framework that looks a little like a sponge. Calcium fills in the gaps, making the outside of bone denser and harder. Bones are spongier toward the center, especially long bones like those found in the arms and legs. Red blood cells are formed within the spongy center and enter the circulatory system.",
        "Toxicology": "Toxicology is the study of toxic or poisonous substances and their effects on the body. The signs and symptoms associated with toxic exposure and poisoning range very widely, from simple annoyances to life-threatening conditions. As an EMT, your primary goals are to ensure your own safety and identify the possibility of a toxic exposure while preserving the patient\u2019s airway, breathing, and circulation.",
        "Psychiatric Disorders and Behavioral Emergencies": "At some point in their lives, most people experience some type of behavioral event that makes them act out of the ordinary. In most situations, acute, severe stress is the trigger. Once the trigger is pulled and the stress passes, they return to their normal behavior. Sometimes the stress is so great that it results in a behavior so out of the ordinary that others become frightened or so concerned that the person is out of control that they contact EMS or law enforcement for assistance."
    },
    {
        "Introduction": "Pain and suffering are not confined within hospital boundaries. Pain is a common complaint of patients cared for by EMS providers. It is estimated that 20% of the approximately 15 million patients transported by EMS annually in the United States experience moderate-to-severe pain. Although prehospital personnel are usually focused on the ABCs, the treatment of pain should be considered an important priority in the care of ill and injured patients. Most studies of EMS analgesia practices show that many patients with moderate-to-severe pain do not receive analgesia in the prehospital phase of their care. NAEMSP currently recommends that EMS systems have a policy to address prehospital pain management. The initial statement in NAEMSP position paper is, \u201cNAEMSP believes that the relief of pain and suffering of our patients must be a priority for every EMS system. Adequate analgesia is an important step for achieving this goal. NAEMSP believes that every EMS system should have a clinical care protocol to address prehospital pain management. Adequate training and education of prehospital personnel and EMS physicians should support the pain management protocol.\u201d Prehospital pain protocols should address the following issues. 1 Mandate for pain assessment 2 Tools for pain measurement 3 Indications and contraindications for prehospital pain management 4 Non-pharmacological interventions for pain management 5 Pharmacological interventions for pain management 6 Patient monitoring and documentation before and after analgesia 7 Transferring information to the receiving medical facility The challenge of treating pain in the prehospital setting is to use agents and techniques that are not only effective but safe and do not lead to physiological compromise or a delay in diagnosis upon arrival in the ED. Because of inordinate fears of and the desire to prevent side-effects, many EMS systems have opted for little or no use of pharmacological analgesics. Providing analgesia has been largely ignored in prehospital care education. Few EMS texts devote significant attention to this topic. Many systems do not have protocols to treat pain and suffering, other than that from ischemic chest pain. Many prehospital providers are frustrated by being unable to offer patients more than the \u201cbite the bullet\u201d approach to providing relief from acute pain. For those systems with reasonable analgesia protocols, the majority of patients are still untreated or undertreated. Many paramedic attitudes have been suggested as reasons for this inadequate treatment of pain. Prehospital pain management is a fertile area for study. Current research topics include barriers to prehospital analgesia, interventions to address barriers, non-opioid alternative analgesics (e.g. ketamine, IV acetaminophen), and alternative routes for pain relief, such as intranasal and transmucosal routes that can be used by basic providers as well as field-based ultrasound-guided nerve blocks that can be useful in wilderness settings or in prolonged extrications.",
        "Literature review": "Several studies have shown that oligoanalgesia is more the rule than the exception in prehospital care. One of the most dramatic studies was performed by White et al. in the city of Akron in the late 1990s. At that time, the EMS system had standing orders for either the administration of morphine sulfate, 2\u20135 mg IV push, or nitrous oxide, 50% self-administered. During the study period, 1,073 patients with suspected extremity fractures were identified. Of this large number of patients, only 18 received analgesia: 16 patients received nitrous oxide and two received morphine. McEachin reported on several different EMS agencies transporting patients to a single hospital in Michigan. Of 124 patients suspected of having lower extremity fractures, only 22 (18.3%) received parenteral analgesia. Many of these patients (38.4%) were triaged from an ALS response to a BLS transport. Hennes et al. reported results from prehospital analgesia practice in Milwaukee where a review of 5,383 patients with acute pain showed that morphine was administered in only 258 patients (4.8%). Of those patients with extremity fractures, 37 of 351 (10.5%) received morphine, and morphine was given to only seven of 258 children (3.0%). In patients with burn injury, 16 of 130 (12.3%) received morphine; only one of 12 children received it. Similar findings showing lack of analgesic administration or oligoanalgesia have been replicated in other studies. The benefits of prehospital analgesia are not only physiological. It improves the perception of quality of care provided by EMS. One study showed that 80% of patients reported the overall quality of EMS care to be excellent when they rated their pain management as excellent. Prehospital analgesia also dramatically decreases the time-to-analgesic administration, ranging from 60 to 120 minutes earlier, when compared to analgesic administration being deferred to the emergency department. Evans made the poignant statement, \u201cTo allow a patient to suffer unnecessary pain does harm to the patient \u2013 a violation of the first ethical principle of medicine.\u201d In a 1999 editorial, the late Peter Baskett states, \u201cThe blame for \u2018oligoanalgesia\u2019 must be laid at the door of physicians in authority who have, through ignorance, underplayed the physiologic and psychological benefits of analgesia and overplayed the potential of deleterious side effects of agents that are commonly available.\u201d",
        "Opioids": "Opioids are the best class of pharmacological agents to treat acute pain in all areas of medicine, including the prehospital environment. (See Box 67.1 for a list of desirable characteristics, most but not all of which are found in the opioids.) Osler referred to opioids as God\u2019s own medicine. The properties that make opioids desirable in the field include rapid onset, high potency, titrateability, relative safety, and reversibility. Morphine sulfate has been used for ischemic chest pain in the field for the past three decades. Over the past several years, fentanyl has gained increased usage. In many EMS systems, it is now the most commonly used opioid for non-cardiac pain. In emergency departments and in the field, it is increasingly replacing morphine for myocardial ischemia and chest pain. For many types of pain, opioids can be titrated by the IV route to produce safe and effective analgesia and can be administered by the intramuscular and intranasal routes as well. One of the major benefits of opioids is that most side effects can be rapidly reversed with an opioid antagonist, such as naloxone, which is carried by most EMS systems for use in opioid overdoses. With all opioids, EMS systems must adhere to Food and Drug Administration guidelines for monitoring and documenting possession and use. Specialized critical care transport teams seem to provide analgesia and achieve significant pain relief more frequently than described in routine ground-based EMS systems.",
        "Fentanyl": "Fentanyl has several properties that make it well suited for prehospital use. It is one of the only opioids that does not cause a release of histamine, thereby preventing potential exacerbation of reactive airway disease, and reducing the chance of inducing significant hemodynamic changes. Fentanyl is very lipid soluble, and it crosses the blood\u2013brain barrier quickly, reaching its peak effect within a few minutes. Its half-life is shorter than most other opioids with a duration of action less than 1 hour. Fentanyl does not cause any decrease in cardiac contractility. Like all opioids, however, it can decrease sympathetic tone and if a patient\u2019s blood pressure is dependent on the sympathetic nervous system, fentanyl can cause some hypotension, but this is relatively uncommon. Kanowitz reported on the use of fentanyl in 2,129 prehospital patients with an average titrated dose of 118 \u03bcg, with a range of 5 to 400 \u03bcg. Only 12 patients had any vital sign abnormalities during the drug\u2019s duration of action, and most of these were relatively minor, with only one patient receiving naloxone reversal. This one patient was an 83-year-old woman with a hip fracture who received two doses of 100 \u03bcg fentanyl and had some respiratory depression while in the ED that was immediately reversed with 0.4 mg of naloxone without any adverse effects. There were no significant complications or deaths as a result of prehospital use of fentanyl. The authors concluded that fentanyl effectively decreased pain scores without causing significant vital sign changes, thereby allowing it to be used safely and effectively for prehospital pain management. Several studies have also been reported showing the safe and effective use of fentanyl in ground and air transport of adult and pediatric patients. Fentanyl has a short half-life and duration of action of 60 minutes or less. Opioid-induced hypotension is rare with fentanyl, but in patients who are only able to maintain normal systemic pressure due to extreme sympathetic drive, fentanyl can blunt the sympathetic response and theoretically lower blood pressure. Should this occur, fluid administration is typically all that is needed, but alpha-adrenergic agents can be used to help to restore blood pressure. The safe and effective use of oral transmucosal use of fentanyl has been described in the battlefield setting. Fentanyl also has been used via the intranasal route through an atomizer device. In some systems, fentanyl is replacing morphine as the opioid of choice for ischemic cardiac chest pain.",
        "Morphine": "Morphine has been widely used in EMS systems for the past three decades. Initially it was largely restricted to the treatment of ischemic cardiac pain, but its indications have expanded to a wide variety of pain states. Despite the potential for a multitude of side-effects related to the prehospital use of morphine, the literature does not suggest that these have been a major clinical issue. Morphine has the advantage of having a wide margin of safety when it is used in careful IV titrated fashion. It is safe in patients with liver disease and for acute pain and can be used safely in renal disease. Morphine does not decrease cardiac contractility but does decrease preload and afterload and therefore should be used with caution in any patient who has borderline or frank hemodynamic instability. It is important to titrate the dose to the analgesia accomplished.",
        "Opioid agonist-antagonists": "Some characteristics of the opioid agonist-antagonist class of analgesics make them ideally suited for prehospital use. Drugs in this group include nalbuphine and butorphanol. The primary benefits of this class are the ceiling on respiratory depression, minimal euphoria and limited abuse potential, lack of biliary spasm, and minimal hemodynamic effects. Stene et al. described the prehospital use of nalbuphine in 46 patients with moderate-to-severe pain due to multiple trauma, burns, fractures, and intraabdominal conditions. The agent was partially to completely effective in 89% of patients and was without any major untoward effects. Nalbuphine also causes very minimal, if any, hemodynamic changes. Since that early study, others have confirmed the value of IV nalbuphine in the field. Another advantage of this drug is that it is not a controlled substance, easing some of the paperwork required when using morphine. Butorphanol is now available as a nasal spray. This agent and route of administration have many theoretical benefits in the prehospital environment, but studies have yet to be reported on the field use of nasal butorphanol. The use of the agonist-antagonist class of analgesics in the field may result in patients in the ED requiring somewhat higher doses of pure opiate agonists to achieve adequate analgesia.",
        "Nitrous oxide": "Nitrous oxide-oxygen mixtures fulfill many of the properties desired for a prehospital analgesic. Several field studies have demonstrated the safety and efficacy of self-administered 50% nitrous oxide in prehospital care. All studies have confirmed that the majority of patients with moderate-to-severe pain from a variety of sources will achieve significant pain relief. In unpublished data from use in the city of Pittsburgh in the past two decades, over 4,000 patients have been treated without any significant major adverse effects. Significant analgesia is achieved in approximately 80% of patients. In a rural EMS system, a nitrous oxide-oxygen mixture led to pain relief in 85% of patients for which it was used. One of the major advantages of the use of nitrous oxide is that it is relatively devoid of serious side-effects. Its major side-effect has been nausea, noted in four patients in a study by Ducasse et al., which also found that numerical rating scores decreased significantly with use of a nitrous oxide-oxygen mixture. In 1994, an alert entitled \u201cControlling exposure of nitrous oxide during anesthetic administration\u201d provided guidelines to prevent environmental levels from exceeding their recommended standards. In a moving vehicle, or one with a fan, short-term administration should be safe for the providers, although well-designed protocols must be written and followed when using this gas mixture. A prototype of a nitrous oxide protocol is shown in Box 67.2; it includes the absolute and relative contraindications to nitrous oxide administration. Recently, Australian authors conducted a systematic review of the safety literature related to the use of 50% nitrous oxide. They identified 12 randomized clinical trials investigating the use of 50% nitrous oxide compared with placebo. They conclude, \u201cNitrous oxide at a concentration of 50% is an effective and safe form of analgesia. The side effect profile of this agent suggests that it could be used by adequately trained laypersons in the prehospital setting. The question of nitrous oxide use by basic EMTs or by even lesser trained individuals such as rescue teams or ski patrol is a legitimate question, particularly in parts of the world where there is a dearth of prehospital advanced life support personnel.",
        "Ketamine": "Ketamine is a dissociative anesthetic that is structurally related to phencyclidine, and it has some unique properties. The dissociative state produced by ketamine is characterized by analgesia and amnesia, while preserving airway protective reflexes. Because ketamine is a bronchodilator, it can be used to treat severe asthma. It can be used as a field anesthetic for unusual situations, such as field amputations, dislocation reductions, or prolonged or complicated extrications. It has also been described as a useful agent for field surgical procedures during disasters, especially among children.\n\nAlthough this agent has had little indication for routine prehospital use, recently, at subdissociative dosages, it has been studied as a primary analgesic agent. The intranasal administration of S-ketamine has been described in Scandinavia. It has also been studied as an adjunct agent to decrease the dose of opioid needed to achieve pain relief in the emergency department. Polomano and others describe the use of low-dose IV ketamine in patients with pain from complex combat injuries, showing it to be safe and effective.",
        "Non-steroidal antiinflammatory agents": "Currently, few EMS systems routinely use aspirin or other nonsteroidal antiinflammatory (NSAID) drugs. Aspirin is now the standard of care as an antiplatelet drug in the treatment of acute coronary syndrome by field personnel, but rarely is aspirin used for pain management. NSAIDs are particularly well suited for treatment of ureteral and biliary colic. These drugs may also potentiate the analgesic action of opiates.\n\nAlthough these agents do not work as quickly as opiates, if given at the scene they will frequently have beneficial effects before the patient arrives at the hospital and definitely before the time that analgesic agents will be administered in the hospital. These agents should not be considered as a substitute for opiates and nitrous oxide but as another helpful adjunct with selected indications. The major side-effects to consider with a single-dose use in the field would be allergic reactions and platelet inhibition. They should therefore be withheld in the field if the patient has known allergies to NSAIDs or if the anti-platelet effect may exacerbate an underlying problem.",
        "Acetaminophen": "Acetaminophen is rarely carried on ambulances or used in the prehospital setting. Acetaminophen, like the NSAIDs, is an effective analgesic, especially in combination with opioids. One potential side-effect, although not likely after a single dose in the field, is the exacerbation of asthma. It is also well known to precipitate acute hepatic failure in patients with underlying liver disease or as a cumulative dose. A single dose in the field is unlikely to lead to acute hepatic failure, but caution would still be advised in these patients. Intravenous acetaminophen is increasingly being used in the hospital and has been studied in the postoperative setting.",
        "Communication techniques": "The most ignored aspect of providing prehospital relief to those with pain and suffering is the powerful effects that can result from therapeutic communication techniques. These techniques can be mastered by all providers and can bring a significant degree of comfort to patients without use of pharmacological agents. Jacobs points out that many patient responses to an injury or illness are occurring at an unconscious level and that every word, phrase, sentence, pause, voice inflection, and gesture can initiate automatic psychophysiologic effect. An example of a suggested dialogue for a patient with burns is as follows. I'll bet you can imagine some place you'd rather be than here. As a matter of fact, go ahead and do that now while we get you bandaged up. Think of your favorite place. When you are there in your mind's eye, look around and notice all the things there are to notice. Listen to the sounds. Feel the good feelings. There might even be a special aroma you can smell. When you are really experiencing that place, let me know by raising your index finger. Good. Although many prehospital providers may feel uncomfortable with guided imagery techniques such as this, they all should recognize the powerful implications of their verbal and non-verbal communication. Providers should be capable of engaging patients in a way that distracts them from their injury or illness. Distraction can also be very helpful while prehospital providers are performing potentially painful interventions, such as starting an IV line or splinting a fracture. Music has been shown to be effective in decreasing the pain of laceration repair in EDs and could be adapted for use on an ambulance. Words should be chosen carefully when communicating; mild discomfort is more useful than terms such as bee sting, prick, or shot.",
        "Assessment of pain": "Objective assessment of pain can be difficult because it is a subjective symptom. The degree of pain cannot be gauged simply by observing vital signs or facial expressions. The pain literature repeatedly documents the unreliability of both vital signs and facial expression in assessing the severity of pain. For pediatric patients, EMS providers often underestimate pain. However, easy-to-use tools are available for adult and pediatric patients that are based upon patient self-report. According to NAEMSP position statement \u201cPrehospital pain management,\u201d self-report scales are \u201cthe most reliable indicator of pain.\u201d These scales allow not just the quantification of pain at one point in time, but also for monitoring the change in the level of pain over time and after analgesic administration. A helpful technique is to use a 1\u201310 (\u201cno pain\u201d to \u201cunbearable pain\u201d) numerical rating scale (NRS), which is a completely verbal scale. This scale is very easy to use for patients who can speak and are fluent in the same language as the prehospital provider. Alternative scales include the verbal rating scale (VRS) and visual analog scale (VAS). These scales require printed diagrams so are more cumbersome. However, they can be useful for patients who are unable to speak or who are fluent in languages other than that of the prehospital provider. The instructions and diagrams for these two scales can be preprinted in any language. The VRS has five listed pain levels and the patient is asked to pick the one that describes his or her pain. The VAS has a line that is 100 mm long, with \u201cno pain\u201d listed on the left and \u201cmaximal pain\u201d written on the right. The patient is asked to indicate where along the line his or her own pain level lies. According to \u201cPrehospital pain management,\u201d one-dimensional pain scales that can be used for pediatric patients include the Color Analogue Scale (in which colors indicate the intensity of pain) and the Faces Pain Scale (in which cartoon facial expressions indicate the intensity of pain). The Faces Pain Scale also may be useful for non-English-speaking patients or those with limited English comprehension skills.",
        "Pitfalls": "The major pitfall regarding analgesia is the attitude that it should not be provided in the field but should wait for hospital evaluation. Safe and effective prehospital pharmacological analgesia should be delivered as soon as possible and non-pharmacological techniques are appropriate for the majority of patients with pain. These techniques will not \u201cmask\u201d the diagnosis or worsen the patient\u2019s condition. Pain is subjective and should be measured by the patient\u2019s words and not expectations of how much a patient should be suffering for a given condition. Another pitfall is to believe that there is a \u201cuniform\u201d dose of analgesic that will bring elimination of pain when using pharmacological therapy. Particularly with the use of opioids, there is tremendous interpatient variability. The best way to approach pain control is to titrate the medication, monitoring for side-effects and efficacy, until the desired result is reached. A particularly common pitfall is the belief that the degree of pain can be gauged by vital signs or facial expressions. The pain literature repeatedly documents the unreliability of either vital signs or facial expression in assessing the severity of pain. The only scale that should be used is verbal expression. A helpful technique to use is a 1\u201310 verbal analog scale, with 10 representing the worst pain the patient has ever experienced. For pediatric patients, using other methods, EMS providers underestimate pain. Another pitfall is to fail to distract the patient while performing painful procedures. Just the opposite usually occurs, with the provider calling attention to every step of the procedure, using terms that are intended to soften the insult but usually actually magnify it. Studies have identified many barriers to prehospital analgesia. These include lack of \u201csignificant objective signs,\u201d concern for malingering, aiming simply to \u201ctake the edge off,\u201d and concern about administering dosages of morphine greater than 5 mg. Specifically in pediatric patients, unfamiliarity with pediatric patients and protocols, insufficient education in pediatrics, difficulty in medication administration in uncooperative pediatric patients and inability to assess pain in children have been reported as barriers to analgesia. Protocol changes have been attempted as a means to improve prehospital analgesia rates by removing protocolized barriers, such as the need for a medical oversight order or restrictive assessment categories (e.g. only allowing analgesics for extremity injury or cardiac chest pain). Removing the need for medical oversight order has been found to increase time to analgesic administration. Neither of these protocol changes has been shown to increase the number of patients receiving analgesia to any clinically important amount. The lack of efficacy of these changes is not surprising considering that they do not address the identified barriers to prehospital analgesia. However, educating prehospital providers about pain management may be a more efficacious route to improving prehospital analgesia because such interventions can address the barriers to analgesia. This has been proven to be the case in multiple studies, showing improved understanding of pain management principles and a significant improvement in prehospital pain treatment after educational interventions.",
        "Conclusion": "Treating acute pain and relieving suffering should be a primary mission of all health care providers. Unfortunately, EMS personnel have not been given the tools or training to satisfactorily accomplish this worthy goal. Although patient \u201csafety\u201d and \u201cdoing no harm\u201d must always be considered, these should not be used as excuses for \u201cdoing no good\u201d for patients with acute pain treated in the field."
    },
    {
        "Introduction": "The patient presenting with altered mental status (AMS), also referred to as altered level of consciousness or ALOC, in the prehospital setting is one of the most common encounters in EMS. Many etiologies of AMS have the potential to cause significant morbidity and mortality. It is essential that proper care be initiated in the field, along with the early consideration of a broad differential diagnosis. Often, treatment must begin before the etiology of AMS is established. In most instances, this treatment should be instituted in conjunction with attempts to determine the underlying cause. The main challenge of a prehospital patient with undifferentiated AMS is to rapidly identify and treat potentially reversible problems in the field in order to prevent added morbidity from the complications of a prolonged condition.\n\nFrom the scene. Because the patient often cannot provide an adequate history, field personnel should seek additional information from alternative sources, such as bystanders, family, and physical surroundings. Important questions include the patient\u2019s baseline health and past medical history, the rapidity of the onset of the symptoms, and any complaints voiced or signs exhibited by the patient. One particularly useful question is whether or not the patient ever had a complete loss of consciousness or seizure-like activity.",
        "Evaluation": "The differential diagnosis for AMS is extensive and complex. Although the definitive treatment for many of these causes may fall outside the scope of practice of the EMS provider or the duration of the prehospital contact, he/she and the EMS physician should focus on identifying and managing conditions that may be effectively treated in the field. A brief on-scene interval and expeditious transport are required for time-critical causes of AMS (e.g. stroke, trauma) if these are identified.\n\nOnce scene safety is assured, EMS personnel of all levels should assess the ABCs, check vital signs, and immediately address life-threatening conditions. Once the ABCs are adequately addressed, additional history, physical examination, and field findings may prove useful in developing an appropriate treatment plan. As the situation permits, EMS personnel should systematically obtain as much information about the patient as possible.\n\nEmergency medical services personnel should search common locations such as bathrooms, medicine cabinets, bedrooms, nightstands, and kitchens for clues about underlying illnesses or possible ingestion. A medical alert bracelet or necklace should be sought. Other household members with similar signs and symptoms, or the presence of multiple patients with altered mental status, or the presence of sick or deceased pets may point to a toxic environmental exposure such as carbon monoxide (CO) poisoning.\n\nIf a drug overdose or poisoning is suspected, EMS personnel should gather further pertinent information, including the route of exposure, the type of substance involved, and the time and amount of exposure. In the majority of cases, overdoses will occur by ingestion. If the exact amount of exposure or ingestion is not known, personnel should try to establish the maximum possible quantity. They should also note any actions taken by the patient or bystanders, including the administration of any \u201cantidotes.\u201d Empty pill containers, liquor bottles, syringes, and other drug paraphernalia can greatly facilitate later treatment decisions.\n\nOne important route of ingestion that is not always considered is \u201chuffing\u201d or the use of chemical vapor to achieve AMS. Data from the 2012 Monitoring the Future Study show that, while inhalant abuse has declined as prescription drug abuse has climbed, inhalants are still easy \u201clegal\u201d drugs to obtain for young teens, with inhalant use declining as age increases. With any inhalant there is a risk of sudden sniffing death caused by an irregular heart rhythm leading to heart failure. Suffocation, asphyxiation, and aspiration are also risks inherent to this form of substance abuse.\n\nRegarding the physical examination, the first task is to determine the degree of the AMS. Unfortunately, a variety of inexact terms are commonly used to describe AMS. Descriptive terms such as stuporous, comatose, semi-comatose, obtunded, confused, and delirious are poorly defined and may lead to different interpretations by bystanders, EMS providers, and hospital-based physicians. In general, it is best for the level of consciousness to be described on the basis of the response that the patient makes to a given stimulus. Field providers can use the simple mnemonic AVPU.\n\nA = the patient is Alert\nV = the patient responds only to loud Verbal stimuli\nP = the patient responds only to Painful stimuli\nU = the patient is Unconscious\n\nEmergency medical services personnel may also use the Glasgow Coma Scale (GCS). A study done with paramedics scoring videotaped patients with AMS confirmed that paramedics can determine GCS scores that correlate well with those of emergency physicians.\n\nThe directed and focused physical exam and secondary survey can aid in determining the cause of AMS.",
        "Evaluation - Head": "The head should be examined for any obvious signs of trauma, such as scalp and facial lacerations, abrasions, and contusions. The pupils should be observed for symmetry and light reactivity. If they demonstrate bilateral mydriasis this may indicate cerebral hypoxia or a toxicological etiology (anticholinergics, sympathomimetics, selective serotonin reuptake inhibitors, etc.). Miosis is often due to opioid overdose. However, clonidine, antipsychotics, organophosphates, sedative-hypnotics, and pontine stroke may also cause miosis. Unequal pupils may be found as a normal variant, but they could also indicate impending herniation from trauma or a spontaneous intracranial hemorrhage. Any odor on the patient\u2019s breath (acetone, bitter almonds, ethanol, or volatile agent) should be noted. The tongue should be checked for bleeding, which may indicate seizure activity.",
        "Evaluation - Neck": "Any upper airway stridor should be documented, and plans to care for a partially or soon-to-be obstructed airway must take precedence. Should signs of possible acute trauma be found in a patient with AMS, the cervical spine should be evaluated and EMS personnel should maintain cervical spine precautions in keeping with protocols.",
        "Evaluation - Chest": "The respiratory rate, pattern, and depth should be noted. Again, any outward signs of trauma should be identified.",
        "Evaluation - Abdomen": "A patient with AMS who presents with a rigid, distended, or tender abdomen may be having an intraabdominal catastrophe. Pregnancy and its complications (eclampsia, HELLP syndrome, ectopic pregnancy) should be considered in females of childbearing age, especially if the patient appears gravid. In these situations, EMS protocols or direct medical oversight should provide the option for the patient to be transported to a medical facility capable of caring for acute surgical patients or pregnancy-related complications.",
        "Evaluation - Neurological": "In addition to pupillary findings, any focal neurological signs suggesting stroke or increased intracranial pressure, such as extremity flaccidity or Cushing\u2019s triad, should be noted and recorded as a baseline for possible progression. Altered speech patterns may also be elicited with the aid of bystanders. EMS personnel should screen for stroke using an established stroke scale, such as the Cincinnati Prehospital Stroke Scale, Los Angeles Prehospital Stroke Screen, or the Melbourne Ambulance Stroke Screen.",
        "Evaluation - Skin": "The skin may be used to determine temperature, which may be increased in infection or heat illness and decreased in cold exposure, dehydration, or alcohol or barbiturate overdose. Rashes potentially indicating infection or allergic reaction should be noted. Track marks consistent with needle injections and narcotic overdose should be checked for. Signs of a previous suicide attempt, such as healed wrist scars, may be apparent. The undifferentiated patient should be log-rolled and examined head to toe for occult puncture wounds or other subtle findings.",
        "Management": "The focus of a care protocol for the patient with AMS is to secure the ABCs and rapidly identify and treat reversible conditions. Appropriate basic life support measures, such as basic airway management and spinal precautions, should be instituted before any attempt is made to gather a complete history or perform a detailed physical examination.",
        "Management - Airway": "For the majority of AMS patients, the first priority is to establish and maintain an adequate airway. If the patient is apneic or hypoventilating, respirations should be assisted by bag-valve-mask (BVM). Advanced airway placement may be considered if BVM ventilation is not effective, but the majority of patients can be managed with airway adjuncts, enough hands, and basic maneuvers. For the patient with adequate respirations, a nasal or oropharyngeal airway with oxygen via a non-rebreather mask may be appropriate. Continuous positive airway pressure (CPAP) may be of great assistance in the patient with adequate respiratory drive but shallow or ineffective ventilation, who may be hypercapneic. End-tidal CO\u2082 monitoring can assist the prehospital provider in both diagnosing and managing the patient with elevated pCO\u2082 as a cause for AMS. Should the patient become agitated or not tolerate CPAP, manual supportive airway measures such as BVM may be required. If no contraindication exists (particularly the need for spinal immobilization), the lateral decubitus position may be advantageous for airway protection in many AMS patients.",
        "Management - Vital signs": "Once the airway is secured, the next step is to accurately measure and frequently reassess the patient\u2019s pulse, blood pressure, pulse oximetry, end-tidal CO\u2082, and cardiac rhythm. Identification of fever or hypothermia may prove helpful in determining the etiology for AMS. A serious mistake is the failure to recognize shock or cardiac dysrhythmia. Many of the newest generation cardiac monitors also have the ability to measure carbon monoxide and methemoglobin levels via cooximetry. Should vital signs taken automatically via the cardiac monitor be incongruent with the rest of the clinical picture, take them manually (e.g. blood pressure measurement via a manual cuff) to ensure accuracy.",
        "Management - Glucose evaluation and administration": "After vital signs have been addressed, the next step in most EMS protocols calls for the measurement of serum glucose and/or drawing other blood samples for point-of-care testing, usually done concurrently with establishment of IV access. Although the defined level for hypoglycemia varies from system to system, many use a level of less than or equal to 70 mg/dL when accompanied by appropriate signs and symptoms of hypoglycemia. This method of testing then treating is generally preferable to the blind administration of exogenous glucose to all patients with AMS. Only 25% of patients with AMS are hypoglycemic. The common assumption that an ampule of dextrose 50% in water \u201cwon\u2019t hurt anyone\u201d has been refuted. Exogenous dextrose may result in skin necrosis after inadvertent extravasation or subcutaneous infiltration, variable elevations in the serum glucose level, hyperosmolality, hyperkalemia, and potentially a worsened neurological outcome in patients with focal or global cerebral or myocardial ischemia. Worsened neurological outcome is the greatest point of concern and the current consensus is that the blind administration of exogenous glucose may be harmful. However, after administration of dextrose to the known hypoglycemic patient, an improvement in mental status is usually seen within 5 minutes. The average increase in serum glucose level following one ampule of dextrose is approximately 150 mg/dL.\n\nEmergency medical services personnel may have difficulty establishing IV access in patients with hypoglycemia. In these cases the use of intramuscular glucagon has been shown to be safe and effective. Some patients without glycogen stores will not respond adequately to glucagon. The mean time to response to glucagon is approximately 6\u20139 minutes, with an increase in glucose level of about 100 mg/dL. Because of the risk of aspiration, EMS personnel must exercise care when using oral glucose solutions in patients with AMS. In general, if IV access is difficult or prolonged in the critically ill patient, placement of an intraosseous (IO) line is an alternative route for IV therapies, including dextrose administration.",
        "Management - Naloxone": "If vital signs have been obtained and shock and/or hypoglycemia are being managed, another common early step in the evaluation and management of AMS is to consider toxic ingestion or overdose. With the rise in prescription drug abuse, including opiates, the next step in many protocols is to consider administration of an opiate antagonist, as opiate overdose is a potentially reversible cause of life-threatening AMS in the prehospital setting.\n\nNaloxone is the current opiate antagonist of choice in the acute care setting. Naloxone is generally safe, with very few serious side-effects, the most common being precipitation of withdrawal. Many EMS physicians advocate a low-dose administration protocol (0.4 mg initially, titrated to respiratory improvement), which may reverse the life-threatening respiratory depression of opiate overdose without precipitating the violent \u201cemergence\u201d from opioid sedation that occasionally accompanies full and rapid reversal. However, failure to give an appropriate amount of an opioid antagonist is a potential pitfall. The synthetic and semi-synthetic opioids, as well as illicit heroin use, especially in the na\u00efve user, may require very large doses of naloxone for reversal. Thus, frequent titration with repeated small doses of naloxone and close monitoring are recommended.\n\nIn cases in which opioid overdose is suspected, ventilation should be supported with a BVM while waiting for the onset of naloxone. Given the effectiveness of prehospital naloxone, early advanced airway management is contraindicated in the opiate overdose patient. Naloxone can be given by the IM, IN, IV, and IO routes, all of which have been shown to be similarly effective in the prehospital setting. Given the comparable efficacy of the intranasal route, IN naloxone may be the initial route of choice, reducing the risk of a needlestick incident. Also, IN naloxone provides a way for BLS providers and even laypersons to deliver a potentially life-saving medicine to those suffering from opioid overdose. In all cases, it is extremely important that the prehospital care provider observe and record any response by the patient to the administered medication, as this will greatly facilitate the management by subsequent medical personnel.",
        "Management - Other \u201creversal\u201d agents: use of flumazenil": "Given the prevalence of benzodiazepine use and abuse, it is tempting to consider flumazenil, a benzodiazepine antagonist, for the obtunded patient with history of benzodiazepine overdose. However, the use of flumazenil in patients who have also ingested seizure-inducing medications (e.g. tricyclic antidepressants) or in those chronically prescribed benzodiazepines may result in seizures. These seizures may be refractory to benzodiazepine treatment because of blockade of the benzodiazepine receptor; death from flumazenil-induced seizures has been reported. Due to these considerations and because benzodiazepine toxicity is generally managed well with supportive care alone, most medical directors and medical toxicologists do not advocate the use of flumazenil in the field.",
        "Challenges with the AMS patient": "There is probably no patient category that can be more challenging than those presenting with AMS. The large differential diagnosis, combined with the lack of direct pertinent information due to the inability of the patient to give a history, contribute to significant potentials for error. In addition, the prehospital provider on the scene with an AMS patient with a broad differential must rapidly either rule in or rule out time-sensitive conditions that require rapid transport rather than further on-scene management.\n\nFor example, a patient who meets trauma criteria should have a short scene time and rapid transport to a trauma specialty center. Trauma, particularly of the head and neck, is always a possibility for patients with AMS. Although AMS (decreased GCS) is a criterion for specialty transport to a trauma center, a patient with AMS and otherwise minimal signs of trauma may have another competing or underlying etiology for his or her AMS.\n\nA major challenge with AMS patients is that they can be easily triaged into the AMS \u201cnot otherwise specified\u201d protocol, while actually having a definable process. In addition to trauma patients, those with ST-segment elevated myocardial infarction (STEMI) and stroke require rapid recognition and transport. Dysrhythmia and/or hypotension associated with inferior MI may present with AMS as the predominant sign, and stroke patients who are non-verbal or who have isolated slurred speech may be classified first as AMS. Indeed, the various forms of shock all may present with AMS, yet must be treated differently. Keeping a broad differential diagnosis throughout the prehospital encounter, and avoiding \u201ctunnel vision\u201d even while proceeding down a treatment pathway, are essential to preventing errors or delaying definitive care in the AMS patient.\n\nFurthermore, patients with AMS may have multiple ongoing causes for their altered level of consciousness that should be addressed in the prehospital environment. For example, it is tempting to assume that a patient with seizures, who may be actively seizing or postictal, has an underlying seizure disorder. However, seizures may be caused by cardiac arrest (ventricular fibrillation), hypoxia, hypoglycemia, trauma, intracranial hemorrhage, stroke, infection and drug overdose and withdrawal, all etiologies which can separately contribute to the patient\u2019s AMS.\n\nAltered mental status patients with any of multiple etiologies may also be physically aggressive or combative, presenting a challenge as well as a risk to EMS providers. Patients with traumatic head injuries, those under the influence of either prescription or illicit drugs or alcohol, and those with medical emergencies such as hypoglycemia, postictal state, decompensated psychiatric disorders, and many others may be violent. The experienced EMS provider will recognize that these patients may have combative altered mental status due to an underlying medical condition, but that does not lessen the risks of physical harm to the patient or the provider. Care should be taken to ensure both crew and patient safety with potentially combative patients, and early involvement of law enforcement in these cases may be warranted.\n\nIn addition, even experienced medical personnel may not be able to immediately differentiate between patients who are simply altered, due to hypoglycemia for example, and relatively easily calmed and treated, and those who are suffering from emergency life-threatening situations such as excited delirium syndrome. Therefore, after immediate attempts at verbal redirection fail, EMS providers may need to assist law enforcement with the application of physical restraints, always with concurrent chemical restraint, in order to assess, treat, and possibly resuscitate these critically ill patients.",
        "Refusal of care after resolution of altered mental status: treatment for hypoglycemia or opiate overdose": "Despite the broad differential diagnosis, EMS providers will many patients with AMS on the scene, especially those with relatively straightforward, isolated conditions such as hypoglycemia or opiate overdose. One of the greatest challenges with these patients is determining who has a single, self-limited process that has been fixed and that is unlikely to recur, and therefore may be safe to not be transported to the ED or otherwise refuse care, and who requires further treatment or extended observation and therefore should be transported to the ED. Many hypoglycemic patients who have improvement in mental status with field treatment will refuse further medical care and transport. This practice has been shown to be generally safe if certain criteria are met. Many EMS systems have \u201ctreat and release\u201d protocols for resolved hypoglycemia.\n\nIn general, some common proposed criteria for safe treatment and non-transport are as follows.\n\n- History of insulin-dependent diabetes mellitus, and/or the patient is not taking long-acting oral hypoglycemics.\n- Posttreatment blood glucose level greater than 80\u2013100 mg/dL.\n- Return of normal mental status within a short time of dextrose administration.\n- Ability to tolerate food and liquid by mouth, and/or the patient must eat a meal in the presence of EMS.\n- A responsible adult is present to assist the patient as needed, especially in case of recurrent hypoglycemia.\n- Absence of complicating factors (e.g. chest pain, arrhythmias, dyspnea, seizures, alcohol intoxication, chronic renal failure requiring dialysis, or focal neurological signs/symptoms).\n\nIt is always important for the EMS provider to determine whether the patient is taking a long-acting oral hypoglycemic agent. Despite any immediate improvement, in the absence of a plan for in-home medical care and close glucose monitoring, all patients taking these medications should be transported to the emergency department for further evaluation and extended observation due to the prolonged half-life of their medications and high likelihood of relapsing hypoglycemia.\n\nA similar controversy may arise for narcotic overdose patients successfully treated with naloxone. These individuals may feel well and wish to refuse transport to the emergency department. Because of the relatively short half-life of naloxone, there is concern that these patients may later develop the recurrence of symptoms.\n\nExperience in EMS systems that have been fully reversing opioid overdose and allowing transport refusals would suggest the actual risk of clinically significant resedation is small. Some EMS systems have protocols that allow uncomplicated narcotic overdose patients to refuse transport, often after consenting to an additional dose of naloxone prior to the end of the EMS encounter. In general, some common proposed criteria for safe treatment and non-transport of resolved narcotic overdose include the following.\n\n- Isolated IV heroin use, and/or the patient has not overdosed on any oral or long-acting opioids.\n- The patient was not in cardiac arrest and naloxone was used only for the treatment of AMS/respiratory depression.\n- A relatively small dose of naloxone, perhaps \u22642 mg, was required to return the patient to normal mental status.\n- The patient consents to receiving an additional naloxone dose and/or has naloxone available to be readministered if necessary.\n- A responsible adult is present to assist the patient as needed.",
        "Conclusion and EMS protocol recommendations": "The EMS physician, and all prehospital providers, must always approach the prehospital management of the patient with AMS in a systematic fashion and with a great deal of care. A broad differential diagnosis must be considered and maintained throughout the patient encounter. Ongoing evaluation must occur even while treatment steps are accomplished. Attention must be given to supporting the patient's vital functions and to reversing those disorders that can be treated in the field.\n\nBasic Life Support protocols for patients with AMS should focus on the evaluation and treatment of airway and breathing problems, while assuring spinal stabilization when indicated. For the patient who is alert and able to take oral glucose, this treatment could be considered within the basic provider's scope of practice, depending on state or regional protocols.\n\nAdvanced Life Support practitioners may provide fluid resuscitation, IV dextrose to known diabetics with hypoglycemia, naloxone via one of multiple possible routes to suspected opioid overdoses, and many other medications to treat the suspected underlying cause of AMS. The advanced provider's greatest tool, however, is perhaps his or her advanced training and ability to maintain a high degree of suspicion for multiple possible contributors to a patient's AMS. The appropriate EMS protocol for AMS is one that prioritizes rapid and thorough assessment and management of vital signs, allows for the correction of conditions that are reversible in the field, and branches to consider other protocols based on the likely underlying cause(s) of AMS."
    },
    {
        "Introduction": "Emergency personnel commonly encounter toxicological emergencies from accidental exposures (e.g. workplace incidents or drug interactions) or intentional exposures (e.g. drug abuse or suicide attempts). In 2011, over 2.3 million human toxin exposures were reported to the American Association of Poison Control Centers. More than 93% of exposures were reported from residences, with routes of exposure by ingestion (83%), through the skin (7%), inhalation (6%), and through the eye (4%). Eighty percent of exposures were unintentional and 62% involved patients under the age of 20 years. The outcome following a poisoning depends on numerous factors, including dose taken, time to first medical contact, and the patient's preexisting health status. Poisonings recognized early and treated quickly often do well. The case fatality rate for self-poisonings in the modern health care setting is approximately 0.5%; however, in the developing world it is 10\u201320%. Therefore, it is imperative that EMS personnel understand the basic management of the poisoned patient.",
        "Evaluation": "When evaluating a patient with a potential toxicological emergency, it is important to maintain a broad differential diagnosis. A comatose patient who smells of alcohol may be harboring an intracranial hemorrhage; an agitated patient who appears anticholinergic may actually be encephalopathic from an infectious etiology. Patients must be thoroughly assessed and appropriately stabilized. There is often no specific antidote or treatment for a poisoned patient and supportive care is the most important intervention.",
        "History": "Emergency medical services personnel should gather as much information as possible about the type of toxin(s) to which the patient was exposed. Poisoned patients are commonly unreliable historians, particularly if suicidal or presenting with altered mental status. If information cannot be obtained from the patient, it is beneficial to obtain information from others at the scene, such as family and friends. Bottles of possibly ingested substance or pills, even if not in the original containers, can assist hospital personnel and poison centers. Other helpful information includes the time of exposure (acute versus chronic), amount taken, route of exposure (e.g. ingestion, IV, inhalation, or dermal), reason for the exposure (e.g. accidental, suicide attempt, or abuse), other medicines routinely taken by the patient (including prescription, over the counter, vitamins, alternative medical preparations), and suicide note, if available. With any unknown exposure, a list of all medications in the home should be obtained, including those of current visitors to the home. This is especially important in an unknown pediatric exposure.",
        "Physical examination": "In the emergency setting, patient stabilization takes precedence over a meticulous physical examination. However, a rapid directed examination can yield important diagnostic clues. Once the patient is stable, a more comprehensive physical examination can reveal additional signs suggesting a specific poison/exposure. Additionally, a dynamic change in clinical appearance over time may be a more important clue than findings on the initial examination. Taking note of odors emanating from the patient or the environment can provide valuable information. Some poisons produce odors characteristic enough to suggest the diagnosis upon first encounter. A complete set of vital signs can further assist the provider in narrowing the differential diagnosis. The skin should be carefully examined by removing patient clothes and assessing for color, temperature, and the presence of dryness or diaphoresis. Absence of diaphoresis is an important clinical distinction between anticholinergic and sympathomimetic poisoning. The presence of bites or similar marks may suggest spider or snake envenomations. The presence of erythema or bullae over pressure points may suggest rhabdomyolysis in the comatose patient, while track marks suggest IV or subcutaneous drug abuse. Finally, a systematic neurological evaluation is important, particularly with patients exhibiting altered mental status. While the Glasgow Coma Scale (GCS) is useful for evaluating trauma victims, it has little role in predicting the prognosis of the poisoned patient.\n\nSeizures are a common presentation of an unknown overdose, and the list of toxins that can induce a convulsion is lengthy. Ocular findings helpful in narrowing the differential diagnosis include miosis and mydriasis. Other useful general neurological signs include fasciculations (from organophosphate poisoning), rigidity (tetanus and strychnine), tremors (lithium and theophylline), and dystonic posturing (neuroleptic agents).",
        "Toxidromes": "A toxidrome is a toxic syndrome or constellation of signs and symptoms associated with a certain class of poisons. Rapid recognition of a toxidrome can determine the class or, in some cases, the specific poison responsible for a patient's condition. It is important to note that patients may not present with every component of a toxidrome and that toxidromes are difficult to identify in mixed ingestions. Certain aspects of a toxidrome can have great significance. For example, noting dry axilla may differentiate an anticholinergic patient from a sympathomimetic patient, and miosis may distinguish opioid toxicity from a benzodiazepine overdose. There are notable exceptions to the recognized toxidromes. For example, several opioid agents (meperidine, propoxyphene, and tramadol) are not always associated with miosis. In most cases, a toxidrome will not indicate a specific poison but rather a class of poisons. Several poisons have unique presentations that make their presence virtually diagnostic. For example, clonidine is associated with sedation, miosis, bradycardia, shallow respirations, and hypotension, yet the patient will become alert with stimulation and then drift rapidly back to sedation with no stimulation.",
        "Cardiac monitor and electrocardiogram": "Electrocardiogram interpretation of in the poisoned patient can be challenging. Numerous drugs can cause ECG changes. The incidence of ECG changes in the poisoned patient is unclear, and the significance of various changes may be difficult to define. Despite the fact that drugs have widely varying indications for therapeutic use, many unrelated drugs share common electrocardiographic effects if taken in overdose. Toxins can be placed into broad classes based on their cardiac effects. Agents that block the cardiac fast sodium channels and agents that block cardiac potassium efflux channels cause characteristic ECG changes, QRS prolongation, and QT prolongation, respectively. The recognition of specific ECG changes associated with other clinical data (toxidromes) can be potentially life saving. The ability of drugs to induce cardiac sodium channel blockade prolonging the QRS complex has been well described in the literature. Cardiac voltage-gated sodium channels reside in the cell membrane and open in conjunction with cell depolarization. Sodium channel blockers bind to the transmembrane sodium channels, decreasing the number available for depolarization. This creates a delay of sodium entry into the cardiac myocyte during phase 0 of depolarization. As a result, the upslope of depolarization is slowed and the QRS complex widens. In some cases, the QRS complex may take the pattern of recognized bundle branch blocks. With tricyclic antidepressant poisoning, rightward axis deviation of the terminal 40 msec of the QRS axis can be present, in addition to QRS widening. In the most severe cases, QRS prolongation becomes so profound that it is difficult to distinguish between ventricular and supraventricular rhythms. Continued QRS prolongation may result in a sine wave pattern and eventual asystole. It has been theorized that the sodium channel blockers cause slowed intraventricular conduction, unidirectional block, the development of a reentrant circuit, and a resulting ventricular tachycardia. This can then degenerate into ventricular fibrillation. Differentiating a QRS prolongation due to sodium channel blockade in the poisoned patient versus other non-toxic etiologies can be difficult. Drugs blocking myocardial sodium channels comprise a diverse group of pharmaceutical agents. Patients poisoned with these agents have varied clinical presentations. For example, sodium channel-blocking medications such as diphenhydramine, propoxyphene, and cocaine may also develop anticholinergic, opioid, and sympathomimetic syndromes, respectively. In addition, specific drugs may affect not only the myocardial sodium channels but also calcium influx and potassium efflux channels, resulting in ECG changes and rhythm disturbances not related entirely to the drug\u2019s sodium channel-blocking activity. All the agents listed induce myocardial sodium channel blockade and may respond to therapy with sodium bicarbonate or hypertonic saline. Displacement of the sodium channel-blocking agents by hypertonic saline or sodium bicarbonate can improve inotropy and prevent arrhythmias. It is therefore reasonable to treat poisoned patients with prolonged QRS intervals, particularly those with hemodynamic instability, empirically with 1\u20132 mEq/kg of sodium bicarbonate (the gold standard for treatment of sodium channel blockade). Shortening of the QRS can confirm the presence of a sodium channel-blocking agent. Approximately 3% of all non-cardiac prescriptions are associated with the potential for QT prolongation. Myocardial repolarization is driven predominantly by outward movement of potassium ions. Blockade of the outward potassium currents prolongs the action potential. This subsequently results in QT interval prolongation and the potential emergence of T- or U-wave abnormalities on the ECG. The prolongation of repolarization causes the myocardial cell to have less charge difference across its membrane, which may result in the activation of the inward depolarization current (early afterdepolarization) and promote triggered activity. These changes may lead to reentry and subsequent polymorphic ventricular tachycardia (VT), most often as the torsades de pointes variant of polymorphic VT. QT prolongation is considered to occur when the QTc interval is greater than 440 msec in men and 460 msec in women, with arrhythmias most commonly associated with values greater than 500 msec. However, the potential for an arrhythmia for a given QT interval will vary from drug to drug and patient to patient. Management of QT prolongation includes infusion of magnesium and possibly calcium to prevent the development of polymorphic VT. There are many agents that can induce human cardiotoxicity, and the resultant ECG changes range from bradycardia (e.g. calcium channel blocker and beta-blocker toxicity) to tachycardia (e.g. sympathomimetics and anticholinergics). EMS personnel managing patients who have taken medication overdoses should be aware of the various ECG changes that can potentially occur.",
        "Treatment": "All patients presenting with potential toxic exposures should be aggressively managed, as the majority of outcomes are good. Airway patency and adequate ventilation should be ensured. If necessary, endotracheal intubation should be performed. Too often, EMS personnel are lulled into a false sense of security by adequate oxygen saturations on high-flow oxygen. A poor gag reflex or inadequate ventilation may increase risk for subsequent aspiration or carbon dioxide retention with worsening acidosis. Intravenous access is generally recommended for poisoned patients, and hypotension should initially be treated with IV fluids. The patient's pulmonary status should be closely monitored for the development of pulmonary edema as fluids are infused. Continuous cardiac monitoring, pulse oximetry, and frequent neurological checks should be documented, noting any changes over time. Glucose should be checked in all patients with altered mental status. EMS personnel must have a low threshold for suspecting carbon monoxide exposure in altered mental status patients. Carbon monoxide is a relatively common, potentially deadly, and easily missed poisoning. Carbon monoxide levels should be measured as early as feasible because these levels can diminish greatly during transport, especially when supplemental oxygen is administered. Many toxins can also cause seizures. In general, toxin-induced seizures are treated similarly to epileptic seizures. EMS personnel should ensure a patent airway and measure blood glucose. Most toxin-induced seizures are self-limited. However, for seizures requiring treatment, the first-line agent should be parenteral benzodiazepines for all poisonings. The use of long-acting paralytic agents should be avoided in intubated poisoned patients because these agents may mask seizures. After initial evaluation and stabilization, toxin-specific therapies should be initiated, and decontamination should be considered. Several poisons have specific antidotes which can be of great benefit if used in a timely and appropriate manner.",
        "Decontaminating the poisoned patient": "External decontamination may be necessary for poisoning by dermal or ocular exposure. Additionally, 83% of poisonings occur by ingestion, which has prompted studies examining the use of gastrointestinal decontamination, which may be required, in the prehospital setting.",
        "Dermal decontamination": "Patients with dermal contamination pose a potential risk of secondary exposure to health care personnel. Decontamination should occur before EMS transport. Personnel conducting dermal decontamination should don personal protective equipment (PPE) appropriate for the contaminating agent. Gas or vapor exposure does not require decontamination (the exception being a need for ocular decontamination in some cases); removal from the site should be sufficient. Potential off-gassing can be avoided by removing and sealing contaminated clothing in a plastic bag. Exposure to liquids or solids requires dermal decontamination. Proceeding from head to toe, brush all solids off the patient's skin and clothing, irrigate the exposed skin and hair for 10\u201315 minutes with water or saline, and scrub with a soft surgical sponge, being careful not to abrade the skin. Patient privacy should be respected if possible, and warm water should be used to avoid hypothermia. Irrigate all wounds for an additional 5\u201310 minutes. Stiff brushes and abrasives should be avoided because they enhance dermal absorption of the toxin and can produce skin lesions that may be mistaken for chemical injuries. Sponges and disposable towels are effective alternatives.",
        "Ocular decontamination": "When required, ocular decontamination should be performed immediately by gentle irrigation of the affected eye(s) and contiguous skin. Ocular irrigation with sterile normal saline or lactated Ringer's solution should continue for at least 15\u201330 minutes. Tap water is acceptable if that is the only solution available. However, due to its hypotonicity relative to the stroma, tap water may facilitate penetration of corrosive substances into the cornea and potentially worsen outcome. Lactated Ringer's solution may be a preferable irrigant due to its buffering capacity and neutral pH. Irrigation should be directed away from the medial canthus to avoid forcing contaminants into the lacrimal duct. Longer irrigation times may be needed with specific substances and the endpoint of irrigation should be normalization of the eye's pH. Because pH paper is not typically carried by EMS units (although it may be available on hazardous materials units), continuing irrigation during transport is frequently required.",
        "Gastrointestinal decontamination": "Significant controversy exists concerning the need for routine gastric decontamination in the poisoned patient, and gastric lavage is no longer recommended. Gastric decontamination may be considered in select cases and specific scenarios, but in general, the prehospital care provider should focus on rapid transportation of the poisoned patient to the hospital. Before performing any gastrointestinal decontamination techniques, including the oral administration of activated charcoal, EMS personnel must clearly understand the hazards of these procedures. Personnel must carefully weigh the risks and benefits prior to making any decisions about the use of gastrointestinal decontamination. Contacting the local poison center (i.e. US poison centers at 1-800-222-1222) can guide decisions to pursue gastric decontamination. Syrup of ipecac, previously a mainstay of poisoning management, is no longer recommended in the management of poisoning. Emesis, either by mechanical stimulation (i.e. placing a finger down the throat) or by use of syrup of ipecac, should be avoided. The prehospital use of activated charcoal is currently controversial, and it is premature to recommend the administration of activated charcoal by EMS personnel without poison center guidance. Activated charcoal is given orally to prevent gastrointestinal absorption of an ingested substance. The administration of charcoal is contraindicated in any person who demonstrates compromised airway protective reflexes unless he or she is intubated. Intubation will reduce the risk of charcoal aspiration but will not totally eliminate its occurrence. Charcoal is also contraindicated in persons who have ingested corrosive substances (acids or alkalis). Charcoal not only provides no benefit in corrosive ingestions, but its administration could precipitate vomiting, obscure endoscopic visualization, or lead to complications if a perforation develops and charcoal enters the mediastinum, peritoneum, or pleural space. Charcoal should be avoided in cases of pure aliphatic petroleum distillate ingestion. Hydrocarbons are not well adsorbed by activated charcoal, and its administration could lead to further aspiration risk. Other commonly encountered substances that do not readily bind to charcoal include lithium, solvents, most metals (iron, lead), potassium chloride, sodium chloride, fluoride, cyanide, and alcohols (to include ethylene glycol, methanol, diethylene glycol).",
        "Antidotes": "The number of pharmacological antagonists or antidotes that EMS personnel may have access to in prehospital management is quite limited. There are few agents that will rapidly reverse toxic effects and restore a patient to a previously healthy baseline state. Administering some pharmacological antagonists actually may worsen patient outcome compared with simply optimizing basic supportive care. As a result, antidotes should be used cautiously and with clearly understood indications and contraindications. Many antidotes are covered in Chapter 47 but two specific antidotes will be discussed here.",
        "Flumazenil": "Benzodiazepines are involved in many intentional overdoses. Although these overdoses are rarely fatal when a benzodiazepine is the sole ingestant, they often complicate overdoses with other central nervous system depressants (e.g. ethanol, opioids, and other sedatives) due to their synergistic activity. Flumazenil should not be administered as a non-specific coma reversal drug and should be used with extreme caution after intentional benzodiazepine overdose because it has the potential to precipitate withdrawal in benzodiazepine-dependent individuals and/or induce seizures in those at risk. The initial flumazenil dose is 0.2 mg administered intravenously over 30 seconds. If no response occurs after an additional 30 seconds, a second dose is recommended. Additional incremental doses of 0.5 mg may be administered at 1-minute intervals until the desired response is noted or until a total of 3 mg has been administered. At present, flumazenil is very rarely used in the out-of-hospital setting.",
        "Naloxone": "Opioid poisoning from the abuse of morphine derivatives or synthetic narcotic agents may be reversed with the opioid antagonist naloxone. Naloxone is commonly used in comatose patients as a therapeutic and diagnostic agent. The standard dosage regimen is to administer from 0.4 to 2 mg slowly, preferably intravenously. The IV dose should be readministered at 5-minute intervals until the desired endpoint is achieved \u2013 restoration of respiratory function, ability to protect airway, and an improved level of consciousness. If the IV route of administration is not viable, alternative routes include intramuscular injection, intraosseous, intranasal, or via nebulization. Intramuscular administration is an accepted alternative route but if the patient is hypotensive, naloxone may not be absorbed rapidly from the intramuscular injection site. Intranasal and intramuscular naloxone have been distributed to bystanders for use in heroin and opioid overdose situations. The onset of action is longer with the intranasal form than the IV form (8\u201312 minutes versus 6\u20138 minutes), but similar to that of intramuscular naloxone. One study suggests intranasal naloxone may induce a gentler reversal with less agitation compared to IV naloxone. Early reports suggest an increased need for redosing with intranasal delivery but it is not clear if this is truly needed or a provider response to the longer onset of action. There are no published data on the optimal dose of intranasal naloxone, but in studies investigating intranasal naloxone delivery a 2 mg dose is frequently used and 1 mg is delivered in each nostril. The cost of the mucosal atomization device that allows for intranasal drug delivery is prohibitive in many areas of the US and worldwide. There is ongoing research on both intramuscular and intranasal naloxone in the prehospital setting for both bystanders and EMS providers. A patient may not respond to naloxone administration for a variety of reasons: insufficient dose of naloxone, the absence of an opioid exposure, a mixed overdose with other central nervous and respiratory system depressants, or medical or traumatic reasons. When it does reverse opioid intoxication, naloxone can precipitate profound withdrawal symptoms in opioid-dependent patients. Symptoms of withdrawal include agitation, vomiting, diarrhea, piloerection, diaphoresis, and yawning. There are reports of patients developing noncardiogenic pulmonary edema in response to naloxone and as an effect of opioid intoxication itself without a clear understanding of the mechanisms behind this. Providers should use care in administering this agent, and only give the amount that is necessary to restore adequate respiration and airway protection.",
        "Special considerations: caustic exposures": "Acids and bases are routinely grouped into a more general category called caustics. In most cases, the concentration of the product, duration of exposure/contact time, and route of exposure (ingestion, inhalation, dermal, ocular) determine the extent of injury suffered by an exposed patient. Traditionally, acids and bases have been associated with different injury patterns. Liquefactive necrosis is a term often used to describe the type of tissue damage encountered with caustics that are characterized as \u201cbases\u201d. Bases can deeply penetrate the tissue, causing fat saponification, protein dissolution, and emulsification of cell membranes. Coagulation necrosis is the type of injury associated with caustics characterized as \u201cacids.\u201d With coagulation necrosis, tissues become erythematous and ulcerated, mucous membranes slough, and eschars can form which theoretically prevent deeper penetration of the acid. While these injury patterns apply to most caustics classified as acids or bases, there are exceptions to the rule. One of these frequently encountered exceptions is hydrofluoric acid. Found in wheel cleaners and glass etching creams, hydrofluoric acid is considered an acid but rarely causes visible tissue damage. Instead, it penetrates the tissues and binds to intracellular calcium and magnesium, leaching them out of the cells, depleting the cells of these ions, and causing significant pain. Patients exposed to this compound develop hyperkalemia, hypocalcemia, and hypomagnesemia, which can result in cardiac dysrhythmias and death. Thorough decontamination of the skin and eyes is necessary for any possible exposures. Antacids containing calcium and magnesium can be given orally in an effort to bind the fluoride molecule of the ingested hydrofluoric acid early, but this should not be done without poison center involvement, especially if multiple agents are ingested. Additionally, treatment consists of aggressive IV electrolyte repletion and cardiac monitoring. Once the patient has been removed from any caustic exposure source, stabilization of the airway, breathing, and circulation remains the initial priority. Stridor or drooling may indicate airway involvement/impending airway compromise, and EMS providers should pay close attention to these patients. The presence or absence of oral lesions does not provide an accurate indication of whether or not significant ingestion has occurred. Decontamination at the scene is preferred if possible to prevent continued injury. The type of decontamination will depend on the route of exposure. The same principles of decontamination previously discussed can be used \u2013 for example, if the patient has been exposed to sodium hydroxide crystals, brushing the solid crystals off prior to removing clothing and washing the skin is necessary. For exposures involving inhalation and vapor exposure, removing the patient from the source and flushing the eyes is important. There are a few instances where dilutional therapy with milk or water may be recommended by the poison center. This may be recommended prior to EMS arrival and has better results when performed within minutes of ingestion, but should not be attempted without poison center recommendation. Basic wound care dressings can be applied to injured skin after the wound has been decontaminated with water or normal saline.",
        "Protocols": "The development of specific protocols for treating each individual type of poisoning is unrealistic due to the vast number of potential toxins. It is also impractical to have one protocol that could easily pertain to all cases of poisoning. It may be necessary to construct protocols for the different problems that require different treatments in the field (e.g. suspected opioid intoxication, carbon monoxide toxicity, and chemical dermal contamination). Integral to these protocols is an outline of the relevant history and physical findings that guide the provider to appropriate generalized management of the intoxicated patient. In addition, each protocol should contain the toll-free national poison center number (1-800-222-1222) where the EMS provider can obtain guidance 24/7 from experts in the field of medical toxicology.",
        "Conclusion": "Emergency medical services providers are often required to care for poisoned patients. Many of these patients do well with standard medical management and never develop significant toxicity. However, for patients who present with serious toxic effects or after potentially fatal exposures, prompt action must be taken. As many poisons have no true antidote and the poison involved may initially be unknown, the first step is good supportive care. Attention to supportive care, vital signs, and prevention of complications are the most important steps. Taking care of these issues will often be all that is necessary to ensure recovery."
    },
    {
        "Introduction": "Obesity is a major health problem in the United States. Body mass index (BMI) is used to quantify obesity and is calculated by dividing the weight in kilograms by the height in meters. More than 69% of the US population is considered overweight, and 36% are obese as determined by BMI. Obesity has numerous effects on health, and is a risk factor for many diseases and health conditions such as hypertension, dyslipidemia, type 2 diabetes mellitus, coronary artery disease, stroke, gallbladder disease, osteoarthritis, obstructive sleep apnea, pulmonary hypertension, and some cancers (notably endometrial, breast, and colon). Obesity does not only contribute to medical conditions, but may also affect one's risk for, and recovery from, trauma. Obese individuals are at increased risk for traumatic injury, may have increased risk of chest, pelvis and extremity fractures, and of pulmonary, renal, and thromboembolic posttraumatic complications. Obstructive sleep apnea, being relatively common in the obese, increases seven-fold the risk of motor vehicle accidents. The variety of anatomical and physiological changes that occur with the bariatric patient not only affects their risk for disease, but can dramatically affect their prehospital management. Mask ventilation can be difficult and poor respiratory mechanics can predispose the bariatric patient to rapid desaturation and hypercarbia. Medication administration can be complicated based upon various drug dosing calculations, and high-quality cardiopulmonary resuscitation (CPR) can be hindered by the habitus of the bariatric patient. Increasing numbers of bariatric surgery procedures present the prehospital provider with unique pathologies, while more practically speaking, the bariatric patient can pose significant challenges to patient packaging, lifting, and movement. This chapter reviews the key anatomical and physiological changes and identifies the critical management considerations that the overweight patient poses to our prehospital care systems.",
        "Airway": "The bariatric patient can provide significant challenges to airway management as a BMI of greater than 26 kg/m\u00b2 is an independent predictor of difficulty in maintaining oxygen saturation with mask ventilation. Redundant soft tissue about the face and neck can complicate both BLS and ALS airway interventions, and positioning of the bariatric patient is critical for successful management of airway and breathing. Whenever practical, the obese patient should be allowed to sit in a Fowler's or semi-Fowler's position. This will displace redundant soft tissue around the neck inferiorly, allowing for easier airway management, and will improve the patient's respiratory dynamics, which is critical as bariatric patients do not tolerate periods of apnea. Mask ventilation of the bariatric patient requires two-person techniques to be effective, where one provider is assigned to establish and maintain a mask seal with a two-hand grip, while the other provides ventilations. Often this simple but important intervention is not performed either because of a perception of \u201cadequacy\u201d with one-person techniques, or because in some systems there may not be enough personnel to accomplish this. Additionally, the use of a properly sized mask with oral or nasal airway adjuncts is critical to achieving effective mask ventilation in the obese patient. Ramp positioning, where the patient\u2019s external auditory canal is aligned with the sternal notch, has been identified as an important tool to improve laryngoscopic view and also improves mask ventilation and subsequent oxygenation. This positioning can be accomplished by aggressive padding behind the shoulders, neck, and head with towels and blankets. Soft tissue displacement during laryngoscopy may be difficult, thus worsening visualization of the glottic opening, and the ramp placement assists with this. Interestingly, although increased BMI does predict difficulty with mask ventilation, there is mixed literature to support a similar correlation with tracheal intubation. Regardless, since the obese patient is clearly difficult to effectively mask ventilate,and such a technique is the basis for initial and failed airway management attempts, the bariatric patient must be approached as if any airway intervention will be difficult.\n\nSurgical airway placement may be challenging in the bariatric patient, regardless of the open or percutaneous technique used. Due to the additional soft tissue about the neck, surgical landmarks are often obscured and conventional cuffed tracheostomy tubes may not have adequate length to assure tracheal placement. As a result, a cuffed endotracheal tube is recommended when performing a surgical airway on a bariatric patient. Supraglottic airway devices may be effective in the bariatric prehospital patient based on operating room data; however, there is scant prehospital literature on the topic, and no published experience with the commonly used King airway.\n\nThe bariatric patient with respiratory distress or airway compromise can create significant clinical management challenges for higher-risk procedures such as rapid sequence intubation. A patient who is inherently unable to tolerate hypoxia, coupled with predictable difficulty in effective mask ventilation, requires a thoughtful and methodological approach to airway management. Preparation is critical, including adequate preoxygenation with continuous positive airway pressure, two-person mask ventilation techniques, and ramp positioning. Having immediate access to surgical airway equipment and supraglottic airways is also required. Most importantly, developing the critical clinical decision-making skills amongst providers who may perform rapid sequence intubation is imperative to balance the risks and benefits of the procedure in the bariatric patient.",
        "Breathing": "The effects of obesity can dramatically affect the acutely ill patient\u2019s respiratory system. The overweight and obese have poor pulmonary reserves as a result of multiple factors. The obese patient demonstrates a restrictive pulmonary physiology as a result of the additional chest wall mass, as well as an increase in resting intraabdominal pressure. Intraabdominal compartment pressure of greater than 12 cmH\u2082O is often considered a compartment syndrome, and the morbidly obese often have intraabdominal pressures at or exceeding this level. This decreases the effectiveness of the diaphragm for inspiratory effort and decreases venous return. Further, the bariatric patient will have decreased lung volumes, a decrease in functional reserve capacity and expiratory reserve volume, and reduced lung and chest wall compliance. These features impart poor respiratory mechanics and are coupled with an increased ventilation/perfusion mismatch compared to a non-obese patient. Thus the bariatric patient has a smaller oxygen reserve, but because of increased metabolic activity has increased oxygen demand and CO\u2082 production. This constellation of physiological insults results in a rapid onset of hypoxemia in even the \u201chealthy\u201d morbidly obese patient. To combat this inherently poor baseline physiology, a few important interventions can enhance the oxygenation of the obese patient. Whenever possible, the obese patient should be positioned in either a semi-Fowler\u2019s or ramped position, even during preoxygenation for advanced airway procedures. For the immobilized patient, even slight reverse Trendelenburg positioning can displace body mass to decrease pressure on the diaphragm or the upper chest muscles and therefore improve respiratory muscle mechanics. When considering continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or mechanical ventilation, obese patients generally require more positive end-expiratory pressure (PEEP) to maintain alveolar ventilation than their lean counterparts and should generally be started at 10 cmH\u2082O. Thus the advantages of PEEP to recruit atelectatic alveoli in the bariatric patient have to be balanced with its negative effects on cardiac output, particularly given the elevated intraabdominal pressures that reduce cardiac preload. Extremely important, however, is remembering that lung volumes are calculated on ideal body weight and not total body weight. This is important for both mask ventilation and when placing the bariatric patient on a ventilator. Exceeding the recommended 6\u20138 mL/kg tidal volume calculated based on the patient\u2019s ideal body weight can increase the risk of acute lung injury and ultimately the morbidity and mortality of the obese patient. The increase in chest wall tissue found in the overweight and obese can also affect the efficacy of needle thoracostomy attempts. The mean chest wall thickness in a Netherlands study was 3.5 cm, and a catheter length of 4.5 cm was found to not penetrate the pleural space in 9.9\u201335.4% of patients, depending on age and sex. A US study found more concerning results, as the mean chest wall thickness was 4.5 cm, and concluded that the standard 4.4 cm catheter would not be successful in 50% (95% confidence interval (CI) 40.1\u201359.3%), requiring emergency pleural decompression. Proper equipment selection and rescuer knowledge of conventional needle catheter success are thus paramount for a successful intervention.",
        "Circulation": "The bariatric patient has an increased circulatory blood volume, a hyperkinetic circulatory system, and often myocardial hypertrophy and diastolic dysfunction. This may limit the physiological response to an acute pathological insult, putting the patient at increased risk for rapid decompensation. Basic staples of resuscitative care such as blood pressure monitoring may be difficult to obtain accurately because of excess adipose tissue, further challenging objective measurements of perfusion in the morbidly obese. Assuring response personnel are using the appropriate sized blood pressure cuff, and understanding limitations of automatic blood pressure machines compared to manual blood pressures, remain essential, important skills when managing the bariatric patient. Effective, high-quality CPR may be negatively affected by obesity. In addition to the challenges of airway and breathing found in the bariatric patient, obtaining proper CPR positioning, sufficient compression depth, and good chest recoil may be difficult. Further, many CPR assistive devices may not fit the bariatric patient, placing increased reliance on conventional CPR techniques. Despite these considerations, there is no clear correlation between BMI and outcome for in-hospital cardiac arrest, and there is scant literature on its effects in the prehospital setting and what, if any, practical implications obesity has on performing high-quality CPR. Venous access can be particularly challenging in the bariatric patient. Excess adipose tissue may limit peripheral venous access, and redundant neck tissue may make external jugular approaches nearly impossible. Longer intravenous catheters may be required, if a suitable site can be found at all. Intramuscular approaches may not effectively administer the medication to the muscle body and instead enter the excess adipose tissue, whose absorption of drug is erratic at best. Various peripheral venous access assistive devices have emerged, including ultraviolet vessel detection, ultrasound, and intraosseous devices, all with their inherent benefits and disadvantages. Intraosseous venous access is a common option in the bariatric patient, and manufacturers have created longer needles to address the limitations of traditional shorter length needles in the overweight subject. Even with advances in intraosseous technology, the bariatric patient often remains a vascular access challenge, primarily related to greater difficulty in establishing the proper landmarks for needle insertion as a result of excess adipose tissue. Once venous access is obtained, there remain unique challenges to drug dosing in the bariatric patient. Drugs are classically dosed based on lean or ideal body weight (IBW), total body weight (TBW), or adjusted body weight. In the bariatric patient, the pharmacokinetic parameters of volume of distribution, clearance, and protein binding can be markedly affected, particularly those medications that are lipophilic. This becomes important when managing the bariatric patient since EMS personnel may provide significantly more medication than is required because of a general tendency to calculate the dose based on TBW. To generalize, lipophilic medications should be dosed according to TBW, while hydrophilic medications should be dosed according to IBW. To add to the confusion, some medications, such as lorazepam and midazolam, should have bolus doses calculated based on TBW and continuous infusions based on IBW. Notably, most vasoactive medications (epinephrine and norepinephrine) are generally titrated to achieve a target goal (mean arterial pressure) and therefore pharmacokinetic data have less effect on the dose regimen. Dopamine is the exception to this and dose is based on IBW in addition to the target goal. Importantly, drug dosage recommendations are typically made based upon the pharmacokinetic or clinical data from individuals with normal weights, so there may be unique variations in the bariatric patient's pharmacokinetic parameters that are simply not known or appreciated. In short, there is a significant paucity of data in dose recommendations for the obese and morbidly obese, and providers and EMS physicians must be prepared for the possibility of erratic absorption, longer onset, and prolonged duration of medications administered to the obese patient.",
        "Bariatric surgery": "As the incidence of morbid obesity has grown, so has the number of patients receiving bariatric surgery. Bariatric surgery is generally reserved for those with a BMI \u226540 kg/m\u00b2 (or \u226535 kg/m\u00b2 with comorbid conditions) and may be accomplished through a number of surgical techniques. Bariatric surgery has the same short-term complications as other surgical procedures including infection, sepsis, delayed wound healing, deep venous thrombosis, and pulmonary embolism. Additional short-term complications unique to bariatric surgery include anastomotic or staple leak which may occur in up to 3% of Roux-en-Y bypass procedures, and approximately 3% of bariatric surgeries will experience postoperative hemorrhage which usually occurs within the first 24 hours after the procedure. Long-term complications found with all procedures can include small bowel obstruction, gastric or small bowel ulcers, and nausea and vomiting. Laparoscopic adjustable gastric banding can be complicated by erosion or slippage of the band, or leakage from the port or band tubing, while Roux-en-Y can be complicated by anastomotic stricture, gastrogastric fistula, and dumping syndrome. Many who undergo bariatric surgery develop gallstones as a result of such rapid weight loss and some surgeons elect to perform prophylactic cholecystectomy because of this frequent postoperative complication.",
        "Patient packaging and movement": "Facilitating the movement and maintaining the dignity of the bariatric patient has received increased attention over the last decade. Industry has responded with numerous features designed to enhance patient comfort, promote patient and provider safety, and decrease injury to prehospital personnel. These include specialized lifting devices such as bariatric transfer sheets, reinforced and wider backboards capable of carrying larger loads, lateral transfer aids to facilitate bed to EMS and EMS to hospital transitions, and various improvements to stretchers and stair chairs such as hydraulic lifts, lateral expansion \u201cwings\u201d to accommodate a larger girth patient on the standard stretcher, wider stretchers, and stretchers with enhanced load limits. Despite this, the bariatric patient poses unique packaging and movement challenges to prehospital personnel. Common disposable cervical collars often do not fit correctly nor provide adequate immobilization because of the additional adipose tissue found around the neck. Personnel must be familiar with other immobilization techniques using towels, blankets, or manual stabilization when caring for an injured victim with high concern for cervical spine injury. Further, because of the excess adipose tissue often found in the upper back, additional padding behind the head may be required to maintain the neck in a neutral position. Older backboards often have lower weight limits than more modern boards and are therefore at risk for breakage. The standard modern backboard is 16 inches wide and most can safely handle up to 450 lbs, which may not be adequate for moving the bariatric patient. Many manufacturers are now offering wider, reinforced backboards that are capable of supporting up to 1,000 lbs. Other immobilization devices such as the Kendrick Extrication Device and various traction splints may not be able to accommodate larger torsos or proximal thighs, requiring improvisation by the responding personnel to meet the immobilization needs of the bariatric patient. The standard EMS stretcher is 23 inches wide and is able to support between 550 and 700 lbs. Often, the challenge is with the girth of the patient and not necessarily the weight; most patients in excess of 400 lbs will not fit safely or comfortably on standard stretchers. Bariatric stretchers often have a width of 29 inches, with stretcher adapters that can expand up to 40 inches, and increased load limits of 850\u20131600 lbs depending on height position. These increased load capacities come at a cost as these stretchers are significantly heavier than the standard stretcher. Critical to the movement of the bariatric patient is to assure that the stretcher is kept in the lowest position possible in order to minimize the risk of tipping. Equally important is to assure that no fewer than four, and ideally six, personnel are used to move the loaded bariatric stretcher. Once safely secured on the stretcher, the loading of that stretcher into specialized ambulances has become commonplace. The so-called \u201cbariatric\u201d ambulance is generally a Type I or III ambulance that includes a ramp or hydraulic system to completely remove the need for personnel to lift the patient and the stretcher into the ambulance. Ramp systems use a set of ramps and a winch to pull the stretcher into the patient compartment, while hydraulic systems use an elevator lift that brings the stretcher from the ground to the level of the patient compartment, allowing the stretcher to be rolled directly in. Both systems have weight limits that are device specific but generally can accommodate up to 1,300 lbs inclusive of stretcher, patient, equipment, etc. Bariatric ambulances also often carry bariatric stair chairs, transfer devices, and other adjuncts that can facilitate the movement of the bariatric patient while maintaining some dignity and potentially reducing the risk of provider lifting injury. Having policies or procedures in place outlining the safe movement of a bariatric patient is critical, as this outlines the capabilities and resources of a community. For example, specific limitations of regional air medical services should be determined well in advance of a request for service. The lifting and moving of bariatric patients represent a significant injury hazard to prehospital personnel, who already experience higher injury rates than workers in most other industries. The majority of these injuries are related to strains and sprains of the back, and represent an important area for injury prevention. Given the increased frequency of caring for bariatric patients, EMS agencies should establish programs to assure personnel are using the proper lifting and moving techniques for all patients, along with frequent familiarization with the specialized bariatric lifting and moving equipment that is available. Training mannikins that approach 540 lbs are available and are an important tool to assist EMS personnel in learning how to safely extricate, package, and move the bariatric patient.",
        "Conclusion": "The bariatric patient poses unique challenges to prehospital personnel. Airway management can be complicated and poor respiratory mechanics can predispose the bariatric patient to rapid desaturation and hypercarbia; however, basic airway skills, preparation, and patient positioning may reduce this risk. An increased potential for barotrauma can result from improperly calculated tidal volumes while vascular access can be challenging despite modern technologies due to difficulties in identifying anatomical landmarks. Medication administration can be complicated based upon various drug dosing calculations, and familiarity with the unique pharmacokinetics of the bariatric patient is critical. The bariatric patient can also pose significant challenges and hazards to patient packaging, lifting, and movement; however, industry responses to this demand provide EMS personnel with new tools to respond to this challenge. Proper lifting techniques and adequate numbers of personnel to safely move the bariatric patient are imperative to reduce injury regardless of the assistive devices used. Whether it is the ABCs or extrication and movement, being familiar with the alterations in physiology along with the pitfalls of management requires familiarization and preparation to improve the care of the bariatric patient."
    },
    {
        "Introduction": "Choking emergencies are important in EMS because of their time-sensitive nature. Victims of choking can rapidly progress from airway obstruction to loss of consciousness and cardiac arrest. Bystanders must act quickly to resolve true choking episodes. EMS personnel will likely arrive on scene several minutes after the onset of choking. Therefore, they must be prepared to manage a patient in the advanced stages of crisis. Choking is an emergency that must be solved on scene; there is limited value in bringing an unresolved choking victim to the emergency department for definitive treatment.",
        "Pathophysiology and epidemiology": "Choking results from obstruction of the trachea by a foreign object. It is the nature of the so-called \u201ccaf\u00e9 coronary\u201d that occurs during or shortly after a meal. Although most choking episodes are associated with food, non-edible objects may also cause airway occlusion; particularly, children may inadvertently aspirate coins, toys, or other objects. Choking can occur with liquids as well as solid substances. Although most obstructions occur in the hypopharynx, a small foreign body may lodge in either bronchus, causing selective obstruction of a lung or lung segment. Because the right bronchus travels more directly off the trachea, most selective obstructions involve the right lung. Choking may be classified as partial or complete. A complete obstruction impairs the ability to breathe, to talk, and to cough and is an immediate life threat. A partial obstruction results in incomplete occlusion of the airway. In these instances the individual may still be able to breathe, talk, or cough. A complete occlusion generally mandates immediate intervention (such as the Heimlich maneuver, or direct laryngoscopy if ALS personnel are present). Other less invasive maneuvers may be appropriate in individuals with partial obstruction. However, in instances of partial obstruction with compromised air exchange, cyanosis, or loss of consciousness, the rescuer must approach the case as though it involves a complete airway obstruction. The incidence of choking varies with age. Children younger than 1 year of age are most likely to choke, with food and liquids causing most of these episodes. Toddlers aged 1\u20134 years tend to choke on non-food items such as coins or latex balloons. Choking is less common in those aged 4\u20139 years and often occurs from gum and candy. Choking incidence rises again at age 60 years from concurrent conditions impairing coordinated swallowing (e.g. Alzheimer dementia, stroke, drinking alcohol, seizure, or Parkinson disease). A prior choking episode significantly increases the chances of future choking.",
        "Patient assessment": "Because complete or partial airway obstruction may rapidly lead to cardiopulmonary arrest, expeditious recognition of choking is essential. Ideally, bystanders will recognize and immediately treat choking victims. Delay of recognition and treatment until EMS arrival will likely result in clinical deterioration. Patients suffering from complete airway obstruction usually present with classic signs, including aphonia, hands to the throat, and hyperemia of the face. Other more serious signs include altered mental status, cyanosis, and unconsciousness. Many conscious choking victims will exhibit the universal choking sign (hands crossed over the throat) and will nod in affirmation to the question, \u201cAre you choking?\u201d Partial airway obstruction may be more difficult to assess, especially in pediatric patients. These individuals may still have partial speaking ability. In many cases, the victim may exhibit paroxysmal coughing, drooling, stridor, or poor feeding. Common conditions mimicking foreign body aspiration include pneumonia, asthma, croup, and reactive airway disease. An esophageal foreign body may also cause or mimic airway obstruction. Vital signs, pulse oximetry, and other diagnostic tools are not typically useful in establishing the severity of a choking episode. In one series, 2% of admitted adult choking patients had normal prehospital vital signs.",
        "Clinical management": "The clinical course and subsequent deterioration due to choking progress rapidly. In ideal circumstances, bystanders should resolve the airway obstruction, because even the most prompt EMS agencies will not arrive in time to perform needed interventions. Patients presenting with complete airway obstruction should receive the Heimlich maneuver. In the classic Heimlich procedure, the rescuer positions himself behind the sitting or standing patient, placing his arms around the chest at the level of the epigastrium. The rescuer places one fist against the epigastrium, using the other hand to apply quick upwards thrusts. The rescuer repeats the process until the obstruction clears. For the unconscious patient, current ACLS guidelines recommend performing standard cardiopulmonary resuscitation (CPR) chest compressions. The only caveat is that when giving breaths, rescuers should look inside the mouth to visualize and remove any foreign bodies. Abdominal compressions and blind finger sweeps are no longer recommended for unconscious persons. For infants less than 1 year of age, the rescuer typically positions the victim with the head downward, alternating back blows with chest compressions. Bulb suction, visualized finger sweeps, and back blows often work well without the need for chest compressions. Emergency medical services personnel responding to a choking emergency must be prepared to manage the advanced stages of crisis, and must act quickly on arriving at the scene. Bystanders may have failed to recognize that the patient is choking, leading emergency medical dispatchers to miscategorize the call as a condition other than choking (e.g. respiratory distress, chest pain, or unconscious person) due to inaccurate or incomplete information from the 9-1-1 caller. Bystanders may have already made unsuccessful attempts to clear the obstruction with the Heimlich maneuver. The patient may be unconscious or in cardiac arrest. On confirming the presence of complete airway obstruction, rescuers should perform the Heimlich maneuver or chest compressions. In cases of partial airway obstruction, rescuers should monitor for signs of cyanosis, inadequate breathing, or unconsciousness, signifying the need to immediately provide the Heimlich maneuver or chest compressions. If the Heimlich maneuver does not resolve the obstruction, ALS personnel may attempt to directly visualize the airway with a laryngoscope, making efforts to remove visualized foreign bodies using Magill forceps. Foreign bodies below the vocal cords may be more problematic. Anecdotal reports suggest using a rigid suction catheter in these situations. Although data in this area are lacking, intubation is risky in these cases and may further lodge the foreign body. As a last resort, rescuers may consider performing cricothyroidotomy or transtracheal jet ventilation (TTJV). This approach will only work if the surgical airway is placed below the foreign body. There are anecdotal reports of high-pressure TTJV to eject entrapped foreign bodies. However, there are no organized reports of choking management using cricothyroidotomy or TTJV. For patients with partial airway obstruction, there are additional management options. The patient should be encouraged to cough and expel the object. High-flow supplemental oxygen may be appropriate, although the sensation of the mask may make the patient feel uncomfortable, aggravating the situation. If the patient is able to adequately move air, it may be acceptable (and even preferable) to carefully transport the patient to the hospital for definitive care. In these cases, close monitoring of vital signs, oxygen saturation, respiratory effort, and level of consciousness are prudent. Monitoring of end-tidal carbon dioxide may also help to reveal early clinical deterioration, though research data on this are lacking. EMS personnel should provide advance notification to the receiving facility so that the emergency department can prepare its equipment and summon appropriate personnel. Because this is an airway emergency, it typically makes the most sense to go to the nearest hospital. At the receiving hospital, the patient may require urgent sedation, direct or video laryngoscopy, or surgical airway intervention by an emergency physician, otolaryngologist, gastroenterologist, anesthesiologist, or surgeon. Many emergency departments have a \u201cdifficult airway\u201d algorithm that involves summoning various specialists to the emergency department to provide assistance in these situations. Many choking victims refuse EMS care and/or transport. In general, however, it is recommended that patients who have their choking resolved before EMS arrival or by EMS providers be transported to the hospital for further evaluation to ensure that no complications have occurred. This recommendation is based primarily on case reports of laryngospasm, pulmonary edema, anoxic brain injury, and retained foreign body occurring after choking episodes. In addition, there are case reports of damaged internal organs following abdominal and chest thrusts. A patient who persists in refusing transport should be made aware of these possible risks. Informed refusal should be obtained by field personnel following system protocols. As a final consideration, an anaphylactic reaction may masquerade as an upper airway obstruction, especially if the patient has recently eaten nuts. If the history and presentation are suggestive of this situation, rescuers should consider therapy with epinephrine and antihistamines.",
        "Medical oversight considerations": "Deterioration after complete airway obstruction occurs so rapidly that direct medical oversight by phone or radio likely provides only limited value. In cases of partial obstruction, direct medical oversight may provide useful guidance regarding management and receiving hospital options. The most important consideration is to educate EMS personnel to recognize signs and symptoms of partial and complete obstruction. As bystander intervention is essential in treating choking, EMS community outreach and education efforts are equally important. Emergency medical services physician presence at the scene may potentially play a role in selected complicated choking cases. Patients with partial airway obstructions may prove tenuous and difficult to manage, requiring a fine balance between supportive care and skilled airway intervention. An on-scene EMS physician may facilitate selection of optimal treatment strategies. In the event of complete airway obstruction unresolved by basic techniques, an on-scene EMS physician may be best qualified to perform advanced airway interventions, such as direct or video laryngoscopy and foreign body removal, rapid sequence intubation, or cricothyroidotomy. In all cases, the EMS physician\u2019s value will be greatest if he/she is present at the earliest stages of the event, before complete airway obstruction or anoxic injury. The most important controversies in choking management are the use of back blows and chest thrusts. The Heimlich Institute opposes both of these techniques. The American Heart Association (AHA) recommends these interventions if the Heimlich maneuver fails and the American Red Cross (ARC) also advocates for both. The AHA and the ARC recommend chest thrusts instead of the Heimlich maneuver for unconscious, pregnant, and obese patients and for children less than 1 year of age. Critics note that back blows can cause the object to lodge deeper and waste valuable time better spent performing the Heimlich maneuver. In a recent study, the Heimlich maneuver was 86.5% effective at removing an obstruction. Back blows may prove effective in children less than 5 years of age. Chest thrusts are associated with significantly higher morbidity and mortality than the Heimlich maneuver and should probably be reserved for the most serious choking victims. Advanced Cardiac Life Support- and PALS-trained public and EMS providers have improved choking survival rates beyond 95%. Expeditious recognition and treatment of choking are essential and should ideally be accomplished by bystanders. EMS personnel arriving on the scene should be prepared to manage a significantly deteriorated patient. Patients with partial airway obstructions may tolerate supportive care and rapid transport to the hospital. All choking victims should receive transport to the hospital for evaluation."
    },
    {
        "Introduction": "Generalized convulsive seizures are frightening to observe and often result in EMS calls. Provoked seizures represent symptoms of an acute underlying medical or neurological condition. Seizures often occur without clear etiology or provocation. Epilepsy, sometimes referred to as a seizure disorder, is defined by recurrent unprovoked seizures. It is estimated that between 1% and 2% of emergency department (ED) visits are for seizure-related complaints, with many of these patients using EMS systems. Most receive advanced-level care. In one study, seizures accounted for almost 12% of pediatric EMS transports. One study showed that seizures were a common cause of repeated ambulance use. Every community has a cadre of patients with poorly controlled seizures or alcohol-related seizures who use EMS frequently. This familiar group of frequent users may lead to a casual indifference to all patients with seizures. Physicians and providers must recall that seizures at some level are the symptom of some central nervous system (CNS) dysfunction and initiate appropriate management steps to terminate seizures to lessen morbidity.",
        "Pathophysiology": "The concept of a seizure threshold suggests that everyone has the capacity to experience seizures at some level of individual physiological stress. The precipitating events may be electrolyte abnormalities, medications, medication withdrawal, toxins, hypoxia, CNS infections, systemic infections, trauma, or even sleep deprivation. A fundamental distinction in management is to determine whether a seizure results from some identifiable cause or if it is unprovoked. When seizures are secondary to some other condition, they are termed symptomatic seizures or provoked seizures. Unprovoked seizures occur without an identifiable cause. Again, epilepsy is defined by episodes of unprovoked seizures. At a cellular level, seizures are thought to originate in the cerebral cortex or thalamus. Lesions of the brainstem, deep white matter, and cerebellum are not epileptogenic. Seizures result from excitation of susceptible groups of cerebral neurons, with progressively larger groups of neurons developing synchronous discharges. Clinical signs and symptoms follow when a critical mass of neurons is reached. At a biochemical level, there is a disturbance in the balance of cellular excitation and inhibition. Glutamate is the most common excitatory neurotransmitter and acts at the n-methyl-D-aspartate (NMDA) receptor. Current theory is that failure of inhibition mediated by the neurotransmitter gamma-aminobutyric acid (GABA) system leads to prolongation of most seizure types. The neurotransmitter receptor sites are thought to be the sites of action of the antiepileptic drugs. With frequent or persistent seizure activity, physiological changes of hypoxia, acidosis, hyperthermia, hypotension, and reduced cerebral perfusion may occur. At one time these were thought to be the cause of neuronal injury. However, many different avenues of investigation have suggested that injury follows prolonged excessive neuronal discharges even if systemic pathophysiological factors are controlled. Some experimental evidence suggests that neurotransmitter receptors may change in sensitivity or quantity with prolonged seizures; potentially effectiveness of medications might change as seizure duration persists.",
        "Differential diagnosis": "There is a differential diagnosis for seizures since a number of clinical conditions may simulate generalized convulsions. Syncope is a frequent consideration in the differential diagnosis. Loss of consciousness is abrupt in syncope and occasionally the brief myoclonic jerks that accompany the faint are a source of confusion. \u201cConvulsive syncope\u201d results from the cerebral hypoperfusion during the syncopal event. Investigations and treatments should be directed toward the cause of syncope.\n\nA person suffering a blow to the head may have a brief episode of extremity stiffening at the time of impact that understandably may be confused with seizure activity. These events clinically resemble brief abnormal extensor posturing, though myoclonic and tonic-clonic movements are also described. Return to consciousness following these events is usually prompt. These convulsive concussions are not associated with injury or neurological sequelae and do not predict future seizures. Posttraumatic epilepsy may occur after head trauma but is associated with more severe head injuries. These seizures are typical in appearance and associated with a postictal confusional state.\n\nIn any series of stroke patients, seizures and postictal states are a significant source of diagnostic confusion. Seizure patients may have postictal weakness or confusion that mimics some stroke symptoms. Subarachnoid hemorrhage may cause fragmentary or repetitive extensor posturing that at times is confused with seizures.\n\nNon-epileptic seizures, also known as pseudoseizures, psychogenic, or hysterical seizures, often result in diagnostic uncertainty. Simply stated, the patient appears to be having a seizure but subsequent observations prove that the apparent convulsion does not follow from the excessive neuronal discharges that characterize epileptic seizures. The usual descriptions of non-epileptic seizures include side-to-side head movements, out-of-phase limb movements, and pelvic thrusting. However, other reports indicate that simple unresponsiveness without motor movements is a frequent presentation.",
        "Classification of seizure types": "In theory, almost any behavior or experience may result from the abnormal synchronous discharges of groups of neurons. Motor movements, sensory experiences, or abnormal behaviors may all represent seizures. Patterns are seen that allow a categorization of seizures. Modern classification schemes are based on video electroencephalogram (EEG) correlations, but at times seizure-type classification may be made from direct patient observation. A fundamental distinction is whether the seizure is of partial onset or generalized onset. This distinction may be important clinically because partial-onset seizures may imply focal or structural CNS abnormalities and because different medications are effective in different seizure types. In partial-onset seizures, clinical information indicates that seizure onset is limited to one part of the brain. Partial seizures may be further divided into simple partial seizures, complex partial seizures, and partial seizures that secondarily become generalized. In a simple partial seizure, the patient remains at normal consciousness. Partial seizures with sensory symptoms include some patients with episodic paresthesias. Special sensory symptoms delineate seizures with gustatory, olfactory, or auditory components. The term complex implies that consciousness is clouded. Symptoms of these patients are often altered mental status with confusion and simple repetitive motor movements such as lip smacking or picking at clothes. Sometimes prolonged confusional states occur with complex partial seizures, one of the types of non-convulsive status epilepticus. Generalized-onset seizures imply that the cerebral cortex is bilaterally involved at seizure onset. This often requires EEG evaluation for definitive diagnosis. The types of generalized seizures are listed. Some seizure types are typical enough in appearance that they can be classified by observation alone. Partial-onset seizures with secondary generalization are the most common type of generalized seizure in adults. An example of a partial-onset seizure with secondary generalization would be a patient with onset of finger twitching, progression of movements to the arm and face, and then a subsequent generalized convulsive seizure. However, often this secondary generalization occurs too rapidly to be appreciated by witnesses or in the field. A few words concerning terminology are in order. Convulsion refers to the motor movements associated with a seizure. Tonic refers to the stiffening of the extremities seen in convulsions. Clonic is the rhythmic, synchronized movements of the extremities. Some patients experience an aura, which is the initial subjective perception of a seizure. Grand mal is generally used in a manner to be synonymous with a generalized convolution. Petit mal, however, is so frequently misused by patients and physicians that perhaps that term is best not used. Correctly used, it is synonymous with absence seizures, a generalized-onset seizure that has a characteristic EEG three-cycle-per-second pattern. In common usage, however, petit mal is corrupted by association with the word petite, meaning \u201csmall,\u201d so that fragments of seizures or partial seizures are incorrectly labeled petit mal seizures.",
        "Symptomatic seizures": "A basic point in assessment and management is whether a seizure is secondary to some medical condition, such as electrolyte abnormalities, toxins, hypoxia, CNS infections, systemic infections, or trauma. EMS plays a key role in gathering historical information to identify likely seizure causes and initiating therapy. A few causes of symptomatic seizures warrant particular comment. Alcohol withdrawal seizure is a type of symptomatic seizure that usually occurs within 48 hours of cessation of drinking. Usually alcohol withdrawal seizures are single and brief, but up to 30% of patients have recurrent seizures in the ED. Studies of patients with status epilepticus show that in a significant proportion, the seizures are alcohol related. Many different toxins may cause seizures. Sympathomimetics, including cocaine, are perhaps the most frequently encountered. Other toxins that may cause seizures include antidepressants, antihistamines, salicylates, and anti-cholinergics. Isoniazid, used to treat tuberculosis, deserves specific mention because the mechanism of action of the drug requires a specific antidote: pyridoxine (vitamin B1). Seizures in association with advanced pregnancy or in the postpartum patient may represent eclampsia. Hypertension is present. Treatment involves magnesium sulfate and possibly benzodiazepines.",
        "Febrile seizures": "Febrile seizures are one of the most common seizure types encountered in emergency practice, in both the field and the ED. Definitions in the literature vary, but a seizure associated with fever in children aged 6 months to 5 years without evidence of intracranial infection or other definite cause of seizure is an accepted definition. The age-delineated definition acknowledges the sensitivity of the maturing brain to fever. Excluded are febrile-associated seizures in patients who have experienced afebrile seizures. Peak incidence is at 18 months. Other events that may simulate seizures in this age group include rigors, breath-holding spells, apneic episodes, and anoxic seizures. History is key in sorting out these events. Many febrile seizures occur early in the course of the underlying illness and may be the presenting symptom of the illness. The magnitude and peak of the fever are likely to be more important than the rate of increase in provoking seizures. Antipyretics have not been shown to be effective in reducing the risk of febrile seizures. Febrile seizures are often divided into simple and complex types. A simple febrile seizure is a generalized tonic-clonic convolution without focal signs lasting less than 10 minutes, resolving spontaneously, and not recurring within 24 hours. Complex febrile seizures fall outside this definition due to focal signs during the seizures, seizure duration, or recurrence. By definition, a simple febrile seizure will likely have ceased by arrival of EMS, unless the response interval is very short. Recurrent or prolonged seizures exclude this diagnosis and point to a complex febrile seizure or another cause for the seizure. EMS and other sources of history are important in eliciting a history of irritability, decreased feeding, or abnormal consciousness that might suggest an underlying CNS infection. Most children experiencing febrile seizures recover within 30 minutes. Postictal alteration of consciousness persisting more than 60 minutes has been suggested as a risk factor for a complicating medical condition.",
        "Status epilepticus": "Ongoing seizures or status epilepticus may occur in any seizure type and terminology may be confusing. Generalized convulsive status epilepticus represents a true emergency condition because the ongoing electrical seizure activity is itself injurious to the brain. In late or decompensated status epilepticus, there may be a dissociation between the ongoing electrical seizure activity and motor convulsions. In other types of status epilepticus, such as the non-convulsive status seen in prolonged absence seizures, the link between prolonged electrical activity and neuronal injury is not established. Morbidity in generalized convulsive status epilepticus is related to the duration of the seizures and, importantly, to any underlying medical causes of the seizures. Modern definitions of generalized convulsive status epilepticus use a period as short as 5 minutes of continuous seizures is used to define status epilepticus and indicates the need to initiate treatment to terminate the seizures. The other component of the definition is generalized seizures without recovery to full consciousness between seizures. There is a differential diagnosis for generalized convulsive status epilepticus.",
        "EMS evaluation and response": "The most appropriate system response to a patient with seizures is not known because presentations vary greatly. Many patients experience a brief event that has terminated by time of EMS arrival. Other patients may be convulsing at the time of EMS arrival and require ALS interventions. Often a patient with a history of seizures requests not to be transported. Usual system protocols should be followed for patient non-transport with the caveat that the patient is awake, alert, and judged to be capable of making decisions. Ideally, there should be a companion present for assistance should the seizures reoccur. A brief period of observation and examination should be performed after EMS arrival. Establish unresponsiveness as a survey for trauma is undertaken. Note if there is resistance to eye opening because most patients with seizures will have open eyes. Forced eye closure may suggest non-epileptic seizures. Safety issues include protection by moving the patient away from any hard or sharp objects that might be struck during convulsive movements. If the teeth are clenched, they should not be pried open. However, if chewing movements are continuing and the tongue is being lacerated, an adjunctive airway device, such as an oropharyngeal airway, may be gently placed between the teeth to prevent further injury. Following a generalized seizure, the patient is often somnolent and snoring respirations are present that will typically resolve with placement of a nasopharyngeal airway. Oxygen supplementation by mask is recommended. Assessment for airway integrity proceeds as usual but with the expectation that the patient will become more responsive as the postictal state resolves. IV access is recommended if the patient is not fully awake. Hypoglycemia is common and may cause seizures. Perform rapid glucose determination if possible; consider dextrose administration in diabetics or if hypoglycemia is suspected.",
        "Pharmacological interventions": "Pharmacological interventions by EMS will often be limited to benzodiazepines, with the exception of some EMS physician units and critical care transport units. Generally speaking, IV administration of benzodiazepines has been the standard because of rapid therapeutic drug levels, but a variety of reports substantiates the effectiveness of intramuscular, rectal, nasal, and buccal administration of different agents. Benzodiazepines are well tolerated, with the primary side-effects of sedation and respiratory depression. The respiratory depression seems to be related to time to peak serum concentration. Somewhat paradoxically, the IV route may offer the quickest time to peak concentrations but at a risk of greater respiratory depression. The use of alternative routes is particularly attractive in the pediatric population. Intraosseous administration should be an effective route of administration but is little studied in seizure patients. Rectal administration of benzodiazepines (particularly diazepam) for status epilepticus in children has been reported for years. Studied dosages are 0.5 mg/kg administered using a syringe and a soft catheter. Corrections should be made for volume left in the catheter. A second dose of 0.25 mg/kg may be administered if needed. Peak levels are thought to be reached within 10 minutes. A Food and Drug Administration (FDA)-approved preparation, Diastat, is available\n\nNasal administration of benzodiazepines (usually midazolam) has been reported in small case series [35]. Ease of use was the focus in studies comparing nasal midazolam with IV diazepam [36]. Time to seizure cessation was comparable. Another report compared intranasal administration of midazolam using an atomizer device with rectal diazepam and found better seizure control and fewer respiratory complications in the group treated with intranasal midazolam\n\nBuccal midazolam has been studied for seizure control in children in the ED, in comparison with rectal diazepam, and has been found to be as effective or more effective without increased risk of respiratory depression [38,39]. Dosages administered were 0.25 mg/kg [39] or 0.5 mg/kg with adjustments by age with a 10 mg maximum dosage for children age 10 or older [38]. As with many of the therapies discussed here, this is off-label usage. Buccal midazolam is advocated by some as a choice for initial management of prolonged seizures in children, although issues of dosing (range 0.2\u20130.5 mg/kg) remain and further study is desirable.\n\nIntramuscular (IM) administration of a benzodiazepine is possible with midazolam, which has solubility characteristics favorable for absorption [42]. IM administration is rapid and aspiration is not a concern. Increased use of midazolam intramuscularly has been noted in some systems [43]. In one small series of children with seizures, comparing treatment with IM midazolam with IV diazepam, the former was found to be an effective alternative.\n\nPart of the efficacy was thought to be from the rapid administration possible by the IM route without waiting for IV access to be established [44]. The recently published RAMPART study established the safety and efficacy of IM midazolam compared to IV lorazepam when administered for prehospital status epilepticus [45]. This large, randomized, double-blind trial administered midazolam intramuscularly using a preloaded autoinjector. Advantages of the intramuscular route included more rapid drug administration. Dosages of midazolam were 10 mg IM for adults and children estimated to weigh more than 40 kg; for children estimated to weigh 13\u201340 kg, the dosage was 5 mg midazolam IM. Adverse events were similar in both groups.\n\nIntravenous administration of midazolam was found to be more effective than IM administration in one prehospital study, with minimal risk of respiratory depression in both groups",
        "Seizure-associated trauma": "In many EMS systems, full spinal immobilization is standard for patients who have experienced seizures. There appears to be very limited evidence to support this practice, although trauma from seizures has been reported in case reports, case series, and retrospective reviews. Seizures uncommonly cause fractures and dislocations. Some uncommon orthopedic injuries, such as bilateral posterior dislocation of the shoulder, fracture-dislocation of the shoulder, or fracture-dislocation of the hip, suggest a generalized convulsion as the etiology. Bilateral hip fractures have been reported. These cases are notable for their rarity. Only very rare cases of cervical fractures from uncomplicated seizures are reported. There is one description of an odontoid fracture following an epileptic seizure. One retrospective study of over 1,600 transports for uncomplicated seizures (i.e. age greater than 5 years, no associated major trauma, afebrile) found no spinal fractures. Transport charges and nursing charges were increased in this group of patients. The authors raise the question of the need for full spinal precautions in patients sustaining uncomplicated seizures. Compression fractures of the thoracic vertebrae were reported in a patient taking steroids. There is one report of a higher risk of cervical spinal cord injuries in patients with refractory epilepsy attributed to seizure-related falls. This residential facility for patients with refractory epilepsy reported four instances of spinal cord injuries in its patient population over 10 years, which they extrapolated to be a 30-fold to 40-fold risk increase. Retrospective chart reviews of patients with seizures have also identified patients with intracranial hematomas resulting from falls associated with seizures. The authors advocate early investigation in patients with head injury due to seizures and caution that decreases in level of consciousness or focal neurological deficits in seizure patients should only cautiously be interpreted as postictal until traumatic hematomas have been excluded. This review was from a neurosurgical service and undoubtedly incorporates significant ascertainment bias. Given the paucity of reports of significant trauma following uncomplicated seizures, routine immobilization in all cases does not seem warranted, although caregivers should keep in mind that unusual injuries may exist.",
        "Continuing management": "Continued patient management in the ED is informed by what occurred in the field. If the patient\u2019s condition does not evolve to an alert state, the degree of unresponsiveness should be continuously monitored as evaluation proceeds along the pattern of primary survey, resuscitation, secondary survey, and definitive care steps. Information from EMS personnel regarding level of alertness in the field is helpful. Should the need for a definitive airway be established, rapid sequence intubation (RSI) is performed in the usual manner, and this is a field option for some paramedics and EMS physicians. Concerns for possible increased intracranial pressure, if suspected from history or physical examination, may prompt consideration for lidocaine administration as part of RSI, although this remains controversial. Most induction agents have some anticonvulsant properties and use of benzodiazepines would seem prudent, although data are lacking to support these actions. The use of short-acting paralytic agents, if necessary, should proceed in the usual manner. There are only rare case reports in medically complex seizure patients of complications from succinylcholine. Longer-acting neuromuscular blockade should be avoided, however, unless EEG monitoring can be established, because of concerns that seizure activity may be disguised by neuromuscular paralysis. Somnolent patients should be observed and monitored. The postictal state is not well defined, but the possibility of ongoing subclinical seizure activity, complex medical issues, or trauma should be considered if a seizure patient is not starting to become alert within approximately 30 minutes.",
        "Refractory generalized convulsive status epilepticus": "Detailed management of status epilepticus is beyond the scope of this chapter. Benzodiazepines are the mainstay of initial therapy whatever the seizure type or cause, and lorazepam is the recommended initial drug. Most reviews recommend doses in adults of 4\u20138 mg. The possibility that the seizures are precipitated by an acute medical condition should be kept in mind and subsequently investigated. Recommendations for second-line drug lack strong evidence and most reviews and guidelines recommend one of several drugs including phenytoin or fosphenytoin, valproate, levetiracetam, or propofol. While these agents are not generally available in typical EMS environments, they may be found in critical care transport situations and physician response teams. There is a trend in recent guidelines to deemphasize barbiturates in favor of levetiracetam or propofol for generalized convulsive status epilepticus that fails to respond to optimal benzodiazepine administration. Refractory status epilepticus may be defined as generalized seizures that persist through administration of optimal benzodiazepines and a second-line drug, historically a phenytoin. There are no prospective, randomized trials to guide third-line therapy. Anecdotal reports and recommendations list a variety of agents, including high-dose phenytoin, lidocaine, etomidate, ketamine, midazolam, propofol, and valproic acid. Because lidocaine is ubiquitously carried on ALS units, it may be a rational choice in systems with prolonged transport times. Definitive airway management and blood pressure support will be needed with the use of many of these agents.",
        "Conclusion": "Seizures are one of the most common conditions resulting in EMS activation. In many cases, the patient is recovering consciousness at the time of EMS arrival, and little if any care is needed. However, generalized convulsive status epilepticus represents an emergency with early interventions potentially limiting morbidity. After brief diagnostic intervention to confirm seizures, early treatment of persistent or recurrent generalized convulsions with benzodiazepines is indicated. A variety of treatment options is available for route of administration and drug choices. Persistent convulsions will require additional ALS interventions."
    },
    {
        "Historical perspective": "Water comprises 70% of the surface of our planet. It is only natural that given this large percentage of our home, human beings would be drawn to explore this environment. It is currently estimated that there are 1.2 million active scuba divers worldwide and that approximately 200,000 new divers are certified every year. Although diving is considered to be a relatively safe sport, operating in an environment with unique hazards where life-supportive breathing gases must be carried leaves little margin for error. Comparing the total hours involved, diving is estimated to be 96 times more dangerous than operating a motor vehicle.",
        "Introduction": "Emergency medical services physicians and medical directors of EMS systems need not be certified scuba divers, but will benefit from developing a fundamental knowledge of dive-related physiology and hazards. There are four main categories of diving injury: injuries on the surface, injuries of descent, injuries at depth, and injuries of ascent. This chapter deals with injuries below the surface.\n\nDue to the high density of water, small changes in depth cause significant changes in the pressure exerted on an object. At the surface, a body is subjected to the weight of the earth\u2019s atmosphere, which is equal to 1 atmosphere absolute (ATA). During descent, for every 33 feet of seawater (fsw) or 34 feet of freshwater (ffw) traveled below the surface, pressure increases by 1 atmosphere (atm). Typical units of measure for pressure include: 33 fsw = 34 ffw = 1 atm = 760 mmHg = 760 torr = 14.7 psi. The majority of recreational diving occurs between 33 and 120 fsw (2 to <5 ATA).",
        "Boyle\u2019s law": "Governing the physiology of barotrauma and recompression therapy, Boyle\u2019s law states that given a constant temperature, the volume and pressure of an ideal gas are inversely related. It also deals with conditions related to changes in pressure in hollow, air-filled organs and structures in the body. As an example, during descent the pressure is doubled; on a descent from the surface (1 ATA) to a depth of 33 fsw (2 ATA), the volume of a gas is halved. The law is typically stated as: P\u2081V\u2081 = P\u2082V\u2082. As a diver is descending in the water column, the volume of air in gas-filled organs will decrease. If the volume of air in the lungs at the surface is V then at 33 fsw the volume will be 1/2 V, at 66 fsw 1/3 V, etc. If using compressed air, as in scuba diving, when a breath is taken at 66 fsw, lung volume returns to V. If ascent occurs at this point without exhalation, as in an unconscious diver, the lung volume will expand to 1.5 V at 33 fsw and 3 V at the surface, with potential for barotrauma. Liquids and liquid-filled organs are non-compressible. The body tissues are composed primarily of water and thus there is no change in volume with pressure increases and decreases.",
        "Dalton\u2019s law": "Dalton\u2019s law explains the physiology of conditions such as oxygen toxicity and nitrogen narcosis. The law states that total pressure exerted by a mixture of gases is the sum of the partial pressures of the gases in the mix. Thus for fresh air: P_total = P\u2080\u2082 + P_CO\u2082 + P_N\u2082. As total pressure is increased, the partial pressures of each gas in the mixture will increase proportionally. Fresh air is composed of 79% nitrogen and 21% oxygen. These ratios remain constant as pressure is increased at depth. The partial pressure of nitrogen in air at sea level is approximately 600 mmHg or 0.79 ATA (0.79\u00d7760 mmHg), and of oxygen is 160 mmHg or 0.21 ATA (0.21\u00d7760 mmHg). At a depth of 66 fsw, the partial pressure of each would be 3\u00d7600=1800 mmHg (2.37 ATA) for nitrogen and 3\u00d7160=480 mmHg (0.63 ATA) for oxygen.",
        "Henry\u2019s law": "Henry\u2019s law is the foundation for decompression sickness (\u201cthe bends\u201d). The law states that at equilibrium, the concentration of a gas dissolved in a liquid is directly proportional to the partial pressure of the gas above the liquid. This is stated as: P = kC where P is the partial pressure of the gas above the liquid, k is a constant, and C is the concentration of the gas in the liquid. The common example is opening a carbonated beverage container. As the pressure is reduced by opening the can, the CO\u2082 dissolved in solution escapes, forming bubbles as the gas equalizes with the atmospheric partial pressure of the gas.",
        "Injury of descent: barotrauma of descent": "Barotrauma is an injury that occurs due to changes in pressure of an air-filled structure during descent or ascent. Barotrauma is the most common medical problem associated with diving and can involve almost any structure that can have entrapment of gases. Barotrauma causes injury by a change in volume of free gas in an air-filled organ resulting in a pressure disequilibrium. Both increasing and decreasing pressure can cause mechanical injury to body structures. Pain is typically the initial complaint.",
        "Middle ear barotrauma": "Middle ear barotrauma, also known as barotitis media or \u201cear squeeze,\u201d is the most common complaint and medical problem of scuba divers. It is experienced by 30\u201340% of novice scuba divers and 10% of experienced divers. As a diver descends in the water column, water pressure against the tympanic membrane (TM) increases. A diver will employ various methods to force air into the middle ear through the eustachian tube to equalize this pressure across the TM. If the diver is unsuccessful at \u201cclearing\u201d his ears, continued attempts may be futile due to the collapsible nature of the medial third of the eustachian tube. Ascent and reattempts at clearing are the only option for resolution. Further descent may cause TM rupture and result in cold water caloric stimulation and vertigo which may precipitate panic, disorientation, rapid ascent with other associated types of barotraumas, or drowning. Treatment of middle ear barotrauma is usually with decongestants and analgesics and it will typically resolve over 3\u20137 days. Refraining from diving with a cold or other symptoms that may cause difficulty with pressure equalization and early recognition of symptoms are common prevention strategies.",
        "Inner ear barotrauma": "Inner ear barotrauma is much less common than middle ear barotrauma, but has a higher morbidity. Damage to the cochleovestibular apparatus is the result of a large negative pressure gradient in the middle ear that occurs due to a forceful Valsalva maneuver against an occluded eustachian tube. As a result of the increased pressure during the attempted Valsalva, the pressure differential between the cerebrospinal fluid through the vestibular and cochlear structures and the middle ear may result in several injuries, including round or oval window rupture, middle ear hemorrhage, Reissner's membrane tear, fistulization of the windows, or a combination of these. A triad of findings are associated with inner ear barotrauma: vertigo, unilateral roaring tinnitus, and hearing loss. In addition, a feeling of ocular fullness, nystagmus, disorientation, ataxia, and nausea and vomiting may be seen. Immediate concerns relate to the occurrence of panic in the underwater environment, uncontrolled ascent, or drowning. Treatment of inner ear barotrauma includes elevating the head of the bed to 30\u00b0, bed rest, avoidance of strenuous physical activity, and symptomatic treatment. Early otolaryngology consultation should be obtained for further treatment recommendations as surgical repair options remain relatively controversial.",
        "External ear barotrauma": "A less common condition than middle ear barotrauma, external squeeze may occur with a tight-fitting wetsuit hood creating a relative negative pressure in the external canal. The TM is pulled outward due to trapped air in the canal. Cerumen, earplugs, and structural abnormalities may also contribute to this condition.",
        "Sinus barotrauma": "The sinus cavities are susceptible to pressure-volume changes according to Boyle's law. The ethmoid, maxillary, and frontal sinuses require patent nasal passages for equalization of pressure. Any mechanical abnormalities such as deviated septum, polyps, or physical conditions such as bacterial and viral infection, or upper respiratory infections may predispose a diver to sinus barotrauma and resultant barosinusitis. The frontal sinus is the most commonly affected sinus cavity due to the long connection to the nasal passage. Common signs and symptoms in barosinusitis include facial pain or fullness during descent or ascent, numbness to the front of the face, upper tooth pain, and epistaxis. Systemic decongestants and topical nasal vasoconstrictors are the mainstay of treatment. Some authors advocate a short corticosteroid burst to hasten recovery and return to diving.",
        "Mask squeeze": "A face mask must seal tightly around the face and forehead, and under the nose. Diving masks enclose the nose to allow nasal exhalation when equalizing the pressure between the mask and the outside environment. Equalization failure may result in capillary rupture with facial petechiae, ecchymosis, and scleral/conjunctival hemorrhage.",
        "Suit barotrauma": "Suit squeeze develops where folds in wet or dry suit material become compressed during descent, causing a partial vacuum and resulting in an impressive area of ecchymosis post dive. Despite the dramatic appearance, the condition is benign and will resolve in days to weeks.",
        "Dental barotrauma": "Tooth squeeze or barodontalgia is an infrequent but dramatic type of barotrauma. Air trapped below decayed teeth or in other dental structures may cause pain during ascent or descent as air bubbles expand, causing a negative or positive pressure related to ambient pressure. This condition is mostly benign and self-limited, although may be quite painful.",
        "Nitrogen narcosis": "Nitrogen is an inert gas and does not interact biochemically in the body. Nitrogen narcosis, also known as inert gas narcosis, develops typically at depths greater than 100\u2013120 fsw. Nitrogen begins to have anesthetic properties at 3.2 ATA. The symptoms result from the intoxicating effects of increased nitrogen tissue concentrations. Divers may become euphoric, have a false sense of well-being, inappropriate laughter, and develop numbness and tingling in the face, lips, or legs. Decreased decision making and judgment combined with loss of fine motor skills and delayed reaction times may result in drowning or contribute to a dive emergency. As in most physiological states, the effects are variable and there are no absolutes as to who is likely to develop this condition and at what depth. The diving describes that every 1 ATA (33 fsw) descended greater than 100 fsw equates to the consumption of one martini. The condition improves rapidly with ascent, assuming that it is recognized in time. Divers may be unaware that they were affected by the condition. Cold temperature, workload, alcohol, hangovers, and fatigue may contribute to the onset and severity. It is generally recommended that recreational divers not dive with compressed air to depths greater than 120 fsw. Commercial divers use other inert gases, such as helium, neon, and argon, in their compressed gas mix to offset the effects of narcosis. Oxygen itself may become narcotic if left unmetabolized in tissues.",
        "Oxygen toxicity": "Despite the necessity for oxygen to sustain life, increased pressures and lengthy durations of exposure can be damaging to living organisms. The damaging effects are a result of increased partial pressures of oxygen and not necessarily the inspired oxygen percentage in the gas mixture. Although all organs may suffer oxygen's toxic effects, brain, lung, and eye function are often the first to be disrupted. Oxygen free radicals are believed to be responsible for the deleterious effects of high partial pressures of oxygen. Intermediates such as superoxide anions, hydroxyl radicals, and hydrogen peroxide are potentially toxic to cell membranes. Two types of oxygen toxicity relevant to diving are central nervous system (CNS) and pulmonary (\u201cwhole body\u201d). CNS toxicity has a more rapid onset even after short exposures. Whole-body toxicities usually follow prolonged exposures to oxygen at lower partial pressures.\nA.: Oxygen is generally considered to become toxic to the CNS when the partial pressure exceeds 1.6 ATA. Partial pressures less than 1.4 are unlikely to produce toxicity. These partial pressures are highly variable among individuals and make planning for dives riskier as high pressures are used for aggressive dive profiles. The toxicity experienced may range from visual changes to the extreme of convulsive activity. The convulsion experienced is not damaging in itself, but obviously in an aquatic environment can lead to life-threatening sequelae. The mnemonic VENTIDC may be used to recall the range of toxicity. V: Visual changes (tunnel or blurry vision) E: Ear ringing/tinnitus N: Nausea T: Tingling, twitching, or muscle spasms (usually facial muscles or lips) I: Irritability, anxiety, agitation, confusion D: Dyspnea, dizziness, fatigue, problems with coordination C: Convulsions Any diver experiencing any of these symptoms should ascend from depth at the earliest opportunity to prevent the potential catastrophic consequences of unconsciousness or convulsions.\nB.: In pulmonary or \u201cwhole-body\u201d toxicities, the lung is the primary organ affected, but many other parts of the body can be affected as well. The term whole-body toxicity is used to include any organ systems other than the CNS. Pulmonary irritation due to prolonged exposure of oxygen at lower partial pressures is an example of whole-body toxicity. Other symptoms that may be experienced in the whole-body category are itching, skin numbness, nausea, dizziness, and headache.",
        "Immersion pulmonary edema": "Cases of immersion pulmonary edema (IPE) have become widely recognized since 1989. IPE, typically occurring in divers with no underlying medical diseases, presents as a rapid onset of dyspnea at the bottom and continued dyspnea on the surface associated with cough and blood-tinged, frothy sputum. Because the fluid builds up in the air-containing spaces of the lungs and interrupts gas exchange, IPE resembles drowning. The important difference is that the obstructing fluid comes from within the body rather than from inhalation of surrounding water. The cause of IPE has yet to be determined. Aggressive hydration prior to diving may be a contributing factor. It has been seen in triathletes and Navy SEALs doing high-intensity surface swims. Divers get IPE when swimming on the bottom without clear evidence of stress. In some cases, the diver mentions a tight-breathing regulator, and in others no evident stress or equipment problems are noted. Immersion pulmonary edema is not a manifestation of decompression sickness and does not require recompression. The treatment is oxygen and diuretics to remove water from the lungs.",
        "Injury of ascent: barotrauma of ascent": "During ascent, the volume of all gases in air-containing structures will increase as the pressure decreases (Boyle\u2019s law). This type of barotrauma is the result of expansion of gases as pressure is decreased during ascent.",
        "Reverse sinus or ear barotrauma (reverse squeeze)": "Reverse sinus or ear barotrauma is less common than its counterparts during descent. The process of equalization on ascending is normally easier. As the ambient pressure is reduced the pressure in the middle ear passively diffuses through the eustachian tube or through the sinus cavities. Initial descent problems may lead to inflammation and subsequent swelling of the passages, disrupting the ability to easily equate these pressures in these structures. Complications can range from blood from the ear or nose to tympanic membrane rupture, sinus fracture, or pneumocephalus.",
        "Alternobaric vertigo": "Alternobaric vertigo may occur during ascent as the middle ear pressures become unequal. Onset is sudden and usually preceded by a full feeling in the ears. The difference in pressures causing asymmetric stimulation of the vestibular system may result in significant vertigo. Nausea and vomiting may accompany the vertigo. Typically a self-limited condition the real danger of alternobaric vertigo is a possibility of diver panic with rapid ascent and resultant pulmonary barotrauma or arterial gas embolism. Near drowning may also occur. Descent of a few feet should result in improvement of symptoms.",
        "Gastrointestinal (GI) barotrauma": "Aerogastralgia is a rare type of ascent barotrauma in divers usually novice divers. Expansion of bowel gas during ascent may cause GI discomfort and abdominal pain. Causes include eating large meals or gas-producing foods (legumes) prior to a dive or drinking carbonated beverages. Swallowing air or Valsalva maneuver with the head down may also contribute to the condition. The standard cure is evacuation of gas through the two anatomical venting orifices with the resultant decrease in pressure.",
        "Pulmonary barotrauma": "Pulmonary barotrauma (PBT) is the most serious type of barotrauma. Overexpansion of gas trapped in the lungs can result in pulmonary overpressurization. Sudden rapid and uncontrolled ascent in sport divers breathing compressed air at depth is the most common cause for PBT. Situations involving panic such as breath-holding out-of-air scenarios, buoyancy compensator malfunctions, loss of regulator, or accidental loss of weight belt can all contribute to these events. During ascent without exhaling, the volume of gas in the lungs will double from a depth of 33 fsw to the surface. The greatest risk for pulmonary barotrauma occurs in less than 10 feet of water. A pressure differential of 80mmHg (alveolar air) above ambient water pressure on the chest wall, equivalent to 3\u20134 feet of seawater depth, is all that is necessary to force air bubbles across the alveolar-capillary membrane. Conditions that may result from this physiology are alveolar hemorrhage, pneumothorax, pneumomediastinum, subcutaneous emphysema, and the most feared complication \u2013 arterial gas embolism (AGE).",
        "Arterial gas embolism": "he most striking and dramatic condition associated with PBT is AGE. The second most common cause of mortality, among sport divers, following drowning, AGE accounts for roughly 30% of diving-related deaths [4]. Victims of AGE manifest symptoms during ascent or within 10 minutes of reaching the surface.\n\nPatients suffering AGE can be classified into three groups. The first group is composed of those patients who suffer immediate loss of consciousness, apnea, and cardiac arrest on reaching the surface. This group represents 4% of AGE patients and in these cases, recompression, cardiopulmonary resuscitation, and advanced life support are unlikely to be successful [10]. These patients are suspected to have suffered a large bolus of air to the central vascular bed, particularly the pulmonary arteries and right ventricle. The resulting vascular obstruction leads to pulseless electrical activity and death.\n\nA second group of patients accounts for an additional 5% of deaths; these patients reach the hospital and will die as a result of the AGE or severe near-drowning accompanying AGE. Fifty percent of the remaining patients will have a complete functional recovery.\n\nVictims suffering from AGE present with a variety of systemic and neurological findings. The severity and location of AGE depend on the amount and distribution of the air embolus. The most common initial findings are neurological in nature and include loss of consciousness, confusion, or stupor. AGE may involve multiple organ systems and the presentation is variable.",
        "Presenting signs and symptoms of patients with arterial gas embolism": "Patients with arterial gas embolism may present with a range of signs and symptoms that fall into neurological, pulmonary, visual, and other categories. Neurological symptoms include loss of consciousness, focal paralysis, confusion, coma, convulsions, vertigo, ataxia, unilateral or bilateral motor and sensory deficits, dizziness, headache, and memory difficulty. Pulmonary symptoms can include chest pain, hemoptysis, crepitance, and dyspnea. Visual disturbances such as blindness, nystagmus, and gaze preference may also be present. Other symptoms that may occur include nausea, vomiting, and cardiac arrest.",
        "Decompression sickness: \u201cthe bends\u201d": "Decompression sickness (DCS) occurs after a reduction in ambient pressure usually due to decompression back to ambient pressure from either a dive or hyperbaric chamber exposure. The pathophysiology of DCS results from the inflammatory and obstructive effects of inert gas bubbles in the vascular system and tissues. DCS represents a spectrum of clinical illnesses previously classified as DCS types I, II, III and now more commonly referred to by the affected organ system (Table 52.2). The incidence of DCS is 2.8 cases per 10,000 dives [5].\n\nRisk of DCS is increased by the length and depth of a dive, and DCS may result despite strict adherence to appropriate dive tables. Contributing factors include age, obesity, dehydration, exercise prior to diving, fever, cold ambient temperatures post dive, exertion, and flying after diving. Men are 2.6 times more likely to experience DCS than women, perhaps due to variable risk-taking behaviors. A patent foramen ovale may also increase risk of DCS, having been found in 65% of divers with serious DCS [5].\n\nThe clinical diagnosis of DCS is suspected based on a history of exposure to increased atmospheric pressure and development of characteristic signs and symptoms. Most patients are symptomatic within 1 hour of reaching the surface. The remainder of patients will develop symptoms within 3 hours. Cases have been reported days following a dive although this amounts to less than 2% of cases [5].",
        "Shallow water blackout": "Shallow water blackout is a loss of consciousness caused by cerebral hypoxia towards the end of a breath-hold dive, when the alveolar PCO\u2082 is lowered to 20\u201330 mmHg without a significant increase in PO\u2082. During the dive or swim, exercise-induced hypoxia sufficient to cause loss of consciousness may occur before CO\u2082 reaccumulates to provide stimulation to breathe. Victims are often established practitioners of breath-hold diving (sport free divers), are fit, strong swimmers, and have not experienced problems before.",
        "Transport and destination hospital considerations": "Patients suspected of suffering from AGE or DCS should be transported as rapidly as possible to a facility with resources for evaluation by a diving physician and possible hyperbaric oxygen therapy. Early treatment is more efficacious than delayed care, but there are numerous cases reported to have benefited even with delays of greater than 6 hours. Recompression is the essential and primary treatment for these disorders. Prehospital care should consist of supplemental oxygen at a flow rate of at least 10L/min by non-rebreather mask, or appropriate airway management in patients suffering near drowning. Maintenance of intravascular volume is also important to support capillary perfusion and assist with elimination of bubbles from the arteriolar-capillary level. Intravenous isotonic fluids should be administered to maintain urine output of 1\u20132 cc/kg/hour. Historically, it was recommended to position a patient in Trendelenburg position for transport. Current recommendations are to position AGE and DCS patients throughout their evaluation and treatment in a manner that allows the greatest access to and care of the patient. The Divers Alert Network (DAN: 919.684.9111) is a 24 hour a day, 7 day a week international resource for dive-related injury management and referral. On-call diving physicians, paramedics, and emergency medical technicians are available to provide medical information, referrals, and evacuation assistance as needed.",
        "Conclusion": "In general, diving is considered to be a relatively safe sport. Most diving operations will be free from major medical problems provided that divers pay attention to some general rules and have been properly trained. Barotrauma of the ears and sinuses is the most common dive injury experienced. Pulmonary barotrauma is an infrequent complication but should be suspected when neurological or pulmonary symptoms are present. The two main dive conditions that may benefit from recompression treatment and hyperbaric oxygen therapy are arterial gas embolism and decompression sickness. Decompression sickness occurs in deep long dives and in about 1% of divers. Arterial gas embolism occurs rapidly upon resurfacing. Rapid diagnosis and appropriate referral to definitive care may prevent additional decline in condition, further injury, and long-term sequelae of dive-related injuries. Emergency medical services physicians and medical directors should have a fundamental knowledge of dive-related physiology and hazards. An understanding of the basic conditions encountered during a dive, combined with the knowledge of the dive phase at which an injury occurred and chief complaint, will help to diagnose and treat an injured diver."
    },
    {
        "Introduction": "Patients with abdominal complaints who activate the EMS system can be among the most challenging. Their histories may be non-specific and their exams and vital signs may be unreliable with regard to the etiology or severity of their illnesses. Vital signs are frequently abnormal in critically ill patients. However, normal vital signs do not preclude the presence of a life-threatening illness. Certain populations with abdominal pain commonly encountered by EMS personnel may deserve special attention, including the elderly, women of child-bearing age, children, post-bariatric surgery patients, and immunocompromised patients. Finally, many significant extraabdominal conditions can present with mostly abdominal complaints. Abdominal pain is the most frequent chief complaint in the emergency department, accounting for 8% of total visits. A recent survey from the Centers for Disease Control found that the chief complaint of non-traumatic abdominal pain increased by 37% between 1999 and 2008. It is also one of the most common reasons to call EMS. At least one in 20 EMS calls is for abdominal complaints. Thus, EMS providers encounter patients with abdominal pain on a regular basis, but options for patient assessment and management are limited.",
        "Approach to the patient with abdominal pain": "Assessment and management of abdominal pain patients in the prehospital setting are difficult for a variety of reasons. The following objectives apply. \u2022 The initial priority must be to recognize patients with abnormal vital signs and provide hemodynamic support. \u2022 Consider life-threatening conditions that can present with abdominal complaints. \u2022 Recognize high-risk patient populations, including the elderly, children, women of child-bearing age, and patients who are immunocompromised (e.g. HIV patients, cancer patients, transplant patients, others receiving immunosuppressive agents). \u2022 Be aware of extraabdominal and systemic illnesses that can present with abdominal pain, including acute myocardial infarction, pneumonia, and diabetic ketoacidosis.",
        "Anatomy and physiology considerations": "The lungs, pleural cavity, and base of the heart are all in close proximity to the abdominal cavity and can be involved in conditions that can be perceived as abdominal pain. During development, the abdominal organs protrude into the peritoneal cavity and become enveloped with a layer of peritoneal lining, the visceral peritoneum. The outer surface of the peritoneal cavity is the parietal peritoneum. The peritoneal cavity allows for normal movement and sliding of the abdominal organs and provides a source of protection to the abdominal contents. The peritoneum provides a potential space for air, blood, or other fluids in pathological conditions. Some structures, such as the kidneys, ureters, pancreas, aorta, and portions of the duodenum, lie in the retroperitoneum. This area contains less sensory innervation, accounting for decreased pain perception and localization of pathological conditions involving these structures. The abdomen is traditionally divided into four quadrants by vertical and horizontal lines through the umbilicus. Use of the quadrant description not only provides common terminology, but is also an important determinant in the development of a differential diagnosis of abdominal complaints. The etiologies of abdominal pain can be described as mechanical, inflammatory, or ischemic in nature. Mechanical etiologies include distension of a hollow organ (e.g. stomach, intestine, gallbladder, ureter) or stretching of the capsule of a solid organ (e.g. liver, spleen, kidney). Inflammatory causes include immune processes such as Crohn's disease or ulcerative colitis and infection like appendicitis or diverticulitis. Ischemic pain may result from thrombotic or embolic disease of the vascular bed of abdominal organs or anatomic torsion (e.g. testicle or ovary). The perception of these pathological states may cause different types of pain: visceral, somatic, or referred pain. Luminal or capsular distension will typically produce visceral pain by stimulation of nerves surrounding a hollow or solid organ. Because the innervation of organs is sparse and multisegmented, this pain is usually dull and poorly localized. When caused by an obstructive process, the pain is typically intermittent or colicky. Distension of a solid organ tends to produce more constant pain (e.g. hydronephrosis, hepatitis). Visceral pain is typically associated with other autonomic phenomena such as anorexia, nausea, and vomiting. Somatic abdominal pain typically results from irritation of the parietal peritoneum from infection or inflammation. The pathological process stimulates peripheral nerves and the pain tends to be more intense and distinct than visceral pain. The evolution of acute appendicitis demonstrates both visceral and somatic pain. Early obstruction and distension of the appendix generate dull, poorly localized pain around the umbilicus. As inflammation progresses, the parietal peritoneum becomes involved and the pain becomes localized to the right lower quadrant. A third type of pain is referred pain; pain at a site not directly involved with the disease process. Visceral and somatic nerves from different areas converge at the spinal cord, allowing for misinterpretation of location by the brain. An example is irritation of the diaphragm by blood in the peritoneal cavity as might be seen following a ruptured ectopic pregnancy. This is perceived as shoulder pain because both the diaphragm and the skin near the shoulder share the C4 sensory level.",
        "History and physical examination": "An organized assessment must be applied to any patient with a presenting complaint of abdominal pain. High priority must be given to life-threatening conditions. A careful history will yield an appropriate list of potential etiologies in most patients. This list can be additionally refined using the abdominal quadrant as an indicator of the source of the complaint. Useful historical data may be obtained directly from the patient or from a parent or other care provider. Emphasizing a SAMPLE history is encouraged. The OPQRST mnemonic highlights important questions regarding signs and symptoms. Ask the patient about allergies prior to medication administration and consider anaphylactic reactions as a source of abdominal discomfort. EMS providers should be encouraged to bring all medications with the patient. Particular attention should be paid to cardiac, diabetic, steroidal, and immunosuppressive agents. Medications such as beta-blockers, antiinflammatory agents, and over-the-counter medications can affect the patient's response to infection and inflammation. The past medical history may provide clues to the underlying condition. This history should include information about previous episodes of similar pain, diagnosis, and management. The patient should be questioned about his/her last oral intake and menstrual period. Finally, the events leading up to the current illness and EMS activation should be elicited. The patient's general appearance should be assessed. Seasoned EMS providers develop an immediate impression of those who are \u201csick.\u201d A patient who limits his or her movement due to abdominal pain may have peritonitis as opposed to one who cannot find a position of comfort (e.g. kidney stones or aneurysmal pain). The focus of the physical examination should be to identify potentially life-threatening conditions. Assessment and monitoring of vital signs are crucial. Indications of shock, including hypotension, tachycardia, narrow pulse pressure, and tachypnea, should be recognized. A hypotensive patient should be presumed to have a serious medical condition requiring immediate intervention. The patient\u2019s temperature should also be evaluated, recalling that both fever and hypothermia may indicate significant disease such as sepsis. A careful examination of the heart and lungs should be completed. Abnormal or diminished lung sounds may indicate pneumonia or pleural effusion, which may present as ipsilateral upper abdominal pain. Cardiac auscultation may detect murmurs or gallop rhythms, which may be associated with an acute myocardial infarction or heart failure which may present with vague abdominal pain or gastrointestinal (GI) symptoms as the chief complaint. Prehospital providers should be taught to perform a brief, directed examination of the abdomen. Inspection of the abdomen should be performed to detect distension, skin lesions, or bruising. The presence of therapeutic appliances such as feeding tubes, dialysis access ports, ostomies, and urinary catheters should be observed as well as their perceived functional status and condition of the surrounding tissue. Auscultation of bowel sounds is neither accurate nor productive in the out-of-hospital setting. Similarly, percussion does not yield any important findings in these patients. Palpation should first be performed in the areas away from the region of discomfort. The area of pain should be assessed last with gradually increased pressure to allow some qualification of the level of discomfort (e.g. pain with mild palpation). Specific findings such as Murphy\u2019s sign (right upper quadrant tenderness with deep inspiration), Rovsing\u2019s sign (right lower quadrant tenderness with left-sided palpation), obturator sign (right lower quadrant pain elicited by external hip rotation of right hip), and psoas sign (right lower quadrant pain with right hip extension) are neither sensitive nor specific for gallbladder disease or appendicitis. Percussion of the patient\u2019s heel while the leg is fully extended may be more effective than depressing and releasing the abdominal wall to detect rebound tenderness. Deep palpation to detect a pulsatile mass in the abdomen is discouraged due to its low yield and theoretical potential for exacerbating the patient\u2019s condition if an aortic aneurysm is present.",
        "Management": "Management of the patient with abdominal pain begins with attention to the patient\u2019s airway, ventilation, and hemodynamic stability. Patients in profound shock may benefit from a secure airway and positive pressure ventilation. Vascular access is critical for fluid and medication administration. If the patient has experienced significant fluid loss or has evidence of shock, two large-bore IVs should be established. If IV access is difficult or unobtainable, intraosseous access may be indicated. Resuscitation with crystalloid solution (normal saline or Ringer\u2019s lactate) is generally indicated for prehospital resuscitation. Vasopressors such as norepinephrine may be indicated if septic shock from an abdominal source is suspected and the mean arterial pressure is below 65mmHg despite adequate volume resuscitation. While such medications are often not available to prehospital EMS personnel, they may be available to EMS physicians or to personnel providing an interfacility transport for more advanced care. Any patient with hemodynamic compromise should have continuous cardiac monitoring; the same may be true for all patients over 50 years of age. A 12-lead ECG should be obtained and interpreted to rule out acute myocardial infarction in patients with cardiac risk factors such as age, diabetes, or hypertension. Continuous pulse oximetry should be used in critically ill patients or those with suspected pulmonary etiologies. Supplemental oxygen should be administered to patients with respiratory distress or measured hypoxia. There are reports describing the use of ultrasound in the pre-hospital setting. New ultrasound technology is lightweight, provides high-quality resolution, and can withstand a wider range of environmental conditions. Paramedics are being trained in the Focused Assessment Sonography in Trauma (FAST) exam as well as abdominal aortic ultrasound to evaluate for aneurysm. Investigations of the value of prehospital ultrasound are still under way. It shows promise as it potentially provides earlier information regarding the patient\u2019s condition, leading to more informed triage decisions, reduced time to diagnosis, and sooner appropriate treatment. Another novel advance in prehospital care is point-of-care lactic acid testing. Several studies have evaluated lactic acid measurement in the trauma patient. However, there are also uses for prehospital measurement of lactic acid in the medical patient with abdominal pain. Elevation in prehospital lactate has been linked to mortality and may provide information superior to that of the patient\u2019s vital signs in detecting occult shock, facilitating resuscitation at an earlier stage in patient care. The prehospital administration of opioid analgesics to the patient with abdominal pain remains a controversial practice. Early surgical literature emphasized the loss of diagnostic accuracy with the use of morphine in the patient with undiagnosed abdominal pain. However, this was in an age of few laboratory and radiological diagnostic aids. Since then, the practice of administering opioid analgesics has found widespread support in the literature. Yet there remains theoretical concern about the loss of diagnostic acumen in medicated patients, as well as continued lack of evidence of effect on the overall outcome of such patients. Analgesics are commonly employed in the care of patients with abdominal pain in both the emergency department (ED) and prehospital environments. The best recommendation for emergency care personnel is to provide small IV doses of opioid analgesics in patients with abdominal pain, titrating the dose with the expectation of reducing, but perhaps not eliminating, the patient\u2019s pain. Additional mention should be made in regard to the resuscitation of patients with abdominal pain and suspected or known intraabdominal hemorrhage, such as ruptured aortic aneurysm or ruptured ectopic pregnancy. Attempts to restore normotensive states may not be possible in the prehospital environment and may, in fact, be harmful. These conclusions are drawn from animal and clinical studies of hemorrhagic shock that demonstrate that some level of \u201cpermissive hypotension\u201d may improve outcomes. Recent animal research showed no difference among organ perfusion, cardiac output, and lactic acid levels between permissive hypotension and normotensive resuscitation groups. It defined permissive hypotension as 60% of baseline mean arterial pressure. Urinary catheters serve as both a source and management of some abdominal pain. Their presence and functionality should be included in the examination of the patient. Patients with both indwelling urethral and suprapubic catheters are at risk for urinary tract infections, mechanical obstruction, or catheter displacement. EMS providers may be trained to place urinary catheters, observing sterile technique, to relieve bladder distension. They should be educated that patients with recent urethral procedures or bleeding from the urethral meatus should not be catheterized due to risk of urethral injury.",
        "Disposition": "Based on the previous discussions, one can assume that it would be difficult for EMS personnel to identify patients who do not require transport and to make the somewhat related decision regarding the need for medical evaluation in an ED. It is possible that a patient may not require EMS transport but may still require medical evaluation. The accuracy of such decisions has been addressed by several authors. Dunne compared the assessment by EMS personnel with physician evaluation of the need for transport. The sensitivity of EMS judgment of the need for transport was 22.1%, with a specificity of 80.5%. The presence of abdominal pain was found to be highly associated with the need for transport as judged by the physicians. On the other hand, Kennedy found an overtriage rate of 84% for the need for ALS services in patients with abdominal pain. Gratton found a low but clinically significant undertriage rate of 11%. Other authors have confirmed significant undertriage rates for a variety of medical conditions by EMS providers. These studies reaffirm the need to exercise due caution in approaching transport decisions in patients with abdominal complaints.",
        "Special populations": "There are certain populations who represent a particular risk for a poor outcome and require a cautious approach.",
        "Elderly patients": "In 2010, there were 40 million people aged 65 and over in the US, accounting for 13% of the population. By 2030 the number is projected to represent nearly 20% of the total US population. This population represents high-volume users of the EMS system. Compared with younger patients, geriatric patients have higher mortality when admitted to a hospital with abdominal pain and a higher rate of surgical intervention. One-third of elderly patients who present with abdominal pain require surgery, compared with 10% for other adult patients. The higher mortality rate in geriatric patients is due to several factors. Elderly patients delay seeking medical care for abdominal complaints and will often present later in their disease processes than younger patients. They tend to have more vague symptoms, which can make the evaluation difficult. The elderly have a decreased perception of abdominal pain. Because of this, many elderly patients with significant underlying pathology are misdiagnosed with benign conditions. Use of medications such as beta-blockers, non-steroidal anti-inflammatory drugs (NSAIDs), pain medications, anticoagulants, and steroids is more common in this population. In addition, other physiological responses including fever, immune responsiveness, rebound tenderness, and laboratory abnormalities may not be as prominent in the older patient. Complex medical problems predispose this population to certain conditions, such as abdominal aortic aneurysm and mesenteric ischemia. Common diagnoses found in the geriatric population with abdominal pain include diverticulitis, diverticulosis, small bowel obstruction, volvulus, malignancy, perforated viscus, urinary tract infection, appendicitis, and biliary tract disease. This list is not exhaustive. As mentioned previously, cardiac or pulmonary pathology can also present in a similar manner, and must be entertained based on the patient's history and physical exam. Additional historical information about abdominal pain as related to food intake, vomiting and/or diarrhea, melena or bright red blood per rectum, previous abdominal surgeries, fever, sick contacts, and other areas of pain should be elicited. Focus on the cardiac, pulmonary, and abdominal components of the physical exam. Cardiac and pulse oximetry monitoring is recommended.",
        "Women of child-bearing age": "Women of child-bearing age represent a particular challenge because the number of problems that cause abdominal pain in this population must be expanded to include conditions involving the pelvic organs. Specifically, ectopic pregnancy, ovarian torsion, ruptured ovarian cyst, and tuboovarian abscess (TOA) as a consequence of pelvic inflammatory disease (PID) are significant causes of pain in this population. The difficulty in establishing the diagnosis lies in the fact that neither pelvic examination nor pregnancy testing is routinely available in the prehospital setting. Many patients do not know they are pregnant, and the physical exam is not reliable in establishing the diagnosis of pregnancy. Ectopic pregnancy is one of the leading causes of pregnancy-related deaths in women. Hemorrhagic shock from a ruptured ectopic pregnancy should be considered in any woman of appropriate age with hypotension and abdominal pain. A past history of PID, known tubal pregnancy, prior tubal surgery, or intrauterine device use increases the likelihood of ectopic pregnancy. Pelvic pain caused by ovarian torsion tends to be sudden in onset in reproductive-age women. It is typically described as sharp and knife-like. Right-sided torsion is more common. The signs and symptoms of a ruptured ovarian cyst are difficult to distinguish from torsion. TOA occurs in approximately 1\u20134% of patients with PID. The pain is more insidious in onset and rupture of the abscess causes signs of peritonitis. Rupture of a TOA carries a mortality of approximately 10%.",
        "Pediatrics": "Pediatric patients present a challenge to EMS providers for a variety of reasons. As a rule, pediatric patients are not high-volume users of the EMS system. In addition, infants and children may be unable to describe their symptoms, which is particularly problematic given the importance of historical data in establishing a cause. It is important to discuss the history of the patient\u2019s symptoms and the reason why EMS was called with a parent or guardian familiar with the situation. Non-specific findings such as irritability, inability to be consoled, and poor feeding may be the only signs of an abdominal problem in the very young. Vomiting, oral intake, urine output, last bowel movement, fevers, sick contacts, and vaccination status are useful points from the history. The birth history is important when treating a neonate. Questions that should be asked include whether the pregnancy was at term at the time of birth, did the mother receive prenatal care, were there any complications during the delivery, did the patient require an extended hospital stay after the birth, or have there been any subsequent hospitalizations since birth for any reason. Vital signs can be difficult to interpret in the pediatric population due to age-related variations and the tremendous physiological reserve that these patients possess. The examination can be compromised by the patient\u2019s fear of pain and of the unfamiliar examiner. Finally, abdominal pain is a particularly common complaint in many extraabdominal conditions, as discussed above. Age is a key factor in the evaluation of abdominal pain in the pediatric patient. For patients up to 1 year old, some of the considerations include infantile colic, Hirschsprung disease, necrotizing enterocolitis, intussusception, pyloric stenosis, volvulus, and incarcerated hernia. Bilious vomiting accompanying abdominal pain in an infant is particularly concerning, often indicating an acute surgical problem. Between 2 and 5 years old, consider testicular torsion, Henoch\u2013Sch\u00f6nlein purpura (HSP), intussusception, and appendicitis. Older children between 5 years and adolescence can have inflammatory bowel disease, testicular torsion, HSP, and pharyngitis. This is not an all-encompassing list, but more of a differential with which to start when obtaining the history. On initial presentation, it may be difficult for EMS providers to distinguish a benign condition in children from a true surgical emergency. Up to one-third of pediatric patients admitted to the ED fail to have diagnoses at the time of discharge, and a significant number of ED discharge diagnoses may be incorrect. Extrapolating such information to prehospital conditions makes it apparent that there should be a low threshold for transporting pediatric patients with abdominal pain.",
        "Immunocompromised patients": "Many patients are considered relatively immunocompromised due to their underlying medical states. Examples include the elderly, cancer patients undergoing treatment, malnourished patients, diabetics, patients with end-stage renal disease, patients on certain medications (e.g. chronic steroids and many medications for diseases such as rheumatoid arthritis and irritable bowel disease) and those with HIV infection but adequate CD4 counts. As a result of their underlying conditions, these patients have depressed inflammatory responses and tend to present later in their courses. Of greater concern are patients who are more profoundly immunocompromised, often based on treatments they receive for their underlying conditions. Examples include AIDS patients with low CD4 counts, transplant patients on chronic immunosuppressive medications, leukopenic cancer patients on chemotherapy, and patients with other conditions requiring immune-modulating medications such as inflammatory bowel disease or rheumatoid arthritis. These patients present with an expanded list of serious conditions leading to abdominal complaints, including neutropenic enterocolitis (typhlitis), graft- versus-host disease, cytomegalovirus perforation, and tuberculous peritonitis. Important questions to ask include history of fevers, vomiting and/or diarrhea, recent changes in medication regimen (including non-compliance due to financial or other logistical barriers), and any prior similar episodes. Transplant patients should have the date and location of their surgery noted. EMS protocols or direct medical oversight should provide the option for such patients to be transported to specialty centers capable of managing their potentially complex conditions. Because immunocompromised patients present late in their courses, their mortality tends to be high.",
        "Obesity and bariatric surgery patients": "Statistics from 2010 estimate that over 35% of US adults are obese, a condition with known links to increased rates of diabetes and heart disease. Obesity may also be linked to an increase in abdominal complaints including dyspepsia, irritable bowel syndrome, and constipation, as well as abdominal wall hernias which predispose patients to bowel obstructions. The care of the obese patient may be hindered by an unreliable physical exam as well as equipment which is not suited for the patient\u2019s size. Not surprisingly, the rate of bariatric surgery has increased dramatically in recent years. The rate of hospital admission of patients after bariatric surgery is 20% during the first postoperative year and increases to 40% within 3 years. Recognized complications include ulceration and bleeding, perforation, and mechanical obstruction. The EMS professional should be aware of the increased rate of these conditions in this patient population.",
        "Conclusion": "Patients with abdominal pain can present a significant challenge to prehospital care providers. An approach that emphasizes immediate consideration of life-threatening abdominal and extraabdominal conditions is imperative. The patient\u2019s history and the location of the pain are the primary determinants of the differential diagnosis. Stabilization of ABCs and restoring hemodynamic stability remain the primary focus of patient management. Controversies in the use of pain medication in patients with abdominal pain and appropriate fluid resuscitation in the face of acute hemorrhage exist. Specific attention to high-risk populations, including the elderly, women of reproductive age, children, immunocompromised, and bariatric patients, must be exercised."
    },
    {
        "Introduction": "While the origin of the perimortem cesarean section is debated, the procedure is reported to have been performed in all cultures dating back to ancient times. The term \u201ccesarean section\u201d is said to come from the performance of the postmortem section, dating back to 715 BC when Roman king Numus Pompilius decreed that no child should be buried within its mother. This was first known as Lex Regis (the law of the king) and later translated into Lex Cesare (the law of Caesar), leading to the term cesarean section. This procedure was described widely through the Middle Ages to aid with baptism, and multiple royal and religious decrees reinforced the performance of postmortem sections. While initially performed to aid in burial, the procedure was later performed in an attempt to save the infant and mother. Literature from the 1800s demonstrates a debate over the pros and cons of the procedure, and medical reports of infants surviving surface at that time. Because of the high frequency of maternal mortality, as well as high rates of sepsis, dehydration, and hemorrhagic shock as the causes of maternal death, infants often died before the mother and survival following postmortem sections remained low for centuries. Over time, the leading causes of maternal mortality in pregnancy have changed to trauma, cardiac disease, and embolism. In these cases, the mother and infant are generally in good health until an insult results in maternal cardiac arrest. Thus, performance of a postmortem c-section could be more likely to result in birth of a live infant than described historically. The term perimortem cesarean section (PMCS) began to be used widely following a landmark literature review of post-mortem cesarean section cases by Katz et al. Of 269 cases reported from 1879 to 1985, 188 infants (70%) survived, a higher infant survival rate than previously considered. The majority of surviving infants (with timing records) were delivered within 5 minutes from death of the mother. All but one neurologically intact infant was delivered within 15 minutes. Katz et al. recommended performance of PMCS within 4 minutes of maternal arrest, with delivery by 5 minutes, in any case with fetal viability. This became known as the \u201c4-minute rule\u201d and remains widely referenced today. A follow-up review of 38 cases between 1985 and 2004 supported this recommendation.",
        "Potential benefits of perimortem cesarean section": "The reasons for performing PMCS have changed over time. While first primarily performed for burial and religious reasons and later to attempt survival of the fetus who would otherwise meet certain death, cases of maternal survival after PMCS reveal the additional potential benefit of the procedure as part of maternal resuscitation. In a pregnant woman at term, the great vessels are compressed by the uterus, which leads to a reduction in cardiac output by two-thirds. Considering that cardiopulmonary resuscitation (CPR) already produces a cardiac output that is only one-third of normal, chest compressions in a supine pregnant mother under the best circumstances produce a cardiac output that is 10% of normal. Emptying the uterus through PMCS alleviates compression of the inferior vena cava, improves venous return, and allows redistribution of uterine blood to other organs, which under normal conditions at term contributes up to 25% of cardiac output. Emptying the uterus also increases the functional residual capacity of the mother\u2019s lungs, allowing for better oxygenation. In combination, this may improve the effectiveness of CPR and lead to successful resuscitation of the mother after delivery of the infant. In the landmark review by Katz et al., 12 cases were identified where there was sudden and often profound improvement in the mother\u2019s condition once the uterus was emptied. There have been multiple additional reports of maternal survival after PMCS, including 13 of 38 mothers discharged in good condition in Katz et al.\u2019s follow-up review of PMCS cases. Dijkman et al. reviewed all cases of maternal cardiac arrest in The Netherlands from 1993 to 2008 and found eight of 12 mothers who regained cardiac output after PMCS, though only two ultimately survived. In none of these cases was PMCS performed within 5 minutes, and timing may have contributed to the ultimate outcomes. In another review of 94 PMCS cases, the authors determined that PMCS was beneficial to the mothers in 31.7% of cases, without demonstration of harm in any case. Because of this potential effect on maternal resuscitation, it has been suggested that physicians should perform PMCS regardless of the gestational age or fetal viability, without delays to assess the status of the infant.",
        "Performance of perimortem cesarean section in the field": "Only a few cases of PMCS performed in the field have been reported in the modern medical literature. In all of these cases, PMCS was performed by a physician working as part of an EMS team. Kupas et al. reported the performance of a PMCS on a 39-year-old woman at 39 weeks gestation who suffered a myocardial infarction. PMCS was performed by an emergency medicine resident functioning as a flight physician, along with a physician neighbor. Neither mother nor infant survived. Bowers and Wagner similarly described a 31-year-old woman at 37 weeks gestation who was involved in a motor vehicle crash into a building. PMCS was performed by an emergency medicine resident as part of a physician/nurse flight team. Neither mother nor infant survived. Kue et al. reported the performance of a PMCS on a 21-year-old woman at unknown gestation involved in a motor vehicle collision. PMCS was also performed by a flight physician, who first performed an ultrasound and determined there was no maternal cardiac activity, but there was fetal cardiac activity. CPR had been ongoing for over 25 minutes prior to PMCS and both mother and infant ultimately died. In each of these cases, cardiac arrest likely ensued for at least 25 minutes prior to PMCS, which may have contributed to the ultimate outcomes. The performance of PMCS in the out-of-hospital setting involves a number of challenges not encountered in the hospital. PMCS is not commonly part of a nurse or paramedic scope of practice and the absence of a physician as part of an EMS team will severely limit the ability to perform this procedure, regardless of maternal or fetal outcome. Therefore, even when medical oversight is contacted, performance of PMCS is almost certainly outside the nursing or paramedic scope of practice. At least one case of PMCS performed by paramedics has been reported in the lay press, and the appropriateness of the providers in performing the procedure was brought into question. It is important for EMS medical directors and EMS providers to review regulations from medical control boards and state licensing bodies in order to develop policies and procedures for how to manage this rare field presentation. On the rare occasion that a physician is present, resources in the prehospital setting may still be limited. Following PMCS, lack of sufficient personnel to resuscitate two patients may result in the need to cease resuscitation efforts on the mother in order to focus on resuscitation of the newly delivered infant. Furthermore, due to the rare in-field presentation of a pregnant woman in cardiac arrest, an EMS physician may not have adequate experience or training in performance of a PMCS. In these cases, if transport can be completed within 5 minutes of maternal arrest, one may consider delaying the procedure in order to transport the patient to a facility with the appropriate obstetrical and neonatal resources to manage this emergency. Similarly, transport teams without practitioners who are licensed to perform this procedure should be dissuaded from performing PMCS in the prehospital setting, focusing on rapid transport with ongoing resuscitation of the mother.",
        "Indications for perimortem cesarean section": "Performance of PMCS within 4\u20135 minutes of maternal arrest beyond 20\u201324 weeks gestation is widely supported for the potential survival of both the infant and the mother. The fundus can be identified 2cm or 1 fingerbreadth above the umbilicus for every 2 weeks past 20 weeks and many experts recommend PMCS for any gestation that is 2 fingerbreadths above the umbilicus (24 weeks gestation). Other experts recommend that maternal resuscitation incorporate a determination of the likelihood of fetal viability by Doppler, audible fetal heart tones, or ultrasonography prior to the performance of PMCS. However, the value of performing these assessments versus potential delays to the time-dependent PMCS has been debated. There have been cases reported in the literature with good fetal outcomes in spite of no fetal heart tones being audible. Also, both ultrasonography and Doppler may be difficult to perform concurrently with CPR, and the fetus may be experiencing a period of bradycardia during resuscitation that complicates assessment of fetal heart rate. Therefore, authors have argued that time should not be spent looking for fetal viability, as it only wastes time to performance of the procedure, decreasing the likelihood that it will be successful in saving the mother or baby. Furthermore, the American Heart Association recommends that PMCS be considered after the 20th week of gestation, or for any obviously gravid uterus that is deemed clinically to be sufficiently large to cause aortocaval compression. The \u201c4-minute rule\u201d may be challenging to apply in the out-of-hospital setting, as the patient is likely to be in cardiac arrest for longer than 5 minutes at the time that appropriate resources and providers arrive on scene. PMCS should still be considered in these situations, as many neurologically intact infants have survived after more than 25 minutes of maternal death. In these or other cases where the mother is determined to not be viable, in-field ultrasound may have its optimal role when considering PMCS solely for the infant.",
        "Education": "Considering that most EMS physicians will never have the opportunity to perform a PMCS in the field, the hesitancy to perform this potentially life-saving intervention could be partly overcome by special training and education. Special courses have been developed to train physicians in maternal resuscitation in cardiac arrest, including the performance of PMCS. These include the Advanced Life Support in Obstetrics (ALSO), Managing Obstetric Emergencies and Trauma (MOET), and Advances in Labour and Risk Management (ALARM) courses. In a study of the management of cardiac arrest in pregnant women over a 15-year period in The Netherlands, there was an increase from 0.36 to 1.6 PMCS procedures per year following the introduction of the MOET course. It is intuitive that without adequate training, physicians would lack the capability and willingness to perform this procedure, especially in the resource-limited prehospital setting. Performance of PMCS should therefore be incorporated in the training of all EMS physicians who may encounter the need to perform this procedure in the field.",
        "Procedure": "As soon as maternal cardiac arrest is identified, resuscitation should begin immediately. While tilting of the mother to the left during CPR has been described, manual leftward displacement of the uterus may be more effective in relieving aortocaval compression. This necessitates one provider focusing on displacement of the uterus, a resource that may not be available in the limited environment of the field setting. Two EMS providers may alternate providing chest compressions with providing manual displacement of the uterus. Defibrillation should be performed for the appropriate rhythms at the same dosages as other adults (Class I, Level C evidence). The PMCS is a relatively simple procedure, which can be performed with limited equipment. Once a decision has been made to perform a PMCS, the operator should proceed without delay. A suggested list of equipment to be used in the out-of-hospital setting is provided in Box 45.1. During the procedure, CPR of the mother should continue to increase chances of survival for both the mother and baby. A generous vertical midline incision of the abdomen has been described most commonly as the preferred method to gain rapid access to the peritoneal cavity. In the gravid woman, the linea nigra runs in the midline of the abdomen and serves as a guide for the incision. The incision should run from pubis to umbilicus and should be carried down through the fascial layers. If needed for access, the incision may be extended to the xiphoid. Alternately, a Pfannenstiel incision, which runs horizontally just above the pubic symphysis, could be performed. The operator should select the incision he or she is most familiar with to facilitate a rapid intervention. Once in the peritoneal cavity, two Richardson retractors may be used to provide access to the uterus and the bladder should be displaced caudally, either manually or with a bladder retractor. A distended bladder may be quickly drained with a Foley catheter. If time does not permit, a stab incision of the bladder can be made, which can be easily repaired if the mother is successfully resuscitated. Once the bladder has been retracted, a short vertical incision should be performed in the lower uterine segment, just cephalad to the bladder. This incision is then extended cephalad using bandage scissors. The fingers of the operator's free hand should be placed inside the uterus to lift the uterine wall and protect the infant as the incision is extended. The incision should be long enough to allow rapid delivery of the infant. If the placenta is embedded in the anterior wall of the uterus, it should be transected while entering the uterus. Though this may result in a significant amount of blood loss, it will facilitate the rapid delivery of the infant. When the uterine incision is complete, all retractors should be removed to avoid injury to the baby. If the fetus is in a vertex position, the operator's hands should be inserted into the uterine cavity between the fetal head and the pubic symphysis, and the head and shoulders should be elevated out of the incision. If the fetus is in a breech or transverse presentation or if the uterine incision is too high to adequately access the head, a feet-first delivery may be easiest. Once the infant is delivered, the mouth and nose should be suctioned with a bulb syringe and the cord clamped and cut while the infant is held at the level of the mother's abdomen. The child should be assessed, cleaned, and warmed immediately. Resuscitation should ensue as appropriate. The uterus should be palpated to evaluate for the possibility of twins and the placenta may be removed if resources and time allow. Packing or suturing the uterus closed will decrease bleeding if maternal circulation is restored. The uterus may be sutured with No. 0 or No. 1 delayed-absorbable sutures using a continuous locking one-layer closure. Direct pressure may also be applied to the mother's aorta, minimizing bleeding from the pelvic vessels and limiting the functional volume of the patient.",
        "Ethical and legal considerations": "The decision to perform a PMCS may invoke ethical and legal concerns. On one hand, there may be concern that the provider could be charged with battery for performing PMCS if consent is not obtained. On the other hand, failing to perform PMCS would result in near-certain death for the infant and mother. Since PMCS was described in 1986, no physician in the United States has been held liable for performing a PMCS, even when this was against the wishes of the mother's family. However, at least two cases have been identified where a lawsuit was brought against physicians and hospital staff for failure to perform a PMCS. Even if PMCS is successful, a concern may be that the provider may deliver an infant who will have persistent neurological deficits. However, a case review of PMCS over 25 years identified no reported cases where an infant surviving beyond the early neonatal period had neurological disability, and multiple neurologically intact infants have survived following PMCS after even prolonged maternal resuscitation. In addition to considering the potential benefits to the infant, one must also consider the risks to the mother. In this case, there is no maternal risk, as withdrawal of support will certainly result in death of both mother and fetus. Ultimately, peer-reviewed resuscitation guidelines may provide the simplest recourse for the EMS physician in deciding whether to perform a PMCS. The American Heart Association recommendation is for the performance of PMCS in any case of maternal cardiac arrest when the gestational age is \u226520 weeks, regardless of fetal viability. This is recommended to be performed within 4 minutes of the onset of maternal cardiac arrest if there is no return of spontaneous circulation (Class IIb, Level C evidence), but may be considered sooner in cases of obvious non-survivable injury, when the maternal prognosis is grave, and the resuscitative efforts deemed futile. The emotional impact of performing PMCS in the field must be considered, both for the provider who performs the procedure and the rest of the EMS team who contribute to the resuscitation of mother and infant. The effect on any family or friends on scene must also be considered. Procedures should be in place to provide critical incident stress management to EMS personnel within 24 hours, with individual follow-up care determined on an individual basis. Community resources may be sought to assist family members as well."
    },
    {
        "Introduction": "Paramedics are typically the first health care personnel to encounter sudden illnesses or other health care emergencies in the community, placing them at risk of communicable and infectious diseases. The Occupational Safety and Health Administration (OSHA) identifies more than 1.2 million community-based first response personnel, including law enforcement, fire, and EMS personnel, who are at risk for infectious exposure. While infectious and communicable disease preparation may not have previously been a priority in some EMS agencies, the 2003 severe acute respiratory syndrome (SARS) outbreaks made it one. Emergency medical personnel during the onset of the SARS outbreaks in Toronto and Taipei were exposed to or contracted SARS in significant numbers resulting in one paramedic fatality. More importantly, the loss of paramedics available for work due to exposure, illness, and quarantine affected the ability to maintain staffing during the outbreak, and highlighted the need for EMS systems to adequately prepare and protect the workforce from potential exposure.",
        "Paramedic and patient": "An infectious disease results from the invasion of a host by disease-producing organisms, such as bacteria, viruses, fungi or parasites. A communicable (or contagious) disease is one that can be transmitted from one person to another. Not all infectious diseases are communicable. For example, malaria is a serious infectious disease transmitted to the human bloodstream by a mosquito bite, but malaria is infectious, not communicable. On the other hand, chickenpox is an infectious disease which is also highly communicable because it can be easily transmitted from one person to another. The mode of transmission is the mechanism by which an agent is transferred to the host. Modes of transmission include contact transmission (direct, indirect, droplet), airborne, vector borne, or common vehicle (food, equipment). Contact transmission is the most common mode of transmission in the EMS setting, and can be effectively prevented using routine practices. Direct contact transmission occurs when there is direct contact between an infected or colonized individual and a susceptible host. Transmission may occur, for example, by biting, kissing, or sexual contact. Indirect contact occurs when there is passive transfer of an infectious agent to a susceptible host through a contaminated intermediate object. This can occur if contaminated hands, equipment, or surfaces are not washed between patient contacts. Examples of diseases transmitted by direct or indirect contact include human immunodeficiency virus (HIV), hepatitis, and methicillin-resistant Staphylococcus aureus (MRSA). Droplet transmission is a form of contact transmission requiring special attention. It refers to large droplets generated from the respiratory tract of a patient when coughing or sneezing, or during invasive airway procedures (e.g. intubation, suctioning). These droplets are propelled and may be deposited on the mucous membranes of the susceptible host. The droplets may also settle in the immediate environment, and the infectious agents may remain viable for prolonged periods of time to be later transmitted by indirect contact. Examples of diseases transmitted by droplet transmission include meningitis, influenza, rhinovirus, respiratory syncytial virus (RSV), and severe acute respiratory syndrome (SARS). Airborne transmission refers to the spread of infectious agents to susceptible hosts through the air. In this case, infectious agents are contained in very small droplets which can remain suspended in the air for prolonged periods of time. These agents are dispersed widely by air currents and can be inhaled by a susceptible host located at some distance from the source. Examples of airborne transmission diseases include measles (rubeola), varicella (chickenpox), and tuberculosis. Vector-borne transmission refers to the spread of infectious agents by means of an insect or animal (the \u201cvector\u201d). Examples of vector-borne illnesses include rabies, where the infected animal is the vector, and West Nile virus or malaria, where infected mosquitos are the vectors. Transmission of vector-borne illness does not occur between emergency personnel and their patients. Common vehicle transmission refers to the spread of infectious agents by a single contaminated source to multiple hosts. This can result in large outbreaks of disease. Examples of this type of transmission include contaminated water sources (E. coli), contaminated food (Salmonella), or contaminated medication, medical equipment, or IV solutions.",
        "General approach and patient assessment": "The risk of communicable disease is not as apparent as other physical risks, such as road traffic, power lines, firearms, or chemical agents. EMS personnel must use the same level of suspicion and precaution whenever approaching a patient. The use of routine practices, as a minimum, is necessary for every patient encounter in order to mitigate this risk. All personnel must take appropriate precautions when a patient presents with any signs or symptoms suspected to be due to an infectious or communicable disease. All EMS and first responder agencies must provide appropriate training that enables personnel to identify at-risk patients and use appropriate personal protective equipment (PPE). The risk assessment begins with information from an EMS dispatch or communication center, prior to making patient contact. Call-taking procedures should include basic screening information to identify potential communicable disease threats and provide this information to all responding personnel. The screening information can identify patients with symptoms of fever, chills, cough, shortness of breath, or diarrhea. The call-taker can also identify if the patient location, such as nursing home, group home or other institutional setting, poses a potential risk to the responding personnel. This information helps responding personnel to determine what precautions are necessary before they make patient contact. When patient contact is made, personnel can determine if the patient has a potential risk for a communicable disease. A rapid history and physical examination can help raise suspicion. The following screening questions help identify a patient with a communicable disease. \u2022 Do you have a new or worsening cough or shortness of breath? \u2022 Do you have a fever? \u2022 Have you had shakes or chills in the past 24 hours? \u2022 Have you had an abnormal temperature (>38\u00b0C)? \u2022 Have you taken medication for fever? \u2022 Have you recently returned, or been in contact with someone who has recently returned, from a geographic region where an outbreak is underway? A screening physical examination will also identify obvious signs of a communicable disease. They may include any new symptom of infection (fever, headache, muscle ache, cough, sputum, weight loss, and exposure history), rash, diarrhea, skin lesions, or draining wounds.",
        "Influenza": "Influenza classically presents with the abrupt onset of fever, usually 38\u201340\u00b0C, sore throat, non-productive cough, myalgias, headache, and chills. Influenza is caused by a virus with three subtypes: A, B, and C. Influenza A causes more severe disease and is mainly responsible for pandemics. Influenza A has different subtypes determined by surface antigens H (hemagglutinin) and N (neuraminidase). Influenza B causes more mild disease and mainly affects children. Influenza C rarely causes human illness and has not been associated with epidemics. Influenza transmission occurs primarily through airborne spread when a person coughs or sneezes, but may also occur through direct contact of surfaces contaminated with respiratory secretions. Hand-washing and shielding coughs and sneezes help prevent spread. Influenza is transmissible from one day before symptom onset to about 5 days after symptoms begin and may last up to 10 days in children. Time from infection to development of symptoms is 1\u20134 days. Influenza has been responsible for at least 31 pandemics in history. The most lethal \u201cSpanish flu\u201d pandemic of 1918\u20131919 is estimated to have caused 40 million deaths globally with 700,000 of those deaths occurring in the USA in a single year. In this pandemic, deaths occurred mainly in healthy 20\u201340 year olds, which differs from the usual young children and elderly pattern of mortality and morbidity in the seasonal outbreaks of influenza. Influenza vaccine is the principal means of preventing influenza morbidity and mortality. The vaccine changes yearly based on the antigenic and genetic composition of circulating strains of influenza A and B found in January to March, when influenza reaches its peak activity. When the vaccine strain is similar to the circulating strain, influenza vaccine is effective in protecting from illness 70\u201390% of those younger than age 65 who are vaccinated. Among those aged 65 and older, the vaccine is 30\u201340% effective in preventing illness, 50\u201360% effective in preventing hospitalization, and up to 80% effective in preventing death. EMS personnel should be immunized annually, typically in October. Four antiviral drugs are available for preventing and treating influenza in the US. When used for prevention of influenza, they can be 70\u201390% effective. Antiviral agents should be used as an adjunct to vaccination, but should not replace vaccination. The Centers for Disease Control and Prevention (CDC) recommends influenza antivirals for individuals who have not as yet been vaccinated at the time of exposure, or who have a contraindication to vaccination, and are also at high risk of influenza complications. Also, if an influenza outbreak is caused by a variant strain of influenza not controlled by vaccination, chemoprophylaxis should be considered for health care providers caring for patients at high risk of influenza complications, regardless of their vaccination status. In the setting of an influenza outbreak, EMS systems may opt to restrict duties for EMS providers who are not immunized or who have not yet received prophylactic antiviral therapy in an attempt to prevent spread of the outbreak.",
        "Avian influenza": "Influenza A virus infects humans and also can be found naturally in birds. Wild birds carry a type of influenza A virus, called avian influenza virus, in their intestines and usually do not get sick from them. However, avian influenza virus can make domesticated birds (including chickens, turkeys, and ducks) quite ill and lead to death. The avian influenza virus is chiefly found in birds, but infection in humans from contact with infected poultry has been reported since 1996. A particular subtype of avian influenza A virus, H5N1, is highly contagious and deadly among birds. In 1997 in Hong Kong, an outbreak of avian influenza H5N1 occurred not only in poultry but also in 18 humans, six of whom died. In subsequent infections of avian influenza H5N1 in humans, more than half of those infected with the virus have died. In contrast to seasonal influenza, most cases of avian influenza H5N1 have occurred in young adults and healthy children who have come into contact with infected poultry, or surfaces contaminated with H5N1 virus. By the end of 2007, there were 346 documented human infections with influenza H5N1 and 213 deaths (62%). Although transmission of avian influenza H5N1 from human to human is rare, inefficient, and unsustained, there is concern that the H5N1 virus could adapt and acquire the ability for sustained transmission in the human population. If the H5N1 virus could gain the ability to transmit easily from person to person, a global influenza pandemic could occur. A vaccine is now available for H5N1, as a two-dose regimen. It is not currently available or advocated for use in the general population, but is being stockpiled by several countries. The H5N1 virus is resistant to the adamantanes, but likely sensitive to the neuraminidase inhibitors. In April 2009, a novel influenza A (H1N1) virus, similar to but genetically and antigenically distinct from other influenza A (H1N1) viruses, was determined to be the cause of respiratory illnesses that spread across North America and many areas of the world. Influenza morbidity caused by the 2009 pandemic influenza A (H1N1) remained above seasonal baselines throughout spring and summer 2009, and was the first pandemic since 1968. Data from epidemiological studies conducted during the 2009 influenza A (H1N1) pandemic indicate that the risk for influenza complications among adults aged 19\u201364 years who had 2009 pandemic influenza A (H1N1) was greater than typically occurs for seasonal influenza.",
        "Tuberculosis": "Tuberculosis is caused by the Mycobacterium tuberculosis complex. The majority of active TB is pulmonary (70%), while the remainder is extrapulmonary (30%). Patients with active pulmonary TB will typically present with cough, scant amounts of non-purulent sputum and possibly hemoptysis. Systemic signs such as weight loss, loss of appetite, chills, night sweats, fever, and fatigue may also be present. Clinically, the EMS provider will be unable to distinguish pulmonary TB from other respiratory illnesses. However, certain risk factors may alert the EMS provider to the possibility of tuberculosis: immigration from a high-prevalence country, homelessness, exposure to active pulmonary TB, silicosis, HIV infection, chronic renal failure, cancer, transplantation, or any other immunosuppressed state. Active pulmonary TB is transmitted via droplet nuclei from people with pulmonary tuberculosis during coughing, sneezing, speaking, or singing. Procedures such as intubation or bronchoscopies are high risk for the transmission of TB. Respiratory secretions on a surface rapidly lose the potential for infection. The probability of infection is related to duration of exposure, distance from the case, concentration of bacilli in droplets, ventilation in the room, and the susceptibility of the host exposed. Effective medical therapy eliminates communicability within 2\u20134 weeks of starting treatment. If transporting a patient who is known to have or suspected of having TB, respiratory precautions should be followed by EMS providers, including use of submicron masks. Patients should cover their mouths when coughing or sneezing, or wear surgical masks. In the event of suspected exposure to a patient with active pulmonary tuberculosis, report the case and the exposure to the EMS system or public health authority. Close contacts should be monitored for the development of active TB symptoms. Two tuberculin skin tests should be performed, based on public health recommendations, on those closely exposed to patients with active TB. Because the incubation period after contact ranges from 2 to 10 weeks, the first test is typically done as soon as possible after exposure, and the second test is typically done 8\u201312 weeks after the exposure. If the EMS provider or contact develops either active TB with symptoms or latent asymptomatic TB, as diagnosed with a new positive TB skin test, treatment should be offered. Treatment for latent TB is typically isoniazid (INH) for 6\u20139 months. This single-drug regimen is 65\u201380% effective. For active TB, a four-drug regimen is typically used for 2 months: isoniazid, rifampin, pyrazinamide, and ethambutol. This is followed by INH and rifampin for an additional 4 months. Several forms of multidrug-resistant TB and extensively drug-resistant TB have been identified. These forms require an aggressive, multidrug regimen for prolonged periods of time and are dependent on the organism\u2019s patterns of drug sensitivity and resistance. In all cases, a physician skilled in management of TB must initiate and monitor treatment and provide suitable follow-up. Public health officials must also be notified.",
        "SARS and related coronaviruses": "It is difficult to distinguish SARS from other respiratory infections because patients present with symptoms similar to other febrile respiratory illnesses. Fever is the most common and earliest symptom of SARS, often accompanied by headache, malaise or myalgia. In patients with SARS, high fever, diarrhea, and vomiting were more common compared to patients with other respiratory illnesses. Cough occurred later in the course of disease and patients were less likely to have rhinorrhea or sore throat compared to other lower respiratory tract illness. Since clinical features alone cannot reliably distinguish SARS from other respiratory illnesses, knowledge of contacts is essential. Contact with known SARS patients, contact with SARS-affected areas, or linkage to a cluster of pneumonia cases should be obtained in the history. Severe acute respiratory syndrome was first recognized in 2003 after outbreaks occurred in Toronto, Singapore, Vietnam, Taiwan, and China. The illness is caused by a coronavirus. About 11% of those who develop SARS eventually die, usually due to respiratory failure. The case fatality is less than 1% for SARS patients less than age 24 and up to 50% for those age 65 and greater or those with comorbid illness. The coronavirus is found in respiratory secretions, urine, and fecal matter. Transmission is via droplets spread from respiratory secretions, with a high risk of transmission during intubation and procedures which aerosolize respiratory secretions. Transmission can also occur from fecal or urine contamination of surfaces. There have been no confirmed cases of transmission from asymptomatic cases. If SARS is suspected, EMS providers must use all routine practices and additional precautions. EMS systems may also elect to limit or avoid any procedures that may increase risk to EMS personnel. These include tracheal intubation, deep suctioning, use of non-invasive ventilatory support, administration of nebulized medication, and any other procedure that may aerosolize respiratory secretions. During the SARS outbreaks in Toronto, EMS medical direction modified medical directives such that paramedics did not intubate patients or deliver nebulized therapy in the prehospital setting. Finally, EMS personnel and systems should also notify the receiving facility of a patient suspected of SARS, permitting the staff to have appropriate PPE in place and a suitable isolation room prepared for the patient. There have not been any cases of SARS infections since 2004 anywhere in the world. However, a novel coronavirus related to SARS emerged in 2012 to cause a number of fatal infections. This new virus is referred to as Middle East respiratory syndrome coronavirus, or MERS-CoV. As of 9 May 2014, 536 laboratory-confirmed cases have been reported to the World Health Organization. Of those, 145 (27%) were fatal. All diagnosed cases were among people who resided in or traveled from one of four countries, Kingdom of Saudi Arabia, United Arab Emirates, Qatar, or Jordan, within 14 days of their symptom onset, or who had close contact with people who resided in or traveled from those countries. Cases with a history of travel from these countries or contact with travelers from these countries have been identified in residents of France, the United Kingdom, Tunisia, and Italy. Like SARS, this novel coronavirus has spread from ill people to others through close contact. However, the virus has not been shown to spread in a sustained way throughout communities. Two cases were reported in the United States, both of them imported by Americans working as health care providers in Saudi Arabia.",
        "Biological weapons": "The CDC categorizes bioterrorism agents as shown in Box 25.1. Certain of these agents are discussed here; additional information about all agents is available via the CDC website.",
        "Anthrax": "The symptoms of anthrax are determined by the route of transmission of the bacterium which causes anthrax, Bacillus anthracis. There are three forms of anthrax: cutaneous, gastrointestinal, and inhalational. Cutaneous anthrax presents as a small, painless, pruritic papule, which progresses to a vesicle which ruptures and erodes, leaving a necrotic ulcer that later gets covered with a black, painless eschar. Pathognomonic features of anthrax include the presence of an eschar, lack of pain, and edema out of proportion to the size of the lesion. Associated symptoms include swelling of adjacent lymph nodes, fever, malaise, and headache. Cutaneous anthrax is caused by B. anthracis entering a cut or abrasion in exposed areas of the body such as the face, neck, arms, and hands. The case-fatality rate can be as high as 20% without antibiotic therapy, but 1% with therapy. Gastrointestinal anthrax presents with more non-specific symptoms. There are two forms: oropharyngeal and intestinal. Oropharyngeal anthrax starts with edematous lesions at the base of the tongue or tonsils that progress to necrotic ulcers with a pseudomembrane. Sore throat, fever, cervical adenopathy, and profound oropharynx edema are associated symptoms. This form of anthrax initially presents with fever, nausea, vomiting, abdominal pain, and tenderness that may progress to hematemesis, bloody diarrhea, and abdominal swelling from hemorrhagic ascites. Gastrointestinal anthrax is caused by consumption of meat contaminated with anthrax. The case-fatality rate of gastrointestinal anthrax is estimated to be 25\u201360%. Inhalational anthrax initially causes non-specific symptoms that mimic influenza. These early symptoms are low-grade fever, non-productive cough, malaise, and myalgias. Two to three days later, the patient rapidly progresses to severe dyspnea, profuse sweating, high fever, cyanosis, and shock. Hemorrhagic meningitis occurs in up to half of patients. It is critical that the EMS provider attempt to distinguish any influenza-like illness from anthrax, because of the narrow window of opportunity for successful treatment. Nasal congestion and rhinorrhea are not common with inhalational anthrax, but more common with influenza-like illness. Further, shortness of breath is more common in inhalational anthrax and less common in influenza-like illness. Chest x-ray demonstrates mediastinal widening or pleural effusion. These findings are the most accurate predictors of inhalational anthrax. Inhalational anthrax can be caused by inhalation of spores, commonly seen following intentional release of aerosolized anthrax, or from the processing of materials from infected animals, such as goat hair. The case-fatality rate of inhalational anthrax can be as high as 97% without antibiotics and up to 75% with antibiotics. Human-to-human transmission of any form of anthrax is rare. A vaccine for anthrax is licensed in the US and is administered in a six-dose schedule with annual boosters thereafter. Vaccination is not currently recommended for emergency first responders or medical personnel. However, it may be indicated for certain military personnel. In cases of deliberate use of anthrax as a biological weapon, first responders should wear a full-face respirator with HEPA filters or a self-contained breathing apparatus, gloves, and splash protection. If clothing is contaminated, it should be removed and placed in plastic bags. Soap and copious amounts of water should be used to decontaminate skin, and bleach should be applied for 10\u201315 minutes in a 1:10 dilution if there is gross contamination. If exposure to aerosolized anthrax occurs, postexposure prophylaxis (PEP) with ciprofloxacin or doxycycline should begin and continue for 60 days. Vaccination for PEP should be administered because of the persistence of anthrax spores in the lungs. Quarantine is not appropriate for persons exposed to anthrax as they are not contagious. Patients suspected of being infected with anthrax and requiring hospitalization should be immediately started on IV antibiotics.",
        "Botulism": "Botulism is caused by a neurotoxin produced by Clostridium botulinum, which ultimately leads to a flaccid paralysis. There are four forms of botulism based on site of toxin production: food-borne, wound, intestinal, and inhalational. In food-borne botulism, early symptoms are non-specific gastrointestinal symptoms, and include nausea, vomiting, and diarrhea. This may progress to blurred vision, double vision, dry mouth, and difficulty in swallowing, breathing, and speaking. Descending muscle paralysis occurs, starting with shoulders and progressing to upper arms, lower arms, thighs, and then calves. Respiratory muscle paralysis ultimately leads to death. Food-borne botulism is caused by the ingestion of Clostridium botulinum toxin present in contaminated food, or by deliberate contamination as a biological weapon. The case-fatality rate in the USA is 5\u201310%. Intestinal botulism is rare and occurs mainly in infants. It causes a striking loss of head control, constipation, loss of appetite, weakness, and an altered cry. Intestinal botulism occurs with ingestion of botulism spores, rather than ingestion of toxin. Spores, which may come from honey, food and dust, germinate in the colon. The case-fatality rate of hospitalized cases is less than 1%. Wound botulism causes the same symptoms as food-borne botulism. This is rare and is caused by spores entering an open wound from soil or gravel. Inhalational botulism would be the most common form if botulinum toxin were used as a biological weapon. Symptoms would be the same as food-borne botulism, but the incubation period may be longer. There are no reported cases of person-to-person transmission of botulism. Therefore, EMS providers do not require any special equipment to manage a patient with suspected or known botulism infection. In the case of suspected aerosol exposure to the toxin, clothing should be removed and placed in plastic bags, and the exposed person should shower thoroughly.",
        "Plague": "Plague is caused by the bacterium Yersinia pestis. Initial signs and symptoms may be non-specific and include fever, chills, sore throat, malaise, and headache. Tender, swollen, warm, and suppurative lymph nodes, mainly in the inguinal area, often follow. Patients infected with the plague may progress to septicemia, meningitis, pneumonia, or shock. Untreated plague has a case-fatality rate of 50\u201390%. If treated, the death rate is 15%. Plague is transmitted to humans by bites, scratches, respiratory droplets, or by direct skin contact. Bites from infected rat fleas are the most frequent source of transmission, but bites or scratches from cats may also transmit plague. With deliberate use as a biological weapon, plague bacilli would be transmitted via the aerosolized airborne droplets. Direct contact with tissue or body fluids of a plague-infected sick or dead animal can lead to transmission to humans through a break in the skin. For patients with pneumonic plague, strict isolation is indicated with precautions against airborne spread until 48 hours after start of antibiotic therapy. Close contacts of patients infected with pneumonic plague should receive chemoprophylaxis and be placed under surveillance for 7 days. Articles soiled with sputum or purulent discharges should be disinfected. Yersinia pestis could be used as a potential biological weapon disseminated through aerosol spread and leading to pneumonic plague. Many patients presenting with fever and cough, particularly hemoptysis in a fulminant course with high case-fatality, should raise suspicions for a biological weapon.",
        "Smallpox": "There are two clinical forms of smallpox: variola major and variola minor. Variola major is the more severe form of disease with a case-fatality rate of greater than 30%, while variola minor is less severe form with a case-fatality rate less than 1%. All smallpox begins with a prodrome that lasts 2\u20134 days. The prodrome starts abruptly and consists of fever, headache, nausea, vomiting, muscle pain, headache, and malaise. Variola major has four principal clinical presentations: ordinary, modified, flat, and hemorrhagic. Ordinary is the most common, occurring in 90% of cases. Modified is mild. Flat and hemorrhagic forms are uncommon, but usually severe and fatal. In ordinary smallpox, after the prodrome, mucous membrane lesions called enanthem begin in the mouth. This consists of red spots on the tongue and mucosa which enlarge and ulcerate quickly, followed by a rash on the face. The rash then progresses from the proximal extremities to the distal extremities and trunk within 24 hours. The macules progress to papules, vesicles, pustules, and crusts. Crusts later separate leaving depigmented skin and pitted scars. The case-fatality rate for ordinary smallpox is about 30%. Modified smallpox occurs in previously vaccinated persons. During the prodrome, fever is absent and the illness is less severe. The skin rash is more superficial and progresses quickly, and lesions are less numerous. This form is more easily confused with chickenpox. Flat smallpox has a more severe prodrome with soft, flat skin lesions that contain little fluid. Most cases are fatal. Hemorrhagic smallpox consists of a more severe and prolonged prodrome along with extensive bleeding into the skin, mucous membranes, and gastrointestinal tract. The skin rash remains flat and does not progress beyond the vesicular stage. Hemorrhagic smallpox is usually abruptly fatal between the 5th and 7th days of illness. The case-fatality rate for hemorrhagic and flat smallpox is greater than 90%. Variola minor produces a rash like ordinary smallpox but results in much less severe systemic reactions. Transmission is via virus inhalation from airborne droplets or fine particle aerosols from the oral, pharyngeal, or nasal mucosa of an infected person, physical contact with an infected person, or with contaminated articles through skin inoculation. EMS personnel should be able to identify the rash due to smallpox, and try to distinguish it from other less virulent diseases, particularly chickenpox. Information to differentiate these illnesses from smallpox is available from the CDC. The last naturally occurring cases of smallpox were identified in 1977, and in 1980 the World Health Organization declared smallpox officially eradicated from the planet. While there are only two sanctioned repositories of smallpox virus in storage and for research purposes, there may exist virus samples outside these two sanctioned repositories. Any new suspected cases of smallpox are a medical and public health emergency. Strict respiratory and contact isolation of confirmed or suspected smallpox cases must be undertaken. Medical personnel in contact with suspected or confirmed smallpox cases should be wearing N95 fit-tested masks, and use other standard precautions. All bedding and clothing should be autoclaved or laundered in hot water with bleach.",
        "Tularemia": "Tularemia, caused by the bacterium Francisella tularensis, has various clinical manifestations related to the route of introduction. All forms have a sudden onset of non-specific influenza-like symptoms, including high fever, cough, sore throat, chills, headache, and generalized body aches. Sometimes nausea, vomiting, and diarrhea may also occur. All forms may lead to sepsis, pneumonia, and meningitis. The clinical forms include ulceroglandular, glandular, oculoglandular, septic, oropharyngeal, and pneumonic. Ulceroglandular tularemia is the most common form. It begins at the skin site of the bite of a tick or fly. A papule appears that becomes pustular and later ulcerates, and finally develops into an eschar. Regional lymph nodes become swollen, painful, and tender and rarely suppurate and discharge purulent material. Glandular tularemia has no skin involvement, only regional lymphadenopathy similar to that which occurs with ulceroglandular disease. Oculoglandular tularemia is caused by the bacillus entering the eye. Conjunctival ulceration occurs followed by regional lymphadenopathy of the cervical and preauricular nodes. Septic tularemia begins with non-specific symptoms of fever, nausea, vomiting, and abdominal pain, eventually leading to confusion, coma, multisystem organ failure, and septic shock. Oropharyngeal tularemia is caused by consumption of contaminated water or food, leading to exudative pharyngitis which may be accompanied by oral ulceration. Abdominal pain, diarrhea, and vomiting may accompany this type. Regional lymphadenopathy occurs affecting the cervical and retropharyngeal nodes. Pneumonic tularemia may be caused by lung exposure to an infective aerosol from soil, grain, or hay, or due to deliberate use of an infective aerosol as a bioterrorist attack. The clinical presentation may be cough, pleuritic pain, and rarely dyspnea. Despite the lungs being the primary route of entry, it is not uncommon for tularemic pneumonia to present as non-specific systemic signs without respiratory symptoms, and often a normal chest-x-ray. Tularemia is transmitted through the skin, mucous membranes, lungs, and gastrointestinal tract. The bacteria pass through the skin by bites, oropharyngeal mucosa, and conjunctiva by contaminated water, or by contaminated blood or tissue while handling carcasses of infected animals. Through the gastrointestinal tract, it is transmitted by ingestion of insufficiently cooked meat of infected animals or by consumption of contaminated water. Finally, tularemia can be transmitted through the lungs by contaminated soil, by handling contaminated furs, or by deliberate aerosolization of the bacterium as a biological weapon. The incubation period is usually 3\u20135 days but can range from 1 to 14 days. There is no documented person-to-person transmission of tularemia. Routine precautions are adequate when transporting and caring for patients. The vehicle and equipment, however, must be thoroughly cleaned and decontaminated after patient transport.",
        "Viral hemorrhagic fevers": "Viral hemorrhagic fevers are caused by different families of viruses and lead to similar clinical syndromes. In the case of bioterrorist attack, it is essential that first responders are able to recognize the illness associated with the intentional release of the biological agent. In hemorrhagic fever, the initial signs and symptoms are non-specific and include high fever, headache, muscle aches, and severe fatigue. There may be associated gastrointestinal symptoms of nausea, vomiting, diarrhea, and abdominal pain. Respiratory symptoms of cough and sore throat may also occur. About 5 days after the onset of illness, a truncal maculopapular rash develops in most patients. As the disease progresses, bleeding occurs from internal organs, the mouth, eyes, ears, and from under the skin, which would be evidenced as petechiae and ecchymosis. Shock, coma, seizures, and kidney failure may ensure in severe cases. Viral hemorrhagic fevers are caused by viruses in four families: arenaviruses, bunyaviruses, flaviviruses, and filoviruses, causing diseases such as Ebola hemorrhagic fever, hantavirus pulmonary syndrome, Lassa fever, Marburg hemorrhagic fever, hemorrhagic fever with renal syndrome, and Crimean-Congo hemorrhagic fever. Transmission occurs when humans have direct contact with infected animals, mainly rodents, or are bitten by a mosquito or tick vector. Once a person has become infected, some viruses can be transmitted from person to person, mainly by close contact with infected people but also indirectly by objects contaminated with infected body fluids. Transmission of viral hemorrhagic fever mainly occurs in the later stages of illness when the patient suffers vomiting, diarrhea, shock, and hemorrhage. In the case of Ebola virus, there are reports of transmission within a few days of the onset of fever. The incubation period ranges from 2 days to 3 weeks, and no transmission has been documented during the incubation period. While there is currently no vaccine for viral hemorrhagic fevers, except for yellow fever and Argentine hemorrhagic fever, significant research and clinical trials are underway to develop a vaccine for Ebola. There are also several experimental treatments under development for patients who have contracted Ebola. To prevent infection, contact with rodents and bites from ticks and mosquitos should be prevented. Person-to-person transmission can be prevented by strict adherence to routine precautions. In addition, patients with known or suspected viral hemorrhagic fever must be isolated. While this is not routinely possible in the EMS setting, there exist portable isolation systems that can enhance the ability to isolate patients with active symptoms of viral hemorrhagic fever during prolonged or interfacility critical care transports. The transport vehicle itself can also serve as an isolation unit, enabling the patient to be isolated from the scene and while in transit. If personnel are exposed to viral hemorrhagic fever, they should be placed under surveillance for fever. The World Health Organization and CDC have prepared a number of documents specific to viral hemorrhagic fever management and control, with detailed and comprehensive strategies to prevent spread and protect health care workers during an outbreak. In 2014, an outbreak of Ebola viral hemorrhagic fever was declared in Guinea, Liberia, Sierra Leone, and Nigeria. As of 16 August 2014, there were 2240 confirmed and suspected cases, and 1229 deaths. Of particular interest was the air medical evacuation of two American health care workers infected with Ebola from Liberia to a hospital in the United States in August 2014. Due to the rapidly evolving nature of this recent Ebola outbreak, the CDC is maintaining up to date information, including methods to prevent disease transmission.",
        "Other infections": "Chickenpox \u2013 varicella zoster virus Varicella zoster virus (VZV) causes two distinct diseases: chickenpox and \u201cshingles\u201d (herpes zoster). Acute chickenpox is highly contagious and usually runs its course in about a week or two, producing immunity, but VZV is not eliminated from the body. The virus becomes dormant in the sensory ganglia and may reactivate decades later to produce zoster. To decrease the incidence of chickenpox in adults who were never exposed to VZV as a child, routine childhood vaccination began in 1995. The full vaccine regimen (two doses) is 90\u2013100% protective against chickenpox and \u201cvirtually 100% effective against severe disease.\u201d Serological screening for VZV IgG is indicated for health care professionals who do not have a documented history of chickenpox. VZV is common, so ensuring prehospital employees are immune prior to patient care is important and cost-effective. Only immune health care professionals should care for patients with chickenpox or shingles. If a pregnant EMS provider has a documented history of chickenpox or has positive titers, she is considered immune and can care for patients. Both she and the fetus are protected. Non-immune adults exposed to either chickenpox or zoster can develop acute chickenpox, complications of which include pneumonia, encephalitis, and death. Non-immune personnel exposed to chickenpox or disseminated zoster must avoid patient contact from 10 days after the exposure (the incubation period) until day 21. An exposure is defined as a breach of contact precautions (such as localized direct contact with uncovered lesions) and/or breach of airborne precautions (chickenpox or disseminated zoster). If an unprotected exposure occurs to a non-immune health care professional, unless that person is pregnant or immunocompromised, the vaccine should be given within 3\u20135 days. If a pregnant or immunocompromised worker is exposed, varicella zoster immune globulin (VZIG) should be offered up to 96 hours after exposure. Meningitis \u2013 bacterial Neisseria meningitidis, or meningococcus, is an uncommon nosocomial transmission but it is possible to contract the disease from a patient infected with N. meningitidis when routine mask use on the patient is not observed. In addition, this disease has a high case-fatality rate (10%). All health care professionals should understand that preventing transmission of meningococcus requires use of droplet precautions and that it is not an airborne transmitted disease. Postexposure prophylaxis should be administered when close, unprotected (mask) contact occurs, such as while performing unprotected mouth-to-mouth resuscitation on an infected patient, or if splash/splatter of secretions into mucous membranes occurs (as with suctioning, intubation, vomiting, coughing, or endotracheal tube management). Simple proximity to the patient does not qualify as close contact, unless the EMS provider was <3 feet from the patient for >8hours. Because many patients with symptoms consistent with N. meningitidis infection are actually infected with viruses or other organisms, PEP should be given only after substantial exposure (as defined above) to a patient with culture- or Gram stain-proven meningococcus. Patients may be considered infectious for 1 week before the onset of symptoms and for 24 hours after effective treatment began. Exposed workers may return to duty 24 hours after PEP was begun. There is time to determine if N. meningitidis is present before empirically administering prophylaxis to many EMS personnel unnecessarily. PEP for meningococcus should be started within 24 hours (but may be begun up to 10 days) after exposure; options include ceftriaxone 250 mg IM, ciprofloxacin 500 mg PO once, or rifampin 600 mg PO bid for 2 days. The medical director plays an important role in ensuring that prehospital personnel are treated quickly and appropriately when a true exposure to N. meningitidis has taken place. Often one of the following situations occurs. \u2022 A crew transports a patient suspected of having meningitis to an ED and calls the infection control officer with concerns about exposure. \u2022 Hospital infection control personnel attempt to contact exposed prehospital personnel involved with treatment/transport of an inpatient now diagnosed with meningococcus. Usually the infection control officer is directly involved, but the medical director can assist hospital infection control, occupational health service, and ED providers by including prehospital providers in the pool of exposed providers. The designated infection control officer should gather specific information, confirming which (if any) prehospital personnel were close enough to the patient to warrant having them report for evaluation and possible PEP administration. Routine vaccination is not recommended for any health care worker group, including fire/EMS personnel. However, such personnel may fall into any of the following categories, and if so, they should contact their regular provider or occupational health service to consider vaccination: persons aged 19\u201355 years who are at increased risk for meningococcal disease, including college freshmen living in dormitories, military recruits, microbiologists routinely exposed to isolates of N. meningitidis, travelers to or residents of countries in which N. meningitidis meningitis is hyperendemic or epidemic, persons with terminal complement-component deficiencies, and persons with anatomical or functional asplenia."
    },
    {
        "Introduction": "The concepts of \u201ctime is muscle\u201d for myocardial infarction (MI) patients and \u201cthe golden hour\u201d for trauma patients are familiar. Until the mid-1990s, the treatment of stroke was focused on rehabilitation, because there were limited treatment options available. There was no urgency. Thankfully, that is no longer the case. With timely treatment, many stroke patients can return to baseline neurological functioning. The EMS system plays a vital role in the sequence of events that gets eligible stroke patients to available interventions that will change their outcomes. In addition to EMS providers\u2019 knowledge and skills at identifying strokes and facilitating patients\u2019 access to timely care, they can participate with other health care colleagues to help improve general public awareness of stroke, its symptoms, and the importance of seeking help early. Early diagnosis, within a narrow window of opportunity, helps to keep treatment options available, including possible administration of fibrinolytics or mechanical clot retrieval. Thus, appropriate triage to a facility that can provide these treatments is essential.",
        "Overview of stroke": "Stroke is now the fourth leading cause of death in the United States, and it remains the leading cause of adult disability. According to the American Heart Association (AHA), approximately 795,000 people in the United States will suffer strokes each year, with 610,000 being first attacks. In broad terms, strokes are classified as either hemorrhagic or ischemic. Greater than 80% percent of strokes are ischemic, but it is difficult to differentiate between these two subtypes in the prehospital setting. Radiographic imaging in a hospital setting is required. An ischemic stroke is caused by either in situ thrombus formation from atherosclerosis or an embolic event (usually from the heart or large vessels) that leads to occlusion of a cerebral blood vessel and subsequent interruption of blood flow and oxygen supply to an area of the brain. For example, one of the contributing causes of embolic strokes is atrial fibrillation, leading to embolization of a clot from the heart. Spontaneous intracranial hemorrhage (ICH) may result from several underlying diseases. Hypertension and arteriovenous malformations are two such predisposing conditions. Patients taking warfarin or with brain tumors are also at risk. Patients with ICH sometimes have more dramatic presentations accompanied by nausea and vomiting, headache, or a sudden decrease in level of consciousness. These are the result of the nature of the insult, where the hemorrhage acts to increase intracerebral pressure. Pupillary changes and motor deficits will be dependent on the location and extent of the bleeding. For example, bleeding into the pontine area of the brainstem will result in pinpoint pupils due to the interruption of sympathetic tracts. Patients with ICH may deteriorate rapidly and require airway support as the hemorrhage expands. The mass effect of an expanding hematoma may also cause contralateral motor deficits, ECG abnormalities, and incidental dysrhythmias. When occlusion of a vessel occurs, there is a central area or \u201ccore\u201d of ischemia in that region of the brain. However, there can also be a surrounding area that has decreased blood supply with the potential to recover without permanent damage. This area surrounding the central area of ischemia is referred to as the \u201cischemic penumbra.\u201d Whether or not the ischemic penumbra can be salvaged depends on the severity and duration of ischemia. If possible, it is important to restore blood flow to this penumbra to decrease the morbidity and mortality of a stroke. In addition to the aspects of stroke related to blood supply, there are several chemical responses that occur on a cellular level that affect brain function. These include the release of excitatory amino acids, alterations in calcium release, and free radical formation. Inflammatory responses and alterations in chemical function affect the penumbra and its ability to recover. When neurological deficits consistent with a stroke occur but resolve spontaneously, this is referred to as a transient ischemic attack (TIA). A TIA, according to the National Institute of Neurological Disorders and Stroke (NINDS), is a focal neurological deficit lasting only a few minutes. TIAs had been previously defined as a neurological deficit that resolved within 24 hours. In fact, most TIAs resolve within 60 minutes and many do so within half an hour. People who experience TIAs have a 10\u201320% risk of stroke in the subsequent 90 days, and half will occur within the next 24\u201348 hours. TIAs should be considered very serious events that require prompt diagnostic evaluations.",
        "Dispatcher guidelines and call prioritization": "As the first contact for the EMS systems, an emergency medical dispatcher has the opportunity to influence the expediency (or delay) of stroke patient care and ultimate arrival at an appropriate ED. In one review of recorded calls to 9-1-1, dispatchers were able to identify and correctly categorize the call as \u201cstroke\u201d only 31\u201352% of the time. It was also noted in this study that when the caller used the word \u201cstroke,\u201d this was highly predictive of an actual stroke. The study concluded that dispatcher recognition of stroke could be improved if key words such as stroke, difficulty communicating, weakness or falling, and facial droop were communicated to the dispatcher by the caller. Another study found that, even when the caller used the word \u201cstroke,\u201d the call was dispatched as a stroke only 48% of the time, and only 41% were dispatched as high priority. The symptoms most frequently reported by callers were speech problems (26%) followed by extremity weakness (22%). Interestingly, \u201cfall\u201d was stated as the primary problem in 21%. Symptoms such as vertigo or sensory impairment were mentioned much less frequently. Use of a modified stroke scale may help dispatchers identify potential stroke victims and ensure appropriate prioritization of calls. The goal is to facilitate patient arrival at an ED as soon as possible to allow imaging studies and treatment to occur within a narrow window of opportunity. After sending appropriate resources, the dispatcher should provide instructions to the caller. In addition to providing dispatch life support, dispatchers can help expedite the time EMS personnel will spend on the scene by preparing the caller for certain important questions.\n\n These include past medical history, a complete list of medications, and, most importantly, when the patient was last known to be at his or her neurological baseline. These factors will be crucial for EMS personnel who can then begin to make decisions about the patient\u2019s eligibility for various interventions at specific receiving facilities. EMS dispatchers should use the guidelines set forth by the AHA and American Stroke Association (ASA). The use of modified stroke assessment tools and software that meet the AHA/ASA standards can help correctly identify stroke patients. All emergency medical dispatchers should complete an emergency medical dispatch course and be certified.",
        "EMS personnel on the scene": "It is imperative that EMS providers be familiar not only with the signs and symptoms of stroke, but also with currently available therapeutic protocols. Case-based education following the guidelines of the AHA can lead to significant improvement in prehospital personnel knowledge of stroke signs and symptoms. The 2010 AHA guidelines for CPR and emergency cardiovascular care should be followed. The Cincinnati Prehospital Stroke Scale (CPSS) and the Los Angeles Prehospital Stroke Scale (LAPSS) are both validated tools that can increase the sensitivity for identification of stroke. The Melbourne Ambulance Stroke Screen (MASS) is a hybrid of the two and is also credible for prehospital stroke assessment. While prehospital stroke scales are valuable tools to help identify potential stroke victims, there are also a number of stroke imposters that should be considered. Not all will be easily differentiated in the field. However, hypoglycemia can manifest with focal neurological findings. Thus, all potential stroke patients should have point-of-care glucose testing, and hypoglycemia should be treated. Additional historical features may help to determine the nature of some problems that subsequently appear similar to strokes. For example, preceding seizure activity might indicate Todd paralysis or increase the probability of ICH. Accompanying symptoms of migraine might indicate a complex migraine. In any case, expediency is important, but so is history that EMS providers may be in the best position to gather quickly.\n\nThere are some immediately relevant points with regard to the medical history of a potential stroke victim. Examples of important pieces of information include any recent trauma or use of warfarin, clopidogrel, or aspirin. Because potential witnesses frequently do not arrive at the hospital with the patient, attempting to determine the inclusion and exclusion criteria for thrombolytic therapy before hospital arrival can be very helpful. However, this should not delay transport, with one caveat. Finding out from family members or others at the scene when the patient was last at his baseline neurological function is imperative.",
        "Prehospital treatment of stroke": "Initial attention should be directed, as always, to airway, breathing, and circulation issues to ensure a stable patient notwithstanding the new neurological deficit. A stroke scale should be completed as it will add a degree of objectivity to the description of exam findings that can be conveyed to medical personnel later in the sequence of care. If possible, an IV cannula may be inserted to facilitate acquisition of blood for point-of-care testing and subsequent laboratory tests.\n\nIn general, dextrose-containing solutions should be avoided unless treating hypoglycemia. Hyperglycemia is associated with delays in recanalization of the occluded vessel. Hypoxia should be treated to decrease further insult to the already ischemic brain. However, indiscriminate administration of high-flow oxygen has not proven to be of any benefit. The current evidence indicates that maintaining normal oxygen saturation levels (i.e. treating hypoxia) is the best recommendation. Supplemental oxygen should only be used to achieve oxygen saturations of 94%.\n\nStroke patients are at risk for arrhythmias due to the increase in catecholamine release. Therefore, continuous cardiac monitoring is recommended. Most stroke patients will not experience arrhythmias that require treatment unless they have a concomitant illness, but this is always a consideration.\n\nBlood pressure control among stroke patients is an area of controversy and active investigation. Perfusion to the ischemic brain following a stroke is dependent on arterial blood pressure to maintain cerebral perfusion. Thus, hypotension or a relatively low blood pressure for a patient with chronic hypertension could theoretically adversely affect necessary cerebral perfusion to at-risk areas (e.g. penumbra). In fact, many patients experience hypertension immediately after a stroke, and studies have indicated that hypertension usually resolves spontaneously within a few hours. Yet, systolic blood pressure greater than 185 mmHg has been associated with increased risk of ICH among patients who subsequently receive fibrinolytic therapy. Blood pressure control is also postulated to be helpful in reducing hematoma expansion among ICH patients. Thus, too little blood pressure is not good, but neither is too much blood pressure. In general, blood pressure management is best deferred until the patient is in a more controlled environment, such as an ED, where invasive monitoring is possible. If there are compelling reasons to lower a patient\u2019s blood pressure in the field, such as coexisting pulmonary edema, for example, great care must be taken not to overcorrect. A suitable initial target is a 10% reduction of systolic blood pressure, but not lower than 150 mmHg.\n\nSome literature suggests that placing the patient supine may increase cerebral perfusion, but this also increases intracranial pressure, and this remains an area of uncertainty and investigation. Obviously, supine positioning is not advised in a patient who has clinical evidence of elevated intracranial pressure. As always, the risk of aspiration must be considered as well.\n\nUltimately, the goals for prehospital care of the possible stroke patient include rapid evaluation, stabilization as necessary, neurological examination, and expedited transport to a hospital capable of caring for a stroke patient. Early communication to the destination hospital is important. Studies have shown that such notification gives time for the stroke team to arrive in the ED and decreases the time from ED door to computed tomography (CT) scans and increased rates of IV tissue plasminogen activator (tPA) administration.",
        "Treatment options and the importance of time": "Pioneers in the 1940s and 1950s contemplated the use of fibrinolytics for the treatment of stroke, and in 1958 Sussman and Fitch reported the first use of thrombolytics to treat acute ischemic stroke. However, early studies using either streptokinase (SK) or urokinase (UK) resulted in high incidences of ICH. Therefore, these therapeutic agents were abandoned for the treatment of stroke until the 1970s, when advanced imaging technology could rule out the possibility of ICH prior to thrombolytic administration and allow for a more definitive diagnosis of ischemic stroke. Unfortunately, high rates of ICH secondary to SK treatment persisted in later trials, and ultimately led to the early termination of the Multicenter Acute Stroke Trial-Italy (MAST-I) and Multicenter Acute Stroke Trial-Europe (MAST-E) in the mid-1990s, as well as the abandonment of SK as a viable ischemic stroke treatment option.\n\nAround the same time as the MAST-E trial, several trials of tPA, which was thought to have a better risk-benefit profile compared to other thrombolytics, were conducted that failed to demonstrate favorable outcomes. However, it was felt that the use of tPA held promise if the correct dose and the right population of patients were selected. The NINDS trial demonstrated improved functional outcomes at 3 months as measured by the National Institutes of Health Stroke Scale (NIHSS) score, the modified Rankin score, and other neurological assessment tools in highly selected ischemic stroke patients treated within 3 hours of symptom onset. Patients treated with tPA were 30% more likely to have minimal to no disability at 3 months compared with patients treated with placebo (absolute benefit of 12%; number needed to treat (NNT)=8). Based upon these findings, in 1996 the Food and Drug Administration (FDA) approved the use of intravenous tPA for the treatment of acute ischemic stroke within 3 hours of symptom onset.\n\nRecently, evidence has emerged supporting the extension of the 3-hour treatment window to 4.5 hours. The European Cooperative Acute Stroke Study (ECASS III) randomized patients to tPA or placebo within 4.5 hours of symptom onset and found that patients receiving tPA were significantly more likely to have a favorable outcome (52.4% versus 45.2%; NNT=14).\n\nAs important, among patients who present within the treatment time windows for tPA, those treated sooner have much better odds of having a good outcome. Specifically, patients treated up to 90 minutes from symptom onset have an odds ratio (OR) of having improved functional outcomes of 2.6 (NNT=4.5) compared to an OR of 1.6 (NNT=9) for those treated between 91 and 180 minutes and an OR of 1.3 (NNT=14.1) for those treated between 181 and 270 minutes.\n\nIntraarterial tPA and devices for mechanical clot extraction are two other options for stroke patients who fall outside the 4.5-hour window or who have not substantially improved after IV tPA therapy.\n\nThe decision to use intraarterial tPA is determined by angiographic imaging and requires an interventional neuro-radiologist with specific expertise. The PROACT II (Prolyse in Acute Cerebral Thromboembolism) study evaluated the safety and efficacy of this procedure using pro-urokinase injected into middle cerebral artery occlusions. The study results indicated that there was a significant improvement in outcome (measured as independent function at 90 days) in 40% of patients in the treated group compared with 25% of patients in the placebo group.\n\nThere are currently several mechanical clot extraction devices approved by the FDA for use in acute ischemic stroke up to 8 hours after symptom onset, including MERCI, Penumbra, SWIFT (Solitaire), and TREVO 2. Rates of successful recanalization with these devices range from 46% using the MERCI device to 85% using the TREVO 2 device. Following a similar trend, good neurological outcomes at 90 days were seen in 28% of patients treated with the MERCI system and 40% of patients treated with the TREVO 2 system. Overall, 90-day mortality ranged from 17% to 44%.\n\nA large-scale trial (IMS-III) comparing endovascular therapy in patients who failed to improve after receiving a reduced dose of tPA within 3 hours of symptom onset was halted early due to futility. Good functional outcomes at 90 days did not differ between the endovascular group (40.8%) and the IV tPA alone group (38.7%). It has been suggested that combining advanced imaging with these devices may lead to optimal patient selection and better functional outcomes. However, the MR RESCUE trial failed to demonstrate a favorable benefit in patients selected for treatment who had an ischemic penumbra as defined by a magnetic resonance diffusion-perfusion mismatch. There are a number of factors that may have affected these negative trials that suggest the need for continuing research to elucidate the best implementation of these devices in practice.\n\nAll of these treatments have potentially devastating complications, the most noteworthy being intracranial bleeding. Also, these interventions have several exclusion criteria that must be considered in the selection of patients but which are beyond the scope of this chapter. Nonetheless, it is important that EMS personnel have at least a general understanding of available stroke treatments, as well as the rationale for accurate and rapid identification of the stroke victim. Box 12.3 describes the current AHA/ASA time-to-treatment goals related to IV tPA. Ideally, the time window from ED arrival to drug administration should not exceed 60 minutes.",
        "Role of the EMS system in promoting early patient arrival": "Given the narrow time windows of opportunity associated with the various interventional stroke therapies and the clearly demonstrated benefit of earlier treatment, EMS is a critical link to ensuring that patients arrive as soon as possible to a facility capable of treating stroke. Numerous studies have shown that stroke patients accessing the EMS system have a significantly greater chance of arriving earlier to a hospital for treatment, which in turn can promote higher thrombolytic treatment rates. More specifically, the California Acute Stroke Prototype Registry (CASPR) collected data from several California hospitals to identify factors that resulted in delayed presentation for treatment. This study indicated that if patients experiencing stroke symptoms (that did not occur overnight) had called EMS immediately, the percentage eligible for tPA would have increased from 4.3% to 28.6%. Furthermore, one randomized trial examining the effect of an intervention comprising a prehospital stroke assessment tool, an ambulance protocol for hospital bypass for potential thrombolysis-eligible patients, and prehospital notification of the acute stroke team demonstrated a significant increase in thrombolytic administration. In this study, the time from symptom onset to ED arrival decreased from 150 minutes to 90 minutes, and the proportion of patients receiving tPA increased from 4.7% to 21.4% after the intervention, with 43% of patients having minimal to no disability at 3 months.",
        "Importance of transport to an appropriate facility": "Rapid stabilization and transport of the stroke patient by EMS is only one important aspect of the critical role of EMS in stroke treatment and care. Equally important is a robust knowledge of the stroke treatment capabilities among area hospitals. Health care facilities that are not stroke centers may be able to administer tPA, but often lack the capability to perform more invasive techniques such as intraarterial tPA administration or mechanical clot retrieval. These procedures require an interventional neuroradiologist trained in these techniques. In addition, the personnel treating strokes must be available quickly and trained in the evaluation of stroke. The staffing of EDs throughout the country still varies widely, as does the relative stroke experience of practitioners. Designation as a primary stroke center by the Joint Commission indicates that a hospital has been evaluated and found to be in compliance with the specific guidelines as set forth by the Joint Commission. More recently, the Joint Commission has begun the process of certifying hospitals as comprehensive stroke centers if they meet specific criteria.",
        "Protocols": "Each community must evaluate its own resources and the population it serves to develop protocols for the treatment of stroke. This should be done in conjunction with the local and regional health care facilities. It should be determined whether the local community hospital is capable of managing acute stroke victims. Hospital transport destinations should be predetermined based on time and distance variables. In addition, air medical transport may be considered, including direct air medical evacuation of stroke patients from the scene. Air medical transport may be an appropriate option if the ground EMS transport time is expected to exceed an hour, and the air medical crew could arrive at a stroke center in time to have appropriate evaluation and treatment within the therapeutic window. In making such a decision, it is important to consider all the elements of air medical response that consume time, including flight time, time to prepare the patient, and time to load and unload. It is easy to overestimate the potential time savings, otherwise. The cost-effectiveness of the helicopter will vary at every setting but must be considered in the formation of any protocol. One study estimated the cost per additional good outcome at 3 months for acute stroke patients transported by helicopter to a tertiary care center for thrombolytic therapy to be $35,000, or $6,100 per quality-adjusted life year (QALY). Published standards consider $200,000 per additional good outcome and $50,000 per QALY to be the limit at which benefits are worth the related costs. Therefore, this study would indicate that air medical transport is a cost-effective procedure, although more research is needed. The medical oversight physician must be familiar with the logistics of air medical transport to ensure the appropriate use of this resource. Air medical transport of stroke patients in rural areas may facilitate access to thrombolytic treatment. A recent study looked at access of rural communities to stroke care. It found that stroke protocols that included the administration of tPA were present in only 31 of 125 facilities. Almost 40% of ischemic stroke patients transported by helicopter in this program were treated with thrombolytic therapy. It seems clear that the role of medical helicopter transport as part of regional systems of care is expanding.",
        "Controversies": "The administration of tPA has potentially serious side-effects, yet these can be minimized by strict adherence to the protocols set forth by the NINDS trial. Protocol violations have been associated with increased rates of ICH. A study of community hospitals found that in 50 patients who received tPA for acute ischemic stroke, NINDS protocol violations had occurred in the treatment of eight patients. It has been determined in other studies that strict protocol adherence can yield patient outcomes similar to those reported for patients in the NINDS study. The best outcomes occur when practitioners are knowledgeable in the treatment of acute stroke, and there is absolute compliance to the protocol. The NINDS trial itself has been criticized and the results questioned. One criticism is that patients treated with tPA had less severe stroke scores than the placebo group, which altered the measured outcome. After further analysis, it was determined that the difference in the stroke severity did not account for the differences. Though this is still somewhat debated, it is the general consensus and the recommendation of the AHA/ASA that tPA be given in the setting of acute ischemic stroke when it can be performed by personnel trained in the care of acute stroke and without protocol violations.",
        "Conclusion": "It is the responsibility of EMS physicians, nurses, and other EMS personnel to work together to develop a stroke system of care that maximizes the use of local resources. This can be accomplished by referring to the current strategies promoted by the ASA. An active public education effort is essential to ensure prompt activation of the EMS system. Ongoing education of EMS personnel in the recognition of stroke and the use of a stroke assessment tool such as the CPSS or LAPSS help stroke victims gain access to therapy in a timely manner. Stroke centers with comprehensive protocols and therapies, technical capabilities, and experienced physicians are the ideal destinations for stroke patients. Through a collaborative effort between health care professionals in the prehospital and in-hospital settings, improved access to acute stroke therapies and interventions can result in improved patient morbidity and mortality from the devastating effects of stroke."
    },
    {
        "Introduction": "Altitude illness can be life-threatening if not recognized and adequately treated in a timely manner. Altitudes as low as 1,500 meters (m) cause physiological changes as the body adapts to the unique environment. Rapid physiological adjustments can become pathological and perhaps fatal. More than 40 million tourists annually visit locations in the United States with elevations greater than 2,400 m. Consequently, an increasing number of health professionals encounter high altitude pathologies. Despite research in altitude medicine, significant morbidity and mortality related to high altitude environments persist. This continual and growing public health risk emphasizes the need for education about altitude medicine not only for the lay person, but for all health professionals. In particular, the EMS physician must understand the pathophysiology and treatment for high altitude illness both as a potential responder and as a medical director for responders.",
        "Physiology": "High altitude is considered to be heights between 1,500 and 3,500 m (4,921 to 11,483 feet (ft)), very high altitude is between 3,500 and 5,500 m (11,483 to 18,045 ft) and extreme altitude is greater than 5,500 m (18,045 ft). No matter how high you climb, the percentage of oxygen in the air remains roughly 21%. What changes as you climb is the density of the air molecules. At sea level, the air molecules are densely packed together from the weight of the air above them. As you climb, there is less pressure on the air molecules and so they are more dispersed. This air pressure is called barometric pressure or atmospheric pressure.\n\nAir molecules that are more dispersed translate into fewer molecules taken in with each breath. Thus, a breath at 3,500 m contains about 60% as much oxygen as at sea level. The concentration of the oxygen is still 21%, but there are fewer oxygen molecules available. At 5,000 m (the altitude of Everest Base Camp), each breath has about half the oxygen available at sea level and at 8,848 m (Mount Everest summit), each breath takes in about one-third as much as at sea level. As the level of inhaled oxygen decreases, the body responds with altitude acclimatization.\n\nMany physiological changes occur as the human body is subjected to the stress of high altitude. Erythropoietin is released from the kidneys once hypoxic conditions are sensed. This hormone stimulates bone marrow to increase red blood cell production. Within 2 hours of ascent, erythropoietin can be measured. Within 4\u20135 days, new red blood cells are in circulation. Over a period of weeks to months, red blood cell mass increases in proportion to the degree of hypoxia, allowing for an improved oxygen uptake and delivery.\n\nThe lungs respond by utilizing normally unused portions. As the human body ascends to altitude, breathing is deeper and faster. Sensing a fall in pO\u2082, the carotid bodies located within the carotid artery signal the central respiratory center in the medulla to increase the rate of pulmonary ventilation. Increased ventilation decreases alveolar and blood concentrations of carbon dioxide, while trying to maintain a normal oxygen concentration. As carbon dioxide continues to fall, pH becomes alkalotic. This alkalosis will reach a maximum threshold in which the central respiratory center limits further increase in ventilation so as to prevent severe alkalosis.\n\nWithin 24\u201348 hours of persistent alkalosis, the kidneys begin to excrete bicarbonate in the urine. Bicarbonate diuresis reverses alkalosis and returns the body's pH to a normal physiological level. This adjusted pH stimulates the cycle to begin again as the ventilatory response again increases, resulting in alkalosis, which prompts the kidneys to excrete bicarbonate. Ventilatory compensation reaches a maximum after 4\u20137 days at the same altitude. For each increase in altitude, the cycle of pulmonary-renal events recurs.\n\nOther physiological changes at altitude include dehydration, edema, and periodic breathing. The lower humidity and air pressure cause the skin and lungs to lose water through evaporation at a faster rate, resulting in dehydration if meticulous attention is not paid to fluid intake. As water is lost, the body tries to maintain fluid balances by minimizing the excretion of water and sodium. Fluid leaks from capillaries into tissues, causing edema. Most noticeable in the face, hands, and feet, high altitude edema seems to affect women more commonly than men. The edema usually worsens with ascent and resolves with descent. Periodic breathing is common at high altitude. As the body attempts to regulate oxygen and carbon dioxide, breathing may fall into a cycle of decreased breathing, followed by complete apnea for 3\u201315 seconds. Once the paCO\u2082 has built up again, breathing resumes.\n\nThe circulatory system responds to altitude with an increase in sympathetic activity, which causes a mild increase in blood pressure. After 24 hours, bicarbonate diuresis begins to decrease pH as well as stroke volume. Fortunately, this decrease in blood volume rarely causes myocardial strain as echocardiographic studies demonstrate a lack of myocardial stress with a decreased stroke volume. Additionally, with acclimatization, resting heart rate returns to normal, except at extreme altitudes. Paradoxical pulmonary hypoxic vasoconstriction shunts blood away from poorly aerated, injured, or diseased lung alveoli to healthy alveoli so as to maintain adequate oxygenation. When exposed to a high altitude environment, this phenomenon occurs throughout the lungs, leading to complete pulmonary vasoconstriction and mild pulmonary hypertension which is usually managed well by the body. Cerebral blood flow depends on the overall balance of hypoxic vasodilation and hypocapnia-induced vasoconstriction. This balance is rigorously tested in high altitude hypoxic environments. One study demonstrated a cerebral blood flow increase of 24% on abrupt ascent to 3,810 m and subsequent return to normal over 3\u20135 days. With severe hypoxia at high altitude, this delicate autoregulation of vasodilation and vasoconstriction becomes impaired, leading to several pathophysiological states discussed below.",
        "Acute Mountain Sickness (AMS) - Pathophysiology": "Acute mountain sickness (AMS) is the most common of the altitude illnesses. AMS has been described in altitudes as low as 2,500\u20132,700 m [1]. We do not fully understand the exact pathophysiology of AMS but it is thought that genetics may play a role. The pathophysiology of AMS includes minor hypoventilation, interstitial edema, and increased sympathetic drive \n\nSeveral theories regarding the cause of AMS are circulating. One theory suggests that AMS results from mild brain swelling. A study using brain imaging of patients with moderate-to-severe AMS showing white matter edema with an elevated intracranial pressure (ICP) supports this concept [8]. However, those with mild AMS do not have cerebral edema [9\u201314]. Hence, this hypothesis only partially explains AMS. Other investigators have postulated that an increase in ICP causes AMS. Although some studies demonstrate an increase of ICP in AMS using optic nerve sheath diameter and lumbar puncture pressure, other studies demonstrate no change in pressure [14\u201317]. Thus, evidence that ICP is elevated in mild AMS remains limited.\n\nA third hypothesis, known as the tight fit hypothesis, theorizes that persons with smaller intracranial and intraspinal cerebral spinal fluid capacity are predisposed to develop AMS, because they cannot tolerate brain swelling compared to those who have more room to accommodate ",
        "Acute Mountain Sickness (AMS) - Symptoms": "Most unacclimatized persons traveling to high altitude experience a mild form of AMS. The most common complaint is headache followed by fatigue, anorexia, and dizziness. Headache is described as throbbing, bitemporal, and worse at night. Additionally, Valsalva maneuvers or bending over exacerbate the headache. Anorexia and nausea are common. Frequent waking from sleep, periodic breathing, and a feeling of suffocation are exaggerated in patients with AMS. Symptoms are often described as similar to an alcohol hangover. Additionally, persons with AMS may complain of a deep inner chill, vomiting, dyspnea on exertion (although pulmonary symptoms vary widely), and lassitude. Symptoms typically begin within 24\u201348 hours of reaching altitude and resolve in 3\u20135 days at the same altitude.\n\nThere are no pathognomonic physical exam findings associated with AMS. Pulse may range from bradycardia to tachycardia. Blood pressure may range from normal to postural hypotension. Rales may be present and oxygen saturation changes correlate poorly in the diagnosis of AMS. Fundoscopic examination may reveal venous dilation as well as retinal hemorrhages, but are not diagnostic. Finally, a decrease in urine output demonstrating poor alkalotic diuresis may also be an early finding of AMS. It is always key to remember that there are no neurological deficits associated with AMS.",
        "Acute Mountain Sickness (AMS) - Treatment": "\n\nManagement depends on the severity of AMS. Mild AMS can be treated by halting further ascent to allow for acclimatization. This may take 3\u20134 days. Additionally, acetazolamide accelerates acclimatization by increasing bicarbonate diuresis. This may prevent AMS or accelerate treatment if given early enough. Acetazolamide is typically given as 250 mg by mouth (PO) twice a day or as a single dose. Symptomatic treatment with analgesics such as ibuprofen (or other non-steroidal anti-inflammatories), acetaminophen (650\u20131,000 mg PO), or aspirin (500\u2013650 mg PO) should be considered. Antiemetics such as ondasetron can be provided. Dexamethasone (4\u20138 mg PO, intramuscularly (IM) or intravenously (IV)) appears to treat symptoms of AMS by an unknown mechanism. However, it has been shown that symptoms increased when dexamethasone was removed in 24 hours. AMS patients should avoid alcohol and other respiratory depressants to avoid further hypoxemia.\n\nFor moderate-to-severe AMS, descent is the treatment. One may descend as far as necessary, but a drop of 500\u20131,000 m is usually effective. Also, lightweight portable hyperbaric chambers mirror descent and can also effectively treat AMS. These hyperbaric chambers are manually inflated fabric pressure bags. Typically an inflation of 2psi is roughly equivalent to a drop in altitude of 1,600 m, though the exact equivalent of psi to altitude drop depends on the initial altitude. Additionally, oxygen given at 0.5\u20131 L/min by mask or nasal cannula (NC) is an effective treatment for moderate-to-severe AMS.",
        "High altitude cerebral edema - Pathophysiology": "High altitude cerebral edema (HACE) is life threatening. With increasing altitude and decreasing atmospheric pressure, capillaries begin to leak, causing edema. When fluid leaks into the closed space of the brain, HACE occurs. Studies demonstrate cerebrospinal fluid pressures of more than 300 millimeters of water and severe edema on cerebral imaging, and autopsies demonstrate petechial hemorrhages along with severe edema. Much like AMS, there is a spectrum of HACE ranging from reversible HACE to severe, end-stage HACE. Reversible HACE demonstrates vasogenic edema whereas end-stage HACE produces gray matter (cytotoxic) edema. As cytotoxic edema progresses, cerebral cells are separated from capillaries, resulting in failure to transport oxygen and nutrients to the cells, leading to brain cell death. Intracranial pressure increases as edema continues on a systemic level. As compression of the brain develops, third and sixth nerve palsies may present, as well as other neurological symptoms.",
        "High altitude cerebral edema - Symptoms": "Unlike AMS, HACE has a more dramatic presentation. The classic symptoms are ataxic gait, severe lassitude, and altered consciousness. Altered consciousness can range from confusion to drowsiness to coma. Additionally headache, nausea, and vomiting may occur. Other neurological presentations such as hallucinations, cranial nerve palsies, seizures, and paralysis have been described, but may not be as common. The progression from AMS to HACE can be as quick as 12 hours, but typically develops in 1\u20133 days.",
        "High altitude cerebral edema - Treatment": "Recognition and treatment of HACE must be swift. At first presentation of ataxia or altered mentation, descent should begin immediately. Treatment with dexamethasone (4\u20138 mg IV, IM, or PO) followed by 4mg every 4\u20136 hours should also be started. Additionally, oxygen therapy via mask or NC at 4L/min should be initiated and titrated to an oxygen saturation of greater than 90%. If the patient is comatose, rescuers should proceed to advanced airway management. Hyperventilation should be used with caution as hyperventilation in an already alkalotic patient can be catastrophic. Furosemide has been successfully used to reduce fluid overload in the cranial vault. It is also reasonable to postulate that hypertonic saline and mannitol can reduce ICP, even without the appropriate studies. Coma for severe HACE can last from an average of 5.6 days to up to 3 weeks, with full recovery in about 2.4 weeks. However, if not recognized and treated appropriately, death will occur.",
        "High altitude pulmonary edema - Pathophysiology": "Three physiological factors drive high altitude pulmonary edema (HAPE): excessive pulmonary hypertension, high-protein permeability leak, and persistent hypoxic exposure. Excessive pulmonary hypertension is a direct result of the paradoxic pulmonary hypoxic vasoconstriction. In the case of high altitude environments, the entire lung is hypoxic, resulting in diffuse vasoconstriction of the pulmonary capillaries. The degree of constriction varies among individuals. While pulmonary hypertension is one of the three necessary factors of HAPE, it is not necessarily the cause, as all persons exposed to high altitude environment have some form of pulmonary hypertension. It is hypothesized that uneven hypoxic pulmonary vasoconstriction results in overshunting of blood to relatively non-constricted vessels. This leads to high pressures and eventual capillary leakage, causing lung edema.",
        "High altitude pulmonary edema - Symptoms": "The most common cause of death related to high altitude illness is HAPE. Victims are typically young athletic males with a rapid ascent from sea level who may not have had HAPE on previous high altitude adventures. Typically, HAPE occurs within the first 2\u20134 days of ascent higher than 2,500 m, and most commonly on the second night. The earliest signs may be decreased exercise performance and increased recovery time. Additionally, fatigue, weakness, and dyspnea on exertion become more obvious. Persistent dry cough develops with other signs of increasing hypoxia, including cyanotic nail beds and lips. AMS occurs in 50% of individuals with HAPE. Symptoms are worse at night and eventually tachycardia and tachypnea develop at rest. More severe forms of HAPE result from increasing respiratory distress.",
        "High altitude pulmonary edema - Treatment": "Treatment for HAPE depends on the severity of the illness. The earlier HAPE is recognized, the better the outcome. The best treatment is early descent of only 500\u20131,000 m. After 2\u20133 days at this altitude, the patient may re-ascend. Supplemental high-flow oxygen (4L/min or more) for more than 24 hours is also essential. If descent is too slow or delayed, administration of high-flow oxygen is life saving. Climbers should not wait for rescue and should descend immediately. Oftentimes waiting for help has proven fatal.\n\nOther treatments include resistance on expiration (expiratory positive airway pressure) or continuous positive airway pressure, which can act as a temporizing measure. If unavailable, pursed lip breathing can be effective. Additionally, diuretics such as furosemide (80 mg every 12 hours) may be used. Phosphodiesterase-5 inhibitors (e.g. sildenafil) demonstrate potential for prevention for HAPE, but have not been approved for treatment. Calcium channel blockers such as nifedipine (30 mg slow release every 12\u201324 hours) reduce pulmonary vascular resistance while improving arterial oxygenation. However, clinical improvement remains minimal with diuretics and calcium channel blockers when compared to descent and supplemental oxygen.\n\nOnce at a more appropriate elevation, recovery is the rule before any re-ascent can be attempted. Typically, bed rest and oxygen sufficient to keep oxygen saturation greater than 90% are key, and medications are rarely necessary. If treated promptly and correctly, intubation is rarely required. Patients should be warned that recovery may take up to 2 weeks and return to normal activity should be gradual.",
        "Considerations for the medical director": "Education for altitude illnesses is key for any EMS physician or medical director. Instruction to medics, first responders, rescuers, and potential patients should be emphasized. Education should be focused on recognition of altitude illness, especially early signs of HACE and HAPE. Differentiation of temporizing treatments, including acetazolamide, from definitive life-saving treatments, like descent, must also be stressed.\n\nClimbers themselves should also be made aware. Although direct education for all potential patients is impossible, indirect education through pamphlets, websites, and frequently asked questions can be made readily available. Instruction should also focus on ensuring frequent contact with appropriate parties, such as a base camp or climbing partner, as well as dispelling treatment myths, such as that simple hydration can treat all climbing pathologies. Identification of climbers can be acquired through the National Park Service, which requires registration of individuals who want to climb to high altitudes.\n\nFinally, interagency cooperation and training with multiple services must be considered by the medical director. Frequent communication and training with rescue teams, first responders, EMS agencies, and hospitals can further facilitate a smoother response should such illnesses present. Input from a variety of personnel may aid in the modification or creation of flexible protocols that allow responders to think critically while simultaneously providing definitive end goals. These exercises can also help the system anticipate unforeseen barriers such as weather, resources, and communications. Such interdepartmental options can facilitate the identification and acquisition of pertinent equipment, from supplemental oxygen to portable hyperbaric chambers, needed for response.",
        "Conclusion": "Travel to high altitude locations can be fun and incredibly gratifying. However, there remains a real risk to health and potentially life when exposed to such extreme environments. Hypoxia is the main insult the body endures. The delicate balance of physiological compensation for hypoxia aids in the comprehension of pathology that may follow.\n\nOf all pathologies described, AMS is the most benign. However, it must be remembered that mild AMS can evolve into severe life-threatening HACE. Like HACE, HAPE can kill very quickly. HAPE remains the most common cause of death of all high altitude illnesses. Definitive treatment for AMS, HACE, and HAPE is descent of about 500\u20131,000 m as well as supplemental oxygen. Other medical treatments are available, but only as temporizing measures.\n\nThere are many factors that a medical director has to be concerned with, but chiefly the EMS system's knowledge of altitude illnesses in conjunction with cooperation between rescue teams, first responders, and hospitals play an important role in the treatment of these patients. The risk of high altitude illness increases as more people participate in travel and recreational activities in these environments. The challenges of high altitude illness are many, but preparation through education and training can help save lives and keep such adventures fun, entertaining, and safe."
    },
    {
        "Introduction": "Humans live in a wide range of environments. Below 82\u00b0F, a healthy naked human being can no longer produce enough heat to maintain body temperature and requires protection from the cold. Cold illness and injuries are common and EMS physicians must be familiar with their epidemiology, presentation, and treatment to improve patient outcomes. Common cold injuries include hypothermia, non-freezing tissue injuries, freezing tissue injuries, and cold water immersion. These four processes account for the majority of cold-related EMS care. Abuse, inadequate nutrition, and inadequate social circumstances. Urban hypothermia is a chronic disease and while the clinical presentation of hypothermia may precipitate the call for EMS and may well be the immediate life threat, it is rarely the only active disease process. It is often considered to be secondary hypothermia. Wilderness or environmental hypothermia, by contrast, is primary hypothermia caused by exposure to cold stress that exceeds the body\u2019s heat production capacity. It is either acute, as in immersion, or subacute hypothermia (over days), as seen in the inadequately prepared hiker in a cold (although not necessarily freezing) environment.",
        "Hypothermia - Definition": "Hypothermia is a core body temperature below 95\u00b0F (35\u00b0C). Stages include mild hypothermia (90\u201395\u00b0F/32\u201335\u00b0C), moderate hypothermia (82\u201390\u00b0F/28\u201332\u00b0C), and severe hypothermia (below 82\u00b0F/28\u00b0C). Measuring a \u201ctrue\u201d core body temperature can be a challenge in the hospital, let alone in the prehospital environment, and individual physiological responses to cold can vary widely. From a practical perspective, hypothermia is best defined from a physiological standpoint: cold stress exceeding the body\u2019s ability to produce sufficient heat to maintain body temperature. The stages can then be based on clinical presentation and a patient\u2019s ability to self-rewarm if the cold stress is eliminated. In this approach, the core temperature is adjunctive but the clinical picture guides the provider\u2019s actions.",
        "Hypothermia - Types": "From 1999 to 2011, there were on average 1301 deaths annually in the United States attributed to hypothermia [3]. While the classic image of hypothermia is the lost hiker huddled in the snow, EMS providers are more likely to encounter urban hypothermia, a multifactorial hypothermia resulting from cold exposure and some combination of medical conditions, medications, changes in temperature perception, substance abuse, inadequate nutrition, and inadequate social circumstances [4\u20137]. Urban hypothermia is a chronic disease and while the clinical presentation of hypothermia may precipitate the call for EMS and may well be the immediate life threat, it is rarely the only active disease process. It is often considered to be secondary hypothermia.\n\nWilderness or environmental hypothermia, by contrast, is primary hypothermia caused by exposure to cold stress that exceeds the body\u2019s heat production capacity. It is either acute, as in immersion, or subacute hypothermia (over days), as seen in the inadequately prepared hiker in a cold (although not necessarily freezing) environment.",
        "Hypothermia - Mechanisms of thermoregulation": "Humans maintain a core temperature within a narrow range of (95\u2013100.7\u00b0F/35\u201338\u00b0C) for optimal metabolic functioning. Four mechanisms, radiation, conduction, convection, and evaporation, contribute to heat loss from the body; homeostasis is maintained by balancing these mechanisms against heat production. Infrared radiation emission accounts for up to 40% of all heat loss. The greater the temperature difference between the individual and the environment, the greater the rate of heat loss. This can occur even when the air temperature is warm if the surrounding environmental features (such as a cave or concrete structure) are colder. Evaporation via sweating dissipates excess heat, with approximately 575 calories of heat lost for each cubic centimeter of evaporated sweat. Unfortunately, this mechanism is just as effective at removing heat during periods of cold stress. Individuals who become wet will rapidly lose heat via evaporation in a cold environment. In conduction, direct transfer of heat from one object to another, a colder object becomes an important source of heat loss for the recumbent ill or injured individual. The greater the area of uninsulated contact, the more heat is lost. Convection, particularly combined with evaporation, also contributes to heat loss. The body heats a small local environment to minimize heat transfer. If this buffer zone is lost, the body is constantly reheating new air (or water) and heat losses increase dramatically. Moving air (wind) augments this effect. Heat loss is a function of the square of wind velocity so doubling the wind speed quadruples heat loss [8] up to a maximum speed of 40 mph (64 km/h), after which the air is moving too quickly to absorb heat [9]. This phenomenon is referred to as wind chill (Figure 48.1). Wind chill describes the rate of heat loss from exposed skin. This has implications for how urgently a rescue must be effected. Use of windproof garments or shelters eliminates the wind chill effect.\n\nTwo primary defenses guard against heat loss. First, in response to cold stress, there is a behavioral imperative to add additional layers of clothing and to seek sources of warmth [8]. The second defense is heat production. Any muscular activity produces heat. The body can uncouple heat production from useful activity via shivering [3]. While shivering will produce additional heat to counter cold stress, it will not prevent worsening hypothermia if the environmental conditions don\u2019t change. Shivering should serve as a signal to take other actions to decrease the environmental cold stress. Performing useful activity that increases the chances of survival also generates heat and is the preferred method of muscular heat production.",
        "Hypothermia - The stages of hypothermia": "Hypothermia is categorized into three stages based on clinical presentation, the ability of the patient to self-rewarm, and body temperature. Mild hypothermia is characterized by shivering, a general loss of fine and then gross motor function, and a progressive loss of intellectual function accompanied by the development of confusion. Patients in this stage typically have a good ability to self-rewarm initially, though this ability diminishes as their temperature decreases. The likely temperature range for mild hypothermia is 90\u201395 \u00baF (32\u201335 \u00baC). Moderate hypothermia involves the loss of shivering, increased vulnerability of the heart to atrial fibrillation, and a progression from confusion to unconsciousness. In this stage, the ability to self-rewarm is poor and may completely disappear. The temperature range associated with moderate hypothermia is 82\u201390 \u00baF (28\u201332 \u00baC). Severe hypothermia presents with muscular rigidity, loss of detectable vital signs, and a significant risk of cardiac arrest due to ventricular fibrillation, especially if the patient is handled roughly. This stage may also involve coma and the complete loss of self-rewarming ability. It occurs when the body temperature falls below 82 \u00baF (28 \u00baC).",
        "Hypothermia - Prevention": "Preventing wilderness hypothermia requires recognizing cold stress and taking actions to decrease it. Sufficient calorie and water intake is crucial to allow effective metabolism and heat generation. Clothing that maintains a microclimate of trapped air, prevents heat loss through convection, and wicks moisture away through all the layers of the clothing decreases the risk of hypothermia. Avoidance of substances that promote vasodilation (e.g. alcohol) or that impair judgment and temperature perception (e.g. alcohol or illicit drugs) will decrease the risk of primary hypothermia.\n\nPreventing urban hypothermia is a far more complex issue with public health and social welfare implications [10]. Programs such as the Low Income Home Energy Assistance Program likely decrease the incidence of urban hypothermia, as do homeless shelters.",
        "Hypothermia - Recognition": "While classification based on core body temperatures is useful for research and statistical purposes, an individual\u2019s performance at a given core body temperature can vary widely and so the assessment and treatment should be based on clinical presentation. In the early stages of hypothermia, a perception of being cold and a behavioral imperative to change or exit the cold environment will predominate. Unless sufficient heat is being developed from useful activity, the patient will shiver and may be mildly agitated. Loss of fine motor control follows. At this stage, if the patient has sufficient calorie reserves and is removed from the cold stress, he will be able to rewarm himself. Left untreated, hypothermia will progress and symptoms will include confusion, slurred speech, loss of gross motor coordination, and loss of judgment. This stage is described as the \u201c-umbles\u201d: the patient stumbles, mumbles, grumbles, fumbles, and tumbles. Eventually as caloric reserves are depleted, shivering stops. At this point, the patient is no longer able to self-rewarm even if cold stress is eliminated. The patient will progress to a state of unresponsiveness. Cardiac dysrhythmias occur, particularly atrial fibrillation. Metabolic demand decreases and the patient becomes bradycardic. As the myocardium becomes more irritable, the risk of ventricular fibrillation with minimal or no stimulation increases. Respiratory rate decreases and the patient may appear apneic. Once the patient is comatose, effort must be focused on minimizing physical movements that could trigger ventricular fibrillation, including bumping, dropping, or otherwise physically stimulating the patient.",
        "Hypothermia - Treatment": "Treatment of hypothermia depends on whether or not the patient is able to self-rewarm if the cold stress is eliminated. Therefore, the most important action is to eliminate the cold stress. This may be as simple as moving the patient to a heated ambulance. If a heated sheltered environment is not readily available, efforts to eliminate further heat loss include insulating the patient from the ground to prevent conduction, removal of wet clothing to minimize evaporation, and sheltering from wind to prevent convection. Although studies have evaluated mechanisms to decrease radiant heat loss, to date none have been particularly successful. Once the cold stress is removed, an assessment must be made of the patient\u2019s ability to self-rewarm. For the patient with mild hypothermia who still has adequate caloric and metabolic reserves (that is, still shivering or recently stopped shivering), elimination of cold stress and feeding the patient should be sufficient to restore normothermia. For patients who are metabolically depleted and unable to self-rewarm, active interventions will be necessary. The historical dogma has been that out-of-hospital interventions are sufficient only to prevent further heat loss and are not adequate to restore normothermia. Such interventions have included heated IV fluids, heated (and preferably humidified) inhaled oxygen, application of heat packs or heated water bottles to the neck, axilla, and inguinal creases, and rescuer/patient skin-to-skin contact. More invasive procedures such as warm water irrigation of the stomach, bladder, peritoneal, and pleural cavity as well as heated dialysis and cardiopulmonary bypass have been reserved for the hospital setting. Over the last decade, research has demonstrated that effective prehospital interventions exist. These include a 600 W heater with a soft rewarming blankets (a forced warm air full-body blanket), 600 or 850 W heater with rigid torso cover, and charcoal vest forced hot air heaters. Of these devices, the charcoal heater is the only one that does not require electricity beyond a D-cell battery to run the fan, is light enough that a single rescuer could carry two, and is inexpensive. On the other hand, it does use a flame source to generate heat (burning charcoal) and therefore poses a risk when used with oxygen. All of these devices have been demonstrated to attenuate afterdrop (the tendency for the core temperature to drop even after the initiation of rewarming) and to actually rewarm the patient. If EMS agencies and providers function in an environment where hypothermia is prevalent, acquisition of at least one of these types of devices should be considered. Avoid immersion in warm water as this increases mortality.",
        "Hypothermia - Disposition": "Due to concomitant medical and social issues, the patient with urban hypothermia must be transported to an emergency department for further evaluation. For the patient with primary hypothermia in a wilderness setting, the disposition is less clear. A patient with mild hypothermia who recovers to normothermia may not need evacuation if changes can be made to the patient\u2019s clothing system or to the route so recurrent cold stress is minimized. For the patient with moderate hypothermia, evacuation is mandatory with one exception. In the case of an expedition with provisions for active rewarming, the decision to evacuate the moderately hypothermic patient restored to normothermia is made in conjunction with the patient, the expedition leader, and medical support staff in the context of the risks of evacuation. For the patient with severe hypothermia and signs of life, evacuation is mandatory. The method of evacuation must be such that the patient experiences as little unnecessary movement and as few bumps as possible. Evacuation may not be possible and in situ rewarming may be necessary. The patient without signs of life presents a challenge. While the mantra \u201cno one is dead until warm and dead\u201d is always operative, it is not always practical. Rescuer safety is primary and while successful resuscitation of severely hypothermic patients has been reported, the risk:benefit ratio of the operation must be considered. In addition, there are indeed patients who are cold and dead. These include those with a core temperature less than 50\u00b0F (10\u00b0C), cold water submersion for greater than 1 hour, obvious fatal injuries, and frozen patients (i.e. ice formation in the airway or chest walls that are so rigid compressions cannot be performed. Cardiopulmonary resuscitation (CPR) is difficult in the wilderness environment and effective performance during patient transport is impossible. Some experts recommend performing rewarming in place while others recommend transporting without CPR if definitive care (any provider capable of providing effective active rewarming) is available within 3 hours. Guidelines for defibrillation, CPR techniques, and medication administration vary widely and the American Heart Association in 2010 noted a lack of research identifying optimal resuscitation techniques.",
        "Non-freezing cold injuries": "Non-freezing cold injury to the foot (trenchfoot or immersion foot) occurs with subacute exposure in cold but non-freezing conditions. The foot becomes macerated with vasomotor instability and anesthesia. Temperature affects the time to onset; for shipwrecked sailors whose feet are immersed in cold water, onset may take as little as 24 hours while the minimum time to onset on land is 4\u20135 days. Injury occurs from local maceration due to water exposure, cold-induced vasoconstriction, and circulatory compromise from excessively tight footwear and immobility. Prolonged vasoconstriction leads to damage to the blood vessels and results in injury to the tissues they feed. Non-freezing cold injuries progress through three phases. In the pretreatment (prehyperemic) phase, the limbs are blanched and yellowish white. Local edema may be present and the patient may complain of anesthesia, particularly as cold exposure progresses. Pain is rare at this phase. In the urban setting, alcoholism and chronic homelessness may contribute to a complete non-awareness of this condition. Once treatment is initiated, the patient enters the hyperemic phase lasting hours to weeks. The vasoconstriction reverses and, due to vasomotor instability, the extremities become hot, red, swollen, and painful. Blisters in this phase indicate more serious injury and gangrene may occur in the most severe cases. The posthyperemic phase may be absent in mild cases or may persist for years after the injury. It is characterized by ongoing symptoms after the resolution of the hyperemic phase, including vasomotor instability, persistent cold sensitivity, and limb coolness. After periods of exertion, blistering, edema, and paresthesias may also reoccur. This phase may last for years. Clean, dry socks changed at least once and preferably twice a day will markedly decrease the risk of non-freezing cold injury. Avoiding immobility, taking breaks from the cold, wet environment, limiting activity to minimize sweating, and keeping the feet dry for 8 out of every 24 hours are important prevention techniques. Remove the wet garments, keep the feet dry and elevated, and keep bedclothes from pressing on the feet. Tissue rewarming is not necessary, but warming the core temperature (if necessary) while providing cooling with a fan to the injured area will markedly decrease pain, edema, and blistering. Remember that the social and environmental conditions that predispose to trenchfoot also contribute to hypothermia.",
        "Frostbite": "Frostbite is a freezing injury to soft tissues. A combination of local (tissue-level) freezing temperatures and an inability of the body to produce or provide sufficient heat allows the tissues to freeze. Frostnip may precede freezing. Frostnip is a condition of superficial ice crystal formation without resulting tissue damage. Cyclic vasoconstriction and vasodilation in the extremities (known as the \u201chunting response\u201d) may be present. This process, which occurs more in cold-acclimatized individuals, protects at-risk tissue from freezing. While it contributes to additional heat loss, cyclic rewarming permits greater dexterity in the hands, improving function in cold environments. Environmental conditions that predispose to frostbite are the same conditions that predispose to hypothermia. Peripheral vasoconstriction may cause blood flow to the distal extremities to essentially cease. The cold also induces vascular endothelial damage with plasma leakage. With continued cooling, freezing occurs and extracellular ice crystals form. This leads to changes in local solute concentrations and intracellular dehydration. Additional injury comes from denaturation of lipid-protein complexes, toxic concentrations of intracellular electrolytes, thermal shock, and, in the event of rapid freezing (seconds to minutes), intracellular ice crystals. However, tissue freezing does not necessarily result in permanent damage. Frozen cells are metabolically inactive and so cell death may not occur when the tissues are frozen. Instead, when rewarming occurs and the tissues become metabolically active, oxygen demand increases. The endothelial damage to the microvascular circulation that occurred during freezing now contributes to local thrombosis and watershed ischemia. Early signs of incipient frostbite include a cold sensation, pain, and pallor. As freezing occurs, pain resolves and anesthesia ensues. The loss of sensation may be accompanied by a sense that the limb is clumsy or that the affected body part is absent. The tissue becomes paler. A noticeable progression of superficial to deep freezing occurs. The skin will begin to feel firm and non-pliable although the underlying tissues will be soft. Ultimately, the entire affected part becomes solid. In severe cases, purplish discoloration may occur. Several grading systems have evolved. The best grading system is one that allows early and accurate prognostication of treatment resource requirements and prognosis. Unfortunately, the ideal system has not yet been developed. For prehospital providers, a grading system of \u201cdegrees\u201d based on findings after freezing and rewarming is commonly used. First-degree injuries are characterized by numbness, erythema, white or yellow plaques in the area of injury, and edema without tissue loss. Second-degree injuries add blisters surrounded by erythema and edema. In a third-degree injury, blisters are more extensive and contain blood. A fourth-degree injury involves the subcuticular tissues. It may be difficult to clinically distinguish fourth-degree from third-degree injuries in the immediate postrewarming period. Prevention of frostbite includes preventing hypothermia so that peripheral circulation is maintained, avoiding constricting garments and boots (including too many layers of socks), and remaining active. Treatment of frostbite is less about what to do and more about what not to do. The two key principles are to avoid thawing and refreezing the frozen part and preventing burns. Honoring these two principles, any appropriate treatment to rapidly thaw the tissue is acceptable, although controlled rewarming with warm water immersion of affected limbs remains the preferred treatment. While there is no additional benefit to rewarming a frozen part that has completely thawed, there is also no harm. If there is any doubt about whether the part is completely thawed, rewarming should be instituted. Rewarming is best accomplished by treating the hypothermia to a core temperature of at least 93\u00b0F (34\u00b0C) and then completely immersing the frozen part in a warm water bath (99\u2013108\u00b0F/37\u201342\u00b0C). All clothing, constricting bands, or items that would decrease peripheral circulation should be removed. The bath should be brought to the appropriate temperature without the part immersed to prevent scalds. Except when rewarming the bath, the part should remain fully immersed until the tissues become pliable and there are no further color changes. The temperature of the bath should be continuously monitored. Rewarming will typically take 30\u201360 minutes. Avoid massage of the injured part since this may increase local damage. Although older guidelines based on the work of Baron Larrey cautioned against rapid rewarming, recent work has demonstrated the superiority of a rapid rewarming approach. In a wilderness or uncontrolled environment, thawing of a frozen part should only occur if the following conditions can be met. 1 The person will not need to use the frostbitten part for evacuation until healing is complete. 2 The person can be kept warm during thawing and until healing is complete. 3 Thawing can be completed in a controlled, uninterrupted manner with accurate temperature management of the rewarming bath. If these conditions cannot be met, the extremity should not be thawed. During rewarming, pain can be intense. Adjunctive parenteral narcotics may be necessary to control this pain. Additional therapies include thromboxane inhibitors (ibuprofen 400 mg PO every 12 hours), tetanus immunization as needed, and strict wound care of the injured part. Antibiotics are indicated for any signs of infection. Sterile dressings should be placed between the digits once they are thawed to decrease tissue adhesion. Unless another traumatic condition or an abscess exists, surgery is contraindicated until the extent of the tissue death is clear, often 3\u20136 months.",
        "Cold water immersion": "Cold water immersion (head above the water, as opposed to submersion or drowning with the head below the water) is immersion in water less than 77\u00b0F (25\u00b0C). In water below 77\u00b0F (25\u00b0C), no amount of exertion can maintain a normal core body temperature in an unprotected individual. In water temperatures below 68\u00b0F (20\u00b0C), a variety of physical and behavioral responses create hazardous conditions that put the immersion victim at increased risk of death either from drowning or eventually from hypothermia. In cold shock response, the first phase of cold water immersion, respiratory patterns change with hyperventilation and a gasp response predominating; unacclimatized individuals also lose breath-holding ability. Breathing becomes erratic and the individual cannot entrain coordinated physical activity with the respiratory cycle. While this phase lasts only a few minutes, the victim may hyperventilate to unconsciousness, panic or aspirate water and, if not wearing a personal flotation device (PFD), may drown. A victim wearing a PFD can focus on controlling breathing and successfully survive the initial immersion. If the victim recovers from the initial cold shock response, a period of approximately 10 minutes remains for useful activity before loss of fine and gross motor function progresses to complete inability to perform any meaningful survival actions. This phase is called cold incapacitation. Core temperatures may increase as significant peripheral vasoconstriction shunts blood centrally. For a victim without a PFD, this phase will typically conclude with drowning as the ability to maintain the head above water is lost. Useful actions that promote recovery or survival should be performed. However, unnecessary physical activity should be avoided as movement promotes heat loss at a rate greater than metabolic heat generation. If the shore is sufficiently close (within 800 m) the victim may consider attempting to swim to shore. While this decision should be made as soon as possible during the cold incapacitation phase, it should not be made lightly as the rate of cooling will increase and, if the swim attempt is unsuccessful, hypothermia will be accelerated. After 30\u201360 minutes, the victim will begin to face a significant risk of hypothermia. Many factors influence the time to onset of hypothermia (body morphology, sea state, protective garments, exercise, shivering, and behaviors). Nonetheless, even if the victim becomes unconscious from hypothermia, as long as submersion can be prevented, the victim may not actually die from hypothermia for up to 2 hours. Sudden death in the period immediately preceding rescue as well as in apparently recovered survivors of cold water immersion has been described up to 24 hours after rescue. This occurs in approximately 20% of immersion victims. Although no one cause has been identified, a number of factors such as afterdrop and return of cold, acidotic or alkalotic blood to the heart, catecholamine release, decreased hydrostatic pressure upon removal from the water, cold-dulled baroreceptor reflexes, increased blood viscosity, intravascular volume depletion, and decreased work capacity of the heart may explain why this happens. Rescuers must make all efforts to keep cold water immersion victims horizontal, prevent unnecessary physical activity (including walking to an aid room or ambulance), and maintain vigilance for this potentially delayed lethal event. Cold water immersion is a threat to rescuers and patients alike. First, and most importantly, anyone at risk for cold water immersion must wear a PFD and preferably protective insulating garments appropriate to the degree of risk. While each circumstance is unique, it is important for anyone immersed in cold water to remember and act based on the 1-10-1 rule. Upon immersion, the victim has 1 minute to control ventilation and prevent panic. This is followed by 10 minutes of useful activity to either signal for rescue or improve the situation to increase the chances of survival and rescue. Finally, it will take approximately 1 hour until unconsciousness occurs due to hypothermia, so any actions taken in the first 10 minutes that result in rescue before 1 hour may well prevent death from hypothermia."
    },
    {
        "Introduction": "Evaluation and treatment of the pregnant patient represent a challenge for all levels of medical providers, from first responder through EMS physician. Thankfully, major complications and acute life-threatening illnesses are rare. However, when they occur, many special considerations must be taken into account in order to provide the best medical care. This chapter will provide an overview of physiological changes in pregnancy and their implications for prehospital care. Although many of the conditions require further diagnostic testing and treatment beyond the current capabilities of EMS, familiarization by EMS providers and EMS medical directors is critical. This will enable EMS providers to consider life-threatening conditions that require immediate intervention, formulate a preliminary differential diagnosis, initiate treatment, and make the best determination for transport destination.",
        "General considerations": "\n\nAnatomical The anatomical changes that a woman undergoes during pregnancy are not confined to the reproductive organs. One of the most apparent changes is weight gain. By full term, a woman of average weight should be expected to gain between 25\u201335 pounds (11.5\u201316kg). Most of this weight is made up of the fetus and uterus, but contributions are also made by the breasts and additional fluid in the form of blood volume and extracellular fluid. This additional weight, particularly its distribution, provides distinct challenges for EMS providers in certain circumstances such as airway management and traumatic injury, which will be discussed in detail later. \n\nPhysiological Innumerable physiological changes occur during pregnancy. Discussion will be limited to those with the most direct prehospital effects. The increase in blood volume, on average 48% above that of a non-pregnant patient, is one of the most dramatic changes. This is an absolute increase of about 1500 mL. This increased volume improves blood flow and provides nutrients to the growing uterus and fetus, protects the fetus from impaired venous return from maternal supine position, and protects the mother from the effects of blood loss during delivery. Other notable changes include increased baseline heart rate, increased cardiac output, and normal to low blood pressure.",
        "Critical care and trauma": "The core of any EMS provider\u2019s training is based on initial evaluation and stabilization of the most critically ill or injured patient. This is best accomplished by using a systematic method such as the ABCs (airway, breathing, circulation). The pregnant patient should be approached in a similar manner, with specific additional considerations. Any resuscitation during pregnancy places at least two lives at stake, considering the mother and one or more fetuses.",
        "Airway": "Airway management is among the most critical skills for the EMS provider to master. Without proper airway maintenance, a patient has a small chance of even arriving at the hospital alive. Several anatomical changes to the airway during pregnancy can complicate airway management in the prehospital setting. Edema, caused by increased extracellular fluid volume, can lead to more profound airway obstruction in states of decreased responsiveness, complicating basic airway maneuvers such as bag-valve-mask ventilation. Edema may also lead to swelling of the glottic structures, causing a decreased glottic opening and complicating advanced airway interventions. Emergency medical services providers must anticipate these issues, and pay close attention to basic airway techniques, with more liberal use of airway adjuncts such as oral or nasal airways as appropriate. Suctioning devices must be ready and available at all times to address vomiting. For advanced airway interventions, ALS providers should perform an airway assessment using standardized scoring systems such as Mallampati to help predict the presence of a difficult airway. A smaller sized endotracheal tube than anticipated should be kept on hand in case of difficulty passing the tube through the glottic opening. Standard monitoring such as oxygen saturation and waveform capnography is critical.",
        "Breathing": "The gravid uterus causes significant upward displacement of the diaphragm, restricting lung function. Functional residual capacity is decreased by approximately 20% in pregnancy. This, in combination with increased oxygen consumption of 30\u201360% and decreased venous return due to inferior vena cava compression, can lead to rapid desaturation with any medical or traumatic insult. The patient with respiratory distress or who is requiring ventilation should be placed as upright as feasible to decrease abdominal pressure on the thorax. Oxygen should be used more liberally to ensure the fetus is receiving adequate oxygenation.",
        "Circulation": "As described earlier, pregnancy is accompanied by increased blood volume which may allow initial compensation for even major blood loss, followed by rapid deterioration. Given this, patients should be treated aggressively with fluid resuscitation for potential hypovolemic states. The shift toward a permissive hypotension approach to trauma patients should likely not be applied to pregnant patients, though data on this are lacking. Given the relative anemia of pregnancy, blood transfusion may be necessary earlier in resuscitative efforts than in a non-pregnant patient. Vasopressors may be used if necessary to correct shock. Complications such as pulmonary edema and third spacing with crystalloid infusions due to lower oncotic pressure should be anticipated. Patients with hypotension and/or those who are The patient who is supine should always be placed tilted to the left 15\u201330\u00b0 using sandbags or pillows. This allows the gravid uterus to be moved off the inferior vena cava, improving venous return to the heart.",
        "Cardiovascular": "Aside from the gynecological system, the cardiovascular system undergoes the most dramatic changes during pregnancy. The heart of the pregnant woman actually remodels, increasing contractile force, and when combined with the increased blood volume, increased heart rate, and decreased vascular resistance, a 50% increase in cardiac output results. When evaluating the pregnant patient, the ALS provider must be aware of ECG changes that occur normally in pregnancy. Due to elevation of the diaphragm and pressure on the heart, ECG changes including left axis deviation, ST-wave flattening, and T-wave inversions are seen particularly near full term. The ST- and T-wave changes seem to appear primarily in the inferior and precordial leads. While most of the cardiovascular changes are beneficial, pathophysiological states can occur. Arrhythmias during pregnancy are fairly common, including supraventricular tachycardia (SVT), paroxysmal atrial fibrillation or flutter, or, more rarely, ventricular tachycardia. Because safety data on many of the antiarrhythmic medications for treatment of the tachyarrhythmias are limited, pharmacological therapy is best avoided when possible during pregnancy. That being said, patients who enter the EMS system often require emergency treatment and medications will be necessary. In cases of SVT, vagal maneuvers should be attempted first. Adenosine is considered a relatively safe intervention if vagal maneuvers fail. Calcium channel blockers such as verapamil and diltiazem are not felt to be as safe, but may be considered. In patients who present in ventricular tachycardia with a pulse, lidocaine is indicated, with procainamide considered a second-line treatment. Amiodarone should be avoided unless absolutely necessary due to reports of fetal bradycardia and other serious adverse effects on the fetus. Electrical cardioversion is considered safe if the patient is unstable or presents with pulseless ventricular tachycardia or ventricular fibrillation. One of the feared cardiovascular complications of pregnancy is idiopathic cardiomyopathy. Patients present with findings consistent with standard congestive heart failure but may be otherwise young and healthy without the standard cardiovascular risk factors. Symptoms include shortness of breath, dyspnea on exertion, orthopnea, and increased peripheral edema. Prehospital management is similar to that of non-pregnant patients, with supplemental oxygen, positive pressure ventilation, and nitrates in the acute setting. For volume overload and chronic treatment, diuretics are used. After the pregnancy is completed, some patients have return of normal cardiac function, and some do not. Subsequent pregnancies carry a significant risk of recurrence of cardiomyopathy.",
        "Pulmonary": "Several changes occur during pregnancy that affect the pulmonary system. Because of the deviation of the diaphragm upward into the thorax, respiratory mechanics are affected. The functional residual capacity, vital capacity, residual volume, and inspiratory capacity all decrease. Patient position greatly affects the patient's mechanics, and EMS providers should place the patient in as much inclination as feasible. Patients with underlying chronic pulmonary disorders, most commonly asthma, are at risk for worsening status during pregnancy due to the restricted respiratory mechanics. Fortunately, standard prehospital treatments for asthma exacerbations are considered safe in pregnancy. Standard therapy with supplemental oxygen, bronchodilators, and corticosteroids is indicated. Continuous monitoring with pulse oximetry and waveform capnography is critical. Positive pressure ventilation should be used as needed to help avoid the need for endotracheal intubation.",
        "Toxicological": "While many medications have different and largely unknown effects in pregnant patients, one of the most relevant toxicological exposures for EMS providers to be aware of is carbon monoxide (CO). This exposure deserves particular attention because it is fairly unique in that the fetus is at higher risk of adverse effects than the mother. Pregnant patients have higher susceptibility to CO due to increased minute ventilation, in addition to increased endogenous production from the fetus. Fetal hemoglobin has a higher affinity for CO than maternal hemoglobin, and the fetus is at risk for life-threatening exposure even if the mother appears relatively well. Treatment includes removing the patient from the source of exposure, initiating high-flow oxygen, and considering hyperbaric oxygen (HBO). EMS providers should consider transport to a specialty center that can provide HBO if indicated according to local protocols.",
        "Neurological": "One of the most serious neurological complications associated with pregnancy is seizures of eclampsia. Preeclampsia can affect almost every organ system in the body, and is typically diagnosed based on the combination of hypertension and proteinuria. Other associated symptoms include headaches, epigastric pain, and visual changes. If the syndrome progresses, the patient may develop eclampsia, with generalized seizure activity and significantly elevated blood pressure.",
        "Thromboembolic conditions": "Venous thromboembolism is an important cause of maternal morbidity and mortality that EMS providers should be aware of. The most important of these conditions includes deep venous thrombosis (DVT) and pulmonary embolism (PE). Pregnant women are 4\u20135 times more likely to develop venous thromboembolism than non-pregnant women due to the hypercoagulable state that is associated with pregnancy. Some studies have quoted rates of 1.72 per 1000 deliveries with 1.1 deaths per 100,000. The major concern regarding DVT is the possibility of dislodgment of the thrombus and travel to the lungs. Pulmonary embolism is a serious life-threatening condition, and prompt diagnosis and treatment are imperative. Diagnosis of DVT is best performed by duplex ultrasonography. PE can be diagnosed by computed tomography angiogram. Treatment includes anticoagulation with heparin or low molecular weight heparin. In cases of massive PE with persistent shock or cardiac arrest, thrombolytics can be considered.",
        "Genitourinary": "Due to anatomical changes, pregnant women are at higher risk for urinary tract infections (UTI) than non-pregnant women. UTI can progress to pyelonephritis, or kidney infection, which is the most common cause of serious bacterial infection in pregnant women. Serious bacterial infections in the mother can put the pregnancy at risk, and so early treatment is important.",
        "Gastrointestinal": "Most women in pregnancy have some degree of nausea and vomiting. This is most common in the first trimester and then typically improves. In some patients, this condition is severe and is referred to as hyperemesis gravidarum, defined as vomiting that is severe enough to produce weight loss, dehydration, and electrolyte abnormalities, particularly hypokalemia. For patients with hyperemesis gravidarum, treatment is centered around antiemetics, IV fluid replacement, and correction of electrolytes. Two surgical emergencies, appendicitis and cholecystitis, deserve specific attention. The evaluation, diagnosis, and treatment are more difficult than in the non-pregnant patient, and missed diagnosis can have adverse outcomes for the mother and fetus. Appendicitis is the most common non-obstetric surgical diagnosis in pregnancy. Diagnosis is more difficult than in the non-pregnant patient due to a variety of factors. Typical presenting signs and symptoms of appendicitis commonly occur under normal conditions during pregnancy. These include nausea and vomiting, decreased appetite, and abdominal pain. In addition, the anatomical location of the appendix has been described as having the tendency to shift superiorly and posteriorly due to displacement by the uterus. Due to these confounding variables, pregnant patients have a higher rate of missed early diagnosis and perforation of the appendix. This puts the fetus at risk, and there is a risk of premature labor and miscarriage. Emergency medical services providers should consider this diagnosis in patients presenting with right-sided abdominal pain. The location may not be necessarily limited to the right lower quadrant, and may be located in the right upper quadrant or right flank area. A second common cause of right-sided abdominal pain in pregnancy is biliary disease. Patients may suffer from recurrent postprandial pain due to biliary colic, or develop acute inflammation and pain in the gallbladder from cholecystitis. Acute cholecystitis is the second most common general surgical condition during pregnancy and can, like appendicitis, put the mother and fetus at risk. Symptoms of cholecystitis include right-sided abdominal pain as described above, as well as nausea, vomiting, and fever. Management may be conservative initially and surgical intervention may be delayed until after delivery if possible.",
        "Endocrine": "While there are many endocrine changes that occur in the pregnant patient, the most commonly encountered and most relevant to the EMS provider is gestational diabetes. Although many patients are diagnosed through routine prenatal screening with glucose tolerance tests, some patients may not be aware of the condition. In cases of hyperglycemia, patients may have typical symptoms of diabetes including polydipsia and polyuria. Rarely, patients may present with hyperglycemic hyperosmolar non-ketotic syndrome or diabetic ketoacidosis (DKA). EMS providers should treat with IV fluids for dehydration, and perform an ECG to evaluate and treat for life-threatening hyperkalemia states which can be associated with DKA. The mainstay of treatment for these conditions in the hospital is insulin therapy and electrolyte management. Complications which may occur due to diabetes for the fetus include macrosomia (increased fetal size) which can lead to difficulties with delivery. In addition, neonates may have episodes of profound hypoglycemia in the minutes after delivery due to high compensatory circulating levels of insulin. EMS providers should anticipate this if necessary and be prepared to give dextrose to the neonate according to local protocol.",
        "Conclusion": "There are many anatomical and physiological changes in pregnancy which require specific awareness and knowledge by EMS providers. With the appropriate training, continuous quality improvement, and medical oversight, providers can have confidence in initiating the best emergency medical care and transporting safely to the appropriate receiving facility."
    },
    {
        "Introduction": "A psychiatric or behavioral health emergency can be defined as an acute change in conduct that results in a behavior that is intolerable for the patient, family, or society. These changes range from the inability to cope with a stressful situation to agitated or violent patients who present a danger to themselves or others. Little has been written directly about behavioral health emergencies in the prehospital setting. The \u201cstandard of care\u201d is extrapolated from emergency departments and psychiatric units. EMS professionals receive little training regarding behavioral conditions during their initial and continuing education.",
        "Evaluation of the problem": "The \u201cstandard\u201d approach field personnel use may be inadequate for the assessment of behavioral health patients for multiple reasons. Providers may be unsure how to evaluate an uncooperative or dangerous patient without involving law enforcement, whose specialized training can help EMS pursue appropriate treatment options. EMS may elect to contact direct medical oversight for help, but it can be equally difficult for the medical oversight physician to assess the patient remotely. Under these circumstances, it is imperative that patients who might pose a threat to themselves or others are fully evaluated. It may require the patient to be brought into the hospital against his or her will. It is important for the EMS medical director to ensure that the prehospital provider and medical oversight physician have the appropriate training and knowledge to deal with these patients before they are encountered. This may include issuing a hold order for cases where the patient lacks capacity for medical decision making. General management guidelines should be provided by protocol. Remember, as with all patients encountered by EMS, behavioral patients have legitimate health problems. Unfortunately, they are sometimes mislabeled as \u201cuncooperative\u201d or \u201cdifficult,\u201d resulting in inappropriate treatment. Education should reinforce that the patient\u2019s behavior is a manifestation of disease, and patience and compassion are essential to providing excellent, supportive care to this vulnerable population. Emergency departments and EMS are common points of entry into the health care system for the psychiatric patient. Medical direction should be familiar with local psychiatric resources as well as common diagnoses including their presentations, complications, and management. These include anxiety disorders, major depression, schizophrenia, and bipolar disorder.",
        "Assessment and treatment": "Making an accurate psychiatric diagnosis in the field is frequently impossible and generally irrelevant. Treatment protocols should describe assessment and care for clinical symptom patterns, not specific diagnoses. Policies and procedures must also be put in place to ensure safety of patient and provider. The first step when confronted by a patient with a behavioral disorder is to evaluate scene safety. If not safe, EMS should withdraw and await the arrival of law enforcement before intervention is attempted. If safe, providers may carefully approach and attempt a brief medical assessment. They should determine if the behavioral changes are due to an organic etiology and/or if the patient is in imminent danger secondary to a medical emergency. There are multiple medical conditions, many reversible, which can present with behavioral changes. Presentation may vary from lethargy and confusion to agitation and violence. Classic examples include the confused patient with acute hypoglycemia, the agitated patient with hypoxia, and the lethargic patient in shock. Initial evaluation must include a thorough history (medical and psychiatric) and physical examination, including measurement of blood sugar level and pulse oximetry. Mental status changes of acute onset without a previous history of psychiatric disorder are highly suggestive of an organic etiology. EMS should inquire about prescribed medications or suspected drug/alcohol abuse. Special attention should be paid during physical examination to eliciting abnormal neurological findings. If vital sign abnormalities are observed, the patient should be considered medically unstable and mental status changes a consequence of an organic problem until proven otherwise. The provider should effect appropriate interventions. Delayed stabilization or failure to transport patients with organic problems is dangerous, especially when dealing with mentally disturbed patients. Occasionally, the patient may not cooperate with the initial assessment and stabilization. In these situations, EMS personnel should try to gain the patient's confidence by providing reassurance, explaining who they are, and describing every step before it is performed. If the patient remains non-compliant, the presence of an EMS physician, as a figure of authority, may be of assistance in obtaining the patient's cooperation. Unfortunately, this is often not possible. Other appropriate alternatives include the indirect medical oversight physician speaking directly to the patient via radio, phone, or video phone or attempting to reach the patient's psychiatrist or primary care physician. If the patient does not cooperate with the initial assessment, physical and/or chemical restraints may be considered. This should be done in cooperation with law enforcement. Patients with behavioral changes must receive at a minimum an appropriate prehospital assessment or be transported to the hospital. Once deemed medically stable, the next step is to determine if the patient's mental status represents a danger to himself or herself or to others. Each case needs to be evaluated on an individual basis as not every patient with abnormal behavior will require transport. If the patient is refusing transport, he or she must meet the following criteria before the non-transport request should be honored. 1. The patient has the capacity to refuse. 2. Organic etiology has been reasonably ruled out by an appropriate medical evaluation. 3. No evidence of suicidal, homicidal, or aggressive behavior is present. 4. There is a known past history of psychiatric disorder with similar behavior. 5. Appropriate social, family, or mental health support is available. Many EMS systems have adopted policies permitting the use of alternative transport destinations such as psychiatric EDs and detoxification facilities. Selected patients may be more amenable to routing to these facilities rather than EDs. Strict criteria must be established in order to assure success and safety. The National Association of EMS Physicians and the American College of Emergency Physicians jointly issued a policy identifying important elements which must be in place to have a successful alternative transport destination program. Examples include EMS physician medical director oversight, medical director-led program development, implementation and quality improvement, as well as education programs at all levels. These programs may result in up to 25% of psychiatric patients being directly transported to psychiatric EDs. They have also demonstrated high sensitivity in detecting the need for medical evaluation. It is the responsibility of the medical director to make sure that a thorough evaluation is completed before EMS personnel release a patient at the scene. Given that most adult patients presenting to the ED with new acute psychiatric symptoms will have an organic etiology and the evaluation and \u201cmedical clearance\u201d of patients in the field can be more challenging than when performed in the ED, protocols should direct providers to err on the side of caution and to transport these patients.",
        "The suicidal patient": "Suicidal ideation is the existence of thoughts pertaining to ending one's own life. Passive suicidal ideation refers to thoughts without a plan. Active suicidal ideation refers to thoughts with a plan, and thus a greater risk. A suicidal gesture is self-inflicted harm without a realistic expectation of death, whereas a suicide attempt is an act with a clear expectation of death. More people die from suicide than homicide in the United States. In 2010, a total of 38,364 Americans took their own lives, compared with 16,259 homicides, making suicide the 10th leading cause of death. There were 12.4 suicides per 100,000, an increase from 10.7 in 2005. Suicide is a serious problem among young people, being the third leading cause of death for 15\u201324 year olds. The most common methods include firearms, suffocation/asphyxiation, and poisonings. Suicide rates tend to increase with age and are highest among white men aged >65. Always take a suicide threat seriously. Suicidal statements indicate a crisis the individual feels he or she is unable to handle. Up to two-thirds of those who commit suicide have visited physicians or health care facilities during the preceding month. It is therefore important to recognize the signs and symptoms, not just declaration of intent, with which a suicide-prone patient could present. Intervention by EMS may be the last opportunity to provide help and prevent tragedy. Initial and ongoing training coupled with comprehensive treatment protocols will help to ensure that EMS provide maximum assistance while ensuring their own safety. After arrival, EMS should perform a complete scene assessment to ensure proper situational awareness, including checking for weapons or potential weapons. Immediately remove any objects that the patient could use to inflict physical harm to him/herself or others. If guns or knives are present, the crew should withdraw to safety and await the police to remove the weapons and secure the scene. Once secured, attempts to initiate communication with the patient should be made as soon as possible. Communication with direct medical oversight, the patient's psychiatrist, or the family physician may be beneficial in understanding the current scenario. During the negotiations, using friends or family members whom the patient trusts and respects can be effective. However, if the patient identifies an individual as being part of the crisis, that individual should be removed. Encourage the patient to discuss the situation. Most patients are relieved to be empowered just to discuss their thoughts. It is important to emphasize during EMS education the need to show sympathy, empathy, and concern, and to avoid potentially frightening or agitating the patient. Providers do not have to agree or disagree with the patient, but should listen to what he or she has to say. Providers should avoid statements such as 'Don't do that!' or 'You know that is not true!' The suicidal patient may consider these comments to be a challenge or that EMS are being judgmental and not supportive. If the patient perceives a negative attitude, it may worsen their already low self-esteem. The provider should offer reassurance that the crisis can be resolved and that authorities are only there to be of assistance. Promises that EMS providers are unable or unwilling to keep will make the patient more suspicious and should be avoided. Suspicion by providers of non-verbalized suicidal ideation or the presence of specific risk factors should prompt a further exploration. If the patient admits to any current or past depression, hopelessness, or despair, he should be asked directly whether he has any thoughts about self-harm. There has been no evidence to support the concern that posing such questions could actually induce suicidal thoughts and behaviors; more often, once broached directly, in a non-judgmental and sensitive manner, the patient typically welcomes the opportunity to unburden himself to caregivers. Often, such patients present with a level of anxiety and agitation that once alleviated will reduce suicidal feelings. Protocols should allow for the use of fast-acting benzodiazepines, such as lorazepam, midazolam, or diazepam, which often prove effective in low doses when titrated as necessary. If there are contraindications to benzodiazepines, such as suspicion of their abuse, another agent such as diphenhydramine or a low dose of a high-potency neuroleptic (e.g. haloperidol) may be employed. Similarly, suicidal patients suffering from severe or chronic pain may become markedly less despondent after adequate analgesia. As cooperation develops, all actions and activities should be clearly explained, in advance if possible. At this point, pharmacological interventions may be considered or may be found to be unnecessary. Before initiating transport, policies should require the patient be fastened on the stretcher and not permitted to sit next to the exit door or in the front seat of the ambulance. EMS personnel should explain that these are security measures for the patient's safety. The provider who has established the best rapport with the patient should ride along with him or her to the hospital. Additional members of the response team should then sit next to the exits. If all reasonable efforts have failed to persuade the patient to cooperate, the question of whether to commit the patient to an involuntary transport must be addressed. This is a decision in which direct medical oversight is often involved. There are several factors that correlate with a higher risk for committing suicide. If it is decided that the patient is in immediate danger of committing suicide, the provider should be directed to proceed with the transport, never leaving the patient unattended. Laws pertaining to involuntary transport and admissions vary from state to state. EMS medical directors must be familiar with the specifics of their state and local statutes. When in doubt, it is always better to direct an involuntary transport and to have the patient evaluated at an ED or psychiatric institution. If, subsequent to the decision for involuntary transport, the patient becomes agitated and/or violent, the use of physical or chemical restraints may be required. This option should be addressed within protocol.",
        "The agitated and violent patient": "Encounters with agitated patients total 1.7 million in the US annually. Agitation may be a component of a medical emergency, established psychiatric illness, intoxication, suicidal ideation, or a precursor to potentially violent behavior. Historically, there have been varied approaches to the assessment and treatment of agitated patients, at times based on anecdote and tradition. With a push for further research and additional training, the Project BETA Workgroup, a consensus group organized by the American Association of Emergency Psychiatrists and comprising emergency psychiatrists, emergency physicians and others, published a series of articles attempting to address agitation and violence in the emergency setting. Many of their findings can be extrapolated to EMS. The acutely agitated patient must be approached with caution and with a high clinical suspicion. As with the suicidal patient, scene and crew safety is of primary concern. EMS personnel should receive ongoing education on interacting with the agitated and violent patient, as well as assessing and evaluating these patients before they erupt. The patient\u2019s level of agitation should be assessed and documented. A patient who is talking in a loud voice, moving around constantly, gesticulating with the arms, or displaying closed fists should be considered potentially violent. To the extent which the patient will allow, a medical examination should be completed. Organic etiologies must be considered and either ruled out or managed. In the prehospital setting, this would include tests such as blood glucose, oxygen saturation, and observation for signs of possible ingestions or intoxication. The patient\u2019s history is crucial and should be corroborated by others if possible. Patient history has a 94% sensitivity and physical exam a 51% sensitivity for detecting medical problems in agitated patients. Further clues to suggest an organic etiology include atypical presentations of known psychiatric disorders and new-onset agitation in patients over the age of 45 without a previous psychiatric history. Special consideration should be given to those with a history of psychosis, paranoia, bipolar and antisocial personality disorder, as these diagnoses are indicators of a higher incidence of violent behavior. After an initial evaluation, there should be a better understanding of the patient\u2019s condition and risk for violence. Even if assessed as low risk for aggressiveness, EMS personnel should remain vigilant and ready to react if necessary. However, if the patient is considered to be at high risk for violence, the following measures should be taken. Never leave the patient unattended. Maintain a safe distance from the patient and protect the exit at all times. Do not allow the patient to block the escape route or exits. Providers should remain positioned between the patient and the provider\u2019s own route of egress. Remove any objects at the scene that could be used by the patient as a weapon. When facing a violent individual, the EMS provider should avoid prolonged eye contact as it may be considered a challenge. One responder should become the \u201cnegotiator.\u201d If the patient is medically stable, providers should be prepared to spend a prolonged time talking. If the negotiator seems to be losing patience, someone else should assume that role. It is better to spend the extra minutes for peaceful solutions than to rush into a physical confrontation. EMS should attempt to \u201cverbally deescalate\u201d the situation while maintaining a calm and reassuring tone. Identify reasons for the crisis and let the patient vent his or her thoughts. EMS providers should be supportive, never argumentative. A tacit \u201cshow of force,\u201d with members of the response team backing the negotiator, is suggestive to the patient of the presence of an overwhelming force and is often enough to calm him or her.",
        "Other situations": "As a consequence of the aging of society, an increasing percentage of EMS responses involve geriatric patients. The elderly, especially those with limited familial and financial resources, occasionally disregard their own personal well-being. Frequently these patients will rebuff treatment and/or transport. Faced with a self-neglectful patient found in unkempt surroundings, providers may be hard-pressed to accomplish transport for an otherwise competent patient. The EMS physician or direct medical oversight must be directly involved in determining the patient\u2019s final disposition. EMS personnel should carefully describe the patient\u2019s medical condition as well as the physical environment. Occasionally, direct communication with the patient by the EMS physician is beneficial. A preestablished \u201cgeriatric referral program\u201d may provide some reassurance that needed resources and services are available on an expedited basis. Patients who present with substance abuse or intoxication are a risk not only to themselves, but to the providers as well. Although many mind-altering substances may generate violent behavior, cocaine and phencyclidine are the two most common; less commonly, marijuana, amphetamines, and hallucinogens may do so as well. Many new synthetic drugs are now available with similar effects. Methylenedioxy pyrovalerone (MDPV), often referred to as \u201cbath salts\u201d among other names, has effects similar to amphetamines and cocaine. Patients with a history of recent exposures should be handled in a manner similar to that of the violent patient.",
        "Patient restraint": "The major indication for restraining a patient in the prehospital environment occurs when the patient is considered to have lost medical decision-making capacity and his or her behavior precludes a thorough evaluation and/or treatment. NAEMSP, in its position paper \u201cPatient restraint in emergency medical services systems,\u201d recognizes that prehospital personnel may find themselves in situations requiring the use of restraints to protect the patient, the public, or themselves from harm. There are three methods of patient restraint: verbal deescalation, physical restraint, and chemical restraint. Treatment protocols should be developed to address the specific clinical scenario encountered, and methods that may be employed individually or in combination; however, the least restrictive method that accomplishes the task while maintaining safety should be employed. NAEMSP position paper establishes 17 principles that are recommended for incorporation in an EMS system\u2019s prehospital patient restraint protocol. Key among these are personnel safety, patient dignity, methods of restraint, indications for restraint, documentation requirements, and, most importantly, medical oversight and quality improvement. Medical oversight must be involved and help decide if the patient should be transported against his or her will. This is a decision with medicolegal implications given the litigious society in which we currently practice. The legal justification for physical or chemical restraint is based on the professional judgment by the EMS physician in charge that the patient lacks capacity to refuse treatment and transport. The EMS medical director must be involved in the decision-making process and should therefore be familiar with the state and local legal statutes. In general, the medicolegal exposure of permitting patients who are at risk of harming themselves or others to remain unevaluated is much higher than the exposure involved in the involuntary transport of that patient for further evaluation. Documentation is of crucial importance not only for legal protection but also for good patient care. \u201cDocumentation of patient assessment, reason for restraint, restraint procedure, frequency of reassessment, and care during transportation should occur for all patients who require restraint.\u201d It is very important to document how the patient represented a threat to him/herself or to others.",
        "Verbal deescalation": "The Project BETA Workgroup highly advocates for verbal deescalation as the initial method for controlling the agitated or violent patient. These techniques require initial and continuing education, but mastery requires actual practice. There are ten recommended domains to improve deescalation attempts. \u2022 Respect personal space \u2022 Do not be provocative \u2022 Establish verbal contact \u2022 Be concise and simple \u2022 Identify wants and needs \u2022 Listen closely \u2013 active listening \u2022 Agree or agree to disagree \u2022 Lay down the law and set limits \u2022 Offer choices and optimism \u2022 Debrief patient and staff Effective use of these techniques will result in fewer chances for injury to both the patient and provider. Taking sufficient time to deescalate the patient will ultimately save time overall. Patients who can be deescalated by verbal means may also develop more trust in the system and effectively seek help in the future.",
        "Physical restraint": "Coercive restraint of patients should be limited due to short- and long-term negative effects, especially on the relationship between patient and health care workers. Surveys of patients have shown that even without injury, restraint can be a very stressful situation. Studies have shown an effective decrease of restraint use in the inpatient setting, but this does not necessarily apply to ED or prehospital situations. In the EMS setting there is often insufficient time and possibly dangerous environmental situations which do not allow for all potentially appropriate non-coercive interventions to take place. Before proceeding, EMS personnel should assemble a \u201crestraint team,\u201d identifying a team leader and assigning each member specific responsibilities. The ideal number of persons on the team is five: one for each extremity and one for the head and neck. The leader should preferably be the same person who to this point has been the \u201cnegotiator.\u201d The patient should be given a last opportunity to cooperate while at the same time explaining that otherwise he will be restrained for his own safety, and to help him maintain self-control. The following is a commonly recommended procedure for physical restraint, although multiple other techniques are available. 1. The leader should continue to communicate. 2. Two persons should approach from behind, while two approach from the front. This will make it difficult for the patient to concentrate in one direction or attack from one flank. 3. If the patient attacks to one side, the persons left behind should grasp both arms at the elbows simultaneously. By placing the rescuer's legs in front of the patient's and pushing forward, the patient can be forced to the floor face down. 4. At this point, the other two members of the team will hold the patient's legs by the knees, while the leader restrains the head to prevent injury and to preclude biting and spitting. 5. The patient should be restrained face-up to the stretcher using the four-point restraint technique. Leather restraints are recommended. 6. One hand should be restrained over the patient's head and the other by the patient's side. This will decrease the amount of force generated in any one direction. 7. Providers should continue talking to the patient throughout. 8. The patient should not be left unattended! Providers should maintain constant monitoring of the patient's vital signs and respiratory status, and the neurovascular status of all extremities distal to the restraints. 9. Clothing should be searched for dangerous objects. Ideally, this should be done in the presence of a law enforcement officer. 10. Once applied, the use of restraints should not be negotiated during transport, and not removed until arrival at the receiving facility. 11. If the patient continues to struggle and poses a potential harm to himself or others, the addition of chemical restraints should be considered. 12. At the receiving facility, providers should ensure the ED staff have all necessary equipment and personnel before removing the restraints. There are multiple risks, to the patient and EMS, involved with the restraint procedure. Patient deaths while in the prone restraint position have been attributed to 'positional asphyxia'; however, a combination of other factors such as underlying medical conditions, drug or alcohol intoxication, and patient resistance to restraint may prove to be the true culprit. Nevertheless, patients should never be transported in a prone, 'hog-tied', or wrapped position. Emergency medical services personnel generally have limited education and experience in appropriate restraint techniques and may become physically injured during the procedure. Ideally, law enforcement officers should be involved in the restraint procedure, as well as during transport. EMS and law enforcement personnel should work closely together, but EMS professionals should not allow police officers to influence the evaluation and treatment of the patient. It is desirable to have frequent interagency training sessions. This can improve interagency communication and cooperation in an actual situation.",
        "Chemical restraint": "Sometimes physical restraint is not enough. It is impossible to perform an adequate evaluation if the patient is still agitated, and needed care may be obstructed by his or her behavior. The use of chemical restraint is more effective and more humane than physical restraint alone. Rapid tranquilization is the technique of giving a psychotropic drug to control behavioral disturbances. The combination of physical and chemical restraints is the best approach to gain control of the patient and proceed with evaluation and transport. The use of medications in the physically restrained patient may reduce the risk of injury or death in cases of excited delirium. The patient may actually be willing to accept medication prior to physical restraint. The option should be presented and the route discussed. The medical director must develop policies and protocols to assist EMS professional in this decision-making process. Direct medical oversight may be required for difficult scenarios. Pharmaceuticals are indicated only when the provider or physician believes that the patient is not competent, his behavior represents an immediate danger, or his behavior hinders a safe transport. The goal is to control agitation and psychotic symptoms. When considering medications for use in the prehospital environment, certain characteristics are of vital importance. The medication should: \u2022 be available for oral, intramuscular, intranasal, or intravenous administration. Frequently, the patient may not have nor cooperate with an IV line \u2022 have a rapid onset of action \u2022 have a short half-life to facilitate a complete evaluation at the receiving facility \u2022 cause limited central nervous system or respiratory depression \u2022 have a low incidence of side-effects. Rapid tranquilization is a fairly common technique used in the ED and psychiatric wards and has been extrapolated for use in the prehospital setting; however, state or regional lists of approved medications may limit the availability of specific medications for EMS usage. Among the several classes of medications used for rapid tranquilization, butyrophenones and benzodiazepines are the two most commonly used by EMS.",
        "Butyrophenones": "Probably the most popular neuroleptic used in the out-of-hospital setting today is haloperidol, which is a first-generation antipsychotic of the butyrophenone class. It may be administered by the oral, IM, or IV route. This high-potency neuroleptic has been shown to be effective in controlling agitation. The classic regimen is administration of 5 mg IM or IV (in extremely agitated or large patients a 10 mg initial dose may be used), repeated every 30\u201360 minutes if needed. One advantage of haloperidol is that the patient remains responsive to commands and is not overly sedated. The onset of effect is 20 minutes via IM and 5\u201310 minutes via the IV route. If the patient cooperates, a 10 mg oral dose may be used with effects similar to that of the IM injection. Haloperidol has a low incidence of side-effects, the most common being extrapyramidal symptoms (<10%), which are easily reversible with diphenhydramine 50 mg IV or benztropine 2 mg IM. Extrapyramidal symptoms can occur after a single dose and up to 12\u201324 hours after administration. Other less common side-effects include akathisia, hypotension, neuroleptic malignant syndrome, and decreased seizure threshold. Another butyrophenone, droperidol, was used for the same indications as haloperidol. \u201cBlack box\u201d warnings from the Food and Drug Administration regarding proarrhythmic effects and the requirements surrounding its implementation have largely eliminated its usage. There have been several studies which have refuted the FDA\u2019s statements. If given in appropriate dosing, 5\u201310 mg IM, there is a very low rate of complications or clinically significant QT prolongation. A direct comparison with midazolam showed more predictable sedation as well as fewer instances of oversedation and airway compromise with the use of droperidol. Second-generation antipsychotics such as olanzapine are also available and have a lower incidence of side-effects. While there have not been any studies looking at their use in the prehospital setting, these medications are being used more commonly in the ED and inpatient settings. However, due to concern about excessively decreased oxygen saturation in alcohol-intoxicated patients, first-generation antipsychotics remain the primary agent.",
        "Benzodiazepines": "The other major group of medications used for prehospital rapid tranquilization are the benzodiazepines. Lorazepam and midazolam both have good IM absorption. Typical regimens are lorazepam 0.05 mg/kg or midazolam 0.1\u20130.2 mg/kg IM every 30\u201360 minutes. The most important indication for benzodiazepine use is in controlling alcohol or sedative withdrawal symptoms, and they are the drug of choice. Side-effects are excessive sedation and respiratory depression. Preexisting diminished mental status and respiratory depression represent relative contraindications to their use. Benzodiazepines and butyrophenones may be used together. Several investigators have reported the use of lorazepam in combination with haloperidol with good results, achieving a synergistic effect while reducing the amount of each drug. A recommended regimen is 5 mg of haloperidol with 2 mg of lorazepam given intramuscularly.",
        "Controversies and common mistakes": "Scenes involving mentally unstable patients may be chaotic. Therefore, it is very easy to commit serious treatment errors. One of the most common is the failure to perform a complete medical evaluation. Failure to perform a physical examination and vital sign assessment may give the false impression that the patient is \u201cjust nuts,\u201d a critical mistake with possible tragic consequences. Conversely, after determining medical stability, there is also a tendency for EMS to minimize the need for intervention. For a variety of reasons, there tends to be a significant lack of empathy engendered by psychiatric patients. This may lead providers to inappropriately believe the patient is \u201cjust faking it\u201d or \u201cwasting our time.\u201d This can be disastrous, especially in the situation of a patient with suicidal ideation. Every patient who is suspected of having suicidal thoughts should be transported for additional psychiatric evaluation. It is better to err on the side of treatment and transport. When faced with an agitated and/or aggressive patient, it is unnecessarily dangerous to simply use force to manage him or her. Not spending sufficient time deescalating the patient and establishing rapport is another common mistake. Providers should convey assurance to the patient and attempt to gain his or trust. Becoming argumentative or trying to reason with a psychotic patient will just cause further agitation. Emergency medical services safety is of paramount importance. Personnel should be instructed to withdraw immediately if the patient is armed and/or extremely agitated. Law enforcement agencies should be notified and assume control of the scene until it is safe for EMS to return. EMS should not attempt to \u201cfight\u201d or restrain the patient without the appropriate personnel and equipment. After a physical or chemical restraint has been applied, the patient should never be left unattended. Close monitoring of vital signs and mental status must be maintained. Providers must be ever watchful for unintentional oversedation or side-effects from pharmacotherapy. Patients and EMS personnel should not be subjected to unnecessary injuries. The medical director should ensure that sufficient policies and protocols are in place to empower providers when treating these types of patients. Finally, a common pitfall is the lack of interagency coordination and cooperation. The approach to the violent or agitated patient must be well organized and preplanned. Arguments among responders, especially in view of the patient, must be avoided. All providers should clearly understand and accept their roles and responsibility before caring for the patient. Coordinated training should be held with law enforcement and other responsible agencies on a periodic basis.",
        "Conclusion": "Psychiatric and behavioral health emergencies represent a unique challenge for the prehospital professional. EMS physicians, paramedics, and EMTs frequently face patients and situations that are difficult to manage regardless of their level of training. Their own safety is even sometimes in jeopardy. Active participation by the EMS medical director and direct medical oversight medical control when needed is important to guarantee that the highest quality of care is provided for the patient as well as to provide reassurance to the EMS provider. Strong treatment protocols and frequent training sessions, including with other public safety agencies, yield the best results."
    },
    {
        "Introduction": "This chapter discusses several chemicals often inhaled, but ingestion and dermal exposures are encountered for a few. EMS physicians and personnel must have appropriate training, personal protective equipment (PPE), and medical protocols to deal with a variety of potential toxic exposures. The offending agent is often unidentified or misidentified during early phases of the response; extreme caution should be exercised until the situation has been fully defined. The toxic effects of most chemicals can be classified into a general range of syndromes, and appropriate triage, decontamination, treatment, and transport often will be based on signs and symptoms. Responders may use patterns of vital signs, mental status, pupil size, mucous membrane irritation, lung examination, and skin examination (for burns or discoloration) to identify suspected toxidromes. Irritant gas exposure, such as chlorine or ammonia, results in irritation of upper airways and mucous membranes. Acetylcholinesterase inhibitors such as organophosphate and carbamate pesticides and nerve agents result in cholinergic symptoms including wheezing, salivation, lacrimation, vomiting, sweating, diarrhea, and sometimes seizures or coma. Solvent exposure may cause lightheadedness, nausea, confusion, and loss of consciousness. On contact with skin or mucous membranes, most solvents cause skin irritation or injury. Metabolic poisons such as cyanide (CN), carbon monoxide (CO), or hydrogen sulfide (H\u2082S) can result in rapid loss of consciousness and cardiorespiratory collapse. Finally, fear of potential exposure may cause persons to present with symptoms such as chest pain, palpitations, shortness of breath, and syncope, attributable to generalized autonomic arousal. Recognition of potential clinical syndromes will guide pre-hospital care and notification of authorities and receiving facilities. Poison centers are a resource that should be considered for additional clinical information regarding antidotal therapy, local trends or uncommon clinical presentations; this resource is available to any health care provider. Some of the agents discussed in this chapter injure the skin and mucous membranes on contact by chemical reaction. Decontamination must be approached in a knowledgeable and focused manner. It is impractical and dangerous to conduct unnecessary decontamination when there is no need; precious minutes will be lost donning excessive protective gear and establishing decontamination stations when not necessary \u2013 minutes that may result in greater casualties. Overall, victims exposed to gas or vapors only, without skin or eye irritation and with no grossly apparent deposition of toxins on their person, have very low risk of secondary contamination and may be evacuated immediately; eye irritation alone may be addressed with gentle irrigation during transport.",
        "Organophosphates and nerve agents": "Organophosphates have widespread civilian use as agricultural pesticides and have been used in military campaigns and terrorist attacks as highly lethal nerve agents. Although organophosphate pesticides are less potent than the military versions, both have the capability to cause significant morbidity or death. In Japan, the Aum Shinrikyo cult used sarin (a nerve agent) in two terrorist events resulting in 19 deaths, 1,000 hospitalizations, and 5,000 people seeking medical attention. \n\nPathophysiology and clinical presentation Toxicity from organophosphate compounds can occur via almost any route of exposure, including dermal, ocular, inhalation, ingestion, or injection. The onset, severity, and duration of effects depend on the potency of the agent; the route, concentration, and duration of exposure; and the use of antidotal therapy. Patients with vapor exposure experience a rapid onset of effects, whereas dermal exposure will often have a delayed onset of toxicity. Organophosphates bind to the enzyme responsible for acetylcholine hydrolysis, acetylcholinesterase, resulting in an elevated synaptic concentration of acetylcholine at both nicotinic and muscarinic receptors. Initially the binding is reversible; water may enter the enzyme active site and hydrolyze the organophosphate moiety off. However, after a time, depending upon the organophosphate, the moiety bound to the enzyme undergoes a chemical change and is no longer able to undergo hydrolysis. This is called aging and results in permanent inhibition of the acetylcholinesterase enzyme. The carbamate pesticides are very similar clinically and pharmacologically to the organophosphosphate compounds, the main difference being that they will not age and pralidoxime is not necessary for therapy. Acetylcholinesterase inhibition results in prolongation and potentiation of acetylcholine action at cholinergic synapses. In the central nervous system, this causes confusion, agitation, and seizures. In the autonomic nervous system, increased cholinergic transmission results in diaphoresis, bradycardia (tachycardia is seen for other reasons), miosis (not always present), lacrimation, salivation, vomiting, defecation, and urination due to overstimulation of muscarinic receptors. The latter constellation of symptoms is represented by the cholinergic toxidrome mnemonic DUMBBELS (diarrhea, urination, miosis, bronchorrhea/bronchospasm/bradycardia, emesis, lacrimation, and salivation). Increased cholinergic activity at neuromuscular junctions results in muscle fasciculations and motor weakness. Late effects of organophosphate poisoning include \u201cintermediate syndrome,\u201d a return of weakness and neuromuscular symptoms 1\u20134 days after initial clinical improvement. Patients may require additional supportive therapy or reintubation. Late neurological sequelae include peripheral neuropathies, persistent miosis, and neuropsychiatric sequelae (nightmares, headache, anxiety); this effect is likely to compound the psychological effect of a nerve agent attack. \n\nDecontamination and personal protective equipment The risk of provider poisoning by an organophosphate depends upon the class of the agent. With the highly lethal war nerve agents (GA, GB, VX, etc.), most are volatile (except VX) and very small doses will potentially be lethal. For protection, a level A fully encapsulated garment is required. Personnel responding to war nerve agent attacks are at significant risk of becoming secondarily exposed and suffering from adverse effects from insufficiently decontaminated victims. In the Tokyo sarin attack, first responders and nurses suffered adverse effects from the vapors of insufficiently decontaminated patients in poorly ventilated areas, but injuries were mild with improvement once they ventilated the vehicles during transport. Exposures to organophosphate pesticides are more common and less lethal to humans. These agents have much lower volatility than the war agents; the smell reported is partially due to the solvent hydrocarbon. Unless the patient is completely drenched in concentrated organophosphate pesticide, standard universal precautions with double nitrile gloves should be sufficient to prevent any significant exposure. The vomitus from patients ingesting concentrated organophosphate pesticide should be handled with caution. Although there is a report about secondary ED staff contamination by \u201cpesticide vapors,\u201d there are uncertainties about the exact etiology of this event. Decontamination includes removal of all clothing and jewelry, physical removal of visible residue, and irrigation with water or soap and water; for the organophosphate pesticides, significant scrubbing with soap and water will be required. Items of leather and cloth are difficult to clean and should not be returned to the patient. There is no consensus regarding gastric decontamination of pesticide organophosphates. In many cases, the patient will already have vomited and so the utility of lavage is questionable. Activated charcoal could be of benefit, but this should only be considered when the airway is secure (i.e. intubation) to prevent possible aspiration. \n\nDetection and diagnosis First responders should be vigilant for potential organophosphate exposures in instances in which there are multiple casualties presenting with similar symptoms. In the 1995 sarin attacks in Tokyo, the most common physical sign was miosis, with presenting symptoms ranging from eye pain, headache, and bronchorrhea to apnea and death. The miosis was a very useful sign to separate those suffering from toxicity from those who were \u201cworried well.\u201d Note that miosis is not useful in organophosphate toxicity with other routes of exposure (such as ingestion). Rapid development of the cholinergic toxidrome in a number of casualties should prompt immediate consideration of an organophosphate. Activity of red blood cell cholinesterase and plasma cholinesterase may assist diagnosis in hospital. \n\nTreatment and disposition After decontamination, supportive care includes airway maintenance and support of ventilation, as respiratory failure is the primary reason for death with organophosphates. Aggressive suctioning may be required because of copious airway secretions and vomiting; aspiration is not uncommon with organophosphate pesticide ingestion. If intubation is required, succinylcholine should be avoided because it may lead to prolonged neuromuscular blockade due to the organophosphate inhibition of butyrylcholinesterase. The mainstay of treatment in nerve agent and organophosphate poisoning consists of antidotal therapy with atropine, pralidoxime, and diazepam. Atropine competitively antagonizes excess acetylcholine effects at central and peripheral muscarinic receptors but has no effect at nicotinic receptors. Atropine can effectively reverse bronchorrhea, bradycardia, and gastrointestinal symptoms and treat seizures, but has no effect on nicotinic symptoms such as fasciculations, weakness, or paralysis. Side-effects may include delirium, tachycardia, and agitation. The initial dose of atropine is 2 mg in adults (0.05 mg/kg in children, minimum 0.1 mg) administered intravenously or intramuscularly. Although it can be administered via the endotracheal route, this has disadvantages because of the excessive secretions and ventilation difficulties. The dose is titrated to effect and may be repeated every 1\u20135 minutes; although tachycardia may develop, atropine is given until the patient is well ventilated as demonstrated by reduced secretions and resolution of bronchoconstriction and/or is no longer bradycardic. Atropine will also potentially decrease vomiting, diarrhea, and bradydysrhythmia. The required dose of atropine can be very large for oral pesticide poisoning, with some patients requiring hundreds of milligrams of atropine; much less is required to treat war nerve agent poisoning. Unless symptoms resolve with a single dose of atropine, patients who require administration of atropine following organophosphate exposure should also receive pralidoxime. Pralidoxime chloride is an oxime that reactivates acetylcholinesterase by reacting with the phosphorus moiety, resulting in an oxime-phosphate compound that leaves the regenerated enzyme. Oxime therapy must be administered before the aging of that bond is complete, a process that can begin within minutes of exposure and depends upon the organophosphate. The initial dose is 1\u20132 g for adults (25\u201350 mg/kg for children), and repeated dosing may be required; continuous infusions of 8\u201310 mg/kg/hour have been recommended. Slow administration over 15\u201330 minutes has been advocated to minimize side-effects which include hypertension, headache, blurred vision, weakness, epigastric discomfort, nausea, and vomiting. Rapid administration can result in laryngospasm, muscle rigidity, and transient impairment of respiration. Benzodiazepines are used for the treatment and prevention of seizures. Diazepam 5\u201310 mg intravenously may be used, but repeated dosing may potentiate organophosphate-induced respiratory depression. All three of these agents are available as autoinjectors; the commercially available MARK I autoinjector contains both 2 mg of atropine and 600 mg of pralidoxime and requires two injections. A new autoinjector, the Antidote Treatment Nerve Agent Auto-Injector (ATNAA or DuoDote*), allows for both atropine (2.1 mg) and pralidoxime (600 mg) to be injected simultaneously; one disadvantage to this device is the inability to give more atropine without also giving more pralidoxime.",
        "Gases (irritants and hydrocarbons)": "Irritant gases include a number of chemicals found or produced throughout our modern society; this section will be limited to chlorine, phosgene, anhydrous ammonia, and hydrofluoric acid (HF). Irritant gases, such as chlorine and phosgene, have had extensive military use as chemical warfare agents. In addition to military use, these agents, as well as anhydrous ammonia, are used in industrial processes and are sometimes transported in massive quantities. Phosgene is rarely transported in bulk; however, it can be formed in small quantities by the heating of chlorinated hydrocarbons. Compounds like hydrogen fluoride and hydrogen chloride are commonly used as aqueous solutions as hydrofluoric acid and hydrochloric acid, although there are some industrial processes that use the gas form. The solubility of a gas in water allows prediction of its warning properties and clinical presentation. Chlorine (good water solubility), HF (excellent water solubility), and ammonia (excellent water solubility) have pungent odors and cause rapid onset of irritant symptoms, a warning property that may prompt victims to escape and limit their exposure. These gases dissolve rapidly on contact with the water in the eyes and upper airway mucosa, where they cause eye irritation, lacrimation, corneal burns, rhinorrhea, and sneezing. With longer duration or higher concentrations of exposure, lower respiratory effects also manifest with alveolar damage and pulmonary edema. However, phosgene (low water solubility) has a subtle odor reported to be similar to newly mown hay that may not be perceptible to all individuals. Phosgene has poor warning properties; it does not cause immediate symptoms and it results in a lower respiratory injury as the lack of water solubility allows for penetration deep into the distal airways, potentially resulting in a more severe exposure. Injury is caused through production of reactive chemical species in the aqueous environment (i.e. pulmonary tract, mucous membranes). Chlorine reacts with water to release hydrochloric acid, hypochlorous acid, and free radicals. Anhydrous ammonia combines with water to form the caustic ammonium hydroxide. Phosgene combines with water to release hydrochloric acid; it also reacts directly with cellular macromolecules. The alveolar damage from phosgene causes delayed-onset non-cardiogenic pulmonary edema and sometimes hypovolemic shock. HF gas is a \u201cweak\u201d acid, meaning it does not completely dissociate in an aqueous environment (but weak\u2260benign). Being undissociated, the fluoride ion is readily absorbed systemically where it binds with calcium to form insoluble calcium fluoride. Fatal hypocalcemia and hyperkalemia occur with significant fluoride exposures. Because these agents are gases at ambient temperatures and pressure, there is little need for decontamination with the gaseous form of these compounds once patients are evacuated to a safe environment. Removal of clothing and gentle eye irrigation for those with ocular irritation are all that is usually required; note that patients with eye exposure to anhydrous ammonia gas may suffer significant corneal injury. There are no specific antidotes for respiratory irritants, although the use of nebulized sodium bicarbonate has been reported to potentially neutralize the acidic compounds formed by chlorine exposure. More severe upper airway exposures can result in development of upper airway edema and laryngospasm. Respiratory distress or stridor mandates intubation to prevent airway compromise. Other supportive measures include supplemental oxygen, suctioning, beta-agonists, anticholinergic agents for broncho-spasm, and fluid resuscitation for hypovolemic shock. Steroids (inhaled, oral) have been used following exposure to irritant gas exposure; they may be beneficial but there is not strong clinical evidence to routinely recommend their use. Patients with mild exposures to water soluble agents who remain asymptomatic 6 hours after exposure are unlikely to worsen, whereas delayed pulmonary edema is common with exposure to poor water solubility compounds such as phosgene thus requiring prolonged observation. For hydrogen fluoride exposures, field administration of IV calcium gluconate to individuals with significant inhalation exposure should be considered prophylactically as the onset of fatal arrhythmias often occurs without warning and the calcium may be normal when first checked; large amounts of IV calcium may be required. Hydrocarbon gases such as methane and propane have minimal physiological effect. At high levels, some can be narcotizing but the primary mechanism for causing human illness is oxygen displacement and resulting hypoxia. Individuals exposed to high levels of volatile hydrocarbons should be removed from the source and provided with 100% oxygen. The initial responder should consider the flammable and explosive nature of the hydrocarbon gas in their initial management; also, care should be taken not to enter a potentially hypoxic environment resulting when hydrocarbon gas levels are extremely high. Hydrocarbon abuse where the individual deliberately inhales the hydrocarbon for euphoric reasons is called huffing (from a rag), sniffing (from a container), or bagging (from a bag). The greatest initial concerns are the cardiac sensitization that occurs with many of the chlorinated or fluorinated hydrocarbons. This is manifested by \u201csudden cardiac death\u201d when a surge of epinephrine triggers a fatal ventricular arrhythmia. For the first responder, awareness of this phenomenon and restraint from using epinephrine are important. The bio-accumulation of the desired hydrocarbon, its metabolite, or other hydrocarbons in the product may also have consequences. Individuals who huff methanol-containing products may develop acidosis and visual disturbances. Huffing metallic spray paints for the toluene results in an acidosis and severe hypokalemia, sometimes to the point of paralysis. Solvents containing methylene chloride will be metabolized to carbon monoxide in the body, necessitating treatment as discussed below.",
        "Carbon monoxide": "Carbon monoxide is an odorless, colorless gas responsible for thousands of ED visits annually. Unintentional CO poisonings occur with the use of malfunctioning equipment that utilizes combustion, generators and portable heaters in poorly ventilated areas during power outages or with people riding behind mechanized vehicles such as boats or farm machinery. Carbon monoxide may be produced chemically; this has rarely been used as a suicide method. The manifestations of CO poisoning form a spectrum ranging from mild, non-specific symptoms to severe illness with hemodynamic instability and central nervous system toxicity. Carbon monoxide binds to hemoglobin 240 times more avidly than oxygen and causes a leftward shift in the oxygen hemoglobin dissociation curve that further decreases oxygen delivery to tissues. CO also binds directly to heme-containing cellular proteins, including cytochromes, myoglobin, and guanylate cyclase. Binding to cardiac myoglobin may cause myocardial depression, hypotension, and cardiac arrhythmias. CO may increase nitric oxide levels, creating free radicals and leading to further systemic hypotension and cellular injury. Acute CO poisoning initially causes non-specific symptoms such as headache, nausea, and dizziness progressing to altered mental status, confusion, syncope, seizures, and coma. Cardiovascular effects include hypotension, cardiac ischemia, infarction, and arrhythmias. Patients with underlying cardiovascular disease are prone to exacerbation of their underlying disease. Other organs may be affected, producing a range of clinical effects including rhabdomyolysis, renal failure, skin bullae, and non-cardiogenic pulmonary edema. Delayed effects of CO poisoning after initial recovery may manifest as long as 40 days after the initial exposure. Memory loss, ataxia, seizures, emotional lability, psychosis, and motor disturbances have been described. Chronic low-level CO poisoning has caused headaches, light-headedness, cerebellar dysfunction, and cognitive and mood changes. It is often difficult to identify and quantify as the symptoms may not be recognized as manifestations of CO poisoning. Symptoms are often alleviated by removal of the patient from the environment. In pregnancy, severe CO toxicity is associated with poor fetal outcomes. Maternal levels do not correlate with fetal exposure, and poor fetal outcomes have been noted with maternal levels that are not extremely elevated. Fetal hypoxia likely contributes to this; the injury is not due to an increased innate fetal hemoglobin affinity for CO over maternal hemoglobin, as was previously believed. Prehospital workers must rely on clinical suspicion and clinical syndromes to recognize CO poisoning. Fire and hazardous material units usually carry CO gas detection equipment, permitting measurement of environmental CO levels. These levels can be useful in making treatment decisions and should be communicated to ED caregivers. The gold standard for diagnosing CO poisoning is CO-oximeter measurement of venous carboxyhemoglobin levels. However, the severity of exposure depends on both the concentration and duration of exposure; therefore blood levels serve to guide, not dictate therapy. A new commercially available non-invasive CO-oximeter is available for clinical use. The CO-oximeter uses eight wavelengths of light instead of the usual two used by traditional pulse oximeters and has a reported error of \u00b13% (1 SD) absolute carboxyhemoglobin level. However, one study demonstrated a false-positive rate of 9% and a false-negative rate of 18% so when clinical suspicion is high, formal CO-oximetry should be used to confirm the level. The role of prehospital CO-oximetry remains undefined. Rescuers should initiate field treatment based on clinical symptoms, history, and possibly environmental levels. Prehospital treatment of CO poisoning begins with evacuation of victims from the exposure, initiating high-flow supplemental oxygen by non-rebreather mask, and supporting cardiovascular and respiratory function. The half-life of carboxyhemoglobin decreases from a range of 240\u2013320 minutes in ambient oxygen to a range of 50\u2013100 minutes with inhalation of 100% oxygen at atmospheric pressure. Although the primary treatment for CO poisoning is supplemental oxygen, hyperbaric oxygen therapy (HBO) is likely beneficial for selected patients with severe poisoning and neurological symptoms. HBO rapidly corrects the relative anemia from the carboxyhemoglobin by decreasing the half-life of carboxyhemoglobin to approximately 20 minutes and increasing dissolved oxygen in the blood, augmenting oxygen delivery. HBO also reduces CO binding to other heme-containing cellular proteins. Benefit from HBO may exist even for the patient with a normal carboxyhemoglobin level as HBO may reduce tissue and free radical-mediated cellular injury by reducing endothelial neutrophil adhesion and lipid peroxidation. Potential complications of HBO include barotrauma, claustrophobia, and oxygen toxicity and unless it is a multiplace chamber, there is no capacity to access the patient when the chamber is pressurized. The Undersea and Hyperbaric Medical Society maintains a directory of hyperbaric facilities. EMS agencies should have preestablished protocols for medical oversight consultation. Depending upon the region and resources, an EMS system may preferentially take stable CO-poisoned patients to an ED within a system that can also offer HBO. This could potentially decrease the time delay for the patient to receive HBO therapy. Despite years of study, the exact indication for HBO for CO-poisoned patients is not clear. A clinical policy paper by ACEP determined that there was the lowest level of evidence for recommending HBO therapy for CO-poisoned patients and such therapy cannot be mandated. However, considering extensive animal and reasonable human evidence, it is common practice for many to recommend HBO therapy for CO-poisoned patients with loss of consciousness (transient or persistent) and/or neurological symptoms (especially cerebellar) and also for the pregnant patient with evidence of fetal distress. There are no studies in pregnant patients with HBO for CO toxicity, but there is good clinical evidence that HBO therapy will not be harmful to the fetus. Adult patients who have been resuscitated from cardiac arrest from CO poisoning have nearly universally fatal outcomes; only pediatric patients or those with witnessed cardiac arrest should be considered for HBO. Some physicians use cardiovascular manifestations as an indication to perform HBO; others feel that a telemetry admission and cardiac work-up are more beneficial. Some have proposed absolute carboxyhemoglobin levels as indications for HBO therapy; levels proposed include greater than 25% or greater than 15% in pregnant patients. These levels are not evidenced based; it is known that carboxyhemoglobin levels do not correlate with toxicity, and fetal injury can occur with low maternal levels. If a patient will receive benefit from HBO therapy, it should be provided as soon as possible (ideally within 6 hours) and no later than 24 hours after the exposure. One well-designed clinical trial randomizing patients with elevated carboxyhemoglobin levels or neurological or cardiac symptoms showed statistically significant improvements in symptoms and in neuropsychiatric sequelae with HBO.",
        "Cyanide": "Cyanide (CN-) is widely used in industries such as mining, metallurgy, electroplating, and plastic polymer production. Cyanide is encountered as a salt such as sodium cyanide or as the gas hydrogen cyanide (HCN), but there are naturally trace amounts found in certain foods. HCN gas is produced when a cyanide salt is mixed with acid. Cyanide has been used in warfare without great success; however, CN- is a potential agent for terrorism, as evidenced by interest in the mutbakar, an improvised cyanide delivery device. HCN is commonly generated during pyrolysis of natural and synthetic substances such as paper, silk, wool, and plastics. Although smoke inhalation usually results in CO poisoning, toxicity may also result from concurrent HCN exposure and this represents one of the most common source in society today. The cyanide ion binds to the ferric ion of cytochrome c oxidase, halting mitochondrial electron transport and stopping aerobic generation of adenosine triphosphate, so tissues switch to anaerobic respiration. Cyanide first affects tissues with high levels of oxygen consumption such as cardiac myocytes and central nervous system neurons. Inhibition of cellular enzymes leads to increased susceptibility to oxidative stress and lipid peroxidation, and neuronal damage ensues. Increased brain glutamate levels may result in excitatory neurotoxicity, whereas decreased gamma-aminobutyric acid levels may lead to seizures. Clinical effects from cyanide exposure depend on the dose, route, and duration of exposure. Low-level exposures to cyanide produce non-specific symptoms such as dyspnea, headache, nausea, anxiety, and altered mental status. Higher levels may result in hyperpnea within seconds, and loss of conscious, apnea, and death within minutes. Cyanide-containing hydrocarbons such as acetonitrile require metabolism to free the cyanide and so symptoms may not develop for several hours after exposure, which is quite different from any other cyanide exposure. Combined with an appropriate history of exposure, the finding of a lactic acidosis and hemodynamic or respiratory compromise that does not respond to supplemental oxygen should prompt consideration for cyanide. Some experts propose lactate levels greater than 10 mmol/L as suggestive of CN poisoning. Other clinical clues to the nature of the exposure may include a bitter almond odor from hydrogen cyanide gas emitted from the patient's lungs, as well as a cherry red color to the skin or bright red venous blood resulting from the inability to use oxygen. These signs are unreliable as many people cannot recognize the bitter almond odor and the cherry red skin color may not be present. Victims exposed to only HCN gas will not require any decontamination beyond disrobing; cases of secondary cyanide poisoning have resulted from dermal contamination or ingestions of cyanide salts with vomiting or when the stomach is opened during autopsy. Currently, there are three antidotal therapies approved for use in the United States: sodium nitrite, sodium thiosulfate, and hydroxocobalamin. Sodium nitrite and sodium thiosulfate are sold as part of one antidotal kit but are available separately as well. Amyl nitrite is no longer part of the FDA-approved cyanide antidotal kit and has very limited use in the USA. Sodium nitrite produces methemoglobin by oxidizing the hemoglobin iron from 2+ to 3+ with the standard dose resulting in a methemoglobin level of around 12%. Cyanide has a higher chemical affinity for methemoglobin (Fe\u00b3\u207a) than for the cytochrome c oxidase, which results in displacing cyanide from mitochondria and binding to the methemoglobin. The toxicity from sodium nitrite includes hypotension and excessive methemoglobinemia. When administered inappropriately, fatalities have occurred. Additionally, oxygen delivery in patients with concomitant carbon monoxide toxicity from smoke inhalation may be reduced due to methemoglobinemia. However, the peak of methemoglobinemia after IV sodium nitrite occurs in about 15 minutes, and the probable decline in carbon monoxide level on 100% oxygen closely matches the increase in methemoglobinemia. The sodium nitrite dose in adults is 300 mg over 2\u20133 minutes; the pediatric dose is based on weight as well as serum hemoglobin. Sodium thiosulfate is a sulfur donor which enables the endogenous conversion of cyanide to thiocyanate, a relatively non-toxic compound, which is excreted by the kidneys. Sodium thiosulfate is cheap, is packaged in a liquid form ready for injection, and has an extremely safe profile with minimal side-effects reported. Sodium thiosulfate takes time (\u224815 minutes) for an effect to be noted. The dose is 12.5 g in adults and in pediatrics it is 0.42 g/kg up to the adult dose; the dose may be repeated once, at half initial dose, if necessary. The newest approved antidote for cyanide is hydroxocobalamin, a derivative of vitamin B\u2081\u2082. A reddish-colored, light-sensitive powder requiring reconstitution before its use, hydroxocobalamin\u2019s mechanism of action is similar to sodium nitrite but instead of turning the hemoglobin into a cyanide scavenger, the hydroxocobalamin is the scavenger. Cyanide has an extremely high affinity for hydroxocobalamin; it binds to the cobalt metal center and forms vitamin B\u2081\u2082 (cyanocobalamin), which is excreted by the kidneys. Hydroxocobalamin has a favorable safety profile and causes only minor adverse effects: self-limited reddish skin, urine and serum discoloration, pustular skin rashes, allergic reactions, and elevations in blood pressure. The latter is potentially advantageous because it may reverse the hypotension from cyanide toxicity. However, the discoloration of serum is known to interfere with colorimetric serum assays and has caused problems when attempting hemodialysis. The adult dose of hydroxocobalamin is 5 g, with a pediatric dose of 70 mg/kg up to 5 g; it may be repeated in cases of massive cyanide poisoning. It is recommended to be administered over 15 minutes. It is incompatible in the same IV line with many other medications, including sodium thiosulfate. When considering which antidotal therapy to use, sodium thiosulfate is cheap, safe, and may be administered immediately when IV access is achieved. Hydroxocobalamin is expensive, has some side-effects, has storage stability issues, requires reconstitution before administration, and has a 15-minute infusion time, a time delay not addressed in most comparative studies. For prehospital care, with a weak clinical suspicion of cyanide toxicity, sodium thiosulfate may be administered empirically, immediately with almost no risk. The combination of thiosulfate and hydroxocobalamin (not given simultaneously through the same IV line) has been proposed as an advantage, as suggested by some animal studies. Sodium nitrite is not as safe and will decrease oxygen-carrying capacity, so if there is a choice, hydroxocobalamin should be administered in smoke inhalation victims.",
        "Hydrogen sulfide": "Hydrogen sulfide is a toxin similar to cyanide in that it causes inhibition of cellular aerobic respiration, but the inhibition of the cytochrome c oxidase is not as profound as with cyanide. It is more irritating than hydrogen cyanide and has a strong odor, but individuals experience odor fatigue and thus may mistakenly believe that the gas has dissipated when the odor disappears. Hydrogen sulfide is produced by decaying organic materials and can collect in enclosed spaces. Most tragedies involving hydrogen sulfide occur when the initial victim enters an area and is overcome, followed by one or more rescuers who are also poisoned. There are only a few substances that can cause rapid loss of consciousness like this (CO, hypoxic environments, and nerve agents, to name the most common). It has also been used in suicide events where an individual mixes calcium polysulfide and acid together, evolving hydrogen sulfide gas. Often this is performed in a closed car; the first responder should be aware of this potential etiology and the danger of this gas. Treatment is supportive, with removal from exposure and 100% oxygen being most important. The standard cyanide antidotal therapies are usually not required as the hydrogen sulfide will spontaneously unbind from the cytochrome c oxidase; for those who are critically ill, there is some limited evidence to support the use of sodium nitrite.",
        "Vesicants": "Sulfur mustard and lewisite are vesicants \u2013 potent alkylating agents that interact with cellular macromolecules and DNA to cause cell death via necrosis or apoptosis. Sulfur mustard has been used since WWI and still occasionally resurfaces to cause illness in fishermen when old munitions are brought up in their nets. The nitrogen mustards (HN1, HN2, HN3) are a group that uses nitrogen rather than sulfur; now these have new life as chemotherapeutic agents: cyclophosphamide, chlorambucil, ifosfamide, and melphalan. Sulfur mustard melts at 57.0\u00b0F (14.4\u00b0C), meaning that if the environment is above this temperature, there will be possible vapor injury. The injury caused by vesicants is proportional to the concentration times the duration of exposure, considering the tissue susceptibility, with delicate tissues (cornea) having high sensitivity to injury. With sulfur mustard, there is a delay of several hours between exposure and development of the initial lesions. Skin and mucous membrane exposure results in desquamation and formation of painful blisters. These blisters are filled with straw-colored liquid on an erythematous base; they become confluent as the injury progresses. Severe corneal damage and eye pain occur with eye exposure; gentle early eye irrigation is recommended along with ophthalmological consultation but permanent blindness from vapor exposure is rare. Inhalation of vesicants results in irritation and necrosis of upper airways and possibly pulmonary edema. Bronchoscopy may be necessary to clean out necrotic upper airway tissue to allow for ventilation. Secondary pulmonary infections often ensue. With significant exposures to sulfur mustard, bone marrow suppression occurs, potentially complicating infections. Sulfur mustard is carcinogenic and theoretically increases risk for neoplasias, although the risk from a single exposure is probably low. Lewisite (an arsenic-containing vesicant) is very similar to sulfur mustard, except the onset of symptoms is much faster (immediate ocular irritation, faster skin changes) rather than hours with sulfur mustard. Vesicants pose a significant risk of secondary contamination of rescuers. Sulfur mustard penetrates most materials and it has no warning properties. Typically, level A PPE is required for operations in the hot zone and during initial decontamination; cases of secondary caregiver injury exist where decontamination was not adequate. All visible chemical agent and victims' clothing, jewelry, and personal items must be removed, followed by copious soap and water. The sulfur mustard reacts rapidly with tissues and after about 15 minutes it has all been internalized or locally reacted; however, sulfur mustard on objects has very long persistence. The bullae fluid does not have any sulfur mustard in it, so universal precautions as protection are sufficient.",
        "Conclusion": "Priorities for treatment of toxic exposures include recognizing a potential chemical source, adopting appropriate PPE if necessary, removing victims from the exposure, and appropriate decontamination of victims if necessary. Therapeutic priorities for toxic exposures include supportive care, including stabilization of airway and cardiorespiratory status. Specific measures such as hyperbaric oxygen and antidotal therapy may be appropriate in selected instances of CO, organophosphate."
    },
    {
        "Introduction": "Diabetes is a commonly encountered disease in the out-of-hospital environment. Characterized by defective insulin production and use, diabetes is the most common endocrine disorder, and hypoglycemia is the most common endocrine emergency. Several types of diabetes are recognized. Type 1 diabetes occurs when the pancreatic beta cells are destroyed, which removes the body's only insulin-producing mechanism. Typically occurring in children and adolescents, type 1 diabetes accounts for 5\u201310% of all cases of diabetes. These individuals require exogenous insulin administration to survive. Type 2 diabetes is more common, responsible for 90\u201395% of all diabetes diagnoses. Rather than a defect of insulin production, type 2 diabetes is characterized by insulin resistance at the cellular level and gradual failure of pancreatic production of insulin. Type 2 diabetes is a disease predominantly in older adults and is associated with physical inactivity, obesity, and a history of gestational diabetes, a form of glucose intolerance found among pregnant women. Typically resolving after delivery of the infant, the individual who was diagnosed with gestational diabetes carries a 35\u201360% chance of developing diabetes over the next 5\u201310 years. Diabetes remains a major cause of coronary heart disease and stroke, and it is the seventh leading cause of death in the United States. Diabetes is a chronic disease that, at present, has no cure. In 2011, it was estimated that 25.8 million persons in the United States suffered from diabetes. This represents 8.3% of the total US population. Of these 25.8 million, 18.8 million are persons with a known diagnosis of diabetes, and the remaining 7 million have unrecognized and untreated diabetes. It is also estimated that 51 million people aged 40\u201374 years have impaired glucose tolerance, impaired fasting glucose, or both. Diabetes occurs more frequently in certain populations, including African Americans, Hispanics, and Native Americans. One-and-a-half million new cases of diabetes are diagnosed each year, and diabetes-related visits to US emergency departments (EDs) totaled 20.2 million between 1997 and 2007. Additionally, there were approximately 5 million ED visits for hypoglycemia between 1992 and 2005, with 25% of these visits resulting in admission to hospital. In the same interval, there were approximately 750,000 ED visits for diabetic ketoacidosis (DKA), with 87% admitted predominantly to intensive care settings. The cost of diabetes in the United States is staggering. An estimated $174 billion is spent annually for direct and indirect medical costs. This is in addition to lost work opportunities and disability, summing to an estimated $58 billion per year. Diabetic emergencies account for 3\u20134% of EMS call volume. The majority of EMS responses for diabetic emergencies are for hypoglycemia. The consequences of both hypoglycemia and hyperglycemia are dire. Therefore, it is imperative that appropriate care is started in the field to decrease morbidity and mortality. EMS physicians and medical directors must have adequate clinical operating guidelines to appropriately manage these patients in the prehospital setting. This chapter addresses the most common diabetic conditions prehospital providers will encounter.",
        "Prehospital assessment": "General approach The initial evaluation of a diabetic emergency starts with the emergency medical dispatcher when 9-1-1 is called. Crucial information may be obtained through the telephone while the response unit is dispatched. Treatment may begin with prearrival instructions. Medical oversight is crucial to ensure quality within the dispatcher's interrogation protocols and that prearrival instructions are appropriately given. Once responders arrive, scene safety is a priority, given that patients experiencing diabetic emergencies have altered mental status and may act in unpredictable ways. Although most diabetic patients may call for an ambulance for a specific diabetic condition, such as hypoglycemia, many patients will have non-specific complaints such as nausea, vomiting, dizziness, or abdominal pain, requiring the responders to gather information to determine the cause of the illness. The initial patient evaluation is the same as any other case in the prehospital setting. In the instance of diabetic emergencies, history taking is important because it provides pertinent information that may alter treatment, particularly in patients with altered mental status. Key history elements in the assessment of a patient with altered mental status should include the following: medical history, especially history of diabetes, medications, onset of symptoms, complete set of vital signs, measurement of glucose.",
        "Measurement of glucose": "Current EMS practice embraces the prehospital measurement of plasma glucose using glucometers. In past decades, dextrose was empirically given to all patients with altered mental status without first measuring plasma glucose. Investigators found that few patients benefited from such empiric treatment, and a few patients were harmed, as in the case of stroke. Glucometer use by prehospital personnel has been found to be safe and accurate. It is important to note that the glucose strips must be stored in temperature-controlled sections of the ambulance so they provide reliable readings. The prehospital measurement of plasma glucose is now considered a standard practice in EMS.",
        "Prehospital treatment - Hypoglycemia": "Hypoglycemia Diabetic management emphasizes tight glycemic control to prevent long-term complications, such as heart disease and blindness. This strategy, however, may lead to adverse consequences, such as the development of hypoglycemia. Hypoglycemia, usually defined as a serum glucose concentration less than 70 mg/dL (3.8 mmol/L), is the most common endocrine emergency. Estimates are that persons with diabetes suffer mild (self-treated) hypoglycemic events 1\u20132 times per week and that 30% of persons with diabetes suffer severe hypoglycemic events annually. Symptomatic hypoglycemia requires intervention to prevent organ compromise. Several treatment options exist for the prehospital environment, including oral glucose, IV dextrose, or intramuscular (IM) glucagon. Oral glucose may be used in alert patients with intact swallowing mechanisms. For patients with decreased level of consciousness or concern for aspiration, IV administration of 50% dextrose has been the standard for many years. One study found that the administration of 50 mL of 50% dextrose raised blood glucose by an average of 166 mg/dL, but the response varied widely among patients, from an increase of 37 mg/dL to 370 mg/dL. In the unconscious patient, IV glucose administration provides a rapid onset of action (2\u20135 minutes). There are, however, several reports in the literature of tissue injury secondary to extravasation, which can cause significant complications, including skin and soft tissue injury, compartment syndrome, and loss of limb. In a controlled clinical trial, Moore and Woollard found no difference in time to regain consciousness in hypoglycemic patients when comparing the administration of 10% dextrose versus 50% dextrose. In their cohort of 51 patients, 25 patients received a 10% dextrose solution and 26 received a 50% dextrose solution. Both groups had a median recovery time of 8 minutes. Patients in the 10% dextrose group received a median of 15 g less glucose than the 50% dextrose group to achieve the same response. Additionally, patients in the 10% dextrose group were less likely to have high glucose levels after treatment. The possibility of intentional overdose in the hypoglycemic, depressed patient, and of inadvertent overdose in the elderly or confused patient should be considered. Attention should be paid to the type of insulin or medication the patient is taking. The use of long-acting insulin formulations may require close monitoring of the patient by a responsible adult at home or continuous monitoring and additional treatment at the hospital. Patients on certain oral hypoglycemic agents should be transported to the hospital because they have a higher risk of recurrent hypoglycemia and, by extension, increased morbidity. Hyperglycemia should prompt prehospital personnel to think about infectious sources such as urinary tract infection or pneumonia, especially in an elderly or debilitated patient. Acute medical illnesses, such as myocardial infarction, stroke, or pancreatitis, can also cause hyperglycemia in the diabetic patient. Recent cocaine use or poor compliance with medication can also be causes of hyperglycemia, all of which should be considered by prehospital personnel. Patients occasionally had difficulty bringing their glucose levels back into a normal range after treatment with 50% dextrose. For patients in whom IV access cannot be achieved in a timely manner, the administration of glucagon provides a means of rescue. However, in alcoholic or malnourished patients with depleted glycogen storage, it is less likely to be beneficial. Recovery time may be significantly longer with glucagon than with dextrose. These response times are dependent on the severity of hypoglycemia and have been shown to be anywhere from 8 to 21 minutes. Although most sources describe glucagon as an IM drug, it has also been used successfully subcutaneously and intranasally. Intranasal (IN) glucagon has been shown to have comparable efficacy to IM or SC glucagon. Hvidberg showed that both intramuscular and intranasal glucagon elevated glucose levels, but the response was faster in those treated via the IM route. Sibley et al. described the case of a diabetic hypoglycemic patient who was successfully treated with IN glucagon in the prehospital setting without further side-effects or complications. Intraosseous (IO) access is another potential route to provide 50% dextrose for critically ill hypoglycemic patients without IV access. However, this should be reserved for extreme clinical circumstances given that IO insertion poses a risk for infection or poor wound healing in diabetic patients",
        "Prehospital treatment - Hyperglycemia": "Hyperglycemia is defined as blood glucose levels greater than 200 mg/dL (11.1 mmol/L). An elevated glucose level alone does not represent a medical emergency. Markedly elevated glucose and hyperglycemia in the setting of DKA are urgent medical problems that should be recognized and treated accordingly. Diabetic ketoacidosis mortality rates range from 9% to 14%. EMS providers will encounter this condition predominantly in type 1 diabetics, but it may also rarely occur in type 2 diabetics. Usually these patients are dependent on daily insulin therapy to maintain glycemic control. DKA may be precipitated by certain metabolic stressors such as infectious processes, myocardial infarction, pregnancy, and trauma, especially if they interrupt the insulin regimen. Patients present with non-specific signs and symptoms that can include fatigue, tachypnea, altered sensorium, abdominal pain, nausea, vomiting, polydipsia, and polyuria. They may also present with severe dehydration and may be hypotensive. EMS providers should be trained to recognize and suspect such an emergency. There has been no research dedicated to the out-of-hospital treatment of DKA patients. However, most of the treatment modalities in emergency medicine for DKA can apply in the out-of-hospital setting. The most important intervention is to recognize the emergency and start treatment without delay. IV fluid resuscitation should be initiated to restore volume depletion. These patients should be closely monitored. There is no role for insulin therapy in the prehospital setting. An important caveat relates to pediatric patients, for whom there is a risk of life-threatening cerebral edema with rapid volume repletion. For them, insulin (at the hospital) plays a more critical early role, and initial resuscitation should only be intended to reverse appearance of shock or hypotension. Additional correction of a fluid deficit should occur over 24\u201348 hours. Patients with hyperglycemia may also present in a non-ketotic hyperosmolar state (NKHS). NKHS is a serious diabetic emergency that carries a mortality rate between 10% and 50%. Providers may not be able to differentiate DKA from NKHS. However, they may be able to suspect it from the patient\u2019s history. NKHS is more common in patients with type 2 diabetes and is triggered by the same stressors that elicit DKA. Patients in NKHS will present with marked volume depletion, necessitating the initiation of intravenous fluid resuscitation without delay. Prehospital providers should promptly establish support according to their scope of practice and clinical operating guidelines. Directing field treatment should be targeted to hemodynamic stabilization first. Supportive measures consist of oxygen, cardiac monitoring, and IV isotonic fluids through two peripheral lines. Fluid boluses should be given with constant reassessment of vital signs.",
        "Prehospital treatment - Pediatric considerations": "Approximately one in every 400\u2013600 children and adolescents has type 1 diabetes. The age of presentation has a bimodal distribution that peaks at 4\u20136 years of age and 10\u201314 years of age. This requires that prehospital providers be alert for hyperglycemia in children who present with volume depletion, weight loss, polydipsia, and polyuria, as this may be the patient\u2019s first presentation of diabetes. In addition, hypoglycemia should be suspected and glucose should be measured in any pediatric patient who is actively seizing, has altered mental status, or has volume depletion secondary to illness or gastroenteritis. In one study of children requiring resuscitation in an ED, 18% were found to be hypoglycemic, requiring administration of dextrose. The prehospital management of pediatric hypoglycemia mirrors that of treatment in the adult. The recognition of hypoglycemia followed by administration of dextrose is important. Dextrose in children and infants is diluted to 25% (from the 50% given to adults) because dextrose is irritating to vascular structures. The current literature regarding the efficacy of 10% dextrose in the field may allow EMS systems to carry a single concentration of dextrose. Hyperglycemia is treated with fluid resuscitation as appropriate, given the patient\u2019s vital signs, with attention to the issue of potential cerebral edema discussed above.",
        "Prehospital treatment - Pregnancy": "Prehospital providers may occasionally encounter derangements of glucose levels in pregnant patients. Insulin resistance is raised during pregnancy. Approximately 7% of pregnant women in the United States develop gestational diabetes. The current practice is to intensively manage glucose in the pregnant patient to avoid complications such as macrosomia or intrauterine fetal death. Because of this very tight glucose control, it is not uncommon for pregnant patients to experience hypoglycemia. Alternatively, given the emphasis on tight glycemic control, hyperglycemia is rare, with the exception of the non-compliant or undiagnosed patient. Treatment of hypoglycemia and hyperglycemia in the pregnant patient is no different from that in the non-pregnant patient.",
        "Prehospital treatment - Medication overdose": "Intentional insulin overdose has been reported with some frequency in the literature. Persistent or refractory hypoglycemia should prompt the prehospital providers to consider the possibility of overdose, whether intentional or unintentional. Treatment should be aimed at restoring glucose levels to a normal range, continued monitoring of glucose levels, and transport to an ED for continued monitoring and care. Recurrent hypoglycemia has been reported for 2\u20133 days in patients with massive overdoses.",
        "Disposition": "The disposition of diabetic prehospital patients with successfully corrected hypoglycemia has been controversial. The concern for adverse outcomes, recurrent hypoglycemia, poor access to care, and possible litigation has fueled the discussion. Currently, it is estimated that between 34% and 69% of hypoglycemic patients may refuse transport after paramedic contact. Several studies have found that the practice of releasing treated hypoglycemic patients appears to be safe. A study of the reasons for EMS non-transport after a 9-1-1 call demonstrated that diabetic calls account for approximately 9% of non-transports. Previous studies had reported diabetes accounting for 2\u20137% of non-transports. Studies examining the safety of allowing patients to refuse care have shown that those who refuse transport are no more likely than transported patients to experience recurrence of hypoglycemia or to require later care. Thus, these studies have derived a set of reasonable guidelines for refusal of care instructions. Patients should be able to eat, have a responsible adult who will remain with them, and not have any condition that would predispose the patient to a repeat episode, such as persistent vomiting. Additionally, the patient should be given written instructions directing follow-up with a physician. Research has shown that patients prefer a permanent protocol that allows the discharge of hypoglycemic patients without admission to the ED. It is clear that EMS systems should develop specific guidelines for patient refusal after hypoglycemia treatment. The most important elements for these prehospital guidelines are summarized in Box 23.2.",
        "Protocols": "Emergency medical services protocols should clearly provide appropriate assessment and treatment guidelines. When hypoglycemia is encountered, treatment protocols should include administration of dextrose in some form (D\u2085\u2080W, D\u2082\u2085W, or D\u2081\u2080W) if IV access can be obtained, or the administration of glucagon when IV access cannot be obtained. Policies concerning treat-and-release protocols or transport refusal in patients successfully treated in the field should be very clear and well understood by all personnel. A strong quality assurance program is necessary to monitor compliance with clinical standards and identify opportunities for improvement and education. It is highly recommended that patients who are not transported to the hospital for whatever reason be audited and reviewed by the EMS medical director. Symptomatic hyperglycemia mandates administration of IV fluid and transport to a hospital."
    },
    {
        "Introduction": "Pregnancy is commonly encountered in the prehospital setting, and its management typically requires little more than a focused history and physical examination along with safe and timely transport to an appropriate hospital. There are notable exceptions, such as imminent delivery, that have the potential to be catastrophic. These are stressful, time-sensitive emergencies.",
        "Pregnancy - Definitions": "Gravidity is the number of times a woman has been pregnant and parity is the number of times a woman has given birth to a fetus of 20 weeks or more, regardless of whether the fetus was alive or stillborn. Neither gravidity nor parity is increased for twin pregnancies. For example, a woman who has one twin pregnancy with successful delivery of both infants is denoted G1P1.",
        "Pregnancy - Gestational age": "Ovulation occurs around day 14 of the menstrual cycle. The egg is fertilized usually in the oviduct and migrates through the fallopian tubes into the uterus. The egg implants in the uterus around day 6 following fertilization. The heartbeat is first detected by ultrasound in weeks 8\u201312. The first fetal movements are felt in weeks 18\u201320 for a primigravid patient and 2 weeks earlier in the multiparous patient. A full pregnancy lasts approximately 40 weeks. It is divided into trimesters and usually measured by weeks. The first trimester is weeks 0\u201313, the second trimester is weeks 14\u201327, and the third trimester is weeks 28\u201342. A pregnancy is considered viable between 22 and 26 weeks. Term pregnancy is carried to at least 37 weeks. Gestational age can be estimated by both last menstrual period and fundal height. Nine months and 7 days are added to the first day of the last menstrual period (Nagele rule) to obtain the estimated due date. Calculation from the last menstrual period usually overestimates gestational age. Fundal height is a rapid clinical tool to estimate gestational age. It is measured in centimeters from the pubic symphysis to the top of the fundus. Centimeters = weeks of gestation +/- 2 weeks. Using this estimation, a 20-week pregnancy reaches the umbilicus.",
        "Pregnancy - Physiological changes of pregnancy": "Many physiological changes occur in pregnancy induced both by hormones and/or by the enlarging uterus.",
        "Evaluation of the pregnant patient": "All levels of EMS providers, from first responders to physicians, should be capable of rapidly ascertaining pertinent information from the ill or injured pregnant patient. In addition to questions relating to the chief complaint, an obstetrical and gynecological history is important to elicit, including last menstrual period, contraceptive use, gravidity, and parity. Providers should be expected to expand that history and determine if the patient has had complications associated with the current pregnancy such as gestational diabetes, preeclampsia, or preterm labor or if the patient has had complications with prior pregnancies. If delivery is imminent, history should include frequency and strength of contractions, and fluid/water leakage. As soon as it is determined that the patient is not going to deliver imminently, vital signs should be obtained and viewed in context of the normal physiological changes of pregnancy. Examination includes thorough evaluation of the mother as well as the fetal status. If the patient has signs of active labor such as contractions, urge to defecate or push, rupture of membranes, or any other concerning signs, a visual examination of the perineum should be performed. Medical directors should carefully craft protocols that specify when visual inspection of the perineum is appropriate. Failure to have a written document for the EMS provider to follow opens the provider, medical director, and system to potential liability.",
        "Ultrasound in pregnancy": "Many prehospital providers are including ultrasound in the evaluation of patients. Ultrasound is especially useful in the evaluation of pregnant patients to confirm intrauterine pregnancy as well as to evaluate fetal well-being with heartbeat and fetal movement. The earliest definitive sonographic finding in pregnancy is the gestational sac, detected at 6\u20138 weeks on transabdominal ultrasound. Later in pregnancy, fetal viability can be assessed by observing fetal movement and fetal heart tones. Fetal heart tones should be 120\u2013160 beats per minute after 12 weeks' gestation. They are first detected on ultrasound around 8 weeks' gestation but it may be up to 12 weeks before heart tones are seen, depending on the habitus of the patient and quality of ultrasound used. A major concern in pregnant patients with abdominal pain is ectopic pregnancy. While it is not expected to be diagnosed in the field, ultrasound can assist in the recognition of ectopic pregnancy. An intrauterine pregnancy visible on ultrasound essentially excludes ectopic pregnancy. Some ultrasound findings suspicious for ectopic pregnancy include pelvic free fluid and adnexal mass other than simple cyst. A gestational sac, yolk sac, or fetal pole with heartbeat outside the uterus confirms the diagnosis of ectopic pregnancy.",
        "Labor and delivery - Active labor": "Labor is \u201cthe presence of uterine contractions of sufficient frequency, duration, and intensity to cause demonstrable effacement and dilation of the cervix.\u201d Active labor is divided into three stages. A nulliparous woman has a longer labor phase (slower cervical dilation) than does a multiparous woman.",
        "Labor and delivery - Imminent delivery": "All women who are in active labor should receive supplemental oxygen and IV access. If a delivery is deemed imminent, crews should ensure they have appropriate personnel to provide resuscitative care for the mother and baby. Obstetric and neonatal resuscitation equipment should be readied. Direct medical oversight should be notified of an impending delivery, in case emergency assistance and advice are required, though deliveries in most cases progress with little intervention.",
        "Labor and delivery - Delivery of the neonate": "If the fetus\u2019 head is visible in the vaginal outlet, the EMS providers should be prepared for imminent delivery. The patient should be placed in the lithotomy position. Using both hands on the anterior and posterior aspects of the head, constant pressure should be placed to maintain control of the delivery. Head delivery should be slow to decrease damage done to the perineum. The occiput should pass below the symphysis pubis and the face should be pointed toward the anus. Once the head is delivered, the nares then mouth should be suctioned out with a bulb syringe. The provider should use one finger at this point to evaluate for a nuchal cord. The baby then rotates, and shoulders begin to appear at the vulva. Both hands of the provider should be placed on either side of the infant\u2019s head, maintaining control and applying downward pressure until the anterior shoulder passes under the symphysis pubis. An upward movement will then deliver the posterior shoulder followed by completion of the anterior shoulder. The rest of the body is typically delivered without difficulty, but some traction may be applied. The umbilical cord should be double-clamped and cut. Separation of the infant from the mother ends stage 2 of labor and marks the beginning of stage 3. The neonate should be immediately dried and evaluated.",
        "Post delivery - Care of the neonate": "Once the umbilical cord is clamped and cut, the neonate should be placed in a supine, head-down position with the head turned to the side. Normally, the newborn begins to breathe and cry almost immediately after birth. If respirations do not occur or are infrequent, suctioning of the mouth and pharynx should be performed. Stimulating the feet or back may also initiate breathing. The neonate should be dried and kept warm. If the neonate is stable, the infant can be held close to the mother\u2019s chest to decrease heat loss and should be encouraged to nurse. This will aid in delivery of the placenta due to release of oxytocin in the mother. A standardized method to evaluate the newborn's condition is the 1- and 5-minute APGAR scores. Scores between 4 and 6 at 1 minute may indicate a mildly to moderately depressed infant, whereas scores below 3 represent a severely depressed infant. If warming and stimulating the neonate do not initiate the infant\u2019s respirations, the prehospital provider will need to begin resuscitating the infant according to standard Pediatric Advanced Life Support (PALS) algorithms. Intravenous access is not necessary in the prehospital setting unless the neonate requires ongoing and active resuscitation. Even then, it should only be performed if adequate resources exist to accomplish all other first-line resuscitative efforts. Consider umbilical vein cannulation or intraosseous access if required. If the baby is in distress, transport should be immediately initiated to the closest appropriate facility.",
        "Post delivery - Delivery of the placenta": "Stage 3 of labor is the delivery of the placenta, which usually occurs spontaneously about 10\u201330 minutes after delivery of the fetus. The prehospital care provider should not delay transport for delivery of the placenta. Physical signs that the placenta is about to be delivered include the uterus becoming globular in shape, the umbilical cord lengthening, and a potential gush of blood just prior to the delivery. The gush of blood marks the separation of the placenta from the uterus. The uterus should be externally massaged at the fundus to assist with contractions. Avoid strong traction on the umbilical cord due to possible complications such as separation of the umbilical cord or uterus inversion. Loss of approximately 500 mL blood is expected throughout the delivery.",
        "Challenges of prehospital deliveries": "Complicated in-hospital deliveries are often attended by multiple providers including obstetricians, labor nurses, and a neonatal resuscitation team composed of neonatologists and neonatal intensive care unit (NICU) nurses. In contrast, unplanned out-of-hospital deliveries have limited equipment and personnel resources and unpredictable environments. They are often managed by two or three EMS providers who likely have limited experience in labor and delivery. Successful delivery of the neonate also doubles the patient load for the EMS providers. Deliveries encountered in the prehospital setting are frequently from known high-risk pregnancies and can be significantly premature. One study found that four factors contribute to unplanned out-of-hospital deliveries: multiparity, lack of or poor prenatal care, extended travel time to the hospital, and unemployment. These factors lend to the increased maternal and infant morbidity and mortality found in the prehospital setting. The role of the EMS medical director is to ensure that crews are properly trained and equipped. This includes adequate high-quality educational offerings for the field crews on this broad range of topics and aggressively reviewing patient care reports to ensure that appropriate, compassionate, and evidence-based care is being consistently delivered. Clear protocols and guidelines must be in place to protect and guide the EMS provider.",
        "Special considerations - Pregnant trauma patient": "The pregnant trauma patient represents an especially difficult challenge in the prehospital setting. Basic trauma life support should be carried out according to local trauma management protocols. Airway and hemorrhage control, high-flow oxygen, immobilization, and rapid transport to an appropriate facility remain top priorities. Severity of injury can be difficult to determine in the pregnant trauma patient. Although normal physiological vital sign changes seen with pregnancy can mimic shock, the pregnant patient\u2019s elevated blood volume can allow for massive blood loss before decompensation. Respiratory reserve becomes increasingly limited as the pregnancy advances. EMS protocols should reflect that seemingly minor trauma (e.g. ground-level falls, low-speed motor vehicle collisions) can cause placental abruption and require transport to an appropriate facility. All supine pregnant trauma patients in the second and third trimester should be transported tilted roughly 15\u00b0 to the left. This positioning allows the uterus to be moved off the inferior vena cava, facilitates blood return to the heart, and maintains uterine perfusion.",
        "Special considerations - Pregnant patient in cardiac arrest": "Cardiac arrest resuscitation strategy for the pregnant patient who is more than 20 weeks differs fundamentally from the non-pregnant patient in that scene interventions should be minimal and immediate transport is the highest priority. Similar to the scene evaluation of a trauma patient, EMS providers are directed to \u201cload and go\u201d and perform all interventions and resuscitation measures en route to the hospital. The primary directive during transport is to maximize maternal resuscitative measures. EMS providers must focus on external chest compressions in an attempt to maintain some degree of perfusion to the fetus. The success of perimortem cesarean section in the ED correlates directly with the length of time the patient has been in cardiac arrest. There are reported cases of good neurological outcome of the neonate if the cesarean section is done within the first 5 minutes of the arrest."
    },
    {
        "Epidemiology": "Drowning remains a leading cause of unintentional death and unintentional injury. The Centers for Disease Control (CDC) place the incidence of non-fatal drowning at between 4,000 and 7,000 cases per year. Fatalities range from 3,200 and 6,000 cases per year. The incidence of non-fatal drownings ranges from one to four times that of fatal drownings. Over 50% of all non-fatal drownings require hospitalization. Drowning and near drowning are the second most common unintentional injuries for ages 1\u20134 and 15\u201319. In infants less than 1 year old, most drownings occur in the bathtub. For children less than 4 years old, most drownings occur in private pools. For age greater than 15 years the predominant drowning locations include natural water settings such as beaches and lakes. Fatalities are higher for victims less than 4 years old. Compared with females, males have twice the rate of non-fatal and five times the rate of fatal drowning. Over half of adolescent and adult drownings involve alcohol or illicit substance use. Approximately 35% of persons who drown under the age of 20 are classified as accomplished swimmers. Preexisting medical conditions may play a role as well, as noted in children with seizures having a four-fold increase in risk compared to the general population. Drowning accidents involving children commonly result from lapses in adult supervision. In the majority of child drownings, the child was under the care of one or both parents and was \u201cout of sight\u201d for less than 5 minutes. While surveyed pool owners favor cardiopulmonary resuscitation (CPR) requirements, less than half of these households actually have a CPR-qualified individual. Of pool owners favoring isolation fencing around pools, only one-third had their pool fenced. The risk of drowning or near drowning is 3\u20134 times higher in unfenced than fenced pools. Epidemiological and public health data highlight the role of education, planning, and other community-level interventions in drowning prevention. Estimates of preventable drowning deaths are as high as 80%. Many EMS systems participate in drowning prevention efforts, such as education and water safety programs.",
        "Pathophysiology of drowning": "Drowning is commonly defined as suffocation and death as the result of submersion in a liquid environment. Historically, two types of drowning have been described: wet and dry. \u201cWet drowning\u201d is the aspiration of material such as water, sand, vomitus, etc. This material can lead to pulmonary edema, pneumonitis, and surfactant dysfunction, impairing gas exchange. \u201cDry drowning\u201d involves minimal aspiration; the inhaled liquid triggers laryngospasm, resulting in suffocation. Experts have questioned the mechanisms and clinical significance of this differentiation. Some postulate that decreasing level of consciousness and increasing hypoxia will eventual break any \u201cspasm,\u201d allowing liquid to enter the lungs. Submersion describes the airway opening beneath the surface of the liquid medium\u2013air interface, while immersion is the splashing of liquid in or about the airway. Classically, drowning begins as a period of panic and struggle, but in a minority of cases (for example, cervical trauma or seizure), this initial phase may not be present. Death from drowning ultimately results from suffocation, tissue hypoxia, and cardiac arrest. Successful resuscitation after a drowning-induced cardiac arrest is rare. Historically, drowning education materials have emphasized differences in fresh-water and salt-water drowning, citing the theoretical electrolyte and fluid shifts occurring with each situation. However, current practice downplays the importance of these differences. Some consideration of the water contaminants may be clinically important in the hospital setting, and the EMS insight into those scene variables may be helpful to hospital staff. Cerebral hypoxia plays a significant role in the functional recovery of the victim. Many drowning survivors suffer some permanent neurological damage, with up to 10% suffering severe lasting effects. The duration of hypoxia is correlated with submersion time and is an important determinant of recovery. Another important consideration is the neuroprotective effect of hypothermia. The medical literature and the lay press are replete with examples of survival after lengthy submersion in frigid or near freezing water. Cold-water submersion does not guarantee survival but may play a significant role in management decisions during and after the resuscitation. The term \u201csecondary drowning\u201d typically refers to patients who survive the submersion injury for some period of time, yet later develop respiratory failure and death attributed to the original submersion event. This deterioration may occur from hours to days later. While the term \u201cdrowning-related death\u201d has been proposed to describe deaths occurring more than 24 hours after a submersion, this definition is not widely used. \u201cNear drowning\u201d is defined as immediate survival after a submersion event. While most of these individuals may survive, many will deteriorate. The definition has some variability among authors and published sources, with some including asphyxia or loss of consciousness in the definition. There remain ongoing efforts to better formalize definitions, including the use of the term \u201cdrowning\u201d (defined as a process resulting in primary respiratory impairment from submersion and immersion in a liquid medium) to classify all events regardless of outcome as drowning. To date, this has not been widely accepted in medicine or by the lay public. The remainder of this chapter will distinguish drowning (death) from near drowning.",
        "Dispatch life support": "Emergency dispatchers should provide dispatch life support, including standard respiratory and/or cardiopulmonary arrest instructions. Minimizing delays in delivering instructions is essential. DeNicola showed that 42% of children drowning in home swimming pools were rescued by bystanders but did not have CPR initiated until EMS personnel arrived. The use of an automated external defibrillator (AED) is appropriate and should be included when such a device is available. A less clear area is whether dispatchers should direct callers to rescue drowning victims. All water rescues involve risk and may potentially result in additional victims.",
        "Scene and crowd control": "The first step in successful drowning management is rapid extraction of the victim from the water. Scene safety is paramount, especially in natural water and moving water scenarios. Rescuers not specifically trained in water rescue should not attempt extraction or rescue in moving water.\n\nCrowd control and prevention of secondary victims are essential. Drownings are dramatic events. Depending on the setting (public pool, hotel pool, natural water setting), a large number of bystanders may be present. Bystanders acting as rescuers may inadvertently become secondary victims, especially in natural water settings or in large groups with several non-swimmers. Rescuers should liberally request and utilize crowd control resources.",
        "Management of the drowning victim in cardiac arrest": "The most dramatic clinical presentation of drowning is cardiopulmonary arrest. Rescuers should initiate standard BLS, ACLS, and Pediatric Advanced Life Support (PALS) protocols on drowning victims in cardiac arrest. CPR should begin as soon as practical, with some advocating initiation of CPR while the victim is still in the water. Airway management should begin immediately with bag-valve-mask (BVM) ventilation. Typically extrication from the water should not be delayed for more definitive airway management. Once extricated from the water, additional airway procedures consistent with cardiac arrest protocols may be considered. Rescuers should anticipate vomiting, which may occur in up to 86% of drowning victims receiving rescue breathing and chest compressions. Maneuvers to clear water from the lungs, such as laying the patient prone and lifting the arms behind the back toward the head, are not necessary and should not be performed. Cardiac arrest treatment algorithms do not require modification for drowning victims. While experts have historically emphasized minimizing movement in the severely hypothermic patient to avoid precipitating ventricular dysrhythmias, this recommendation seems to be based more on theory and conjecture than data. Advanced airway management is appropriate in services and personnel competent in the skill. Airway management while in the water is fraught with difficulty and risk of aspiration and delay of CPR initiation. While each scene may pose a unique risk-benefit analysis around patient access and timely egress, typically anything more than basic maneuvers should be deferred to accomplish rapid extrication and initiation of full resuscitation efforts. In the severely hypothermic patient, advanced airway placement may allow for warmed, humidified ventilation. Vascular access and drug therapy should follow standard resuscitation protocols. Some experts have raised concerns that medications may reach toxic levels in the circulation due to decreased metabolism in the severely hypothermic patient. However, little scientific evidence distinguishes drug metabolism in hypothermic versus normothermic cardiac arrest patients. Despite this concern, most guidelines recommend minor alterations of cardiac arrest protocols for patients with hypothermia. Specifically, in moderate hypothermia (30\u201334\u00b0C), rescuers may increase the time interval between intravenous medications. Rescuers should also perform active external rewarming for moderate-to-severe hypothermia. For severe hypothermia (<30\u00b0C), current ACLS guidelines recommend providing a single defibrillation attempt and withholding intravenous medications until the core temperature is >30\u00b0C. The determination of an accurate core temperature in the field setting is difficult, and rescuers should base their actions on the best available clinical information.",
        "Management of near drownings": "By definition, the near drowning patient has vital signs. Near drownings may include patients who never lost vital signs, and those successfully resuscitated. Airway management, hemodynamic stabilization, and transport are the mainstays of treatment. These individuals may be apneic, hypotensive, or hypothermic and should receive appropriate resuscitative interventions. Near drowning victims have strong potential for pulmonary injury and should receive emergency department evaluation. Over half of near drowning victims ultimately require hospital admission. Near drowning victims should be transported and evaluated, as initial presentation can progress rapidly, and refusals should be strongly discouraged.\n\nField management should focus on management and evaluation of oxygenation. Monitoring of pulse oximetry, cardiac rhythms, vital signs, and overall neurological status is warranted. Monitoring of end-tidal CO\u2082 may also be helpful. Continuous positive airway pressure (CPAP) in the conscious breathing patient is being increasingly advocated. Rapid deterioration in ventilation, oxygenation, or ability to protect the airway may require more aggressive airway management techniques consistent with medical respiratory distress protocols. Secondary aspiration from vomiting is a risk in the declining near drowning victim. Intravenous access should be established in most near drownings. Consideration should be given to potential concurrent trauma. Victims may have had concurrent medical conditions that triggered the event, such as hypoglycemia, seizures and cardiac dysrhythmias. These should be addressed and treated appropriately.",
        "Management of concurrent trauma": "Many drownings occur concurrently with other major trauma. For example, an individual may sustain a cervical or spinal cord injury after diving into shallow water. Swimmers in lakes have sustained traumatic brain injuries or penetrating trauma after being struck by motor boats.\n\nThe most important consideration in drowning victims is the potential for cervical spine injury. Hwang et al. identified seven cervical spinal injuries in 143 pediatric drowning and near drowning patients transported to a pediatric trauma center. Watson et al. identified 11 cervical spine injuries in 2,244 drowning victims. All patients in each series were identified with mechanisms of injury suggestive of trauma (diving, high-impact, or assault).\n\nEmergency medical services rescuers should consider cervical spine injuries in all diving, high-impact (e.g. dive from a height), white water, and submersion injuries. However, the rescuers must weigh the risks and benefits of cervical immobilization. For example, cervical immobilization may be dangerous and difficult in swift water rescues. Current American Heart Association guidelines state \u201c\u2026 routine stabilization of the cervical spine is not necessary unless the circumstances leading to the submersion episode indicate that trauma is likely \u2026\u201d Drowning circumstances potentially linked to cervical injury include a history of diving, water slide use, concern for alcohol intoxication, or physical signs of injury. The decision to initiate spine immobilization while in the water is a risk-benefit decision for the patient and rescue team. An absence of identified risk for cervical injury precludes the need for spine immobilization in or out of the water. Swimming pools in particular may be a more appropriate setting for floating backboards or baskets and application of cervical collars without undue risk to the patient or the rescue team. Swift water environments may require a more limited cervical spine control maneuver and rapid extrication to the water\u2019s edge prior to application of rigid collars and boards. In all events, if secondary concerns for cervical injury are discovered by examination or history, cervical protection measures should be instituted.",
        "Rewarming of drowning victims": "Rewarming is appropriate for severely hypothermic patients. Initial thermal management begins with removal of the patient from the offending environment. The patient should be removed from the water. The resuscitation effort should continue in a warmed environment. EMS rescuers should prewarm the ambulance if possible. To prevent further heat loss, the patient\u2019s wet clothing should be removed.\n\nAdditional rewarming techniques are commonly classified as active external rewarming and active internal rewarming. Active external rewarming includes the use of warm packs, warm water packs, forced air, thermal blankets, warmed O\u2082, and warmed IV infusions. Care should be taken to avoid secondary thermal injury from warm packs against the native skin. Concern for a paradoxical drop in the core temperature due to vasodilation of the peripheral vasculature during rewarming has been postulated. Careful hemodynamic monitoring should be instituted.\n\nActive internal rewarming includes the use of peritoneal lavage with warmed fluids, esophageal tubes for rewarming, chest lavage with warm fluids via chest tubes, and the cardiac bypass or extracorporeal circulation; these measures are typically not carried out in the prehospital environment.\n\nTraditionally, most experts argued for rewarming by whatever means available and to do so aggressively during the resuscitation. The old adage \u201cA victim is not dead until warm and dead\u201d may require reconsideration. Mounting evidence has shown that induced hypothermia after return of spontaneous circulation may impart some neurological benefit for ventricular fibrillation arrest and possibly other arrhythmias. It would seem logical that a drowning victim may benefit from induced or continued hypothermia. Additionally, ACLS guidelines now target core temperature to 32\u201334\u00b0C with return of spontaneous circulation in cardiac arrest due to accidental hypothermia. In the absence of specific drowning data, and the success of prehospital hypothermia in general cardiac arrest, the historic practice of aggressive rewarming is being questioned. Some in medicine are specifically calling for abandoning the practice altogether.",
        "Destination decisions": "Patients in cardiac arrest should be transported to the nearest emergency facility. Patients with perfusing rhythms may benefit from transport to a specialized facility (for example, trauma or pediatric center), provided that the additional transport time is limited. While many victims have concurrent trauma, it is not clear whether transport to a trauma center is warranted for all drownings.",
        "Grief reactions": "Drownings are unexpected events in typically young and healthy patients. Relatives and bystanders may express significant grief from these events. After the incident, attention should be paid to possible grief reactions in rescue personnel so that appropriate referral or interventions can be implemented."
    },
    {
        "Introduction": "Human pregnancy is generally divided into three 13-week trimesters. While this terminology is useful, it is easier to divide the pregnancy into two halves, each lasting about 20 weeks. The first half is commonly referred to as early pregnancy and the latter as late pregnancy. Each half of pregnancy has its own unique emergencies that the EMS physician should keep in mind. The most common disorder of early pregnancy is miscarriage. Only 20% of miscarriages occur after the first trimester. Ectopic pregnancy is the most life-threatening emergency of early pregnancy. High suspicion for ectopic pregnancy should always be maintained for females of child-bearing age, and prompt diagnosis and therapy should be reflexive. The most common emergencies of late pregnancy include placenta previa and placental abruption.",
        "Evaluation of the pregnant patient": "An EMS physician should rapidly ascertain pertinent information from any pregnant patient. This includes estimated due date or weeks of gestation, last menstrual period, number of previous pregnancies, number and type of deliveries, contraction intervals, membrane rupture, bleeding, and complications with previous pregnancies such as gestational diabetes, preeclampsia, or preterm labor. The EMS physician's challenge is to identify life threats and initiate treatment in spite of the fact that pregnancy status is often unknown by the patient.",
        "Miscarriage": "Miscarriage is the most common complication of early pregnancy. Approximately 15\u201320% of clinically evident pregnancies are miscarried. Eighty percent of all miscarriages occur before the 12th week of gestation. In most cases, the primary focus for the EMS physician is to provide psychological support to the patient and her family. If the patient has passed tissue it should be transported with the patient to the receiving facility. If the patient is showing signs or having symptoms of hemorrhagic shock, a large-bore intravenous catheter should be inserted for access and the patient appropriately resuscitated with boluses of normal saline.",
        "Ectopic pregnancy": "Ectopic pregnancy is the implantation of a fertilized ovum outside the endometrial cavity. It occurs in approximately 1.5-2.0% of pregnancies, with some studies reporting the incidence of ectopic pregnancy as high as 2.6% of all pregnancies. The reported rise in incidence of ectopic pregnancy is strongly associated with an increased incidence of pelvic inflammatory disease. The clinical use of sensitive pregnancy testing, transvaginal sonography, and diagnostic laparoscopy has had a major effect on the diagnosis of ectopic pregnancy before rupture. Nevertheless, ruptured ectopic pregnancies continue to occur, often because the clinician or the patient did not recognize the early signs and symptoms of the condition, and such pregnancies account for 6% of all maternal deaths and remain the leading cause of first-trimester pregnancy-related death. The most frequent causes of death for women with ectopic pregnancies in the United States are hemorrhage, infection, and anesthetic complications. The etiology of ectopic pregnancy is multifactorial and as many as 50% of women with ectopic pregnancies have no identifiable risks. Factors that are strongly associated with an increased risk of ectopic pregnancy include damage to the ovarian tubes from pelvic inflammatory disease, previous tubal surgery, or a previous ectopic pregnancy. A history of cigarette smoking, age over 35 years, and many lifetime partners have been identified as minor factors. The risk of recurrence of ectopic pregnancy is approximately 10% among women with one previous ectopic pregnancy and at least 25% among women with two or more previous ectopic pregnancies. Women in whom the affected fallopian tube has been removed are at increased risk for ectopic pregnancy in the remaining tube. Ectopic pregnancies that involve implantation outside the fallopian tube account for less than 10% of all ectopic pregnancies. These unusual pregnancies are difficult to diagnose and are associated with high mortality. Abdominal pregnancies occur in 10.9 per 100,000 pregnancies and in 9.2 per 1,000 ectopic pregnancies. The maternal mortality rate has been reported to be 7.7 times higher than that observed in tubal ectopic pregnancies, and 90 times higher than in an intrauterine pregnancy. Heterotopic pregnancy, the co-occurrence of an ectopic pregnancy and intrauterine pregnancy, has increased in incidence and occurs in 0.3\u20130.8% of the general population and 1\u20133% of women pregnant as a result of assisted reproduction. The patient history (including an assessment for risk factors) and physical examination are the principal tools used to evaluate a patient with possible ectopic pregnancy. In the out-of-hospital setting, any woman of reproductive age with abdominal pain or vaginal bleeding should be considered to have an ectopic pregnancy until proven otherwise.",
        "Ectopic pregnancy - Patient history": "The location, nature, and severity of pain with ectopic pregnancy are highly variable. Colicky pain presents mainly in the hypogastric or iliac regions and is most likely due to small-volume intraperitoneal hemorrhage. Localized abdominal or pelvic pain is caused by acute distension of the fallopian tube at the site of implantation. Tubal rupture is typically associated with a longer-lasting, more generalized pain due to hemoperitoneum, but rupture may also be associated with a decrease in or resolution of pain altogether. Pain referred to the shoulder, indicating irritation of the diaphragm from intraperitoneal blood (Kehr\u2019s sign), is a late sign. Vaginal bleeding may be small in volume (spotting) or equivalent to a menstrual period. The passage of tissue does not distinguish failing intrauterine from ectopic pregnancy and may simply represent a cast of endometrial tissue.\n\nClassic signs and symptoms of tubal ectopic pregnancy include abdominal pain, vaginal bleeding, and delay of an expected menses with classic presentation around 6 to 8 weeks of gestation. However, fewer than half of women with ectopic pregnancy have the classically described symptoms of abdominal pain and vaginal bleeding. In fact, these symptoms are more likely to indicate miscarriage.",
        "Ectopic pregnancy - Physical examination": "Women with ectopic pregnancy may have pelvic or adnexal tenderness and vaginal bleeding. Hypovolemia, tachycardia, hypotension, diaphoresis, and shock are late signs that may indicate ruptured ectopic pregnancy with intraperitoneal hemorrhage. Although it is less common for women to present with these signs, due to improved diagnostic methods, a woman with hemodynamic instability or peritoneal signs and a positive pregnancy test result or a delay of an expected menses potentially has a ruptured ectopic pregnancy, and should have prompt evaluation by an obstetrician.",
        "Ectopic pregnancy - Management": "For the EMS physician, the key to treating a pregnant patient with early obstetrical complaints is maintaining a high index of suspicion for a possible ectopic pregnancy and recognizing hemodynamic instability secondary to hemorrhagic shock. If the patient is in shock, large-bore intravenous access should be obtained and the patient resuscitated appropriately with crystalloids. In a woman of child-bearing age with abdominal pain and hypotension, the finding of free abdominal fluid on prehospital ultrasound should increase the suspicion of ruptured ectopic pregnancy.",
        "Placental abruption": "Placental abruption, defined as the premature separation of the placenta from the uterine wall, complicates approximately 1% of births. Abruption is believed to account for approximately 30% of episodes of bleeding during the second half of pregnancy. It is associated with significant perinatal mortality and morbidity. Abruption may be \u201crevealed,\u201d in which case blood tracks between the placenta and the endometrium, and escapes through the cervix into the vagina. The less common \u201cconcealed\u201d abruption occurs when blood accumulates behind the placenta, with no obvious external bleeding. Finally, abruption may also be classified as total, involving the entire placenta, in which case it typically leads to fetal death, or partial, with only a portion of the placenta detached from the uterine wall. Placental abruption has a wide spectrum of clinical significance, varying from minor bleeding with few or no consequences to massive abruption with fetal death and severe maternal morbidity. Maternal risks include massive bleeding, disseminated intravascular coagulopathy, and death. The risk to the fetus depends on both the severity of the abruption and the age at which the abruption occurs, whereas the danger to the mother is posed primarily by the severity of the abruption. The incidence of placental abruption is reported to be between 1% and 3.8% of deliveries. The incidence of abruption peaks at 24\u201326 weeks gestation and drops precipitously with advancing gestation. Other risk factors include trauma, thrombophilias, dysfibrinogenemia, hydramnios, advanced maternal age, and intrauterine infections. Bleeding in early pregnancy carries an increased risk of abruption in later pregnancy. Placental abruption is usually the result of shearing forces, may occur without direct abdominal trauma, and is independent of placental location. Approximately 6% of all trauma cases and 20\u201325% of major trauma cases are associated with placental abruption but placental abruption is difficult to predict based on the severity of trauma. Placental abruption usually manifests within 6\u201348 hours after trauma but can occur up to 5 days later. Perhaps the greatest determination of abruption risk, however, is an abruption in a prior pregnancy. When examined, the risk increased 15\u201320-fold in subsequent pregnancies when an earlier pregnancy was complicated by abruption. The diagnosis of abruption is a clinical one and the condition should be suspected in women who present with vaginal bleeding or abdominal pain or both, a history of trauma, and those who present in otherwise preterm labor. The differential diagnosis includes all causes of abdominal pain and bleeding in pregnancy, such as placenta previa, appendicitis, urinary tract infection, preterm labor, ovarian pathology, and muscular pain.",
        "Placental abruption - Patient history": "The clinical presentation of abruption varies widely. Classically, placental abruption presents with vaginal bleeding and abdominal pain. It is important to realize, however, that severe abruption may occur with neither or just one of these signs. Vaginal bleeding occurs in 80% of cases. The amount of vaginal bleeding correlates poorly with the degree of abruption. The severity of symptoms depends on the location of the abruption, whether it is revealed or concealed, and the degree of abruption. Backache may be the only symptom, especially when the placental location is posterior. Finally, abruption may present as idiopathic preterm labor.\n\nIn addition to the standard obstetric history, a history should be obtained that focuses on cocaine and drug use, hypertension, preeclampsia, and other predisposing factors.",
        "Placental abruption - Physical examination": "Upon physical examination, typically there is uterine hypotonus with associated high-frequency, low-amplitude uterine contractions. The uterus is frequently tender and may feel hard on palpation. In cases of severe abruption, typically, the uterus is contracting vigorously and labor rapidly progresses. The remainder of the physical examination should be performed looking for signs of trauma, preeclampsia, or other predisposing factors.\n\nThe ultrasonographic appearance of abruption depends to a large extent on the size and location of the bleed, as well as the duration between the abruption and the time the ultrasonographic examination was performed. In cases of acute revealed abruption, the examiner may detect no abnormal ultrasonographic findings. The ultrasonographic appearance of abruption in the acute phase is hyperechoic to isoechoic when compared with the placenta. The sensitivity, specificity, and positive and negative predictive values of ultrasonography for placental abruption are 24%, 96%, 88%, and 53% respectively. Thus ultrasound will fail to detect at least one half of cases of abruption.",
        "Placental abruption - Management": "A patient with signs or symptoms of placental abruption should have a large-bore IV catheter inserted for access and transport expeditiously to a facility with obstetrical capabilities. The patient should be monitored closely during transport, observing for the development of signs of shock.\n\nBleeding caused by placental abruption can lead to maternal hypovolemic shock. Blood loss may be underestimated because of a concealed abruption. If the patient exhibits signs or symptoms of shock, she should be resuscitated with boluses of normal saline.\n\nIn the case of trauma, transport expeditiously to a trauma center where the patient can be evaluated by both a trauma surgeon and an obstetrician and undergo fetal monitoring.",
        "Placenta previa": "Placenta previa is another cause of bleeding episodes during the second half of pregnancy. Placenta previa refers to a placenta that overlies or is proximate to the internal os of the cervix. Normally, the placenta implants in the upper uterine segment.\n\nMorbities associated with placenta previa include antepartum bleeding, need for hysterectomy, morbid adherence of the placenta, intrapartum hemorrhage, postpartum hemorrhage, blood transfusion, septicemia, and thrombophlebitis. Placenta previa is also associated with an increase in preterm birth. In the United States, maternal mortality occurs in 0.03% of cases with placenta previa. Placenta previa complicates approximately 0.3-0.5% of pregnancies. The annual incidence in the United States is reported to be 4.8 per 1,000 deliveries.\n\nThe likelihood of placenta previa increases in a dose-response fashion with a greater number of prior cesarean sections and with greater parity, with a relative risk of placenta previa rising from 4.5 (95% confidence interval (CI) 3.6\u20135.5) in women with one prior cesarean section to 44.9 (95% CI 13.5\u2013149.5) in women with four prior cesarean sections.",
        "Placenta previa - Patient history": "The classic presentation is painless bleeding in the late second trimester or early third trimester. However, some patients with placenta previa will experience painful bleeding, possibly due to uterine contractions or placental separation, whereas others will experience no bleeding at all before labor.",
        "Placenta previa - Physical examination": "Women who present with bleeding in the second half of pregnancy should have a sonographic examination for placental location. Digital vaginal examination with a placenta previa may provoke catastrophic hemorrhage and should not be performed, either in the field or in the emergency department.",
        "Placenta previa - management": "A large-bore intravenous cannula should be inserted and the patient transported expeditiously to a hospital. She should be closely monitored during transport. If at any time she shows signs of shock, fluid resuscitation with normal saline should be performed.",
        "Hypertension during pregnancy": "Hypertension is observed in approximately 6\u20138% of pregnancies and is generally divided into several categories. Gestational hypertension occurs during pregnancy, resolves during the postpartum period, and is recognized by a new blood pressure reading of 140/90 mmHg or higher. Preeclampsia is gestational hypertension with proteinuria, and eclampsia is the occurrence of seizures in the patient with signs of preeclampsia. Progression of preeclampsia to eclampsia is unpredictable and can occur rapidly.\n\nApproximately 2\u20137% of pregnancies are complicated by pregnancy-induced hypertension. Hypertensive emergencies during pregnancy are the second leading cause of maternal deaths in the United States, with a 15% occurrence. The incidence of eclampsia has progressively declined, but it is still one of the major causes of maternal mortality.",
        "Hypertension during pregnancy - Preeclampsia": "Preeclampsia is a multisystem disorder characterized by the presence of hypertension and proteinuria after 20 weeks of gestation. It affects 12% of pregnancies and is responsible for nearly 20% of maternal deaths in the United States. Urinary protein excretion greater than 300 mg daily is required for diagnosis. This amount of proteinuria usually corresponds to a positive reaction (+1) on a urine dipstick via random urine sample. Severe preeclampsia is defined by blood pressure readings higher than 160/110 mmHg and more than 5 g of urinary protein excretion daily.\n\nPreeclampsia may also be associated with many other signs and symptoms, such as edema, visual disturbance, headache, and epigastric pain. Features of severe preeclampsia include hypertensive emergency, acute renal failure, cerebral and visual disturbances, and pulmonary edema or cyanosis. Common risk factors for the development of preeclampsia include primiparity, multiple gestations, previous preeclampsia, obesity, diabetes mellitus, and connective tissue disorders.",
        "Preeclampsia - Management": "The use of magnesium sulfate in all patients with preeclampsia for the prevention of eclampsia is controversial. The large Magpie prospective trial suggested that the prophylactic use of magnesium sulfate in preeclampsia decreased the overall risk of eclampsia and may reduce maternal death. Prehospital treatment should be centered around supportive care and transport to an appropriate receiving facility.",
        "Eclampsia": "Eclampsia is defined as the presence of new-onset grand mal seizures in a woman with preeclampsia. Eclampsia is rare and occurs in less than 1% of preeclamptic patients and may occur in the absence of preeclampsia. In 10\u201315% of patients with eclampsia, hypertension is absent or modest and/or proteinuria is not detected. The incidence of eclampsia is about 1 in 3,250 pregnancies in the United States. More than 90% of eclamptic seizures present after gestational week 28, but reports exist of eclampsia presenting as early as gestational week 16 and as late as 23 days postpartum. Eclampsia is associated with increased rates of abruptio placentae, microangiopathic hemolytic anemia, pulmonary edema, acute renal failure, and preterm delivery. Eclamptic seizures can occur at any time during pregnancy and infrequently 48 hours to 1 month post partum. One-third or more of patients having eclamptic seizures in the postpartum period present without ever having manifested signs and symptoms of preeclampsia. The rate of preeclampsia in subsequent pregnancies following a pregnancy complicated by eclampsia is as high as 25%. Seizures from eclampsia are usually grand mal. Other clinical features of eclampsia include nausea, vomiting, hyperreflexia, severe headaches, and altered mental status. However, many of these features are also seen in preeclampsia. Rarely cortical blindness occurs with severe preeclampsia/eclampsia. Focal neurological signs are unusual, but have been reported.",
        "Eclampsia - Management": "Several large randomized controlled trials have demonstrated that parenteral magnesium sulfate is superior to both phenytoin and diazepam in preventing the initial and recurrent seizures and lowering maternal mortality. In the Collaborative Eclampsia Trial, magnesium sulfate reduced the risk of recurrent seizures in eclamptic women by 52% when compared to diazepam and by 67% when compared to phenytoin.\n\nThe American College of Obstetricians and Gynecologists recommends a 4\u20136 g loading dose given intravenously over 15\u201320 minutes, followed by a continuous infusion rate of 2 g/hour. There is concern for magnesium toxicity while administering such high doses. Toxicity is manifested by loss of tendon reflexes, respiratory depression, muscular paralysis, respiratory arrest, and maternal cardiac arrest. Tendon reflexes disappear considerably before serious toxicity such as cardiac arrhythmias and respiratory arrest occur.",
        "Conclusion": "The most important action that an EMS physician can undertake in any emergency of pregnancy is to maintain a high index of suspicion and protect the life of mother and child."
    },
    {
        "Introduction": "Syncope is defined as a 'loss of consciousness and postural tone caused by diminished cerebral blood flow.' Also, by definition, the condition must be self-corrected so as to cause a return to normal state of consciousness. Syncope is a common complaint in both the emergency department (ED) and in prehospital medicine and is the sixth leading cause of hospital admission in people over the age of 65. Of course, estimates are limited by the accuracy of determining true syncope versus other transient causes of loss of consciousness. Transient loss of consciousness has a cumulative lifetime incidence of approximately 35%.",
        "Pathophysiology": "It is important to understand the multiple etiologies that lead to the final pathway of a transient loss of consciousness. Any process that results in a loss of consciousness must affect both cerebral hemispheres simultaneously or involve the reticular activating system in the brainstem. In the case of syncope, the pathological process is transient, resulting from a loss of needed substrate to the brain (be it oxygen or other nutrients) that corrects without external therapeutic intervention (such as the administration of IV dextrose). Typically, the impairment of substrate delivery is caused in part by upright posture. Thus, assuming a supine position after consciousness is lost improves substrate delivery and typically leads to spontaneous recovery. As with any disease process, classification of etiology aids in diagnosis, treatment, and prognosis for patients. Understanding the patient's prognosis helps in ensuring a safe disposition. Unfortunately, the classification schemes for etiologies of syncope are broad, vary by author, are to some degree subjective, and frequently overlap. For the purpose of this discussion, syncope will be classified into four broad categories: cardiac, neurological, vascular (or reflex mediated), and idiopathic.",
        "Cardiac Syncope": "Cardiac syncope is due to a transient lack of adequate cardiac output, causing inadequate cerebral perfusion and subsequent loss of consciousness. Dysrhythmia is a common cardiac etiology and is one of great clinical importance. The most common dysrhythmia associated with syncope is transient ventricular tachycardia (VT). These occurrences are seen most frequently in patients with histories of congestive heart failure and low ejection fraction and portend a poor prognosis (1-year mortality up to 40%). Other culprit dysrhythmias include severe sinus bradycardia or transient high-grade heart blocks, supraventricular tachycardias, sick sinus syndrome, and atrial fibrillation with rapid ventricular response. As a rule, all of the aforementioned dysrhythmias must be paroxysmal in nature to cause a syncope episode, because there must be a return of cerebral perfusion for the patient to regain consciousness. Other cardiac causes of syncope include restrictive cardiomyopathies, valvular heart disease (especially severe aortic stenosis and mitral regurgitation), pulmonary embolus, and, rarely, cardiac ischemia (although syncope from such is most likely dysrhythmia related). Although these pathologies can cause transient reductions in cardiac output sufficient to create a syncopal episode, their overall occurrence is rare. One population of young patients who have dangerous syncope are those with congenital prolonged QT syndrome. This is why it is important to check a rhythm strip on every syncope patient.",
        "Reflex-Mediated Syncope": "Reflex-mediated syncope is the most common cause and (barring secondary trauma, as from a subsequent fall or automobile collision) poses the best prognosis. Although listed as 35% here, some studies have attributed up to 58% of syncope to this etiology. Reflex-mediated syncope occurs when the body has an inappropriate autonomic response to a change in posture. Under normal circumstances, when a person moves from recumbent to upright, a significant amount of blood (300\u2013800 mL) will pool in the lower extremities. In response, the sympathetic nervous system causes peripheral vasoconstriction, stimulates increased cardiac contractility, and increases the heart rate. These processes counteract the transient experienced by the central nervous system, thus preventing syncope. For patients experiencing reflex-mediated syncope, there is an inappropriate reflexive stimulation of the parasympathetic nervous system that overshadows the appropriate sympathetic response. These patients experience hypotension, with or without bradycardia. The resultant lack of cerebral perfusion results in a syncopal episode.",
        "Neurogenic Syncope": "Neurogenic syncope, as a pure cause of transient loss of consciousness, is actually a rare event. Many of the neurological events that result in syncope have poorly explained mechanisms. Additionally, many neurological events that involve a loss of consciousness are incorrectly labeled as syncope. It is important to note, however, that some neurological causes of syncope represent serious pathological processes, such as subarachnoid hemorrhage and transient ischemic attack. It is rare that such diseases manifest as syncopal episodes, but caution must be exercised if these diagnoses are considered.",
        "Assessment": "The first task in assessing and managing syncope, in both the prehospital and ED settings, is to separate syncope from the other potential reasons for a loss of consciousness. First, any non-transient loss of consciousness, by definition, is not syncope. A patient who has a loss of consciousness from hypoglycemia, requires IV dextrose, and then awakens to a normal level of consciousness has not had a syncopal episode. Likewise, if the patient has a complex non-motor seizure and then recovers from a postictal state to a normal mental status, this too is not syncope. However, for the EMS provider, all of these might be dispatched as status, unconscious, syncope, variables, including the quality of information exchanged between the caller and call-taker. This can incorrectly prejudice providers to presume or discount syncope as the diagnosis. As with all medical problems, proper assessment and evaluation begin with an appropriately focused history and physical examination. Although 85\u201390% of all patient pathology can be determined by history and physical exam, these are even more important in the case of syncope. There are very few diagnostic tests that will aid in determining the cause of a syncopal episode or in ascertaining syncope as the problem versus another malady. If one takes a diagnosis such as appendicitis, we know that it can be determined clinically almost 90% of the time, but also can be by computed tomography (CT) scanning, by surgical findings, or by the pathology results. However, in the case of a syncopal episode, there are few laboratory or other diagnostic studies that will aid significantly in the diagnosis. History is the most important information in the case of syncope. For patients in the prehospital setting, the history obtained by EMS providers is pivotal to the patient's evaluation. Because true syncope involves a loss of consciousness, there will be details of the event that patients will not be able to provide. Frequently these patients arrive alone to the ED, and the emergency physician has no opportunity to interview others who may have witnessed the episode. Therefore, maximizing history obtained at the scene and relaying this to the ED staff is pivotal to accurate diagnosis and treatment. It is important to ask the patient what he or she can remember before the event. No recollection at all is of particular importance. If the patient felt no prodromal symptoms at all, and then had a period of unconsciousness, this is particularly concerning for cardiac causes of syncope. Chest pain, palpitations, and shortness of breath are other symptoms that can be associated with dysrhythmia or other cardiac pathology. Abdominal pain, nausea, or lightheadedness frequently precede reflex-mediated syncope. Always attempt to ascertain the last thing the patient remembers before the event, as well as the first thing he or she can remember after regaining consciousness. In the case of a true syncopal event, the patient will not be able to convey information about happenings during his or her period of unconsciousness. Bystander interview is paramount, and, as mentioned previously, EMS personnel may be the only medical providers able to obtain this vital information. Did the bystanders notice anything before the patient lost consciousness? Was there any seizure activity noted (tonic/clonic, focal, etc.)? Were there any periods of apnea noted? Bystander history is also imperative for determining the length of the unresponsive period. Unfortunately, this time interval will frequently be overestimated due to the anxiety provoked in bystanders seeing someone unresponsive. Still, careful and compassionate interviews by EMS personnel can frequently elicit valuable references to attempt to establish a time course. Was the patient unconscious for the entire 9-1-1 phone call? How long before EMS arrival did the patient regain consciousness? Finally, prehospital providers must obtain the bystanders\u2019 history of events as the patient regained consciousness. Did the patient\u2019s mental status improve rapidly or was there a period of confusion? Did the patient have any complaints on awakening that he or she cannot recall now? Did the patient appear hot or cold, sweaty, or pale? If the bystanders took the patient\u2019s pulse, what was the rate and quality? Beyond the history of present illness, EMS providers must also obtain other pertinent medical history. Chronic health problems (especially cardiac, vascular, or neurological problems) need to be documented because they are important risk factors in syncope. A complete medication list (as always) must be obtained because many medications can predispose a patient to syncope. Additionally, medications can frequently point to other causes of loss of consciousness that are not syncopal episodes, such as seizures or hypoglycemia. Last oral intake should be ascertained to determine if the patient is at risk for hypoglycemia and to see if there are any confounders to the mental status examination, such as drugs or alcohol. A focused physical examination is always important for any complete patient assessment. Vital signs, skin condition, heart, lung, and abdominal examination, and a thorough neurological examination are essential. Many recommend checking orthostatic vital signs, at least lying and sitting (for fear of patient trauma if there is a fall when standing). However, there are many confounders to positive or negative orthostatic vital signs and even much debate over what are the appropriate and inappropriate changes. But if the patient becomes symptomatic with changes in position, this is important to note. It is important to remember that, at the time of EMS assessment, the physical examination may be completely normal. Vital signs may be within normal limits, and the remainder of the examination may be unremarkable. Unfortunately, this does not preclude the existence of serious pathology. Cardiac syncope in particular is likely to present with a normal physical examination, despite being potentially lethal. Consistent with most prehospital encounters, diagnostic testing is of limited value. A glucometer reading should be obtained, despite the fact that glucose abnormalities rarely cause transient loss of consciousness. A prehospital 12-lead ECG is indicated because this may help to risk-stratify the patient\u2019s potential syncopal etiology. According to the 2009 European Society of Cardiology (ESC) guidelines, the following ECG findings are considered diagnostic for syncope due to a dysrhythmia. Persistent sinus bradycardia <40 bpm, Repetitive sinoatrial blocks or sinus pauses >3 seconds, Mobitz II \u2013 second-degree heart block, Third-degree heart block, Alternating left and right bundle branch blocks, Ventricular tachycardia, Rapid paroxysmal supraventricular tachycardia, Automatic implantable cardioverter defibrillator or pacer dysfunction. It is important to note, however, that a normal 12-lead ECG does not preclude life-threatening causes of syncope, as the event has usually passed at the time of EMS assessment. As in the ED, it is hoped that future research can determine which patients are at risk for a life-threatening cause of syncope.",
        "Differential Diagnosis": "One of the most important steps in evaluating syncope is to ensure the event was truly a syncopal episode and not a loss or alteration of consciousness attributable to some other pathology. The most common pathology confused with syncope is seizures. Both clearly involve a loss of consciousness, and other findings classically associated with seizures can occur with true syncopal episodes. Incontinence is rare in syncope but does occur. Also, shortly following a syncopal episode, a patient may experience myoclonic jerks that can be confused with seizure. The most important distinguishing feature is the postictal period. Generalized seizure patients typically have postictal phases lasting minutes, whereas the return to normal mentation after a syncopal episode rarely exceeds 30 seconds. Pseudosyncope is a psychiatric condition in which there is no actual loss of consciousness, and a syncopal episode is fabricated for whatever psychiatric reason exists. This condition is separate from psychogenic syncope, which involves a true syncopal episode (with an actual loss of consciousness) that is caused by a psychiatric stimulus (severe emotional distress, pain, other psychiatric condition). Frequently, it will be difficult to separate these in the prehospital environment. Confronting the patient regarding presumed pseudosyncope will frequently destroy the therapeutic relationship in an uncontrolled environment, and therefore should be discouraged. Two other rare conditions that may be confused with syncope are narcolepsy and cataplexy. Narcolepsy is a condition in which patients have profound daytime sleepiness such that they may suddenly fall asleep in the middle of the day. This will rarely occur so suddenly, however, as to result in a loss in postural tone. Cataplexy, however, is defined as a sudden, uncontrolled loss of postural tone, and to witnesses this may appear as a syncope episode. However, patients with true cataplexy will not lose consciousness. Many of the other presentations that are commonly confused with syncope are readily identifiable by health care providers once they assess the patient and situation. Pathologies such as hypoglycemia, stroke, cardiac failure, hypoxia, anaphylaxis, and the like should be readily identifiable by EMS physicians and other providers performing the history and physical examination.",
        "Treatment": "For most cases of true syncope in the prehospital environment, immediate treatment needs are minimal. Unless witnessed by prehospital personnel, the event has almost by definition resolved on EMS arrival. As always, each patient requires a careful, thorough, but focused history and physical examination. Each patient should also receive cardiac monitoring to evaluate for dysrhythmia. The value of IV access is debatable, unless the suspicion for a cardiac dysrhythmia (which may recur and require IV medication) is high. Glucose testing is indicated. Although ischemia is rare, a 12-lead ECG should be performed by EMS.",
        "Disposition": "Experience shows that determining patient disposition after EMS contact can be complicated, time consuming, and fraught with medical and legal hazards. This is particularly true for patients who, at the time of EMS assessment, are not having any complaints or lack an obvious acute pathology that requires intervention. Unfortunately, patients experiencing syncope frequently fall into this category. Usually, by the time of EMS arrival, the patient has regained consciousness and his or her mental status has returned to baseline. Even patients with potentially life-threatening causes of syncope, such as dysrhythmia, may have no complaints or physical examination findings during prehospital assessment. So what should we do with these patients? In the vast majority of EMS systems, the only two choices are to transport the patient or obtain an informed refusal of care and transport. It is rare that syncope patients require specialty referral centers, especially if they are asymptomatic at time of EMS arrival. Usually, the rare causes of syncope that may require specialty referral (e.g. myocardial infarction, subarachnoid hemorrhage, and trauma after syncope) do not present asymptomatically. Therefore, for patients who agree to transport to the ED for evaluation, the closest facility is usually appropriate. For the patient refusing transport, EMS personnel must decide if the patient has adequately displayed decision-making capacity, including full understanding of risks, benefits, and alternatives. The explanation of the risks is perhaps the most important issue when considering the syncopal patient's capacity to refuse transport. It is imperative that the prehospital personnel have a clear understanding of the pathologies previously mentioned and can correlate those with the patient's presentation. The level of training of the prehospital personnel (EMT, paramedic, nurse, or physician) will alter the ability to determine possible pathologies, the understanding of these, and the risk of not receiving evaluation in the ED. The prehospital environment presents a complicated and dynamic practice arena, even more so than the ED. Due to this, it is impossible to cover all possibilities regarding patient presentation and disposition. In the end, it is up to the prehospital provider to ensure that the patient's final disposition is safe and in his or her best interest. Although the patient's right to make decisions regarding his or her health care must be respected, it is equally important that all patients fully understand the potential risks associated with their conditions, and the evaluation and treatment options that exist.",
        "Conclusion": "Syncope is a transient loss of consciousness with a spontaneous return to a normal, baseline mental status. It is a common complaint in both the prehospital and ED settings. Although the exact etiology of syncope is frequently not ascertained, careful history and physical examination can determine the cause for the majority of those patients who can be diagnosed. Certain diagnoses, especially cardiac dysrhythmias, can be potentially life threatening and require proper evaluation and observation. Safe disposition of the patient requires a careful evaluation in the prehospital setting, and appropriate explanation to those who frequently have no symptoms at the time of evaluation."
    },
    {
        "General considerations and resource management": "Out-of-hospital deliveries not attended by physicians or midwives are a rare occurrence, comprising less than 2% of all births in the US. The majority of out-of-hospital deliveries encountered by EMS personnel are uncomplicated vertex presentations and require only routine supportive care of both mother and neonate. Maternal risk factors for unattended out-of-hospital delivery include younger maternal age, multiparity, and poor prenatal care. These same risk factors are associated with not only prematurity but higher incidence of fetal morbidity and mortality. Literature over the last two decades shows a trend towards increasing numbers of unattended out-of-hospital deliveries and an increasing medicolegal burden of such cases. It is imperative that medical directors provide robust training, protocol, and direct medical oversight support to crews managing out-of-hospital births.\n\nDue to the low frequency and high-risk nature of unattended out-of-hospital births, along with the significant emotional component of these situations for both patient and provider, catastrophic outcomes are possible and do occur. It is important for EMS personnel to realize that the same risk factors that contribute to unattended out-of-hospital birth also contribute to prematurity (often extreme) and neonatal morbidity. Some complications are not amenable to successful resolution within the scope of practice of prehospital providers and will necessitate temporizing measures and rapid transport. The most practical approach is to focus training on the methodical application of interventions within the scope of care and whenever possible to expedite transport to an appropriate receiving facility.\n\nResource management at the scene of an unattended out-of-hospital childbirth also presents challenges as there will be at minimum two patients for the prehospital personnel to manage. As the proportion of overall pregnancies involving multiple gestations continues to rise, it is reasonable to expect EMS personnel to encounter increasing numbers of multiple birth situations, further complicating resource management. The request for additional resources, if available, should be made as soon as a multiple gestation birth, an abnormal presentation, or other childbirth emergency is identified. In some systems mother and neonate may also require transport to separate receiving facilities. Finally, given the emotionally charged nature of an out-of-hospital childbirth, attention must be paid to caring for other family members or loved ones on scene to ensure not only their support but also that they do not interfere with the provision of appropriate care.",
        "Management of abnormal presentations": "\n\nUmbilical cord prolapse is a rare complication characterized by an umbilical cord descending through the cervix prior to the presenting fetal part, and may lead to fetal distress if the fetus compresses the cord as it subsequently traverses the birth canal. Incidence of prolapsed umbilical cord has been variously reported but is generally felt to occur in approximately 0.5\u20131% of all deliveries. Although no specific data have been offered on the incidence of prolapsed umbilical cords encountered in the prehospital environment, it is reasonable to expect a rate generally similar to overall incidence.\n\nRisk factors for prolapsed cord include abnormal presentation of the fetus (particularly breech), lack of prenatal care, twinning (particularly the second-born twin), and gestational diabetes/macrosomia. The presence of a prolapsed cord is associated with lower Apgar scores and increased perinatal mortality, and it is imperative that the prehospital provider assesses for this potentially disastrous condition by visualizing the perineum. For crews with advanced fetal monitoring capability, unexplained fetal distress should prompt sterile vaginal exam to assess for the presence of this complication. Emergency treatment of umbilical cord prolapse centers on the temporizing decompression of cord by elevation of the presenting fetal part followed by rapid delivery to remove the neonatal dependence on umbilical cord blood flow for oxygenation.\n\nUsing a gloved hand, the provider gently elevates the presenting part. The exposed cord may be covered in a moist sterile towel. If Doppler is not available to assess cord blood flow, an attempt may be made detect pulsation in the cord; however, this may be faint and care must be taken to avoid further manual compression of the cord during palpation. Because prolapsed cord is associated with abnormal presentations, rapid completion of delivery, particularly in the prehospital setting, may be less likely. Providers should expedite transport if at all possible in these situations while attempting to preserve cord blood flow via manual elevation of the presenting part as described above and positioning of the mother in the knee-to-chest position or steep Trendelenburg to aid in reducing pressure on the cord. Most often, cesarean section is undertaken to expedite delivery once at the hospital.\n\nBreech presentations are encountered in 3\u20134% of deliveries overall. In the prehospital environment, one series showed a breech incidence of 2.5% (2/81). Both were feet-first breeches and neither was completely delivered in the field. Breech presentations may be of three types: complete, with flexion at both hips and knees; incomplete or footling, where one or both hips are not flexed, resulting in a foot as the presenting part; and frank, where both hips are flexed and both knees are extended so that the legs lie along the abdomen of the fetus.\n\nComplications during breech presentation are related to incomplete dilation of the cervix by a small presenting part, entrapment of the after-coming head, prolapsed cord (particularly with footling presentation), and injury due to excessive traction by the attendant. There is general agreement that once a breech presentation is recognized, every effort should be made to obtain obstetric expertise and rapid availability of c-section. EMS clinicians should therefore initiate transport as soon as possible. If delivery is already in progress, the presenting body part should be wrapped in a towel and supported but not elevated. Providers should be alert for a prolapsed cord as this is a known complication of breech presentation. Traction should be avoided. If only an after-coming head remains undelivered, crews may be instructed to place fingers on the maxilla to gently flex the neck to facilitate passage of the head.\n\nShoulder dystocia is defined as failure of the fetal shoulders to deliver following delivery of the fetal head and occurs in between 0.2\u20133% of deliveries. Some authors have proposed a more concrete definition based on a time interval of >60 seconds between delivery of the fetal head and shoulders and the necessity for maneuvers beyond simple gentle downward traction to facilitate delivery of the anterior shoulder, but there is not consensus. Physiologically, shoulder dystocia results from the impaction of the fetal shoulders against the maternal pelvic inlet. Most commonly, the anterior fetal shoulder is impacted against the pubic symphysis, but the posterior fetal shoulder may also impact against the sacral promontory. The most common cause is fetal macrosomia. Dystocia may also be precipitated by very rapid delivery of the fetal head without time for the shoulders to appropriately rotate and possibly by overzealous external rotation of the fetal head by an inexperienced attendant. There are no reliable prediction criteria for dystocia.\n\nShoulder dystocia is classically heralded by the \u201cturtle sign\u201d which involves the retrograde movement of the fetal head back into the introitus following its initial delivery. Shoulder dystocia should be suspected whenever delivery does not complete with gentle downward movement of the fetal head. It constitutes a true emergency and is associated with significant fetal morbidity and mortality resulting from mechanical injury to the brachial plexus and neck of the neonate and frank suffocation. Fortunately, if the dystocia is relieved within a few minutes, the incidence of permanent injury and perinatal death is very low, having been reported to be between 0\u20131.6% and 0\u20132.9% respectively.\n\nDisagreement exists over the optimal combination and sequence of maneuvers designed to relieve shoulder dystocia. Interventions in the prehospital environment will likely be limited by the scope of practice of personnel unless an EMS physician is on scene. The primary focus should be on positioning and gentle suprapubic pressure to attempt to reduce the anterior shoulder impaction and facilitate completion of delivery.\n\nThe most commonly applied maneuver is McRoberts, which consists of hyperflexion of the maternal hips which results in increased sacral\u2013pubic distance. This maneuver is easy to perform and is in fact used routinely by many obstetricians to prevent development of dystocia. McRoberts should be accompanied by application of suprapubic \u2013 not fundal \u2013 pressure. Application of the McRoberts maneuver alone has been reported to relieve approximately 40% of dystocias, and when suprapubic pressure was added, success climbed to nearly 60%. If the combination of McRoberts and suprapubic pressure fails to relieve the dystocia, a trial of rolling the patient to the \u201call fours\u201d position (Gaskin maneuver) should be undertaken. If the dystocia cannot be relieved with this sequence of maneuvers, focus should shift to immediate emergency transport for more invasive maneuvers.\n\nEmergency medical services physicians may elect to attempt fetal rotation maneuvers (Woods corkscrew and Rubin) to complete delivery, or direct their crews to perform these maneuvers via on-line consult; however, providing adequate and effective guidance via radio or cell phone in these situations will likely be difficult. If on scene, an EMS physician may also attempt replacement of the fetus into the uterus (Zavenelli maneuver) as a temporizing measure until cesarean section can be completed. While episiotomy may be useful in facilitating such maneuvers, it is unlikely itself to relieve the bone-on-bone impaction of a shoulder dystocia. Deliberate fracture of the fetal clavicle has also widely been described, but is not universally accepted as an appropriate practice.",
        "Vaginal hemorrhage": "Postpartum hemorrhage is the leading cause of maternal death worldwide and may be classified into primary and secondary hemorrhage. Primary occurs in the first 24 hours following delivery, and secondary occurs after 24 hours until weeks following delivery. Primary postpartum hemorrhage complicates 4\u20136% of pregnancies, although the incidence has recently been shown to be on the rise. Most (80%) primary hemorrhage is due to uterine atony. Other causes include inherited coagulopathies (i.e. von Willebrand), retained placenta, placenta accreta, uterine inversion, and pelvic/vaginal trauma. Secondary postpartum hemorrhage is most often due to retained products of conception with or without infection, and coagulopathies both inherited and acquired.\n\nPrehospital management of postpartum hemorrhage centers on treatment of uterine atony, as this represents the majority of cases encountered. Fundal massage using a circular motion over the uterine fundus should be the first maneuver attempted by clinicians of all levels. Specialty or critical care transport units may also have the capacity to administer pharmacological agents to assist with uterine contraction such as oxytocin, misoprostol (Cytotec), methylergonovine (Methergine), and prostoglandins (Hemabate and Dinoprostone). Crews should establish large-bore IV access if not already done, and initiate fluid resuscitation per protocol for hemorrhagic shock. Prehospital efforts to complete delivery of the placenta if it does not spontaneously deliver (i.e. traction on the umbilical cord) have the potential to exacerbate hemorrhage and may precipitate uterine inversion. They should be attempted under the direction of medical oversight, if at all. Bleeding from lacerations to the perineum and vagina should be controlled using standard hemorrhage control techniques, including direct pressure and vaginal packing if necessary. If an inverted uterus is identified, direct medical oversight may consider having crews attempt manual reduction to facilitate hemorrhage control in remote locations with prolonged transport times."
    },
    {
        "Introduction": "The EMS system was designed to respond to emergencies to prevent disability and untimely death. With the aging of the population, EMS resources are now frequently called for patients with serious, life-threatening illness and for patients at or near the end of life. Many patients may not want the potentially life-extending interventions that are directed by standard EMS protocols. A Canadian study found that nearly 10% of cardiac arrest calls were for patients with a terminal illness. In 63% of these cases, there was either a verbal (by family) or written request for no resuscitation. Similarly, a Washington state study found that families of dying, terminally ill patients often called EMS because \u201cthey didn\u2019t know what else to do.\u201d Fewer than 10% of those patients had state-recognized formal written requests to withhold resuscitation, but a protocol allowing verbal and informally written requests to withhold resuscitation resulted in a significant decrease in unwanted interventions. In addition, the American Heart Association reports that roughly 360,000 out-of-hospital cardiac arrests (OHCA) occur annually, with 60% treated by EMS professionals. The chance of survival from OHCA is generally poor. Survival rates vary based on the presenting rhythm, with survival from ventricular fibrillation ranging from 11% to 25%, and overall survival to hospital discharge for all presenting rhythms being much smaller, and in some systems approaching zero. There is also evidence that patients who do not have return of spontaneous circulation in the field have a very low likelihood (0.4%) of survival to hospital discharge. Thus, EMS professionals need to determine whether the OHCA patient desires resuscitation, and to compassionately interact with family in the aftermath of a death in the field. The EMS physician must design protocols to determine which patients should have attempts at cardiopulmonary resuscitation (CPR), or other life-sustaining interventions, and those who should not. Considering the goals and ethical principles of medicine while remaining consistent with applicable local laws and regulations, these protocols should take into consideration patient preferences as well as the likelihood that the interventions will benefit the patient. It is not reasonable to assume that every patient found in cardiac arrest should undergo attempts at resuscitation, nor that everyone for whom resuscitation was attempted should be transported to the hospital. The basic ethical principles on which modern medicine is founded include respect for patient autonomy, beneficence, non-maleficence, and justice. Decisions about resuscitation are generally based either on the principle of respect for autonomy or on beneficence. Respect for patient autonomy requires honoring patient preferences for or against treatments, including advanced airway support, CPR, and transport to the hospital when those preferences are known. Based on both beneficence and non-maleficence, an intervention should not be performed if there is no chance that it will benefit the patient. The American College of Emergency Physicians\u2019 position statement stipulates, \u201cAll emergency medical services (EMS) systems should have a policy addressing their response to \u2018Do Not Attempt Resuscitation\u2019 (DNAR) orders and other advance directives \u2026\u201d and \u201cIf the patient\u2019s preferences regarding resuscitation are clear, they should be respected. Patient preferences to refuse resuscitative efforts can be communicated directly by the patient, or by an advance directive, a valid DNAR order, or by the patient\u2019s legal representative. Unofficial documentation may be considered when determining patient preferences.\u201d The number of states authorizing out-of-hospital DNAR orders increased from 11 in 1992 to 42 in 1999. As of 2002, most United States EMS systems did not have palliative care protocols. In the last few years states have been implementing Physician Orders for Life-Sustaining Treatment (POLST) programs to document and honor patient preferences.",
        "Clackamas and Washington County, Oregon Death & Dying Protocol": "A. DEATH IN THE FIELD Purpose: To define under what conditions treatment can be withheld or stopped. Resuscitation efforts may be withheld if: 1. The patient has a \\order. 2. The patient is pulseless and apneic in a mass casualty incident or multiple patient scene where the resources of the system are required for the stabilization of living patients. 3. The patient is decapitated. 4. The patient has rigor mortis in a warm environment. 5. The patient is in the stages of decomposition. 6. The patient has skin discoloration in dependent body parts (dependent lividity). Traumatic Cardiac Arrest: 1. A victim of trauma (blunt or penetrating) who has no vital signs in the field may be declared dead on scene. If opening the airway does nor restore vital signs/signs of life, the patient should NOT be transported unless there are extenuating circumstances. 2. A cardiac monitor may be beneficial in determining death in the field when you suspect a medical cause or hypovolemia: A narrow complex rhythm (QRS < .12) may suggest profound hypovolemia, and may respond to fluid resuscitation. 3. At a trauma scene, the paramedic should consider the circumstances surrounding the incident, including the possibility that a medical event (cardiac arrhythmia, seizure, and hypoglycemia) preceded the accident. When a medical event is suspected, treat as a medical cardiac event. VF should raise your index of suspicion for a medical event. 4. In instances prior to transport where the patient deteriorates to the point that no vital signs (i.e. pulse/respiration) are present, a cardiac monitor should be applied to determine if the patient has a viable cardiac rhythm. A viable rhythm especially in patients with penetrating trauma may reflect hypovolemia or obstructive shock (tamponade, tension pneumothorax) and aggressive care should be continued. Medical Cardiac Arrest: 1. If the patient's EKG shows asystole or agonal rhythm upon initial monitoring, and after at least two lead changes, the patient, in the paramedic's best judgment, would not benefit from resuscitation: a. The PIC should determine DIF and notify the Medical Examiner or Law Enforcement; OR b. Begin BLS procedures, and contact OLMC with available patient history, current condition, and with a request to discontinue resuscitation. 2. If after the airway is established and the asystole protocol has been exhausted the patient persists in asystole, (confirm in 3 leads) consider termination of efforts. The PIC may declare the patient to be dead in the field. 3. The patient who has PEA and has not responded to the initial cycle of ACLS may be determined to be dead at the scene after appropriate consultation with OLMC. 4. All patients in VF should be treated and transported. Notes & Precautions: 1. ORS allows a layperson, EMT or Paramedic to determine \u201cDeath in the Field\u201d 2. The EMS provider is encouraged to consult OLMC if any doubt exists about the resuscitation potential of the patient. 3. A person who was pulseless or apneic and has received CPR and has been resuscitated, is not precluded from later being a candidate for solid organ donation. 4. ETCO\u2082 may be a useful adjunct in the decision to terminate resuscitation with PEA. An ETCO\u2082 of 10 or less in patients in PEA after 20 minutes of ACLS resuscitation does not correlate with survival. 5. Survival from trauma arrest is low, but not completely zero. B. POLST ORDERS AND DECISION MAKING 1. In the pulseless and apneic patient who does not meet DEATH IN THE FIELD criteria, but is suspected to be a candidate for withholding resuscitation, begin CPR and contact OLMC. 2. A patient with decision-making capacity or the legally authorized representative has the right to direct his or her own medical care and can change or rescind previous directives. 3. EMS providers may honor a Do Not Resuscitate (DNR) order signed by a physician, nurse practitioner or physician assistant. DNR orders apply only to the patient in cardiopulmonary arrest and do not indicate the types of treatment that a person not in arrest should receive. POLST was developed to convey orders in other circumstances. 4. Physician Orders for Life-Sustaining Treatment (POLST): The POLST was developed to document and communicate patient treatment preferences across treatment settings. While these forms are most often used to limit care, they may also indicate that the patient wants everything medically appropriate done. Read the form carefully! When signed by a physician (MD or DO), nurse practitioner, or physician assistant, POLST is a medical order and EMS providers are directed to honor it in their Scope of Practice unless they have reason to doubt the validity of the orders or the patient with decision making capacity requests change. If there are questions regarding the validity or enforceability of the health care instruction, begin BLS treatment and contact OLMC [OAR 847-035-030 (7)] If the POLST is not immediately available, a POLST form as documented in the Electronic POLST registry hosted at MRH (503-494-7333) may also be honored. \u2022 Section A: Applies only when patient is in cardiopulmonary arrest \u2022 Section B: Applies in all other circumstances \u2022 For a POLST form to be valid it must include: i. Patient\u2019s name ii. Date signed (forms do not expire) iii. Health care professional\u2019s signature (patient signature is optional) 5. The legally authorized representative may make decisions for the patient who is unable to make medical decisions. However, when in doubt or for unresolved conflict on the scene contact OLMC. The order is: a. A legal guardian b. A power of attorney for health care as designated by the patient on the Oregon advance directive c. Spouse or legal domestic partner d. Adult children e. Parent 6. Death with Dignity Act: If a person who is terminally ill and appears to have ingested medication under the provisions of the Oregon Death with Dignity Act, the EMS provider should: a. Provide comfort care as indicated. b. Determine who called 9-1-1 and why (i.e. to control symptoms or because the person no longer wishes to end their life with medications). c. Establish the presence of DNAR orders and/or documentation that this was an action under the provisions of the Death with Dignity Act. d. Contact OLMC. e. Withhold resuscitation if: DNAR orders are present, and there is evidence that this is within the provisions of the Death with Dignity Act and OLMC agrees. C. PATIENTS ENROLLED IN HOSPICE AND DYING PATIENTS 1. Look for POLST forms (contact Registry if needed) and attempt to honor patient preferences. Always provide comfort measures. 2. If patient is enrolled in hospice and the patient has not already done so, contact hospice if possible. 3. EMS providers cannot take medical orders from a hospice nurse but their advice is often invaluable and may be followed with direction from OLMC. 4. Treat dying persons with warmth and understanding. Do not avoid them. Allow them to discuss their situation, but do not push them to talk. 5. Many dying people are not upset by discussions of death as long as you do not take away all of their hope. 6. Touching a dying person is important. Use words like \u201cdeath\u201d. Do not use meaningless synonyms. 7. Ask the person how you might help. 8. Give factual information. 9. Be aware of your own fears regarding death and admit when a dying person reminds you of a loved one. If a particular person is too disturbing, have your partner or other members of the responding team take over. D. CARE OF GRIEVING PERSONS Resuscitation phase: 1. As time allows give accurate and truthful updates about the patient's prognosis. If available, assign one person to interact with and support family members. 2. Consider gently remove children from the resuscitation area. 3. Depending upon the emotional state of family members, consider allowing them to watch and/or participate in a limited and appropriate way. 4. If family or friends were doing CPR prior to your arrival, commend their efforts. 5. If family or friends are disruptive consider removing them or try assigning simple tasks, such as helping bring in the stretcher, holding doors open, telling other family about the event and calling the doctor or minister. 6. Be respectful. Make requests. Don't give orders. Once death is determined: 1. Treat the recently dead with respect. 2. Tell family and friends of the death honestly. Use the words \u201cdeath\u201d or \u201cdead\u201d. Avoid using euphemisms such as \u201cpassed away\u201d or \u201cgone\u201d. 3. Avoid using past tense terms when speaking to survivors of the recently dead. 4. Allow family and friends to express their emotions. Listen to them if they want to talk but don\u2019t push them. 5. Give factual information. 6. Genuine warmth and compassion will be more helpful than almost anything else for survivors. Don\u2019t feel it necessary to say the \u201cright\u201d things. Listening often provides grieving people with the most comfort. Focusing on survivors: 1. See to it that survivors have a support system present before you leave. Consider calling TIP through EMS Dispatch, if available in your jurisdiction. Call friends, family, clergy, or neighbors to be with them. Respect the survivor\u2019s wishes to be alone. 2. Explain the next steps to them after you have pronounced death. This will include the police coming to make reports, possibly the medical examiner, and the possible need for an autopsy in certain instance. 3. Contact the Medical Examiner\u2019s office before moving or altering the body (as soon as possible). 4. Allow family and friends to say their good-byes if possible. 5. A chaplain may be helpful in assisting with survivors. It is advisable to call early, as the chaplains do not have code-3 capabilities. 6. Help survivors make decisions such as which people should be called. If they ask you to make calls, try to comply, mention the need to find a funeral home, if one has not already been chosen. Clergy may also be helpful with this decision. E. DEATH OF A CHILD: 1. Do not accuse the parents of abuse or neglect, but take careful note of the patient\u2019s surroundings and the general physical condition of the child. 2. Do not be overly silent, which may imply guilt to the parents. 3. Ask the parents only necessary questions and do not judge or evaluate them. Do not tell them what they \u201cshould have\u201d been doing before your arrival. 4. Remind parents to arrange for child care of other children. 5. Listen carefully to their statements and answer only with accurate information. 6. If there is a police investigation, tell the parents that this is routine. 7. Successful management of child deaths requires supportive, compassionate and tactful measures.",
        "Advance directives": "An advance directive is a written document, completed by the patient when he or she has decision-making capacity, expressing future wishes and/or appointing a surrogate decision maker. Advance directives have not been as effective as people had hoped. The two main types of advance directives are living wills and durable powers of attorney for health care. Since 1991, the Patient Self-Determination Act has required all hospitals that accept Medicare and Medicaid funds to provide information about and develop policies for implementation of advance directives. Although there has been an increase in advance care planning since then, in many cases advance directives are still lacking when patients are transferred to emergency departments (EDs). One study found that many ED patients have never thought about advance directives or prefer that families make the decisions at the time of an event. An expert panel has recommended that, \u201cin the absence of signs of irreversible death, patient preferences regarding resuscitation should be the most important consideration of EMS personnel.\u201d EMS personnel need to make rapid decisions about attempting resuscitation for patients who are in extremis. Often the patients are unable to verbalize preferences about treatment and EMS professionals must make these time-critical decisions based on written instructions, when available. Unfortunately, written instructions are not always completed, or are unclear, which may be why systems such as King County now allow verbal statements. One type of advance directive, the living will, expresses the wishes of patients regarding life-sustaining procedures in the event of conditions such as permanent coma or terminal illness. Living wills are theoretical documents that may state, for example, that the person would not want resuscitation if he or she is terminally ill, death is imminent, and resuscitation would only prolong the dying process. Because of these restrictive phrases, living wills are often difficult for EMS professionals to apply to decisions about specific life support measures and in many cases health care providers do not follow them. In at least one state, these documents explicitly do not apply except in a hospital or clinic setting, and one author has suggested that they may be misinterpreted as applying when they do not. Living wills are not precise enough to predict all scenarios and consequently cannot outline appropriate guidance for all potential care situations. Another form of patient-completed advance directive is the durable power of attorney for health care, which gives another person the authority to make decisions if the patient is unable to make decisions either temporarily or permanently. The person designated in the power of attorney becomes a legally recognized proxy decision maker. When a durable power of attorney exists, EMS protocols may allow the designated person to make decisions regarding the patient\u2019s medical care. Immunity is generally granted to providers who carry out the proxy\u2019s decision in good faith, but it is always wise to know local laws. Some states allow surrogates without a specific health care power of attorney to make decisions about resuscitation and end-of-life care for incapacitated patients, and others do not. Appointing surrogates who are aware of the patient\u2019s preferences can be effective, as long as the surrogate and the documentation confirming their status can be found at the time of an emergency.",
        "Do Not Resuscitate orders": "Unlike living wills and health care powers of attorney, DNAR orders are written by health care professionals to indicate that resuscitation should not be attempted in the patient who is pulseless and apneic. A national survey of EMTs found that 89% of respondents were willing to honor a state-approved DNAR order and that 77% of those surveyed had local protocols for termination of resuscitation in the out-of-hospital setting. Although DNAR orders only apply when the patient is pulseless and apneic, many primary care providers, who complete the orders for their patients, believe that they apply in other circumstances and that intubation and cardioversion are not appropriate in a patient with DNAR orders. There is variability in honoring DNAR orders. One EMS study found that even with DNAR orders present, resuscitation was attempted 21% of the time. Some states have had success with their DNAR programs but problems remain. For example, some states use a DNAR bracelet program requiring EMS professionals to honor these DNAR orders and providing immunity from liability for honoring the order. However, one study suggests that bracelet DNAR programs are used infrequently. In addition, advance directives and DNAR orders may not be available when EMS arrive and often do not accompany patients to the ED. On the other hand, there are EMS systems that allow responders to accept verbal requests from family to withhold resuscitation. Out-of-hospital DNAR programs typically provide only orders about resuscitation with no guidance for patients who are breathing and have a pulse. It is often hard for out-of-hospital providers to know what interventions are appropriate for the seriously ill patient who is not in cardiopulmonary arrest but cannot speak for himself or herself and does not have a surrogate present. A recent study found that half of patients with DNAR orders wanted comfort measures only, but half wanted higher levels of care.",
        "The Physician Orders for Life-Sustaining Treatment program": "In 1991, a group of Oregon health care professionals and organizations, including EMS and long-term care providers, began development of the Physician Orders for Life-Sustaining Treatment (POLST) program (states use various names including POLST, POST, MOLST, LaPOLST). The goal of this program is to honor patient end-of-life care preferences by turning those preferences into medical orders that can be implemented as patients transition between multiple care settings, such as from home or long-term care to the ED. POLST is intended for patients with serious illness or frailty. The POLST form is a brightly colored set of medical orders designed to be placed in a prominent location. It provides clear guidance for resuscitation as well as a range of medical interventions, in contrast to advance directives and DNAR orders. The form is divided into several sections, the first two of which are especially helpful in the emergency setting. The national POLST Taskforce oversees POLST initiatives and endorses programs. There are 43 states that have or are developing POLST programs and as of August 2013, 15 programs were endorsed by the National POLST Taskforce. The National Quality Forum noted that, \u201cCompared with other advance directive programs, POLST more accurately conveys end-of-life preferences and yields higher adherence by medical professionals.\u201d Communities have found that POLST is an effective means of conveying patient preferences. States have begun to develop electronic registries to facilitate access to POLST forms. The first statewide POLST-only registry was initiated in Oregon in December 2009. Legislatively enacted, the registry accepts POLST forms signed throughout the state and provides access to verbal orders for EMS, emergency departments, and acute care units through a non-public 24/7 call center. The legislation enacting the registry also mandated submission of completed forms by signers unless patients opt out. By July 2013, the Oregon registry had received over 150,000 forms for nearly 90,000 Oregonians, and over 2,500 emergency calls. The Oregon registry\u2019s operations and patient matching algorithm have been found to limit release of \u201cfalse-positive\u201d matches and also helped understand the EMS implications of the registry. Several other states have developed registries or electronic mechanisms for accessing POLST forms or other documents like advance directives. In a 2011 report on behalf of the National POLST Paradigm Task Force, POLST registry efforts are outlined in seven states: California, Idaho, New York, Oregon, Utah, Washington, and West Virginia. Studies indicate that POLST is effective in communicating patient preferences. Studies in long-term care settings found that having a POLST form prevents unwanted life-sustaining treatments and hospitalization, and orders regarding resuscitation are typically followed, though medical intervention orders were followed less consistently. One study surveyed a random sample of EMS professionals in Oregon to evaluate their experiences and attitudes regarding the use of the POLST form. Nearly three-quarters of respondents in this study had treated at least one patient with a POLST form, and in nearly half of the cases in which a POLST form was present, the EMS professionals used it to change the treatment plan, often avoiding interventions that the patient did not want. Thus, the POLST paradigm is one model program for expressing patient preferences and helping EMS professionals to determine the best level of intervention for the patient.",
        "Hospice and EMS": "Hospice care focuses on the treatment of pain and other uncomfortable symptoms, as well as the patient\u2019s emotional and spiritual needs. Hospice is a benefit of Medicare when a physician determines that the person likely has less than 6 months to live and the patient is no longer seeking curative treatment. In the United States, most hospice care is provided at home. A patient enrolled in hospice generally has a nurse who is on call 24/7, and is encouraged to call that nurse for any problem that arises. Nonetheless, patients or their families often call EMS in times of crisis. When they do, the hospice nurse can be a great resource. Contacting the hospice nurse can help to alleviate the patient\u2019s and family\u2019s distress and provide solutions other than transport to an ED.",
        "Care of the grieving survivors": "The responsibility of EMS professionals does not end with the death of a patient. Once a person is determined to be dead at the scene, the survivors who are present become our patients. The survivors may have both physical and psychological needs. When a person dies, the remaining spouse has an increased risk of death. EMS professionals have a responsibility to inform family members of a death in a compassionate manner and to provide care and comfort to the survivors. Most survivors find EMS professionals to be supportive and are accepting of a death in the field without the need for transport and families accept the non-transport of loved ones found in asystole. A study of survivors found that the most frequently reported complaints concerned a lack of information and questions left unanswered. Death notification can be stressful for EMS professionals. A recent Canadian study found that paramedics find death notification stressful and think that they need more education in this area. Deaths from violent crime, drunk driving crashes, or suicides, or the death of a child, increase the provider\u2019s distress regarding notification. A 2009 survey of EMS professionals found that only 48% felt prepared to communicate death to family. A 16-hour workshop based on the Emergency Death Education and Crisis Training (EDECT) program, with a 2-hour session on death notification, divided EMS professionals into three groups: long intervention, short intervention, and control. The authors found that after the training, 92% of those in the long intervention group felt that their training was adequate, compared with 43% in the short intervention group and 21% in the control group. Although this study did not test whether or not death notification skills can be improved, it did show that education can improve EMS professionals\u2019 comfort with death notification. A final study by these authors also suggested that behaviors can be changed. One recent study of a 90-minute education model found that educating paramedics to use a structured communication model improved confidence and competence in delivering death notification. Other studies have analyzed emergency physicians, the group most likely to become EMS physicians and medical directors. Most emergency physicians report that they have insufficient education on how to perform death notification. A study of emergency medicine residents showed that role-playing increases their comfort with death notification. Another study found that most respondents recommend that education on death notification be part of Advanced Cardiac Life Support courses.",
        "Conclusion": "Just as EMS medical directors have an obligation to ensure high-quality medical care by the EMS professionals that they supervise, they also have an obligation to ensure high-quality, compassionate, and medically appropriate end-of-life care. This includes protocols and education to determine when and when not to provide resuscitation and other life-sustaining treatments, often based on patient preferences, which are documented by various means. The POLST paradigm is a proven and growing method for communicating end-of-life wishes. Additionally, EMS professionals must provide support to the grieving survivors left behind."
    },
    {
        "Introduction": "Potential allergic reactions and their sequelae are common complaints encountered in the EMS system. Allergic reactions can be triggered by many agents, such as foods, medications, topical products, and limitless environmental exposures including arthropod stings. Severity can vary from local reactions and discomfort to life-threatening systemic anaphylaxis. EMS physicians and other providers must be able to rapidly recognize the manifestations of allergic reactions and begin to provide pre-hospital treatment that can be life-saving.",
        "Physiology of allergic reactions": "Allergic reactions are hypersensitivity reactions resulting from the exposure to an allergen. In milder forms they may result in localized edema and pruritus. Systemic reactions can also be mild, resulting in a more widespread rash that can be pruritic. In their most severe form, allergic reactions progress to anaphylaxis with multisystem and potentially life-threatening manifestations that include respiratory failure, circulatory collapse, and shock. There are four types of hypersensitivity reactions. Type I accounts for most cases of anaphylaxis. Type II reactions are typically seen in the setting of blood transfusions, drug reactions, and cases of idiopathic thrombocytopenic purpura. Type III reactions are responsible for serum sickness, reactions to tetanus toxoid, and poststreptococcal glomerulonephritis. Type IV reactions are T-cell-mediated and delayed hypersensitivity responses which do not cause anaphylaxis. Urticaria, or hives, is an often-encountered symptom and physical sign of an acute allergic reaction. Although the potential etiologies of urticaria are numerous, the temporal link to a likely allergen can often be made upon consideration of recent exposures. For example, the patient might have recently started a new medication, been stung by an insect, or eaten a certain food. Urticaria, itself, is not particularly concerning. However, its potential as an indicator of a reaction in the evolution of systemic effects should not go unrecognized. Allergic reactions that present as urticaria can progress to angioedema that results in facial or tongue swelling. Subsequently, airway obstruction might develop precipitously with obvious consequences. Angioedema also often occurs without other apparent manifestations of an allergic reaction. One of the more common causes is angiotensin-converting enzyme inhibitors. The patient may have been taking the medication for some time before such a reaction occurs, which can be confusing to some who assume that a reaction would have occurred earlier if the patient was going to exhibit one. Hereditary angioedema, on the other hand, does not represent a response to a specific allergen, but it deserves mention because of its similar presentation to allergic reactions and other forms of angioedema. Hereditary angioedema is an autosomal dominant genetic disorder caused by a defect in the complement pathway that results in either a low C1 esterase level or a high level of dysfunctional C1 esterase. Symptoms can include pruritus, urticaria, wheezing, facial and tongue swelling, dizziness, hypotension, syncope, and gastrointestinal distress.",
        "Causative agents": "Almost anything can be a potential allergen. Common agents include medications, foods and food additives, latex, arthropod bites and stings, mold, radiographic contrast media, and certain marine envenomations. Some insect bites or stings, such as those of millipedes, caterpillars, and centipedes, most often cause only pain and local skin reactions such as blistering. Certain species of caterpillars have venom-filled hair and spines that can cause systemic reactions, including anaphylaxis, within 2 hours of the sting. Bites from kissing bugs are painless and usually occur during sleep. Most often, this results in localized swelling at the bite site, but can progress to systemic reactions. There are also occasional rare reports of anaphylaxis from the bites of horse flies, deer flies, rats, and mice. Hymenoptera account for the majority of severe allergic responses and anaphylaxis related to insect bites. There are three families of Hymenoptera: bees (honeybees and bumblebees), vespids (yellow jackets, hornets, and wasps), and stinging ants (fire ants). Since fire ants are in the Hymenoptera order, the venom in fire ant bites is similar to that of bees and hornets, so that a patient allergic to bee stings will also display an allergic reaction to a fire ant bite. Africanized honeybees (\u201ckiller bees\u201d) are an aggressive hybrid of the honeybee and have the same venom, but they sting repeatedly, thus increasing the risk of a severe reaction. Approximately 1% of children and 3% of adults have reportedly had severe systemic allergic reactions to Hymenoptera venom. Anaphylaxis can occur with a first-time exposure. Insect stings are the only allergen for which specific immunotherapy currently exists. This is most likely due to the prevalence and severity of such responses in humans.",
        "Assessment and general approach": "The first step in EMS response to calls regarding allergic reactions and/or bites and stings is to ensure that the scene is safe. No rescue or treatment can occur if providers fall victim to the same process that is affecting the patient. Next, EMS providers should determine how the patient was stung or what activity was occurring before the allergic reaction. This will help the provider determine if there is any special treatment needed and the potential for development of a severe reaction or anaphylaxis. EMS personnel should take all proper equipment including life support, emergency drugs, and monitoring equipment with them when initially approaching the patient. Failure to do so may delay necessary treatment and result in further physiological decompensation of the patient. Patient assessment should be done rapidly, first ensuring a patent airway. The patient should be queried about subjective shortness of breath or dysphagia, and the provider should note if the patient\u2019s voice is hoarse. The EMS provider should listen to breath sounds, assessing for stridor or wheezing. Facial, tongue uvula, or orbital swelling should be noted. A full set of vital signs should be obtained. The patient should be evacuated from the scene as soon as feasible to prevent further contact with the allergen. Continuous patient reassessment should center on ensuring a patent airway and monitoring vital signs. Any patient with a significant allergic reaction or potential for deterioration during transport should have at least one large-bore IV line started with normal saline. The patient should be transported expeditiously to the closest most appropriate facility, depending on availability of local resources and other factors such as distance, weather, and terrain.",
        "Prehospital treatment": "If the patient is wheezing or in respiratory distress, 100% oxygen should be given with a non-rebreather mask. A large-bore IV with normal saline should be started and a fluid bolus given of at least 500 mL for an adult and 10 mL/kg for a child. If the patient was stung, any wounds should be inspected for retained stingers. If discovered, removal should be accomplished by scraping across the sting with a rigid thin object, such as an identification badge or credit card, to dislodge the stinger. Forceps or other squeezing devices should not be used because they may inadvertently disrupt the venom sac and release more venom into the patient. Local wound care with cool compresses and gauze covering should be applied. If there is the possibility of injected venom, the patient should be kept still and the affected extremity should be kept dependent, below the level of the heart, to slow the spread of venom. If there is only a local isolated reaction, patient comfort and pain relief are all that is necessary. However, if the patient has a systemic allergic response, there is an immediate need for additional medications. Several medications are useful in this setting, and their use will depend on the severity of the patient\u2019s symptoms, vital signs, and past medical history. Before administering any medication, the provider should ensure that the patient has no medication allergies. The provider should also determine if the patient has taken any of his or her own medication (e.g. epinephrine autoinjector, oral diphenhydramine, or other oral antihistamine) before EMS arrival that may be masking the severity of the reaction or affect any of the medications EMS will administer. If the patient has his or her own autoinjector, EMS personnel of all training levels may assist with administration. Research has demonstrated that epinephrine autoinjectors can be used safely by EMTs in the treatment of anaphylaxis in the field. Antihistamines are by far the most commonly used class of medication. Antihistamines block the action of histamine at H1 receptors, but do not decrease histamine release. Diphenhydramine is the most common medication in this class and can be given orally, intravenously, intraosseously, or intramuscularly in a typical dose of 25\u201350 mg for adults, depending on their weight and the severity of the reaction. Research suggests that H2 blockers have a synergistic action when used in conjunction with diphenhydramine, blocking both H1 and H2 cellular histamine receptors. Both famotidine and ranitidine are useful H2 blockers, but cimetidine is not recommended due to its multiple drug interactions. Adult doses are IV famotidine 20 mg or IV ranitidine 50 mg. Corticosteroids, either orally or intravenously, may also be useful to prevent return of symptoms once other medications are metabolized. Peak onset of action of corticosteroids is 2\u20134 hours. Nebulized beta-agonists, such as albuterol, can be used for patients with persistent bronchospasm. Nebulized ipratropium bromide may also be used in conjunction with albuterol but should not be used alone. Although both the multidose inhaler and the nasal spray formulations of ipratropium contain an ingredient that may cause an allergic reaction in patients with known peanut allergies (soy lecithin, used to keep the medication in suspension), the nebulized formulation typically used by EMS and emergency departments lacks this ingredient. All of the aforementioned drugs may also be used in children, but, as with any pediatric medication, dosages must be calculated based on the child\u2019s weight. Local allergic reactions can progress from one body system to anaphylaxis involving several systems, including skin, respiratory, and circulatory. If untreated, this can progress to anaphylactic shock with circulatory collapse and hypotension. Epinephrine is the first-line medication for a patient with anaphylaxis. Delaying its administration has been associated with poor outcomes. However, epinephrine should be used with caution in patients older than 50 years, those with known coronary artery disease, or in cases with life-threatening tachydysrhythmias. Infrequently, myocardial ischemia and infarction can be precipitated and have been reported. Two different concentrations of epinephrine may be used, and the provider must be attentive to use the proper dosage and formulation when administering it. In adults, 0.3 mL of epinephrine 1:1000 solution can be given subcutaneously or intramuscularly except when the patient is on the verge of cardiovascular collapse. The intramuscular route at the lateral thigh is preferred. This route produces higher peak plasma concentrations in less time than subcutaneous injection or intramuscular injection in the deltoid. Faster absorption from intramuscular injection in the thigh is thought to be due to the increased vascularity of the vastus lateralis muscle. If the patient is hemodynamically unstable, 1 mL of epinephrine 1:10,000 mixed with 10 mL of normal saline can be given slowly by IV or intraosseous push over 5\u201310 minutes. Caution is advised. On the one hand, epinephrine given intravenously to a patient who is not in cardiac arrest can be risky, resulting in hypertension or myocardial ischemia. On the other hand, it can be life-saving and should not be delayed in the case of a hemodynamically unstable or 'crashing' patient. Epinephrine may also be nebulized by placing 0.5 mL of 1:1000 solution in 2.5 mL of normal saline. If the patient is hypotensive, rapid fluid resuscitation with 1\u20132 liters of normal saline (20\u201340 mL/kg in children) is indicated in addition to the aforementioned medications. Patients often will become intermittently hypotensive and require multiple fluid boluses and additional medications, so frequent monitoring of vital signs is imperative. At least two large-bore IV lines are desirable. Localized angioedema is treated as an allergic reaction with antihistamines and steroids, along with epinephrine in severe cases. However, little actual benefit or significant improvement has been shown with these medications. As with medication-induced angioedema, hereditary angioedema is generally not responsive to antihistamines, steroids, or epinephrine, although they are routinely administered. The mainstay of treatment is supportive, with early consideration for intubation if there is airway compromise. Emergency medical services personnel should anticipate that any airway intervention for a patient with an allergic reaction or angioedema is going to be especially difficult. The edema can extend to the glottic and subglottic regions and not be externally visible. The only clue the provider might have is that the patient's voice is hoarse or different from normal. Oral-pharyngeal, glottis, and subglottic edema can obscure anatomical landmarks and decrease airway caliber that alter the effective sizes of airway tools. If bronchospasm is present, ventilation before and between intubation attempts may be difficult, adding pressure for expedient success. Thus, it is imperative that the provider is prepared for a difficult airway with airway skills, adjuncts, and emergency rescue devices and techniques, such as cricothyrotomy, especially if rapid sequence intubation (RSI) is also being performed.",
        "Special considerations": "Several points may be helpful to remember when responding to allergic reactions in the field. In general, stinging insects, especially Hymenoptera, can cause systemic allergic reactions and anaphylaxis, but these reactions are rare with biting insects. There is a greater chance of a systemic reaction with multiple stings. One should remember that the clinical presentation may be quite varied and the history may be vague. Patients may have significant symptoms yet not be able to recall exposure to a specific allergen. In cases such as these, interventions necessary for stabilization should take priority over identification of the culprit allergen. In cases of true anaphylaxis, the axiom 'stabilize first, diagnose later' should be followed. After emergency interventions are completed, care should be taken to frequently reassess the patient and document pertinent findings, which may be the first clue that an allergic reaction is present if the patient does not relate an exposure or inciting event. Symptoms can be exacerbated by fear, exercise, alcohol intake, heat exposure, or underlying cardiovascular disease. The provider should be careful not to become complacent or attribute clinical signs and symptoms solely to these conditions because allergic reactions can progress insidiously. Anaphylaxis to stings can occur abruptly years after the first exposure, even without intervening stings. Furthermore, approximately 20% of patients exhibit biphasic anaphylaxis responses where the initial symptoms resolve and there is a symptom-free period before the onset of the late phase reaction 4\u20136 hours after the initial symptoms began. The symptoms of the late reaction can be markedly different from those of the initial reaction, and can be life-threatening even if those of the initial reaction were not. It is nearly impossible to predict which patients will exhibit this biphasic response. This could result in repeat EMS calls for allergic reactions featuring substantially different symptoms, particularly if a patient refuses transport or is seen and discharged from an ED before the late phase reaction occurs. If the patient experiencing a severe allergic reaction or anaphylaxis routinely takes beta-blocker medications, the action of epinephrine may be blunted. Glucagon may be given in 1 mg increments by any parenteral route to overcome the effects of beta-blockade. Cutaneous symptoms are the most common clinical response in both adults and children. Hypotension is uncommon in children, but it has been reported in up to 60% of adults. Patients will sometimes complain of a prodrome of chest pain or shortness of breath before development of a more generalized severe allergic reaction. Emergency medical services providers should have a high index of suspicion on calls with these complaints to ensure that there was no contact with an allergen that may have caused these symptoms. For instance, allergy-producing contrast media are frequently given in free-standing imaging centers. Consider the possibility of allergic reactions and anaphylaxis when responding to calls of shortness of breath or chest pain at these sorts of facilities. Anaphylaxis should be one of the etiologies considered when responding to cardiac arrests in outdoor areas, such as golf courses, because the patient may have been stung before the cardiac arrest. Although bites from a Gila monster are infrequent, if it is still attached to the patient, the provider should remove it by prying its jaws apart with a stick or metal object, holding a flame under the lizard's chin, or submerging it in cold water. Obviously, care should be taken to avoid additional bites to the patient or the providers. To determine the most appropriate destination facility for allergic reaction patients, it helps to consider the etiology of the reaction and the availability of certain subspecialties, such as otolaryngology, anesthesia, critical care, toxicology, and so on, which may be necessary to definitively treat the reaction. Transportation time should also be considered. If the patient is unstable or is likely to become unstable during an extended transport time to an appropriate facility, then air medical evacuation should be considered. Transport to the closest available facility for stabilization followed by transfer of the patient to a higher level of care is also an option, and will depend on the availability of air medical services, the distance to the closest facility, weather, traffic, terrain and other conditions which must be factored in when making destination decisions."
    },
    {
        "Introduction": "The older adult (age \u226565 years) group is the fastest growing segment of the US population. In 2000, 40 million older adults lived in the United States and comprised 13% of the population. The Census Bureau estimates that this number will double by 2040 to 80 million, and older adults will then comprise 21% of the US population. This large number of older adults and the rapid increase in their numbers will significantly affect prehospital physicians and providers. Assuming that use rates remain constant, EMS must prepare for a significant increase in the number of older adult patients requesting assistance, with approximately half of the EMS call volume being comprised of older patients by 2030. EMS leaders must ensure that the EMS system is prepared for this massive demographic change.",
        "Changes of normal aging": "The physiological changes of normal aging are important considerations in the approach to the geriatric patient. Aging itself is not a disease. Age should be viewed as a risk factor, but not sufficient in and of itself to cause disease. Aging produces a diminished physiological capacity; therefore, older adults may not have the same functional reserve in organ systems to recover from injury or illness. Even healthy and active older adults may need prolonged periods to recover from acute illness or trauma due to this reduced physiological capacity. There are normal and predictable physiological changes that occur with normal aging. The EMS medical director must consider these changes when developing protocols, and the EMS physician must be aware of these changes when caring for older patients in the field. For instance, as skin becomes thinner and less elastic with a reduction in subcutaneous fat, trauma patients can suffer skin tears, and pressure ulcers can form more easily when patients are on backboards. The EMS medical director must ensure that EMS providers understand these concepts. Otherwise, the providers may encounter difficulty while caring for their patients. For instance, there is a predictable reduction in pulmonary and cardiac function with older age. When an older adult is physiologically stressed, he or she will have reduced ability to compensate for changes in blood pressure or respiratory illness, leading to significant clinical consequences.",
        "Assessment of the geriatric patient": "For EMS professionals caring for the geriatric patient, the initial steps are unchanged. A primary survey should be completed, evaluating the patient's ABCs. Vital signs should be obtained and considered while accounting for existing medical problems and medications. Any immediate interventions necessary should be completed. A full history should be taken, including the symptoms the patient has experienced, allergies, medications (including over-the-counter and herbal medications, and medications that the patient is not taking despite prescription), and past medical history. A full examination should be completed. Although not traditionally considered, an environmental assessment should also be completed because the environment can provide clues as to the extent of the disease or the precipitating factors for disease. Finally, a social history should be obtained because psychosocial issues could either be the primary reason for the request for assistance or could precipitate or exacerbate medical issues. Communication with older patients is key in performing an effective assessment. A common error is to assume that an older patient is deaf, has dementia, or is otherwise unable to communicate or participate in medical evaluation or care. It is common for medical personnel to rely on family members of older patients to contribute collateral information regarding current illness or medical history. However, this often comes at the cost of speaking exclusively to others and entirely excluding the older patient. The general rule of thumb when caring for older patients is to always speak to the patient first and establish his or her level of understanding and participation. Use a strong, clear voice, but avoid shouting as this tends to distort words and makes it more difficult to understand. If hearing aids or eyeglasses are available and practical for the patient to use in the situation, these can make a dramatic difference in communication. When obtaining the history, it is important to establish the baseline cognitive and physical functioning of the patient. If EMS is responding to a patient with reported 'confusion' or 'weakness,' does this patient have a history of dementia or physical limitations from a prior stroke or other condition? It is also relevant to consider the social context of the patient. Does he or she reside in an assisted living facility, nursing home, or his or her own home? This may influence the decision to transport a patient to the hospital if there are other caregivers available to be with the patient compared with one who lives alone without support. Family members and caregivers can also provide valuable information about the patient. A report by those present during a fall, episode of syncope, or witnessed seizure becomes a crucial element of the medical history, and it is important to communicate this information to subsequent emergency personnel. The final area to consider is the presence of advance directives and communicating these treatment preferences and goals of care throughout the health system. Patient decisions regarding resuscitation, hospitalization, and appointment of health care agents (health care proxy or durable power of attorney for medical care) are relevant care directives for EMS personnel to quickly identify, honor, and transfer across care settings. Most states have standardized out-of-hospital 'do not resuscitate' forms for patients which should be available for immediate review in a patient\u2019s place of residence, whether it is a home or a long-term care facility. For patients with advanced chronic or life-threatening illness, these advance directive papers may be the most important tools in guiding subsequent decision making with regard to emergency care.",
        "Geriatric medical conditions - Cognitive impairment": "Cognitive impairment is a common condition among older adults and has been shown to increase as people age. Estimates show that up to 10% of non-institutionalized older adults, 13% of EMS patients, and approximately a quarter of older adult emergency department (ED) patients suffer from it. Because cognitive impairment has been associated with significant morbidity and mortality, it is important to identify this condition, even in the EMS setting. A validated instrument to assess a patient\u2019s cognitive function, particularly suited to EMS, is the Six-Item Screener. This has been shown to have a sensitivity of 89% and specificity of 88% to identify cognitive impairment in a community sample and can be easily used by EMS professionals.",
        "Geriatric medical conditions - Depression": "Depression is a common problem among older adults, with studies reporting that up to 20% of community-dwelling older adults suffer from depressed mood. Depressive symptoms are a risk factor for increased use of medical services and for death and disability. Thus, this could be a precipitating factor for repeated EMS use by a patient or deterioration of a patient\u2019s medical condition. Due to this increased risk of morbidity and mortality, identification of depression is critical. However, estimates suggest that fewer than one half of depressed older adults receive the correct diagnosis or treatment. A number of screening instruments exist for use in the outpatient setting with reasonable sensitivity and specificity to identify potential depression. The Patient Health Questionnaire-2, or PHQ-2, has been shown to be effective in identifying patients who may be depressed. This tool can be easily used by EMS because it is short and has a simple scoring scheme and excellent sensitivity and specificity for major depressive disorder. Recommendations can then be provided to the ED or primary care physician to ensure that the mood issues are considered.",
        "Geriatric medical conditions - Falls": "Falls are a leading and preventable cause of morbidity, mortality, and loss of quality of life among community-dwelling older adults. Among older adults, 30% fall annually and 50% of them fall repeatedly. Falls result in fear, functional deterioration, and even institutionalization. Up to 25% of those who fall suffer serious physical injuries including fractures, joint injuries, and intracranial injuries, and the remainder may suffer emotional consequences.",
        "Geriatric medical conditions - Medications and drug toxicity": "A common problem in geriatric medicine is the phenomenon of polypharmacy. This problem stems from the fact that many older adults are on numerous medications, either due to their medical needs or because multiple medical providers have prescribed medications without full knowledge of the patient's current medication list. The metabolism, distribution, elimination, and excretion of medications can be altered with aging. As patients take an increasing number of prescribed medications, the potential for adverse drug reactions and drug-to-drug interactions also increases. There are also inappropriate medications, particularly those with cardiovascular or anticholinergic side-effects, that can contribute significantly to cardiac or respiratory compromise, falls, urinary problems, delirium, hospitalizations, and even death. Older patients presenting to EMS and the ED are often taking many of these potentially inappropriate medications. Patients may not report medication lists accurately, so it is important for EMS personnel to observe the environment for medications and to consider prescription, over-the-counter, herbal, and dietary supplement use. It often is helpful to ask the patient and family members or caregivers about other medical providers prescribing medications. For example, an older patient may consider medications prescribed by a cardiologist to be different from those prescribed by the primary care physician. A patient with cognitive difficulties may find it challenging to remember when and how to take prescribed medications, especially if he or she has multiple prescriptions. This cognitive impairment places older patients at risk for errors in taking medications and increases the chance for unintentional overdose. EMS physicians and personnel should look for pill-taking strategies and reminders in the patient's home, including pill boxes, calendars, and prescription bottles. An empty (or full) prescription bottle may sometimes be the only clue as to the patient's actual medication use at home.",
        "Geriatric medical conditions - Altered mental status": "Altered mental status refers to a disturbance in consciousness and a change in the behavior of a patient. In geriatric medicine, this acute change in mental status is often referred to as delirium. Delirium usually occurs over a relatively short period of time and is marked by a reduced ability to focus, a change in cognition, and a fluctuation throughout the course of a day. Patients with delirium tend to have poor attention, are often disoriented, and have altered levels of consciousness ranging from alert, or even hypervigilant, to profound lethargy. Older patients may be at risk for developing delirium simply because of their acute illnesses. Patients with dementia, cancer (especially brain tumors), stroke, renal or hepatic disease, and metabolic disturbances are at highest risk for developing delirium. A common condition such as pneumonia or a urinary tract infection is sometimes enough to precipitate an older patient's decline in mental status with the development of acute confusion and altered behavior. Medication side-effects, drug toxicity, and overdosage of medications can also be precipitants of delirium. A careful history from the patient or family caregivers is important in establishing if newly observed behavioral and cognitive symptoms are a change from a person's baseline function, especially in cases with preexisting cognitive impairment or dementia. A recent history of an unwitnessed fall may raise the clinical suspicion for head trauma and resultant traumatic brain injury or even the development of an intracranial hemorrhage (subdural hematoma) which sometimes can manifest several days after the traumatic event. A focused neurological assessment is critical in establishing the urgency of new symptoms and communicating findings to hospital personnel for further evaluation.",
        "Geriatric medical conditions - Cardiac arrest": "Approximately one half of EMS patients suffering from cardiac arrest are older adults. The overall survival rate for all patients suffering cardiac arrest is poor, with most studies reporting fewer than 10% of patients surviving to discharge home. One challenge for field personnel is determining which patients suffering cardiac arrest should be transported to an ED and which should have interventions terminated in the field. Traditionally, EMS professionals have depended on direct medical oversight communication to terminate resuscitation efforts. However, Morrison et al. have found that for BLS systems, a patient who suffers a cardiac arrest not witnessed by EMS, does not receive a shock from an automated external defibrillator during resuscitation, and fails to have return of spontaneous circulation in the field can have the resuscitation appropriately terminated in the field (positive predictive value 99.5%). Applying these criteria to patients receiving ALS care has been reported to be 100% predictive by the same group. These criteria should be considered but must be weighed against psychosocial issues related to leaving the newly deceased in the home or another setting and related to each family's response to the death. These criteria should also be weighed against local system issues related to handling of the body. Local EMS protocols should address all of these issues.",
        "Geriatric medical conditions - Trauma": "The Guidelines for the Field Triage of Injured Patients, developed by the Centers for Disease Control and Prevention, guide EMS personnel in their trauma triage decisions and determining the receiving hospital to which an injured patient should be transported. The goal of the Guidelines is to minimize undertriage (patients who need the resources of a trauma center but are taken elsewhere) without excessive overtriage. Despite these formal guidelines, numerous studies suggest that older adults are less likely to receive trauma center care than younger adults with similar injury severity. This variation in care may occur because the Guidelines are not age specific. No age-specific cut-offs for anatomical or physiological parameters exist, despite older adults having different physiological responses to injury and significantly worse outcomes than younger adults from minor injuries. Additionally, the Guidelines poorly consider preexisting medical conditions and the use of multiple medications, both of which can affect response to injury and lead to worse outcomes. The most recent revision of the Guidelines recognizes this and includes an expanded section on geriatric patients under Step Four, the \u201cSpecial Considerations\u201d section. Age >55 is a \u201cspecial consideration,\u201d meaning EMS providers should consider transporting those patients to trauma centers. However, age as a \u201cspecial consideration\u201d is subjective and does not require transport to a trauma center. Ultimately, the considerations rely on the ability of EMS personnel to recognize serious injury in older adults with limited testing and time, which studies suggest may be inadequate and result in undertriage. Since time to definitive care is considered important in trauma care, EMS medical directors must focus their attention on destination decisions for older adults trauma patients to ensure that EMS providers can appropriately transport these patients to the correct destination.",
        "Social emergencies - Medication and alcohol abuse": "Substance abuse is actually quite common among older adults, with over 17% of adults aged 60 and older misusing alcohol or prescription drugs. This can result in frequent ED visits, as well as an increased risk for falls and hip fractures. Because older adult medication abusers tend to be more socially isolated and less public regarding their addiction and related problems, EMS professionals may be the first to truly identify the problem when they enter the home.",
        "Social emergencies - Elder abuse and maltreatment": "Unlike child abuse, elder abuse and mistreatment have not received much public attention. They are common, with studies reporting that 1\u20132 million older adults have been injured, exploited, or mistreated. Elder mistreatment includes financial, psychological, physical, and sexual abuse. EMS professionals need training on the risk factors for mistreatment and ways to identify potential abuse. A number of risk factors for elder abuse have been examined and the literature is somewhat inconsistent. Risk factors that have been validated include social isolation of the older adult, dementia, and a shared living arrangement with the abuser. Characteristics of the abuser that have been identified include mental illness, alcohol abuse, and dependency on the older adult. Each EMS agency should have an established protocol for reporting suspected cases of abuse, particularly if EMS providers are mandated reporters by state law.",
        "Social emergencies - Caregiver distress": "A third social emergency is sometimes identified by the EMS professionals: caregiver distress and burnout. Family members and friends may provide the majority of care for older adults with medical, psychological, or behavioral problems. Over time, this can be exhausting and lead to significant stress for families without sufficient social supports or opportunities for periods of respite. As such, when a request for assistance for elderly patients is made, EMS professionals should pay attention to the family members as much as the primary patient. If the primary caregiver seems to be stressed, overwhelmed, or unable to manage the patient, then he or she may also be in need of assistance. A caregiver may also feel a personal sense of failure if a loved one becomes ill under his or her care, adding to the perceived burden, and the caregiver may be seeking reassurance and support. The EMS professional can help address caregiver needs by reporting information to the ED providers, calling family or friends to provide further support, and by being a calm and professional presence during the care of the patient.",
        "Special considerations": "There are a number of special considerations that EMS leaders must acknowledge and address in their systems. EMS professionals may need special equipment to care for older adults. Padding at the upper back is needed to properly stabilize and transport older adults with kyphosis. Padded backboards are needed to prevent the rapid development of decubitus ulcers. Protocols that minimize the use of backboards should be considered. Proper temperature control mechanisms and blankets are needed to prevent hypothermia or hyperthermia. Electronic medical records, preferably integrated through a regional health information organization, would be of particular benefit because older adults tend to have a number of comorbidities and medications, and having these data readily available can result in improved care. The medical and social condition of an older adult who refuses transport to a hospital needs to be considered carefully before allowing him or her to \u201csign off.\u201d Research has shown that approximately half of older adults cared for by EMS and transported to the ED are admitted to the hospital, and also that older adults experience a decline in functional status after ED visits. Therefore, older adults are a high-risk group and EMS providers should not merely accept the refusal of care, but should instead work to convince the patient to accept transport so he or she can benefit from care in the ED. Potential options to convince a patient to accept transport may include speaking to a medical oversight physician or the patient\u2019s primary care physician, or involving family. If the patient persists in refusing, EMS should consider notifying the patient\u2019s primary care physician to ensure that careful follow-up occurs. An EMS physician on scene may be able to convince a patient to accept treatment and transport.",
        "Nursing homes and assisted living facilities": "Long-term care facilities encompass a spectrum of services and housing options that are designed to address many of the needs of an older adult population. These facilities may include group homes, senior apartments, assisted living facilities, and nursing homes. Nursing homes remain key providers for the frailest older adults: those with complex care needs, high levels of functional dependence, advanced dementia, and those without sufficient social or financial supports to meet their needs at home. Emergency medical services are often called to evaluate and transport residents of long-term care facilities to and from the hospital. Most commonly, the resident has experienced an acute illness, sustained traumatic injury following a fall, or exhibited a change in behavior. The transfer of appropriate information between these facilities and the hospital is often inadequate and has been recognized as a vital component in ensuring proper continuity of care for these patients. Assisted living facilities and other senior housing centers are much more varied in the level of documentation available for their residents. It is of value for each EMS agency to collaborate with long-term care facilities in the community to improve access to information and ensure that copies of relevant documentation are readily available when patients are transported to and from the hospital.",
        "Public health": "Although the EMS system was originally developed primarily to care for patients with acute injuries and illnesses, it is being increasingly recognized that EMS personnel can fulfill an important public health role, including preventing injuries and illnesses and helping patients maintain physical, social, and emotional function. This public health role is being called \u201ccommunity paramedicine.\u201d Surveys of EMS providers have indicated that they believe that prevention is a core mission of EMS systems and should be implemented. Work has shown that EMS personnel can successfully screen older adults and perform other public health roles. However, the ideal structure, effectiveness, and cost-effectiveness of the screening programs and associated intervention programs still need to be evaluated. One obstacle to EMS personnel involvement in public health activities is the fragmentation of the US health care system. This prevents EMS personnel from confirming public health needs and ensuring that interventions are provided. Furthermore, the financial fragmentation prevents EMS organization from realizing financial benefits from community paramedicine programs. EMS system leaders and medical directors are encouraged to work with the local medical and social service community to better integrate public health and medical care activities of the EMS system into the health care system, improve communications, and ensure patients receive the highest quality and safest care possible.",
        "Conclusion": "Geriatric patients require a thoughtful and focused approach when they are experiencing acute illness or injury. Their chronic medical conditions, functional impairments, and social settings make the older adult population among the most complex that EMS providers may encounter. At the same time, the data gathered in the home setting, treatment interventions, and transfer of information to other providers can have a profound effect on the quality of health care for the most vulnerable of geriatric patients."
    },
    {
        "Introduction": "For humans to fly, they must adapt to a very dynamic environment. The Wright brothers were successful because they understood that stability was not possible. To stay in the air, the pilot and aircraft had to be able to adjust to the changing conditions. To care for critically ill and injured patients in this setting requires a basic knowledge of both the forces affecting an aircraft and the forces that affect humans within that aircraft. There are the classic forces of aerodynamics: lift, gravity, thrust, and drag. The forces affecting humans also include vibration, barometric pressure, acceleration, spatial disorientation, and thermal stresses, among others.",
        "Aerodynamic forces": "In order to understand how the flight environment affects patients and air medical providers, the EMS physician must have a basic understanding of aerodynamic forces and terminology. For an aircraft to fly, there must be a source of lift. For the fixed wing airplane, that source is the wing. In the helicopter, the rotor blade supplies the lift. In both cases, the wing or rotor passing through the air encounters two phenomena. Bernoulli's principle states that when air is accelerated, it has a lower pressure. A wing with a curved upper surface and a straight lower surface causes air traveling over the upper surface to speed up to catch its counterpart moving beneath the wing. The pressure on the upper surface is reduced compared to that of the lower surface, producing lift. Helicopters often have essentially symmetrical airfoils for their rotors; thus the speed of the air relative to the rotor is the same for the upper and the lower surface. For these rotors, and for the wings of many aerobatic aircraft, lift depends on the angle of attack. This is the angle that develops between the chord line (the imaginary line formed between the most forward point in the leading edge and the farthest aft point in the trailing edge) and the direction of the air. Children who put their hands outside the car window and feel the air move their arm up and down take advantage of this phenomenon. The density of air determines how much lift a given wing or rotor can generate. Hot air does not have as much density as does cold air. Air pressure also decreases with altitude. The combination of the actual altitude above sea level and the effect of the temperature is expressed as the density altitude. Thus an aircraft that might be able to generate enough lift to take off in the winter at JFK airport (at sea level) might not be able to take off in Denver, the Mile High City, in August. Gravity, or weight, is the force that opposes lift. For aircraft, the weight of the aircraft, its fuel, and its passengers or load determines the effects of gravity. An aircraft that is too heavily loaded cannot overcome the effects of gravity with the effects of lift. Aircraft are tested to determine their useful load, which is the remainder when the weight of the aircraft and its necessary supplies (e.g. fuel, oil) is subtracted from the amount of lift that can be generated. Thrust is the ability of the engine, or the main rotor, to move the aircraft through the air. A propeller, or a jet engine, provides the thrust for airplanes. For helicopters, the main rotor provides this thrust. The Wright brothers were among the first to understand that an aircraft propeller is essentially a rapidly spinning wing. The term airscrew has been used to describe how a propeller pulls the aircraft through the air. Just as a screw pulls itself through a piece of wood, the propeller bites into the air and pulls the airplane forward through the air. This pulling allows the wing to pass through the air and generate lift. Drag is the force that opposes the aircraft's movement through the air. Thin, smooth, gradually curved shapes move through a fluid more easily than boxy shapes. If one has rowed a jon boat, with its squared bow and flat bottom, then paddled a long, slender kayak, it is easy to appreciate the effects of drag. A slender, tapered business jet experiences much less drag than a biplane.",
        "Effects on humans": "The first recorded ascents of humans into the air occurred in the 1780s, with the French balloonists, Montgolfier, Charles, and de Rosier. Charles, using a hydrogen-filled balloon, was the first to note that when he ascended rapidly he became exceptionally cold and that when he descended he developed ear pain. Others ascended even higher, with Glaisher and Coxwell noting the effects that occurred when they climbed to 9,450 meters, nearly perishing in the attempt. Even before powered flight was achieved, the effects of altitude on the organism had become apparent.",
        "Atmospheric effects": "The atmosphere has a significant effect on humans in flight. Temperature decreases with altitude at a rate of about 2\u00b0C (3.5\u00b0F) per 1,000 feet \u2013 the adiabatic lapse rate. For patients and medical crews this phenomenon can become important, as even in helicopters an ascent to 5,000 feet above ground level is not uncommon, resulting in an uncomfortable temperature change. While the Commission on Accreditation of Medical Transport Systems (CAMTS) standard 02.05.15 requires \u201cclimate control,\u201d knowing the extent of the changes that may occur during a flight is an important consideration in patient packaging. Barometric pressure at 18,000 feet/5,500 meters is half of that found at sea level, resulting in a doubling of the gas volume, in accordance with Boyle\u2019s law. The most familiar manifestation of this phenomenon is the ear discomfort that many people experience as an airliner descends for landing. Barotitis media and barosinusitis may occur because of these gas volume changes and should be taken seriously as they can incapacitate crew members during critical phases of flight. Although the middle ear and the sinuses are dramatic examples, any gas-filled structure or device can be affected. A pneumothorax or an endotracheal balloon may expand or contract depending on the pressure/altitude change. While common sense might suggest that any patient transported by air with a pneumothorax should have a thoracostomy, the research is not as clear. A case series from Somalia is illustrative: two patients, treated with needle thoracostomy, survived a trip at 3,000 meters without difficulty. A third patient, who was transported at a lower cabin altitude, also survived his trip but later succumbed to his wounds. The latter patient had extensive adhesions secondary to tuberculosis, making thoracic drainage more difficult. Although they caution the reader against air transport of a pneumothorax, the writers of another case report note that the patient underwent a 2-hour airplane flight without complication, the pneumothorax being discovered incidentally after her arrival at the receiving burn center. Placing a needle or a tube in a patient\u2019s chest is not without risk in itself. In an elegant study from the University of Oklahoma, an experimental model of pneumothorax was flown in a helicopter and the volume changes measured at 1,000 and 1,500 feet above ground level (AGL), altitudes commonly encountered in helicopter EMS (HEMS) transport. The authors noted a 1.5% increase in pneumothorax size per 500 ft increment. They also suggest that the use of oxygen may mitigate some of the effects. It appears that prophylactic placement of a tube, even in a known pneumothorax, may not be needed. Pneumocephalus and penetrating eye trauma also produce worries regarding pressure changes, but there is little literature surrounding the effects of flight on these. Concerns have been raised about endotracheal tube cuff pressures exceeding 30 cmH\u2082O and producing tracheal mucosal injury. A Swiss group adjusted the pressure of the cuff prior to departure, and then measured the pressures during flight, noting that almost all of their patients\u2019 cuff pressures exceeded 30 cmH\u2082O during flight. A group from France notes that it is their practice to fill the cuff with saline when treating intubated patients in a hyperbaric chamber, suggesting that this may be useful for helicopter transfers. However, few follow this practice in air medical transport. On descent, the converse problem can become apparent: the cuff can contract and the patient may develop an air leak. Regular monitoring of cuff pressures with a manometer is recommended. The pressure decrease associated with altitude also produces hypoxia, with its obvious effects on both the patient and providers. Pulse oximetry and routine use of supplemental oxygen can be employed to mitigate these effects, but providers should be particularly cautious in managing patients with cardiovascular compromise or anemia.",
        "Aircraft effects": "The type of aircraft can have a significant effect on both patient and crew. A smooth flight in a newer jet aircraft may produce little fatigue for the passengers. A helicopter flight, even through smooth air, subjects the passengers to constant vibrations of several different frequencies, which can have a pronounced effect on crew fatigue. Some have postulated that back pain, a common problem among helicopter pilots, is in part due to vibration. Vibration may affect the spinal muscles, as well as the vertebrae, depending on the frequencies produced by the individual aircraft type. Vibration may also affect monitors, pumps, and other patient care devices. These devices, and the cables and wires associated with them, must be inspected regularly. In addition to the issue of vibration is the problem of noise. From the perspective of human physiology, these are closely related. Aircraft engines, propellers, transmissions, and rotors generate significant levels of noise in many different frequency bands. In commercial transport airplanes the engines are at a distance from the cabin, and the pressure hull of the fuselage tends to attenuate engine and wind noise. Modern high-bypass jet engines also tend to produce less noise. Most helicopters, however, have little structure to attenuate the noise, and the engines, transmission, and rotor system are located directly above the passenger cabin. Vibration and noise contribute to fatigue and may be part of the accident chain. Helicopter companies have recognized the importance of this problem and have embarked on studies to better address this issue. At the present time, the best solution is the use of headphones or helmets. Helmets are required by CAMTS for helicopter operations. Both the HGU-56/P and the HGU-86/P helmets, worn by the US military and many HEMS programs, provide substantial hearing protection. Testing of other helmets has yielded similar results. Aircraft motion may have significant effects on patients and crew members. Most medical aircraft are not flown in a manner that produces substantial G forces. The one notable exception to this may occur during takeoff and landing in fixed wing aircraft, where the acceleration may cause patients, crew, and, most importantly, equipment to shift. Crews must package patients and secure equipment accordingly. If the patient has a condition that is likely to be affected by the aircraft movement (e.g. fractures), the crew should discuss this with the pilot to see if the takeoff or landing profile can be modified. Motion sickness is the most commonly reported side-effect of aircraft travel. Unusual head positions, unexpected turbulence, and the need to concentrate on tasks in the aircraft cabin contribute to this phenomenon. Patients, especially those with conditions that preclude their ability to look out a window or who have nauseogenic medications or conditions, may benefit from prophylactic administration of antinausea medications prior to departure. Crew members may occasionally require antiemetics in order to remain functional. Sedating medications such as the phenothiazine-based antiemetics or antihistamines such as dimenhydrinate should be avoided if at all possible by crew members. Ondansetron, especially in its quick-dissolving form, may be useful for crew members. Other motion sickness remedies, such as ginger root or Sea Bands (Sea-Band Ltd, www.seaband.com) are used by many who seek natural remedies for this malady. Some crew members may be able to overcome motion sickness by looking outside when patient care duties permit. The conflict between what the instruments say and what the pilot's vestibular system is experiencing produces spatial disorientation, a sensation that is difficult to overcome. Spatial disorientation is a particular problem for pilots. The most profound and deadly manifestation of spatial disorientation occurs during inadvertent or unexpected flight into instrument conditions. Dark night conditions can produce this same problem, in which the pilot cannot distinguish ground from sky. General Jimmy Doolittle, best known for the \u201cDoolittle Raid\u201d on Tokyo in 1942, demonstrated that aircraft could be flown solely with reference to instruments in September 1929. Since that time thousands of pilots have become \u201cinstrument rated.\u201d Nevertheless, pilots who crash after unexpectedly encountering instrument flight conditions remain a serious problem. Repetitive practice, either in a simulator or with a safety pilot acting as a lookout for the hooded training pilot, allows a pilot to safely manage spatial disorientation. Pilots must keep \u201cinstrument current\u201d by performing a series of instrument procedures every 6 months. Flicker vertigo is a problem that primarily affects helicopter crews. Most noticeable on a sunny day, the rotors produce a visual flicker as they spin. Helicopter rotor systems often produce flicker within a range that produces vertigo (4\u201320 Hz). When motion detected by the eyes is in conflict with that perceived by the vestibular system, nausea, or at least a sopite syndrome, can be induced. Flicker vertigo produces nausea and disorientation; in rare cases seizures have been reported. Visors or other headgear that limit the view of the rotor system may be helpful in preventing flicker vertigo. Night vision goggles do not appear to enhance or decrease this problem.",
        "Other concerns in the flight environment": "Many HEMS services in the United States use night vision goggles (NVGs) when operating after dark, a practice encouraged by the National Transportation Safety Board. NVGs enhance the available light and present what is essentially a black and white picture in front of the crew member's eyes. Although NVGs improve the ability of pilots and crews to see at night, they are not without their problems. They have a markedly reduced field of view, and their visual acuity is equivalent to approximately 20/200. The ANVIS goggles weigh about 800 grams including their mount. When a counterweight is added to the occupit, the NVG, helmet and counterweight weigh about 3.7kg. This results in neck pain being a common complaint among helicopter crews. Because of these concerns, it is important that helmets fit the crew member well. The air medical service has been described as one of the most dangerous jobs in the United States. In order to mitigate risks, crews wear helmets, flame-retardant uniforms, and boots. Like many other forms of personal protective garb, this flight equipment can make it difficult for individuals to cool during hot and humid operations. Attention must be paid to fluid intake to prevent heat injuries. Conversely, cold weather operations can pose a threat as many cold weather garments are made of synthetic materials that melt when exposed to a heat source. Flight crew members should wear natural fiber underwear and socks (i.e. cotton, wool, silk). Boots and outerwear should be made of leather or flame-retardant fabrics, such as Nomex\u00ae.",
        "Conclusion": "The provision of emergency care in the aerospace environment poses a number of challenges. Providers must be mindful of the unique characteristics of the airplane or helicopter in which they are caring for their patient. Pressure and temperature changes can significantly affect the patient and the crew. Noise, vibration, and other aircraft effects will alter the way in which care can be delivered. Special consideration must be given to protect the patient and the crew from the environment and the emergencies that can arise as the result of flight."
    },
    {
        "Introduction": "Heat-related illnesses are a spectrum of disorders more commonly seen when the patient is in a warm environment, has underlying comorbidities, is physically active, and/or has attire which does not readily permit easy removal of body heat (such as firefighter \u201cturnout gear\u201d). If not diagnosed and managed appropriately, significant morbidity and mortality may result. This chapter will discuss the physiology of thermoregulation and the various heat-related illnesses, including management strategies.\n\nAccording to the Centers for Disease Control and Prevention (CDC), an average of 688 people die annually from heat-related illness. Between 1999 and 2003, an estimated 3,442 deaths were attributed to heat injury. Males accounted for 66% of the deaths. Fifty-three percent of those who died were between the ages of 15 and 64 years, while 40% were greater than 64 years of age.\n\nEmergency medical services protocols should reflect the most up-to-date science on the management of patients with heat-related illness. The best management strategies incorporate expected transport times given the acuity of the patient\u2019s illness, local geography, weather, hospital proximity, and local traffic patterns.",
        "Physiology of thermoregulation": "Normal oral temperature has been demonstrated to be 33.2\u201338.2\u00b0C [2]. Rectal temperature averages 34.4\u201337.8\u00b0C, while the normal tympanic temperature is 35.4\u201337.8\u00b0C.\n\nThe human body generates heat through metabolism. Basal metabolic rate is a measure of the number of calories expended at rest while sedentary. The maintenance of body temperature to a narrow window, or thermoregulation, is a complex task controlled by the hypothalamus. The body\u2019s extremities have a greater variation in temperature, dependent on environmental factors, including clothing. Generally, the extremities tend to be cooler than the rest of the body, while the core temperature fluctuates very little.\n\nWhile metabolism of the various body tissues generates heat, the majority of body heat comes from skeletal muscle activity. Endocrine function can also affect metabolic rate and increase temperature. For example, epinephrine and norepinephrine can increase basal metabolic rate and subsequent heat generation. Similarly, thyroid hormones can produce an elevation of metabolic rate as well as an increase in body temperature.\n\nBody temperature homeostasis occurs with heat generation in balance with heat dissipation. The narrow homeostatic range prevents enzymatic and cellular dysfunction or injury. Several reflexes or semi-reflexes help to maintain temperature. The reflexes or semi-reflexes activated by cold include shivering, hunger, increased voluntary activity, curling up, decreased heat loss, cutaneous vasoconstriction, epinephrine and norepinephrine release, and erection of the short body airs (i.e. \u201cgoose bumps\u201d). The reflexes or semi-reflexes activated by heat include cutaneous vasodilation, sweating, decreased voluntary movement, anorexia, decreased heat production, and increased respiration. The posterior hypothalamus controls the reflexes activated by cold, while those for warmth are located in the anterior hypothalamus. Sweating and cutaneous vasodilation occur with activation of the anterior hypothalamus. Sensors in the spinal cord, skin, deep tissues, hypothalamus, and extrahypothalamic regions of the brain provide feedback to the hypothalamus on body temperature. The hypothalamus is activated by core temperature increases of less than 1 \u00b0C. Lesions of the anterior area of the hypothalamus cause hyperthermia.\n\nHeat is dispersed from the body by several different mechanisms including conduction, convection, evaporation, and radiation. Heat loss by conduction occurs through direct contact with an object or environment that is cooler. Skin temperature greatly affects the amount of body heat lost or gained through conduction. The amount of heat dispersed from the body\u2019s core to the skin is reliant on cutaneous blood flow. When the cutaneous vessels dilate, more blood flows to the skin, allowing for greater heat transfer from the deeper tissues (tissue conductance). Horripilation is the erection of the cutaneous hairs which helps to trap air near the skin and inhibit heat transfer from the skin. Clothing also inhibits tissue conductance by limiting transfer of heat from the skin to the environment. Convection refers to the removal of heat as cooler air passes over exposed skin. The more air passes over the skin (e.g. from a fan), the more heat can be dispersed. Evaporation is the heat lost via converting a liquid to a gas. In the human body, about 600 kcal/hour in ideal conditions can be removed through evaporation. Radiation is the transfer of heat by infrared electromagnetic waves. Approximately 250\u2013300 kcal/hour can be transferred to the human body by solar radiation, with clothing acting as a barrier and providing some protection, estimated at 100 kcal/hour. Additionally, the body disperses heat by radiating to cool objects in the vicinity.\n\nAt an ambient temperature of 21\u00b0C and while at rest, heat loss from the body occurs through radiation and conduction (70%), evaporation (27%), respiration (2%), and urination and defecation (1%). As the ambient temperature increases, radiation losses decline and heat loss through evaporation increases. At higher ambient temperatures, evaporation plays a more critical role in body heat removal. The removal of heat is reliant upon the gradients of moisture and temperature. As the environmental temperature and humidity increase, the exchange of heat becomes impaired. Therefore, hot humid environments confer the greatest risk to patients for heat-related illness.\n\nThe body adapts over time to more efficiently manage heat stress, primarily through salt retention and increased fluid secretion from sweat glands to increase the rate of evaporation. Other adaptations include increased circulating plasma volume, improved renal filtration, and increased resistance by the kidney to exertional rhabdomyolysis. Adaptation through production of acute-phase reactants also protects tissues from heat stress. Individual cells produce intracellular heat shock proteins which protect them from sudden heating. The mechanism is believed to occur through the binding of heat shock proteins to cellular proteins which inhibit the cellular proteins from denaturing (or unfolding) in hot environments.",
        "Pathophysiology": "Regardless of the etiology, if hyperthermia is not addressed, tissue and cellular swelling and disruption will occur with widespread hemorrhage. Heat injury causes denaturation of proteins, a severe inflammatory response, and disruption of the coagulation cascade. The denaturation of proteins causes direct injury to the cells and cellular function. Pyrexia above 41.6\u00b0C for a few hours can cause cellular damage. Temperatures above 49\u00b0C can cause nearly immediate cell death. Organs most susceptible to apoptosis secondary to hyperthermia include the mucosa of the small intestine, thymus, lymph nodes, and spleen. Injury caused by inflammatory response is due to the release of several inflammatory cytokines including tumor necrosis factor-alpha, interleukin (IL)-1 (beta), and interferon gamma. Several anti-inflammatory cytokines are also released during heat stress, including IL-6, IL-10, and tumor necrosis factor receptors p55 and p75. Animal models with injection of IL-1 and tumor necrosis factor-alpha have demonstrated changes similar to heat stroke. Heat injury causes activation of the coagulation cascade, injury to the vascular endothelium, and increased permeability of the vasculature. This has been demonstrated through surrogate markers of endothelial damage or activation as seen in heat stroke patients. Some of these markers include von Willebrand factor antigen, endothelin, and intracellular adhesion molecule 1.\n\nMinute ventilation, heart rate, and cardiac output increase in response to elevated body temperature, while at the same time, perfusion to the viscera decreases. Medications may impede body heat removal. For example, vasoconstrictors and beta-blockers can prevent the body from transferring warm blood from the core to the skin for dissipation.\n\nUnderlying chronic medical conditions can also predispose individuals to heat illness. The elderly are at risk as they often have reduced cardiopulmonary reserve. Additionally, they are more often prescribed medications that put them at risk, tend to be less mobile, and are often volume depleted secondary to a decreased thirst mechanism. Age-related decreases in heat shock proteins, lessening their ability to tolerate increased temperatures, also put the elderly at increased risk. Chronic metabolic conditions (e.g. thyrotoxicosis) predispose individuals to heat-related illness. Obesity increases hyperthermic risk, as adipose tissue impedes cooling, and decreases cardiac reserve. Those who are physically active in hot and humid environments are also at risk. For example, those in the military, athletes (e.g. high school athletes have an increased risk of heat illness over other sports by about 10 fold), and outdoor workers are at increased risk for heat-related illness (e.g. 20-fold increased rate of heat-related death compared to individuals in other employment).",
        "Heat edema": "In the continuum of heat-related illness, heat edema is one of the mildest forms. Presenting as edema of the hands and/or feet, heat edema is caused by vasodilation and pooling of interstitial fluid, usually in the dependent extremities. Limited to the extremities, the patient's core temperature is unaffected. Heat edema is most commonly observed in the elderly and those unacclimatized to hot environment.\n\nHeat edema is managed symptomatically. Elevation of the affected extremities and compression stockings are the mainstay of treatment, in addition to moving the patient to a cooler environment. Medication interventions are not recommended. Use of diuretics in these patients should be avoided, unless they present with signs of heart failure, as the edema is from heat stress and not from heart failure.",
        "Heat syncope": "Heat syncope is constellation of symptoms that can include syncope, dizziness, and orthostatic hypotension. These symptoms are related to venous pooling and peripheral vasodilation. The patients often experience syncope after standing following exertion, or quickly changing their body position during exertion (e.g. standing after completing heavy bench presses). Patients suffering from this ailment usually have an unremarkable core temperature.\n\nThe mainstay of treatment for this ailment is to move the patient to a cooler environment and provide intravenous normal saline. Usually an initial infusion of 20 mL/kg is sufficient to alleviate symptoms, with an initial maximum bolus of 1 liter of normal saline.",
        "Heat tetany": "Heat tetany refers to spontaneous muscle spasm, such as carpopedal spasm or laryngospasm. Often a Chvostek or Trousseau sign may be elicited. This arises from a respiratory alkalosis from hyperventilation due to heat stress. Patients may also complain of circumoral paresthesias. The tetany appears to be related to the rate of PCO\u2082 change more than the absolute pCO\u2082 change. The core temperature in these patients may be either normal or elevated.\n\nTreatment for heat tetany consists of removal from the warm environment. Once the heat stress is removed, the compensatory hyperventilation, subsequent hypocarbia, and associated spasms will resolve. Using a paper bag for rebreathing may also help resolve the symptoms, but does create the risk of hypoxemia. Given this risk, the use of a paper bag is generally not recommended. The recommended management strategy to alleviate these symptoms is simply removal from the heat stress.",
        "Heat cramps": "The cramping of skeletal muscle during or after exertion in a warm environment is called heat cramps. The muscles most commonly involved include the legs (typically the larger muscle groups of the legs such as the quadriceps), calves, abdomen wall, and least commonly the arms. Heat cramps arise from heavy sweating and repletion with hypotonic fluids, causing a dilutional hyponatremia. Core temperature is either normal or may be elevated, but usually not in excess of 40\u00b0C.\n\nTreatment consists of rehydration with oral electrolyte solutions or intravenous normal saline as well as stretching and massage of the affected muscle and rest. Gradual rehydration is preferred, as an aggressive rehydration strategy might worsen hyponatremia. Oral rehydration with electrolyte solutions may be of benefit in preventing additional cramping of the same or other muscles. In the past, salt tablets were used for both treatment and prevention. Currently, their use is not recommended during the acute management stage of this disease process.",
        "Heat exhaustion": "Some overlap between heat exhaustion and heat stroke occurs and unlike the previously described milder forms of heat-related illness, these patients display systemic symptoms. Heat exhaustion signs and symptoms may include anorexia, dizziness, fatigue, headache, malaise, nausea, sweating, visual changes, weakness, anxiety, confusion, diaphoresis, fever, hypotension, oliguria, skin flushing, tachycardia, or vomiting.\n\nTypically, the core temperature is elevated, but is usually less than 40\u00b0C. Unlike heat stroke, heat exhaustion patients present with near-normal mental status (although in some cases mild confusion is present which resolves after a short course of treatment). Seizures or coma are not part of the heat exhaustion spectrum.\n\nTreatment consists of cooling. Moving the patient out of the hot environment is important (e.g. moving to a shaded or air-conditioned area). Removal of unneeded clothes will facilitate cooling. Cooling by immersing in cool water, running cold water over the patient, or evaporative cooling are all effective cooling methods. Rehydration is also important, with oral rehydration preferred as long as the patient is conscious, able to safely swallow, and does not have vomiting or diarrhea.",
        "Heat stroke": "The most serious of the heat-related illnesses is heat stroke. While there is some overlap between this entity and heat exhaustion, these patients are hyperthermic with central nervous dysfunction. In population studies, this diagnosis carries up to a 10% mortality risk. A medical emergency, heat stroke may present with anorexia, dizziness, fatigue, headache, malaise, nausea, visual changes, or weakness. More concerning symptoms include anhydrosis, cardiac dysrhythmias, hepatic failure, hyperthermia, neurological signs (e.g. ataxia, coma, confusion, irritability, seizures), pulmonary edema, renal failure, rhabdomyolysis, shock, tachycardia, and tachypnea. Core temperature is often between 40\u00b0C and 44\u00b0C. Temperatures may be higher in some cases. Although anhydrosis is described in the classic case of heat stroke, this is not a reliable sign and patients may be diaphoretic and still have this illness.\n\nWhen severe, heat stroke can lead to multiorgan dysfunction. Factors associated with high case fatality rates include delay in presentation, delay in initiation of treatment, and increased disease severity upon presentation.\n\nHeat stroke is classified in two forms: classic and exertional. Classic heat stroke often occurs during heat waves, is more common in the elderly and debilitated, and typically develops over days, not hours or minutes. The inciting etiology is due to external heat stress. Physical activity, or exertion, is usually not a contributing factor to development of classic heat stroke. Patients are often anhydrotic due to the time period over which this condition develops. Exertional heat stroke often occurs in healthy, young adults who are physically active in hot and humid environments without sufficient acclimatization. Developing secondary to internal heat generation (i.e. body metabolism), it is more commonly seen in athletes, firefighters, foundry workers, and military recruits.\n\nTreatment for heat stroke is similar to that for heat exhaustion. Cooling the patient is critical. Moving the patient from the warm environment to a cooler one is important (e.g. moving to a shaded or air-conditioned area). Removal of excess clothing will help facilitate cooling. Cooling by any of the previously mentioned methods will work (e.g. immersing in cool water, running cold water over the patient, or mist sprayer and fans). Rehydration is also important, with intravenous rehydration preferred given the patient's neurological changes. Seizures should be managed according to protocol, usually with benzodiazepines.",
        "Cooling techniques": "One of the key elements in treating patients with heat exhaustion and heat stroke is rapid cooling. Decreased mortality and improved outcomes have been observed with rapid cooling to a temperature of 38.3\u00b0C. Evaporation combined with convection (e.g. mist spray and a fan) is practical in a clinical setting, commonly employed, and efficient, but does depend on ambient humidity. Ice water immersion is an efficient way of rapidly cooling patients and a metaanalysis supported its use with heat stroke. There are, however, practical challenges when using ice water immersion which include difficulty in monitoring and difficulty in obtaining intravenous access after immersion. There are also several commercial body cooling units available. Ice packs to the groin and axilla may have utility when used in combination with evaporative cooling to lower body temperature.\n\nIn the prehospital environment, ice water immersion is often impractical due to equipment requirements, difficulty in moving a wet patient, placing defibrillation pads, monitoring the patient, maintaining the airway (i.e. aspiration risk), and obtaining intravenous access. Commercial cooling units are also impractical in the prehospital setting. They require special equipment which does not readily fit into an ambulance, can be cost prohibitive, and adds another piece of equipment with components that have a limited shelf-life.\n\nThere are few studies comparing the various methods of rapid cooling. Most have methodological challenges. Given the practical challenges (including expense) with the various cooling methods in the prehospital environment, evaporative cooling with convection may be the best alternative, especially in a patient with altered mental status. In an ambulance, this could entail cool mist spray with air conditioning. Supplementary cooling with ice packs to the groin and axilla may also help expedite cooling. Simply removing the patient from the warm environment to the shaded ambulance will also help reduce the patient's heat stress.",
        "Conclusion": "The heat-related illness continuum ranges from minor illness with mild discomfort to life-threatening heat stroke. The human body is able to acclimatize to heat stress but once those adaptive strategies have been overwhelmed, illness ensues. Early recognition by EMS providers, in combination with patient treatment protocols that the medical director creates incorporating state, regional, and local practices, will help to reduce patient discomfort, morbidity, and mortality in the spectrum of disease. Management usually involves removal from the heat stress, cooling, and hydration as appropriate."
    },
    {
        "Introduction": "Renal failure in its various forms represents a spectrum of disease with profound implications for patient management. With differing etiologies for both acute and chronic forms of the disease, patients may present with a wide variety of complaints that directly relate to their renal function. This chapter will discuss the array of disorders including acute, chronic, and end-stage renal disease, the complications thereof, and treatments most pertinent to the emergency prehospital care provider.",
        "Definitions and pathophysiology": "The kidney functions through a series of both microscopic and macroscopic elements that serve to filter blood. In doing so, the renal system manages fluid balance, processes waste, and removes complex compounds from the body. It also affects blood electrolytes and pH. The smallest functional unit of the kidney is the nephron, where blood filters through the glomerulus and into a system of tubules. Through microscopic transporters and diffusion gradients, electrolytes and other compounds are shifted to and from the blood and filtrate. The resultant fluid at the distal end of the nephron leaves the body as urine. Structurally, the nephrons' tubules combine into larger structures forming the renal calyces, which then form the ureter, exiting at the renal hilum near the artery and vein. A single artery delivers blood flow from the body for filtration while the renal vein returns filtered, deoxygenated blood back to the central circulation. The ureter carries the urine to the bladder for storage. Damage to any of the aforementioned structures can result in renal dysfunction and/or failure. Together, the two kidneys receive about 20% of the cardiac output. Renal function is largely defined by the estimated glomerular filtration rate (eGFR), which is an objective measure of the kidney's ability to filter blood. It is by convention measured in mL/min/1.73 m\u00b2 (body surface area). eGFR is directly related to renal function, and the lower the eGFR, the more severe the renal impairment.",
        "Acute kidney injury": "Acute kidney injury (AKI), formerly known as acute renal failure, is defined as the rapid loss of the kidney's excretory function and is typically diagnosed by the accumulation of urea and creatinine or decreased urine output. According to the Acute Kidney Injury Network recommendations, AKI is defined as an increase in serum creatinine by \u22650.3 mg/dL within 48 hours, increase in serum creatinine to \u22651.5 times baseline within the prior 7 days, or urine volume <0.5 mL/kg/h for 6 hours. The causes of AKI are often designated by the location at which the pathophysiology occurs. Prerenal causes of failure refer to a disease process affecting the kidney before the renal artery enters the kidney. Postrenal causes are those that occur after the collection system forms. Intrarenal causes are those affecting the microscopic and macroscopic structures of the kidney, directly. Acute causes of renal failure occurring before the kidney result from systemic processes that decrease blood flow to the organ. Systemic hypotension and shock states are easily recognized. Reduction of blood flow to the kidney can result in injury. Operating through a similar pathway, dehydration (especially in the elderly with limited reserve) can also lead to renal damage. Additionally, low-flow states, as found in decompensated heart failure, can lead to AKI. In many other disease conditions, renal dysfunction is a key marker of end-organ damage and carries a higher rate of morbidity and mortality. Pathology occurring after the collection system of the kidney can result in postrenal or obstructive kidney disease. Obstruction causes backflow of urine into the kidney, increasing the hydrostatic pressure within the tubules, thus hindering filtration of fluids and excretion of compounds. Any lesion obstructing the flow of urine, from the tip of the urethra to the renal calyx, can cause postrenal failure. One of the more common causes in this category is urolithiasis. Lesions within the bladder causing delayed or impaired emptying as well as strictures or compression of the urethra can cause similar pathology. In a patient with a history of hematuria, clot formation in the bladder can result in obstruction and renal failure. Regardless of the cause, treatment of these conditions revolves around identification and relief of urinary tract obstruction. Causes of injury that are neither prerenal nor postrenal make up the spectrum of acute intrinsic causes of renal failure. The multitude of etiologies of this category includes processes affecting the blood vessels, nephron, glomerulus, tubules, and the interstitium of the kidney. The most common cause of intrinsic renal failure is acute tubular necrosis. A variety of medications such as non-steroidal anti-inflammatory drugs, certain antibiotics, and intravenous contrast dye are commonly implicated in causing intrinsic renal failure. Special care must be taken by the EMS and the emergency department providers to avoid nephrotoxic drugs in patients with suspected renal failure. Rhabdomyolysis is caused by muscle breakdown and release of intracellular material including myoglobin, leading to renal damage. In adults, alcohol and drug intoxication, trauma, prolonged immobility, excessive strenuous activity, toxic ingestions, and infections can lead to this syndrome. Symptoms include weakness, myalgia, mental status change, and darkened urine. The mainstay of treatment is resuscitation with a potassium-free crystalloid IV fluid, and often admission for treatment of metabolic abnormalities.",
        "Chronic kidney disease": "Chronic kidney disease (CKD) is based on the presence of kidney damage or renal dysfunction with eGFR <60 for greater than 3 months duration. The majority of CKD is a result of intrarenal disease. Chronic kidney disease is broken into categories of dysfunction with the ultimate being termed end-stage renal disease (ESRD). CKD usually follows an irreversible and progressive course that requires early detection, lifestyle modification, and medications to slow down progression to kidney failure.",
        "Epidemiology": "As of 2011, approximately 616,000 people in the United States are being treated for ESRD with hemodialysis, a functional renal transplant, or peritoneal dialysis [7]. This represents one in 526 Americans, and one in 2,800 will be newly diagnosed each year. Forty-four percent of newly diagnosed ESRD patients have a history of diabetes and 28% have a history of hypertension, common problems encountered by EMS personnel. African Americans have an incidence of ESRD 3.4 times higher than Caucasians. The annual costs for treating ESRD in the US is more than $49.3 billion, and it takes more than 7.2% of the US Medicare budget",
        "Treatment of renal disease": "Depending on the degree of renal dysfunction, definitive management involves measures to temporize and protect the remaining renal capabilities, and/or renal replacement through dialysis or transplantation. Patients with kidney disease are often advised to eat a certain diet, optimized for the decreased excretion abilities of their kidney. Foods are often low in protein, phosphorus, calcium, and potassium. Consideration of supplementation with vitamin D, vitamin C, and iron is suggested. Oral medications can be taken by patients to assist with binding bloodstream chemicals and excreting them through the gastrointestinal (GI) tract, compensating for impaired renal function. Such medications are typically phosphate binders, which exist as multiple drug classes, often calcium salts. Newer agents are entering the market which seek to provide the same therapeutic advantage without risk of supplying extra exogenous calcium. Dialysis refers to a process by which fluids and chemicals are removed from the body. The system uses a variety of membranes and fluids of different concentrations for diffusion and osmosis, extracting unwanted substances into the dialysate, effectively removing them from the circulation. Hemodialysis uses an external machine to filter the patient's blood, rapidly removing fluid and solutes. This requires specialized high-volume IV access to the patient with either a catheter or a surgical vascular device. The patient typically requires three sessions of dialysis a week, averaging 3\u20134 hours per session. Home hemodialysis is also possible for a selected patient population. In peritoneal dialysis (PD), the patient's own abdominal contents serve as the membrane rather than those of an external machine. The patient has a permanent catheter through the abdominal wall. Fluid is delivered into the abdomen, allowed to dwell for a period of time, and then extracted by a machine. The fluids infused into the abdominal cavity are specially calibrated to allow for removal of electrolytes and excess body fluid. Typically, the patient will require several exchanges of fluid to reach goal. This is either performed with an automated process during sleep, or can be performed with several extraction/replacements of fluid spaced out throughout the day. An alternative to dialysis in the ESRD patient is renal transplantation. A successful transplant can allow a dialysis-dependent patient to live a nearly normal lifestyle without the need for multiple weekly visits for renal replacement therapy. With this therapeutic option comes a variety of specialized concerns regarding the patient's care. Typically, the patient's new kidney is implanted in the abdominal cavity or pelvis. This has implications for any patient complaining of abdominal pain. A renal cause must be considered. Furthermore, the kidney is not protected in its usual location in the retroperitoneum. The physical exam and focused history after trauma should be mindful of this anatomical difference, although outcomes and injury patterns may not be greater than in the non-transplant patient. As of 2011, approximately 616,000 people in the United States are being treated for ESRD with hemodialysis, a functional renal transplant, or peritoneal dialysis. This represents one in 526 Americans, and one in 2,800 will be newly diagnosed each year. Forty-four percent of newly diagnosed ESRD patients have a history of diabetes and 28% have a history of hypertension, common problems encountered by EMS personnel. African Americans have an incidence of ESRD 3.4 times higher than Caucasians. The annual costs for treating ESRD in the US is more than $49.3 billion, and it takes more than 7.2% of the US Medicare budget. Kidney transplant patients continue to receive immunosuppressive medication to avoid rejection. These patients may not mount a fever with infection and are at risk for atypical and opportunistic infections. Many vague and mild symptoms may be a concerning sign for infection and should warrant careful evaluation. A thorough medication history can alert the provider to the presence of immunosuppression. Similarly, non-compliance with the regimen should lower the threshold for a rejection evaluation.",
        "Complications of renal disease": "Many of the complications of renal failure are more likely to be found in those with no remaining renal function. While possible in the acute renal failure patient, those known to be dialysis dependent more often present to the EMS provider with one of the following acute complications of chronic disease.",
        "Fluid status": "As one of the primary roles of the kidney is regulating fluid balance, those with impaired or absent renal function may present with derangement of their fluid status. In the healthy patient, the kidney filters 180 liters of blood, producing almost 2 liters of extra water and waste products excreted in the form of urine daily. Without the ability to excrete this extra fluid, patients with renal disease may rapidly become fluid overloaded. Much like a patient with congestive heart failure, patients may present in respiratory distress. They may report weight gain, which combined with dyspnea may suggest a state of fluid overload to the provider. Congestive heart failure is a similar condition to the fluid overload in renal disease. Given the comorbid cardiac disease in this population, dyspnea and pulmonary edema may result from either pump failure from a primary cardiac etiology or excretion failure from the poor renal function. Additionally, the ESRD patient may enter a state of high-output heart failure due to the presence of an AV fistula. The inability to clear waste products can also result in a uremic cardiomyopathy. Diagnosis and treatment of fluid overload in this patient population overlap with the heart failure cohort. In the acutely ill patient, management is similar, with use of oxygen and nitrates. Non-invasive positive pressure ventilation or intubation and ventilation may be required for worsening respiratory failure. Field or bedside echocardiogram can provide information regarding the nature of cardiac contractility or pericardial effusion from uremia. Ultimately, dialysis may be required to offload the fluid burden and allow for return to baseline hemodynamic and pulmonary function.",
        "Electrolytes": "The kidney plays a dominant role in regulation of serum electrolyte levels. Renal failure can cause life-threatening imbalances in this chemistry. Medications and diet in the renal patient must be considered for their effects on the patient\u2019s impaired electrolyte regulation.",
        "Potassium": "Perhaps the most well-known and feared complication of renal failure is hyperkalemia. The healthy kidney excretes 95% of the daily potassium intake. Fatal arrhythmias are most likely to occur with serum levels over 9 mEq/L. Of note, the patient with CKD can often tolerate higher levels of potassium than the healthy individual and has lower rates of mortality for any given serum potassium level. In contrast to other electrolytes, the patient with hyperkalemia may not voice any specific complaints. The ECG is often used as a screening test for electrolyte disturbance, but it has overall poor sensitivity and specificity. ECG tracing changes that may be seen in hyperkalemia are listed in Box 24.1. While it is an easy and non-invasive test, the provider must not exclusively rely on an ECG for evaluation of the patient. Specific management of hyperkalemia will be addressed later in the chapter.",
        "Magnesium": "Like potassium, the kidney functions to excrete magnesium from the body. A kidney that is impaired by acute or chronic kidney disease can lose its ability to conserve magnesium, while ESRD implies loss of ability to excrete magnesium. Thus, hypomagnesemia can occur in kidney disease and hypermagnesemia in ESRD. The patient with a magnesium disturbance may have an arrhythmia or ECG disturbance, often related to QT interval changes. Classically, patients with low magnesium have increased reflexes and weakness, while hypermagnesemia is associated with hyporeflexia. Mental status changes and respiratory depression may also occur.",
        "Phosphate": "The kidneys are very effective at eliminating phosphate from the body. Profoundly elevated phosphate levels are relatively unique to the dialysis patient. When phosphate circulates in excess levels in the bloodstream, it can bind and precipitate with calcium, causing symptoms of hypocalcemia such as weakness, increased reflexes, and neurological disturbances. The calcium-phosphate complex can deposit in cardiac tissue, leading to arrhythmia and death.",
        "Pericarditis": "Inflammation of the pericardium with or without effusion is a known complication in the dialysis patient. While uremia predisposes the patient to pericarditis, more classic etiologies such as infections are also possible. A patient with uremic pericarditis may present with chest pain that can be positional in nature and there may be a friction rub on exam. Classic ECG findings may not be present as the inflammatory cells associated with non-infectious uremic pericarditis do not penetrate the myocardium. Cardiac tamponade is a realistic possibility and should be considered in the hypotensive ESRD patient.",
        "Anemia": "Patients with kidney disease are often anemic. Their red blood cell counts tend to be low, with hemoglobin usually less than 10g/dL upon starting dialysis. The cause is multifactorial and includes renal undersecretion of erythropoietin, a hormone responsible for red blood cell production.",
        "Infection": "Patients, especially those on dialysis, have an increased risk for infection, with greater associated morbidity. Those with indwelling devices for dialysis access have an obvious source for contamination and seeding with bacteria. All patients possess a degree of immunodeficiency, partially caused by uremia but also related to nutrition and direct dysfunction of white blood cells. Sepsis is a common manifestation of bacterial infections.",
        "Cardiovascular disease": "A direct relationship exists between the degree of renal dysfunction and the risk of coronary artery disease (CAD). While both kidney disease and heart disease have similar causal factors, unique properties of the renal patient's physiology also impose higher cardiac risk. Such factors as inflammation, oxidative stress, uremia, and metabolic abnormalities contribute to higher CAD incidence and mortality. Diagnosis of cardiac disease can be more difficult in this patient population. Typical ECG findings of ischemia may be subtle due to underlying left ventricular hypertrophic morphologies on the tracing. Stroke is also more common in the renal disease patient than the general population. The risk is increased in patients with more advanced CKD, and even higher rates of stroke exist in the first year after dialysis begins. Both hemodialysis and peritoneal dialysis carry elevated stroke risks, although incidence may be slightly lower for the latter.",
        "Complications of hemodialysis - Hypotension": "Hypotension is common, occurring in 10\u201350% of patients. Often, this is a direct result of fluid shifts from the dialysis procedure. At times, there may be calibration issues and the patient has an overzealous removal of fluid, leaving him or her intravascularly depleted. Additionally, medications and temperature shifts commonly found in the dialysis circuit, combined with the patient's baseline autonomic irritability, contribute to high rates of decreased blood pressure. However, care must be taken not to attribute all postdialysis hypotension to hypovolemia, as these patients are at higher risk for infection and sepsis, cardiac tamponade, bleeding, myocardial ischemia, and heart failure. Treatment of hypotension is directed at the cause. Should dialysis-related hypovolemia be the likely insult, small boluses (250\u2013500 mL) of isotonic IV fluid should be considered, followed by reassessment of the patient for response and any respiratory distress.",
        "Complications of hemodialysis - Air embolism": "Since the patient's vascular circuit is violated and connected to the outside world during hemodialysis, concern exists for the introduction of air into the patient's bloodstream. While small amounts of air into the vascular system can be asymptomatic, larger amounts can cause serious sequelae. It is estimated that 3\u20135 mL/kg of air is the lethal dose. Should air travel through the vasculature toward the brain, it can cause cerebral blood outflow obstruction, leading to increasing intracranial pressure. If the air travels into the right side of the heart and migrates to the lung, it can act as a pulmonary embolism and cause hemodynamic instability. In rare cases, a heart defect could allow air to pass from the right-sided circulation into the arterial flow to the body, leading to stroke or myocardial infarction as an arterial gas embolism. Management of the patient with air embolism requires hemodynamic support, high-flow oxygen, and prevention of further air aspiration. In the rapidly deteriorating patient, there is a role for aspiration of air from the right ventricle. Positioning an affected patient in the left lateral recumbent position (right heart up) may help to stabilize trapped air in the right heart, stopping further embolization. Hyperbaric oxygen has been established as a treatment modality for this disease process in the patient stable enough for therapy.",
        "Complications of hemodialysis - Bleeding": "Patients undergoing hemodialysis have a high-capacity vascular structure accessed multiple times weekly, leading to increased risk of bleeding. Grafts and fistulas have high rates of blood flow and pressure compared to peripheral veins. Aneurysms are rare but can occur, and may catastrophically rupture, causing exsanguination. More common is persistent bleeding after dialysis from the needle insertion site. The patient's underlying platelet dysfunction contributes to difficulty in obtaining hemostasis. Typically, oozing of blood after dialysis will respond to firm pressure for extended periods of time. Immediate use of topical hemostatic compounds can be useful. Failing this, life-saving measures to stop bleeding may need to be implemented, including suturing the wound or applying a proximal tourniquet. Damage control measures such as these may result in permanent damage or loss of the patient's dialysis access and should be considered only in critical situations.",
        "Complications of hemodialysis - Infection (Hemodialysis)": "With the frequency of vascular access comes an increased risk of infection. The specific classes of dialysis access will be discussed later, but all patients with ESRD have higher risk of infection. With vascular access infections occurring in 103 per 1000 patient-years and admissions for sepsis and bacteremia in 116 per 1000 patient-years, the provider must be mindful to consider evaluation for and early treatment of severe infection. When resuscitation with IV fluids is needed on the basis of sepsis and hypotension, it should not be withheld for fear of inducing volume overload in a dialysis-dependent patient. The consequences of fluid overload can be managed, but the consequences of underresuscitation might be more permanent.",
        "Complications of hemodialysis - Dysequilibrium syndrome": "Patients undergoing hemodialysis are at risk for a neurological manifestation of fluid and electrolyte shifts called dysequilibrium syndrome. This syndrome may be severe enough to produce altered consciousness, seizures, or coma, although typically it involves mild symptoms of malaise, nausea, and headaches. This syndrome is a diagnosis of exclusion, as many life-threatening entities can cause similar symptoms. Thus, the renal patient with new onset of these features requires prompt evaluation. Treatment is similar to that of cerebral edema with consideration of IV hypertonic therapy and termination of dialysis.",
        "Medication concerns": "Many pharmacological agents existing today have interactions with the renal system. Frequently, dose adjustments are required in the renal disease patient. As a corollary, dialysis can remove some medications from the circulation, leading to decreased efficacy. Depending on medication timing and properties, patients may have subtherapeutic or supratherapeutic drug levels if prescriptions are not tailored appropriately.",
        "Complications of peritoneal dialysis": "While electrolyte disturbances can occur, they are typically not as severe as in patients on hemodialysis. As the patient's dialysis exchange occurs over a longer period of time, there is less gradient with the dialysate, and thus electrolyte shifts are of a smaller magnitude. The most common complication in peritoneal dialysis (PD) is peritonitis, with a hospitalization rate of 85 per 1000 patient-years. The indwelling abdominal catheter used is a nidus for infection. Patients with peritonitis may complain of abdominal pain or non-specific symptoms of nausea, fatigue, or fever. They may range from being asymptomatic to frankly septic, with guarding of the abdomen and hypotension. One clue to peritonitis is a change in the fluid coming from the catheter during a fluid exchange. The fluid used for dialysis in PD often contains high amounts of glucose, drawing water out of the body. In rare cases, patients can absorb the glucose and present with a hyperglycemic, hyperosmolar state and critical illness from the same. Peritoneal dialysis patients have the highest rate of admission for any infection, with 558 cases per 1000 patient-years in 2010. The rate of admission for peritonitis is 85 per 1000 patient-years, and for peritoneal catheter infections it is 152 infections per 1000 patient-years.",
        "The missed dialysis patient": "Non-compliance with dialysis is known to occur about 33% of the time, with some studies indicating 50% of patients not following some portion of their dialysis instructions [22]. Younger patients and smokers consistently are found to have higher rates of compliance issues [22,23]. As these patients require dialysis to sustain life, the patient who has missed a session (or several) is at higher risk for deterioration.\n\nWhen a patient who admits to having missed dialysis sessions presents to the EMS provider, the more likely pathophysiology and required treatments can be inferred. Should the patient present in respiratory distress, the potential for fluid overload exists, and management can be multimodal. Non-invasive positive pressure ventilation can be implemented in the awake patient, using continuous positive airway pressure (CPAP)/bilevel positive airway pressure (BiPAP) to improve oxygenation [24]. Consideration of nitroglycerin or other vasodilators is an option, facilitating fluid shifts by increasing venous capacitance. In the setting of uncomplicated fluid overload from dialysis non-compliance, the patient should be hypertensive and tolerate nitrates well [24]. Should the patient be exhibiting signs of cardiogenic shock, consideration of pericardial tamponade should ensue.\n\nDiuretics such as furosemide can be used in the renal disease patient, provided he or she makes urine. Careful assessment of the patient\u2019s volume status should be made, as giving diuretics to an intravascularly depleted patient can worsen renal function. In the euvolemic or hypervolemic patient, higher than average doses of diuretic will be needed to overcome renal dysfunction ",
        "The hyperkalemia patient": "Dialysis-dependent patients are already at risk for hyperkalemia; those who miss one or more regular sessions are at much greater risk. If the patient presents with arrhythmia, hypotension, or obvious ECG changes, empiric management of hyperkalemia is warranted. Intravenous calcium is administered to stabilize the cardiac membrane. This therapy lasts 30\u201360 minutes, and may require redosing depending on transport times. Ampules of sodium bicarbonate given as a slow IV push help alkalinize the blood and promote the shift of potassium intracellularly. It can also be administered as an infusion with a concentration of 150 mmol/L (typically 3 ampules in a liter of D5W), with caution for fluid overload. Albuterol can also be administered to shift potassium from plasma; it is non-invasive and easy to deliver, although its onset is slower and may cause tachyarrhythmia. Regardless of the medication(s) used in the field, definitive management will still be required, as these therapies are only temporary. These treatments shift potassium rather than remove it, so total body potassium does not decrease. Communication with the receiving providers is essential, as serum potassium assays may give falsely reassuring results.",
        "Vascular access": "All hemodialysis patients require specialized vascular devices to allow for rapid infusion and removal of blood. These devices must be able to support over 350mL/min of blood flow, with some patients achieving rates of 600\u20131200mL/min. A variety of devices are commonly used today. Nephrologists often prefer that the patient\u2019s dialysis access not be used except in extreme emergency (e.g. cardiac arrest resuscitation). Patients are advised to avoid use of blood pressure cuffs, tourniquets, and venepuncture distal to their devices, and will typically convey this concern to EMS personnel.",
        "Arteriovenous fistula": "A surgically created connection between an artery and a vein, usually the brachial or radial artery to the cephalic vein. It takes over 4 weeks (and often more than 8 weeks depending on local practices) to mature and be ready to use. A patient may have a fistula created and be in the process of maturation while using a different device for dialysis.",
        "Arteriovenous graft": "Similar to a fistula, the artery and the vein are connected by way of a synthetic device. It is more prone to complication than the fistula.",
        "Tunneled catheter": "A large IV catheter that accesses a central vein, usually the internal jugular. Prior to entering the vein, the catheter is run through the skin and soft tissue from a different site. In doing so, this can reduce infection and need for frequent dressing changes. These catheters are often held in place by balloons and other securing devices. This method has the advantage that it is immediately available for use once inserted. Compared to other long-term methods of venous access, the catheter has the highest rates of complication and mortality.",
        "Non-tunneled catheter": "A large-bore IV in a central vein with two ports. Usually used as a temporary measure as a bridge to a different device.",
        "Complications of vascular devices": "The hemodialysis access site is effectively a large vascular structure that undergoes multiple punctures a week in a patient with underlying hemodynamic, hematological, and immunological compromise. Screening for complication and failure can occur through a careful evaluation and history. Thrombosis of the device may be reported by the patient or staff who find they were unable to obtain blood flow during a dialysis session. In the case of the AV fistula, one should palpate and auscultate the site for presence of a thrill and bruit indicating proper function. Interventional procedures to remove thrombosis from the device may cause migration of the clot, leading to pulmonary embolism. This should be considered in the acutely short of breath dialysis patient status post device manipulation. Hemorrhage is easily recognized on physical exam and usually results from delayed hemostasis after hemodialysis. Development and rupture of an aneurysm is rare and requires prompt surgical evaluation. Immediate management of bleeding from the dialysis access site involves direct and constant pressure on the epicenter of the bleed. As there are higher pressures in this location than at typical cutaneous bleeds, one must be mindful to not allow thick loose gauze dressings to absorb and mask ongoing bleeding. Specialized clamp devices exist to deliver hands-free pressure to the bleed. A low-cost solution exists by using a glass spherical marble on the puncture site and tightly wrapped gauze forming a pressure dressing. The ill-appearing ESRD patient may be suffering from bloodstream infection, possibly related to the access device. Inspection of the skin overlying a fistula or graft or around the entry point of a catheter may provide valuable clues.",
        "Fluid resuscitation": "Administration of fluids to the renal patient should be performed with careful consideration of cardiopulmonary reserve. This does not mean that necessary fluids should be withheld, for example when resuscitating a septic patient. Rather, clinicians should be aware that standard 1L bags of isotonic fluids may represent too much of a bolus volume without an intervening assessment. Patients should receive serial smaller aliquots of IV fluids, delivered rapidly, with frequent reassessments to assess ongoing needs. The EMS provider should clearly communicate fluid volumes administered to the ED staff.",
        "Cardiac or respiratory arrest": "Specific consideration of the patient's electrolyte status must be made. A hyperkalemic cardiac arrest is a realistic possibility in the dialysis patient. While not routinely used in algorithms for resuscitation, sodium bicarbonate could be considered for empiric shift of potassium. Calcium chloride or gluconate should also be considered. Should the renal patient require rapid sequence intubation for airway management, the choice of neuromuscular blockade agent needs to take into account potassium levels and the well-documented hyperkalemic effects of succinylcholine. In other words, unless the serum potassium level is known, succinylcholine is best avoided.",
        "EMS pearls": "When the EMS provider encounters a dialysis patient, a set of focused questions from the patient and any family/medical staff present can greatly assist in their hospital care. Dialysis schedule. Knowing what days of the week the patient has dialysis, as well as the day of their last session, is useful. Length of sessions. Attempt to determine how many hours each dialysis session is, as well as if the patient is completing the full length each time, with attention to the last session. Weights. Patients should have a known 'dry weight,' which is the ideal euvolemic weight of the patient. Additionally, knowing the patient's current weight can greatly help with fluid status assessment. The patient may also be able to state how much weight/fluid is removed with each dialysis. Vitals. Dialysis patients may have abnormal vitals at their baseline and if so, careful documentation of their normal heart rate and blood pressure is important.",
        "Destination selection": "Should a patient with ESRD require transport, it may be necessary to choose a destination hospital that can care for his or her needs. Even if the patient is not presenting to EMS for a dialysis-related complaint, should he/she require hospital admission, he/she will eventually need renal replacement therapy. The higher incidence of CAD and stroke may necessitate specialty care more often than the otherwise healthy non-dialysis patient. Local protocols may be beneficial to facilitate triage to the appropriate facility.",
        "Resource preplanning": "The individual in the community who is dialysis dependent requires unique resources for his or her survival. Under normal conditions the patient likely has established mechanisms for obtaining transportation and treatment, but this system can be disrupted in the case of disaster. The local emergency management agency should work alongside medical directors and the dialysis providers to develop contingency plans appropriate for the local environment. Other government and local agencies will need to contribute to this planning process, as operation of a hemodialysis machine requires infrastructure that is easily disrupted. Identification and registry of the patients who will require emergency dialysis services in times of need can allow for continued access to life-sustaining care.",
        "Convalescent transportation": "Hemodialysis patients in particular have a frequent need for transportation to a medical facility. Patients may require assistance in this regard, relying on non-emergency transportation services. There exists a wide variety in the training level of personnel handling this form of transportation. Providers in this field may become well acquainted with the dialysis patients and be able to recognize subtle changes in their condition which may require diversion to a higher level of care. Protocols should be established to assist these caregivers in the recognition of emergencies in this high-risk population. If the particular transport unit does not possess the capabilities to care for emergency medical conditions, the provider should know the best method of accessing the resources required to do so."
    },
    {
        "Introduction": "In the United States, someone experiences a myocardial infarction every 26 seconds, and alarmingly the disease claims one life each minute. Acute myocardial infarction (AMI) accounts for almost five times as many deaths in the United States as are attributed to unintentional injuries, which has major implications for EMS systems. About half of those who suffer acute myocardial infarctions are transported to the hospital by EMS, and many more patients call EMS for help because they are experiencing chest pain. The prehospital management of chest pain has improved with better clinical examination, earlier administration of effective medications, and the broad use of 12-lead ECGs to detect acute coronary syndromes (ACS) and myocardial infarction more accurately before arrival in the emergency department (ED). Because more rapid reperfusion during acute myocardial infarction improves heart function and patient survival, EMS and health care systems have focused on developing strategies to identify chest pain patients with myocardial infarction quickly and to provide effective treatment while transporting them directly to definitive care. The goals of management for patients with chest pain include rapid identification of patients with ACS, relief of their symptoms, and transport to an appropriate hospital. This chapter will cover the assessment and treatment of patients with a chief complaint of chest pain and will focus on the scientific basis for prehospital medical care of those patients. It will also review common conditions that can cause chest pain.",
        "General approach": "When evaluating a patient with a complaint of chest pain, EMS professionals should begin by assessing the patient's stability and then obtain a basic clinical history and examination. Early in the assessment, an EMS provider should apply a cardiac monitor to rapidly identify dysrhythmias, perform a diagnostic 12-lead ECG, and administer specific treatment depending on the results of the initial evaluation. Because only a small minority of the patients with chest pain actually have ACS, maintaining vigilance in this assessment and diagnostic routine can be difficult. Complete accuracy in the diagnosis of chest pain is not always possible in any setting, not even in the hospital. The prehospital provider should not expect to diagnose a patient with a complaint of chest pain definitively. A careful history can lead the provider to a correct \u201ccategory\u201d of diagnosis much of the time. As a general approach, the patient should be treated as if he or she has the most likely serious illness consistent with the signs and symptoms. Discomfort due to cardiac ischemia is usually, but not always, substernal and may radiate to the shoulder, either arm, both arms, upper abdomen, back, or jaw. Other symptoms such as nausea and diaphoresis are commonly present but do not predict the presence or absence of ACS accurately. Cardiac disease is most often seen beginning in middle-aged men and older women. However, even younger adults under the age of 40 with no cardiac risk factors and a normal ECG have a 1\u20132% risk of ACS. Taking a focused history using the \u201cPQRST method\u201d can be helpful. There are many causes of chest pain and their incidence changes depending on the characteristics of the population being studied. Patients calling on EMS are more likely to have acute myocardial infarction or other serious causes of chest pain than are patients in the general emergency department (ED) population. Although the majority of this chapter focuses on the management of an ACS, other causes of chest pain are present more commonly.",
        "Role of emergency medical dispatch": "Prehospital care of the patient with a complaint of chest pain begins at emergency medical dispatch. Identification of patients suspected to have ACS allows an EMS system to send advanced-level providers to the patient. Many EMS systems with both basic and advanced-level ambulances use a trained emergency medical call taker who asks the caller a series of questions to determine the nature of the emergency and the likelihood that advanced-level care will be needed. A retrospective cohort study from England took a rigorous approach to determining the accuracy of one set of dispatcher questions in identifying patients with ACS. About 8% of calls at the \u201c9-9-9\u201d center were classified as \u201cchest pain.\u201d Subsequent chart review at the hospital identified all patients with the ultimate diagnosis of ACS and found that this represented only 0.6% of all 9-9-9 patients. About 80% of the ACS patients were classified correctly as chest pain at the dispatch level. Another 7% were classified in a variety of other categories that still received a paramedic level response (e.g. severe respiratory distress). Sensitivity of the dispatch system for detecting ACS was 71% and specificity was 93%. However, a great deal of overtriage occurred, and the positive predictive value of the dispatch system for detecting ACS was only 6%. Additional refinement of the dispatch question sequence to reduce overtriage seems possible. The emergency dispatch question sequence for stroke performs much better, with a positive predictive value of 42% and a similar sensitivity to ACS at 83%. The American Heart Association (AHA) and American College of Cardiology (ACC) recommend that emergency medical dispatchers prompt patients with non-traumatic chest pain to take aspirin if they have no contraindications while awaiting EMS arrival. This recommendation is based on extrapolation from data showing that patients who take aspirin before hospital arrival are less likely to die and that the practice is likely quite safe.",
        "The 12-lead electrocardiogram": "The 12-lead ECG remains the quickest method of detecting myocardial ischemia or infarction. Although ECGs have been used to diagnose ACS since 1932, the technology has now advanced to the point that a prehospital ECG can be done quickly and accurately and can be sent wirelessly to the receiving hospital at a relatively low cost. Additional benefit can be gained by having the prehospital ECG become the first of a series of ECGs, increasing the sensitivity of diagnosis of coronary syndromes. Performing a prehospital ECG on a patient exhibiting signs and symptoms of ACS is a Class I AHA/ACC recommendation. This recommendation is based on evidence demonstrating that, despite at most slightly increased time spent on scene for patients receiving ECGs, the time to definitive treatment for ST-elevation myocardial infarction (STEMI) with fibrinolysis or percutaneous coronary intervention (PCI) is shortened overall, with a significant reduction in mortality.",
        "Prehospital electrocardiogram: interpretation": "With the ease of obtaining a prehospital 12-lead ECG comes the need for its accurate interpretation. Precise interpretations can influence decisions to transport patients to more appropriate but more distant facilities, as well as immediate management strategies on hospital arrival. A 12-lead ECG is required to diagnose STEMI and can often provide evidence that ACS is present. Currently three methods of out-of-hospital ECG interpretation exist: computer algorithms integrated into the ECG machine, direct interpretation by paramedics, or wireless transmission of the ECG to a physician for interpretation. One, two, or all three can be used in a given EMS system. All prehospital 12-lead ECG machines contain computer programs that will interpret the ECG, and the machines can be configured to print the interpretation on the ECG. If this technology is sufficiently sensitive and specific for STEMI, the EMS professionals would theoretically not require education in interpretation, which would allow EMS systems to use advanced- and basic-level providers to acquire 12-lead ECGs. Additional benefits of using the computer\u2019s interpretation include avoidance of the technical issues and cost of establishing base stations dedicated to receiving incoming ECGs, as well as the provision of consistent interpretation that does not depend on the variable skills and experience of EMS providers. Many prehospital 12-lead ECG systems use computerized interpretation systems which have high specificity, but the computer interpretation alone can miss up to 20% of true STEMI events. Despite the high specificity, many emergency physicians and cardiologists do not place enough trust in the computer interpretation alone to routinely activate the cardiac catheterization PCI team that can provide rapid reperfusion treatment for a STEMI patient. EMS provider interpretation is another option. More extensive training is required, and interpretation accuracy can be affected by both experience and interest in the subject matter. Although several studies have shown that trained paramedics can accurately interpret the presence of STEMI, experience also plays an important role. Having a paramedic identify and report \u201ctombstones\u201d on the 12-lead is a powerful motivator for action by experienced physicians.\n\n The third method of interpretation is by transmission of the acquired ECG to a base station for interpretation by a physician. This method has generally been used as the gold standard when comparing other methods of interpretation, and its accuracy has been shown to be slightly better than other methods. It relies both on the availability of the interpreting physician and on an infrastructure that allows reliable transmission of the ECG. In one observational cohort study, positive predictive value of prehospital 12-lead ECGs was improved by transmitting them to emergency physicians compared with interpretation solely by paramedics. In some cases automated systems have been developed that allow simultaneous transmission of the 12-lead ECG to the receiving ED and to an invasive cardiologist on call. These systems have the potential to decrease treatment times further because both the ED staff and the PCI team are activated early. The AHA guidelines state that the ECG may be transmitted for remote interpretation by a physician or screened for STEMI by properly trained paramedics, with or without the assistance of computer interpretation. Advance notification should be provided to the receiving hospital for patients identified as having STEMI. Implementation of 12-lead ECG diagnostic programs with concurrent medically directed quality assurance is recommended. No diagnostic test is perfect, and the 12-lead ECG is no exception. There are a number of conditions other than acute myocardial infarction that can cause ST-segment elevation, such as left bundle branch block and hyperkalemia. Some of the differences between STEMI and the mimics of acute ST-segment elevation are subtle and missed easily.",
        "Oxygen": "Despite its historical use, the evidence review leading up to the 2010 AHA guidelines did not find sufficient evidence to recommend the routine use of oxygen therapy in patients with uncomplicated AMI or ACS who have no signs of hypoxemia or heart failure. The guidelines do, however, recommend oxygen administration if the patient is dyspneic, or has an arterial oxyhemoglobin saturation <94%, signs of heart failure, or shock.",
        "Medications": "Several medications are important for EMS management of the patient with chest pain. Providing the chest pain patient with medication for relief of pain whenever safe and feasible and regardless of the etiology of the pain is fundamental. Treatment of pain reduces anxiety in addition to relieving the patient's discomfort. For ACS patients, treatment of pain can reduce catecholamine levels and thus improve the balance between oxygen demand and supply for ischemic cardiac muscle.",
        "Aspirin": "Aspirin is inexpensive, readily available, and has been shown to benefit patients having myocardial infarction or other ACS. The ISIS-2 study established that the absolute benefit of aspirin administration for myocardial infarction patients results in 26 fewer deaths per 1,000 patients treated, with the maximum benefit occurring in the first 4 hours. Prehospital administration of aspirin is safe and may improve outcome, and should be given as soon as possible to patients with suspected ACS unless contraindicated. Varying doses of aspirin have been proposed, but for ACS the most widely used dose is four 81 mg baby aspirin tablets. These tablets are well tolerated, easy to swallow, and more rapidly absorbed than other preparations. Rectal preparations (300 mg) should be considered in patients unable to swallow. Acceptable contraindications to aspirin administration include definitive aspirin allergy or a history of active gastrointestinal bleeding.",
        "Nitroglycerin": "Nitroglycerin is a time-honored treatment to relieve chest pain due to angina by decreasing myocardial oxygen demand and increasing collateral blood flow to ischemic areas of the heart. Somewhat surprisingly, nitroglycerin is not effective at reducing STEMI patient mortality, nor is the response, or lack thereof, to nitroglycerin administration an accurate diagnostic test to determine whether cardiac ischemia is the underlying cause of a patient's chest pain. For example, because it relaxes smooth muscle, nitroglycerin may also relieve pain in patients with esophageal spasm. Nitroglycerin can be administered as sublingual tablets or an oral spray. The usual dose of either method of delivery is 0.4 mg. Although up to three doses can be given at an interval of 5 minutes between doses, current AHA/ACC recommendations for self-administered patient use of nitroglycerin is for them to call EMS if chest pain is not improved 5 minutes after only a single dose of nitroglycerin to avoid a 15\u201320-minute delay before activating the EMS system among STEMI patients. Nitroglycerin should be avoided in several groups of patients with chest pain. Patients who have used phosphodiesterase inhibitors and then take nitrates can have profound, refractory hypotension. Nitrates generally should be avoided for 24 hours following sildenafil or vardenafil use, and for 48 hours following tadalafil use. Patients with right ventricular infarction are dependent on right ventricular filling pressure to maintain cardiac output and a normal systolic blood pressure. If the patient has a systolic blood pressure below 100 mmHg or a heart rate below 60 beats per minute, nitroglycerin should be avoided until a 12-lead ECG, including right-sided leads, documents the absence of a right ventricular infarction. Nitroglycerin should also be avoided in patients who already have systolic blood pressures <90 mmHg or heart rates <50 or >100 beats per minute.",
        "Morphine sulfate": "A large retrospective case series of hospitalized patients with non-ST segment elevation ACS found that patients who received morphine had a higher mortality than those who did not. It is unclear whether this was a causal effect or simply indicated that those who required morphine may have had more severe disease. The AHA/ACC treatment guidelines for patients with unstable angina or non-ST-elevation MI (NSTEMI) reduce the strength of recommendation for morphine from Class I to Class IIa for patients with NSTEMI. The 2013 AHA/ACC STEMI guidelines give morphine a Class I recommendation in STEMI patients because those patients are going to have reperfusion therapy. The recommended dose of morphine in the patient with chest pain is 2\u20134 mg intravenously with increments of 2\u20138 mg intravenously repeated at 5\u201315-minute intervals when pain is not adequately controlled with nitroglycerin.",
        "Beta-blockers": "Older guidelines recommended IV beta-blocker (typically metoprolol) administration early in the course of acute myocardial infarction because of data suggesting reduced rates of reinfarction and recurrent ischemia when patients received both fibrinolitics and IV beta-blockers. A large placebo-controlled randomized trial showed that the effect of beta-blockers in reducing arrhythmic events is equally offset by an increase in development of cardiogenic shock, and survival is similar regardless of early administration of intravenous beta-blockers. Current AHA/ACC recommendations for administration of intravenous beta-blockers in the setting of STEMI are limited to patients who are hypertensive or have ongoing ischemia with no contraindications to their use. On balance, the guidelines suggest that the need for prehospital administration of beta-blockers to patients with STEMI is limited.",
        "Prehospital fibrinolysis": "Since fibrinolitics were introduced to emergency cardiac care in the mid-1980s, some have proposed initiating these drugs in the prehospital setting. Several studies published in the early 1990s showed that the strategy was feasible and that it could decrease mortality from STEMI in settings that had relatively long EMS response and/or transport time intervals. Additional studies reinforced the original findings, and a metaanalysis of pooled results from six randomized trials enrolling more than 6,000 subjects concluded that prehospital initiation of fibrinolitics decreased all-cause mortality by shortening initiation of treatment by 58 minutes. Few systems in the United States have implemented prehospital fibrinolysis, although additional research has continued to show time savings over in-hospital treatment. In Europe, particularly where there are often physician-staffed ambulances, prehospital fibrinolysis is used more frequently. A primary reason why prehospital fibrinolysis is not used regularly in the United States has been a shift in favor of primary PCI for treatment of STEMI. In a prospective observational cohort study of 26,205 consecutive patients with STEMI in Sweden, representing about 95% of the population of STEMI patients in the country, those who were treated with primary PCI had lower 30-day mortality than those treated with fibrinolytics in the hospital (4.9% versus 11.4%). Primary PCI patients also had lower mortality than those treated with prehospital fibrinolitics (4.9% versus 7.6%). Several large clinical trials have examined the strategy of transferring patients to a PCI-capable institution from a local hospital compared with administration of fibrinolytics at the local hospital. A metaanalysis of six large studies involving 3,750 patients showed that timely transfer for primary PCI strategy is superior in reducing rates of reinfarction, stroke, and the combined end-point criteria of death, reinfarction, or stroke. For situations in which transfer directly to a center capable of primary PCI is not possible in a timely fashion, a strategy of prehospital or non-PCI hospital-based fibrinolysis is reasonable. The available science suggests that the drugs can be safely administered by full-time paramedics or EMS physicians in the field. The EMS system should have a medical director with experience in STEMI management and a well-organized quality assurance program.",
        "Systems of care for ST-elevation myocardial infarction": "The EMS system plays a key role in shortening the process of caring for patients with STEMI. Patients who are transported by EMS have shorter treatment intervals than those of patients who arrive at the hospital by other means. Patients can be encouraged to use EMS appropriately. A community intervention to shorten the time interval from symptom onset to ED arrival was shown to increase the proportion of ACS patients who used EMS for transport to the ED.",
        "Prehospital notification and field cardiac catheterization laboratory activation": "A key benefit of a prehospital 12-lead ECG is notification of the receiving facility of an impending STEMI patient's arrival. Shortening door-to-balloon time by 30 minutes reduces in-hospital mortality from STEMI by about 1%. Implementation of a prehospital 12-lead ECG program with prehospital notification shortened door-to-balloon times by about 60 minutes in San Diego. In an evaluation of a large patient registry, prehospital notification with ED activation of the catheterization team before patient arrival at the hospital shortened door-to-balloon time by about 15 minutes. Occasional false-positive activation of the PCI team is a necessary byproduct of an aggressive field approach to alerting hospitals about patients with suspected STEMI. One report suggests that up to 15\u201320% of team activations may not result in any intervention. The rate of false-positive activations depends on the pretest probability of finding a STEMI. If EMS providers perform 12-lead ECGs broadly (e.g., everyone over the age of 30 with any of the following characteristics: chest pain, shortness of breath, abdominal pain, diabetes, or cardiac history), such that the prevalence of actual STEMI is between 0.5% and 5%, then the positive predictive value of a \u201cSTEMI-positive\u201d prehospital 12-lead ECG may be around 50%. Such a system would result in more false-positive than true-positive activations of the PCI team. When patients have a reasonable likelihood of STEMI based on their clinical presentations and 12-lead ECG findings, prehospital cardiac catheterization PCI team activation has consistently been shown to shorten time to definitive treatment of STEMI patients considerably. For example, Nestler et al. showed that prehospital activation of the catheterization laboratory reduced the median door-to-balloon times from 59 to 32 minutes. Cone et al. found that field activation of the catheterization laboratory was associated with 37 and 35 minute shorter door-to-balloon times than ED activation for walk-in STEMI patients or STEMI patients arriving by EMS without field activation, respectively. In addition, field activation of the catheterization laboratory was associated with better compliance with 90-minute STEMI treatment benchmarks. Finally, Horvath et al. found similar reduction in the door-to-balloon times (44 versus 57 minutes) in EMS-transported STEMI patients who had prehospital activation of the cardiac catheterization laboratory compared to those who had the laboratory activated after ED arrival. In summary, field activation of the cardiac catheterization laboratory when a prehospital ECG shows evidence of STEMI is strongly supported by published data. EMS systems should work with their PCI-capable hospitals to establish cardiac catheterization laboratory prehospital STEMI activation protocols and quality improvement monitoring.",
        "Destination protocols": "Almost 80% of the adult population of the United States lives within 60 driving minutes of a PCI-capable center. Of those patients whose closest hospital is not capable of PCI, 74% require additional transport time less than 30 minutes to reach a PCI-capable institution. Therefore, several urban communities have developed protocols to encourage EMS to transport STEMI patients directly to hospitals with 24/7 capability to perform PCI. In Ottawa, a STEMI bypass protocol for EMS was implemented in May 2005. Paramedics performed a 12-lead ECG, and if STEMI was identified in a hemodynamically stable patient, the patient was transported directly to the region\u2019s single cardiac center catheterization lab with prehospital notification of the impending arrival of the STEMI patient, often bypassing one of the four other EDs in the city. The median first door-to-balloon time was 69 minutes for patients brought to the catheterization lab directly by EMS, compared with 123 minutes for those needing interhospital transfer. In The Netherlands, prehospital identification of patients with STEMI and transport to a PCI-capable center bypassing other EDs was associated with improved left ventricular function. Some systems are directing EMS to take STEMI patients directly to the heart catheterization lab, bypassing the ED. The strategy reduces door-to-balloon time up to 60 minutes. In more rural settings without available PCI centers, coordinated programs with regional STEMI receiving centers can achieve remarkable door-to-balloon times, even when measuring from the first door (i.e., the door of the rural ED). Two reports from Minnesota show that excellent treatment times can be achieved. In the Minneapolis area, the median first door-to-balloon time was 95 minutes if the referring hospital was less than 60 miles from the PCI center and 120 minutes if the referring hospital was further away. In the Mayo Clinic STEMI system, patients were transferred from 28 regional hospitals up to 150 miles away from the PCI center. The median first door-to-balloon time for the transferred patients was 116 minutes.",
        "Air medical evacuation of ST-elevation myocardial infarction patients": "A key to a successful regional STEMI system is ready access to air medical transport. Rapid transport of the patient by highly skilled teams in medical helicopters can save significant time from the first door to balloon. Some air medical programs are working closely with referring hospitals and ground EMS systems to dispatch helicopters before arrival of a STEMI patient at a referring hospital.",
        "Expanding the role of Basic Life Support providers": "Many prearrival 9-1-1 instructions already direct callers to take aspirin if they have chest pain. Allowing BLS providers to administer aspirin, if not contraindicated, and if permitted by EMS laws and regulations, seems the next logical step. One reason stated for the lack of aspirin administration to eligible ACS patients is the inability of BLS providers to administer it based on local protocols or regulations. Basic Life Support providers can be taught to acquire and transmit 12-lead ECGs. This approach may be particularly beneficial in rural areas, with scant ALS coverage and long transport times to definitive care. Using the 12-lead ECG to triage STEMI patients to air transport from the scene may lead to improved cardiac care in rural areas and more efficient use of available resources.",
        "Other common causes of chest discomfort": "Although most of the available prehospital interventions for chest pain are focused on the identification and treatment of ischemic cardiac disease, the majority of EMS chest pain patients will have other causes for their symptoms, some of which are also immediate threats to life. A chest pain protocol should focus on treatments that may benefit the ACS/STEMI patient while considering the effects of these treatments on other causes of chest pain.",
        "Aortic dissection": "Acute aortic dissection classically causes sudden pain in the chest, sometimes radiating to the back. The dissection is caused by a tear in the intimal lining of the aorta with entry of high-pressure blood into the wall of the aorta. The dissection propagates distally and sometimes also proximally. If the dissection extends around the origin of a peripheral artery, then that vessel can be partially or completely occluded, creating a >15\u201320 mmHg difference in blood pressures between both patient arms. If the origin of a carotid or vertebral artery is occluded, then the patient may develop neurological signs suggesting a stroke. Occlusion of a spinal artery off the aorta can cause acute paralysis of both legs. Most patients with dissection have long-standing hypertension, but the problem can occur in younger patients with other conditions such as Marfan syndrome. In the majority of cases of aortic dissection, the 12-lead ECG will be abnormal, but will not show ST-segment elevation unless the origin of a coronary artery is occluded by the dissection. Without imaging capability that exists in the hospital, EMS providers may suspect, but cannot identify, aortic dissection definitively. If aortic dissection is suspected, morphine can be used for pain control but aspirin should be avoided since patients with acute aortic syndrome who receive antithrombotic agents such as aspirin or fibrinolytics are more likely to bleed.",
        "Pericarditis": "Individuals with pericarditis may present to EMS with ST-segment elevation on an ECG that looks similar to an extensive myocardial infarction. Administration of fibrinolytics in this condition may be fatal because these patients can bleed into the pericardial sac, resulting in pericardial tamponade. Aspirin administration is somewhat less concerning because antiinflammatory medications are part of the recommended treatment.",
        "Pneumothorax": "A pneumothorax may cause chest pain, shortness of breath, hypoxia, and diaphoresis. Clinical signs may point more to this diagnosis than to acute myocardial infarction. EMS systems should have a separate protocol for management of a pneumothorax. Oxygen and morphine may help the patient. Nitroglycerin should be avoided because it can cause hypotension by further decreasing venous return if the patient is developing a tension pneumothorax. If a developing tension pneumothorax is evident, needle decompression is required.",
        "Pulmonary embolism": "Pulmonary embolism is a great masquerader because its symptoms may be similar to those of other causes of chest pain and shortness of breath. Its presentation can easily be confused with myocardial infarction or anxiety. Treatment should focus on maximizing oxygenation to the patient. If pulmonary embolism is suspected, nitroglycerin should be avoided because it can cause significant hypotension. Administration of fibrinolytics may potentially benefit the patient, but it is preferable to delay administration until the patient has reached a hospital and undergone a definitive diagnostic imaging study.",
        "Esophageal perforation": "A patient with a perforated esophagus may present with chest pain. A careful and focused history and examination will often help differentiate this condition from other causes of chest pain. Nitroglycerin should be avoided because it may cause significant hypotension, and fibrinolytics are contraindicated because of the need for immediate surgery.",
        "Conclusion": "Quality prehospital care of patients with chest pain can relieve discomfort and improve outcome. EMS systems should have the capability to perform prehospital 12-lead ECGs and regional protocols should focus on delivering patients with STEMI to PCI centers promptly. Prehospital activation of the cardiac catheterization laboratory is highly effective at shortening the time to definitive reperfusion treatment and should be encouraged."
    },
    {
        "Learning objectives": "After reading this chapter, and completing the class activities, you will have the information needed to:\n\u2022 Identify behavior that suggests a person may be experiencing a behavioral emergency.\n\u2022 Describe how to approach and care for a patient experiencing a behavioral change or psychological crisis.\n\u2022 Make appropriate decisions about care when given an example of an emergency in which someone is experiencing a behavioral emergency.\n\u2022 Identify risk factors for suicide.\n\u2022 Describe how to assess a patient who is contemplating or has already attempted violence toward themselves.",
        "Key Terms": "Anxiety disorder: A condition in which normal anxiety becomes excessive and can prevent people from functioning normally; types include generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, phobias and social-anxiety disorder., Behavior: How people conduct themselves or respond to their environment., Behavioral emergency: A situation in which a person exhibits abnormal behavior that is unacceptable or intolerable, for example violence to oneself or others., Bipolar disorder: A brain disorder that causes abnormal, severe shifts in mood, energy and a person\u2019s ability to function; the person swings from the extreme lows of depression to the highs of mania; also called manic-depressive disorder., Child abuse: Action that results in the physical or psychological harm of a child; can be physical, sexual, verbal and/or emotional., Child neglect: The most frequently reported type of abuse in which a parent or legal guardian fails to provide the necessary, age-appropriate care to a child; insufficient medical or emotional attention or respect given to a child., Clinical depression: A mood disorder in which feelings of sadness, loss, anger or frustration interfere with everyday life for an extended period of time., Elder abuse: Action that results in the physical or psychological harm of an older adult; can be physical, sexual, verbal and/or emotional, usually on someone who is disabled or frail., Elder neglect: A type of abuse in which a caregiver fails to provide the necessary care to an older adult., Hallucination: Perception of an object with no reality; occurs when a person is awake and conscious; may be visual, auditory or tactile., Mania: An aspect of bipolar disorder characterized by elation, hyperexcitability and accelerated thoughts, speech and actions., Panic: A symptom of an anxiety disorder, characterized by episodes of intense fear and physical symptoms such as chest pain, heart palpitations, shortness of breath and dizziness., Paranoia: A condition characterized by feelings of persecution and exaggerated notions of perceived threat; may be part of many mental health disorders and is rarely seen in isolation., Phobia: A type of anxiety disorder characterized by strong, irrational fears of objects or situations that are usually harmless; may trigger an anxiety or panic attack., Rape: Non-consensual sexual intercourse often performed using force, threat or violence., Rape-trauma syndrome: The three stages a victim typically goes through following a rape: acute, outward adjustment and resolution; a common response to rape., Schizophrenia: A chronic mental illness in which the person hears voices or feels that their thoughts are being controlled by others; can cause hallucinations, delusions, disordered thinking, movement disorders and social withdrawal., Self-mutilation: Self-injury; deliberate harm to one\u2019s own body used as an unhealthy coping mechanism to deal with overwhelming negative emotions., Sexual assault: Any form of sexualized contact with another person without consent and performed using force, coercion or threat., Suicide: An intentional act to end one\u2019s own life, usually as a result of feeling there are no other options available to resolve one\u2019s problems.",
        "INTRODUCTION": "Behavior is how people conduct themselves or respond to their environment. A behavioral emergency is a situation in which a patient exhibits abnormal behavior that is unacceptable or intolerable. Such is often the case with people who become violent, attempt to take their own lives or believe that other people are out to harm them. A behavioral emergency can pose unique problems that, as an emergency medical responder (EMR), you will have to manage.",
        "BEHAVIORAL EMERGENCIES": "A behavioral emergency can be present in someone who acts abnormally, or in ways that are unacceptable or dangerous to themselves, their family or the community at large. People exhibiting abnormal behavior may be violent toward themselves or others. They may appear agitated or speak in a rapid or incoherent manner, or they may be subdued or withdrawn. They may also appear to be intoxicated.",
        "Assessment": "Assume that a patient with a behavioral emergency has an altered mental status. Size up the scene to gather information relevant to safety. Consider the mechanism of injury (MOI) or nature of illness. When it is safe to enter the scene, remain cautious as you approach the person. Just because the scene may appear safe does not necessarily mean that it is. A person may be carrying a weapon or other object, or have one nearby, that could cause injury. Always be prepared for any potential threat, keep your eyes on the person and never turn your back. Observe the person\u2019s general appearance and behavior as you talk. Determine the person\u2019s level of consciousness (LOC) and activity level. Is the person active or subdued? How does the person speak? Explain what you would like to do, including checking vital signs and providing care for any injuries, such as external bleeding. If family or friends of the patient are available, ask if the patient has a history of aggressive behavior or if there are any underlying medical issues. A seemingly intoxicated person may have an underlying medical condition that is triggering the behavior. Signs and symptoms commonly seen during a behavioral emergency may present with a rapid onset and include: \uf0a7 Emotional reactions such as panic, anxiety, fear, agitation, depression, withdrawal, confusion and anger. \uf0a7 Unusual appearance. \uf0a7 Unusual speech patterns. \uf0a7 Abnormal or bizarre behavior or thought patterns. \uf0a7 Loss of contact with reality. \uf0a7 Aggressive behavior including threats or intent to harm self or others. Certain odors on the patient\u2019s breath, such as alcohol.\tPupils that are dilated, constricted or that react unequally.\tExcess salivation.\tLoss of bladder control.\tVisual hallucinations.",
        "Behavioral Changes": "Causes of Behavioral Emergencies\nThe primary causes of behavioral emergencies include:\n\uf0a7 Injury. Any condition that reduces the amount of oxygen to the brain, such as a head injury, can result in a significant change in behavior. Too little oxygen could make a normally calm person suddenly become anxious or even violent. Cognitive changes associated with head injury can also be factors in behavioral change.\n\uf0a7 Physical illness.\n\uf0a7 Past history of behavioral emergency.\n\uf0a7 Alcohol or drug use or abuse.\n\uf0a7 Noncompliance regarding taking prescribed psychiatric medications.\n\uf0a7 Adverse effects of prescribed medications.\n\uf0a7 Mental illness. Mental illnesses that can alter behavior include depression, schizophrenia and bipolar disorder. The exact cause of mental illness is not always known, but it is sometimes the result of a chemical abnormality in the brain. The behavior exhibited by a patient with a mental illness can be bizarre and can include excited or depressed behavior.\n\uf0a7 Extreme stress. Extreme emotional distress, such as grief at the loss of a loved one, can trigger a change in an individual\u2019s behavior. People react differently to stressful situations. The impact of the incident and the way the person copes or fails to cope can lead to an emotional situation that the person cannot handle. People can react with uncontrollable crying, denial, anger or depression.\nOther circumstances that can lead to altered behavior include heat or cold exposure, diabetes, low blood sugar, lack of oxygen, shock, head trauma, brain infection, seizure disorders, poisoning or drug overdose, withdrawal from alcohol or drugs, mind-altering substance or substance abuse and problems with the nervous system associated with aging.\nSome behavioral emergencies may pose a particular danger to the EMR, to the patient and to others, including when the patient displays agitation, bizarre thinking and behavior, danger to themselves or danger to others.",
        "Excited Delirium Syndrome": "Excited delirium syndrome poses challenges for police as well as EMS personnel. With excited delirium, the person exhibits some or a combination of the following signs and symptoms:\n\uf0a7 Agitation\n\uf0a7 Violent or bizarre behavior\n\uf0a7 Insensitivity to pain\n\uf0a7 Extreme increase in body temperature\nIndividuals with excited delirium develop high body temperatures. They may also exhibit increased body strength. Unfortunately, this syndrome is life threatening, and if immediate advanced medical intervention is not sought out, it usually ends in death. This syndrome is most often associated with incidents involving the police. It can be associated with drug use, particularly cocaine or methamphetamine, but can occur in non-drug users as well.",
        "CRITICAL FACTS 2": "A behavioral emergency is a situation in which a patient exhibits abnormal behavior that is unacceptable or intolerable. Such is often the case with people who become violent, attempt to take their own lives or believe that other people are out to harm them.\nSigns and symptoms commonly seen during a behavioral emergency may present with a rapid onset and can include emotional reactions, such as fear, panic or anger; unusual appearance or speech; abnormal or aggressive behavior; loss of bladder control and hallucinations.",
        "Anxiety and Panic": "While a certain amount of anxiety is a normal reaction to stress, excessive anxiety may be part of an anxiety disorder . There are several types of anxiety and panic disorders, all with potential to have dramatic effects on the afflicted person. People having a severe anxiety or panic attack are in real distress and need assistance. A person\u2019s anxiety and panic are often based on the feeling that they have no control over the situation and a fear of what may happen next. Anxiety attacks can last any length of time, but panic attacks generally last no longer than 30 minutes. Someone who is experiencing an anxiety attack may show any of these signs and symptoms: \uf0a7 Fatigue \uf0a7 Headaches \uf0a7 Muscle tension \uf0a7 Muscle aches \uf0a7 Difficulty swallowing \uf0a7 Trembling or twitching \uf0a7 Irritability \uf0a7 Sweating \uf0a7 Hot flashes People experiencing a panic attack may have any of the above signs and symptoms, as well as: \uf0a7 Difficulty breathing. \uf0a7 Heart palpitations. \uf0a7 An out-of-control feeling.",
        "Phobias": "Phobias are irrational fears of objects or events that are usually harmless. They can cause an anxiety or panic attack. When people have a phobia about a certain situation or event, they may display an exaggerated response of fear, referred to as a phobic reaction, when exposed to the situation or event.A person having a phobic reaction, such as an anxiety or panic attack, may display any of these behaviors: \uf0a7 Irrational fear \uf0a7 Unexplained, uncontrolled anxiety \uf0a7 Desire to flee the situation or avoid the object \uf0a7 Inability to continue functioning as long as the person is in the situation or the object is present \uf0a7 Acknowledgement that the fear reaction is out of proportion to the situation or event \uf0a7 Physical symptoms such as heart palpitations, difficulty breathing and sweating",
        "Clinical Depression": "Although clinical depression is a chronic illness, people who are clinically depressed can have an emergency that may trigger thoughts of suicide. Depression is more than just \u201cthe blues.\u201d It is a recognized medical illness that may require not only psychological therapy but also medical intervention. It is important to keep in mind that there are many ways people can exhibit signs and symptoms of depression, including thoughts of impending suicide. For more information about suicide, refer to the section later in this chapter. Signs and symptoms of clinical depression are numerous. They include but are not limited to: \uf0a7 Persistent feeling of being useless. \uf0a7 Loss of interest in regular activities. \uf0a7 Feeling hopeless or guilty. \uf0a7 Unexplained sadness. \uf0a7 Crying spells. \uf0a7 Irritability and restlessness. \uf0a7 Insomnia or sleeping too much. \uf0a7 Lack of appetite or overeating (followed by weight loss or gain). \uf0a7 Inability to concentrate and make decisions. \uf0a7 Physical aches and pains with no medical basis. \uf0a7 Loss of sexual desire. \uf0a7 Thoughts of suicide.",
        "CRITICAL FACTS 3": "The primary causes of behavioral emergencies include injury, physical illness, past history of behavioral emergencies, alcohol or drug use/abuse, noncompliance regarding taking prescribed psychiatric medications, adverse effects of prescribed medications, mental illness and extreme stress.",
        "Bipolar Disorder": "Bipolar disorder is a mental illness in which the person swings from the extreme lows of depression to the highs of mania. A person with mania exhibits elation, hyperexcitability and accelerated thoughts, speech and actions. Bipolar disorder is sometimes called manic-depression. Because of the extreme mood swings, the person can be in danger of self-harm when on either end of the spectrum. When depressed, the person may consider suicide. When manic, self-destructive or risky behaviors could result in severe injury or death. Someone who is in a depressive episode would exhibit signs and symptoms of depression such as feeling useless or hopeless, alternating between sleeping too much or too little, being unable to go to work and being unable to concentrate. When experiencing the manic phase, the person could show signs and symptoms such as: \uf0a7 Rapid speech and quickly changing thought patterns. \uf0a7 Inability to sit still and/or concentrate. \uf0a7 Inability to finish a task. \uf0a7 Euphoria. \uf0a7 Increased physical activity. \uf0a7 Participating in risky activities. \uf0a7 Inability to sleep. \uf0a7 Increased desire to have sex. \uf0a7 Agitation. \uf0a7 Aggressive behavior.",
        "Paranoia": "Paranoia is a condition characterized by feelings of persecution and exaggerated notions of perceived threat. It may be part of many mental health disorders and, rarely, is seen in isolation. Paranoia is marked by irrational and delusional behavior. Paranoid individuals often believe that someone or several people are \u201cout to get them.\u201d Paranoia can be limited to believing that they are being watched or followed, or it can become more fantastical in nature, such as believing there are implants in the brain being monitored by people who want to do the paranoid person harm. Paranoia can also be a side effect of medication or recreational drug use, particularly stimulants. If a patient is paranoid, it can be difficult for you to provide care because they may fear that you are part of the plot or group trying to cause harm. Patients who are paranoid may display behaviors such as: \uf0a7 Checking for wiretaps (bugs) in every room. \uf0a7 Accusing people of following them or listening to their conversations. \uf0a7 Being suspicious of every person who approaches them. \uf0a7 Refusing to eat or drink anything that they have not prepared.",
        "Schizophrenia": "Schizophrenia is a severe, chronic mental illness in which the person hears voices or feels that their thoughts are being controlled by others. These voices or thoughts can instruct the person to do things they would otherwise not do, like becoming violent toward a family member or a stranger. For this reason, you must exercise particular caution when attempting to help a patient whom you know or suspect suffers from schizophrenia. Someone with schizophrenia may display some or all of the following: \uf0a7 Hallucinations (visual or auditory, but mostly auditory) \uf0a7 Delusions \uf0a7 Lack of personal care or hygiene \uf0a7 Inappropriate emotions for the situation or lack of emotions altogether \uf0a7 Anger \uf0a7 Suspicions and paranoid behavior \uf0a7 Social isolation",
        "VIOLENCE": "Behavioral emergencies require extra sensitivity. Every person copes in a different way and every person has a breaking point. People experiencing a behavioral emergency may have no control over what they are feeling at any given moment, and those feelings are real and valid. A behavioral emergency may cause a person to become violent toward self or others. A head injury, low blood sugar in someone with diabetes, a lack of oxygen, and mind-altering substances (such as alcohol, depressants, stimulants or narcotics) can all cause a person to act in a violent manner.",
        "Patients Who Are Violent Toward Themselves": "Patients who are violent toward themselves may attempt or threaten suicide. Your primary concern as an EMR is to treat any injuries or medical conditions arising from the violence or suicide attempt and then transport the patient to a facility where they can receive medical and psychiatric treatment. If it is necessary to prevent the patient from harming you, themselves or others, you may need to use medical restraints to transport the patient.",
        "Suicide": "The term suicide refers to an intentional act to end one\u2019s own life. People who commit suicide often feel they have no other option for resolving their problems but to end their own lives. Males are about four times more likely to commit suicide than females, although females are more likely to have suicidal thoughts. People of any age, race or socioeconomic status are at risk of making suicide attempts. Those in the 15\u201334 age group are at the highest risk of dying by suicide. Suicide is the second-leading cause of death for people in this age group in the United States.",
        "CRITICAL FACTS 4": "People experiencing a behavioral emergency may have no control over what they are feeling at any given moment and can become violent toward themselves or others. Males are about four times more likely to commit suicide than females, although females are more likely to have suicidal thoughts. People of any age, race or socioeconomic status are at risk of making suicide attempts.",
        "Assessing Suicide Risk": "Many people who attempt suicide suffer some form of mental or emotional problem or illness, especially depression. Substance misuse or abuse, primarily of alcohol and other drugs, plays a major role in attempted suicides. In any behavioral emergency, it is important to assess the patient\u2019s risk for attempting suicide. Some risk factors include: \uf0a7 Mental or emotional disorders, especially depression. \uf0a7 History of substance misuse or abuse. \uf0a7 Feelings of hopelessness. \uf0a7 Impulsive or aggressive tendencies. \uf0a7 Past attempts at suicide. \uf0a7 Failing or failed relationship with a spouse, family or friend. \uf0a7 Serious illness or death of a close family member or friend. \uf0a7 Serious, prolonged or chronic personal illness. \uf0a7 A long period of failure at work or school or a long period of unemployment. \uf0a7 Failure to achieve sufficient occupational, educational or financial success. \uf0a7 Dramatic change in the economy. \uf0a7 Feelings of isolation. \uf0a7 Mass suicides (e.g., in a group/cult setting). \uf0a7 Reluctance to seek help for mental-health problems due to the stigma attached to suicidal thoughts, suicide attempts or general mental health problems. \uf0a7 Inability to access mental health services. When assessing a patient for suicide risk, keep the following in mind: \uf0a7 Take any threat of suicide seriously, ensure the patient is transported for evaluation and ask the patient if they have ever considered suicide. \uf0a7 Address any injuries or medical conditions related to a suicide attempt. \uf0a7 Always listen carefully, as the patient may reveal important information indirectly. \uf0a7 Do not dismiss what you may consider to be unimportant feelings. \uf0a7 Be nonjudgmental and remember that people react differently to different problems. \uf0a7 The patient may tell you that everything is fine but transport the patient anyway, as help may still be needed. \uf0a7 Make specific plans to help the patient, for example making arrangements for the patient to meet with a particular healthcare worker or clergy. \uf0a7 Be careful not to show disgust or fear when caring for the patient. These feelings can be revealed through your words and your body language. \uf0a7 Never deny that the patient attempted suicide. This may give the message that you are unable to accept the patient\u2019s feelings.\nNever try to use strong emotions to either shock the person out of attempting suicide or to call the person\u2019s bluff and provoke them.\nTo better assess the patient, ask the patient questions to improve your understanding of the situation. These questions include:\nHow do they feel?\nIs the patient thinking of hurting or killing themselves or anyone else?\nIs the patient a threat to themselves or others?\nDoes the patient have a medical problem?\nIs the patient suffering from a recent trauma?\nDoes the patient have any weapons on them or nearby?\nWhat interventions are necessary?",
        "Self-Mutilation": "Self-mutilation, or self-injury, refers to deliberately harming one\u2019s own body, through acts such as burning or cutting. It is not usually meant as an attempt to commit suicide, but is an unhealthy coping mechanism to deal with overwhelming negative emotions such as tension, anger and frustration. The individual experiences momentary calmness and a release of tension but then quickly feels a sense of shame and guilt, in addition to a return of the negative feelings the person was trying to avoid. Self-mutilation may be a component of a mental illness such as depression, an eating disorder or a personality disorder. Sometimes, a suicidal patient may have a last-minute change of heart and inflict nonlethal wounds (sometimes called hesitation marks) to receive help or to punish someone. Child abuse and rape survivors may turn to self-mutilation such as nonlethal cutting or burning as a way to cope with the trauma. A patient who has committed self- mutilation will need to be treated for bleeding, shock and other soft-tissue injuries.",
        "CRITICAL FACTS 5": "There are many factors to consider when assessing a patient\u2019s suicide risk. Risk factors include mental or emotional disorders; history of substance abuse or past suicide attempts; feelings of hopelessness or isolation; impulsiveness or aggressiveness; failed relationships; personal illness; and failure at work, school or in financial matters.",
        "Patients Who Are Violent to Others": "Patients experiencing a behavioral emergency may become aggressive or violent. The violence may be caused by a medical emergency, a mental health issue, alcohol or drug intoxication, a lack of oxygen or a head injury. Violent behavior can take many forms, from verbal abuse to punching, kicking, biting and using weapons. While the violence may not be directed toward you, you could easily become an indirect victim caught in the middle. In some cases, these acts may be specifically targeted to people in positions of authority, like you. Attempt to identify exit or escape routes for your safety. A patient\u2019s posture and comments can indicate potential violence. Threatening comments and posture, such as clenching fists or assuming a fighting stance, may indicate the patient\u2019s intentions. Be alert to the following signs: \uf0a7 Agitation; the patient may pace or move erratically \uf0a7 Rapid or incoherent speech \uf0a7 Shouting or making threats \uf0a7 Clenched fists or a fighting stance \uf0a7 Using objects as a weapon or throwing objects",
        "Sexual Assault": "Sexual assault is defined as any form of sexual contact, against a person\u2019s will, often by coercion, force or threat. Victims of rape and sexual assault often know their attackers\u2014a friend, a family member, a relative, a date or a friend of the family. These patients suffer from physical and emotional trauma, and need to be treated with sensitivity.",
        "Rape": "Rape is defined as non-consensual sexual intercourse often performed using force, threat or violence. It is devastating, and many patients will go into acute emotional distress and shock during and after the attack. Some common signs and symptoms include: \uf0a7 Confused, dazed state. \uf0a7 Nausea, vomiting, gagging or urination. \uf0a7 Intense pain from assault and penetration. \uf0a7 Psychological and physical shock and paralysis. \uf0a7 Possible bleeding or body fluid discharge. \uf0a7 Torn or removed clothing. Because of the significant legal issues, it is vital to manage the rape scene appropriately to preserve evidence that will be required for the police investigation. If possible, the patient should be treated by someone of the gender of their choosing to avoid further emotional trauma. If present, work with the sexual assault nurse examiner (SANE). If possible, transport the victim to a medical facility that has a rape crisis unit and can take the proper specimens as well as comfort the victim. Tell the patient what you will be doing and why you are doing it. Encourage having the patient treated on a clean white sheet. If the victim must remove clothing or if clothing must be removed from the patient in order to provide care, do so while on the clean white sheet to catch any debris that was left on the patient during the crime. Try to determine the patient\u2019s emotional state and complete a patient assessment, checking for trauma around the lower abdomen, thighs, genital and anal areas. Do not clean the patient. Prevent the patient from showering, bathing, brushing teeth or urinating, since cleaning can destroy evidence. Police will be responsible for evidence collection. Any evidence you collect while treating the patient for injuries should be isolated, and each piece of evidence needs to be bagged individually in a paper bag to prevent cross-contamination. Plastic bags do not allow for air movement and cause the DNA to deteriorate due to moisture buildup. Follow local protocols, and give the evidence to the police as soon as possible.",
        "CRITICAL FACTS 6": "Asking the patient questions will help you better assess the situation. These questions can include: \u201cHow do you feel?\u201d; \u201cAre you thinking of hurting yourself or anyone else?\u201d; \u201cHave you suffered a personal trauma recently?\u201d; or \u201cDo you have a weapon nearby?\u201d Patients experiencing a behavioral emergency may become aggressive or violent. Violent behavior can take many forms, from verbal abuse to punching, kicking, biting and using weapons. Be alert to signs of violence, such as agitation, rapid or incoherent speech, shouting, making threats, clenched fists or other aggressive stances, throwing objects or using objects as a weapon.",
        "Rape-Trauma Syndrome": "Most victims of rape experience symptoms of rape-trauma syndrome following a rape. There are three stages:\n\uf0a7 Acute. This occurs immediately after the rape, a time when the patient needs critical support. Whether or not a patient suffered physical injuries, a rape victim has experienced significant emotional trauma. This phase lasts anywhere from a few days to a few weeks.\n\uf0a7 Outward adjustment. This phase may last weeks or months after the attack. The victim resumes what appears to be their \u201cnormal\u201d life, but is experiencing turmoil internally, including depression, rage and flashbacks.\n\uf0a7 Resolution. Moving on from a rape may take months or years, and may involve professional counseling to assist the patient in dealing with the lasting emotional trauma.",
        "Child Abuse and Neglect": "You may encounter a situation involving an injured child in which you have reason to suspect child abuse. Child abuse is the physical, verbal, psychological or sexual assault of a child resulting in injury and/or emotional trauma. Typically, the child\u2019s injuries cannot be logically explained, or a parent or legal guardian gives an inconsistent or suspicious account of how the injuries occurred.",
        "Signs and Symptoms of Child Abuse": "The signs and symptoms of child abuse include:\n\uf0a7 Situations in which the description of the injury does not fit the cause.\n\uf0a7 Patterns of injury that include cigarette burns, whip marks and hand prints.\n\uf0a7 Obvious or suspected fractures in a child less than 2 years of age.\n\uf0a7 Unexplained fractures.\n\uf0a7 Injuries in various stages of healing, especially bruises and burns.\n\uf0a7 Unexplained lacerations or abrasions, especially around the mouth, lips and eyes.\n\uf0a7 Injuries to the genitals; pain when the child sits down.\n\uf0a7 More injuries than are common for a child of the same age.\n\uf0a7 Repeated calls to the same address.",
        "Child Neglect": "Child neglect is a type of abuse in which the parent or legal guardian fails to provide the necessary, age-appropriate care to a child.",
        "Signs and Symptoms of Child Neglect": "Signs and symptoms include:\n\uf0a7 Lack of adult supervision.\n\uf0a7 A child who appears to be malnourished.\n\uf0a7 An unsafe living environment.\n\uf0a7 Untreated chronic illness; for example, an asthmatic child with no medications.",
        "Providing Care for Abused Children": "When providing care for a child who may have been abused, your first priority is to care for the child\u2019s injuries or illness. An abused child may be frightened, hysterical or withdrawn. The child may be unwilling to talk about the incident in an attempt to protect the abuser. If you suspect abuse, explain your concerns to responding police officers or other emergency medical services (EMS) personnel, if possible.",
        "Reporting Suspected Abuse": "If you think you have reasonable cause to believe that abuse has occurred, you must report your suspicions to the proper authorities. Familiarize yourself with the mandatory reporting laws in your state or jurisdiction. Depending on your role and state, you may be considered a mandatory reporter and be required to report suspected incidents of abuse or neglect.\nDo not be afraid to report suspected abuse because of fear of getting involved or of being sued. In most states, when you make a report in good faith, you may be immune from civil or criminal liability or penalty, even if you made a mistake. In this instance, \u201cgood faith\u201d means you honestly believe that abuse has occurred or the potential for abuse exists and a prudent and reasonable person in the same position would also believe this. You do not need to identify yourself when you report child abuse, although your report will have more credibility if you do.",
        "Elder Abuse and Neglect": "As with child abuse, older adults are also susceptible to abuse from the willful infliction of injury by physical or sexual assault, emotional mistreatment and neglect. Elder abuse is a growing problem in the United States as the population ages. EMRs may encounter a situation that involves the possible abuse of an older adult. The signs and symptoms of elder abuse include:\n\uf0a7 Any unexplained injury or an injury that has an unlikely explanation.\n\uf0a7 Burns, bruises or reddened areas that do not go away.\n\uf0a7 Abrasions on arms, legs or torso.\n\uf0a7 Unexplained hair loss.\n\uf0a7 Injuries in various stages of healing (especially bruises and burns).\n\uf0a7 Scratches, cuts or bite marks.\n\uf0a7 Cuts and scratches around the breasts, buttocks or genitals; vaginal or rectal bleeding.\n\uf0a7 Withdrawn, sad or fearful demeanor and failure to make eye contact.\n\uf0a7 Upset or fearful behavior when the abuser enters the same room.",
        "Elder neglect": "Elder neglect is a type of abuse in which a caregiver fails to provide the necessary care for an older adult. The signs and symptoms of elder neglect include:\n\uf0a7 An unkempt appearance.\n\uf0a7 Improper clothing for the weather conditions.\n\uf0a7 Lack of availability of food, water or utilities.\n\uf0a7 An unsafe living environment.\n\uf0a7 Dehydration.\n\uf0a7 Untreated or chronic medical conditions.\n\uf0a7 Confusion or disorientation.\n\uf0a7 Withdrawn, sad or fearful demeanor and failure to make eye contact.\n\uf0a7 Upset or fearful behavior when the abuser enters the same room.",
        "Reporting": "If you think you have reasonable cause to believe that elder abuse or neglect has occurred, report your suspicions to the proper authorities. Familiarize yourself with the mandatory reporting laws in your state or jurisdiction. Depending on your role and state, you may be considered a mandatory reporter and be required to report suspected incidents of elder abuse or neglect. Refer to Chapter 26 for more information.",
        "PROVIDING CARE FOR BEHAVIORAL EMERGENCIES - Scene Size-Up and Personal Safety": "When responding to a possible behavioral emergency, assess the scene to identify any possible sources of harm to yourself, the patient or any bystanders. Do not approach the scene unless you feel confident that it is safe to do so. Be wary of sudden behavior changes in the patient, which are the most common cause of injuries to responders. Be sure to identify and locate the patient before you enter the scene. A disturbed individual may try to jump you from behind or otherwise take you by surprise. Attempt to identify exit or escape routes for your safety and make sure you remain between the patient and an exit, so you can leave the scene if it is necessary for your own safety. As soon as possible, clear the scene of any objects that can be used to injure the patient or others. Do not enter the scene if the patient has any kind of weapon. Keep in mind there may be more than one patient (as in a suicide pact). Assessing the scene can also provide you with hints about what has happened to cause or contribute to the crisis. Are there empty beer, liquor or pill bottles lying around? Do you see drug paraphernalia or signs of injury, such as blood stains? As with other behavioral emergencies, your first job upon arriving at a scene of a potential suicide is to ensure your own safety. Selected methods of suicide, such as carbon monoxide in fumes from a running vehicle engine in an enclosed area or emissions from a gas stove, can create a dangerous environment for responders. In addition, the suicidal individual may further endanger you by attacking or attempting to attack you to prevent your interference.Some patients may be experiencing hallucinations or delusions. Do not play along with these or lie to the patient and say that you believe they are real. Do not think that you can manage a situation involving an emotional crisis by yourself. A suicidal person or a rape victim needs professional counseling. Summon more advanced personnel. This could include law enforcement, EMS personnel, or local mental health or rape crisis center personnel. While waiting for others to arrive, continue to talk with the patient.",
        "Establishing Rapport": "Once you have entered the scene, you will need to establish rapport with the patient before getting too close. To do this, speak directly to the patient and maintain eye contact. Acknowledge that the patient appears upset and state that you are there to help. Tell the patient who you are and exactly what you want to do to help. Use a calm, reassuring voice, and keep your distance until the patient has indicated it is acceptable to approach. Use slow, deliberate movements. Do not touch the patient without permission. Touch can be very disturbing to some patients, particularly for those who are recent victims of an attack. Once you have established a rapport with the patient, you can begin to communicate to find out what happened and determine what interventions are needed. Speak directly to the patient and be supportive and empathetic, never threatening, judgmental or confrontational. Show you are listening by repeating and rephrasing the patient\u2019s answers to your questions, nodding or stating phrases such as \u201cgo on\u201d or \u201cI understand.\u201d Make sure that no one interrupts, except in the case of medical necessity.",
        "CRITICAL FACTS": "When responding to a possible behavioral emergency, assess the scene to identify any possible sources of harm to yourself, the patient or any bystanders. Do not think that you can manage a situation involving an emotional crisis by yourself. Summon more advanced personnel and continue to talk to the patient while waiting for help to arrive. Once you have entered the scene, you will need to establish rapport with the patient before getting too close. Once you have established a rapport with the patient, you can begin to communicate to find out what happened and determine what interventions are needed.",
        "Scene Size-Up and Personal Safety - Patient Assessment": "Observe the patient and look for signs of disorientation or life-threatening conditions, such as a serious injury or difficulty breathing. Also, continue to observe the patient for signs of potential violence, such as a threatening posture or the possession of a weapon. Look for signs of fear, anxiety, confusion, anger, mania, depression, withdrawal or loss of contact with reality. Also look for sudden behavioral changes, such as quiet withdrawal followed by sudden, explosive anger. Once you get the patient talking, try to find out what happened. Determine the level of orientation and responsiveness, and attempt to find out what the chief complaint is. If the patient allows, take a set of baseline vital signs. Also try to obtain a SAMPLE history. If the patient is unconscious, perform a rapid head-to-toe assessment and try to obtain a SAMPLE history from family, friends or other bystanders.",
        "Scene Size-Up and Personal Safety - Calming the Patient": "In addition to maintaining a calm voice and slow, deliberate movements, several techniques can be used to help calm a patient. If the patient is disoriented, explain who you are, where you are and what is happening. Reassure the patient that the disorientation is temporary. Do not stand too close to the patient. If the patient\u2019s friends or family members are around, ask the patient if it is okay to enlist others to help in calming the patient. Encourage the patient to tell you what the problem is and explain that you are there to listen. Never leave the patient alone, and stay alert to any changes in the patient\u2019s emotional state.",
        "Scene Size-Up and Personal Safety - Restraining the Patient": "When patients are so agitated or violent that they cannot be approached safely and may pose a danger to themselves or others, you may need to assist EMS personnel with the use of restraints. If this occurs, follow their instructions exactly. Try to stay clear of the patient\u2019s arms and legs. Do not use restraints unless instructed to do so by more advanced medical or law enforcement personnel. When using restraints, the goal is to use the minimum force needed. Thus, the amount of force used will depend on factors such as the patient\u2019s strength and level of agitation. Soft leather or cloth straps are considered humane restraints, while metal cuffs are not.",
        "Scene Size-Up and Personal Safety - Legal Considerations": "Restraining a person without justification can give rise to a claim of assault and battery. You may be required to obtain police authorization before you can use patient restraints. Be aware of the laws regarding the use of patient restraints in your jurisdiction. Wait for someone who is authorized to use restraints if you are not legally allowed to do so. Seek medical direction and approval before applying restraints. Be aware of and follow local protocols involving the use of patient restraints. Be sure a restrained patient can breathe. The patient should be placed in a face-up position, and breathing should be monitored regularly. A struggling patient who appears to calm down may actually be suffering from breathing difficulties or may have lost consciousness. For legal reasons, it is important to document everything you do while participating in the use of restraints.",
        "PUTTING IT ALL TOGETHER": "Behavioral emergencies pose special challenges for EMRs. Patients experiencing behavioral emergencies may act in unexpected ways, and may pose a danger to themselves or others by reacting in a violent or aggressive manner. Behavioral emergencies can be triggered by injury, physical or mental illness, extreme stress, or the use of alcohol or other drugs. When responding to a patient with a behavioral emergency, begin by assessing the scene to identify any possible sources of harm to you, the patient or any bystanders. Do not enter the scene unless you feel confident that it is safe to do so. Be wary of sudden behavioral changes in the patient, which is a common cause of injury to responders. Consider the need for law enforcement personnel. If a patient appears to be a threat to themselves or others, or the patient appears to be a victim of sexual assault, rape or child abuse, summon law enforcement support immediately. When dealing with a rape or sexual assault patient, remember that emotional trauma will be present, even when physical injuries are absent. Acute emotional shock is a normal reaction. Be careful not to disturb any evidence found at the scene. Cases of child abuse or neglect need to be carefully documented. You must follow local protocols around mandatory reporting if you suspect the injuries are due to abuse or neglect. Assess both the patient\u2019s physical and mental status: Assess both the patient\u2019s physical and mental status by asking specific questions in a calm and reassuring manner. Evaluate the patient\u2019s mental status by observing appearance, demeanor, level of activity and speech. Ask bystanders if the patient has underlying medical conditions, or a history of mental issues or violent actions. Do not leave the patient alone. Good communication skills, respect and empathy can defuse potentially explosive situations. Restraining a patient should be a last resort: Restraining a patient should be a last resort, done in consultation with law enforcement and advanced medical direction. Use only as much force as is necessary to restrain the patient, and always follow local protocols. Ensure that you clearly document all the circumstances if medical restraints are required, including the names and contact information for any third-party observers, law enforcement personnel and medical personnel."
    },
    {
        "Key Terms": "Alzheimer\u2019s disease: The most common type of dementia in older people, in which thought, memory and language are impaired., Asperger syndrome: A disorder on the autism spectrum; those with Asperger syndrome have a milder form of the disorder., Autism spectrum disorder (ASD): A group of disorders characterized by some degree of impairment in communication and social interaction as well as repetitive behaviors., Bereavement care: Care provided to families during the period of grief and mourning surrounding a death., Catastrophic reaction: A reaction a person experiences when the person has become overwhelmed; signs include screaming, throwing objects and striking out., Chronic diseases: Diseases that occur gradually and continue over a long period of time., Cognitive impairment: Impairment of thinking abilities including memory, judgment, reasoning, problem solving and decision making., Deafness: The loss of the ability to hear from one or both ears; can be mild, moderate, severe or profound, and can be inherited, occur at birth or be acquired at a later point in life, due to illness, medication, noise exposure or injury., Dementia: A collection of symptoms caused by any of several disorders of the brain; characterized by significantly impaired intellectual functioning that interferes with normal activities and relationships., Edema: Swelling in body tissues caused by fluid accumulation., Hard of hearing: A degree of hearing loss that is mild enough to allow the person to continue to rely on hearing for communication., Hospice care: Care provided in the final months of life to a terminally ill patient., Mental illness: A range of medical conditions that affect a person\u2019s mood or ability to think, feel, relate to others and function in everyday activities., Service animal: A guide dog, signal dog or other animal individually trained to provide assistance to a person with a disability., Sundowning: A symptom of Alzheimer\u2019s disease in which the person becomes increasingly restless or confused as late afternoon or evening approaches.",
        "INTRODUCTION": "When responding to older adult patients, remember that patience, kindness and respect will help you care for the patient in the most effective manner. Misconceptions about older adult patients, such as that they are all weak or sickly, hard of hearing and have difficulty learning new things, can often lead to older adults being treated like children and not like responsible adults. Explaining the steps you are taking to treat and care for them, and using the same kind and respectful manner you would use with younger adult patients, will prove to be successful with older adult patients. This chapter will provide you with the information needed to assist older adult patients and identify and deal with any special healthcare or functional needs they may have, such as dementia, including Alzheimer\u2019s disease. You will also learn about patients with special healthcare or functional needs, such as those with mental illness, intellectual disabilities and other special needs, such as visual impairment or deafness. Special healthcare or functional needs also exist for the physically challenged, as well as for those suffering from chronic diseases. In this section, you will learn about important factors to take into account when caring for patients with conditions such as arthritis, cancer, cerebral palsy and multiple sclerosis.",
        "OLDER ADULT PATIENTS": "The older adult population, those aged 65 years and older, is the fastest-growing age group in the United States. Because people are living longer, older adults make up a large proportion of the population and, thus, make up a greater segment of those requiring care. Older adult patients are, in many ways, no different from younger adult patients, but everyone undergoes some changes in their physical and mental health as they age, and these changes need to be considered when providing care.",
        "CRITICAL FACTS": "As people age, normal changes in physical and mental functioning occur. These changes occur in all body systems, including nervous, digestive, respiratory, circulatory, musculoskeletal, integumentary, genitourinary and endocrine.",
        "Physical and Mental Differences to Consider in Older Adults": "As people age, normal changes in physical and mental functioning occur. These changes occur in all body systems, including nervous, digestive, respiratory, circulatory, musculoskeletal, integumentary, genitourinary and endocrine.",
        "Sensory Changes in Older Adults": "Aging patients often have decreased sharpness of the senses, and this loss of sensory awareness brings possible risks that are unique to this age group.",
        "Vision": "Because vision in older adults may be poor due to problems such as decreased night and peripheral vision, farsightedness, cataracts and decreased tolerance to glare, incidents are more likely to occur. Misreading instructions for medication, falls and motor-vehicle crashes are common among older adults, and may be due, in part, to vision problems.",
        "Hearing": "The ability to hear gradually diminishes with age, especially for higher frequency sounds. Hearing loss can be an indirect cause of injury; for example, an older adult might have trouble hearing a warning alarm or siren.",
        "Sense of Touch and Pain": "Diminished pain sensation can also prove dangerous for older adults, as they may not be aware of an injury or of the seriousness of an injury.",
        "Diminished Taste and Smell": "A decrease in sense of taste and/or smell can lead to health problems such as poor nutrition, decreased appetite and even food poisoning, if an older adult is unable to detect that food has gone bad. A decrease in the ability to smell can also be a safety concern, as odors such as natural gas, propane or gasoline may not be easily detected.",
        "Heart/Blood Vessels": "Aging causes the heart to work harder. The heart muscle thickens and becomes less elastic, and arteries stiffen, which makes it harder for blood to flow through them. Over the years, plaque can build up within the arteries and restrict or block blood flow in a condition called atherosclerosis. Blood clots can also form and further restrict blood flow, factors which can lead to heart attack or stroke. Heart failure also develops when the heart cannot pump enough blood to meet the body\u2019s demand. Valve problems, including narrowing or leaking of the aortic or mitral valve, are also common in older adults. Arrhythmias are usually categorized according to the affected part of the heart\u2014the atrial (upper) part, or the ventricular (lower) part of the heart\u2014as well as by the change in rhythm. An aneurysm is a widening or ballooning out of a major artery that develops in the aorta or one of the other major arteries in the chest or abdomen. Aneurysms are common in older adults, especially those with high blood pressure or coronary artery disease.",
        "Lungs and Breathing": "Aging also affects the lungs, which become stiffer and less elastic, shrinking the airways and weakening the chest muscles. This causes the total flow of air into and out of the lungs to decrease, and increases the chances of developing breathing problems. Older people are also more prone to lung infections, such as pneumonia, due to changes in the lungs and immune system.",
        "Stomach and Intestines": "With aging, the digestive tract becomes stiffer, and the contractions that allow food to move effectively through the digestive system decrease. Older adults may also suffer from conditions and diseases, such as hardening of the arteries and diabetes, which can upset the function of the intestines and lead to symptoms and complications. Medications commonly prescribed for older adults can also cause problems in the digestive tract. Problems in various digestive organs can cause different symptoms, such as difficulty swallowing, stomachache, nausea, diarrhea and constipation. This often affects appetite and nutrition, leading to fatigue and weight loss.",
        "Nervous System": "The majority of middle-aged and older adults retain their abilities to learn, remember and solve problems. However, cognitive impairment, exhibited by memory loss and other problems, such as issues with perception, balance, coordination, reasoning, judgment and sleep, can occur and are not a normal part of aging. They can be the result of reversible causes, such as acute illness, or the side effects of medication. Cognitive impairment also can be the result of certain neurological disorders including a range of dementias. Some changes also may be due to clinical depression, which is more common in older adults.",
        "Muscles and Bones": "Problems of the musculoskeletal system are common in older adults and can range from minor sprains or inflammation to fractures, arthritis or cancer. Bones become less dense over time, especially in women, and this can lead to fractures. Musculoskeletal problems can also lead to a more sedentary lifestyle, and the inactivity itself can lead to a further decline in function.",
        "Other": "Other common health issues for older patients include urinary problems, skin diseases, decreased ability to fight off illness and nutritional problems.",
        "Assessing the Older Adult Patient": "When assessing an older adult patient, follow the same care and procedures, including checking breathing and pulse, as you would for a younger adult. However, you should keep the following points in mind when providing care. Patients who appear untidy and uncared for may not be taking good care of themselves and might have been neglectful in tending to their own medical needs. Whenever possible, speak to the patient\u2019s family or caregivers to identify the patient\u2019s usual behavioral patterns and whether the patient is behaving normally or has changed in response to an emergency.When speaking with older adult patients, speak a little more slowly and clearly, and allow time to ensure they understand, unless the situation appears urgent. Speak to the patient at eye level, and turn lights on to make it easier for the patient to see you. When obtaining the SAMPLE history from the patient, consider the following: \uf0a7 The patient may become tired easily. \uf0a7 You will need to clearly explain what you are doing before beginning the examination. \uf0a7 The patient may downplay symptoms due to fear of institutionalization or losing independence. \uf0a7 It may be difficult to assess peripheral pulses. \uf0a7 Some signs and symptoms you observe may be a part of normal aging; distinguish these from any that may be related to the emergency. Due to many factors, including diminished senses, an older adult may not show severe symptoms, even if very ill. Continue to reassess the patient\u2019s condition, as it may deteriorate quickly. Some older patients may be participants in the Vial of Life program, which was designed to allow patients to provide medical information to emergency medical services (EMS) personnel. The Vial of Life kit is offered to patients across North America and is kept on the patient\u2019s refrigerator to alert responders to the patient\u2019s health conditions, medications and any other medical information the patient wishes to supply. The kit includes a form, a plastic bag to store the form and decals to inform responders that the information is available. One decal is kept on the patient\u2019s front door and the other is on the bag. The kit is ideal for a situation in which a patient is unconscious, home alone and unable to provide vital information. Check the patient\u2019s door and refrigerator to see if the patient is a participant in the program.",
        "CRITICAL FACTS 1": "When assessing an older adult patient, follow the same care and procedures, including checking breathing and pulse, as you would for a younger adult.",
        "Caring for the Older Adult Patient": "Some key considerations exist in the care of an older adult patient: \uf0a7 Explain everything you are doing, calmly and slowly. \uf0a7 Handle the patient\u2019s skin with special care, as it can tear easily. \uf0a7 If the patient is responsive and a stroke is suspected, the patient may have difficulty chewing, swallowing and clearing the airway of secretions. \uf0a7 Dentures and other dental devices can cause airway obstruction.\uf0a7 If artificial ventilation is required and the patient is wearing dentures, it may be easier to leave the dentures in place.\nIf it is difficult to tilt the patient\u2019s head back due to conditions such as a curvature of the spine, perform a jaw-thrust (without head extension) maneuver.\nBlood-thinning medications and aspirin may make any bleeding more difficult to control.\nIf the patient\u2019s mental status changes and the patient is unable to maintain the airway, consider inserting an oropharyngeal airway (OPA). OPAs should only be used on unconscious patients with no gag reflex.\nBe prepared to assist with ventilation, but do not apply too much pressure, as this could result in chest injury.\nContinue to re-evaluate during transport.\nConsider the following conditions when positioning a patient for transport:\nIf the patient is responsive and able to breathe, place the patient in the Fowler\u2019s position.\nIf the patient has an altered mental status and you cannot protect the airway, place the patient in a side-lying recovery position.\nIf a spinal injury is suspected, a patient with a curvature of the spine could be injured if placed on a backboard. Use blankets or another extrication device such as a scoop stretcher for immobilization.\nAs a precaution, immobilize unresponsive patients during extrication from the scene to the ambulance, based on local protocols.",
        "Dementia": "Older adult patients can become confused when their cognitive functions decrease. Confusion is a symptom of memory loss, and can be a sign of cognitive impairment. Some types of cognitive impairment are chronic and cannot be reversed; these are referred to as dementias. Dementia is a set of symptoms characterized by problems with memory, reasoning, orientation and personal care. A patient with dementia may behave oddly and become anxious or aggressive. As people with dementia become increasingly unaware of their surroundings, they ultimately become unable to perform normal tasks. Dementia is not caused by stress or a crisis, but often during a time of crisis others may notice something is wrong, as the person becomes increasingly confused. About 50 percent of all people admitted to nursing homes suffer from some type of dementia.",
        "CRITICAL FACTS 2": "There are several considerations when caring for an older adult. These include working calmly, slowly and with extra care; being aware of dentures and how to deal with them; being aware of blood-thinning medications and aspirin; and knowing what care procedures are appropriate for an older adult, such as being aware of the amount of pressure you use when assisting with ventilation to avoid chest injury.",
        "Alzheimer\u2019s Disease": "Alzheimer\u2019s disease is the most common type of dementia among older adults. Those with the disease have the same basic needs as other patients. Alzheimer\u2019s dementia is not a normal part of growing older, but it is estimated that of the 5.5 million Americans living with dementia, an estimated 5.3 million are age 65 and older. This means approximately 1 in 10 people (or 10 percent) age 65 and older has Alzheimer\u2019s dementia. Witnessing a patient behaving dysfunctionally can be frustrating, but try to focus on the patient and their attempts to tell you something is wrong. Your job is to find out what the patient is trying to communicate, so that you can provide appropriate care. A person with Alzheimer\u2019s disease may demonstrate some common patterns such as: \uf0a7 Putting up a social facade by pretending not to know or remember a certain situation. \uf0a7 Pacing and wandering. \uf0a7 Rummaging and hoarding. \uf0a7 Extreme catastrophic reactions , such as screaming, throwing objects or striking out. \uf0a7 Sundowning (restlessness and confusion in the evening). \uf0a7 Speaking nonsense. \uf0a7 Hallucinating or believing things that are not true. \uf0a7 Exhibiting depression, anger or suspicion. If you know how to respond to these behaviors, you can provide better care and treat the patient with dignity and respect. If you encounter a patient who is walking aimlessly and then walking away, ask if you may walk with them, and use this as a way to guide the patient back to the appropriate place. Talk to the patient and listen carefully to what the patient has to say. Take steps to prevent the patient from leaving. In the case of a catastrophic reaction, reassure the patient that you are not going to cause any harm and that you also will not allow them to hurt anyone. Let the patient know the limits by saying something such as, \u201cIt\u2019s not okay to hit someone.\u201d A person with Alzheimer\u2019s disease may become increasingly restless or confused as late afternoon or evening approaches, becoming more demanding, upset, suspicious or disoriented. This type of behavior is called sundowning and is common in people with Alzheimer\u2019s disease. These patients may exhibit the following types of behavior: \uf0a7 Restlessness, anxiety \uf0a7 Worried expression \uf0a7 Reluctance to enter their own room \uf0a7 Reluctance to enter brightly lighted areas \uf0a7 Crying \uf0a7 Wringing hands \uf0a7 Pushing others away \uf0a7 Gritting teeth \uf0a7 Taking off clothing These behaviors may represent real physical needs, such as needing to use the bathroom or being hungry, uncomfortable or in pain. Responding in a kind, gentle manner will help calm the patient so you can discover what the problems are.",
        "CRITICAL FACTS 3": "Older adults can become confused when their cognitive functions decrease. Confusion is a symptom of memory loss, and can be a sign of cognitive impairment. Some types of cognitive impairment are chronic and cannot be reversed; these are referred to as dementias. Alzheimer\u2019s disease is the most common type of dementia among older people.",
        "Elder Abuse": "Elder abuse occurs when someone does something that harms or threatens the health and welfare of an older adult, or when a caregiver fails to provide adequate care for an older adult. Research suggests that 4 percent of adults older than 65 are subjected to elder mistreatment in the United States. This mistreatment can occur within the family, in formal care settings, or in the community or society at large. Elder abuse within the family is often the result of a caregiver being overwhelmed or not knowing what is needed when providing care for an older adult. Reluctance to provide care can also lead to mistreatment. Mistreatment in a formal care setting is often attributable to staff who have not had adequate training in providing direct patient care. Elder abuse can include: \uf0a7 Physical abuse. \uf0a7 Emotional abuse. \uf0a7 Neglect (intentional or unintentional). \uf0a7 Financial exploitation. \uf0a7 Abandonment. \uf0a7 Any combination of the above.",
        "Fading Memories": "According to the Alzheimer\u2019s Association, Alzheimer\u2019s disease affects an estimated 5.5 million Americans, making it the only disease among the top 10 causes of death without prevention, a cure or a way to slow its progression. While most people with the disease are older than 65, Alzheimer\u2019s disease can strike people in their 40s and 50s. Men and women are affected almost equally. At this time, scientists are still looking for the cause.",
        "Signs and symptoms of Alzheimer": "Signs and symptoms of Alzheimer\u2019s disease develop gradually and include confusion; progressive memory loss; and changes in personality, behavior, and the ability to think and communicate. Eventually, people with Alzheimer\u2019s disease become totally unable to care for themselves. While there are no treatments to stop or reverse a person\u2019s mental decline from Alzheimer\u2019s disease, several drugs are now available to help manage some of these symptoms. In addition, because a number of disorders have signs and symptoms similar to those of Alzheimer\u2019s disease, and can be treated, it is very important for anyone who is experiencing memory loss or confusion to have a thorough medical examination.",
        "Care at home for Alzheimer": "Most people with illnesses such as Alzheimer\u2019s disease are cared for by their families for much of their illness. Giving care at home requires careful planning. The home has to be made safe, and routines must be set up for daily activities, such as mealtimes, personal care and leisure.",
        "Support for caregivers": "It is important for anyone caring for a person with Alzheimer\u2019s disease or a related problem to realize that they are not alone. There are people and organizations that can help them and the person with Alzheimer\u2019s disease. For healthcare services, a physician\u2014perhaps their family physician\u2014or a specialist can give them medical advice, including help with difficult behavior and personality changes.",
        "Basic services": "When caring for a person with Alzheimer\u2019s disease living at home, people may also need help with basic services such as nutrition and transportation. A visiting nurse or nutritionist and volunteer programs such as Meals on Wheels may be helpful, and volunteer or paid transportation services may be available.",
        "Home assistance": "Visiting nurses, home health aides and homemakers can come to their home and give help with healthcare, bathing, dressing, shopping and cooking. Many adult day care centers provide recreational activities designed for people with Alzheimer\u2019s disease. Some hospitals, nursing homes and other facilities may take in people with Alzheimer\u2019s disease for short stays.",
        "Alternative living arrangements": "For persons with Alzheimer\u2019s disease who can no longer live at home, group homes or foster homes may be available. Nursing homes offer more skilled nursing care, and some specialize in the care of those with Alzheimer\u2019s or similar diseases. A few hospice programs accept persons with Alzheimer\u2019s disease who are nearing the end of their lives. Caregivers may need to search to find out which, if any, services are covered by Medicare, Medicaid, Social Security, disability or veterans\u2019 benefits in their state. A lawyer or a social worker may be able to help them.",
        "Locating services": "To locate services that can help the caregiver, the person with Alzheimer\u2019s disease and other family members, individuals can search for social service organizations and state and local government listings on the Internet or in the phone book. They can also contact their local health department, area office on aging or department of social services. Senior centers, as well as churches, synagogues and other religious institutions, may also have information and programs. Another great resource is the Alzheimer\u2019s Association. To locate the chapter nearest to them, individuals can call the association\u2019s 24-hour, toll-free number: 800-272-3900 or log onto alz.org.",
        "Risk factors for elder abuse": "Mental impairment in the dependent person or caregiver (or both). Isolation of the dependent person or the caregiver (or both). Inadequate living arrangements for the dependent person. Inability to perform daily functions. Frailty. Family conflict. Family history of abusive behavior, alcohol or drug abuse, mental illness or intellectual disability. Stressful family events. Poverty. Financial stress, especially related to healthcare needs.",
        "Signs of elder abuse": "Watch for visible signs and certain behaviors by either the older adult patient or the caregiver that may provide clues that elder abuse has occurred. Some signs that may raise suspicion of elder abuse include: A person who is frequently left alone. A history of frequent trips to the emergency department. Old and new fractures or bruises, especially bruises on both sides of the inner arms and thighs. Repeated falls. Unexplained hair loss, skin rashes, irritation or skin ulceration. Inappropriate dress. Malnourishment. Lack of energy or spirit. Poor hygiene. Reports of the patient being left in unsafe situations or having an inability to get needed medication.",
        "Response to suspected elder abuse": "Maintain a proper perspective if you suspect an abusive situation. Do not confront the suspected abuser. Take note of any inconsistencies between the reports received from the patient and the suspected abuser. Follow local protocols in relation to elder abuse and the legal obligations to report suspected elder abuse. Document your findings as per local protocols and report your suspicions to the hospital upon arrival.",
        "Mental Illness": "Mental illness is a broad term that describes a range of medical conditions that affect a person\u2019s mood or ability to think, feel, relate to others and function in everyday activities. About one-quarter of Americans suffer from a diagnosable mental disorder in a given year, though some of these are temporary conditions. About 6 percent of Americans suffer from serious mental illnesses, such as schizophrenia, major depression, panic disorder, bipolar disorder or personality disorder, although many are treatable with medication and psychosocial treatment. The National Institute of Mental Health describes several types of mental illnesses: Mood disorders; for example, major depression and bipolar disorder Schizophrenia\n Anxiety disorders; for example, panic disorder, obsessive-compulsive disorder and posttraumatic stress disorder\nEating disorders\nAttention-deficit/hyperactivity disorder (ADHD)\nAutism\nAlzheimer\u2019s disease",
        "CRITICAL FACTS 6": "Elder abuse takes many forms: physical, emotional, neglect, financial exploitation, abandonment or any combination of these. Risk factors of elder abuse include mental impairment or isolation of the patient and/or caregiver, inadequate living situation, inability to perform daily functions, frailty, family conflict, abuse or stress or history of these, poverty and financial stress. Signs of possible elder abuse include a patient who is frequently left alone, a history of emergency department visits, old and new injuries, unexplained skin problems or hair loss, inappropriate dress, poor hygiene, malnourishment and a lack of energy or spirit.",
        "Intellectual Disabilities": "Patients with an intellectual disability have a significantly below-average score on a test of mental ability or intelligence. Their ability to function in areas of daily life, such as communication, self-care, and getting along in social situations and school activities, is also limited. Different degrees of intellectual disability exist, and a person\u2019s level can be defined by the intelligence quotient (IQ), or on how dependent the person is on others to perform daily needs.",
        "Down Syndrome": "Down syndrome is a genetic condition that results from having an extra copy of chromosome 21. Both mental and physical symptoms will be evident, although the symptoms can range from mild to severe. Individuals with Down syndrome have mild-to-moderate intellectual impairment. Additionally, other health problems, such as heart disease, dementia, hearing loss, and problems with the intestines, eyes, thyroid and skeleton, are common in people with Down syndrome. It is not uncommon for people with Down syndrome to live productive lives well into adulthood.",
        "Visually Impaired": "When a person is visually impaired, their eyesight cannot always be corrected to a \u201cnormal\u201d level. Types of visual impairments include a loss of visual acuity, where the eye does not see objects as clearly as normal, or a loss of visual field, where the eye cannot see as wide an area as normal without moving the eyes or turning the head. When approaching patients, look for signs of visual impairment, such as glasses or a white cane. When approaching someone you know has a visual impairment, announce that you are approaching, who you are and why you are there so that the patient is not frightened. Ask if the person can see. Keep in mind that some blind patients are able to use other senses to compensate for their lack of sight. Especially at an incident scene, these patients may find the unfamiliar sights and sounds disorienting and may be frightened. Explain what is happening at the scene, what the sounds and smells are, and what may happen at the scene such as additional loud sounds caused by equipment or traffic. If a patient wears glasses, try to find them at the scene or in the home. This is especially important for older adults, who may try to hide the fact that they are visually impaired. As with all patients, reassure them, explain what you are doing and use a gentle touch to keep them calm. Explain what is happening at each step so the patient feels more in control. Nearly two-thirds of children with visual impairment also have one or more other disabilities, such as intellectual disability, cerebral palsy, deafness or epilepsy. Children with more severe visual impairment are more likely than children with milder visual impairment to have additional disabilities.",
        "Deaf and Hard of Hearing": "Deafness is the loss of the ability to hear from one or both ears. It can be inherited, occur at birth, or be acquired at a later point in life due to illness, medication, noise exposure or injury. The severity of the deafness can be mild, moderate, severe or profound. Two main types of deafness exist, and they are defined by the location of the problem. A conductive hearing loss occurs when there is a problem with the outer or middle ear; a sensorineural hearing loss is due to a problem with the inner ear and possibly the nerve that goes from the ear to the brain. Some people have both types of deafness. The term \u201cdeaf\u201d describes someone who is unable to hear well enough to rely on hearing as a means of communication. The term hard of hearing can be used to describe people who have a less severe hearing loss and are still able to rely on their hearing for communication. Hearing loss is a disability that may not be immediately obvious to you when approaching a patient. Be certain a patient can hear you, especially when treating older adults. Identify yourself, and speak slowly and clearly, but do not shout. Ask if the patient can hear you. Position yourself so the patient can hear you better by facing the patient; some patients who are hard of hearing can read lips. You can also try speaking directly into the person\u2019s ear. If possible, turn off background noise, such as a television or radio. If this does not work, write down your questions.",
        "Physically Challenged": "A person who is physically challenged may have been born with the condition or may have acquired it later in life. The person may have a general diminished ability to move due to injury or illness, and may use a mobility aid, such as a walker, wheelchair or cane. If you are aware that someone is physically challenged, ask what help the patient needs, for example to transfer from one surface to another (bed to chair) or to walk.",
        "Traumatic Brain Injury": "Someone who has suffered a traumatic brain injury may have been involved in a motor vehicle collision, suffered a fall or been the victim of an assault. Someone who has survived a traumatic brain injury may have permanent cognitive and physical problems. Cognitive impairment often includes difficulty with attention, memory, judgment, reasoning, problem solving and decision making. Physical problems can range from mild to severe and may result in the person moving slowly or relying on a mobility aid, such as a walker or wheelchair.",
        "Chronic Diseases and Disabilities": "Illnesses that occur gradually and continue over a long period of time are referred to as chronic conditions. Often, a chronic condition lasts throughout the person\u2019s life. Chronic conditions include heart disease, diabetes and arthritis. Patients with some chronic conditions, such as multiple sclerosis, can live for years with few symptoms and then suddenly experience a flare-up with many symptoms appearing at once. In such an acute phase, the patient will often consult a physician and, following treatment, the acute phase may be resolved. However, the patient will continue to live with the effects of the chronic condition.",
        "Arthritis": "Arthritis is a condition that causes joints to become inflamed, swollen, stiff and painful. A few or many joints may be affected as the smooth tissues that cover the ends of bones become rough or wear away, causing painful friction between bones upon movement. Because of this friction, tissues around the joints swell, leading to stiffness, which makes normal movement difficult. When providing care for a patient with arthritis, keep the following in mind: \uf0a7 Assure the patient that you are aware that movement is painful, and that you are there to help. \nNever move a joint that is painful, red or swollen. \uf0a7 Handle the patient\u2019s joints carefully, supporting the areas above and below the joint when you move them.",
        "Cancer": "Cancer is the abnormal growth of new cells that can spread and crowd out or destroy other body tissues in the form of a malignant tumor, which is a solid mass or a growth of abnormal cells that can grow anywhere in the body. Malignant tumors can spread to other parts of the body, growing quickly and invading and destroying other body tissue. Typically, cancer is treated according to the type and location of the cancer, and whether or not it has spread. The three most common approaches to treatment are surgery, chemotherapy and radiation. Common side effects of chemotherapy include nausea, diarrhea, loss of hair and extremely dry skin. Many people will experience skin burns, fatigue, and possibly nausea and vomiting with radiation treatment; others may experience hair loss as a result of the radiation treatment. When providing care for a person being treated for cancer, infection control is important because chemotherapy and radiation affect a person\u2019s immune system. Strict hand-washing guidelines and standard precautions must be taken. Never provide care for a patient who is receiving cancer treatment if you have a cold or flu. A patient receiving chemotherapy or radiation treatment may feel tired. Skin changes and rashes from some drugs or burns from radiation treatment are common, so be gentle.",
        "Cerebral Palsy": "Cerebral palsy is the name given to a group of disorders affecting a person\u2019s ability to move and maintain balance and posture. It does not get worse over time, although symptoms can change over a patient\u2019s lifetime. Cerebral palsy causes damage to the part of the brain that controls the amount of resistance to movement in a muscle (muscle tone), which allows you to keep your body in specific postures or positions.",
        "Service Animals": "A service animal is any guide dog, signal dog or other animal individually trained to provide assistance to an individual with a disability. These animals are considered service animals under the Americans with Disabilities Act (ADA), whether or not they have been licensed or certified by a state or local government. Service dogs perform some of the functions and tasks that the individual with a disability cannot perform independently. These dogs receive special training to help assist patients with many different types of disabilities, such as visual impairment, limited mobility, balance problems, autism, seizures, or other medical problems like low blood sugar or psychiatric disabilities. Services include retrieving objects, pulling wheelchairs, opening and closing doors, turning light switches off and on, barking when help is needed, finding another person, leading the person to the handler, assisting with balance and counterbalance, providing deep pressure and many other individual tasks. A service animal is not a pet and can be identified by either a backpack or special harness. By law, service animals must be allowed into most establishments. EMRs should not handle the service animal unless absolutely required. Never separate the patient from the service animal, as this could cause stress, agitation and anxiety to both parties which can complicate patient care. It could also become a safety issue.",
        "Cystic Fibrosis": "Cystic fibrosis (CF) is an inherited disease of the mucous and sweat glands, affecting the lungs, pancreas, liver, intestines, sinuses and sex organs. CF causes mucus to become thick and sticky, blocking the airways. This makes it easy for bacteria to grow, which leads to repeated serious lung infections. These infections can cause serious damage to the lungs. Mucus can also block tubes, or ducts, in the pancreas, so that digestive enzymes cannot reach the small intestine. Without these, the intestines cannot absorb fats and proteins fully. The most common symptoms of CF include: \uf0a7 Frequent coughing that brings up thick sputum, or phlegm. \uf0a7 Frequent bouts of bronchitis and pneumonia that can lead to inflammation and permanent lung damage. \uf0a7 Salty-tasting skin. \uf0a7 Dehydration. \uf0a7 Infertility (mostly in men). \uf0a7 Ongoing diarrhea or bulky, foul-smelling and greasy stools. \uf0a7 Huge appetite but poor weight gain and growth. \uf0a7 Stomach pain and discomfort caused by gas.",
        "Multiple Sclerosis": "Multiple sclerosis (MS) is a chronic disease that destroys the coating on nerve cells in the brain and spinal cord, interfering with the nerves\u2019 ability to communicate with each other. MS is more common in females than in males, and the onset typically occurs as early as the teen years and as late as age 50. Symptoms usually appear and disappear over a period of years and can include: \uf0a7 Feelings of numbness, tingling and burning. \uf0a7 Overwhelming fatigue at all times. \uf0a7 Vision problems. \uf0a7 Insomnia. \uf0a7 Speech problems. \uf0a7 Bowel and bladder problems. \uf0a7 Fits of anger or crying. \uf0a7 Paralysis. \uf0a7 Forgetfulness and slowness in understanding. \uf0a7 Edema and cold feet due to lack of circulation. When treating patients with MS, help them focus on what they can do.",
        "Muscular Dystrophy": "Muscular dystrophy is a group of genetic disorders in which patients suffer progressive weakness and degeneration of the muscles. About a quarter of a million children and adults are living with the disease in the United States. In the most common form, Duchenne muscular dystrophy, the disease begins in early childhood; in other forms, it begins later in life. People with muscular dystrophy may have mild-to-severe muscle weakness, depending on the type. Although the disorder primarily affects the skeletal muscles\u2014the muscles that allow you to move\u2014some types of muscular dystrophy affect cardiac muscles. In the later stages of the disease, patients with muscular dystrophy often develop respiratory problems and may require assisted ventilation",
        "Autism": "Autism spectrum disorder (ASD) consists of a range of developmental disorders, including autism at the more severe end of the spectrum and Asperger syndrome at the less severe end. The diagnosis of autism seems to have become more common in recent years. The Centers for Disease Control and Prevention reports that the rate of ASD is 14.6 per 1000 for children 8 years of age, and that in this age group, males are 4.5 times more likely to have ASD than females. Children with ASD have deficits in social interaction and communication, and exhibit repetitive behaviors and interests. Some may also have sensory disturbances. People with these disorders interpret the world only through verbal reasoning. Children with autism exhibit unusual behaviors that are usually noticed first by the parents. A baby may seem unresponsive to people or focus intently on one item for long periods of time. However, symptoms can also appear in older children who have been developing normally. A normal child who has shown affection and spoken as a toddler can become silent, withdrawn, self-abusive or indifferent to social overtures. Remember that patients with autism might not look at you directly and physical touch may be disturbing to them. Avoid interpreting these mannerisms or responses as being unsociable. When communicating with patients with autism, it may help to use verbal explanations of emotions.",
        "CRITICAL FACTS 7": "Illnesses that occur gradually and continue over a long period of time (even lifetime) are referred to as chronic conditions. Chronic conditions include heart disease, diabetes and arthritis. Patients with some chronic conditions, such as multiple sclerosis, can live for years with few symptoms and then suddenly experience a flare-up with many symptoms appearing at once.",
        "Hospice Care": "Hospice care is the care provided to a terminally ill patient in the final 6 months of life, consisting of a group of caregivers who offer medical, mental, physical, social, economic and spiritual support. Central to the hospice way of thinking are the ideas that the dying person is an individual who should not be separated from the family or support system, and that dying is a normal and expected part of the life cycle. The family is encouraged and trained to participate in the care. The focus of hospice care is on keeping the person as comfortable and pain-free as possible, because the fear of pain greatly contributes to the person\u2019s stress, as well as that of the family and caregivers. The emphasis is not on curing the illness, but rather on providing physical, emotional, social and spiritual comfort to the dying person. The hospice philosophy also provides practical assistance, emotional support and bereavement care to the dying person\u2019s family. Pain relief is administered without the use of needles; instead, caregivers use oral medications, pain-relieving patches and pills that can be given between the cheek and gums. Emergency medical responders (EMRs) are usually not required during hospice care. However, you may sometimes be called in by a family member or other caregiver when, for example, a patient becomes short of breath. You may be required to attend to a patient who has made special arrangements regarding their treatment or care in an emergency, such as the patient\u2019s wishes regarding resuscitation. You must understand the type of hospice you are being called to and any living wills or advance directives that may be in place. You may require official forms, such as do not resuscitate (DNR) orders, as confirmation regarding a living will.",
        "PUTTING IT ALL TOGETHER": "In this chapter, you have learned the importance of treating all patients with respect, regardless of age, health condition, mental status or physical ability. You have learned about common issues the older adult may face and how to deal with challenges such as hearing loss, loss of sensory acuity and other health conditions. You are now aware of the different types of dementias you may encounter with older adult patients, including Alzheimer\u2019s disease, and the importance of recognizing that not all older adults have diminished cognitive abilities. Along with the challenges the older adult faces, you have also learned about dealing with different chronic illnesses and the importance of dealing with patients on an individual basis in accordance with their specific symptoms and difficulties. All patients require clear communication and respect during assessment and treatment."
    },
    {
        "Key Terms": "Abruptio placentae: Placental abruption; a life-threatening emergency that occurs when the placenta detaches from the uterus., Amniotic fluid: The fluid in the amniotic sac; bathes and protects the fetus., Amniotic sac: \u201cBag of waters\u201d; sac that encloses the fetus during pregnancy and bursts during the birthing process., APGAR score: A mnemonic that describes five measures used to assess the newborn: Appearance, Pulse, Grimace, Activity and Respiration., Birth canal: The passageway from the uterus to the outside of the body through which a baby passes during birth., Bloody show: Thick discharge from the vagina that occurs during labor as the mucous plug (mucus with pink or light red streaks) is expelled; often signifies the onset of labor., Braxton Hicks contractions: False labor; irregular contractions of the uterus that do not intensify or become more frequent as genuine labor contractions do., Breech birth: The delivery of a baby\u2019s feet or buttocks first., Bulb syringe: Small nasal syringe to remove secretions from the newborn\u2019s mouth and nose., Cervix: The lower, narrow part of the uterus (womb) that forms a canal that opens into the vagina, which leads to the outside of the body; upper part of the birth canal., Cesarean section: C-section; delivery of a baby through an incision in the mother\u2019s belly and uterus., Contraction: During labor, the rhythmic tightening and relaxing of muscles of the uterus., Crowning: The phase during labor when the baby\u2019s head is visible at the opening of the vagina., Dilation: During the first stage of labor, refers to the opening of the cervix to allow the baby to be born., Dropping: \u201cEngagement\u201d or \u201clightening\u201d; when the baby drops into a lower position and is engaged in the mother\u2019s pelvis; usually takes place a few weeks before labor begins., Eclampsia: A complication during pregnancy in which the patient has convulsions or seizures associated with high blood pressure., Ectopic pregnancy: A pregnancy outside of the uterus; most often occurs in the fallopian tubes., Embryo: The term used to describe the early stage of development in the uterus, from fertilization to the beginning of the third month., Fetal monitoring: A variety of tests used to measure fetal stress, either internally or externally., Fetus: The term used to describe the stage of development in the uterus after the embryo stage, beginning at the start of the third month., Hemorrhagic shock: Shock due to excessive blood loss., Implantation: The attachment of the fertilized egg to the lining of the uterus, 6 or 7 days after conception., Labor: The birth process, beginning with the contraction of the uterus and dilation of the cervix, and ending with the stabilization and recovery of the mother., Meconium aspiration: Aspiration of the first bowel movement of the newborn; can be a sign of fetal stress and can lead to meconium aspiration syndrome., Miscarriage: A spontaneous end to pregnancy before the 20th week; usually because of birth defects in the fetus or placenta; also called a spontaneous abortion., Mucous plug: A collection of mucus that blocks the opening into the cervix and is expelled, usually toward the end of the pregnancy, when the cervix begins to dilate., Multiple birth: Two or more births in the same pregnancy., Obstetric pack: A first aid kit containing items especially helpful in emergency delivery and initial care after birth; items can include personal protective equipment, towels, clamps, ties, sterile scissors and bulb syringes., Placenta: An organ attached to the uterus and unborn baby through which nutrients are delivered; expelled after the baby is delivered., Placenta previa: Placental implantation that occurs lower on the uterine wall, touching or covering the cervix; can be dangerous if it is still covering part of the cervix at the time of delivery., Preeclampsia: A type of toxemia that occurs during pregnancy; a condition characterized by high blood pressure and excess protein in the urine after the 20th week of pregnancy., Premature birth: Birth that occurs before the end of the 37th week of pregnancy., Prolapsed cord: A complication of childbirth in which a loop of the umbilical cord protrudes through the vagina before delivery of the baby., Stabilization: The final stage of labor in which the mother begins to recover and stabilize after giving birth., Stillbirth: Fetal death; death of a fetus at 20 or more weeks of gestation., Toxemia: An abnormal condition associated with the presence of toxic substances in the blood., Trimester: A three-month period; there are three trimesters in a normal pregnancy., Umbilical cord: A flexible structure that attaches the placenta to the fetus, allowing for the passage of blood, nutrients and waste., Uterus: A pear-shaped organ in a woman\u2019s pelvis in which an embryo forms and develops into a baby; also called the womb., Vagina: Tract leading from the uterus to the outside of the body; often referred to during labor as the birth canal.",
        "INTRODUCTION": "Someday, you may be faced with a situation requiring you to assist with childbirth. If you have never seen or experienced childbirth, your expectations probably consist of what others have told you. Terms such as exhausting, stressful, exciting, fulfilling, painful and scary are sometimes used to describe a planned childbirth, one that occurs in the hospital or at home under the supervision of a healthcare provider. If you find yourself assisting with the delivery of a baby, however, it is probably not happening in a planned situation. Therefore, your feelings, as well as those of the expectant mother, may be intensified by fear of the unexpected or the possibility that something might go wrong. Take comfort in knowing that things rarely go wrong. Childbirth is a natural process. Thousands of children all over the world are born each day, without complications, in areas where no medical assistance is available during childbirth. By following a few simple steps, you can effectively assist in the birth process. This chapter will help you better understand the birthing process, how to assist with the delivery of a baby, how to provide care for both the mother and newborn, how to recognize complications and what complications could require more advanced care.",
        "ANATOMY AND PHYSIOLOGY OF PREGNANCY": "The developing fetus is contained in the uterus and surrounded by amniotic fluid. The uterus is made up of a special arrangement of smooth muscle and blood vessels that allow it to enlarge significantly during pregnancy and to forcibly contract during labor and delivery. The ability of the uterus to produce strong contractions helps pass the baby from the uterus into the birth canal. Strong contractions also help the uterus constrict blood vessels, thus preventing hemorrhage, and help the uterus return to its previous size. The cervix (or neck of the uterus) is the lower, narrow part of the uterus that forms a canal that opens into the vagina, which contains a mucous plug up to the time of labor. The mucous plug seals the uterine opening and prevents any contamination. Once labor begins and the cervix begins to dilate (widen), the mucous plug is expelled. The fetus is pushed through the cervix and vagina. The placenta, or \u201corgan of pregnancy,\u201d begins to develop inside the uterus after the egg attaches itself to the uterine wall. It is rich in blood vessels, and its purpose is to deliver oxygen and nourishment to the fetus from the mother, and remove carbon dioxide and waste products.",
        "NORMAL PREGNANCY": "The duration of a full-term pregnancy spans a 9-month period, or 38 weeks from the time in which the embryo becomes implanted into the woman\u2019s uterus. The due date is usually calculated as 40 weeks from the woman\u2019s last menstrual period (Fig. 24-1). Pregnancy is broken down into 3 trimesters, each lasting approximately 3 months.",
        "CRITICAL FACTS 1": "The duration of a full-term pregnancy spans a 9-month period, or 38 weeks from the time in which the embryo becomes implanted into the woman\u2019s uterus. The due date is usually calculated as 40 weeks from the woman\u2019s last menstrual period. Pregnancy is broken down into 3 trimesters, each lasting approximately 3 months.",
        "First Trimester": "Implantation and rapid development of the embryo occur during the first trimester of pregnancy. Usually implantation takes place with no noticeable symptoms, although slight bleeding may occur in some women. The gradual appearance of morning sickness is common during the first trimester. Morning sickness occurs in 70 percent of pregnant women and usually disappears by the second trimester. Also, the first trimester is generally the time in which a miscarriage, also called a spontaneous abortion, might occur. As the embryo grows, its organs and body parts develop. After about 8 weeks, the embryo is called a fetus. To continue developing properly, the fetus must receive nutrients, which it receives from the mother through the placenta. The placenta is attached to the fetus by a flexible structure called the umbilical cord.",
        "Second Trimester": "Pregnant women commonly experience a feeling of re-energization during the second trimester. This is also when a woman will begin to \u201cshow,\u201d putting on more weight with the growth of the fetus. The mother can now detect \u201cquickening,\u201d or movement of the fetus. The fetus has begun to produce insulin and is urinating, and the placenta is fully developed. Teeth are visible inside the gums, and it is now possible to determine if the fetus is male or female.",
        "Third Trimester": "The mother gains the most weight during the third trimester, when the fetus grows most rapidly. An expanding abdomen sometimes causes the mother\u2019s navel to become convex. Growth of the baby can cause discomfort for the mother, including weak bladder control and backache. The size and movement of the baby may also cause pain or discomfort when pressure is applied to the woman\u2019s ribs and spine. The baby moves into a head-down position in preparation for birth, which is known as dropping. Babies born during the third trimester, but prior to full term, have a good chance of surviving, due to ever-advancing technology and improved intensive care practices.",
        "CRITICAL FACTS": "Implantation and rapid development of the embryo occur during the first trimester of pregnancy. Pregnant women commonly experience a feeling of re-energization during the second trimester. This is also when a woman will begin to \u201cshow,\u201d putting on more weight with the growth of the fetus. The mother gains the most weight during the third trimester, when the fetus grows most rapidly. An expanding abdomen sometimes causes the mother\u2019s navel to become convex. Pregnancy culminates in the birth process, or labor, during which the baby is delivered. Labor begins with rhythmic contractions of the uterus. This may follow or be accompanied by rupture of the amniotic sac (\u201cwater breaking\u201d) and a gush of clear fluid. The labor process has four distinct stages. The length and intensity of each stage vary.",
        "BIRTH AND LABOR PROCESS": "Pregnancy culminates in the birth process, or labor, during which the baby is delivered. Labor begins with rhythmic contractions of the uterus. This may follow or be accompanied by rupture of the amniotic sac (the \u201cwater breaking\u201d) and a gush of clear fluid. As contractions continue, they dilate the cervix. When the cervix is sufficiently dilated, it allows the baby to travel from the uterus through the birth canal and into the outside world. For first-time mothers, this process normally takes between 12 and 24 hours. Subsequent deliveries usually require less time. The labor process has four distinct stages. The length and intensity of each stage vary.",
        "First Stage: Dilation": "In the first stage of labor, the mother\u2019s body prepares for the birth. This stage covers the time from the first contraction until the cervix is fully dilated. A contraction is a rhythmic tightening and relaxing of the muscles in the uterus. Like a wave, it begins gently, rises to a peak of intensity and then subsides. A break occurs between contractions, and a contraction usually lasts about 30 to 60 seconds. Contractions cause dilation, the process that allows the mother\u2019s cervix to expand enough for the baby to pass through during the birth. During this stage of labor, the mucous plug may emerge. The release of the mucous plug, referred to as the bloody show, may also have occurred prior to labor. Before or during labor the amniotic sac will break, releasing the amniotic fluid. When this happens, people often say the woman\u2019s \u201cwater has broken.\u201d As the time for delivery approaches, the contractions occur closer together, last longer and feel stronger. Normally, when contractions are less than 3 minutes apart, delivery is near. The woman may be in considerable discomfort at this time. This stage is the longest, and may last for 18 hours or more, especially for a first delivery. For a woman who has already gone through labor, this stage may last only a few hours.",
        "Second Stage: Expulsion": "The second stage of labor begins when the cervix is completely dilated, and includes the baby\u2019s movement through the birth canal and delivery. During this stage of labor, the mother will experience enormous pressure, similar to the feeling she has to have a bowel movement. This sensation is an indication that it is time for her to push or \u201cbear down,\u201d to help ease the baby through the birth canal. Considerable blood may come from the vagina at this time. Contractions are more frequent during this stage, and may last between 45 and 90 seconds each. In a normal delivery, the baby\u2019s head becomes visible as it emerges from the vagina. When the top of the head begins to emerge, called crowning, birth is imminent and you must be prepared to receive the baby.",
        "Third Stage: Placental Delivery": "Once the baby\u2019s body emerges, the third stage of labor begins. During this stage, the placenta usually separates from the wall of the uterus and exits from the birth canal. This process normally occurs within 30 minutes of the delivery of the baby.",
        "Fourth Stage: Stabilization": "The final stage of labor involves the initial recovery and stabilization of the mother after childbirth. Normally, this stage lasts approximately 1 hour. During this time, the uterus contracts to control bleeding, and the mother begins to recover from the physical and emotional stress that occurred during childbirth.",
        "Assessing Labor": "If you are called to assist a pregnant woman, you will need to determine whether she actually is in labor. The woman may be experiencing Braxton Hicks contractions, or false labor contractions. During false labor, the contractions do not get closer together, do not increase in how long they last and do not feel stronger as time goes on\u2014as they would with true labor. Also, false labor contractions tend to be sporadic; true labor has regular intervals of contractions and they are accompanied by the water breaking. But because there is no real, safe way to determine if the labor is false, transporting the woman to a medical facility is a prudent decision. If the woman is in labor, you should determine how far along she is in the pregnancy, including when the baby is due, and whether she expects any complications. You can determine these factors by asking a few key questions and making some quick observations. To determine if the birth is imminent, ask the woman her due date. Time the contractions to determine how far apart they are. Take the following steps: 1. Feel the mother\u2019s abdomen with a gloved hand for involuntary tightening and relaxing of the uterine muscles. 2. Time the length of the movements in seconds from the time the abdomen tightens to the time it relaxes. 3. Time the start of one contraction to the start of the next in minutes. If the contractions are 5 minutes apart or longer, the woman should be transported to a medical facility if possible. If the contractions are 2 minutes apart or less, you will not have time to transport the woman because the birth is imminent. Calm the mother and make her feel confident you are there to keep her and the baby safe. Continue with the following questions: \uf0a7 Is there a chance of a multiple birth? Labor does not usually last as long in a multiple birth situation. Also, if you know it is a multiple birth, you can prepare what you will need to help in the delivery of more than one baby. Additional information on multiple births is presented later in this chapter. \uf0a7 Is this a first pregnancy? The first stage of labor normally takes longer with first pregnancies than with subsequent ones, but not always. \uf0a7 Is there a bloody discharge? A pink or light red, thick discharge from the vagina is the mucous plug that falls from the cervix as it begins to dilate, which also signals the onset of labor. This discharge is also referred to as the bloody show. \uf0a7 Has the amniotic sac ruptured? When this happens, fluid flows from the vagina in a sudden gush or a trickle. Some women think they have lost control of their bladder. The breaking of the sac usually signals the beginning of labor. People often describe the rupture of the sac as \u201cthe water breaking.\u201d \uf0a7 Does she have an urge to bear down? If the expectant mother expresses a strong urge to push, labor is far along. \uf0a7 Is the baby crowning? If the baby\u2019s head is visible, the baby is about to be born.",
        "CRITICAL FACTS 2": "If you find yourself helping the mother with labor and delivery, check the woman\u2019s breathing and pulse as part of your primary assessment. Check for a potentially closed airway. Breathing rate may be increased due to pain, anxiety or blood loss.",
        "PREPARING FOR DELIVERY": "The realization that you are about to assist with childbirth can be as intimidating as it is exciting. Childbirth involves a discharge of watery, sometimes bloody fluid and other body fluids or substances, such as urine or feces, at stages one and two of labor, in addition to what appears to be a rather large loss of blood after stage two. Fluid discharge sometimes creates splashes, and it is important for the emergency medical responder (EMR) to follow standard precautions using appropriate personal protective equipment (PPE) (see Chapter 6). An obstetric pack is a first aid kit containing items especially helpful in emergency delivery and can include items such as PPE, towels, clamps, ties, sterile scissors and bulb syringes. Try not to be alarmed at the loss of blood. It is a normal part of the birth process. Only bleeding that cannot be controlled after the baby is born is a problem. Take a deep breath and try to relax. Remember that you are only assisting in the process; the expectant mother is doing all the work.",
        "Helping the Mother with Labor and Delivery": "As part of your primary assessment, check the woman\u2019s breathing and pulse. Check for a potentially closed airway. Breathing rate may be increased due to pain, anxiety or blood loss. Heart rate may be increased, peripheral pulses may be weak or absent, skin may be cool and clammy, and shock is possible where there has been excessive bleeding. The woman\u2019s vital signs may show normal blood pressure; however, blood pressure will decrease in case of shock and increase in the case of preeclampsia. Your physical exam will include evaluating the contractions, inspecting for crowning and preparing for delivery. If the woman is conscious and seems to be experiencing normal symptoms of labor, find out any other pertinent medical history. Explain to the expectant mother that the baby is about to be born. Be calm and reassuring. A woman having her first child often feels fear and apprehension about the pain and the condition of the baby. Labor pain ranges from discomfort similar to menstrual cramps to intense pressure or pain. Many women experience something in between. Factors that can increase pain and discomfort during the first stage of labor include: \uf0a7 Irregular breathing. \uf0a7 Tensing up because of fear. \uf0a7 Not knowing what to expect. \uf0a7 Feeling alone and unsupported. You can help the expectant mother cope with the discomfort and pain of labor. By staying calm, firm and confident, and offering encouragement, you can help reduce her fear and apprehension. Reducing fear will aid in reducing her pain and discomfort. Begin by reassuring her that you are there to help. Explain what to expect as labor progresses. Suggest specific physical activities that she can do to relax, such as regulating her breathing. Ask her to breathe slowly and deeply, in through the nose and out through the mouth. Ask her to focus on one object in the room while regulating her breathing. Breathing slowly and deeply in through the nose and out through the mouth during labor can help the expectant mother in several ways because it: \uf0a7 Aids muscle relaxation. \uf0a7 Offers a distraction from the pain of strong contractions as labor progresses. \uf0a7 Ensures adequate oxygen delivery to both the mother and the baby during labor. Taking childbirth classes, usually offered at local hospitals, may help you become more competent in techniques to help an expectant mother relax. Expect delivery to be imminent when you observe the following signs and symptoms:\n\uf0a7\tIntense contractions are 2 minutes apart or less and last 60 to 90 seconds.\n\uf0a7\tThe woman\u2019s abdomen is very tight and hard.\n\uf0a7\tThe mother reports feeling the infant\u2019s head moving down the birth canal or has a sensation like an urge to defecate.\n\uf0a7\tCrowning occurs (the infant\u2019s head appears at the opening of the birth canal).\n\uf0a7\tThe mother reports a strong urge to push.\nIf these signs and symptoms are present, contact medical direction for assistance. The decision will need to be made whether to deliver on-site. If an on-site delivery does not occur within 10 minutes, you will need medical direction\u2019s decision to transport.",
        "DELIVERY": "Assisting with the delivery is often a simple process. The expectant mother does all the work; your job is to create a clean environment and to help guide the baby from the birth canal, minimizing injury to the mother and baby. Begin by positioning the mother. She should be lying on her back, with her head and upper back raised, not lying flat. Her legs should be bent, with the knees drawn up and apart. Position the mother in a way that will make her more comfortable.\nEstablish a clean environment for delivery. Because it is unlikely that you will have sterile supplies, use items such as clean sheets, blankets, towels or clothes. To make the area around the mother as sanitary as possible, place these items over the mother\u2019s abdomen and under her buttocks and legs. Keep a clean, warm towel or blanket handy to wrap the newborn. Because you will be coming in contact with the mother\u2019s and baby\u2019s body fluids, be sure to wear disposable latex-free gloves. Wear protective eyewear and a disposable gown, if they are available, to protect yourself from splashing.\nOther items that can be helpful include supplemental oxygen, a bulb syringe to suction secretions from the infant\u2019s mouth and nose, gauze pads or sanitary pads to help absorb secretions and vaginal bleeding, and a large plastic bag or towel to hold the placenta after delivery.\nContinually check the mother for indications the baby is crowning. You may actually see the head of the baby appear, or the vagina may be bulging. Once crowning takes place, take the following steps to assist with delivery:\n\uf0a7\tAs crowning occurs, place a hand on the top of the baby\u2019s head and apply light pressure. By doing so, you allow the head to emerge slowly, not forcefully. Gradual emergence will help prevent tearing of the vagina and injury to the baby.\n\uf0a7\tAt this point, the expectant mother should stop pushing. Instruct the mother to concentrate on her breathing techniques. Have her pant. This technique will help her stop pushing and help prevent a forceful birth.\n\uf0a7\tYou may have to puncture the amniotic sac with your fingers if the water has not yet broken.\n\uf0a7\tAs the head emerges, the baby will turn to one side, which enables the shoulders and the rest of the body to pass through the birth canal. Check to see if the umbilical cord is looped around the baby\u2019s neck. If it is, gently slip it over the baby\u2019s head. If you cannot slip it over the head, slip it over the baby\u2019s shoulders as they emerge. The baby can slide through the loop.\nGuide one shoulder out at a time. Do not pull the baby.\nAs the baby emerges, the baby will be wet and slippery. Use a clean towel to receive/hold the baby.\nPlace the baby on its side, between the mother and you. By doing so, you can provide initial care without fear of dropping the newborn.\nIf possible, note the time the baby was born.",
        "CARING FOR THE NEWBORN AND MOTHER": "An obstetric pack contains items useful for help in caring for the newborn after delivery.",
        "Caring for the Newborn - Cutting the Umbilical Cord": "Cutting the Umbilical Cord\nThe umbilical cord will stop pulsating not long after the baby is born. When it does, clamp or tie the cord very securely with gauze in two places between the mother and child. The clamp closest to the newborn should be about 6 inches from the baby. There should only be about 3 inches between the two clamps. Follow local protocols and medical direction for guidance on cutting the cord.",
        "Assessing the Newborn": "The APGAR scoring system is the universally accepted method of assessing a newborn at 1 minute and again at 5 minutes after birth. However, if the baby is in distress and needs lifesaving care, the APGAR score is not a priority. APGAR stands for Appearance, Pulse, Grimace, Activity and Respiration. The baby is assigned a number from 0 to 2 for each part of the assessment, for a total possible score of 10. Tally the five scores for a total score out of 10. Here are the guidelines for interpreting that score: \uf0a7 7 to 10 points: Active and vigorous newborn; ready for routine care. \uf0a7 4 to 6 points: Moderately depressed; provide stimulation and oxygen based on local protocols. \uf0a7 1 to 3 points: Severely depressed; provide extensive care including administering supplemental oxygen based on local protocols with bag-valve-mask ventilations and CPR. Also, stimulate the baby to encourage breathing by tapping the soles of the feet or rubbing the back.",
        "Routine Care": "When handling a newborn, always be sure to support the newborn\u2019s head. Newborns lose heat quickly; therefore, it is important to keep them warm and dry. Dry the newborn, particularly the head, and wrap the baby in a clean, warm towel or blanket. Place the dried and wrapped newborn on their side, with the head slightly lower than the trunk. It is vital you ensure that you clear the nasal passages and mouth thoroughly. You can do this by using your finger, a gauze pad or a bulb syringe. Squeeze a bulb syringe before insertion in the mouth and nose. Clear or suction the mouth before the nose. Repeat this until you are sure the airway is clear. If the newborn does not breathe, you must begin giving ventilations. Most newborns begin crying and breathing spontaneously. If the newborn has not made any sounds, stimulate a cry reflex by tapping your fingers on the soles of the feet.",
        "Resuscitation of the Newborn": "Resuscitation of a newborn begins immediately if any of these conditions exist: \uf0a7 Respirations fall to less than 30 respirations per minute or the newborn is gasping or not breathing normally. \uf0a7 Pulse is less than 100 beats per minute. \uf0a7 Cyanosis (bluish skin) around the chest and abdomen persists after administering supplemental oxygen. If the newborn\u2019s respirations are low (less than 30 breaths per minute) and/or the pulse rate is below 100 beats per minute, provide positive-pressure ventilations. If the newborn\u2019s respirations are less than 30 breaths per minute or the newborn is unresponsive: \uf0a7 Tap the bottom of the foot to stimulate a reflex. \uf0a7 Rub the lower back, firmly but gently. \uf0a7 Clear the airway again, with a bulb syringe. \uf0a7 Administer high-concentration oxygen based on local protocols. Remember that a newborn\u2019s lungs are very small and they need very small puffs of air. You may use a mask only if you have the appropriate size for a newborn. If the newborn\u2019s pulse drops to less than 60 beats per minute or does not rise to more than 60 beats per minute during ventilation and the newborn shows signs of poor perfusion, begin CPR.",
        "CRITICAL FACTS 3": "The APGAR (appearance, pulse, grimace, activity and respiration) scoring system is the universally accepted method of assessing a newborn at 1 minute and again at 5 minutes after birth. However, if the baby is in distress and needs lifesaving care, the APGAR score is not a priority. The baby is assigned a number from 0 to 2 for each part of the assessment, for a total possible score of 10. When handling a newborn, always be sure to support the newborn\u2019s head. Newborns lose heat quickly; therefore, it is important to keep them warm and dry.",
        "Controlling Bleeding After Birth": "Expect some additional vaginal bleeding when the placenta is expelled. Using gauze pads or clean towels, gently clean the mother. Place a sanitary pad or towel over the vagina; do not insert anything into the vagina. Instruct the mother to place her legs together. Feel her abdomen for the uterus, which will feel like a grapefruit-sized mass in the lower sector. Massage the uterus to help expel large blood clots and to help the uterus contract. This should slow the bleeding. Watch for signs of shock from uncontrolled bleeding. If signs and symptoms of shock appear, care for the mother accordingly.",
        "Providing Care": "After delivery, be sure to continue caring for the mother, both emotionally and physically. Keep her calm and comfortable, and continue to monitor her vitals until more advanced medical care takes over. If available, offer her a cloth to dry her face, as well as a clean blanket if she is cold. Remove any bloody sheets, blankets and other supplies used for delivery from the immediate area.",
        "CRITICAL FACTS 4": "Resuscitation of a newborn begins immediately if respirations fall to less than 30 respirations per minute or the newborn is gasping or not breathing normally, if pulse is less than 100 beats per minute or if cyanosis (bluish skin) around the chest and abdomen persists after administering supplemental oxygen.",
        "Caring for the Mother": "Delivery of the Placenta Following delivery of the newborn, the placenta will still be in the uterus, attached to the baby by the umbilical cord. Uterine contractions usually expel the placenta within 10 minutes of delivery and almost always within 30 minutes. The mother may experience strong contractions, similar to childbirth, and you may have to tell her to bear down in order for the placenta to be expelled. When the placenta appears, slowly guide it out of the vagina (do not pull) and place it in a clean towel or container.",
        "Caring for the Mother\u2019s Emotions with Stillborn/Aborted Fetuses": "Stillbirth , or fetal death, is the term for the death of a fetus prior to delivery but at 20 or more weeks of gestation. The term miscarriage usually refers to a pregnancy lost prior to 20 weeks of gestation. Whether the loss occurs early in the pregnancy or at 40 weeks of pregnancy or beyond, it can be devastating. The mother should have time to grieve. The bond a parent makes with the unborn fetus begins early on in the pregnancy, so it is normal to experience a powerful sense of loss when their baby dies. Sensitivity on the part of the EMR is of utmost importance. It may be helpful to suggest a referral to a counselor or clergy member who has experience dealing with this kind of loss. Some people find it helpful to join a support group of parents who have had a similar experience where they can share their feelings with others who understand what it is like. Encourage them to seek out a bereavement group in their area.",
        "Spontaneous Abortion": "A miscarriage, or spontaneous abortion, is the loss of a fetus due to natural causes before about 20 weeks of pregnancy. About 85 percent of miscarriages occur during the first 12 weeks of pregnancy. During miscarriage, the woman will experience vaginal spotting, bleeding and discharge, as well as cramping. Miscarriage later in pregnancy is accompanied by severe cramping, resulting in the expulsion of the fetus. The blood lost in these cases often contains mucus or clots.",
        "Ectopic Pregnancy": "In a normal pregnancy, the fertilized egg attaches itself to the lining of the uterus. With an ectopic pregnancy , the fertilized egg most commonly implants in one of the fallopian tubes, which carry eggs from the ovaries to the uterus. This type of ectopic pregnancy is known as a tubal pregnancy. Less commonly, an ectopic pregnancy occurs in the abdomen, ovary or cervix. The fertilized egg of an ectopic pregnancy cannot survive, and the growing tissue may destroy various maternal structures. Therefore, if left untreated, life-threatening blood loss is possible. Early treatment of an ectopic pregnancy, in the form of termination, is necessary to preserve the chance for healthy pregnancies in the future. Symptoms of an ectopic pregnancy include: \uf0a7 Light vaginal bleeding (can be life threatening as it can lead to severe bleeding). \uf0a7 Lower abdominal pain. \uf0a7 Cramping on one side of the pelvis. In the case of the fallopian tube rupturing, symptoms include: \uf0a7 Sharp, stabbing pain in the pelvis, abdomen or even the shoulder and neck. \uf0a7 Dizziness. \uf0a7 Light-headedness.",
        "CRITICAL FACTS 5": "Following delivery of the newborn, the placenta will still be in the uterus, attached to the baby by the umbilical cord. Uterine contractions usually expel the placenta within 10 minutes of delivery and almost always within 30 minutes. Expect some additional vaginal bleeding when the placenta is expelled. After delivery, be sure to continue caring for the mother, both emotionally and physically. Keep her calm and comfortable, and continue to monitor her vitals until more advanced medical care takes over. Complications during pregnancy are rare. A miscarriage, or spontaneous abortion, is the loss of a fetus due to natural causes before about 20 weeks of pregnancy.",
        "Preeclampsia (Toxemia) and Eclampsia ": "Preeclampsia or toxemia , is a common problem during pregnancy and is sometimes referred to as pregnancy-induced hypertension. If left untreated, eclampsia , the final and most severe phase of preeclampsia, occurs. Eclampsia can cause coma and even death of the mother and baby, and can occur before, during or after childbirth. The only cure for preeclampsia is delivery of the baby and, when it occurs near the end of pregnancy, delivery is advised. Signs and symptoms of preeclampsia include: \uf0a7 High blood pressure. \uf0a7 Excess protein in the urine after 20 weeks of pregnancy. \uf0a7 Severe headaches. \uf0a7 Changes in vision, such as temporary loss of vision, blurred vision or light sensitivity. \uf0a7 Upper abdominal pain, usually under the ribs on the right side. \uf0a7 Nausea or vomiting. \uf0a7 Dizziness. \uf0a7 Decreased urine output. \uf0a7 Sudden weight gain, more than 2 pounds per week. \uf0a7 Swelling (edema), particularly in the face and hands. \uf0a7 Seizures, if eclampsia develops.",
        "Vaginal Bleeding in Pregnancy": "Vaginal bleeding during the first trimester does not typically require treatment. Spotting, or light, irregular discharges of a small amount of blood, may be normal. More bleeding may indicate a problem that needs a healthcare provider\u2019s attention. When the thick plug of mucus that seals the opening of the cervix is dislodged, a thick or stringy discharge tinged with blood may appear. This \u201cbloody show\u201d is normal when it occurs near the end of pregnancy and indicates delivery may occur in a week or two. Since the nature and extent of most complications related to pregnancy can only be determined by a medical professional through examination, you should not be concerned with trying to diagnose a particular problem. Instead, concern yourself with recognizing signs and symptoms that suggest a serious complication; two such symptoms are vaginal bleeding and abdominal pain. Any persistent or profuse vaginal bleeding, or bleeding in which tissue passes through the vagina during pregnancy, is abnormal, as is any abdominal pain. When bleeding is accompanied by the following symptoms, immediate attention is required: \uf0a7 Pain \uf0a7 Cramping \uf0a7 Fever \uf0a7 Chills \uf0a7 Contractions \uf0a7 Passing tissue from the vagina An expectant mother exhibiting these signs and symptoms needs to receive more advanced medical care quickly. While waiting for an ambulance or other transport vehicle, take steps to minimize shock. These include: \uf0a7 Helping the woman into the most comfortable position. \uf0a7 Controlling bleeding. \uf0a7 Keeping the woman from getting chilled or overheated. \uf0a7 Administering supplemental oxygen based on local protocols.",
        "CRITICAL FACTS 6": "With an ectopic pregnancy, the fertilized egg most commonly implants in one of the fallopian tubes. Preeclampsia, or toxemia, is a common problem during pregnancy and is sometimes referred to as pregnancy-induced hypertension. If left untreated, eclampsia, the final and most severe phase of preeclampsia, occurs. Vaginal bleeding during the first trimester does not typically require treatment. Spotting, or light, irregular discharges of a small amount of blood, may be normal.",
        "Trauma During Pregnancy": "Trauma during pregnancy can be caused by motor-vehicle collisions, falls, assaults or penetrating injuries. When the placenta peels away from the inner wall of the uterus before delivery, it is called abruptio placentae. This occurs in 1 to 5 percent of patients with minor trauma and 20 to 50 percent of patients with major trauma. Hemorrhage can occur from disruption of the placenta and spontaneous or traumatic uterine rupture. Pregnant women who have suffered an injury should be evaluated in the emergency department. If the patient appears to be in shock, remember that the treatment of shock in a pregnant patient differs from the treatment of shock in other adults in two important respects. First, the organ systems change during pregnancy. Second, two patients are vulnerable: the mother and the fetus. Therefore, obstetric critical care involves simultaneous assessment and management of both the mother and fetus. The management of hemorrhagic shock requires immediate administration of supplemental oxygen based on local protocols. Fetal monitoring should be performed to detect fetal distress or fetal hypoxia. Pregnant patients in the third trimester should be placed on their left side to avoid compression of the inferior vena cava. If a spinal injury is suspected, the backboard or other extrication device should be tilted to the left after the patient is fully secured.",
        "COMPLICATIONS DURING DELIVERY": "The vast majority of all births occur without complication, but this is only reassuring if the one you are assisting with is not complicated. For the few births that do have complications, delivery can be stressful and even life threatening for the expectant mother and the baby. All require the help of more advanced medical personnel.",
        "Hemorrhage": "The most common complication of childbirth is persistent vaginal bleeding, known as postpartum hemorrhage. It is defined as the loss of more than 1 pint of blood following delivery of the placenta. It can occur right after delivery or as late as 1 month later. Hemorrhage can occur when the uterus fails to contract after delivery, as this contraction facilitates the closing of blood vessels that were opened during detachment of the placenta. It can also occur if the uterus was stretched too much during pregnancy or if a piece of placenta remains inside the uterus following delivery. It occurs more commonly following the birth of multiples, a prolonged or abnormal labor, or when a woman has been pregnant several times. Women who have bled excessively following labor in the past are at increased risk of reoccurrence. In the case of hemorrhage, summon more advanced medical care and take steps to minimize shock. Massaging the lower abdomen and encouraging breastfeeding can also help stimulate the uterus to contract. Other childbirth complications include a prolapsed cord, breech birth, limb presentation, multiple births, premature birth and meconium aspiration.",
        "Prolapsed Umbilical Cord": "A prolapsed cord occurs when a loop of the umbilical cord protrudes from the vaginal opening while the baby is still in the birth canal. This can threaten the baby\u2019s life, because as the baby moves through the birth canal, the cord will be compressed against the unborn child and the birth canal, cutting off blood flow. Without this blood flow, the baby will die within a few minutes from lack of oxygen. If you notice a prolapsed cord, have the expectant mother assume a knee-chest position. This will help take the pressure off the cord. Cover any exposed cord with a moist, sterile dressing. Never attempt to push the cord back into the vagina. Administer supplemental oxygen to the mother based on local protocols. Summon more advanced medical personnel, if they have not already been contacted.",
        "Breech Birth": "Most babies are born headfirst. However, on rare occasions, the newborn is delivered feet- or buttocks-first. This condition is commonly called a breech birth. If you encounter a breech delivery, support the newborn\u2019s body as it leaves the birth canal while you are waiting for the head to deliver. Do not pull on the newborn\u2019s body. Pulling will not help deliver the head. Do not attempt to push a protruding foot back up into the birth canal. If a single limb is presenting, you cannot successfully deliver the infant, and the mother must be transported to a hospital as quickly as possible. Call for more advanced medical personnel if they have not already been contacted. Place the mother in a head-down, hips-elevated position, and cover the presenting limb with a sterile towel. Do not attempt to push or pull on the protruding limb. Because the weight of the unborn baby\u2019s head lodged in the birth canal will reduce or stop blood flow by compressing the umbilical cord, the unborn baby will be unable to get any oxygen. Should the unborn baby try to take a spontaneous breath, they will also be unable to breathe because the face is pressed against the wall of the birth canal. As a result, if the head has not been delivered after 3 minutes, you will need to help create an airway for the baby to breathe. To help the baby breathe, place the index and middle fingers of your gloved hand into the vagina next to the baby\u2019s mouth and nose. Spread your fingers to form a V. Though this will not lessen the compression on the umbilical cord, it may allow air to enter the baby\u2019s mouth and nose. You must maintain this position until the baby\u2019s head is delivered. Administer supplemental oxygen to the mother based on local protocols. Summon more advanced medical personnel, if they have not already been contacted. Should the unborn baby\u2019s head be delivered, check the infant for breathing. Be prepared to provide ventilations and perform CPR as necessary.",
        "Limb Presentation": "If the baby is delivered in an incomplete breech, or transverse lie (horizontal) position, the baby\u2019s foot (or feet), arm or shoulder will appear first. This is known as a limb presentation. If you encounter this, do not attempt to deliver the baby in the field. The mother should be transported to a medical facility. Never pull on the limb. Avoid even touching the limb, as this can stimulate the baby to try to take a breath, which can result in aspirating amniotic fluid. A cesarean section will be needed to deliver the baby safely. Summon more advanced medical personnel, if they have not already been contacted. Administer supplemental oxygen to the mother based on local protocols. Place her in a knee-chest position with her pelvis elevated. If she feels the need to push with contractions, have her pant, which can help ease the urge.",
        "Multiple Births": "Although most births involve only a single baby, a few will involve delivery of more than one. If the mother has had proper prenatal care, she will probably be aware that she is going to have more than one baby. Multiple births should be handled in the same manner as single births. The mother will have a separate set of contractions for each child being born. There may also be a separate placenta for each child, though this is not always the case. Keep in mind that the risk of hemorrhage following delivery is higher after giving birth to multiples.",
        "Premature Birth": "When a baby is born before the end of 37 weeks of pregnancy, it is called a premature birth . Premature babies require special care because they are not fully developed. They are at increased risk for such complications as lung and breathing problems, infections and digestive difficulties. They are also more vulnerable to hypothermia. Premature infants can typically be identified by their small, thin appearance and red, wrinkled skin. They also typically have a single crease along the sole of the foot; fuzzy, fine scalp hair; and ears that are not fully developed. After the delivery of a premature baby, dry the infant thoroughly and wrap the baby in blankets, preferably warmed, or in a plastic bubble-bag swaddle. Cover the head, leaving the face clear so the baby can breathe. Keep the baby in a warm place. Use a bulb syringe to gently suction away fluid from the baby\u2019s mouth and nose. Tie off the umbilical cord immediately, as a premature infant cannot tolerate even the smallest loss of blood. Administer supplemental oxygen by blowing oxygen across (not directly into) the baby\u2019s face based on local protocols. Reduce the risk of infection by minimizing the number of people who handle the child. Do not let anyone breathe into the baby\u2019s face.",
        "Meconium Aspiration": "Meconium is the baby\u2019s first bowel movement. Amniotic fluid that is contaminated with meconium will be greenish or brownish yellow instead of clear. The presence of meconium-stained amniotic fluid is an indication that the baby experienced a period of oxygen deprivation (hypoxia), which causes the baby to have a bowel movement. The primary danger is that the baby will aspirate the contaminated fluid, which can result in complications including a blocked airway or respiratory distress, pneumonia and infection. If you observe meconium staining in the amniotic fluid, it is important that you clear the mouth and nose before the baby takes the first breath. Suction the baby\u2019s mouth and nose with a bulb syringe as soon as the baby emerges from the birth canal. Avoid stimulating the baby in any way before clearing the mouth and nose, as this can induce the baby to try to take a breath. Do not squeeze the baby\u2019s chest or put your finger in the baby\u2019s mouth to try to prevent meconium aspiration. Administer supplemental oxygen to the baby based on local protocols. Summon more advanced medical personnel if they have not already been contacted. Keep the baby as warm and calm as possible and maintain the airway, if needed.",
        "PUTTING IT ALL TOGETHER": "Ideally, childbirth should occur in a controlled environment under the guidance of healthcare professionals trained in delivery. In a controlled environment, the necessary medical care is immediately available for mother and baby, should any problem arise. However, unexpected deliveries do occur outside of the controlled environment and may require your assistance. By understanding the four stages of labor and knowing how to prepare the expectant mother for delivery, assist in the delivery and provide proper care for the mother and baby, you will be able to successfully assist in bringing a new child into the world.",
        "CRITICAL FACTS 7": "If the baby is delivered in an incomplete breech, or transverse lie (horizontal) position, the baby\u2019s foot (or feet), arm or shoulder will appear first. This is known as a limb presentation. The mother must be transported to a medical facility. Never pull the limb. Avoid touching it. Multiple births should be handled in the same manner as single births. The mother will have a separate set of contractions for each child being born. When a baby is born before the end of 37 weeks of pregnancy, it is called a premature birth. Premature babies require special care because they are not fully developed. Meconium is the baby\u2019s first bowel movement. Amniotic fluid that is contaminated with meconium will be greenish or brownish yellow instead of clear. If this contaminated fluid is aspirated, it can cause a blocked airway, respiratory distress, pneumonia and infection.",
        "Placenta Previa": "In most pregnancies, the placenta implants itself on the upper part of the uterine wall to establish its rich blood supply. In about one out of every 200 to 250 pregnancies, the placenta implants lower on the uterine wall, touching or covering the cervix, resulting in placenta previa. The condition can be: \uf0a7 Marginal: The placenta touches the edge of the cervix. \uf0a7 Partial: The placenta covers part of the cervix. \uf0a7 Total or complete: The placenta covers the cervix completely. The danger occurs if the placenta pulls away from the uterine wall, causing bleeding of oxygen-rich blood. Causes of the placenta tearing away include: \uf0a7 Labor. \uf0a7 Dilation of the cervix. \uf0a7 Fetal movement. The initial and only symptom of placenta previa is painless vaginal bleeding. To provide care, arrange for immediate transport. Elevate the patient\u2019s legs and maintain body temperature",
        "Abruptio Placentae": "Abruptio placentae is a life-threatening emergency for both mother and child in which the placenta prematurely detaches from the uterus either partially or completely. It occurs in about one out of every 120 to 150 pregnancies and can occur at any time after 20 weeks gestation. The chance of its occurrence rises if it occurred in a previous pregnancy. Abruptio placentae can occur spontaneously or as a result of hypertension or maternal injury (trauma). Symptoms of abruptio placentae, also called placental abruption, are: \uf0a7 Abdominal pain. \uf0a7 Back pain. \uf0a7 Rapid uterine contractions. \uf0a7 Uterine tenderness. \uf0a7 Vaginal bleeding. Bleeding may not be apparent at first, as blood accumulates between the placenta and uterine wall. Therefore, the first signs of abruptio placentae may be pain, abdominal rigidity and shock. To provide care, arrange for immediate transport. Monitor vital signs and treat for shock if necessary.",
        "Ruptured Uterus": "Rupture of the uterus is rare, but its occurrence is associated with a high incidence of infant fatality, reportedly as high as 65 percent. Maternal mortality associated with a ruptured uterus is significantly lower, but it can occur if significant time passes between the event and medical intervention. The uterine wall, which thins during pregnancy, can rupture spontaneously or as the result of an abdominal trauma. Women who have had prior caesarian sections are at a higher risk of experiencing a ruptured uterus than women with first-time pregnancies or those who have delivered vaginally previously. Advanced maternal age is also a risk factor. Signs and symptoms of a ruptured uterus are: \uf0a7 Abdominal pain. \uf0a7 Abnormal fetal heart pattern. \uf0a7 Cessation of contractions. \uf0a7 Deceleration of fetal heartbeat. \uf0a7 Failure of labor to progress. \uf0a7 Hyperstimulation of the uterus (excessive contractions). \uf0a7 Signs of shock. \uf0a7 Vaginal bleeding. Once a uterine rupture is suspected, arrange for immediate transport. Stabilization of the mother and delivery of the fetus is imperative. The time available for intervention is only 18 minutes before the baby experiences significant hypoxia, and only 30 minutes until the baby suffers major neurological impairment.",
        "Shoulder Dystocia": "Shoulder dystocia occurs when the fetus\u2019s shoulders are larger in width than the head. When the mother begins to deliver the baby, the head will emerge from the vagina, but a shoulder or both shoulders becomes caught between the maternal symphysis pubis (joint between the pubic bones) and the sacrum (base of the spine). Other than a large fetus, often due to maternal diabetes, no risk factors for shoulder dystocia are recognized. If the fetal head emerges from the vagina and then retracts, it is considered a symptom of shoulder dystocia. This is often called the \u201cturtle sign.\u201d Shoulder dystocia has no other recognized symptoms. The danger with shoulder dystocia lies with the umbilical cord being compressed between the fetus and the maternal pelvis. Do not apply excessive force, as this is unlikely to free the fetus and may cause injury. The HELPERR mnemonic is a tool used by healthcare providers that describes a set of maneuvers for managing shoulder dystocia during childbirth. These maneuvers are only performed by a healthcare provider and are presented here for information only, as EMRs do not perform them:\n\uf0a7 Help: Request the appropriate personnel to respond.\n\uf0a7 Evaluate: Evaluate for episiotomy (incision between the vaginal opening and anus to prevent a more extensive vaginal tear during delivery will not release the shoulder on its own, as shoulder dystocia is a bone impaction).\n\uf0a7 Legs: Maneuver the mother\u2019s legs in the McRoberts maneuver (repositions the baby).\n\uf0a7 Pressure: Apply suprapubic pressure (making a fist, placing it just above the maternal pubic bone and pushing the fetal shoulder in one direction or the other).\n\uf0a7 Enter: Enter maneuvers (internal rotation of the fetus).\n\uf0a7 Remove: Remove the posterior arm from the birth canal.\n\uf0a7 Roll: Roll the patient onto an all-fours position, which may dislodge the impaction; gravity may also assist."
    },
    {
        "KEY TERMS": "Absorbed poison: A poison that enters the body through the skin., Addiction: The compulsive need to use a substance; stopping use would cause the user to suffer mental, physical and emotional distress., Anabolic steroid: A drug sometimes used by athletes to enhance performance and increase muscle mass; also has medical use in stimulating weight gain for people unable to gain weight naturally., Antidote: A substance that counteracts and neutralizes the effects of a poison., Antihistamine: A type of drug taken to treat allergic reactions., Anti-inflammatory drug: A type of drug taken to reduce inflammation or swelling., Cannabis products: Substances such as marijuana and hashish that are derived from the Cannabis sativa plant; can produce feelings of elation, distorted perceptions of time and space, and impaired motor coordination and judgment., Carbon monoxide (CO): An odorless, colorless, toxic gas produced as a byproduct of combustion., Dependency: The desire or need to continually use a substance., Depressant: A substance that affects the central nervous system and slows down physical and mental activity; can be used to treat anxiety, tension and high blood pressure., Designer drugs: Potent and illegal street drugs formed from a medicinal substance whose drug composition has been modified (designed)., Drug: Any substance, other than food, intended to affect the functions of the body., Hallucinogen: A substance that affects mood, sensation, thinking, emotion and self-awareness; alters perceptions of time and space; and produces hallucinations or delusions., Ingested poison: A poison that is swallowed., Inhalant: A substance, such as a medication, that a person inhales to counteract or prevent a specific condition; also a substance inhaled to produce mood-altering effects., Inhaled poison: A poison breathed into the lungs., Injected poison: A poison that enters the body through a bite, sting or syringe., Naloxone: A medication used to reverse the effects of an opioid overdose., Opioid narcotics: Drugs often derived from opium or opium-like compounds; used to reduce pain and can alter mood and behavior; also known as opioids., Overdose: The use of an excessive amount of a substance, resulting in adverse reactions ranging from mania (mental and physical hyperactivity) and hysteria, to coma and death., Poison: Any substance that can cause injury, illness or death when introduced into the body, especially by chemical means., Poison Control Center (PCC): A specialized health center that provides information on poisons and suspected poisoning emergencies., Stimulant: A substance that affects the central nervous system and speeds up physical and mental activity., Substance abuse: The deliberate, persistent, excessive use of a substance without regard to health concerns or accepted medical practices., Substance misuse: The use of a substance for unintended purposes or for intended purposes but in improper amounts or doses., Synergistic effect: The outcome created when two or more drugs are combined; the effects of each may enhance those of the other., Tolerance: A condition in which the effects of a substance on the body decrease as a result of continued use., Toxicology: The study of the adverse effects of chemical, physical or biological agents on the body., Toxin: A poisonous substance produced by microorganisms that can cause certain diseases but is also capable of inducing neutralizing antibodies or antitoxins., Withdrawal: The condition of mental and physical discomfort produced when a person stops using or abusing a substance to which the person is addicted.",
        "INTRODUCTION": "A poison is any substance that causes injury, illness or death if it enters the body. A person can be poisoned by ingesting or swallowing poison, breathing it, absorbing it through the skin or by injecting it into the body. In 2014, Poison Control Centers (PCCs) received more than 2.1 million calls from people who had come into contact with a poison. Over 91 percent of these poisonings took place in the home and 48 percent involved children under age 6. Poisoning deaths in children under age 6 represented about 1.4 percent of the total deaths from poisoning, while the 20- to 59-year-old age group represented about 66 percent of all deaths from poisoning. Child-resistant packaging for medications and preventive actions by parents and others who care for children have resulted in a decline in child poisonings. At the same time, there has been an increase in adult poisoning deaths, which is linked to an increase in both suicides and drug-related poisonings. A toxin is a poisonous substance produced by microorganisms that can cause certain diseases but is also capable of inducing neutralizing antibodies or antitoxins. Toxicology is the scientific study of poisons and antidotes and how they affect people. Some poisons\u2014including many medications\u2014are not deadly or harmful in small doses, but become dangerous if taken into the body in larger amounts. When a dangerously large amount of a drug is taken, this is called an overdose. Poisons can be solid, liquid, spray or fumes (gases and vapors). A solid or liquid substance may turn into a gas if heated or under pressure. Poisonings can be accidental or intentional, and intentional poisoning can be self-inflicted\u2014in the case of a suicide\u2014or caused by another person intending to harm or kill the person. The severity of a poisoning depends on the type and amount of the substance; the time that has elapsed since the poison entered the body; and the patient\u2019s age, size (build), weight and medical conditions. Many substances that are not poisonous in small amounts are poisonous in larger amounts. Medications (prescription or over-the-counter [OTC]) can be poisonous if they are not taken as prescribed or directed. In a manufacturing facility, Safety Data Sheets (SDSs) are required on site for every product/chemical in use. Formerly called Material Safety Data Sheets (MSDSs), SDSs consist of 16 standardized sections, arranged in a strict order and based on the Globally Harmonized System (GHS) of Classification and Labelling of Chemicals. In the case of a poisoning, the SDS should go with the patient to the hospital, as it will give emergency medical services (EMS) personnel and hospital staff more detailed information as to the treatment of the exposed worker. In this chapter, you will learn about the four ways in which poisons can enter the body\u2014ingestion, inhalation, absorption and injection. You will also learn about the types of poisons that fall into each of these categories, how to recognize the signs and symptoms of each type of poisoning and how to provide care for each. You will learn about how and when to contact the national Poison Help line or summon more advanced medical personnel. This chapter also provides an overview of substance abuse and substance misuse: the types of substances that can be abused or misused, how they enter the body and how to provide care for someone who has been exposed to, inhaled or ingested a poisonous substance.",
        "POISON CONTROL CENTERS": "Poison Control Centers (PCCs) are specialized health centers that provide information on poisons and suspected poisoning emergencies. A network of PCCs exists throughout the United States. Medical professionals in these centers have access to information about virtually all poisonous substances and can tell you how to care for someone who has been poisoned. The American Association of Poison Control Centers operates a 24-hour national Poison Help line, which is staffed by pharmacists, physicians, nurses and toxicology specialists and can be reached at 800-222-1222. PCCs answer over 2 million calls about poisoning each year. Since many poisonings can be treated without the help of EMS personnel, PCCs help prevent overburdening of the EMS system and hospitals. Approximately 70 percent of poison exposure cases can be managed over the phone without a referral to a healthcare facility. For more information, visit the American Association of Poison Control Centers website at aapcc.org. Call for more advanced medical personnel if you are unsure about what to do, you are unsure about the severity of the problem or if it is a life-threatening condition. Otherwise, call the national Poison Help line for assistance. In general, call for more advanced medical personnel if the patient: \uf0a7 Is unconscious, confused or has an altered mental status. \uf0a7 Has trouble breathing or is breathing irregularly. \uf0a7 Has persistent chest pain or pressure. \uf0a7 Has pressure or pain in the abdomen that does not go away. \uf0a7 Is vomiting blood or passing blood. \uf0a7 Has a seizure, severe headache or slurred speech. \uf0a7 Acts violently.",
        "HOW POISON ENTERS THE BODY": "Poisons are generally placed in four categories, based on how they enter the body: ingestion, inhalation, absorption and injection.",
        "CRITICAL FACTS": "A poison is any substance that causes injury, illness or death if it enters the body. A person can be poisoned by ingesting or swallowing poison, breathing it, absorbing it through the skin or by injecting it into the body. A toxin is a poisonous substance produced by microorganisms that can cause certain diseases but is also capable of inducing neutralizing antibodies or antitoxins. PCCs are specialized healthcare centers that provide information on poisons and suspected poisoning emergencies.",
        "Ingested Poison": "Types of Ingested Poisons Ingested poisons are poisons that are swallowed and include items such as foods (e.g., certain mushrooms and shellfish), drugs (e.g., alcohol), medications (e.g., aspirin) and household items (e.g., cleaning products, pesticides and even household plants). Young children tend to put almost everything in their mouths, so they are at a higher risk of ingesting poisons, including household cleaners and medications. Older adults may make medication errors if they are prone to forgetfulness or have difficulty reading the small print on medicine container labels. In 2011, the Centers for Disease Control and Prevention (CDC) estimated that 48 million people contract foodborne illnesses each year in the United States. Approximately 128,000 people are hospitalized and more than 3000 die from foodborne illness. Two of the most common categories of food poisoning are bacterial and chemical food poisoning. Bacterial food poisoning typically occurs when bacteria grow on food that is allowed to stand at room temperature after being cooked, which releases toxins into the food. Foods most likely to cause bacterial food poisoning are meats, fish and dairy or dairy-based foods. Chemical food poisoning typically occurs when foods with high acid content, such as fruit juices or sauerkraut, are stored in containers lined with zinc, cadmium or copper or in enameled metal pans. Another primary source of chemical food poisoning is lead, which is sometimes found in older pipes that supply drinking and cooking water. Mercury, a heavy metal, can also be a source of food poisoning. Fish and shellfish, such as shark and swordfish, are a major dietary source of mercury. However, mercury can also come from other dietary items and contact with mercury metal or its compounds (e.g., a mercury thermometer). Two of the most common causes of food poisoning are salmonella bacteria (most often found in poultry and raw eggs) and Escherichia coli (E. coli) (most often found in raw meats and unpasteurized milk and juices). The most deadly type of food poisoning is botulism, which is caused by a bacterial toxin usually associated with home canning.",
        "Signs and Symptoms of Ingested Poisons": "A person who has ingested poison generally looks ill and displays symptoms common to other sudden illnesses. If you have even a slight suspicion that a patient has been poisoned, seek immediate medical assistance. Signs and symptoms to look for include: \uf0a7 Nausea, vomiting or diarrhea. \uf0a7 Chest or abdominal pain. \uf0a7 Difficulty breathing. \uf0a7 Sweating. \uf0a7 Changes in level of consciousness (LOC). \uf0a7 Seizures. \uf0a7 Headache or dizziness. \uf0a7 Weakness. \uf0a7 Irregular pupil size. \uf0a7 Double vision. \uf0a7 Abnormal skin color. \uf0a7 Burn injuries around the lips or tongue or on the skin around the mouth. The symptoms of food poisoning, which can begin between 1 and 48 hours after eating contaminated food, include nausea, vomiting, abdominal pain, diarrhea, fever and dehydration. Severe cases of food poisoning can result in shock or death, particularly in children, older adults and those with an impaired immune system.",
        "Providing Care for Ingested Poisons": "If the patient is fully conscious and alert, immediately call the national Poison Help line and follow the directions given. DO NOT give the patient anything to eat or drink unless you are told to do so. If you do not know what the poison was and the patient vomits, save some of the vomit. The hospital may analyze it later to identify the poison. In some cases of ingested poisoning, the PCC may instruct you to induce vomiting. Vomiting may prevent the poison from moving to the small intestine, where most absorption takes place. CRITICAL FACTS The national Poison Help line\u2014which is staffed by pharmacists, physicians, nurses and toxicology specialists\u2014can be reached at 800-222-1222. Call for more advanced medical personnel if you are unsure about what to do, you are unsure about the severity of the problem or if it is a life-threatening condition. Otherwise, call the national Poison Help line for assistance. Several scenarios warrant calling for more advanced medical personnel, including unconsciousness, breathing problems, chest or abdominal pain or pressure, vomiting blood or passing blood, seizures or violent behavior. Poisons are generally placed in four categories, based on how they enter the body: ingestion, inhalation, absorption and injection. However, vomiting should be induced only if advised by a medical professional. The PCC or a medical professional will advise you exactly how to induce vomiting. In some instances, vomiting should not be induced. This includes when the patient:\n\uf0a7\tIs unconscious.\n\uf0a7\tIs having a seizure.\n\uf0a7\tIs pregnant (in the last trimester).\n\uf0a7\tHas ingested a corrosive substance (such as drain or oven cleaner) or a petroleum product (such as kerosene or gasoline).\n\uf0a7\tIs known to have heart disease.\nExamples of such poisons are caustic or corrosive chemicals, such as acids, that can eat away or destroy tissues. Vomiting these corrosives could burn the esophagus, throat and mouth. Diluting the corrosive substance decreases the potential for burning and damaging tissues. DO NOT give the patient anything to eat or drink unless medical professionals tell you to do so.\nSome people who have contracted food poisoning may require antibiotic or antitoxin therapy. Fortunately, most cases of food poisoning can be prevented by proper food handling and preparation.",
        "Types of Inhaled Poisons": "Poisoning by inhalation occurs when a person breathes in poisonous gases or fumes. A commonly inhaled poison is carbon monoxide (CO), which is present in substances such as car exhaust and tobacco smoke. CO can also be produced by fires (gas and natural), defective gas cooking equipment, defective gas furnaces, gas water heaters and kerosene heaters. CO, which is colorless, odorless and tasteless, is highly lethal and can cause death after only a few minutes of exposure.\nOther common inhaled poisons include carbon dioxide, chlorine gas, ammonia, sulfur dioxide, nitrous oxide, chloroform, dry cleaning solvents, fire extinguisher gases, industrial gases and hydrogen sulfide. Paints and solvents produce fumes that some people deliberately inhale to get high, as do certain drugs, such as crack cocaine.",
        "Signs and Symptoms of Inhaled Poisons": "Look for paint or solvent around the mouth and nose of the patient if you suspect deliberate inhalation. A pale or bluish skin color, which indicates a lack of oxygen, may signal CO poisoning. Other signs and symptoms of inhaled poisons include:\n\uf0a7\tDifficulty breathing or respiratory rate faster or slower than normal.\n\uf0a7\tChest pain or tightness.\n\uf0a7\tBurning in the nose or eyes.\n\uf0a7\tNausea or vomiting.\n\uf0a7\tCyanosis.\n\uf0a7\tHeadaches, dizziness, confusion.\n\uf0a7\tCoughing, possibly with excessive secretions.\n\uf0a7\tSeizures.\n\uf0a7\tAltered mental status with possible unresponsiveness.",
        "Providing Care for Inhaled Poisons": "When providing care to a patient who may have inhaled poison, follow appropriate safety precautions to ensure that you do not also become poisoned. Toxic fumes may or may not have an odor. If you notice clues at an emergency scene that lead you to suspect toxic fumes are present\u2014such as a strong smell of fuel (sulfur or skunk smell) or a hissing sound (which could indicate gas escaping from a pipe or valve)\u2014you may not be able to reach the patient without risking your own safety. In cases like this, call for specialized services instead of entering the scene. Let EMS professionals know what you discovered, and only enter the scene if you are told it is safe to do so or if you are trained to do so.\nAll patients who have inhaled poison need supplemental oxygen as soon as possible based on local protocols. If you can remove the patient from the source of the poison without endangering yourself, then do so. You can help a conscious patient by getting them to fresh air and then calling for more advanced care personnel. If you find an unconscious patient, remove the patient from the scene if it is safe to do so, and call for more advanced medical personnel. Then provide care for any life-threatening conditions.",
        "Types of Absorbed Poisons": "An absorbed poison enters through the skin or the mucous membranes in the eyes, nose and mouth. Absorbed poisons come from plants, as well as from chemicals and medications. Millions of people each year suffer irritating effects after touching or brushing against poisonous plants such as poison ivy, poison oak and poison sumac Other poisons absorbed through the skin include dry and wet chemicals, such as those used in flea collars for dogs and in yard and garden maintenance products, which may also burn the skin. Some medications, such as topical medications or transdermal patches, can also be absorbed through the skin.",
        "Signs and Symptoms of Absorbed Poisons": "Some of the signs and symptoms of absorbed poisons include:\n\uf0a7\tTraces of the liquid, powder or chemical on the patient\u2019s skin.\n\uf0a7\tSkin that looks burned, irritated, red or swollen.\n\uf0a7\tBlisters that may ooze fluid, or a rash.\n\uf0a7\tItchy skin.",
        "Providing Care for Absorbed Poisons": "To care for a patient who has come into contact with a poisonous plant, follow standard precautions and then immediately rinse the affected area thoroughly with water. Using soap cannot hurt, but soap may not do much to remove the poisonous plant oil that causes the allergic reaction. Before washing the affected area, you may need to have the patient remove any jewelry. This is only necessary if the jewelry is contaminated or if it constricts circulation due to swelling. Rinse the affected areas for at least 20 minutes, using a shower or garden hose if possible. If a rash or weeping lesion (an oozing sore) develops, advise the patient to seek the opinion of a pharmacist or healthcare provider about possible treatment. Medicated lotions may help soothe the area. Antihistamines may also help dry up the lesions and help stop or reduce itching. OTC antihistamines are available at pharmacies and grocery stores and should be used according to the manufacturer\u2019s directions. If the condition worsens or if large areas of the body or the face are affected, the patient should see a healthcare provider, who may administer anti-inflammatory drugs, such as corticosteroids, or other medications to relieve discomfort. If the poisoning involves dry chemicals, brush off the chemicals using gloved hands before flushing with tap water (under pressure). Take care not to inhale any of the chemical or get any of the dry chemical on you, in your eyes, or in the eyes of the patient or any bystanders. Many dry chemicals are activated by contact with water. However, if continuous running water is available, it will flush the chemical from the skin before the activated chemical can do harm. If wet chemicals contact the skin, flush the area continuously with large amounts of cool, running water. Running water reduces the threat to you and quickly and easily removes the substance from the patient. Continue flushing for at least 20 minutes or until more advanced medical personnel arrive. If poison has been in contact with the patient\u2019s eye or eyes, irrigate the affected eye or eyes, from the nose side of the eye, not directly onto the middle of the cornea of the eye, with clean water for at least 15 minutes. If only one eye is affected, make sure you do not let the water run into the unaffected eye. To ensure this, tilt the head so the water runs from the nose side of the eye downward to the ear side. Continue care while transporting the patient if you can.",
        "Types of Injected Poisons": "Injected poisons enter the body through the bites or stings of certain insects, spiders, marine life, animals and snakes, or as drugs or misused medications injected with a hypodermic needle. Insect and animal bites and stings are among the most common sources of injected poisons. See Chapter 16 for more information about the signs of these bites and how to provide care for them.",
        "Signs and Symptoms of Injected Poisons": "Some of the signs and symptoms of injected poisons include:\n\uf0a7\tBite or sting mark at the point of entry.\n\uf0a7\tA stinger, tentacle or venom sac in or near the entry site.\n\uf0a7\tRedness, pain, tenderness or swelling around the entry site.\n\uf0a7\tSigns of allergic reaction, including localized itching, hives or rash.\n\uf0a7\tSigns of a severe allergic reaction (anaphylaxis), including weakness, nausea, dizziness, swelling of the throat or tongue, constricted airway or difficulty breathing.",
        "Providing Care for Injected Poisons": "Size up the scene and follow standard precautions. Perform a primary assessment and care for conditions found. Applying a cold pack can reduce pain and swelling of the bitten area. To provide specific care for certain bites and stings, see Chapter 16. Call for more advanced medical personnel if there are signs and symptoms of anaphylaxis, and assist the patient with their prescribed epinephrine auto-injector if protocols allow and you are trained to do so.",
        "SUBSTANCE ABUSE AND MISUSE": "A drug is any substance, other than food, intended to affect body functions. A drug given therapeutically to prevent or treat a disease or otherwise enhance mental or physical well-being is a medication. Substance abuse is the deliberate, persistent and excessive use of a substance without regard to health concerns or accepted medical practices. Substance misuse refers to the use of a substance for unintended purposes or for appropriate purposes but in improper amounts or doses. Because of the publicity they receive, we tend to think of illegal (also known as illicit or controlled) drugs when we hear of substance abuse. However, legal substances (also called licit or noncontrolled substances) are among those most often abused or misused. These include nicotine (found in tobacco products), alcohol, and OTC medications such as sleeping pills and diet pills. In the United States, substance abuse costs tens of billions of dollars each year in medical care, insurance and lost productivity. Even more important, however, are the lives lost or permanently impaired each year from injuries or medical emergencies related to substance abuse or misuse. In 2014, drug overdose resulted in a total of 47,055 deaths in the United States. Drug overdose is the leading cause of accidental death in the country, resulting in even more deaths than motor-vehicle collisions. Experts estimate that as many as two-thirds of all homicides and serious assaults occurring annually involve alcohol. Other problems directly or indirectly related to substance abuse include dropping out of school, adolescent pregnancy, suicide, involvement in violent crime and transmission of the human immunodeficiency virus (HIV). If you think someone has taken an overdose or has another substance abuse problem requiring medical attention or other professional help, size up the scene for safety, then check the person. If you have good reason to suspect a substance was taken, call the national Poison Help line and follow the directions given.",
        "Forms of Substance Abuse and Misuse": "Many substances that are abused or misused are legal. Other substances are legal only when prescribed by a healthcare provider. Some are illegal only for those under a certain age, such as alcohol. Any drug can cause dependency, or the desire to continually use the substance. Those with drug-dependency issues feel that they need the drug to function normally. Those with a compulsive need for a substance and those who would suffer mental, physical and emotional distress if they stopped taking it are said to have an addiction to that substance. The term withdrawal describes the condition produced when people stop using or abusing a substance to which they are addicted. Stopping the use of a substance may occur as a deliberate decision or because the person is unable to obtain the specific drug. Withdrawal from certain substances, such as alcohol, can cause severe mental and physical distress. Because withdrawal may become a serious medical condition, medical professionals often oversee the process. When someone continually uses a substance, its effects on the body often decrease\u2014a condition called tolerance. The person then has to increase the amount and frequency of use to obtain the desired effect. An overdose occurs when someone uses an excessive amount of a substance. Symptoms can vary but may range from mania and hysteria to coma and death. Specific reactions include changes in blood pressure and heartbeat, sweating, vomiting and liver failure. An overdose may occur unintentionally if a person takes too much medication at one time. For example, an older adult might forget about taking one dose of a medication and thus take an additional dose. An overdose may also be intentional, as in a suicide attempt. Sometimes the patient takes a sufficiently high dose of a substance to be certain to cause death. In other cases, the patient may take enough of a substance to need medical attention but not enough to cause death.",
        "Abused and Misused Substances": "Substances are categorized according to their effects on the body (Table 15-1). The six major categories are stimulants, hallucinogens, depressants, opioid narcotics, inhalants and cannabis products. The category to which a substance belongs depends mostly on the effects it has on the central nervous system or the way the substance is taken. Some substances depress the nervous system, whereas others speed up its activity. Some are not easily categorized because they have various effects or may be taken in a variety of ways. A heightened or exaggerated effect may be produced when two or more substances are used at the same time. This is called a synergistic effect, which can be deadly.",
        "CRITICAL FACTS 3": "Substance abuse is the deliberate, persistent and excessive use of a substance without regard to health concerns or accepted medical practices. Substance misuse refers to the use of a substance for unintended purposes or for appropriate purposes but in improper amounts or doses.",
        "Commonly Abused and Misused Substances - Stimulants": "Substances: Caffeine, Cocaine, Crack cocaine, Amphetamines, Methamphetamine, Dextroamphetamine, Nicotine, Ephedra, OTC diet aids, Asthma treatments, Decongestants. Common Names: Coke, Snow, Nose candy, Blow, Flake, Big C, Lady, White, Snowbirds, Powder, Foot, Crack, Rock, Cookies, Freebase rocks, Speed, Uppers, Ups, Bennies, Black beauties, Crystal, Meth, Crank, Crystal meth, Ice, Ma huang. Possible Effects: Increase mental and physical activity; Produce temporary feelings of alertness; Prevent fatigue; Suppress appetite.",
        "Commonly Abused and Misused Substances - Hallucinogens": "Substances: Diethyltryptamine (DET), Dimethyltryptamine (DMT), LSD, PCP, Mescaline, Peyote, Psilocybin, 4-Methyl-2,5-dimethoxyamphetamine (DOM). Common Names: Psychedelics, Acid, White lightning, Sugar cubes, Angel dust, Hog, Loveboat, Peyote, Buttons, Cactus, Mesc, Mushrooms, Magic mushrooms, 'Shrooms, STP (Serenity, Tranquility and Peace). Possible Effects: Cause changes in mood, sensation, thought, emotion and self-awareness; Alter perceptions of time and space; Can produce profound depression, tension and anxiety, as well as visual, auditory or tactile hallucinations.",
        "Commonly Abused and Misused Substances - Depressants": "Substances: Barbiturates, Benzodiazepines, Narcotics, Alcohol, Antihistamines, Sedatives, Tranquilizers, OTC sleep aids, Ketamine, Rohypnol\u00ae, GHB. Common Names: Valium\u00ae, Xanax\u00ae, Downers, Barbs, Goofballs, Yellow jackets, Reds, Quaaludes, Ludes, Club drugs, Date rape drugs, Special K, Vitamin K, Roofies, Roach, Rope, Liquid ecstasy, Soap, Vita-G. Possible Effects: Decrease mental and physical activity; Alter level of consciousness; Relieve anxiety and pain; Promote sleep; Depress respiration; Relax muscles; Impair coordination and judgment.",
        "Commonly Abused and Misused Substances - Opioid narcotics": "Substances: Morphine, Codeine, Heroin, Oxycodone, Methadone, Opium. Common Names: Pectoral syrup, OxyContin\u00ae, Percodan\u00ae, Percocet\u00ae, Smack, Horse, Mud, Brown sugar, Junk, Black tar, Big H. Possible Effects: Relieve pain; Produce stupor or euphoria; Can cause coma or death; Highly addictive",
        "Commonly Abused and Misused Substances - Inhalants": "Substances: Medical anesthetics, Lacquer and varnish thinners, Propane, Toluene, Butane, Acetone, Fuel, Propellants. Common Names: Laughing gas, Whippets, Glue, Lighter fluid, Nail polish remover, Gasoline, Kerosene, Aerosol sprays. Possible Effects: Alter mood; Produce a partial or complete loss of feeling; Produce effects similar to drunkenness such as slurred speech, lack of inhibitions, and impaired motor coordination; Can cause damage to the heart, lungs, brain, and liver.",
        "Commonly Abused and Misused Substances - Cannabis products": "Substances: Hashish, Marijuana, THC, Synthetic cannabinoids. Common Names: Hash, Pot, Grass, Weed, Reefer, Ganja, Mary Jane, Dope, K2, Spice. Possible Effects: Produce feelings of elation; Increase appetite; Distort perceptions of time and space; Impair motor coordination and judgment; Irritate throat; Redden eyes; Increase heart rate; Cause dizziness.",
        "Commonly Abused and Misused Substances - Other (MDMA and similar drugs)": "Substances: MDMA. Common Names: Ecstasy, E, XTC, Adam, Essence. Possible Effects: Elevate blood pressure; Produce euphoria or erratic mood swings; Cause rapid heartbeat, profuse sweating, agitation, and sensory distortions.",
        "Commonly Abused and Misused Substances - Anabolic steroids": "Substances: Androgens. Common Names: Hormones, Juice, Roids, Vitamins. Possible Effects: Enhance physical performance; Increase muscle mass; Stimulate appetite and weight gain; Chronic use may cause sterility, disruption of normal growth, liver cancer, personality changes, and aggressive behavior.",
        "Commonly Abused and Misused Substances - Aspirin": "Substances: Aspirin. Possible Effects: Relieves minor pain; Reduces fever; Impairs normal blood clotting; Can cause inflammation of the stomach and small intestine.",
        "Commonly Abused and Misused Substances - Laxatives and emetics": "Substances: Ipecac syrup, Senna. Possible Effects: Relieve constipation or induce vomiting; Can cause dehydration, uncontrolled diarrhea, and other serious health problems.",
        "Commonly Abused and Misused Substances - Decongestant nasal sprays": "Substances: Decongestant nasal sprays. Possible Effects: Relieve congestion and swelling of nasal passages; Chronic use can cause nosebleeds and changes in the nasal lining, making it difficult to breathe without the sprays.",
        "Stimulants": "Stimulants are drugs that affect the central nervous system by speeding up physical and mental activity. They produce temporary feelings of alertness and prevent fatigue. They are sometimes used for weight reduction because they also suppress appetite, or to enhance exercise routines because they provide bursts of energy. Many stimulants are ingested as pills, but some can be absorbed or inhaled. Amphetamine, dextroamphetamine and methamphetamine are stimulants. On the street, an extremely addictive, dangerous and smokable form of methamphetamine is often called \u201ccrystal meth\u201d or \u201cice.\u201d The street term \u201cspeed\u201d usually refers to amphetamine or methamphetamine. Other street terms for amphetamines are \u201cuppers,\u201d \u201cbennies,\u201d \u201cblack beauties,\u201d \u201ccrystal,\u201d \u201cmeth\u201d and \u201ccrank.\u201d Cocaine is one of the most publicized and powerful stimulants. It can be taken into the body in different ways. The most common way is sniffing it in powder form, known as \u201csnorting.\u201d In this method, the drug is absorbed into the blood through capillaries in the nose. Street names for cocaine include \u201ccoke,\u201d \u201csnow,\u201d \u201cblow,\u201d \u201cflake,\u201d \u201cfoot\u201d and \u201cnose candy.\u201d A potent and smokable form of cocaine is called \u201ccrack.\u201d The vapors of crack are inhaled into the lungs, reach the brain and cause almost immediate effects. Crack is highly addictive. Street names for crack include \u201crock\u201d and \u201cfreebase rocks.\u201d Ephedra, also known as \u201cma huang,\u201d is a stimulant plant that has been used in China and India for over 5000 years. Until it was banned by the Food and Drug Administration (FDA) in 2004, it was a common ingredient in dietary supplements sold in the United States. The dried stems and leaves are put into capsules, tablets, extracts, tinctures or teas, and then ingested. It is used for weight loss, increased energy and to enhance athletic performance. The FDA banned ephedra because it appears to have little effectiveness, along with some substantial health risks. Taking ephedra can cause nausea, anxiety, headache, psychosis, kidney stones, tremors, dry mouth, irregular heart rhythms, high blood pressure, restlessness and sleep problems. It has been found to increase the risk of heart problems, a stroke and even death. Interestingly, the most common stimulants in America are legal. Leading the list is caffeine, present in coffee, tea, high-energy drinks, many kinds of sodas, chocolate, diet pills and pills used to combat fatigue. The next most common stimulant is nicotine, found in tobacco products. Other stimulants used for medical purposes are asthma medications or decongestants that can be taken by mouth or inhaled",
        "Hallucinogens": "Hallucinogens, also known as psychedelics, are substances that cause changes in mood, sensation, thought, emotion and self-awareness. They alter one\u2019s perception of time and space and produce visual, auditory and tactile (relating to the sense of touch) delusions. Among the most widely abused hallucinogens are lysergic acid diethylamide (LSD), called \u201cacid\u201d; psilocybin, called \u201cmushrooms\u201d; phencyclidine (PCP), called \u201cangel dust\u201d; mescaline, called \u201cpeyote,\u201d \u201cbuttons\u201d or \u201cmesc\u201d; and ketamine, called \u201cspecial K\u201d or \u201cvitamin K.\u201d These substances are usually ingested, but PCP is also often inhaled. Hallucinogens often have physical effects similar to stimulants but are classified differently because of the other effects they produce. Hallucinogens sometimes cause what is called a \u201cbad trip.\u201d A bad trip can involve intense fear, panic, paranoid delusions, vivid hallucinations, profound depression, tension and anxiety. The person may be irrational and feel threatened by any attempt others make to help.",
        "Depressants": "Depressants are substances that affect the central nervous system by slowing down physical and mental activity. Depressants are commonly used for medical purposes. All depressants alter consciousness to some degree. They relieve anxiety, promote sleep, depress respiration, relieve pain, relax muscles, and impair coordination and judgment. Like other substances, the larger the dose or the stronger the substance, the greater its effects. Common depressants are barbiturates, benzodiazepines (e.g., Valium\u00ae, Xanax\u00ae), narcotics and alcohol. Most depressants are ingested or injected. Their street names include \u201cdowners,\u201d \u201cbarbs,\u201d \u201cgoofballs,\u201d \u201cyellow jackets,\u201d \u201creds\u201d or \u201cludes.\u201d Two depressants that have gained popularity as club drugs (so called because they are used at all-night dance parties) include Rohypnol\u00ae (also referred to as \u201croofies,\u201d \u201croach\u201d or \u201crope\u201d), a benzodiazepine that is illegal in the United States; and gamma-hydroxybutyrate (GHB) (also referred to as \u201cliquid ecstasy,\u201d \u201csoap\u201d or \u201cvita-G\u201d), an illicit drug that has depressant, euphoric and body-building effects. These drugs are particularly dangerous because they are often used in combination or with",
        "Alcohol": "Alcohol is the most widely used and abused substance in the United States. In small amounts, its effects may be fairly mild. In higher doses, its effects can be toxic. Alcohol is like other depressants in its effects and risks for overdose. Frequent drinkers may become dependent on the effects of alcohol and increasingly tolerant of those effects. Alcohol poisoning occurs when a large amount of alcohol is consumed in a short period of time and can result in unconsciousness and, if untreated, death. Drinking alcohol in large or frequent amounts can have many unhealthy consequences. Alcohol can irritate the digestive system and even cause the esophagus to rupture, or it can injure the stomach lining. Chronic drinking can also affect the brain and cause memory loss, apathy and a lack of coordination. Other problems include liver disease, such as cirrhosis. In addition, many psychological, family, social and work problems are related to chronic drinking.",
        "Opioid Narcotics": "While they have a depressant effect, opioid narcotics (which are often derived from opium) are used mainly to relieve pain. Opioid narcotics are so powerful and highly addictive that all are illegal without a prescription, and some are not prescribed at all. When taken in large doses, opioid narcotics can produce euphoria, stupor, coma or death. The most common natural opioid narcotics are morphine and codeine. Most other opioid narcotics, including heroin, are synthetic or semi-synthetic. Oxycodone, also known by the trade names Oxycontin\u00ae or Percocet\u00ae, is a powerful semi-synthetic opioid narcotic that has recently gained popularity as a street drug. Opioid narcotic abuse has become a major health concern in the United States and throughout the world. Of the 47,055 deaths in the United States in 2014 attributed to drug overdose, 28,647 (61 percent) involved some type of opioid narcotic. While there are many factors in treating this epidemic, including increased awareness and education, a medication that can reverse the effects of opioid narcotics is becoming increasingly available. This medication, called naloxone, is commonly used by EMS personnel to reverse the effects of opioid drugs. Recent legislation has allowed individuals in some states who are being prescribed opioids by their physician to also be given a prescription for naloxone. In fact, in some states this medication can even be obtained directly from the pharmacist without a prescription. Naloxone typically comes as a nasal spray (atomizer) or an injectable. Auto-injectors, similar to those used to deliver epinephrine, are also being manufactured for use in the treatment of opioid poisoning. Before using naloxone, it is important to be trained in how to recognize when to administer it and how to give it. Signs and symptoms of opioid overdose include:\n\uf0a7 Slowed and/or shallow breathing (or no breathing).\n\uf0a7 Extreme drowsiness or becoming unconscious.\n\uf0a7 Small pupils. Severe opioid poisoning is a life-threatening emergency; in severe cases, the patient may be unconscious, not breathing, and have bluish skin (cyanosis) and a faint or absent heartbeat. If you suspect opioid overdose in a patient, the most important thing to do is to call for more advanced personnel. If used appropriately, based on local protocols, naloxone can reverse all of the effects of opioid poisoning, including unconsciousness and breathing difficulties.",
        "Inhalants": "Substances inhaled to produce mood-altering effects are called inhalants . Inhalants also depress the central nervous system. In addition, inhalant use can damage the heart, lungs, brain and liver. Inhalants include medical anesthetics, such as amyl nitrite and nitrous oxide (also known as \u201claughing gas\u201d), as well as hydrocarbons, known as solvents. The effects of solvents are similar to those of alcohol. People who use solvents may appear to be drunk. Other effects of inhalant use include swollen mucous membranes in the nose and mouth, hallucinations, erratic blood pressure and pulse, and seizures. Solvents include toluene, found in glues; butane, found in lighter fluids; acetone, found in nail polish removers; fuels, such as gasoline and kerosene; and propellants, found in aerosol sprays.",
        "Cannabis Products": "Cannabis products, including marijuana, hash oil, tetrahydrocannabinol (THC) and hashish, are all derived from the plant Cannabis sativa. Marijuana is the most widely used illicit drug in the United States. Street names include \u201cpot,\u201d \u201cgrass,\u201d \u201cweed,\u201d \u201creefer,\u201d \u201cganja\u201d and \u201cdope.\u201d It is typically smoked in cigarette form or in a pipe, but it can also be ingested. The effects include feelings of elation, distorted perceptions of time and space, and impaired judgment and motor coordination. Marijuana irritates the throat, reddens the eyes, and causes dizziness and often an increased appetite. Depending on the dose, the person and many other factors, cannabis products can produce effects similar to those of substances in any of the other major substance categories. Marijuana, although still illegal throughout much of the United States, has been legalized in some states and is available in others for limited medical use to help alleviate symptoms of certain conditions such as multiple sclerosis. Marijuana and its legal synthetic versions are used as an anti-nausea medication for people undergoing chemotherapy for cancer, for treating glaucoma, for treating muscular weakness caused by multiple sclerosis, and to combat the weight loss caused by cancer and acquired immunodeficiency syndrome (AIDS). Newer, more potent synthetic marijuana-like products have been available in the United States since the early 2000s. These products are known as synthetic marijuana or synthetic cannabinoids. Street names include \u201cK2\u201d and \u201cspice.\u201d These products are typically smoked or taken orally. They are not a safe alternative to marijuana and, in fact, have more side effects than marijuana and can cause hallucinations, seizures, stupor, coma or death",
        "Other Substances": "Some other substances do not fit neatly into these categories. These substances include designer drugs, steroids and OTC substances, which can be purchased without a prescription.",
        "Designer Drugs": "Designer drugs are variations of other substances, such as narcotics and amphetamines. Through simple and inexpensive methods, the molecular structure of substances produced for medicinal purposes can be modified into extremely potent and dangerous street drugs; hence the term \u201cdesigner drug.\u201d When the chemical makeup of a drug is altered, the user can experience a variety of unpredictable and dangerous effects. The people who modify these drugs may have no knowledge of the effects a new designer drug might produce. One of the more commonly used designer drugs is methylenedioxymethamphetamine (MDMA). Another popular club drug, it is often called \u201cecstasy\u201d or \u201cE.\u201d Although ecstasy is structurally related to stimulants and hallucinogens, its effects are somewhat different from either category. Ecstasy can evoke a euphoric high that makes it popular. Other signs and symptoms of ecstasy use range from the stimulant-like effects of high blood pressure, rapid heartbeat, profuse sweating and agitation to the hallucinogenic-like effects of paranoia, sensory distortion and erratic mood swings.",
        "Anabolic Steroids": "Anabolic steroids are drugs sometimes used by athletes to enhance performance and increase muscle mass. Their medical uses include stimulating weight gain for persons unable to gain weight naturally. They should not be confused with corticosteroids, which are used to counteract toxic effects and allergic reactions. Chronic use of anabolic steroids can lead to sterility, liver cancer and personality changes, such as aggressive behavior. Steroid use by younger people may also disrupt normal growth. Street names for anabolic steroids include \u201candrogens,\u201d \u201chormones,\u201d \u201cjuice,\u201d \u201croids\u201d and \u201cvitamins.\u201d",
        "OTC Substances": "Aspirin, nasal sprays, laxatives and emetics are among the most commonly abused or misused OTC substances. Aspirin is an effective minor pain reliever and fever reducer that is found in a variety of medicines. People use aspirin for many reasons and conditions. In recent years, cardiologists have praised the benefits of low-dose aspirin for the treatment of heart disease and stroke prevention. As useful as aspirin is, misuse can have toxic effects on the body. Typically, aspirin can cause inflammation of the stomach and small intestine that can result in bleeding ulcers. Aspirin can also impair normal blood clotting. Decongestant nasal sprays can help relieve the congestion of colds or hay fever. If misused, they can cause physical dependency. Using the spray over a long period can cause nosebleeds and changes in the lining of the nose that make it difficult to breathe without the spray. Laxatives are used to relieve constipation. They come in a variety of forms and strengths. If used improperly, laxatives can cause uncontrolled diarrhea that may result in dehydration, the excessive loss of water from the body tissues. The very young and older adults are particularly susceptible to dehydration. Emetics are drugs that induce vomiting. Ipecac syrup is an emetic that has been used in the past to induce vomiting following the ingestion of some toxic substances. The administration of ipecac syrup for ingested poisons is not recommended. Use of ipecac can be quite dangerous and may cause recurrent vomiting, diarrhea, dehydration, pain and weakness in the muscles, abdominal pain and heart problems. Over time, the recurrent vomiting can erode tooth enamel, causing dental problems. For these reasons, it is no longer widely available in the United States, and the American Academy of Pediatrics and the American Association of Poison Control Centers do not recommend that ipecac syrup be stocked at home. The abuse of laxatives and emetics is frequently associated with attempted weight loss and eating disorders, such as anorexia nervosa or bulimia. Anorexia nervosa is a disorder that most often affects young women and is characterized by a long-term refusal to eat food with sufficient nutrients and calories. People with anorexia typically use laxatives and emetics to keep from gaining weight. Bulimia is a condition in which people gorge themselves with food, then purge by vomiting (sometimes with the aid of emetics) or using laxatives. For this reason, the behavior associated with bulimia is often referred to as \u201cbinging and purging.\u201d Anorexia nervosa and bulimia have underlying psychological factors that contribute to their onset. The effect of both of these eating disorders can be severe malnutrition, which can result in death.",
        "Considerations for Older Adults - Substance Abuse and Misuse": "Substance Abuse and Misuse Among Older Adults Substance abuse and misuse does occur in older populations. Older adults are likely to suffer from chronic diseases or conditions that require multiple prescription medications. These medications can interact with each other or with alcohol, and cause adverse reactions. The slower metabolisms of older adults can cause alcohol and medications to remain in the body longer, increasing the chance of an overdose. Sometimes, because of failing eyesight, an older adult may unintentionally take a drug at the wrong time or consume the wrong dosage and experience an overdose. Mixing medications or mixing drugs with alcohol and failing to follow directions are also factors in substance abuse and misuse among older people.",
        "Adolescents and Substance Abuse and Misuse": "Adolescents and young adults are more likely to be involved in substance abuse and misuse. Males are somewhat more likely to use illicit drugs and alcohol than females, although they are almost equally likely to use psychotherapeutic drugs for nonmedical purposes. Middle and high school students are also likely to abuse or misuse prescription drugs such as narcotic pain killers, sedatives or stimulants because they can access them easily at home, from people they know or on the Internet.",
        "Signs and Symptoms of Substance Abuse and Misuse": "Many of the signs and symptoms of substance abuse and misuse are similar to those of other medical emergencies. Do not necessarily assume that individuals who are stumbling, disoriented or have a fruity, alcohol-like odor on the breath are intoxicated by alcohol or other drugs, as this may also be a sign of a diabetic emergency. As in other medical emergencies, you do not have to diagnose substance abuse or misuse to provide care. It can be helpful, however, if you detect clues that suggest the nature of the problem. Such clues help you provide more complete information to more advanced medical personnel so that they can provide prompt and appropriate care. Often these clues will come from the patient, bystanders or the scene. Look for containers, pill bottles, drug paraphernalia and signs of other medical problems. If the patient is incoherent or unconscious, try to get information from any bystanders or family members. Since many of the physical signs of substance abuse mimic other conditions, you may not be able to determine that a patient has overdosed on a substance. To provide care, you only need to recognize abnormalities in breathing, skin color and moisture, body temperature and behavior, any of which may indicate a condition requiring professional help. The abuse or misuse of stimulants can have many unhealthy effects on the body that mimic other conditions. For example, a stimulant overdose can cause moist or flushed skin, sweating, chills, nausea, vomiting, fever, headache, dizziness, rapid pulse, rapid breathing, high blood pressure and chest pain. In some instances, it can cause respiratory distress, disrupt normal heart rhythms or cause death. The patient may appear very excited, restless, talkative or irritable, or may suddenly lose consciousness. Stimulant abuse can lead to addiction and can cause a heart attack or stroke. Specific signs and symptoms of hallucinogen abuse, as well as abuse of some designer drugs, may include sudden mood changes and a flushed face. The patient may claim to see or hear something not present, or may be anxious and frightened. Specific signs and symptoms of depressant abuse may include drowsiness, confusion, slurred speech, slow heart and breathing rates, and poor coordination. A person who abuses alcohol may smell of alcohol. A person who has consumed a great deal of alcohol in a short time may become unconscious or hard to arouse. The person may vomit violently. Specific signs and symptoms of alcohol withdrawal, a potentially dangerous condition that can be life threatening, include confusion and restlessness, trembling, hallucinations and seizures. A telltale sign of cannabis use is red, bloodshot eyes, while those abusing inhalants may appear drunk or disoriented in a similar manner to a person abusing hallucinogens.",
        "Providing Care for Substance Abuse and Misuse": "Always summon more advanced medical personnel if you suspect a patient is suffering from alcohol withdrawal or from any form of substance abuse. Since substance abuse and misuse are forms of poisoning, care follows the same general principles as for other types of poisoning. As in other medical emergencies, however, people who abuse or misuse substances may become aggressive or uncooperative when you try to help. If the person becomes agitated or makes the scene unsafe in any way, retreat until the scene can be secured. Provide care only if you feel the patient is not a danger to you and others. Your initial care for substance abuse or misuse does not require that you know the specific substance taken. Follow these general principles as you would for any poisoning: \uf0a7 Size up the scene to be sure it is safe. \uf0a7 Perform a primary assessment to check for any life-threatening conditions. \uf0a7 Summon more advanced medical personnel. \uf0a7 Perform a physical exam. \uf0a7 Take a SAMPLE history (signs and symptoms, allergies, medications, pertinent medical history, last oral intake and events leading up to the incident) to try to find out what substance was taken, how much was taken and when it was taken. \uf0a7 Calm and reassure the patient. \uf0a7 Keep the patient from getting chilled or overheated. \uf0a7 Keep the patient\u2019s airway clear. \uf0a7 If the patient is having difficulty breathing, administer supplemental oxygen based on local protocols.",
        "Preventing Substance Abuse and Misuse": "Experts in the field of substance abuse generally agree that prevention efforts are far more cost effective than treatment. Yet preventing substance abuse is a complex process that involves many underlying factors. Various approaches, including educating people about substances and their effects on health and attempting to instill fear of penalties, have not by themselves proved particularly effective. It is becoming clearer that, to be effective, prevention efforts must address the various underlying issues of substance abuse and ways to approach it. The following factors may contribute to substance abuse: \uf0a7 A lack of parental supervision \uf0a7 The breakdown of traditional family structure \uf0a7 A wish to escape unpleasant surroundings and stressful situations \uf0a7 The widespread availability of substances \uf0a7 Peer pressure and the basic need to belong \uf0a7 Low self-esteem, including feelings of guilt or shame \uf0a7 Media glamorization, especially of alcohol and tobacco, promoting the idea that using substances enhances fun and popularity \uf0a7 A history of substance abuse in the home or community environments Recognizing and understanding these factors may help in the prevention and treatment of substance abuse. Some poisonings from medications occur when patients knowingly increase the dosage beyond what is directed. Medications should be taken only as directed. On the other hand, many poisonings from medications are not intentional. The following guidelines can help prevent unintentional misuse or overdose: \uf0a7 Read the product information and use only as directed. \uf0a7 Ask your healthcare provider or pharmacist about the intended use and side effects of prescription and OTC medication. If you are taking more than one medication, check for possible interaction effects. \uf0a7 Never use another person\u2019s prescribed medications; what is right for one person is seldom right for another. \uf0a7 Always keep medications in their original, marked containers. \uf0a7 Discard all out-of-date medications. Time can alter the chemical composition of medications, causing them to be less effective and possibly even toxic. \uf0a7 Always keep medications out of the reach of children.",
        "PUTTING IT ALL TOGETHER": "Poisonings can occur in four ways: ingestion, inhalation, absorption and injection. Substance abuse and misuse are types of poisoning that can occur in any of these ways. Substance abuse and misuse can produce a variety of signs and symptoms, most of which are common to other types of poisoning. You do not need to determine the cause of a poisoning to provide appropriate initial care. If you see any of the signs and symptoms of sudden illness, follow the basic guidelines of care for any medical emergency. For suspected poisonings, contact the national Poison Help line or summon more advanced medical personnel. Beyond following the general guidelines for providing care for a suspected poisoning, medical professionals may advise you to provide some specific care, such as neutralizing the poison. Six major categories of substances, when abused or misused, can produce a variety of signs and symptoms, some of which are indistinguishable from those of other medical emergencies. Remember, you do not have to know the specific condition to provide care. If you suspect that the patient\u2019s condition is caused by substance abuse or misuse, provide care for a poisoning emergency.",
        "Administering Nasal Naloxone": "With a growing epidemic of opioid (commonly fentanyl, heroin and oxycodone) overdoses in the United States, local and state departments of health have increased access to the medication naloxone, which can counteract the effects of an opioid overdose including respiratory arrest. Naloxone (also referred to by its trade name NarcanTM) has few side effects and can be administered intranasally. Trained and authorized responders should assist with the administration of naloxone or administer the drug when the patient is in respiratory arrest or is unconscious and an opioid overdose is suspected. Other signs and symptoms of overdose include small pupils, respiratory depression, such as slowed or shallow breathing, as well as the presence of drug paraphernalia. Responders should always follow local protocols and regulations for the administration of naloxone including dosing, timing and route of administration. One of the most common and available routes of administration for naloxone is intranasal, using a nasal atomizer device attached to a syringe containing 2.0 mg of naloxone. To reverse the effects of the opioid, 1.0 mg of naloxone is administered into each nostril of the patient. While naloxone has very few side effects and is considered generally safe for any patient, emergency medical responders should ensure that more advanced medical personnel have been called as the half-life of naloxone (the amount of time the medication will have the desired effect) is often shorter than the half-life of the opioid causing the overdose. Other complications can occur if the patient has overdosed on several medications at one time. Responders should be ready for different reactions from patients, from improving respiratory effort to regaining consciousness to acting out violently or vomiting. It is important to remember that the purpose of naloxone is to improve a patient\u2019s respiratory effort. In other words, ensure that they are breathing normally on their own. It is not necessary to wake up the patient. All EMRs should follow local protocols when considering the administration of naloxone. If authorized to assist with or administer intranasal naloxone, always follow local protocols and the following steps: \uf0a7 Ensure scene safety. \uf0a7 Maintain appropriate body substance isolation (BSI) precautions. \uf0a7 Maintain an open airway and assist with ventilations if the patient has a pulse but is not breathing. \uf0a7 Suction the airway, as needed. \uf0a7 Assess the level of consciousness and vital signs. \uf0a7 Summon advanced medical personnel by calling 9-1-1 or the designated emergency number. \uf0a7 Assist with the administration of Naloxone 2.0 mg Nasal via atomizer (1.0 mg per nostril). yRemove the caps from both ends of the needle-free syringe. yRemove the cap from the naloxone vial. yScrew the open end of the vial into the syringe; it will become difficult to turn when it is sufficiently threaded. yAttach the nasal atomizer to the opposite end. yGive ventilations using a BVM. yAssess the patient to ensure their nasal cavity is free of blood or mucus. yControl the patient\u2019s head with one hand. yGently but firmly place the atomizer in one nostril, carefully occluding the opposite nostril. yAim slightly upward and toward the ear on the same side as the nostril. yBriskly compress the syringe to administer up to 1.0 mg of atomized spray. yRepeat in the other nostril. (Note: using both nostrils doubles the surface area available for absorption.) \uf0a7 Continue giving ventilations as needed. \uf0a7 If the patient\u2019s mental status and respiratory effort do not improve after 3 to 5 minutes, give a second 2.0 mg dose, if available and local protocols allow.",
        "Administering Activated Charcoal": "If a patient has ingested poison, activated charcoal may be recommended by the PCC or medical control. Ideally, this will be administered within 1 hour of the patient swallowing the poison. Activated charcoal should only administered if the patient is fully conscious and alert and you have been directed by medical control or the PCC. A patient who is not able to swallow should not be given activated charcoal, nor should it be given to a patient who has overdosed on cyanide, swallowed acids or swallowed alkalis (including hydrochloric acid, bleach and ammonia). Many patients experience black stools after taking activated charcoal. Vomiting is another common side effect, especially if the patient is already feeling nauseated. If the patient does vomit, ask medical control or the PCC for permission to give a second dose of the activated charcoal, and arrange to take the patient to the hospital immediately. The PCC or local medical authority will give you instructions on how to administer the activated charcoal. The container should also list instructions. Generally, you will be told to shake the bottle to mix the activated charcoal with water. Give it to the patient to drink. Using a straw or opaque container may make it easier for the patient to tolerate the mixture\u2019s less-than-appetizing appearance. If the charcoal settles, shake it again to mix it thoroughly; then let the patient finish drinking. Medical control or the PCC may give you directions about the dose. In general, the dosage is calculated at 1 gram of activated charcoal per kilogram of the patient\u2019s weight or 1 g/kg. An adult dose is usually between 30 and 100 grams; for a child or an infant, the dose is between 12 and 25 grams. Follow the correct dosage that is given by the PCC or by local protocols.",
        "Carbon Monoxide": "Thousands of individuals die each year in the United States, and thousands more are hospitalized, due to CO poisoning. People often think about CO as related to car exhaust. However, CO is the byproduct of many combustible types of machinery, several of which people have in their homes, including wood stoves and barbecues. It is also the byproduct of larger fires, such as industrial or building fires. CO, which is present in substances such as tobacco smoke, can also be produced by defective cooking equipment, defective furnaces and kerosene heaters. CO is also found in indoor skating rinks and when charcoal is used indoors.\nEveryday items that emit CO include:\n\uf0a7 Heating systems, large or small (including portable types), that burn coal, gasoline, kerosene, oil, propane and wood; this includes camping stoves.\n\uf0a7 Barbecues or grills, both propane and charcoal.\n\uf0a7 Natural gas water heaters.\n\uf0a7 Gas lawn mowers or any gas-powered vehicle.\n\uf0a7 Portable generators, often used during power outages.\n\uf0a7 Kitchen stoves, when used for heating homes or house trailers.\nCO poisoning is the leading cause of death by poisoning in the United States. Its colorless and odorless presentation increases its danger, as patients may never be aware of its presence before succumbing to its poisonous effects. CO is highly lethal and can cause death after only a few minutes of exposure. CO detectors, which work much like smoke detectors, are widely available for use in homes and businesses. CO is lighter than air, which is why detectors should be placed in homes near sleeping areas at as high an elevation as possible, consistent with the manufacturer\u2019s operating instructions.",
        "Signs and Symptoms of CO Poisoning": "The initial symptoms of CO poisoning, such as a dull or throbbing headache, nausea and vomiting, can easily be mistaken for something benign. Other signs and symptoms of CO poisoning include:\n\uf0a7 Bluish skin color.\n\uf0a7 Chest pain.\n\uf0a7 Confusion.\n\uf0a7 Convulsions.\n\uf0a7 Dizziness.\n\uf0a7 Drowsiness.\n\uf0a7 Fainting.\n\uf0a7 Hyperactivity.\uf0a7 Impaired judgment.\n\uf0a7 Irritability.\n\uf0a7 Loss of consciousness.\n\uf0a7 Low blood pressure.\n\uf0a7 Muscle weakness.\n\uf0a7 Rapid or abnormal heartbeat.\n\uf0a7 Shock.\n\uf0a7 Shortness of breath.",
        "Providing Care for CO Poisoning": "Because of the danger of CO, it is essential that responders are properly outfitted for safety and that the patient is removed from the situation as quickly as possible. If a patient experiences symptoms of CO poisoning, get the patient to fresh air immediately by opening doors and windows, turning off combustion appliances and leaving the building. If CO poisoning is suspected, make sure emergency department staff and physicians are aware. Questions to ask the patient should include:\n\uf0a7 Where the symptoms occurred.\n\uf0a7 Whether symptoms disappear or decrease away from that location (e.g., home).\n\uf0a7 Whether anyone else in the building is complaining of similar symptoms and whether those symptoms appeared at about the same time.\n\uf0a7 Whether there are any fuel-burning appliances in the location.\n\uf0a7 Whether these appliances have been inspected recently to ensure they are working properly.\nIf CO poisoning has occurred, the patient may be asked to undergo a blood test, which is done soon after exposure to confirm the diagnosis. Everyone present in the area of the poisoning, even if they do not display any signs or symptoms, should be monitored or treated. The only treatment for CO poisoning that can be administered on the scene is providing supplemental oxygen, based on local protocols.",
        "Cyanide Poisoning": "Cyanide poisoning makes your body unable to utilize oxygen and can quickly cause death. It can occur through the digestive and respiratory tracts and through the skin. It can also be injected. Cyanide poisoning is generally thought of as a weapon used in terrorism or wartime. However, cyanide is found naturally in some everyday foods, such as apricot pits; in other products, such as cigarettes; and as byproducts of production such as plastic manufacturing. Cyanide is also used in some production processes such as making paper and textiles, developing photographs, cleaning metal and in rodent poisons.",
        "Signs and Symptoms of Cyanide Poisoning": "The signs and symptoms of cyanide poisoning depend on the extent of the exposure and the route by which it enters the body. If exposure is through eating products that have naturally occurring cyanide or by absorbing it through the skin, symptoms may include sudden onset of:\n\uf0a7 Dizziness.\n\uf0a7 Headache.\n\uf0a7 Nausea and vomiting.\n\uf0a7 Rapid breathing.\uf0a7 Rapid heart rate.\n\uf0a7 Restlessness.\n\uf0a7 Weakness.\nPatients who were subjected to larger, concentrated or more intense exposure to cyanide, such as from an industrial incident or a terrorist attack, could display symptoms such as:\n\uf0a7 Convulsions.\n\uf0a7 Loss of consciousness.\n\uf0a7 Low blood pressure.\n\uf0a7 Lung injury.\n\uf0a7 Respiratory failure leading to death.\n\uf0a7 Slow heart rate.",
        "Exams and Tests for Cyanide Poisoning": "There is no quick, simple blood test that will confirm a patient is suffering from cyanide poisoning at the scene of an incident or at a fire. There are several cyanide detectors available to test for cyanide in the air, but they are often delayed to the scene. Cyanide poisoning must therefore be assumed when it is likely based on circumstances, so that lifesaving care may be started quickly. You should suspect cyanide poisoning at the scene of a fire if the patient has been exposed to smoke in a confined space, whether or not the patient has been burned. If the patient has soot around the mouth and nose and an altered LOC, the probability of cyanide toxicity is greater. The most likely set of symptoms in someone who has suffered cyanide toxicity is altered mental status, abnormal pupil dilation (widening), low respiratory rate, low systolic blood pressure with increased heart rate, metabolic acidosis (increased plasma acidity) and a large increase in lactate levels in the plasma.",
        "Providing Care for Cyanide Poisoning": "Hydrogen cyanide can enter the body through inhalation or ingestion, or by being absorbed into the skin or eyes. Avoid all contact. If you or someone else is exposed, seek medical attention immediately.\nIf there is a risk of inhalation, seek ventilation or local exhaust, or use breathing protection with a gas mask that has a hydrogen cyanide (HC) canister (escape). The use of positive-pressure self-contained breathing apparatus (SCBA) or SCBA CBRN (chemical, biological, radiological and nuclear), if available, is recommended when responding to nonroutine emergency situations. Use a CBRN, full face-piece air purifying respirator (APR), when available, in nonroutine, emergency situations, environments less than immediately dangerous to life or health concentrations, but above recommended exposure limit or permissible exposure limit levels. If you or someone else is exposed to hydrogen cyanide via inhalation, seek fresh air and rest in a half-upright position. Avoid mouth-to-mouth resuscitation, and administer supplemental oxygen if it is available, based on local protocols.\nIf there is risk of absorption into the skin, use butyl rubber gloves and Teflon\u00ae or Tychem\u00ae protective clothing as appropriate. If you or someone else has been exposed through absorption into the skin, remove the contaminated clothing and rinse the skin with plenty of water or use a shower to rinse. Wear protective gloves when administering first aid, and seek medical attention immediately.\nHydrogen cyanide vapor can be absorbed through the eyes. For prevention, wear safety goggles, a face shield or eye protection in combination with breathing protection. If the eyes are exposed, rinse with plenty of water for several minutes. If you or the patient exposed is wearing contact lenses, remove them if easily possible. Seek medical attention immediately.\nHydrogen cyanide can also be ingested. To prevent such an exposure, do not eat, drink or smoke during work, and wash your hands before eating. If you are exposed by ingestion, rinse your mouth and follow the same steps as for inhalation. Do not induce vomiting. Seek medical attention immediately.\nHydrogen cyanide poses several hazards associated with fire. It is extremely flammable, and the fire emits toxic or irritating gases. To prevent fire around this gas, ensure that there is no smoking and there are no open flames or sparks. If fire does break out, shut off the gas supply. If this is not possible and there are no risks to the surrounding environment, let the fire burn out on its own. If you can extinguish it, use powder, water spray, foam or carbon dioxide. When mixed with air, hydrogen cyanide also poses a risk of explosion. Keep the area closed and well ventilated, and use explosion-proof electrical equipment and lighting. To prevent an explosion, if there is a fire, keep the cylinder cool by spraying it with water. If you do have to fight the fire, do so from a sheltered position. If a patient is suspected of exposure to hydrogen cyanide, the SAMPLE history and scene size-up will be vital. The hospital will administer blood tests, X-rays, other diagnostic tests and IV lines. It is important to accurately convey details about the scene to healthcare providers, as they will use this information, along with the patient\u2019s presentation and the test results, to determine if the patient has indeed suffered from cyanide poisoning. Also, because cyanide poisoning is rare, healthcare providers may not consider the possibility unless you report it, and treatment may come too late."
    },
    {
        "Key Terms": "Absence seizure: A type of generalized seizure in which there are minimal or no movements; patient may appear to have a blank stare; also known as a petit mal or nonconvulsive seizure., Acute abdomen: The sudden onset of severe abdominal pain that may be related to one of many medical conditions or a specific injury to the abdomen., Altered mental status: A disturbance in a patient\u2019s level of consciousness (LOC) including confusion and delirium; causes include injury, infection, poison, drug abuse and fluid/electrolyte imbalance., Aneurysm: An abnormal bulging of an artery due to weakness in the blood vessel; may occur in the aorta (main artery of the heart), brain, leg or other location., Aphasia: A disorder characterized by difficulty or inability to produce or understand language, caused by injury to the areas of the brain that control language., Aura phase: The first stage of a generalized seizure, during which the patient experiences perceptual disturbances, often visual or olfactory in nature., Blood glucose level (BGL): The level of glucose circulating in the blood; measured using a glucometer., Clonic phase: The third phase of a generalized seizure, during which the patient experiences the seizure itself., Complex partial seizure: A type of partial seizure in which the patient may experience an altered mental status or be unresponsive., Diabetes mellitus: A disease in which there are high levels of blood glucose due to defects in insulin production, insulin action or both., Diabetic coma: A life-threatening complication of diabetes in which very high blood sugar causes the patient to become unconscious., Diabetic emergency: A situation in which a person becomes ill because of an imbalance of insulin and sugar in the bloodstream., Diabetic ketoacidosis (DKA): An accumulation of organic acids and ketones (waste products) in the blood; occurs when there is inadequate insulin and high blood sugar levels., Embolism: A blockage in an artery or a vein caused by a blood clot or fragment of plaque that travels through the blood vessels until it gets stuck, preventing blood flow., Epilepsy: A brain disorder characterized by recurrent seizures., Fainting: Temporary loss of consciousness; usually related to temporary insufficient blood flow to the brain; also known as syncope, \u201cblacking out\u201d or \u201cpassing out.\u201d, FAST: An acronym to help remember the symptoms of stroke; stands for Face, Arm, Speech and Time., Febrile seizures: Seizure activity brought on by an excessively high fever in a young child or an infant., Generalized tonic-clonic seizures: Seizures that affect most or all of the brain; types include absence (petit mal) seizures and grand mal seizures., Gestational diabetes: A type of diabetes that occurs only during pregnancy., Glucometer: A medical device that measures the concentration of glucose in the blood., Glucose: A simple sugar that is the primary source of energy for the body\u2019s tissues., Grand mal seizure: A type of generalized seizure; involves whole-body contractions with loss of consciousness., Hemodialysis: A common method of treating advanced kidney failure in which blood is filtered outside the body to remove wastes and extra fluids., Hyperglycemia: A condition in which too much sugar is in the bloodstream, resulting in higher than normal BGLs; also known as high blood glucose., Hyperkalemia: Abnormally high levels of potassium in the blood; if extremely high, can cause cardiac arrest and death., Hypervolemia: A condition in which there is an abnormal increase of fluid in the blood., Hypoglycemia: A condition in which too little sugar is in the bloodstream, resulting in lower than normal BGLs; also known as low blood glucose., Hypovolemia: A condition in which there is an abnormal decrease of fluid in the blood., Hypoxemia: A condition in which there are decreased levels of oxygen in the blood; can disrupt the body\u2019s functioning and harm tissues; may be life threatening., Insulin: A hormone produced by the pancreas to help glucose move into the cells; in patients with diabetes, it may not be produced at all or may not be produced in sufficient amounts., Partial seizures: Seizures that affect only part of the brain; may be simple or complex., Peritoneal dialysis: A method of treatment for kidney failure in which waste products and extra fluid are drawn into a solution which has been injected into the abdominal cavity and are withdrawn through a catheter., Physical counter-pressure maneuver (PCM): Physical maneuver used to hinder the progression from presyncope to syncope., Post-ictal phase: The final phase of a generalized seizure, during which the patient becomes extremely fatigued., Presyncope: The medical term for \u201cfaintness\u201d or \u201cfeeling faint\u201d; symptoms include light-headedness or dizziness, blurry vision and nausea, while signs include sweating and pallor., Seizure: A disorder in the brain\u2019s electrical activity, sometimes marked by loss of consciousness and often by uncontrollable muscle movement; also called a convulsion., Sepsis: A life-threatening illness in which the body is overwhelmed by its response to infection; commonly referred to as blood poisoning., Shunt: A surgically created passage between two natural body channels, such as an artery and a vein, to allow the flow of fluid., Simple partial seizures: Seizures in which a specific body part experiences muscle contractions; does not affect memory or awareness., Status epilepticus: An epileptic seizure (or repeated seizures) that lasts longer than 5 minutes without any sign of slowing down; should be considered life threatening and requires prompt advanced medical care., Stroke: A disruption of blood flow to a part of the brain which may cause permanent damage to brain tissue., Syncope: A term used to describe the loss of consciousness; also known as fainting., Thrombus: A blood clot that forms in a blood vessel and remains there, slowing the flow of blood and depriving tissues of normal blood flow and oxygen., Tonic phase: The second phase of a generalized seizure, during which the patient becomes unconscious and muscles become rigid., Transient ischemic attack (TIA): A condition that produces stroke-like symptoms but causes no permanent damage; may be a precursor to a stroke., Type 1 diabetes: A type of diabetes in which the pancreas does not produce insulin; formerly known as insulin-dependent diabetes or juvenile diabetes., Type 2 diabetes: A type of diabetes in which insufficient insulin is produced or the insulin is not used efficiently; formerly known as non-insulin-dependent diabetes or adult-onset diabetes.",
        "INTRODUCTION": "As an emergency medical responder (EMR), you could someday face a situation involving an unidentifiable medical emergency. Therefore, you may feel uncertain about how to provide care. When you face an emergency that is unclear, it is normal to feel indecisive. Yet, like any EMR, you will still want to provide care to the best of your ability. You do not have to \u201cdiagnose\u201d or choose among possible problems to provide appropriate care. By following a few basic guidelines for care, you can provide appropriate care until more advanced medical personnel arrive. Because you know these guidelines for care, you can approach any medical emergency with confidence. Medical emergencies can develop rapidly (acute conditions) or gradually (chronic conditions) and may persist for a long time. Sometimes, there are no warning signs or symptoms to alert you or the patient that something is about to happen. At other times, the only symptoms the patient complains of are feeling \u201cill\u201d or feeling that \u201csomething is wrong.\u201d Symptoms may also be atypical; older adults or those with diabetes, for example, may have a heart attack without experiencing chest pain. Medical emergencies have a wide range of causes, including chronic problems from diseases such as heart disease and diabetes, allergies, seizures from illnesses such as epilepsy, or overexposure to heat or cold. There can be a variety of signs and symptoms, including sudden, unexplained altered mental status. A patient may complain of feeling light headed, dizzy or weak. Or, the patient may feel nauseated or may vomit. Breathing, pulse and skin characteristics may change. Ultimately, if a person looks and feels ill, there could be a medical emergency that requires immediate care.",
        "GENERAL MEDICAL COMPLAINTS": "Making the Assessment and Providing Care The assessment and care of general medical complaints follow the same general guidelines: \uf0a7 Size up the scene to ensure your own safety and the safety of others. \uf0a7 Form a general impression of the patient as you approach to determine if there are any obvious life-threatening conditions such as severe, life-threatening bleeding and if the patient appears to be conscious or unconscious. \uf0a7 Conduct your primary assessment to identify and correct any immediately life-threatening conditions. \uf0a7 Conduct a SAMPLE history and secondary assessment to gather additional information, whenever possible. \uf0a7 Obtain vital signs. \uf0a7 Summon more advanced medical personnel. \uf0a7 Help the patient rest comfortably. \uf0a7 Keep the patient from getting chilled or overheated. \uf0a7 Provide reassurance. \uf0a7 Prevent further harm. \uf0a7 Administer supplemental oxygen if it is indicated based on local protocols.",
        "ALTERED MENTAL STATUS": "Causes Altered mental status can result from many causes. Some of these include the following: \uf0a7 Fever \uf0a7 Infection \uf0a7 Poisoning or overdose, including substance abuse or misuse \uf0a7 Blood sugar/endocrine emergencies \uf0a7 Head injury \uf0a7 Inadequate oxygenation or ventilation \uf0a7 Any condition resulting in decreased blood flow or oxygen to the brain \uf0a7 Cardiac emergencies \uf0a7 Diabetic emergencies \uf0a7 Shock \uf0a7 Stroke \uf0a7 Behavioral illness \uf0a7 Seizures",
        "CRITICAL FACTS 1": "Medical emergencies have a wide range of causes, including overexposure to heat or cold; chronic problems from diseases such as heart disease and diabetes; allergies; and seizures from illnesses such as epilepsy.",
        "Signs and Symptoms of Altered Mental Status": "Altered mental status is one of the most common medical emergencies. It is often characterized by a sudden or gradual change in a person\u2019s level of consciousness (LOC), including drowsiness, confusion and partial or complete loss of consciousness.",
        "Providing Care for Altered Mental Status": "To care for patients with altered mental status, complete primary and secondary assessments, vital signs and history as needed. Perform ongoing assessments as you provide care. Make sure the airway is open, and place an unresponsive patient who is breathing normally with no suspected head, neck, spinal, hip or pelvic injury in a side-lying recovery position following the assessment. If a head, neck, spinal, hip or pelvic injury is suspected, keep the patient in the supine (face-up) position. Have suction equipment available if needed. If the patient is conscious or becomes conscious, do not give anything to eat or drink. Eating or drinking can increase the chance of vomiting. If possible, attempt to get information from the patient, family members or bystanders. This is important, as a patient\u2019s condition may deteriorate rapidly in these situations, making conversation impossible. Any information you can obtain may help with the patient\u2019s treatment upon arrival at the hospital.",
        "Syncope": "Sometimes altered mental status is caused by a temporary reduction of blood flow to the brain, such as occurs when blood collects or pools in the legs and lower body. When the brain is suddenly deprived of its normal blood flow, it momentarily shuts down. This condition is called fainting, or syncope. Fainting can be triggered by an emotional shock, such as the sight of blood. It may be caused by pain, specific medical conditions like heart disease, standing for a long time or overexertion. Some people, such as pregnant women or older adults, are more likely to faint when suddenly changing positions, for example when moving from lying down to standing up. Whenever changes inside the body momentarily reduce the blood flow to the brain, fainting may occur. A person may faint with or without warning. Often, the person may first feel light headed or dizzy (presyncope). There may be signs of shock, such as pale or ashen, cool, moist skin. The person may have blurry vision, feel nauseated and complain of numbness or tingling in the fingers and toes. The person\u2019s breathing and pulse may become faster.",
        "CRITICAL FACTS": "Altered mental status is a common medical emergency often characterized by a sudden or gradual change in a person\u2019s LOC, including drowsiness, confusion and partial or complete loss of consciousness.",
        "Care for Presyncope and Syncope": "A patient with presyncope will feel as if they are going to faint. To prevent a syncopal episode (fainting), help the patient lie down. While they are lying down, you should monitor their breathing and level of consciousness. Have the patient perform a physical counter-pressure maneuver (PCM): \uf0a7 Grip one hand at the fingers with the other and try to pull them apart without letting go. They should hold the grip for as long as they can or until their symptoms disappear. \uf0a7 Hold a rubber ball or similar object in their writing hand and then squeeze the object for as long as they can or until their symptoms disappear. \uf0a7 Cross one leg over the other and squeeze them together tightly. Hold this position for as long as they can or until their symptoms disappear. Be sure to instruct the patient to avoid holding their breath while performing counter-pressure maneuvers. An easy way to ensure this is to have the patient talk while performing the maneuver. Physical counter-pressure maneuvers help raise the blood pressure through skeletal muscle contraction and, in many cases, will resolve symptoms of faintness. If a person with faintness feels worse with PCM, simply discontinue the maneuver. If a person complains of chest pain, they should be provided care for chest pain, not for presyncope. If a patient suffers a syncopal episode (faints), it often resolves itself when the patient is moved from a standing or sitting position to a lying-down position, as normal circulation to the brain often resumes. The patient usually regains consciousness within a minute. Syncope alone does not usually harm the patient, but an injury may occur from falling. Although a fainting patient usually recovers quickly, you may not be able to determine if the fainting is associated with a more serious medical condition. For this reason, more advanced medical care is indicated and the EMS system should be activated.",
        "Altered Mental Status in Pediatrics": "Children who are experiencing altered mental status may exhibit a change in behavior, personality or responsiveness beyond what is expected at their age. These children may exhibit anxiety, agitation, aggression and/or combativeness. Alternatively, they may be difficult to rouse, sleepy or even unresponsive. It is not unusual for altered mental status to result in decreased muscle tone. Common causes of altered mental status requiring immediate medical attention include respiratory failure, deficiency in oxygen concentration in arterial blood (hypoxemia), shock, hypoglycemia, brain injury (including shaken baby syndrome), seizures, poisoning, intentional overdose, sepsis, meningitis, hyperthermia and hypothermia. Left untreated, altered mental status can lead to life-threatening problems, including inefficient respiration, hypoxemia, airway obstruction and respiratory failure. For care of children with altered mental status, consider the possibility of a spinal injury if the cause is not clear or trauma is suspected. Treat any breathing emergency and care for any other injuries or conditions found. Obtain more advanced medical care and provide ongoing assessment and care.",
        "SEIZURES": "When the normal functions of the brain are disrupted by injury, disease, fever, infection, metabolic disturbances or conditions causing a decreased oxygen level, a seizure may occur. The seizure is a result of abnormal electrical activity in the brain and causes temporary involuntary changes in body movement, function, sensation, awareness or behavior.",
        "Types of Seizures - Generalized Seizures": "Generalized tonic-clonic seizures, also called grand mal seizures, are the most well-known type of seizure. They involve both hemispheres (halves) of the brain and usually result in loss of consciousness. The seizure activity is known as tonic-clonic, which refers to the initial rigidity (tonic phase) followed by rhythmic muscle contractions (clonic phase), or convulsions. This type of seizure rarely lasts for more than a few minutes.",
        "CRITICAL FACTS 2": "A seizure is temporary abnormal electrical activity in the brain caused by injury, disease, fever, infection, metabolic disturbances or conditions that decrease oxygen levels. Generalized seizures, also called grand mal seizures or tonic-clonic seizures, are the most easily recognized type of seizure.",
        "Signs and Symptoms of Generalized Seizures": "Before a generalized seizure occurs, the patient may experience an unusual sensation or feeling called an aura. An aura can include a strange sound, taste, smell or an urgent need to get to safety. If the patient recognizes the aura, there may be time to warn bystanders and to sit or lie down before the seizure occurs. Generalized seizures usually last 1 to 3 minutes and can produce a wide range of signs and symptoms. When a seizure occurs, the patient loses consciousness and can fall, causing injury. The patient may become rigid, and then experience sudden, uncontrollable muscular contractions (convulsions), lasting several minutes. Breathing may become irregular and even stop temporarily. The patient may drool and the eyes may roll upward. As the seizure subsides and the muscles relax, the patient may have a loss of bladder or bowel control. The stages of most generalized seizures are as follows: 1. Aura phase \u2014patient may sense something unusual (not all patients will experience an aura) 2. Tonic phase \u2014unconsciousness then muscle rigidity 3. Clonic phase \u2014uncontrollable muscular contractions (convulsions) 4. Post-ictal phase \u2014diminished responsiveness with gradual recovery and confusion (patient may feel confused and want to sleep)",
        "Partial Seizures": "Partial seizures may be simple or complex. They usually involve only a very small area of one hemisphere of the brain. Partial seizures are the most common type of seizure experienced by people with epilepsy. Partial seizures can spread and become a generalized seizure. In simple partial seizures, the patient usually remains aware. Complex partial seizures usually last for 1 to 2 minutes, though they may last longer and awareness is either impaired or lost while the patient remains conscious.",
        "Signs and Symptoms of Partial Seizures": "With simple partial seizures, the patient usually remains aware, but someone experiencing a complex partial seizure experiences altered mental status or unresponsiveness. In simple partial seizures, there may be involuntary, muscular contractions in one area of the body, for example the arm, leg or face. Some people cannot speak or move during a simple partial seizure, although they may remember everything that occurred. Simple partial seizures may produce a feeling of fear or a sense that something bad is about to happen. Simple partial seizures can also produce odd sensations such as strange smells or hearing voices. In rare instances, feelings of anger and rage or joy and happiness can be brought on by the seizure. Auras are a form of simple partial seizure. Complex partial seizures often begin with a blank stare followed by random movements such as smacking the lips or chewing. The patient appears dazed, the movements are clumsy and the patient\u2019s activities lack direction. They may be unable to follow directions or answer questions. This type of seizure usually lasts for only a few minutes but it may last longer. The patient cannot remember what happened after the seizure is over, and may be confused. This is called the post-ictal phase.",
        "Absence (Petit Mal) Seizures": "Individuals may also experience an absence seizure, also known as a petit mal seizure. These are most common in children. During an absence seizure, there is brief, sudden loss of awareness or conscious activity. There may be minimal or no movement, and the person may appear to have a blank stare. Most often these seizures last only a few seconds.",
        "Signs and Symptoms of Absence Seizures": "Absence seizures cause the person to experience loss of awareness for short periods that may be mistaken for daydreaming. This type of seizure may also be referred to as a nonconvulsive seizure, because the body remains relatively still during the episode, though eye fluttering and chewing movements may be seen.",
        "Febrile Seizures": "Young children and infants may be at risk for febrile seizures, which are seizures brought on by a rapid increase in body temperature. They are most common in children under the age of 5. Febrile seizures are often caused by ear, throat or digestive system infections and are most likely to occur when a child or an infant runs a rectal temperature of over 102\u00b0 F (38.9\u00b0 C). An individual experiencing a febrile seizure may experience some or all of the following symptoms: \uf0a7 Sudden rise in body temperature \uf0a7 Change in LOC \uf0a7 Rhythmic jerking of the head and limbs",
        "CRITICAL FACTS 3": "Young children and infants may be at risk for febrile seizures, which are seizures brought on by a rapid increase in body temperature. Protecting the patient from injury and managing the airway are your priorities when caring for a patient having a seizure.",
        "Epilepsy": "Epilepsy is a common neurological disorder, estimated to affect approximately 3 million people in the United States alone. Epilepsy is not a specific disease but a term used to describe a group of disorders in which the individual experiences recurrent seizures as the main symptom. In about one-third of all cases, seizures occur as a result of a brain abnormality or neurological disorder, but in two-thirds there is no known cause. The risk of having epilepsy for young people (up to the age of 20) is approximately 1 percent, with the greatest likelihood occurring during the first year of life. People aged 20 to 55 may also develop epilepsy but have a somewhat lower risk. The risk increases again after the age of 65 and, in fact, the highest rate of new epilepsy diagnoses are in this age group. The prevalence of epilepsy, or the number of individuals suffering with it at any time, is estimated to be approximately 5 to 8 in every 1000 people. By age 75, approximately 3 percent of people will have been diagnosed with epilepsy. People of any age can be affected by epilepsy. Patients who have epilepsy often can control the seizures with medication. Those with difficult-to-control seizures may also be treated with surgical resection, which can be curative, or with implanted devices, such as the vagus nerve stimulator, that help reduce their seizure frequency. While some patients require lifelong medical therapy, sometimes medication may be reduced or even eliminated over time. Some childhood epilepsies may resolve with age.",
        "Providing Care for Seizures": "Seeing someone have a seizure may be intimidating, but you can easily care for the patient. The patient cannot control any muscular contractions that may occur and it is important to allow the seizure to run its course, because attempting to stop it or restrain the patient can cause musculoskeletal injuries. Protecting the patient from injury and managing the airway are your priorities when caring for a patient having a seizure. To help avoid injury, you should move nearby objects, such as furniture, away from the patient. People having seizures rarely bite the tongue or cheeks with enough force to cause any significant bleeding. Do not place anything in the mouth to prevent this type of injury. Foreign bodies in the mouth may cause airway obstruction. Do not put fingers into the mouth of an actively seizing patient to clear the airway. During the seizure, position the uninjured patient on their side in a recovery position, if it is possible and safe to do, so that fluids (saliva, blood, vomit) can drain from the mouth. Keep the patient in a side-lying recovery position until they regain consciousness after the post-ictal phase. It is important to have a suction device available for all seizure patients. In many cases, the seizure will be over by the time you arrive. In this case, the patient may be drowsy and disoriented; this is the post-ictal phase. Check to see if the patient was injured during the seizure. Offer comfort and reassurance, especially if the seizure occurred in public, as the patient may feel embarrassed and self-conscious. If this is the case, keep bystanders well back to provide maximum privacy, and stay with the patient until they are fully conscious and aware of the surroundings. Care for a child or an infant who experiences a febrile seizure is similar to the care for any other patient experiencing a seizure. Immediately after a febrile seizure, cool the body by removing excess clothing. Do not rapidly cool the patient with cold water as this could bring on other complications. Contact a healthcare provider before administering any medication, such as acetaminophen, to control fever. Do not give aspirin to a feverish child under 18 years of age, as this has been linked to Reye\u2019s syndrome, an illness that affects the brain and other internal organs.",
        "When to Call for More Advanced Medical Personnel": "The patient will usually recover from a seizure in a few minutes. If you discover the patient has a medical history of seizures that is medically controlled, there may be no further need for medical attention. However, in the following cases, more advanced medical care and transportation to a medical facility by ambulance should be provided: \uf0a7 The seizure lasts more than 5 minutes or a seizure is followed by another seizure without a period of consciousness (status epilepticus). \uf0a7 This is the patient\u2019s first seizure. \uf0a7 The patient appears to be injured. \uf0a7 You are uncertain about the cause of the seizure. \uf0a7 The patient is pregnant. \uf0a7 The patient is known to have diabetes. \uf0a7 The patient is a child or an infant. \uf0a7 The seizure takes place in water. \uf0a7 The patient fails to regain consciousness after the seizure. \uf0a7 The patient is a young child or an infant who experienced a febrile seizure brought on by a high fever. \uf0a7 The patient is an older adult and could have suffered a stroke. Status epilepticus is an epileptic seizure (or repeated seizures) that lasts longer than 5 minutes or a seizure that is followed by another seizure without the patient regaining consciousness. A status epilepticus seizure is a true medical emergency that may be fatal. If you suspect the patient is experiencing this type of seizure, call for more advanced medical personnel immediately. During and after the seizure, place the patient on the side and suction the airway, if possible. If the patient is having difficulty breathing, administer ventilations with a bag-valve-mask (BVM) resuscitator, along with supplemental oxygen based on local protocols.",
        "DIABETIC EMERGENCIES - Incidence": "Diabetes mellitus is one of the leading causes of death and disability in the United States today. In 2016, 29 million Americans were living with diabetes and 86 million had prediabetes, a serious health condition that increases a person\u2019s risk of type 2 diabetes and other chronic diseases. Diabetes contributes to other conditions, including blindness, kidney disease, heart disease, periodontal (gum) disease, stroke and amputations.",
        "Diabetes": "There are two major types of diabetes. Type 1 diabetes, formerly known as insulin-dependent diabetes or juvenile diabetes, causes the body to produce little or no insulin. Most people who have Type 1 diabetes have to inject insulin into their bodies daily. In type 2 diabetes, formerly known as non-insulin-dependent diabetes or adult-onset diabetes, the body produces insulin, but either the cells do not use the insulin effectively or not enough insulin is produced. This type of diabetes is more common than type 1 diabetes. Most people with type 2 diabetes can regulate their blood glucose level (BGL) sufficiently through diet, and sometimes through oral medications, without insulin injections. People with diabetes must carefully monitor their BGL, diet and amount of exercise. People with diabetes must also regulate their use of insulin. When diet and exercise are not controlled, either of two problems can occur: too much or too little sugar in the body. This imbalance of sugar and insulin in the blood causes illness. Some women develop diabetes in the late stages of pregnancy; this form usually goes away after the baby is born. This type is called gestational diabetes and is caused by the hormones of pregnancy or a shortage of insulin. Women who have had this condition have an increased likelihood of developing type 2 diabetes later in life.",
        "High Blood Glucose": "When the insulin level in the body is too low, the sugar level in the blood is high. This condition is called hyperglycemia. Sugar is present in the blood but cannot be transported from the blood into the cells without insulin, causing body cells to become starved for sugar. The body attempts to meet its need for energy by using other stored food and energy sources, such as fats. However, converting fat to energy is less efficient, produces waste products and increases the acidity level in the blood, causing a condition known as diabetic ketoacidosis (DKA). As this occurs, the person becomes ill. The patient may have flushed, hot, dry skin and a sweet breath odor that can be mistaken for the smell of alcohol. The patient may also appear restless or agitated, have abdominal pain or be thirsty. If this condition is not treated promptly, diabetic coma, a life-threatening emergency in which very high blood sugar causes the patient to become unconscious, can occur.",
        "CRITICAL FACTS 4": "Type 1 diabetes is characterized by the body\u2019s inability to produce insulin. Type 2 diabetes is characterized by the body\u2019s inability to use insulin effectively. Type 2 diabetes is more common.",
        "Low Blood Glucose": "When the insulin level in the body is too high, the patient has a low sugar level, known as hypoglycemia. The blood sugar level can become too low if the person with diabetes: \uf0a7 Takes too much insulin. \uf0a7 Fails to eat adequately. \uf0a7 Over-exercises and burns off sugar faster than normal. \uf0a7 Experiences great emotional stress. In this situation, the small amount of sugar is used up rapidly, so not enough sugar is available for the brain to function properly. If left untreated, even for a short time, hypoglycemia from an insulin reaction can cause brain damage or death. Call for more advanced medical care immediately. This condition is also known as insulin shock.",
        "Role of Glucose": "To function normally, body cells need sugar as an energy source. Through the digestive process, the body breaks down food into simple sugars, such as glucose, which are absorbed into the bloodstream. However, sugar cannot pass freely from the blood into the body cells. Insulin, a hormone produced in the pancreas, is needed for sugar to pass into the cells. Without a proper balance of sugar and insulin in the blood, the cells will starve and the body will not function properly. Maintaining normal BGLs reduces the risk of eye, kidney, heart and nerve problems. Many people with diabetes have blood glucose monitors, called glucometers, that can be used to check their BGL at home. Many hypoglycemic and hyperglycemic episodes are now managed at home because of the rapid information these monitors provide.",
        "CRITICAL FACTS 5": "Hypoglycemia and hyperglycemia have similar signs and symptoms, including changes in LOC, irregular breathing, abnormal pulse, feeling and looking ill and abnormal skin characteristics.",
        "Signs and Symptoms of Diabetic Emergencies": "Although hypoglycemia and hyperglycemia are different conditions, the major signs and symptoms are similar. These include: \uf0a7 Changes in LOC, including dizziness, drowsiness and confusion. \uf0a7 Irregular breathing. \uf0a7 Abnormal pulse (rapid or weak). \uf0a7 Feeling and looking ill. \uf0a7 Abnormal skin characteristics.",
        "Providing Care for Diabetic Emergencies": "To care for diabetic emergencies, first perform a primary assessment and care for any life-threatening conditions. If the patient is conscious, conduct a physical exam and SAMPLE history, looking for anything visibly wrong. Ask if the patient has diabetes, and look for a medical identification tag. If the patient is known to have diabetes and exhibits the signs and symptoms previously stated, then suspect a diabetic emergency. If the patient is awake, is able to follow simple commands and can safely swallow, give 15 to 20 grams of sugar, preferably in the form of glucose tablets. If glucose tablets are not available, other forms of dietary sugars have been found to be an effective substitute, including candies containing glucose or sucrose that can be chewed, jelly beans, orange juice, fructose-based fruit strips and whole milk. If none of these options are available, the patient can be given 4 to 5 teaspoons of table sugar dissolved in a glass of water. Sometimes, patients with diabetes will be able to tell you what is wrong and will ask for something with sugar in it. If the patient\u2019s problem is low sugar (hypoglycemia), the sugar you give will help quickly. If the patient already has too much sugar (hyperglycemia), the excess 15 to 20 grams sugar will do no immediate harm. Do not try to assist the patient by administering insulin. Only give something by mouth if the patient is fully conscious. If the patient is unconscious, monitor the patient\u2019s condition, keep the patient from getting chilled or overheated, summon more advanced medical personnel and administer supplemental oxygen based on local protocols. If the patient is conscious but does not feel better within approximately 10 to 15 minutes after taking sugar, summon more advanced medical personnel and consider giving the patient another 15 to 20 grams of sugar based on local protocols.",
        "STROKE": "A stroke, also called a cerebrovascular accident (CVA), is a disruption of blood flow to a part of the brain, which may cause permanent damage to brain tissue if not appropriately treated within several hours.",
        "Causes of STROKE": "Most commonly, a stroke is caused by a blood clot, called a thrombus or embolism, that forms or lodges in the arteries supplying blood to the brain. Fat deposits lining an artery (atherosclerosis) may also cause a stroke known as an ischemic stroke. Another less common cause of stroke is bleeding from a ruptured artery in the brain. Known as a hemorrhagic stroke, this condition is brought on by high blood pressure or an aneurysm\u2014a weak area in an artery wall that balloons out and can rupture. Less commonly, a tumor or swelling from a head injury may cause a stroke by directly compressing an artery or brain tissue.",
        "Transient Ischemic Attack (TIA)": "A transient ischemic attack (TIA), often referred to as a \u201cmini-stroke,\u201d is a temporary episode that, like a stroke, is caused by reduced blood flow to a part of the brain. Unlike a stroke, the signs and symptoms of a TIA disappear within a few minutes or hours of its onset. If symptoms persist after 24 hours, the event is not considered a TIA but a stroke. Although the indicators of TIA disappear quickly, the patient is not out of danger. In fact, someone who experiences a TIA has a nearly 10 times greater chance of having a stroke in the future than does someone who has not experienced a TIA.",
        "Risk Factors for stroke and TIA": "The risk factors for stroke and TIA are similar to those for heart disease. Some risk factors are beyond the patient\u2019s control, such as age, gender or family history of stroke, TIA, diabetes or heart disease. Others can be controlled, such as blood pressure, smoking, diet and exercise. Stroke is common in the older adult population, but a person of any age, including children, can have a stroke.",
        "CRITICAL FACTS 6": "Two causes of stroke are blood clots that form or lodge in arteries supplying blood to the brain and arteries in the brain that rupture and bleed. Blood clots are the most common cause of stroke. A TIA, sometimes called a \u201cmini-stroke,\u201d is caused by reduced blood flow to a part of the brain, but unlike a stroke its signs and symptoms disappear within a few minutes or hours of onset.",
        "Sudden Signs and Symptoms of Stroke": "As with other sudden illnesses, looking or feeling ill or displaying abnormal behavior are common signs of a stroke or TIA. Other specific signs and symptoms of stroke come on suddenly, including:\n\uf0a7 Facial droop or drooling.\n\uf0a7 Weakness or numbness of the face, arm or leg, often on one side of the body.\n\uf0a7 Difficulty with speech. The patient may have trouble talking, getting words out or being understood when speaking and may have trouble understanding (aphasia).\n\uf0a7 Loss of vision or disturbed (blurred or dim) vision in one or both eyes; pupils of the eyes may be of unequal size.\n\uf0a7 Sudden severe headache (unexplained and often described as the worst headache ever).\n\uf0a7 Dizziness, confusion, agitation, loss of consciousness or other severe altered mental status.\n\uf0a7 Loss of balance or coordination, trouble walking or ringing in the ears.\n\uf0a7 Incontinence.",
        "CRITICAL FACTS 7": "As the common mnemonic for stroke identification, FAST stands for Face, Arm, Speech and Time. Facial drooping, arm weakness and slurred speech are distinctive symptoms, and timely advanced medical care is critical if any one sign or symptom is present.",
        "Stroke Alert Criteria": "Two common stroke assessment scales used in the prehospital setting are the Cincinnati Prehospital Stroke Scale and the Los Angeles Prehospital Stroke Screen (LAPSS), which assess facial droop, arm drift and speech. Both scales should be included in your assessment of the stroke patient and reported to the medical facility. A Glasgow Coma Score (GCS) also should be obtained on the patient (see Chapter 7 for further information). Collecting and reporting this information will help ensure the required management of the stroke patient.",
        "FAST": "The FAST mnemonic is based on the Cincinnati Prehospital Stroke Scale, which was originally developed for EMS personnel in 1997. The scale was designed to help paramedics identify strokes in the field so that the emergency department can be prepared before the patient arrives. The FAST method for public awareness has been in use in the community of Cincinnati, Ohio, since 1999, and has since been used in several other variations of the message.\nFAST stands for the following:\n\uf0a7 Face: Ask the patient to smile. Does one side of the face droop?\n\uf0a7 Arm: Ask the patient to raise both arms. Does one arm drift downward?\n\uf0a7 Speech: Ask the patient to repeat a simple sentence such as, \u201cThe sky is blue.\u201d Are the words slurred? Can the patient repeat the sentence correctly?\n\uf0a7 Time: Try to determine the time of onset of symptoms. If the patient shows any one sign or symptom of a stroke, time is critical. Immediate transport of the patient to a stroke-capable medical facility is necessary.",
        "LAPSS": "The LAPSS mnemonic is another common one-page tool designed to help prehospital personnel rapidly identify strokes in the field.",
        "Providing Care for Stroke": "If the patient is unresponsive, ensure that their airway is open, and care for any life-threatening conditions. If fluid or vomit is in the unresponsive patient\u2019s mouth, position the patient in a side-lying recovery position to allow any fluids to drain out of the mouth. You may have to remove some fluids or vomit from the patient\u2019s mouth using a finger or suctioning equipment. Stay with the patient and monitor their condition. If the patient is conscious, check for non-life-threatening conditions. A stroke can make the patient fearful and anxious due to not understanding what has happened. Offer comfort and reassurance and have the patient rest in a comfortable position. Do not give anything to eat or drink. Although a stroke patient may find it difficult to speak, the patient may understand what you say. If the patient is unable to speak, you may have to use nonverbal forms of communication, such as hand squeezing or eye blinking (once for yes, twice for no) and communicate in ways that require a yes-or-no response. In the past, a stroke almost always caused irreversible brain damage. Today, stroke management with new medications and medical procedures can limit or reduce the damage caused by stroke. Many of these new treatments are time sensitive; therefore, you should immediately call for more advanced medical personnel to get the best care for the patient. It is very important to interview the patient, family members and bystanders to determine the time of the onset of symptoms or the time the patient was last known to be well, and to transport the patient to an appropriate stroke-capable medical facility immediately.",
        "ABDOMINAL PAIN": "Abdominal pain is felt between the chest and groin, which is commonly referred to as the stomach region or belly. There are many organs in the abdomen, so when a patient is suffering from abdominal pain it can originate from any one of them. These include digestive organs such as the inferior end of the esophagus, stomach, small and large intestines, liver, gallbladder, pancreas, aorta, appendix, kidneys and spleen. Abdominal emergencies can be life threatening and require immediate care to prevent shock, so they should always be treated seriously. A sudden onset of abdominal pain is called acute abdomen.",
        "Causes of ABDOMINAL PAIN": "Abdominal pain can be difficult to pinpoint, as the pain may start from somewhere else and could be a result of any number of generalized infections including the flu or strep throat. The intensity of the pain does not always reflect the seriousness of the condition. Severe abdominal pain can be from mild conditions, such as intestinal gas, whereas relatively mild pain or no pain may be present with life-threatening conditions such as an ectopic pregnancy or appendicitis.",
        "CRITICAL FACTS 8": "Modern stroke management with medications and medical procedures can limit the damage caused by stroke, but timely administration is crucial to reduce the effects of stroke to the brain.",
        "Signs and Symptoms of Abdominal Pain": "If you are called to see a patient who is experiencing abdominal pain, assume the pain is serious, as the patient or family members were concerned enough to seek emergency medical attention. Patients suffering from abdominal pain may show the following signs and symptoms: \uf0a7 Colicky pain or cramps that come in waves \uf0a7 Abdominal tenderness, local or diffuse (spread out) \uf0a7 Guarded position \uf0a7 Anxiety \uf0a7 A reluctance to move, for fear of pain \uf0a7 Loss of appetite \uf0a7 Nausea or vomiting \uf0a7 Fever \uf0a7 Rigid, tense or distended stomach \uf0a7 Signs of shock \uf0a7 Vomiting blood with a red or brownish appearance \uf0a7 Blood in the stool, appearing red or black \uf0a7 Rapid pulse \uf0a7 Blood pressure changes When conducting an assessment, monitor the patient\u2019s movements. Take note if the patient is restless or quiet and if the patient feels pain when moving. Check to see if the abdomen is distended and, if possible, confirm with the patient whether the appearance of the stomach is normal. See if the patient is able to relax the abdomen, and palpate the 4 quadrants of the abdomen, using the navel as the center point, to determine if it is rigid or soft. Examine the area the patient indicates as the location of the pain last. Do not overpalpate, as this can aggravate the condition as well as cause more pain.",
        "CRITICAL FACTS 9": "The source and causes of abdominal pain can be difficult to pinpoint, and intensity of abdominal pain does not always reflect the seriousness of the condition.",
        "Providing Care for Abdominal Pain": "First, ensure there is no severe, life-threatening bleeding and that the patient has an open airway. Call for transport to a medical facility. In the case of abdominal pain, it is important to watch for signs of potential aspiration due to vomiting. In cases in which the patient is experiencing nausea, place the patient on their side if it is not too painful. Do not give the patient food, water or medication. Watch for signs of shock. If vital signs and other observations indicate the patient is in shock, place the patient on their back, maintain normal body temperature and administer supplemental oxygen based on local protocols.",
        "Pediatric Considerations - Abdominal Pain": "Abdominal pain in children can indicate a vast range of conditions. A sudden or progressive onset of pain, excessive vomiting or diarrhea, blood noted in vomit or stool, abdominal distention, high blood sugar, altered mental status and abnormal vital signs are all signs the child could be suffering from a serious condition or illness. Vomiting and diarrhea in children are significant symptoms as they may cause dehydration, which can lead to shock. To assess a child complaining of abdominal pain, take the following steps: \uf0a7 Obtain a general impression of the child\u2019s appearance, breathing and circulation to determine urgency. \uf0a7 Evaluate the child\u2019s mental status, airway, adequacy of breathing and circulation. \uf0a7 Take the child\u2019s history and perform a hands-on physical examination, noting any injury, hemorrhage, discoloration, distention, rigidity, guarding or tenderness within the four abdominal quadrants. \uf0a7 If a life-threatening condition is noted, provide immediate treatment before continuing. Children of different ages tend to have different causes of pain. Causes in an infant can include colic, allergy to cow\u2019s milk, reflux esophagitis, volvulus (bowel obstruction) or Hirschsprung\u2019s Disease (congenital disease affecting the large intestine). In school-age children, the most frequent cause of abdominal pain is gastroenteritis or \u201cstomach flu,\u201d which may result in significant fluid loss. Also common is the ingestion of toxic substances or food poisoning. In adolescents, growth, development and fertility issues can cause problems such as testicular torsion (twisting of the testicles), ovarian torsion, ovarian cysts, pelvic inflammatory disease, ectopic pregnancy (pregnancy that occurs outside the womb), inflammatory bowel disease, ulcerative colitis, Crohn\u2019s disease, DKA, pneumonia and sickle cell anemia.",
        "Considerations for Older Adults - Abdominal Pain": "Understanding that older adult patients may experience vague symptoms and have non-specific findings on examination is important. Keep in mind that abdominal pain may actually be caused by a heart attack or other medical conditions. Many older adult patients may have much less severe pain than expected for a particular illness or disease, which can lead to patients with serious conditions being misdiagnosed with less serious conditions such as gastroenteritis or constipation. Vomiting and diarrhea are significant symptoms in older adults, as they can cause dehydration and shock. Causes of abdominal pain in older adults may include biliary tract disease, appendicitis, diverticulitis, mesenteric ischemia (reduced blood flow to the small intestines), bowel obstruction, abdominal aortic aneurysm, peptic ulcer disease, malignancy and gastroenteritis.",
        "Common Abdominal Emergencies": "Many different conditions can cause abdominal pain, including inflammation of the appendix (appendicitis), bowel obstruction, inflammation of the gallbladder, abdominal aortic aneurysm, diverticular disease, shingles, food allergies, food poisoning, gastroenteritis and others. Consider the situation an emergency when the abdominal pain restricts activity.",
        "GASTROINTESTINAL BLEEDING": "There are multiple causes of gastrointestinal bleeding, and these tend to be classified as either upper or lower, depending on the location of the problem within the gastrointestinal tract. Bleeding in the upper gastrointestinal tract originates in the esophagus, stomach or duodenum (first part of the intestine) and may include such problems as peptic ulcers, gastritis, stomach cancer or ingestion of caustic poisons. Bleeding in the lower gastrointestinal tract originates in the small intestine, large intestine, rectum or anus, and includes diverticular disease, polyps, hemorrhoids and anal fissures, as well as cancer and inflammatory bowel disease. A patient with gastrointestinal bleeding may experience vomiting of blood, bloody bowel movements or black, tarry stools. Symptoms that may accompany the bleeding include fatigue, weakness, abdominal pain, pale appearance and shortness of breath. Severe gastrointestinal bleeding can have a significant impact on vital signs\u2014for example, causing blood pressure to drop sharply and heart rate to increase. Summon more advanced medical personnel, as the patient may require a blood transfusion or surgery.",
        "HEMODIALYSIS": "People with advanced renal failure, or kidney failure, often need dialysis to filter waste products from the blood using a special filtering solution. There are two types of dialysis: peritoneal dialysis , which injects a solution through the abdominal wall and then withdraws it after a period of time, and hemodialysis , which uses a machine to clean waste products from the blood. Dialysis is often used on patients with renal disease while they are waiting for a kidney transplant. Complications of dialysis include hypotension (abnormally low blood pressure), disequilibrium syndrome (a reduction of the blood urea level relative to the levels found in brain tissues), hemorrhage (abdominal, gastrointestinal [GI] and intracranial bleeding), introduction of an air embolus or other foreign body into the patient\u2019s circulatory system due to equipment malfunction, and complications caused by temporarily stopping a patient\u2019s medications during the dialysis process.",
        "Special Considerations for Hemodialysis Patients": "The following details should be considered when taking a history and physical exam with a patient who has renal failure: \uf0a7 A comprehensive history should include information about past dialysis and complications; recent sodium, potassium and fluid intake; information about the current dialysis session; and the patient\u2019s dry weight and how much fluid was removed before the session was terminated. \uf0a7 The general physical assessment should include fluid status, mental status, cardiac rhythm and shunt location. NOTE: Shunts in the arm are common in long-term hemodialysis patients. If an active shunt is located in the patient\u2019s arm, do not take blood pressure using that arm. Old, nonfunctional shunts are not uncommon, and blood pressure can be taken on an arm with a nonfunctional shunt. Ask the patient about active and nonfunctional shunt locations when taking a history. Shunts can also be potential sites of infection and/or blockage. \uf0a7 Pay attention for associated medical problems such as arrhythmias, internal bleeding, hypoglycemia, altered mental status and seizures. \uf0a7 Be aware that, after dialysis, patients may have hypovolemia (reduced blood volume) and exhibit cold, clammy skin; poor skin turgor (elasticity); tachycardia; and hypotension. Delayed dialysis patients will have hypervolemia (increased blood volume) and may have abnormal lung sounds such as crackles, generalized edema, hypertension or jugular venous distension. \uf0a7 Be alert for altered mental status. \uf0a7 Be sure to assess cardiac rhythm.",
        "Life-Threatening Emergencies Associated with Dialysis Patients": "Patients on dialysis can experience several types of complications, for example uremia (accumulation of urinary waste products in the blood), fluid overload (reduction in the body\u2019s ability to excrete fluid through urine), anemia (hemoglobin deficiency), hypertension, hyperkalemia (excess potassium in the blood) and coronary artery disease. Emergencies also can occur as complications of the dialysis itself, including hypotension, disequilibrium syndrome, hemorrhage, equipment malfunction (e.g., introducing an air embolus or other foreign body into the circulatory system) or complications from being temporarily removed from medications.",
        "CRITICAL FACTS 10": "People with advanced renal failure, or kidney failure, often need dialysis to filter waste products from the blood using a special filtering solution.",
        "PUTTING IT ALL TOGETHER": "As is true of all emergencies, a medical emergency can strike anyone, at any time. The signs and symptoms for each of the medical emergencies described in this chapter, such as changes in LOC, sweating, confusion, weakness and appearing ill, will indicate the necessary initial care you should provide. In most cases involving a medical emergency, your biggest challenge is that you may not know the cause. In the case of a diabetic emergency, seizure, stroke and fainting, the causes may be easier to ascertain. However, you can provide proper care without knowing the exact cause, allowing the patient to remain as comfortable and safe as possible until arrival at a medical facility. You can also recognize the dangers and complications of dealing with those with diabetes or renal failure. And you have learned the importance of age considerations in many conditions, such as abdominal pain and seizure. Performing a proper assessment and following the general guidelines of care for any emergency will help prevent the condition from becoming worse. While it is not your role to diagnose the problem, it is your job to provide initial care to the patient until a proper diagnosis can be made.",
        "Common Forms of Medication": "Emergency medical responders (EMRs) are often called upon to help give or administer medications. These medications come in several types and forms, including tablets, capsules, powders, liquids, creams, auto-injectors and aerosol sprays. They also have a range of options regarding how they are administered and the doses used in a given circumstance.",
        "Drug Name": "Upon initial discovery, a drug is given a chemical name based on its chemical properties. It is then given a generic, or non-proprietary name, usually a shorter version of the chemical name. This is the name used for the Food and Drug Administration (FDA) approval application. Drugs are also given a brand or trade name, which is used in marketing. It may or may not sound like the generic name, depending on the complexity of the generic name and the drug\u2019s purpose. For example, with a chemical name of N-acetyl- p-aminophenol, the generic name of this drug is acetaminophen and the trade name is Tylenol\u00ae.",
        "Drug Profile": "A drug\u2019s profile is a description of what it does, what it is or is not given for and any issues that may develop as a result of taking it.",
        "Drug Profile - Actions": "The action of a medication is what it does. If you are administering a drug, you should know how the drug works. For example, does the medication dilate the blood vessels (vasodilator) to lower blood pressure?",
        "Drug Profile - Indications": "The indication of a drug is the intended use for a specific condition. Why is the drug given? What are you trying to achieve? For example, the indication for nitroglycerin would be for chest pain or angina.",
        "Drug Profile - Contraindications": "Not everyone can take every medication. Contraindications are the conditions in which you would not administer a drug to a patient. This could be because the patient has a medical condition that would be worsened by administration of the drug, because of adverse interactions with other medications or because the patient may be allergic to the medication. For example, it would be contraindicated to give morphine to a patient who is allergic to it, or to give a medication with a known effect of hypotension (lowering blood pressure) to a patient whose blood pressure is already low.",
        "Drug Profile - Side effects": "Side effects are reactions caused by the drug that were not intended. Side effects may or may not cause problems. If they do cause problems, these are called adverse effects, adverse reactions or untoward effects. These are the effects you must watch for when administering medications such as nitroglycerin. Nitroglycerin works by dilating the blood vessels, but it can cause the sudden and possibly harmful side effect of lowering blood pressure.",
        "Drug Profile - Dose": "The usual dose is a range of an acceptable amount of the medication, given the patient\u2019s age, weight and reason for giving the drug. There are also times when the patient\u2019s gender must be taken into account. Administering an overdose, or too much of a drug, can result in severe, sometimes fatal, consequences. Administering too little of a drug may cause the problem to worsen, because the drug will not have the desired effect on the patient.",
        "Drug Profile - Route": "You must know by which route a drug is to be given. Some medications can be given in different ways\u2014for example, by injection or intravenously. However, there is a significant difference in the dose given by each route. If a patient receives a dose intravenously that was intended to be delivered by injection, this could result in death.",
        "Prescribing Information": "Medication prescriptions must contain the following information: \uf0a7 Pharmacy\u2019s name and address \uf0a7 Prescription\u2019s serial number \uf0a7 Date of the prescription (initial filling or refill date) \uf0a7 Prescriber\u2019s name\uf0a7 Patient\u2019s name \uf0a7 Directions for use, including any precautions \uf0a7 Medication name and strength \uf0a7 Federal law inscription on transfer of drugs Medication prescriptions also commonly contain the following additional information: \uf0a7 Patient\u2019s address \uf0a7 Pharmacist\u2019s initials or name \uf0a7 Pharmacy\u2019s telephone number \uf0a7 Manufacturer\u2019s lot number\uf0a7 Drug\u2019s expiration date \uf0a7 Manufacturer\u2019s or distributor\u2019s name \uf0a7 Quantity of medication dispensed \uf0a7 Number of refills remaining",
        "Routes of Administration": "Medications can be given in many ways, including the following: \uf0a7 By mouth: Many medications, such as tablets, capsules, powders and liquids, may be given by mouth to be absorbed by the stomach and intestines. The amount of time it takes for them to become effective can vary considerably. The patient must be responsive enough to follow directions to swallow and be able to swallow. \uf0a7 Sublingually: These medications dissolve under the tongue and are absorbed into the bloodstream through the mucous membrane. \uf0a7 By inhalation: Some medications are inhaled (i.e., through mouth, nose or tracheostomy) directly into the lungs. These are usually medications for respiratory illnesses like asthma. Oxygen, which is inhaled, is also considered a medication. \uf0a7 By injection: These medications are usually administered by a licensed healthcare professional or by a caregiver. They can be given straight into the muscle or under the skin, depending on the product. \uf0a7 Topically: Topical medications are given by patch or gel and absorbed by the skin. EMRs must be careful when encountering a patch on a patient\u2019s skin, as the medication could be absorbed by the responder when trying to remove the patch. \uf0a7 Intravenously: Medications given intravenously must be administered by a licensed healthcare professional. It is one of the quickest ways to deliver fluids and medications, as substances are directly transmitted to the veins. \uf0a7 Vaginally: Some creams and suppositories must be given vaginally. \uf0a7 Rectally: Many medications are available in rectal suppository format.",
        "Administering Medications Overview": "The \u201cRights\u201d of Drug Administration Healthcare personnel who administer medication follow a concept called the \u201cFive Rights.\u201d These help ensure the medication is being given correctly. \uf0a7 Right patient: If administering a patient\u2019s own medication, you must ensure it truly is the patient\u2019s medication. Check the label for the correct name. An exception may be if medical direction calls for a medication that is available but does not belong to the patient. If you are administering a stock medication (one that is kept on hand until needed), you must understand the action and effects to be sure that it is right for this patient. \uf0a7 Right medication: When reaching for a medication, read the label properly and ensure that the medication in the bottle is what the label says it is. If in doubt, do not give it. If you are reaching for a stock medication, read the label as you remove it from your stock, while you remove the medication from the container and again as you give it to the patient. \tRight route: Be sure you are administering the drug as prescribed. You may find a prescription for a drug given by a route with which you are not familiar. When in doubt, double check.\tRight dose: Double check the dosage of the drugs you give to patients. Some medications vary considerably in dose between patients.\tRight date: Medications have expiration dates. This is the first day of the month listed, unless otherwise specified. Do not give expired drugs.",
        "Administration of Medication Versus Assistance with Medication": "Administering a medication means you are physically giving the medication to the patient. In some situations, the patient is able to take medication alone, such as by a metered dose inhaler (MDI) for a respiratory emergency. In this case, you may assist by helping get the medication ready and perhaps holding the inhaler while the patient presses the pump. Always follow medical direction, regulations and local protocols regarding your role in administering or assisting patients with medications.",
        "Administration Routes": "You may only administer medications by routes you have been licensed or authorized to administer. Generally, for EMRs, this is by inhalation, orally or sublingually (under the tongue). There may be regulatory exceptions regarding EMR use of auto-injectors and inhalers. Check local protocols and medical direction to know the medications that you can deliver.",
        "Reassessment": "After administering a drug, you must always assess the effect. You will need to watch for:\n\uf0a7 Signs and symptoms of the original problem.\n\uf0a7 Improvement or deterioration in the patient\u2019s condition, including the following:\n yMental status\n yRespiratory status\n yPulse rate and quality yBlood pressure\n ySkin color, temperature and condition\n yAdverse effects",
        "Documentation": "Any time a drug is administered, from a patient\u2019s supply or from your stock, this must be documented thoroughly. You must document: 1) the reason for administration, 2) drug name, 3) dose, 4) route of administration, 5) time(s) of administration, 6) any side effects noted, 7) how often administered, and 8) any improvement noted and any changes in the patient\u2019s status.",
        "Role of Medical Oversight in Medical Administration": "Medical direction, the oversight provided by a physician who assumes responsibility for care, provides direction on what medication to give, as well as the dose, route of administration and how often it is given. When receiving medical direction, you must repeat back the order for confirmation even if you are sure you understood correctly.",
        "Administering Aspirin - Generic and Trade Names": "Aspirin was the original trade name of acetylsalicylic acid (ASA). It has been marketed under several trade names, such as Ecotrin\u00ae Enteric Coated Aspirin, Excedrin\u00ae (which also contains acetaminophen), Pravigard\u00ae and St. Joseph\u00ae. In countries where aspirin is trademarked (owned by Bayer), the term ASA is the generic name.",
        "Administering Aspirin - Indications": "Aspirin, or ASA, was originally an analgesic, which is a type of pain reliever. However, today healthcare providers often use it for its blood-thinning capability to prevent blood clots. Aspirin is used to provide relief for mild-to-moderate pain, including headache, menstrual pain, muscle pain, minor pain of arthritis and toothache. It also reduces fever and inflammation. Aspirin may also be given for angina and heart attack (see Chapter 13 for more information on aspirin and heart attacks). A healthcare provider should be consulted before using aspirin to treat or prevent any cardiovascular condition.",
        "Administering Aspirin - Contraindications": "Patients already on blood thinners should not take aspirin. It should not be given to patients who have a known allergy to non-steroidal anti-inflammatory drugs (NSAIDs). Because of the rare complication of Reye\u2019s Syndrome, children and adolescents who show flu-like symptoms or who may have a viral illness such as chicken pox should not be given aspirin or products that contain aspirin. Women who are pregnant or nursing should avoid taking aspirin unless they are instructed to by their healthcare provider. Patients with asthma, ulcer or ulcer symptoms; a recent history of stomach or intestinal bleeding; or a bleeding disorder, such as hemophilia, should not take aspirin. Aspirin will not prevent hemorrhagic strokes and should not be given to someone showing signs and symptoms of a stroke.",
        "Administering Aspirin - Actions": "Aspirin acts to thin the blood by reducing the platelets\u2019 ability to produce a chemical that helps form blood clots. To relieve pain, aspirin reduces inflammation at the source, thereby reducing the pain.",
        "Administering Aspirin - Side Effects": "The majority of side effects and complications associated with aspirin are due to taking too much of the medication or from taking it for too long a period. However, side effects can occur with just a few doses in some people. The most common side effects include heartburn, nausea, vomiting and gastrointestinal bleeding. Some people are allergic to aspirin, so it is important to watch for an allergic reaction to the medication.",
        "Administering Aspirin - Expiration Date": "It is important not to administer aspirin past its expiration date. The effect of the drug decreases if it is too old. Therefore, by giving a dose of expired aspirin, you will not know how much of the drug the patient will actually receive. Do not use the aspirin if there is a strong smell of vinegar as this may indicate the medication is expired.",
        "Administering Aspirin - Dosage": "The dosages for pain relief and for blood thinning differ. The average adult dose for minor pain and fever relief is one to two 325-milligram (mg) tablets about every 3 to 4 hours, not to exceed 6 doses a day. For the prevention of a heart attack, the average adult dose is one 81-mg/low-dose tablet daily. For a patient experiencing chest pain that suggests a heart attack, the dose is two to four 81-mg low-dose (162 mg to 324 mg) aspirins or one 5-grain (325-mg) adult aspirin. Have the patient chew the aspirin completely, which speeds up the absorption of the aspirin into the bloodstream. A healthcare provider may recommend a stronger dosage of aspirin. Follow local protocols and medical direction before giving aspirin to treat or prevent cardiovascular conditions.",
        "Administering Aspirin": "Aspirin is most commonly available in oral form; however, it is also available as a rectal suppository and in a liquid form for children.",
        "Administering Nitroglycerin - Generic and Trade Names": "Nitroglycerin is the generic name for Nitrolingual\u00ae Pump Spray, Nitrostat\u00ae Tablets and the Minitran\u00ae Transdermal Delivery System. It is also available by the generic name.",
        "Administering Nitroglycerin - Indications": "Nitroglycerin is given to patients with angina pectoris, a condition in which the blood vessels in the heart constrict and do not allow enough blood and oxygen to circulate. This, in turn, causes chest pain.",
        "Administering Nitroglycerin - Contraindications": "Nitroglycerin should not be given to patients whose systolic blood pressure is below 90 mmHg. Also, it should not be given more often than prescribed (usually one to three times is indicated, with 5 minutes spaced between doses). Do not give nitroglycerin to patients taking sildenafil (Viagra\u00ae) or other similar phosphodiesterase type 5 (PDE) inhibitors, as this could lead to life-threatening complications such as a dangerous drop in blood pressure. Nitroglycerin should not be given to individuals who have severe anemia or a brain injury, hemorrhage or tumor. Nitroglycerin may be harmful to an unborn baby.",
        "Administering Nitroglycerin - Actions": "Nitroglycerin dilates the blood vessels, allowing blood to flow more freely, thus providing more oxygen to the heart tissue.",
        "Administering Nitroglycerin - Side Effects": "Rapid dilation of the blood vessels can cause a severe and sudden headache. The headaches may become gradually less severe as the individual continues to take nitroglycerin. Other side effects may include dizziness, flushed skin of the neck and face, light-headedness and worsened angina pain.",
        "Administering Nitroglycerin - Precautions": "Nitroglycerin tablets are reactive to light and should be stored in a dry area in a dark-colored container to maintain their potency.",
        "Administering Nitroglycerin - Expiration Date": "Check expiration dates for all types of nitroglycerin. Failure to do so may result in administering medication that is no longer active, thereby delaying proper treatment.",
        "Administering Nitroglycerin - Dosage and Administration": "Nitroglycerin sprays and tablets are usually administered as one spray or pill under the tongue, and can be taken by the patient up to three times, with 5 minutes between each dose, if there is no change in their condition. Have the patient sit while taking nitroglycerin as it can cause dizziness or fainting. Nitroglycerin is a very potent medication. It should never be given without a healthcare provider\u2019s order.",
        "Administering Oral Glucose - Action": "Oral glucose acts by increasing the amount of blood glucose (sugar) in the bloodstream.",
        "Administering Oral Glucose - Indication": "Oral glucose is administered to patients who have diabetes and whose blood sugar level has dropped below tolerable levels. At this point, the insulin has no glucose to metabolize.",
        "Administering Oral Glucose - Contraindications": "Oral glucose should not be given to patients with diabetes whose blood sugar is within normal range or above normal range. It also should not be given to patients who are unresponsive and unable to follow instructions to swallow safely.",
        "Administering Oral Glucose - Side Effects": "Side effects may include nausea, heartburn and bloating.",
        "Administering Oral Glucose - Dose": "The product comes as glucose tablets that are 4 to 5 grams each.",
        "Administering Oral Glucose - Route": "Oral glucose is given by mouth.",
        "Blood Glucose Monitoring": "Blood glucose monitoring refers to the measurement of blood sugar (glucose). Everyone\u2019s blood has some glucose in it because our bodies turn the food we eat into this form of sugar, which is transported throughout the body. Insulin, a hormone from the pancreas, helps get the glucose into our cells to be used for energy. Without insulin (e.g., in patients with type 2 diabetes), the BGL rises, leading to long-term health complications if untreated. In patients taking insulin, low blood glucose creates critical health risks and must be treated immediately.",
        "Blood Glucose Monitoring - Testing B GL with a Glucometer": "Patients with diabetes check their BGLs regularly, often using a portable device called a glucometer. Monitoring can be done at any time using a glucometer. The test requires a drop of blood on a test strip containing a chemical substance, which is then inserted into the glucometer. The drop of blood is obtained by piercing the skin of a finger pad with a sharp sterile device such as a lancet or needle.",
        "Blood Glucose Monitoring - Using a Glucometer": "\uf0a7 Ensure your hands are clean and the glucometer is in good working order. \uf0a7 Wipe the pad of the patient\u2019s finger with an alcohol swab, or clean the finger with soap and water. Allow the skin to dry completely. \uf0a7 Using a sterile lancet, prick the pad of the finger and allow a blood drop to form. \uf0a7 Collect a drop of blood on the test strip. \uf0a7 Insert the test strip into the glucometer, read and record the numerical result. Read the owner\u2019s manual for the glucometer carefully, and only use the test strips specified for that meter. Otherwise, the device may fail to give results or may generate an inaccurate reading.",
        "Blood Glucose Monitoring - What the Numbers Mean": "Although the result may vary depending upon the patient and the testing device used, it is generally accepted that the normal range before meals is 90\u2013130 milligrams per deciliter (mg/dL) and after meals is less than 180 mg/dL. Low blood glucose, also called hypoglycemia, occurs when the BGL drops below 70 mg/dL. This requires immediate treatment. If the patient is conscious, provide 15 to 20 grams of glucose (4 to 5 glucose tablets, depending on the manufacturer) and recheck the blood glucose level after 10 to 15 minutes. If the patient is unconscious or unable to swallow, seek advanced life support immediately.",
        "Blood Glucose Monitoring - Pediatric Considerations": "Blood Glucose Monitoring The American Diabetes Association (ADA) warns of the problems that could be caused by blood sugar levels that are too low in children under 7 years of age. Young children require higher blood sugar levels than do adults for brain development. Also, children\u2019s food intake and activity level tend to vary quite a bit from day to day, causing blood sugar levels to fluctuate, so they are more at risk of blood sugar levels falling too low. Further, it may be difficult for very young children to report and describe symptoms of low blood sugar, so this may go undetected. Also keep in mind that, before reaching puberty, children seem to be at lower risk of the complications of diabetes even when blood sugar levels are abnormally high. The ADA recommends aiming for the safe adult range of BGL only when children grow older and can recognize the early symptoms of BGLs dropping too low."
    },
    {
        "Key Terms": "Anaphylaxis: A form of distributive shock caused by an often sudden severe allergic reaction, in which air passages may swell and restrict breathing; also referred to as anaphylactic shock., Antivenom: A substance used to counteract the poisonous effects of venom., Arterial gas embolism: A condition in which air bubbles enter the bloodstream and subsequently travel to the brain; results from a rapid ascent from deep water, which expands air in the lungs too quickly., Barotrauma: Injury sustained because of pressure differences between areas of the body and the surrounding environment; most commonly occurs in air travel and SCUBA diving., Conduction: One of the ways the body loses or gains heat; occurs when the skin is in contact with something with a lower or higher temperature., Convection: One of the ways the body loses or gains heat; occurs when air moves over the skin and carries away or increases heat., Core temperature: The temperature inside the body., Decompression sickness: A sometimes fatal disorder caused by the release of gas bubbles into body tissue; also known as 'the bends'; occurs when SCUBA divers ascend too rapidly, without allowing sufficient time for gases to exit body tissues and be removed through exhalation., Dehydration: Inadequate fluids in the body\u2019s tissues., Drowning: An event in which a victim experiences respiratory impairment due to submersion in water. Drowning may or may not result in death., Electrolytes: Substances that are electrically conductive in solution and are essential to the regulation of nerve and muscle function and fluid balance throughout the body; include sodium, potassium, chloride, calcium and phosphate., Evaporation: One of the ways the body loses heat; occurs when the body is wet and the moisture evaporates, cooling the skin., Exercise-associated muscle cramps: Formerly known as heat cramps, these muscle spasms can be intense and debilitating and typically occur in the legs, arms and abdomen; painful involuntary muscle spasms occur during or after physical exertion, particularly in high heat and humidity, possibly due to loss of electrolytes and water from perspiration; not associated with an increase in body temperature., Exertional heat exhaustion (EHE): An inability to cope with heat and characterized by fatigue, nausea and/or vomiting, loss of appetite, dehydration, exercise-associated muscle cramps, dizziness with possible fainting, elevated heart and respiratory rate, and skin that is pale, cool and clammy or slightly flushed; if a core body temperature can be obtained, it is typically higher than 104 \u00b0 F (40\u00b0 C). The person may be weak and unable to stand but has normal mental status; often results from strenuous work or wearing too much clothing in a hot, humid environment, and may or may not occur with dehydration and electrolyte imbalance., Exertional heat stroke (EHS): The most serious form of heat-related illness; life threatening and develops when the body\u2019s cooling mechanisms are overwhelmed and body systems begin to fail. People with EHS have exaggerated heat production and an inability to cool themselves., Free diving: An extreme sport in which divers compete underwater without any underwater breathing apparatus., Frostbite: A condition in which body tissues freeze; most commonly occurs in the fingers, toes, ears and nose., Heat index: An index that combines the air temperature and relative humidity to determine the perceived, human-felt temperature; a measure of how hot it feels., Heat stroke: The most serious form of heat-related illness; life threatening and develops when the body\u2019s cooling mechanisms are overwhelmed and body systems begin to fail; can be classified as classic heat stroke or exertional heat stroke., Hyperthermia: Overheating of the body; includes exercise-associated muscle cramps, exertional heat exhaustion and heat stroke (exertional and classic)., Hypothalamus: Control center of the body\u2019s temperature; located in the brain., Hypothermia: The state of the body being colder than the usual core temperature, caused by either excessive loss of body heat and/or the body\u2019s inability to produce heat., Metabolism: The physical and chemical processes of converting oxygen and food into energy within the body., Rabies: An infectious viral disease that affects the nervous system of humans and other mammals; has a high fatality rate if left untreated., Radiation: One of the ways the body loses heat; heat radiates out of the body, especially from the head and neck., Tetanus: An acute infectious disease caused by a bacterium that produces a powerful poison; can occur in puncture wounds, such as human and animal bites; also called lockjaw.",
        "INTRODUCTION": "Environmental emergencies include a wide range of situations\u2014from exertional heat stroke and frostbite, to snakebites and drowning. They range from minor to life threatening. In some cases, the same problem\u2014such as a bee sting\u2014can result in minor pain and discomfort in one patient while causing a life-threatening condition in another, such as anaphylaxis. Environmental emergencies often occur during the course of everyday events. For example, a teenager may get caught without shelter and proper clothing during a sudden downpour while on a hike, an older adult may collapse from dehydration during a heat spell or a bathtub may be the cause of a drowning for a small child. In this chapter, you will learn how to recognize and care for heat-related illnesses and cold-related emergencies, bites and stings, anaphylaxis and drowning incidents.",
        "BODY TEMPERATURE": "The human body usually keeps itself at a constant core temperature (internal temperature) of 98.6\u00b0 F, or 37\u00b0 C. The control center of body temperature is in the brain and is called the hypothalamus. The hypothalamus receives information and adjusts the body\u2019s function accordingly. The body needs to be kept within a specific range of temperatures for the cells to stay alive and healthy (97.8\u00b0 F to 99\u00b0 F, or 36.5\u00b0 C to 37.2\u00b0 C). It is vital the body responds properly to temperature signals.",
        "How the Body Stays Warm": "Heat is a byproduct of metabolism, the conversion of food and drink into energy. The body also gains heat with any kind of physical activity. If the body starts to become too cold, it responds by constricting (closing up) the blood vessels close to the skin so it can keep the warmer blood near the center of the body. This helps keep the organs warm. If this does not work, the body then begins to shiver. The shivering motion increases body heat because it is a form of movement.",
        "CRITICAL FACTS": "The human body usually keeps itself at a constant core temperature (internal temperature) of 98.6\u00b0 F, or 37\u00b0 C. In a warm or hot environment, the hypothalamus detects an increase in blood temperature. Blood vessels near the skin dilate (widen), to bring more blood to the surface, which allows heat to escape.",
        "How the Body Stays Cool": "In a warm or hot environment, the hypothalamus detects an increase in blood temperature. Blood vessels near the skin dilate (widen), to bring more blood to the surface, which allows heat to escape. Radiation: This process involves the transfer of heat from one object to another without physical contact. The body loses the majority of heat through radiation, mostly from the head, hands and feet. Convection: This process occurs when cold air moves over the skin and carries the skin\u2019s heat away. The faster the air is moving, the faster the body will be cooled. Convection is what makes warm skin feel cooler in a breeze. Convection also assists in the evaporation process. Conduction: This occurs when the body is in direct contact with a substance that is cooler than the body\u2019s temperature. Through conduction, the body\u2019s heat is transferred to the cooler substance (e.g., if you are swimming in cold water or sitting on a cool rock in the shade). Evaporation: This is the process by which a liquid or solid becomes a vapor. When body heat causes one to perspire and the perspiration evaporates, the heat that was absorbed into sweat dissipates into the air which cools off the skin. Respiration: Heat is also lost through respiration, another term for breathing. Before air is exhaled, it is warmed by the lungs and airway. Respiration normally accounts for approximately 10 to 20 percent of heat loss.",
        "PEOPLE AT RISK FOR HEAT-RELATED ILLNESSES AND COLD-RELATED EMERGENCIES": "Although anyone can be at risk for heat-related illnesses and cold-related emergencies, some people are at even greater risk than others. People who are susceptible to a heat-related illness or cold-related emergency include those who: Work or exercise strenuously in a warm or hot and humid environment or a cold environment. Have a pre-existing health problem, such as diabetes or heart disease. Pre-existing health problems can increase susceptibility to a heat-related illness. Medications taken for these conditions can also cause dehydration. Have had a previous heat-related illness or cold-related emergency. Take medications to eliminate water from the body (diuretics). Diuretics increase the risk of dehydration, which, in turn, causes an increase in core body temperature by preventing adequate blood flow to remove excess heat. Consume other substances that have a diuretic effect, such as fluids containing caffeine, alcohol or carbonation. Live in a situation or environment that does not provide them with enough heating or cooling, depending on the season. Do not maintain adequate hydration by drinking enough water to counteract the loss of fluids through perspiration, exertion or exposure to heat and humidity. Wear clothing inappropriate for the weather. Heat-related illnesses and cold-related emergencies occur more frequently among older adults, especially those living in poorly ventilated or poorly insulated buildings, or buildings with poor heating or cooling systems. Young children and people with health problems are also at greater risk because their bodies do not respond as effectively to temperature extremes.",
        "CRITICAL FACTS 1": "Heat-related illnesses and cold-related emergencies occur more frequently among older adults, especially those exposed to poor living conditions. The young and those with health problems are also considered high-risk groups. There are several types of illness related to overheating of the body, or hyperthermia: exercise-associated muscle cramps, exertional heat exhaustion and heat stroke (exertional or classic).",
        "HEAT-RELATED ILLNESSES": "There are several types of illness related to overheating of the body, or hyperthermia, including exercise-associated muscle cramps, exertional heat exhaustion and heat stroke (exertional or classic). Heat-related illnesses can happen to anyone, but several predisposing factors can put some people at higher risk. These factors include:\n\uf0a7 Climate. In very warm or hot and humid weather, the body may not be able to cool off sufficiently. If the temperature is high, the body is not as able to lower its temperature through radiation. The more humid the air, the less the body is able to cool down through sweating. Evaporation decreases as the relative humidity increases because the air contains excessive moisture.\n\uf0a7 Exercise and activity. Exercise or strenuous labor in the heat does not allow the body to cool off, particularly since exercise itself increases body temperature. When combined with a high heat index, there is a much greater risk of increasing the core temperature as it becomes more difficult to cool the body.\n\uf0a7 Age. The very young and very old are not as able to regulate body temperature as others are. Infants and young children, for example, may not be able to get the fluids they need, move away from the heated area, or speak up and tell someone they are too warm.\n\uf0a7 Pre-existing illness and/or conditions. Certain illnesses and conditions can make someone feel the heat more than others. Examples include people with diabetes, infections (which can cause fever, increasing the body temperature even more), obesity and heart disease.\n\uf0a7 Drugs and/or medications. Medications or substances, such as alcohol and diuretics, cause an increase in blood vessel constriction, increase urination, increase the risk of dehydration and increase core temperature.",
        "CRITICAL FACTS 2": "Dehydration can be a serious and even life-threatening situation. The people at highest risk of dying from dehydration are the very young and the very old.",
        "Dehydration": "Dehydration refers to inadequate fluids in the body\u2019s tissues. Dehydration can be a serious and even life-threatening situation. The people at highest risk of dying from dehydration are the very young and the very old. The signs and symptoms of dehydration worsen as the body becomes dryer. The first signs of dehydration include:\n\uf0a7 Fatigue.\n\uf0a7 Weakness.\n\uf0a7 Headache.\n\uf0a7 Irritability.\n\uf0a7 Nausea.\n\uf0a7 Dizziness.\n\uf0a7 Excessive thirst.\n\uf0a7 Dry lips and mouth.\nAs dehydration worsens, symptoms can include:\n\uf0a7\tDisorientation or delirium.\n\uf0a7\tLoss of appetite.\n\uf0a7\tSevere thirst.\n\uf0a7\tDry mucous membranes.\n\uf0a7\tSunken eyes.\n\uf0a7\tLowered blood pressure.\n\uf0a7\tRapid pulse.\n\uf0a7\tDry skin that does not spring back if pinched, creating a \u201ctenting\u201d effect.\n\uf0a7\tLack of tears (particularly important among young children).\n\uf0a7\tDecrease in perspiration.\n\uf0a7\tDark, amber urine or complete lack of urine output.\n\uf0a7\tUnconsciousness.",
        "Providing Care for Dehydration": "To care for a patient who is dehydrated, you need to help them replace the lost fluid. If the patient is still awake and able to swallow, encourage them to drink small amounts of a commercial sports drink or, if not available, water. The patient should be allowed to drink until their thirst sensation is quenched. However, do not let the patient gulp the fluid down; instead, have them sip it at a slow pace. If the patient drinks too quickly, vomiting may occur. If dehydration is severe, the patient will likely need more advanced medical care to receive fluids intravenously.",
        "Exercise-Associated Muscle Cramps": "The exact cause of exercise-associated muscle cramps is not known, although it is believed to be a combination of loss of fluid and electrolytes from heavy sweating. Exercise-associated muscle cramps develop fairly rapidly and usually occur after heavy exercise or work in warm or even moderate temperatures.",
        "Signs and Symptoms of Exercise-Associated Muscle Cramps": "Exercise-associated muscle cramps are painful spasms of skeletal muscles. While they usually affect the legs, arms and abdomen, they can occur in any voluntary muscle. The person\u2019s body temperature is usually normal and the skin moist.",
        "Providing Care for Exercise-Associated Muscle Cramps": "Exercise-associated muscle cramps must be taken seriously, particularly if there is a history of heart disease or the patient is on a low-sodium diet. To care for exercise-associated muscle cramps, the most important initial action is to reduce the cramps and remove the patient from the heat. Have the patient rest, then gently massage and lightly stretch the cramped muscles to ease the discomfort. To replace what was lost to perspiration, encourage the patient to drink an electrolyte- and carbohydrate-containing fluid such as a commercial sports drink, fruit juice or milk. Water also may be given if the drinks are not available. While the patient should rest as long as possible, if the cramping has gone away and the patient feels better, activity can be resumed with caution. Advise the patient to rest frequently and drink fluids to prevent further dehydration and cramping.",
        "Exertional Heat Exhaustion": "Exertional heat exhaustion (EHE) is a form of heat-related illness. EHE results when fluid lost through perspiration is not replaced by other fluids. This results in the body pulling the blood away from the surface areas of the body to protect the vital organs, such as the heart and brain. Anyone can be at risk for developing EHE from exposure to a hot or humid environment.",
        "Signs and Symptoms of Exertional Heat Exhaustion": "The signs and symptoms of exertional heat exhaustion include:\n\uf0a7 Cool, pale, clammy or slightly flushed skin.\n\uf0a7 Fatigue.\n\uf0a7 Nausea and/or vomiting.\n\uf0a7 Loss of appetite.\n\uf0a7 Dehydration.\uf0a7 Dizziness with possible fainting.\n\uf0a7 Elevated heart and respiratory rate.\n\uf0a7 Muscle cramps.",
        "CRITICAL FACTS 3": "Exertional heat exhaustion is a more severe form of heat-related illness. Exertional heat exhaustion results when fluid lost through perspiration is not replaced by other fluids.\nTo provide care for exertional heat exhaustion, move the patient out of the heat to a cooler area and loosen or remove as much clothing as possible. Spray the person with cool water, apply cool wet cloths or towels to the skin, and fan the person. If the patient is awake and able to swallow, encourage them to drink small amounts of a commercial sports drink or fruit juice; if these are not available, milk or water may also be given.",
        "Providing Care for Exertional Heat Exhaustion": "Care for exertional heat exhaustion includes the following:\n\uf0a7 Move the patient from the hot environment to a cooler environment with circulating air.\n\uf0a7 Loosen or remove as much clothing as possible.\n\uf0a7 Apply cool, wet cloths, such as towels or sheets, taking care to remoisten the cloths periodically. Spraying the patient with water and fanning also can help increase the evaporative cooling.If the patient is awake and able to swallow, give them small amounts of a cool fluid such as a commercial sports drink or fruit juice to restore fluids and electrolytes. Milk or water also may be given. Do not let the patient drink too quickly. Let the patient rest in a comfortable position, and watch carefully for changes in their condition. The patient should not resume normal activities the same day. If the patient\u2019s condition does not improve, or they refuse fluids, have a change in level of consciousness or vomit, call for more advanced medical personnel, as these are indications that the patient\u2019s condition is getting worse. Stop giving fluids and place the patient on their side in a recovery position if needed. Watch for signs and symptoms of breathing problems. Keep the patient lying down and continue to cool the body any way you can (see Providing Care for Heat Stroke for cooling methods). Low blood pressure and rapid, weak pulse are signs of shock, so take steps to prevent or minimize shock. Refer to Chapter 18 for more information on how to care for shock.",
        "Heat Stroke": "The most serious of heat-related illnesses is heat stroke. Heat stroke is a life-threatening condition that most often occurs when people ignore the signs and symptoms of exertional heat exhaustion or do not act quickly enough to give care. Heat stroke develops when the body systems are overwhelmed by heat and begin to stop functioning. Sweating may stop when body fluid levels are low (i.e., dehydration) but may also still be present for a person suffering from heat stroke. The body\u2019s exaggerated heat production, combined with an inability to cool itself, causes body temperature to rise quickly, soon reaching a level at which the brain and other vital organs, such as the heart and kidneys, begin to fail. If the body is not cooled, convulsions, coma and death will result.",
        "Types of Heat Stroke": "Two types of heat stroke are typically reported\u2014classic heat stroke and exertional heat stroke. Classic heat stroke is normally caused by environmental changes and often occurs during the summer months. Classic heat stroke most often occurs in infants, children, older adults, those with chronic medical illnesses and those who suffer from inefficient body heat-regulation mechanisms\u2014such as those in poor socioeconomic settings with limited access to air conditioning and those on certain medications (e.g., antihistamines, amphetamines, diuretics, and blood pressure and heart medicines). Typically, classic heat stroke develops slowly, over a period of several days, with the person presenting with minimally elevated core temperatures. Exertional heat stroke is the opposite of classic heat stroke and is experienced more frequently than classic heat stroke. Exertional heat stroke\u2014which primarily affects younger, active individuals, such as athletes (recreational and competitive), military recruits and heavy laborers\u2014occurs when excess heat is generated through exercise and exceeds the body\u2019s ability to cool off. Exposure to factors such as high air temperature, high relative humidity and dehydration increases the risk for developing exertional heat stroke.",
        "Signs and Symptoms of Heat Stroke": "Heat stroke is a serious medical emergency. You must recognize the signs and symptoms of heat stroke and give care immediately. The signs and symptoms include: Changes in level of consciousness, including confusion, agitation, disorientation or unconsciousness. Trouble seeing. Seizures. Extremely high body temperature (above 104\u00b0 F, or 40\u00b0 C). Flushed or red skin that can be either dry or moist. Rapid, shallow breathing. Throbbing headache. Dizziness, nausea or vomiting.",
        "CRITICAL FACTS 4": "The most serious of heat-related illnesses is heat stroke. Heat stroke is a life-threatening condition that occurs when the body has become overheated and is no longer able to cool itself down.",
        "Providing Care for Heat Stroke": "Since heat stroke is life threatening, you should immediately call for more advanced medical personnel. Your next priority is to begin rapid cooling of the patient\u2019s body, to bring the core temperature down. The quicker you can get the body temperature down, the better the outcome. Bring down the patient\u2019s body temperature quickly, to reduce the possibility of brain damage, organ failure or death. Perform a primary assessment and then provide care by using any of the following techniques to cool the patient rapidly: \uf0a7 Immerse the patient in cold water up to their neck (preferred method) if it is safe to do so and the resources are available. \uf0a7 Douse the patient with ice water-soaked towels over the entire body, frequently rotating the cold, wet towels, spraying with cold water, fanning the patient or covering the patient with ice towels or bags of ice placed over the body. \uf0a7 If you are not able to measure and monitor the patient\u2019s core temperature, apply rapid cooling methods for 20 minutes or until the patient\u2019s LOC improves. Low blood pressure and rapid pulse are signs of shock, so take steps to prevent or minimize shock. Refer to Chapter 18 for more information on care for shock. A person in heat stroke may experience respiratory or cardiac arrest. Be prepared to give ventilations or perform CPR, if needed.",
        "Hypothermia (Generalized Cold Exposure)": "Hypothermia is the state of the body being colder than the usual core temperature. It is caused by either excessive loss of body heat and/or the body\u2019s inability to produce heat. Hypothermia can come on gradually or it can develop very quickly. In hypothermia, body temperature drops below 95\u00b0 F (35\u00b0 C). As the body cools, an abnormal heart rhythm (ventricular fibrillation, or V-fib) may develop. If this happens, the heart will eventually stop and the patient will die if not cared for.",
        "Contributing Factors for Hypothermia": "As with heat-related illnesses, anyone can develop hypothermia, but predisposing factors put some people at a higher risk. These factors include: \uf0a7 A cold environment. Even if the ambient temperature is not extremely low, hypothermia can occur if a person is not adequately protected from the cold. \uf0a7 A wet environment. The presence of moisture (e.g., perspiration, rain, snow or water) will increase the speed at which body heat is lost. \uf0a7 Wind. Wind makes the environment a lot colder than the ambient temperature indicates. The higher the wind chill effect, the lower the temperature actually is. \uf0a7 Age. The very young and the very old may have difficulty keeping warm in cool or cold conditions. Infants may not yet be able to shiver effectively. Older adults may not have enough body mass to retain body heat. Both age groups may be unable to help themselves stay warm by removing themselves from the cold environment or by protecting themselves with warmer clothing. In addition, many older adults have impaired circulation. \uf0a7 Medical conditions. People with certain medical conditions, such as generalized infection, hypoglycemia, shock and head injury, may be at higher risk of developing hypothermia. \uf0a7 Alcohol, drugs and poisoning. Alcohol and certain types of drugs or poisons can reduce a patient\u2019s ability to feel the cold, or can cloud judgment and impede rational thought, preventing the patient from taking proper precautions to stay warm. \uf0a7 Clothing inappropriate for the weather.",
        "CRITICAL FACTS 5": "In cases of heat stroke, call for more advanced medical personnel immediately. Your next priority is to begin rapid cooling methods, such as cold water immersion. The quicker you can get the body temperature down, the better the outcome. Hypothermia is the state of the body being colder than the usual core temperature. It is caused by either excessive loss of body heat and/or the body\u2019s inability to produce heat.",
        "Signs and Symptoms of Hypothermia": "The signs and symptoms of hypothermia include:\n\uf0a7 Shivering (may be absent in later stages of hypothermia).\n\uf0a7 Numbness.\n\uf0a7 Glassy stare.\n\uf0a7 Apathy or decreasing LOC.\n\uf0a7 Weakness.\n\uf0a7 Impaired judgment.\nIn cases of severe hypothermia, the patient may be unconscious. Breathing may have slowed or stopped. The body may feel stiff as the muscles become rigid.",
        "Providing Care for Hypothermia": "Your priority is to move the patient into a warmer environment, if possible. Be careful to move the patient gently, as any sudden movements can cause a heart arrhythmia and possibly cardiac arrest. Then:\n\uf0a7 Perform a primary assessment, including a pulse check for up to 30 to 45 seconds based on local protocols.\n\uf0a7 Call for more advanced medical personnel.\n\uf0a7 Remove any wet clothing and dry off the patient.\n\uf0a7 Passively rewarm the patient by wrapping all exposed body surfaces with anything at hand, such as warm blankets, clothing or newspapers. Be sure to also cover the head, since a 9\u02da-9\u02da 32\u02da",
        "CRITICAL FACTS 6": "For hypothermia, your first priority is to move the patient to a warmer environment. Other critical care steps include removing wet clothing, drying the patient, passively rewarming the patient with dry clothes or blankets, giving the patient warm liquids, administering supplemental oxygen based on local protocols and monitoring the patient\u2019s condition.",
        "Hypothermia": "A significant amount of body heat is lost through the head. If you are far from definitive healthcare, you may begin active rewarming. Place the patient near a heat source and apply heat pads, hot water bottles or chemical hot packs lightly wrapped in a towel or fabric to the wrists, ankles, armpits, groin and back of the neck to warm the blood in major blood vessels. Active rewarming should not delay definitive care. Do not immerse the patient in warm water. Do not rub or massage the extremities. Give warm, not hot, liquids that do not contain alcohol or caffeine if the patient is alert and able to swallow. Provide supplemental oxygen based on local protocols. Monitor the patient\u2019s condition. Capillary refill is affected by cold environments, so refill may be slow and therefore may not be an ideal method for assessing circulation. For more on capillary refill, see Chapters 7 and 8. Continue to warm the patient. Be prepared to perform CPR and use an automated external defibrillator (AED), if necessary.",
        "Frostbite (Localized Cold Exposure)": "Frostbite is the freezing of body tissues, usually the nose, ears, fingers or toes. In both superficial and deep frostbite, the situation is serious and could result in loss of the body part. In fact, frostbite of the fingers and toes can cause enough damage to warrant amputation of hands and feet, and even arms and legs. In early (or superficial) frostbite, only the first layers of skin are frozen. In late (or deep) frostbite, the skin and underlying tissues are frozen.",
        "Signs and Symptoms of Frostbite": "Signs and symptoms of frostbite include: Lack of feeling in the affected area. Swelling. Skin that appears waxy, is cold to the touch or is discolored (flushed, white, yellow, blue or black). In more serious cases, blisters may form and the affected part may turn black and show signs of deep tissue damage.",
        "CRITICAL FACTS 7": "Frostbite is the freezing of body tissues, usually the nose, ears, fingers or toes. Frostbite can cause serious damage, including loss of the body part or the need for amputation.",
        "Providing Care for Frostbite": "As with hypothermia, the priority is to get the patient out of the cold. Once the patient is removed from the cold, you should also do the following: \uf0a7 Handle the area gently. Rough handling can damage the body part. Never rub the affected area, as this can cause skin damage. \uf0a7 If there is a chance the body part may refreeze or if you are close to a medical facility, do not attempt to rewarm the frostbitten area. \uf0a7 For minor frostbite, rapidly rewarm the affected part using skin-to-skin contact such as with a warm hand. \uf0a7 For a more serious injury, rewarm the body part by gently soaking it in water not warmer than about 105\u00b0 F (41\u00b0 C). If you do not have a thermometer, test the water temperature yourself. If the temperature is uncomfortable to your touch, it is too warm. Keep the frostbitten part in the water until normal color returns and it feels warm (for 20 to 30 minutes). \uf0a7 Loosely bandage the area with dry, sterile dressings. \uf0a7 If the fingers or toes are frostbitten, place dry, sterile gauze between them to keep them separated. If the damage is to the feet, do not allow the patient to walk. \uf0a7 Avoid breaking any blisters. \uf0a7 Take precautions to prevent hypothermia. \uf0a7 Monitor the person and care for shock. \uf0a7 Do not give any ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs) when caring for frostbite.",
        "CRITICAL FACTS 8": "Your priority in caring for a frostbite patient is getting the patient out of the cold. Handle the frostbitten area carefully. Rewarm in warm water, but only if there is no risk of the body part refreezing and you are not close to a medical facility. Loosely bandage the area. If fingers and toes are frostbitten, place dry, sterile gauze between them. Avoid breaking blisters and take precautions to prevent hypothermia.",
        "PREVENTING HEAT-RELATED ILLNESSES AND COLD-RELATED EMERGENCIES": "Generally, illnesses caused by overexposure to extreme temperatures are preventable. The easiest way to prevent illness caused by temperature extremes is to avoid being outside during the parts of the day when temperatures are most extreme. For instance, if working outdoors in hot weather, it is safer if the work can be done in the early morning and evening hours when the sun is not as strong. In cold weather, outside work is safer during the warmer part of the day. Appropriate clothing for the weather and activity level adds protection against illness. It is best to wear light-colored clothing in the heat, which helps reflect the sun\u2019s rays. In the cold, the best clothing is made of tightly woven fibers, such as wool, to trap warm air against the body. Head coverings should be worn in both heat and cold. A hat or cap protects the head from the sun\u2019s rays in the summer and prevents heat from escaping in the winter. Also, other areas of the body, such as the fingers, toes, ears and nose, should be protected from cold exposure by wearing protective coverings. Take additional precautions, such as changing activity level and taking frequent breaks. For instance, in very hot conditions, it is best to exercise only for brief periods, then rest in a cool, shaded area. Frequent breaks allow the body to readjust to normal body temperature, enabling it to better withstand brief periods of exposure to temperature extremes. Avoid heavy exercise during the hottest or coldest part of the day. Extremes of temperature promote fatigue, which hampers the body\u2019s ability to adjust to changes in the environment. Whether in the heat or cold, it is important to drink enough fluids. Drinking at least six 8-ounce glasses of fluids daily is the most important way to prevent heat-related illness and cold-related emergency. It is best to drink fluids when taking a break. Drink cool fluids in the summer and warm fluids in the winter. Cool and warm fluids help the body maintain a normal temperature. If cool or warm drinks are not available, drink plenty of water. Avoid beverages containing caffeine or alcohol, which hinder the body\u2019s temperature-regulating mechanism.",
        "ANAPHYLAXIS": "Severe allergic reactions to poisons are rare, but when one occurs, it is truly a life-threatening medical emergency. This reaction, called anaphylaxis, is a form of shock. It can be caused by an insect bite or sting, or contact with certain drugs, medications, foods and chemicals. Anaphylaxis can result from any of the four modes of poisoning (ingested, inhaled, absorbed and injected) described in Chapter 15. Every year in the United States, fewer than 100 deaths are caused by anaphylaxis. Fortunately, some deaths can be prevented if anaphylaxis is recognized immediately and cared for quickly.",
        "Allergic Reactions": "Our immune systems help to keep us healthy by fighting off harmful pathogens that can cause disease. But sometimes our immune systems overreact and try to fight off ordinary things that are not usually harmful, such as certain foods, grass or pet dander (tiny flakes of skin that animals shed). A person can have an allergy to almost anything. Common allergens (allergy triggers) include venomous insect stings, certain foods, animal dander, plant pollen, certain medications (such as penicillin and sulfa drugs) and latex. Over 15 million people in the United States have food allergies. Every year in the United States, over 200,000 visits to emergency departments are because of food-related allergies. Certain types of food commonly cause an allergic reaction in individuals with sensitivities to those foods. Peanuts and tree nuts cause the most cases of fatal and near-fatal allergic reactions to food. Other common food allergens include cow\u2019s milk, eggs, seafood (especially shellfish), soy and wheat.",
        "Signs and Symptoms of Anaphylaxis": "An allergic reaction can range from mild to very severe. A person who is having a mild to moderate allergic reaction may develop a skin rash, a stuffy nose, or red, watery eyes. The skin or area of the body that came into contact with the allergen usually swells and turns red. A person who is having a severe, life-threatening allergic reaction (anaphylaxis) may develop one or more of the following signs and symptoms within seconds or minutes of coming into contact with the allergen:\n\uf0a7 Trouble breathing\n\uf0a7 Swelling of the face, neck, tongue or lips\n\uf0a7 A feeling of tightness in the chest or throat\n\uf0a7 Skin reactions (such as hives, itchiness or flushing)\n\uf0a7 Stomach cramps, nausea, vomiting or diarrhea\n\uf0a7 Dizziness\n\uf0a7 Loss of consciousness\n\uf0a7 Signs and symptoms of shock (such as excessive thirst; skin that feels cool or moist and looks pale or grayish; an altered level of consciousness; and a rapid, weak heartbeat)\nTo determine if a patient is having a severe, life-threatening allergic reaction (anaphylaxis), look at the situation as well as the patient\u2019s signs and symptoms (Table 16-1).",
        "Care for Anaphylaxis": "If you know that the patient has had a severe allergic reaction before, and the patient is having trouble breathing or is showing signs and symptoms of anaphylaxis, call for more advanced medical personnel. If the patient carries medication (e.g., epinephrine) used for the emergency treatment of anaphylaxis, offer to help them use the medication. If you are alone, help the patient administer the medication and then call for additional resources. While you wait for advanced medical personnel to arrive, make sure the patient is sitting in a comfortable position, or have the patient lie down if they are showing signs of shock.",
        "Epinephrine": "Epinephrine is a drug that slows or stops the effects of anaphylaxis. If a patient is known to have an allergy that could lead to anaphylaxis, they may carry an epinephrine auto-injector (a syringe system, available by prescription only, that contains a single dose of epinephrine). Devices are available containing different doses because the dose of epinephrine is based on weight (0.15 mg for children weighing between 33 and 66 pounds, and 0.3 mg for children and adults weighing more than 66 pounds). Many healthcare providers advise that people with a known history of anaphylaxis carry an anaphylaxis kit containing at least two doses of epinephrine (i.e., two auto-injectors) with them at all times. This is because more than one dose may be needed to stop the anaphylactic reaction. A second dose is administered only if emergency medical responders are delayed and the patient is still having signs and symptoms of anaphylaxis 5 to 10 minutes after administering the first dose. It is important to act fast when a patient is having an anaphylactic reaction because difficulty breathing and shock are both life-threatening conditions. If the patient is unable to self-administer the medication, you may need to help. You may assist a patient with using an epinephrine auto-injector when the patient has a previous diagnosis of anaphylaxis and has been prescribed an epinephrine auto-injector; the patient is having signs and symptoms of anaphylaxis; the patient requests your help using an auto-injector; and your state laws permit giving assistance. Where state and local laws allow, some organizations (such as public safety agencies or schools) keep a stock epinephrine auto-injector for designated staff members who have received the proper training to use it in an anaphylaxis emergency. If you are using a stock epinephrine auto-injector, follow your organization\u2019s emergency action plan, which may include verifying that the patient is showing signs and symptoms of anaphylaxis, ensuring that the patient has been prescribed epinephrine in the past as appropriate and making sure to use a device containing the correct dose based on the patient\u2019s weight.\nDifferent brands of epinephrine auto-injectors are available, but all work in a similar fashion. Begin by holding the patient\u2019s leg firmly just above the knee to help prevent injury to the patient, and then activate the device by pushing it against the patient\u2019s mid-outer thigh. Once activated, the device injects the epinephrine into the thigh muscle. The device must be held in place for the recommended amount of time (e.g., 3 seconds, although the recommended time may vary by device) to deliver the medication. Some medication may still remain in the auto-injector even after the injection is complete. After removing the auto-injector, massage the injection site for several seconds (or have the patient massage the injection site). Handle the used device carefully to prevent accidental needlestick injuries. When placing the used auto-injector in a sharps container, hold it with one hand and avoid touching. the tip. If a sharps container is not available, give the auto-injector to the transporting EMS personnel when they arrive so they can properly dispose of the discharged device. For step-by- step instructions on helping a patient to use an epinephrine auto-injector, see Skill Sheet 16-1. If a patient is awake and able to use the auto- injector, help them in any way they ask you to. This might include getting the auto-injector from a purse, car, home, or out of a specially designed carrier or belt; taking it out of the plastic tube; or assisting with or administering the injection.",
        "BITES AND STINGS - Insects": "Between 0.5 and 5 percent of the American population is severely allergic to substances in the venom of bees, wasps, hornets and yellow jackets. For highly allergic people, even one sting can result in anaphylaxis, a life-threatening condition. Such highly allergic reactions account for an average of 34 reported deaths from insect stings each year. For most people, however, insect stings may be painful or uncomfortable but are not life threatening.",
        "Providing Care for an Insect Sting": "To care for an insect sting, follow standard precautions and examine the sting site to see if the stinger is in the skin. Remove it, if it is still present. Scrape the stinger away from the skin with the edge of a tongue depressor or plastic card, such as a credit card. With a bee sting, the venom sac may still be attached to the stinger and can continue to release venom for up to several minutes afterward. Do not use tweezers to grasp the stinger or the venom sac that could still be attached to the stinger. Grasping the stinger or venom sac could squeeze it, resulting in more venom being released. Cleanse the site and cover with a dressing. A cold pack may be applied to the area to reduce pain and swelling. Ask if the patient has any history of allergies to insect bites or stings and observe for signs of an allergic reaction, even if there is no known history. An allergic reaction can range from a minor localized skin rash to anaphylaxis. Look for signs of anaphylaxis, including:\n\uf0a7 Difficulty breathing, wheezing or shortness of breath.\n\uf0a7 Tight feeling in the chest and throat.\n\uf0a7 Swelling of the face, neck or tongue.\n\uf0a7 Weakness, dizziness or confusion.\n\uf0a7 Rash or hives.\n\uf0a7 Low blood pressure.\n\uf0a7 Shock.\nIf anaphylaxis occurs, provide emergency care immediately, including assisting with the patient\u2019s prescribed epinephrine auto-injector or administering an epinephrine auto-injector, if local protocols allow. Administer supplemental oxygen based on local protocols and call for more advanced medical personnel.",
        "CRITICAL FACTS 9": "In the United States, up to 5 percent of the population is severely allergic to insect stings. Such allergic reactions account for approximately 34 reported deaths each year. If anaphylaxis occurs, provide emergency care immediately, including assisting with the patient\u2019s epinephrine auto-injector or administering an epinephrine auto-injector if local protocols allow. Administer supplemental oxygen based on local protocols, and call for more advanced medical personnel.",
        "BITES AND STINGS - Ticks": "Ticks can contract, carry and transmit serious diseases to humans. These include Rocky Mountain spotted fever and Lyme disease. For signs and symptoms of these diseases, see Table 16-2.",
        "Providing Care for Tick Bites": "If a tick is still embedded in the skin, it must be removed. With a gloved hand, grasp the tick with fine-tipped, pointed, nonetched, nonrasped (smooth inside surface) tweezers as close to the skin as possible. Pull slowly, steadily and firmly. \uf0a7 Do not try to burn the tick off. \uf0a7 Do not apply petroleum jelly or nail polish to the tick. Place the tick in a jar containing rubbing alcohol to kill it. Clean the bite area with soap and water, and apply antiseptic or antibiotic ointment if protocols allow and the patient has no known allergies or sensitivities to the medication. Advise the patient to seek medical advice, because of the risk of contracting a tickborne disease. If the tick cannot be removed, the patient should seek more advanced medical care.",
        "Infections from Ticks - Rocky Mountain spotted fever": "Fever, nausea, vomiting, muscle pain, lack of appetite, severe headache, rash, abdominal pain, joint pain and diarrhea",
        "Infections from Ticks - Babesia infection": "Nonspecific flu-like symptoms, such as fever, chills, sweats, headache, body aches, loss of appetite, nausea or fatigue, and anemia which can lead to jaundice and dark urine",
        "Infections from Ticks - Ehrlichiosis": "Fever, headache, fatigue, muscle aches, nausea, vomiting, diarrhea, cough, joint pains, confusion and occasional rash",
        "Infections from Ticks - Lyme disease": "Fever, headache, fatigue and a characteristic skin rash (e.g., \u201cbull\u2019s-eye\u201d)",
        "BITES AND STINGS - Spiders and Scorpions": "Few spiders in the United States have venom that causes serious illness or death. However, the bites of black widow and brown recluse spiders. The venom of recluse spiders (known as brown recluse, fiddle back or violin) is necrotizing (tissue destroying), while the venom of widows (black, red and brown) contains neurotoxin and affects neuromuscular function. Symptoms will vary depending on the amount of venom injected and the patient\u2019s sensitivity to the venom. Most spider bites resolve on their own with no adverse effects or scarring. Signs and symptoms of venomous spider bites can mimic other conditions. The only sure way of knowing a person has been bitten by a spider is to have witnessed it. Bites usually occur on the hands and arms of people reaching into places where spiders are residing. The bite of the black widow spider and its relatives is the more painful and often the more deadly, especially in very young and older adult patients. The bite usually causes an immediate sharp pinprick pain, followed by a dull pain in the area of the bite. Sometimes, however, no pain is felt initially. Other signs and symptoms may include muscular rigidity in the shoulders, chest, back and abdomen; restlessness; anxiety; dizziness, headache and profuse sweating; weakness; and drooping or swelling of the eyelids. A brown recluse spider bite may produce little or no pain initially, but localized pain develops an hour or more later. The brown recluse is also called the \u201cfiddle back\u201d or \u201cviolin\u201d spider because of the distinctive violin-shaped pattern on the back of its front body section. A blood-filled blister forms under the surface of the skin, sometimes in a target or bull\u2019s-eye pattern. Over time, the blister increases in size and eventually ruptures, leading to tissue necrosis (destruction) and a black scab. Another potentially dangerous spider is the northwestern brown, or hobo, spider. It can produce an open, slow-healing wound similar to that of the brown recluse. An antivenom to counteract the poisonous effects of the venom is available for black widow bites. Antivenom is used mostly for children and older adults, and is rarely necessary when bites occur in healthy adults. Scorpions typically live in dry regions of the southwestern United States and Mexico, but they are also common in other southern regions of the United States including Florida. They are usually about 3 inches long and have 8 legs and a pair of crablike pincers.",
        "BITES AND STINGS - Scorpions": "A scorpion is a stinger, used to inject venom. Scorpions live in cool, damp places, such as basements, junk piles, woodpiles and under the bark of living or fallen trees. They are most active in the evening and at night, which is when most stings occur. Like spiders, only a few species of scorpions have a potentially fatal sting, and these are mostly found in the southwest. Scorpions from the southeastern part of the country are usually nonpoisonous. Their sting can cause localized allergic reactions similar to a bee sting and can be cared for in the same way. However, because it is difficult to distinguish highly poisonous scorpions from nonpoisonous scorpions, all scorpion stings should be treated as medical emergencies. If it is possible and safe to do so, carefully attempt to capture the scorpion so that it could possibly be identified as poisonous or nonpoisonous by the Poison Control Center.",
        "General signs and symptoms of spider bites and scorpion stings": "A mark indicating a possible bite or sting. Severe pain in the sting or bite area. A blister, lesion or swelling at the entry site. Nausea and vomiting. Stiff or painful joints. Chills or fever. Difficulty breathing or swallowing or signs of anaphylaxis. Sweating or salivating profusely. Irregular heart rhythms. Muscle aches or severe abdominal or back pain. Dizziness or fainting. Chest pain. Elevated blood pressure and heart rate. Infection of the bite.",
        "Providing Care for Spider Bites and Scorpion Stings": "If a patient has been bitten by a spider or stung by a scorpion, wash the wound thoroughly and bandage it. Additionally, consider applying a topical antibiotic ointment to the bite to prevent infection, if protocols allow and the patient has no known allergies or sensitivities to the medication. Apply a cold pack to the site to reduce swelling and pain. The patient should seek medical attention or, if severe symptoms are present, should be transported to a medical facility, keeping the bitten area elevated and as still as possible.",
        "BITES AND STINGS - Venomous Snakes": "Snakebites kill few people in the United States. Of the estimated 7000 to 8000 people reported bitten annually, fewer than five die. Most deaths occur because the person has an allergic reaction, is in poor health or because too much time passes before the person receives medical care. Rattlesnakes account for most snakebites and nearly all deaths from snakebites.",
        "Signs and symptoms of a venomous snakebite": "One or two distinct puncture wounds, which may or may not bleed. The exception is the coral snake, whose teeth leave a semicircular mark. Severe pain and burning at the wound site immediately after or within 4 hours of the incident. Swelling and discoloration at the wound site immediately after or within 4 hours of the incident.",
        "CRITICAL FACTS 10": "If a patient has been bitten by a spider or stung by a scorpion, wash and bandage the wound. Consider applying a topical antibiotic if no known allergies or sensitivities to the medication exist and local protocols allow. Apply a cold pack to reduce swelling and pain. The patient should seek medical attention. Severe symptoms require immediate transportation to a medical facility. While seeking more advanced medical attention, keep the bitten area elevated and as still as possible.",
        "Providing Care for Snakebites": "If the bite is from a venomous snake such as a rattlesnake, copperhead, cottonmouth or coral snake, call for more advanced medical personnel. To give care until help arrives:\n\uf0a7 Wash the site with soap and water. Keep the injured area still and lower than the heart. Consider splinting the extremity if feasible. The patient should walk only if absolutely necessary.\n\uf0a7 For any snakebite:\n\tyDo not apply ice.\n\tyDo not cut the wound.\n\tyDo not apply suction.\n\tyDo not apply a tourniquet.\n\tyDo not use electric shock, such as from a car battery.While considered controversial based on available evidence, some local protocols recommend the use of a pressure immobilization bandage (elastic bandage) to slow the spread of venom through the lymphatic system for all venomous snakes in North America. However, evidence supports the use of a pressure immobilization bandage only for the coral snake when access to advanced care and antivenom is delayed. To apply a pressure immobilization bandage follow these steps:\n\uf0a7 Check for feeling, warmth and color of the limb and note changes in skin color and temperature.\n\uf0a7 Place the end of the bandage against the skin and use overlapping turns.\n\uf0a7 The wrap should cover a long body section, such as an arm or a calf, beginning at the point farthest from the heart. For a joint, such as the knee or ankle, use figure-eight turns to support the joint.",
        "CRITICAL FACTS 11": "To care for a venomous snakebite, wash the wound and keep the injured area still and lower than the heart. For any snakebite, never apply ice, cut the wound, apply suction, apply a tourniquet or administer an electric shock.",
        "Marine-Life Stings": "The stings of some forms of marine life are not only painful but can also make you sick and, in some parts of the world, can kill you (Table 16-3). The side effects include allergic reactions that can cause breathing and heart problems, as well as paralysis and death. The lifeguards and public safety officials in your area should know the types of marine life that may be present.",
        "Signs and Symptoms of Marine-Life Stings": "Signs and symptoms of marine-life stings include:\n\uf0a7 Rash, which may be red, raised or purplish in the shape of tentacles.\n\uf0a7 Tentacles stuck to the skin.\n\uf0a7 Puncture wounds (from stingrays or sea urchins).\n\uf0a7 Pain or itching.\n\uf0a7 Swelling.\n\uf0a7 Signs and symptoms of an allergic reaction.",
        "Providing Care for Marine-Life Stings": "Call for advanced life support resources if the patient does not know what stung them, has a history of allergic reactions to marine-life stings, is stung on the face or neck, or starts to have trouble breathing. Additional steps to take if you encounter someone who has sustained a marine-life sting include:\n\uf0a7 Get a lifeguard to remove the patient from the water as soon as possible. If a lifeguard is not available, use a reaching assist, if possible. Avoid touching the patient with your bare hands, which could expose you to the stinging tentacles.\n\uf0a7 Use gloves or a towel when removing any tentacles. A credit card edge or shell can be used to gently scrape away remaining tentacles.\n\uf0a7 If you know the sting is from a jellyfish, irrigate the injured part with large amounts of seawater as soon as possible for at least 30 seconds. This can help to remove the tentacles and stop the injection of venom.\n\uf0a7 Do not rub the wound or apply a pressure immobilization bandage, aluminum sulfate, meat tenderizer or other remedies because these may increase pain.\n\uf0a7 Once the stinging action is stopped and the tentacles are removed, care for pain by hot-water immersion. Have the patient take a hot shower if possible for at least 20 minutes. The water temperature should be as hot as can be tolerated (non-scalding) or about 113\u00b0 F (45\u00b0 C) if the temperature can be measured.\n\uf0a7 Pain from most jellyfish stings in U.S. waters resolves within 20 minutes. If pain persists, consider applying a topical over-the-counter lidocaine gel or cream.\n\uf0a7 If you know the sting is from a stingray, sea urchin or spiny fish, flush the wound with tap water. Seawater also may be used. Keep the injured part still and soak the affected area in non-scalding hot water (as hot as the patient can stand) for at least 20 minutes or until the pain goes away. If hot water is not available, packing the area in hot sand may have a similar effect if the sand is hot enough. Carefully clean the wound and apply a bandage. Watch for signs and symptoms of infection and check with a healthcare provider to determine if a tetanus shot or additional care is needed.",
        "CRITICAL FACTS 12": "The stings of some forms of marine life are not only painful, but they can make you sick, and in some parts of the world, can kill you. The side effects of a marine-life sting can include allergic reactions that can cause breathing and heart problems, as well as paralysis and death. For stingray, sea urchin or spiny fish stings, flush the wound with tap or ocean water, immobilize the injured part, and soak it in water as hot as the patient can stand for 30 minutes or until the pain subsides.",
        "Venomous Marine Life - Jellyfish": "East and west coasts of the continental United States",
        "Venomous Marine Life - Portuguese man-of-war (bluebottle jellyfish)": "Tropical and subtropical waters",
        "Venomous Marine Life - Stingray": "Tropical and subtropical waters",
        "Venomous Marine Life - Sea urchin": "Oceans all over the world (warm and cold water); found in rock pools and mud, on wave-exposed rocks, on coral reefs, in kelp forests and in sea grass beds",
        "Domestic and Wild Animals bites": "The bite of a domestic or wild animal carries the risk of infection, as well as soft tissue injury. Dog bites are the most common of all bites from domestic or wild animals.",
        "Providing Care for Animal Bites": "A patient who is bitten should be removed from the situation if possible, but only without endangering yourself or others. Do not restrain or capture the animal. Your concerns should be for your own safety and caring for the patient. Clean minor wounds with large amounts of saline or clean water and control any bleeding. The patient should be transported or advised to see a healthcare provider for more advanced medical care. If the wound is bleeding heavily, control the bleeding and transport the patient for further medical care. Tetanus and rabies immunizations may be necessary, so it is vital that bites from any wild or unknown domestic animals be reported to the local health department or other agency according to local protocols. Follow local protocols regarding contacting animal control to capture the animal. Try to obtain and provide a description of the animal and the area in which the animal was last seen.",
        "Humans bites": "Human bites are quite common and differ from other bites because they may be more contaminated, tend to occur in higher-risk areas of the body (especially on the hands) and often receive delayed care. Children are often the inflictors and the recipients of human bite wounds. As with animal bites, if the wound is minor, clean it with large amounts of saline or clean water and control any bleeding. Advise the patient to seek follow-up care by a healthcare provider or medical facility. If the bite is severe, control bleeding and prepare the patient for transport to a medical facility.",
        "WATER-RELATED EMERGENCIES - Drowning Incidents": "One of the most common water-related emergencies is drowning. Drowning occurs when a person experiences respiratory impairment due to submersion in water. Drowning may or may not result in death; however, it is the fifth most common cause of death from unintentional injury in the United States among all ages, and it rises to the second leading cause of death among those 1 to 14 years of age. More than 3500 Americans die annually from drowning, and more than 50 percent of drowning victims treated in emergency departments require hospitalization or transfer for further care. Children younger than 5 years of age have the highest rate of drowning.",
        "Drowning Incidents - Contributing Factors": "Drowning cannot just happen on its own. A person must be in a situation that causes the submersion. These situations include: \uf0a7 Young children left alone or unsupervised around water (e.g., tubs, pools, lakes). \uf0a7 Use of alcohol and recreational drugs, which may cause people to do things they otherwise would not. Traumatic injury, such as diving into a shallow body of water.\tCondition or disability, such as heart disease, seizure disorder or neuromuscular disorder, that may cause sudden weakness or loss of consciousness while in the water.\tHistory of mental illness; for example, depression, suicide attempt, anxiety or panic disorder.",
        "CRITICAL FACTS 13": "The bite of a domestic or wild animal carries the risk of infection, as well as soft tissue injury. Dog bites are the most common of all bites from domestic or wild animals. Clean minor wounds from animal bites and control bleeding. Patients should seek more advanced medical care. Heavy bleeding requires immediate control and transportation to a medical facility. Tetanus and rabies immunizations may be necessary. It is vital that wild or unknown domestic animal bites are reported to the local health department or other agency according to local protocols. Human bites are common, tend to be more contaminated than other bites and occur in higher-risk areas, and often receive delayed care. Caring for human bites is the same as for animal bites.",
        "WATER-RELATED EMERGENCIES - Severity": "Whether people die depends on how long they have been submerged and are unable to breathe. It also can depend on the temperature of the water. Children submerged in icy water have been successfully revived after considerable periods of time. Brain damage or death can begin to occur in as little as 4 to 6 minutes. The sooner the drowning process is stopped by getting the patient\u2019s airway out of the water, opening the airway and providing resuscitation (ventilations or CPR), the better the chances for survival without permanent brain damage. If the submersion lasts any longer, often the result is death. These times are estimates; brain damage and/or death can occur more quickly.",
        "Signs and Symptoms of Drowning": "Signs of a drowning incident include: \uf0a7 Persistent coughing. \uf0a7 Shortness of breath or no breathing at all. \uf0a7 Disorientation or confusion. \uf0a7 Unconsciousness, although the patient may have regained consciousness. \uf0a7 Vomiting. \uf0a7 Respiratory and/or cardiac arrest. Signs of a fatal drowning incident include: \uf0a7 Unconsciousness. \uf0a7 No breathing. \uf0a7 No pulse. \uf0a7 Rigor mortis. Because drowning victims may appear deceased when they are not (imperceptible heart rate and breathing), CPR and emergency efforts are recommended in all cases.",
        "Water Rescues": "Before beginning the rescue, consider the patient\u2019s condition, the condition of the water and the resources available once you get the patient on dry land. Also consider the responders\u2019 ability to affect a rescue safely. You should make every effort to assist without entering the water.",
        "Shallow Water Blackout": "The practice of voluntarily hyperventilating (extremely rapid or deep breathing) followed by holding one\u2019s breath and then swimming underwater or holding one\u2019s breath for extended periods of time is dangerous and can be fatal. Some swimmers use this technique to try to swim long distances underwater or to try to hold their breath for an extended period while submerged in one place. People mistakenly think that by taking a series of deep breaths in rapid succession and forcefully exhaling, they can increase the amount of oxygen they breathe, allowing them to hold their breath longer underwater. This is not true. Instead, it lowers the carbon dioxide level in the body. The level of carbon dioxide in the blood is what signals a person to breathe. When a person hyperventilates and then swims underwater, the oxygen level in the blood can drop to a point where the swimmer passes out before the carbon dioxide level is high enough to trigger the need to inhale. When the need to inhale finally does trigger instinctively, water rushes into the unconscious person\u2019s mouth and nose, causing laryngospasm and allowing the drowning process to begin. Even highly skilled swimmers can die from this practice.",
        "CRITICAL FACTS 14": "Contributing factors for submersion incidents include children left alone or unsupervised around or with access to water, use of alcohol and recreational drugs, traumatic injury, sudden illness or mental illness.",
        "Water Rescues - Patient\u2019s Condition": "Ask yourself the following questions: \uf0a7 Is the patient responsive and able to cooperate with the rescue? If so, the safest method may be a reaching or throwing assist, such as by using a pole or rope. \uf0a7 What position is the patient in? If the patient is submerged, basic life support will likely be needed right away. Submersion may also make it difficult to find the patient in murky or cloudy water. \uf0a7 Does the patient seem to be injured? If so, you may have to remove the patient from the water before providing care. \uf0a7 Is their condition potentially due to head or neck trauma (e.g., a diving incident)? If so, you may need to stabilize the spine while attempting to remove the patient from the water.",
        "Water Rescues - Condition of the Water": "There are several aspects of the water\u2019s condition that will influence how you respond to a water rescue, including: \uf0a7 Visibility. Are you able to see the patient and visualize any injuries? Are you able to see any hazards under the water? \uf0a7 Water temperature. You will need to continue resuscitation for a cold-water drowning until the patient is rewarmed at the hospital. Also, consider the type of clothing the patient is wearing. A wetsuit provides much more protection against hypothermia than do street clothes. \uf0a7 Movement of the water. How fast is the water flowing? Fast-flowing water can be deceivingly strong. If the water is above your knees, do not attempt to wade through without being harnessed. Otherwise, you could be swept away. Also, be aware that a patient\u2019s location can change in fast-moving water. \uf0a7 Depth of the water. Is the depth of the water such that you will be able to stand or will you require additional equipment? \uf0a7 Additional hazards. In floods or situations where a motor vehicle is submerged, there is the potential for exposure to a hazardous material, such as oil or gas. Hazardous materials may also escape from buildings in a flood.",
        "Water Rescues - Resources Available": "Determine what other resources are available to assist in a water rescue. Are you the only responder? Will there be several other responders available once you get the patient on dry land? Are they all able to swim? Are there sufficient personal flotation devices (PFDs) for each responder?",
        "Water Rescues - Rescuing the Victim": "People who drown are not always in easy-to-manage situations. If the patient is in the water, consider your own safety before all else when attempting a water rescue. As mentioned earlier, water rescues require special training and should only be attempted by those who are properly trained. To attempt a water rescue, you must be: \uf0a7 A good swimmer. \uf0a7 Specially trained in water rescue. \uf0a7 Wearing a PFD. \uf0a7 Accompanied by other qualified responders. If you are not trained in water rescue, do not attempt one unless the patient is conscious and close to shore and the emergency has taken place in open, shallow water with a stable bottom. Before entering the water, be sure you are secure so you will not be pulled in. Any sturdy object that can be grasped will do. Follow the \u201creach, throw, row then go\u201d technique. You can reach with an object, such as an oar, a sturdy branch or even a large towel. If the victim is too far for a reaching assist, you can throw out a floating object for the victim to hang on to, such as a life preserver or even an",
        "CRITICAL FACTS 15": "Submersion situations are not always easy to manage. Consider your own safety above all else when working on a water rescue. Water rescues require special training and should only be attempted by properly trained responders. To perform a water rescue, follow the \u201creach, throw, row then go\u201d technique. \u201cGo\u201d is only for those who are trained to perform deep-water rescue.",
        "Providing Care for Drowning": "Remove any victim of a drowning incident from the water as soon as possible. How and when to remove the victim depends on their overall condition (e.g., LOC), the victim\u2019s size, the potential for spinal injury, how soon help is expected to arrive and whether anyone can help. The priority in providing care in a water emergency is ensuring the patient\u2019s face (mouth and nose) is out of the water and appropriate care is given. Ventilations and/or CPR must be initiated immediately on an unresponsive patient who is not breathing and has no pulse. Ventilations may be started in the water; however, chest compressions cannot. If CPR is required, the patient must be removed from the water first. If a spinal injury is suspected, minimize movement to the spine, but priority must be given to airway management. Make sure additional personnel have been summoned. Follow local protocols for spinal motion restriction. This may include the application of a cervical collar (C-collar), as well as using a backboard or another extrication device to remove the patient from the water. Before you place the patient on the backboard, make sure there are enough responders helping you. Their role is to make sure the patient\u2019s face does not become submerged. Once the head and neck are stabilized, slide the board under the patient. Let the board float up until it is against the patient\u2019s back. Secure the patient to the backboard. Many patients who have been submerged vomit because water has entered the stomach or air has been forced into the stomach during ventilations. If the patient vomits, roll them onto their side to prevent aspiration or choking. To remove vomit from the mouth, use a finger or suction device. Always take patients who have been involved in a drowning incident to the hospital, even if you think the danger has passed. Complications can develop as long as 72 hours after the incident and may be fatal.",
        "PUTTING IT ALL TOGETHER": "Environmental emergencies include a wide range of situations that often occur during the course of everyday events. As an emergency medical responder (EMR), it is important you know how to identify the signs and symptoms of environmental emergencies and be able to provide appropriate care. Maintaining body temperature is vital for proper cell function. If the body temperature drops below or rises above the acceptable level, the body tries to protect itself but can only do so to a certain extent. If the body cannot protect itself, it begins to shut down. Therefore, it is crucial for you to be able to identify the various issues that can contribute to heat-related illnesses and cold-related emergencies, including who is at highest risk of falling ill and how to help a patient who is succumbing to such an emergency. While there are many thousands of species of snakes, spiders and insects, only a few are venomous and pose any danger to humans. Quick action by the EMR can minimize or reduce the effects of a sting or bite that has the potential to cause a serious reaction. Finally, with all the access to water in this country, be it a bathtub, a bucket full of water, a creek or the ocean, people are constantly exposed to the danger of drowning, particularly young children. As always, it is essential that EMRs ensure their own safety before they try to help others, so you must know your limits when it comes to water rescues. You cannot help a drowning person if you become a victim yourself. Drownings can be caused by other emergencies, such as a spinal injury or a cardiac arrest. An EMR must be prepared for any situation when it comes to water rescue.",
        "Administering an Epinephrine Auto-Injector": "After conducting a scene size-up, checking the patient, and calling for more advanced medical personnel:\n\n\u2022 Remove the auto-injector from the carrier tube or package, if necessary.\n\u2022 If applicable, confirm it is prescribed for the patient.\n\u2022 Check the expiration date. Do not use the auto-injector if it has expired.\n\u2022 If the medication is visible, confirm that the liquid is clear and not cloudy. If it is cloudy, do not use it.\n\u2022 Put on disposable latex-free gloves.\n\u2022 Make sure the patient is sitting or lying down.\n\nNOTE: These instructions are based on the EpiPen\u00ae. If using a different device, follow the manufacturer\u2019s instructions.\n\nSTEP 1: With the patient sitting or lying down, locate the outside middle of one thigh to use as the injection site. If injecting through clothing, ensure there are no obstructions (such as a pant seam, keys, or phone).\n\nSTEP 2: Grasp the auto-injector firmly in one fist and pull off the safety cap with your other hand. Hold the injector with the orange tip (needle end) pointing down. Pull the blue safety cap straight up without bending or twisting it. Do not put your thumb, fingers, or hand over either end of the auto-injector.\n\nSTEP 3: Hold the patient\u2019s leg firmly just above the knee to limit movement. Keep your hands away from the injection site.\n\nSTEP 4: Hold the auto-injector so that the needle end is against the patient\u2019s outer thigh at a 90-degree angle.\n\nSTEP 5: Quickly and firmly push the tip straight into the outer thigh. You should hear or feel a click, indicating activation.\n\nSTEP 6: Hold the injector in place for 3 seconds (counting: '1-1000, 2-1000, 3-1000') to deliver the medication.\n\nSTEP 7: Remove the injector and massage the injection area with gloved hands for 10 seconds.\n\nSTEP 8: Encourage the patient to remain seated and to lean forward to ease breathing. If signs of shock are present, encourage the patient to lie down and provide reassurance while waiting for EMS.\n\nSTEP 9: Handle the used auto-injector carefully and place it in a sharps container. If none is available, give it to EMS personnel for proper disposal.\n\nSTEP 10: Ensure more advanced medical personnel have been called if not already done. Monitor the patient:\n\u2022 Reassure the patient.\n\u2022 Ask how they feel.\n\u2022 Check their breathing.\nIf, after 5 to 10 minutes, EMS has not arrived and symptoms of anaphylaxis have not improved\u2014or improve then worsen\u2014administer a second dose in the other thigh.",
        "Lightning": "On average, lightning causes more deaths annually in the United States than any other weather hazard, including blizzards, hurricanes, floods, tornadoes, earthquakes and volcanic eruptions. The National Weather Service (NWS) estimates that lightning kills nearly 100 people annually and injures about 300 others. Lightning occurs when particles of water, ice and air moving inside a storm cloud lose electrons. Eventually, the cloud becomes divided into layers of positive and negative particles. Most electrical currents run between the layers inside the cloud. However, occasionally the negative charge flashes toward the ground, which has a positive charge. An electrical current travels back and forth between the ground and the cloud many times in the moment you see lightning flash. Anything with demonstrable height (e.g., a tower, tree or person) can provide a path for electrical current. Traveling at speeds of up to 300 miles per second, a lightning strike can hurl a person through the air, burn clothes off and cause the heart to stop beating. The most severe lightning strikes carry up to 50 million volts of electricity, enough to light 13,000 homes. Lightning can \u201cflash\u201d over a person\u2019s body or, in its more dangerous path, it can travel through blood vessels and nerves to reach the ground. Besides burns, lightning can also cause neurological damage, fractures and loss of hearing or eyesight. The patient sometimes acts confused and may describe the episode as getting hit on the head or hearing an explosion. People should use common sense during thunderstorms to prevent being struck by lightning. If a thunderstorm threatens, the NWS advises individuals to: \uf0a7 Postpone activities promptly and not wait for rain to begin. Thunder and lightning can strike without rain. \uf0a7 Go quickly inside a completely enclosed building, not a carport, open garage or covered patio. If no enclosed building is convenient, a cave is a good option outside, but move as far back as possible from the cave entrance. \uf0a7 Watch cloud patterns and conditions for signs of an approaching storm. \uf0a7 Designate safe locations and move or evacuate to a safe location at the first sound of thunder. Every 5 seconds between the flash of lightning and the sound of thunder equals 1 mile of distance. \uf0a7 Use the 30-30 rule where visibility is good and there is nothing obstructing your view of the thunderstorm. When you see lightning, count the time until you hear thunder. If that time is 30 seconds or less, the thunderstorm is within 6 miles. Seek shelter immediately. The threat of lightning continues for a much longer period than most people realize. Wait at least 30 minutes after the last clap of thunder before leaving shelter. \uf0a7 If inside during a storm, keep away from windows. Injuries may occur from flying debris or glass if a window breaks. \uf0a7 Stay away from plumbing, electrical equipment and wiring during a thunderstorm. Water and metal are both excellent conductors of electricity. \uf0a7 Do not use a corded telephone or radio transmitter except for emergencies. If people are caught in a storm outdoors and cannot find shelter, they should avoid: \uf0a7 Water. \uf0a7 High ground. \uf0a7 Open spaces, such as meadows, football fields and golf courses. \uf0a7 All metal objects, including electric wires, fences, machinery, motors and power tools. \uf0a7 Unsafe places, such as under canopies, under small picnic shelters or rain shelters, or near trees. If lightning is striking nearby when people are outside and cannot access shelter, they should:\n\uf0a7 Crouch down and limit the amount of the body that is touching the ground. Feet should be placed together. If possible, weight should be placed on only the balls of the feet. Hands can be placed over the ears to minimize possible hearing damage from thunder.\n\uf0a7 Avoid proximity to other people. A minimum distance of 15 feet between people should be maintained.\nIf there is a tornado alert, a previously specified location (as indicated by a disaster plan) should be located as soon as possible. This may be the basement or the lowest interior level of a building.",
        "SCUBA": "Barotrauma simply means pressure-related (baro) injury (trauma), and results from the inability to equalize the body\u2019s internal pressure with that of the external environment. The most frequent examples of barotrauma occur in air travel and SCUBA diving. The external pressure exerts a crushing type force on the body parts affected; hence the nickname, \u201clung squeeze.\u201d Barotrauma can affect multiple areas of the body. Signs and symptoms may vary depending on the body part or parts affected. The most common areas affected are the lungs, face and ears, with predominant signs and symptoms including pain in the affected area, disorientation, dizziness, nausea and bleeding from the mouth, nose or ears.",
        "Pulmonary Overinflation Syndrome": "Pulmonary Overinflation Syndrome (POIS), or Pulmonary Overpressure Syndrome, occurs because gases under pressure (including air) contract and take up less volume. The air inhaled at depth will expand during ascent as the pressure decreases, and can go beyond the lungs\u2019 capacity. If a SCUBA diver holds their breath while ascending, the lungs can rupture, hence the common name \u201cburst lung.\u201d POIS can also result in arterial gas embolism, as the excess volume of air created on ascent can be forced into the bloodstream and travel to the brain. Signs and symptoms may include numbness or tingling of the skin, weakness, paralysis and loss of consciousness. Under pressure, inert gases from inhaled air\u2014mostly nitrogen\u2014are absorbed into body tissues at higher concentration than normal. The longer time spent at depth, the more this occurs. In addition, at increased depths, more gases are forced into body fluids and tissues due to the increased pressure.",
        "Decompression Sickness": "Decompression sickness occurs when a diver ascends too quickly, without sufficient time for gases to exit body tissues and be removed from the body through exhalation. These gases expand as pressure decreases during ascent, creating bubbles in the body. Decompression sickness is often called \u201cthe bends\u201d because when these bubbles occur in joints (specifically the elbow, shoulder, knee and/or hip), the joint(s) involved feels better when held bent rather than held straight. Type I decompression sickness signs and symptoms include: \uf0a7 Rash. \uf0a7 Dull, deep and/or throbbing pain in the body tissues or joints. \uf0a7 Itching or burning sensation of the skin or bubbles under the skin (subcutaneous emphysema). Type II signs and symptoms can have delayed onset of up to 36 hours and include the following: \uf0a7 Pulmonary problems, such as: yA burning sensation in the chest upon inhalation yNon-productive coughing yRespiratory distress \uf0a7 Hypovolemic shock and neurological symptoms",
        "Nitrogen Narcosis": "Another common danger to recreational divers is nitrogen narcosis. This condition occurs at depths over 100 feet when the pressure causes nitrogen to dissolve into brain nerve membranes. This causes a temporary disruption in nerve transmission, resulting in an altered LOC similar to intoxication. It is particularly dangerous because, like any type of intoxication, judgment is impaired and bad judgment underwater can lead to the conditions mentioned above or drowning.",
        "Free Diving": "Free diving is an extreme sport in which divers compete to see how deep they can dive without any underwater breathing apparatus. This is accomplished through excessive breath holding and hyperventilation. It is a dangerous activity because of the risk of loss of consciousness due to lack of oxygen to the brain (hypoxia), and subsequent drowning. Some divers utilize buoyancy devices to pull them to the surface if they lose consciousness, but this is not a reliable method of getting to oxygen in time. Other conditions associated with free diving include barotrauma, ear perforation, nitrogen narcosis and drowning.",
        "Free Diving - Providing Care": "All of the conditions mentioned above are life threatening and require immediate medical attention. The diver needs immediate medical attention if they lose consciousness, show paralysis or show symptoms of stroke within 10 minutes of surfacing.\n\uf0a7 If the patient is alert, place them in a supine position.\n\uf0a7 If their mental state is altered, place the patient in a supine (face-up) position.\n\uf0a7 If a spinal injury is suspected, maintain spinal motion restriction.\n\uf0a7 If breathing appears adequate, administer supplemental oxygen, if available, based on local protocols.\n\uf0a7 If breathing is inadequate, begin positive pressure ventilation and log the exact time of oxygen delivery.\n\uf0a7 If needed, initiate ventilations or CPR and apply the AED.\n\uf0a7 Try to obtain the patient\u2019s diving log and bring it to the hospital. (Divers keep diving logs to mathematically track how long they have been at a given depth in order to avoid decompression sickness.)\n\uf0a7 Transport immediately or call for more advanced medical personnel.\n\uf0a7 Medical control will determine if the patient should be transported directly to a facility with a recompression (hyperbaric) chamber. The Divers Alert Network (DAN) maintains a list of recompression facilities and can be reached around the clock at 919-684-9111 or 919-684-4326 collect; you can also visit diversalertnetwork.org."
    },
    {
        "Introduction": "A poison is a substance that causes illness or death when eaten, drunk, inhaled, injected, or absorbed in relatively small quantities. This chapter covers the signs, symptoms, emergency care, and treatment of patients who have experienced accidental or intentional poisoning, bites or stings, or alcohol or substance abuse. You can save a patient\u2019s life by quickly recognizing and promptly treating a serious poisoning.",
        "Patient Assessment for Poisoning": "As an emergency medical responder (EMR), you need to be a good detective when caring for patients who have come in contact with poisons. Poisoning can be classified according to the way the poison enters the body. Poisons can enter the body by four primary routes: 1. Ingestion occurs when a poison enters the body through the mouth and is absorbed by the digestive system. 2. Inhalation occurs when a poison enters the body through the mouth or nose and is absorbed by the mucous membranes lining the respiratory system. 3. Injection occurs when a poison enters the body through a small opening in the skin and spreads through the circulatory system. Injection can occur as a result of an insect sting, a snakebite, or the intentional use of a hypodermic needle to inject a poisonous substance into the body. 4. Absorption occurs when a poison enters the body through intact skin and spreads through the circulatory system. Even though poisons can be introduced into the body by different routes, some of the effects of the poison on the body may be similar. In general, when you assess and treat patients who have been poisoned, begin with a thorough assessment that follows the patient assessment sequence. If you suspect poisoning, obtain a thorough history from the patient or from bystanders. A good history of the incident will help guide you in your patient assessment.\n\nBe alert for any visual clues that may indicate the patient has been in contact with a poison. These findings include traces of the substance on the patient\u2019s face and mouth (ingested poisons), traces of the substance on the skin (absorbed poisons), needle pricks or sting marks (injected poisons), and respiratory distress (inhaled poisons).\n\nMuch of the emergency care you provide will be based on the patient\u2019s signs and symptoms. A patient with a poisonous substance on the skin needs to have the substance removed, which may require special training or the assistance of a hazardous materials (HazMat) team. A patient who shows signs of respiratory distress needs to receive respiratory support. A patient who is exhibiting signs of digestive distress needs to receive support for that condition. Sometimes the patient\u2019s signs and symptoms will be less specific, and you will have to base your treatment on general signs and symptoms. The general signs and symptoms of poisoning are shown in Table 11-1.",
        "Table 11-1 General Signs and Symptoms of Poisoning": "Table 11-1 lists the general signs and symptoms of poisoning. Under **history**, there might be evidence of ingestion, inhalation, injection, or absorption of a poison. **Respiratory** symptoms include difficulty breathing or decreased respirations. **Digestive** signs can feature nausea and vomiting, abdominal pain, and diarrhea. From a **central nervous system** standpoint, patients may experience unconsciousness or altered mental status, pupil changes (dilation or constriction), and possible convulsions. **Other** signs include excess salivation, sweating, cyanosis, and the presence of empty containers at the scene.",
        "Safety": "Conduct a scene size-up (overview) of the scene to determine whether it is safe for you to enter. Be alert for odors. Look for containers close to the patient. If you believe the scene is unsafe, stay a safe distance away and call for specialized assistance.",
        "Special Populations": "The rate of deaths caused by drug poisoning varies widely across different age groups. In the past, the rate of deaths from accidental poisonings was higher in children between birth and age 12 years. The advent of child-resistant caps in the 1960s and other safety containers has significantly decreased poisoning deaths among children. According to the Centers for Disease Control and Prevention (CDC), the age-adjusted drug poisoning death rate has more than doubled between 2000 and 2013. Most of these deaths occur in adults and are the result of opioid overdose, such as hydrocodone, morphine, and oxycodone.",
        "Ingested Poisons": "An ingested poison is taken by mouth. More than 80% of all poisoning cases are caused by ingestion. Often, you will find chemical burns, odors, or stains around the patient\u2019s mouth. The person may also be experiencing nausea, vomiting, abdominal pain, or diarrhea. Later symptoms may include abnormal or decreased respirations, unconsciousness, or seizures.",
        "Signs and Symptoms of ingested poisons": "Signs and symptoms of ingested poisons include the following:\nUnusual breath odors\nDiscoloration or burning around the mouth\nNausea and vomiting\nAbdominal pain\nDiarrhea\nAny of the other signs and symptoms of poisoning listed in Table 11-1",
        "Treatment for Ingested Poisons": "To treat a person who has ingested a poison, do the following:\nIdentify the poison.\nCall the National Poison Center (1-800-222-1222) for instructions, and follow those instructions. If you are unable to contact the poison center, dilute the poison by giving large quantities of water, provided the patient is conscious and able to swallow.\nArrange for prompt transport to a hospital.\nWhen you encounter a patient who has ingested a poison, first attempt to identify the substance that has been ingested. Question the patient\u2019s family or bystanders and look for empty containers, such as empty pill bottles, that may indicate what the patient ate or drank. You should have the number of your local poison control center accessible in your EMR life support kit. The poison control center can tell you if you should start any treatment before the patient is transported to the hospital.",
        "Treatment": "Place an unconscious patient in the recovery position to help keep the airway open and to facilitate the drainage of mucus and vomitus from the mouth and nose.",
        "Special Populations_0": "Laundry detergent pods are a new category of cleaning product. Many people use them because they are premeasured, easy to handle, and do not spill. The coating on the pod dissolves in the wash, releasing the liquid detergent into the washing machine. These multicolored pods present a poisoning hazard for children, who may mistake them for candy and bite into them. Serious side effects can occur quickly and include difficulty breathing, severe vomiting, burns to the esophagus, and possible unconsciousness. In addition, the liquid detergent can cause burns to the skin and eyes. If a child bites into a detergent pod, immediately remove it from the child\u2019s mouth. Wash the child\u2019s face and hands. Gently wipe out the child\u2019s mouth. Call Poison Control for assistance and arrange for transport to an appropriate medical facility.",
        "Activated Charcoal": "Administering activated charcoal is another method of treating ingested poisons. Activated charcoal is a finely ground powder that is mixed with water to make it easier to swallow. It works by binding to the poison, thereby preventing the poison from being absorbed in the patient\u2019s digestive tract. Activated charcoal may be used by some emergency medical services (EMS) systems to treat poisonings if the nearest medical facility is a long distance away. However, give activated charcoal only if you are trained in its use and have approval from your medical director or your poison control center. Do not give activated charcoal if the patient is unconscious or if he or she has ingested an acid (a chemical substance with a pH level of less than 7.0 that can cause severe burns) or a base (a chemical that has a pH level greater than 7.0, also known as an alkali or caustic). An example of a base is liquid drain cleaner. The usual dose of activated charcoal for an adult patient is 25 to 50 grams. The usual dose for a pediatric patient is 12.5 to 25 grams. Because the mixture looks like mud, you can serve the mixture in a covered cup and give the patient a straw. This step may make it easier for the patient to drink.",
        "Treatment_1": "Two general treatments for poisoning by ingestion are as follows:\n1. Dilution using water\n2.Activated charcoal\nFollow the directions from your local poison control center or medical director.",
        "Vomiting": "Do not do anything to induce vomiting. In the past, syrup of ipecac was used to induce vomiting, but today, the American Association of Poison Control Centers does not endorse using ipecac in children or adults. It often can do more harm than good. Activated charcoal is considered more effective and safer than syrup of ipecac.",
        "Inhaled Poisons": "Poisoning by inhalation occurs if a toxic substance is breathed in and absorbed through the lungs. Some toxic substances such as carbon monoxide are poisonous but are not irritating to the respiratory tract. Carbon monoxide is an odorless, colorless, tasteless gas that cannot be detected by your normal senses. Other toxic gases such as chlorine gas and ammonia are irritating to the respiratory tract and will cause coughing and severe respiratory distress. These gases can be classified as irritants.",
        "Signs and Symptoms of inhaled poisons": "Signs and symptoms of inhaled poisons include the following: Respiratory distress Dizziness Cough Headache Hoarseness Confusion Chest pain Any other signs and symptoms of poisoning listed in Table 11-1",
        "Carbon Monoxide": "One of the most common causes of carbon monoxide poisoning is an improperly vented heating appliance, such as a space heater, grill, or generator. Carbon monoxide is also present in smoke. People caught in building fires often experience carbon monoxide poisoning. When a person inhales even a relatively small quantity of carbon monoxide gas, severe poisoning can result because carbon monoxide combines with red blood cells about 200 times more readily than oxygen does. Therefore, a small quantity of carbon monoxide can \u201cmonopolize\u201d the red blood cells and prevent them from transporting oxygen to all parts of the body.\n\nThe signs and symptoms of carbon monoxide poisoning include headache, nausea, disorientation, and unconsciousness. Low levels of carbon monoxide poisoning often cause signs and symptoms that are very similar to the flu. If you find several patients together who are all reporting these symptoms (especially in winter), suspect carbon monoxide poisoning and remove everyone from the structure or vehicle.",
        "Safety_3": "Residential carbon monoxide detectors have been installed in many homes. These detectors are designed to sound an alarm before the residents of the house show signs and symptoms of carbon monoxide poisoning. Once the residential carbon monoxide detector is activated, specially trained and equipped personnel must be summoned to investigate the source of the carbon monoxide and to verify that everyone is out of the building. Many newer detectors are combination alarms, which will activate in the presence of either smoke or carbon monoxide.",
        "Signs and Symptoms of carbon monoxide": "Signs and symptoms of carbon monoxide poisoning include the following:\nHeadache\nNausea\nDisorientation\nUnconsciousness\nMultiple people with flulike symptoms in the same location",
        "Irritants": "Many gases irritate the respiratory tract. Two of the more frequently encountered gases are: \n\n1. Ammonia. Inhalation of ammonia usually occurs in agricultural settings where it is used as a fertilizer. Ammonia is also a chemical that is used to manufacture amphetamine. It has a strong, irritating odor that is highly toxic. Inhaling large amounts of ammonia gas deadens the sense of smell and severely irritates the lungs and upper respiratory tract, causing violent coughing. Ammonia can also severely burn the skin. Anyone who enters an environment containing ammonia must wear a proper encapsulating suit with a self-contained breathing apparatus (SCBA). This apparatus contains a mask, regulator, and air supply and delivers air to rescuers when they enter contaminated areas.\n\n2.Chlorine Chlorine gas is commonly found in large quantities around swimming pools and water treatment plants. The odor of chlorine is familiar to anyone who has used chlorine bleach or been in a swimming pool or hot tub. Chlorine gas can severely irritate the lungs and the upper respiratory tract, causing violent coughing. Chlorine gas can also cause skin burns. Anyone who enters an environment containing chlorine gas must wear a proper encapsulating suit with a SCBA.",
        "Treatment for Inhaled Poisons": "The first step to take in treating a patient who has inhaled any poisonous gas is to remove him or her from the source of the gas. If the patient is not breathing, begin mouth-to-mask breathing. If the patient is breathing, administer large quantities of oxygen (if available and if you are trained to do so). Promptly transport any patient who has inhaled a poisonous gas to an appropriate medical facility for further examination because the patient may have a delayed reaction to the poison.\n\nIn some situations, your first response is to evacuate people. If you are called to the scene of a large poisonous gas leak (or other HazMat leak), you may have to evacuate large numbers of people to prevent further injuries. Once this has been done, begin to evaluate and treat the evacuees as necessary.",
        "Safety_5": "Do not venture into areas where poisonous gases may be present. Call an agency (such as the fire department) that is equipped with SCBA and other appropriate personal protective equipment. Be especially aware of the hidden dangers found in tanks, confined spaces, farm silos, sewers, and other below-ground structures. Every year, rescuers lose their lives by venturing into a silo, sewer, or pit to save a person who may already be dead. Often these calls are initially reported as a \u201csick person\u201d or a person who has experienced a \u201cheart attack.\u201d",
        "Injected Poisons": "The two major causes of poisoning by injection are (1) animal bites and stings and (2) toxic injection. This section covers animal bites and stings; toxic injection will be discussed later, as part of substance abuse. If a person has received a large amount of poison (for example, multiple bee stings) or if a person is especially sensitive to the poison (has an anaphylactic reaction), he or she may collapse and become unconscious.",
        "Signs and Symptoms of injected poisons": "Signs and symptoms of injected poisons from bites and stings include the following:\nObvious injury site (bite or sting marks)\nTenderness\nSwelling\nRed streaks radiating from the injection site\nWeakness\nDizziness\nLocalized pain\nItching",
        "Treatment for Insect Bites and Stings": "When a person has been bitten or stung by an insect, encourage the patient to keep calm and still. This step will help slow the spread of the poison throughout the patient\u2019s body. Wash the site with soap and water. Remove the stinger using gauze wiped over the area or by scraping a fingernail over the area. Never squeeze the stinger or use tweezers. Apply ice to reduce swelling, if available. Avoid scratching the sting as this may increase swelling, itching, and the risk of infection.\nSome people experience an extreme allergic reaction to stings and bites and may go into anaphylactic shock. The signs and symptoms of anaphylactic shock include itching; hives (patches of swelling, redness, and intense itching on the skin); swelling; wheezing and severe respiratory distress; generalized weakness; unconsciousness; rapid, weak pulse; and rapid, shallow breathing. The patient\u2019s blood pressure drops, and the patient may develop hypovolemic shock and go into cardiac arrest.\nYour first step should be to maintain the patient\u2019s airway, breathing, and circulation. Administer oxygen if available and if you are trained to do so. Treating the patient for shock may help in some cases. Remove the allergen if possible. Monitor the patient\u2019s vital signs. If the patient\u2019s condition progresses to the point of respiratory or cardiac arrest, begin mouth-to-mask breathing or cardiopulmonary resuscitation (CPR).\n\nIf a patient appears to be going into anaphylactic shock, immediately arrange for rapid transport to a medical facility where the patient can receive treatment with specific medications. Paramedics, nurses, and physicians can give medications that may reverse the allergic reaction. Some patients who have severe allergies carry an epinephrine auto-injector so they can give themselves a shot of epinephrine. If the patient has a prescribed auto-injector, help the patient to use it. Support the patient\u2019s thigh and place the tip of the auto-injector against the outer thigh. Using a quick motion, push the auto-injector firmly against the thigh and hold it in place for several seconds. You can administer epinephrine if you have been trained in its use and have permission from your local medical director. Be aware of and follow your local protocols.",
        "Treatment_7": "The complete steps for administering epinephrine by auto-injector are as follows:\n1. Remove the safety cap from the auto-injector. If possible, quickly clean the site with an alcohol pad, but do not delay administration of the drug. In extreme emergencies, it is possible to administer the auto-injector through the patient\u2019s clothing.\n2. Place the tip of the auto-injector against the lateral part of the patient\u2019s thigh, halfway between the groin and the knee.\n3. Push the injector firmly against the thigh until a click is heard. This sound indicates that the injector has activated and medication is being administered. Maintain steady pressure to prevent kickback from the spring in the syringe and to prevent the needle from being pushed out of the injection site too soon. Hold the injector in place for 10 seconds to administer all the medication.\n4. Remove the injector from the patient's thigh and dispose of it in the proper container.\n5. Rub the area for 10 seconds.\n6. Reassess the patient\u2019s vital signs. If vital signs do not improve after 5 minutes, consider administering a second dose of the medication if available.",
        "Snakebites": "There are four kinds of venomous snakes in the United States: rattlesnake, cottonmouth (water moccasin), copperhead, and coral snake. When a snake bites, it injects its venom into a person\u2019s skin and muscle with its fangs. This toxic venom can cause local injury to the skin and muscle and may even involve the entire extremity. Signs and symptoms may affect the entire body. A bite from a venomous snake is rarely fatal. The Centers for Disease Control and Prevention (CDC) estimate that 7,000 to 8,000 people per year receive venomous snakebites in the United States. Only about five people die from these bites each year. However, permanent injury can result if proper medical care is not obtained.",
        "Signs and symptoms of anaphylactic shock": "Signs and symptoms of anaphylactic shock include the following:\nItching all over the body\nHives, swelling\nGeneralized weakness\nUnconsciousness\nRapid, weak pulse\nRapid, shallow breathing",
        "Signs and symptoms of snakebites": "Signs and symptoms of snakebites include the following:\nImmediate pain at the bite site\nSwelling and tenderness around the bite site\nFainting (from the emotional shock of the bite)\nSweating\nNausea and vomiting\nShock\n\nThe bite of the coral snake delivers a slightly different venom that may cause these additional conditions\nRespiratory difficulties\nSlurred speech\nParalysis\nComa (state of unconsciousness from which the patient cannot be aroused)\nSeizures",
        "Treatment of Snakebites": "The field treatment of a poisonous snakebite is basically the same as the treatment of shock. Keep the patient calm and still; have the patient lie down and try to relax. This step can slow the spread of venom. Gently wash the bite area with soap and water. If the bite occurred on the arm or leg, splint the affected extremity to decrease movement. Place the splinted extremity below the level of the patient\u2019s heart to decrease the absorption of the poison. Treat the patient carefully and arrange for prompt transport to the hospital or appropriate medical facility. The only effective treatment of venomous snakebites is the administration of antivenin in the hospital.",
        "Absorbed Poisons": "Poisoning by absorption occurs when a poisonous substance enters the body through the skin. Insecticides and industrial chemicals are two common poisons absorbed through the skin. Common household products can also result in poisoning by absorption. For example, because aspirin is included as an ingredient in many common ointments, excess amounts can be absorbed and result in poisoning, especially in young children. A person experiencing poisoning by absorption may have both localized and systemic signs and symptoms.",
        "Signs and Symptoms of absorbed poisons": "Signs and symptoms of absorbed poisons include the following:\nTraces of powder or liquid on the skin\nInflammation or redness of the skin\nChemical burns\nRash\nBurning\nItching\nNausea and vomiting\nDizziness\nShock",
        "Treatment for Absorbed Poisons": "Your first step in treating a patient who has absorbed a poisonous substance through the skin is to ensure that the patient is no longer in contact with the toxic substance. Make sure that you do not come into contact with the poison. You may have to ask the patient to remove all clothing. Then brush off\u2014do not wash\u2014any dry chemical from the patient. Contact with water may activate the dry chemical and result in a burning or caustic reaction.\n\nAfter removing all the dry chemical, wash the patient completely for at least 20 minutes. Use any water source that is available: an industrial shower, a home shower, a garden hose, or even a fire engine\u2019s booster hose. Do not forget to wash out the patient\u2019s eyes if they have been in contact with the poison. If additional EMS personnel are delayed, contact the poison control center or your medical director for additional treatment information.\n\nIf the patient is experiencing shock, have the patient lie down. If the patient is having difficulty breathing, administer oxygen if it is available and you are trained to use it.",
        "Treatment_11": "When in doubt in absorbed poison situations, have the patient remove all clothing so that he or she is no longer in contact with the toxic substance.",
        "Nerve Agents": "Nerve agents represent a special type of poison that attack the central nervous system. These agents can be absorbed through the skin, inhaled, or injected. Nerve agents are among the most deadly chemicals developed. Small quantities of these chemicals can kill large numbers of people by causing cardiac arrest within minutes of exposure. Four of the most commonly mentioned nerve agents are sarin (GB), soman (GD), tabun (GA), and V agent (VX). Nerve agents were discovered by scientists who were in search of a superior pesticide; however, nerve agents are much stronger organophosphates than those found in insecticides. Nerve agents, like insecticides, block an essential enzyme in the nervous system. The symptoms listed in Table 11-2 can be remembered using the mnemonic SLUDGEM. Additional symptoms include shortness of breath; slow heart rate; muscle weakness or paralysis; slurred speech; seizures; and loss of consciousness. In the event you are called to the scene of an organophosphate or nerve agent poisoning, your primary responsibility is to keep yourself, other rescuers, and bystanders from becoming contaminated. A well-trained HazMat team in special protective equipment (SCBA and encapsulating suits) is needed to remove patients from the contaminated area and decontaminate them before they are turned over to you for treatment.\n\nTreatment of exposed patients includes assessing and supporting the patient\u2019s airway, breathing, and circulation. A nerve agent antidote kit called the DuoDote Auto-Injector can be administered to exposed patients or to yourself if you have become exposed. Use the DuoDote kit only if you or the patient have signs and symptoms of organophosphate or nerve agent poisoning (SLUDGEM). You must have the approval of your medical director and have received proper training in its use. Organophosphate and nerve agents may require large quantities of medication.\n\nThe DuoDote kit contains one auto-injector syringe that contains two drugs, atropine and pralidoxime chloride. The instructions for using this kit are listed in Table 11-3.",
        "Instructions for the Administration of a DuoDote Auto-Injector Kit": "1. Check the kit to be sure it contains the proper medication and that it has not expired. 2. Remove the gray protective cap. 3. Press the green end of the injector firmly against the lateral part of the patient\u2019s thigh. 4. Hold in place for 10 seconds to allow the medication to get into the muscle. 5. Dispose of the syringe in a medical sharps container. 6. Reassess the patient\u2019s vital signs and symptoms. *Follow your local protocols.",
        "Voices of Experience": "Based on our report, the ED physician contacted a pediatric hospital and had a life flight helicopter start to the hospital. Early in my EMS career, I was assigned to an advanced life support unit in a rural setting. We received a call for an accidental ingestion involving a 4-year-old child. While en route, the dispatcher informed us that the child had ingested a large quantity of amitriptyline, a tricyclic antidepressant. We had recently been issued cellular phones for our EMS units and I had made a list of important numbers. One of those numbers was the Georgia Poison Center. I called them while en route to the call and was able to get some valuable information from the toxicologist. On arrival, we found a lethargic child who responded to verbal stimulation. We began a rapid assessment and administered high-flow oxygen. An intravenous (IV) line was established and a normal blood glucose was obtained. We prepared the patient for rapid transport to our local critical access hospital because a pediatric hospital was over 45 miles (72 km) away and air transport was not readily accessible in those days. While en route, the child became unresponsive. We secured the airway with an endotracheal tube and began to assist ventilations. I made contact with medical control to get orders for treatment recommended by the toxicologist, which was not part of our standing orders. The emergency department (ED) physician agreed and we administered an injection of sodium bicarbonate followed by a bicarbonate drip. Based on our report, the ED physician contacted a pediatric hospital and had a life flight helicopter start to the hospital. The ED physician assessed the child on our arrival. The child\u2019s vital signs were stable and he was becoming more responsive. The child was sedated and prepared for air transport to the pediatric hospital. Thanks to some quick thinking and new technology, the child made a complete recovery.",
        "Substance Abuse": "Substance abuse is widespread in our society. According to the National Survey on Drug Use and Health, 8.1% of the US population (21.5 million people) have a substance use disorder; that is, they are dependent on alcohol or other drugs. Substance abuse results in an increased incidence of injuries and illness; therefore, many of your emergency calls will involve people who are under the influence of alcohol or other drugs. Even if the primary reason for the call is not substance abuse, it will still be a contributing factor in many calls.",
        "Alcohol": "Alcohol is the most commonly abused drug in the United States today. Alcohol intoxication may be seen in people of any age, including children, teenagers, and older adults. According to the National Institute on Alcohol Abuse and Alcoholism, nearly 88,000 people die from alcohol-related deaths each year, which makes it the fourth leading cause of preventable death in the United States. In 2014, alcohol-impaired driving fatalities accounted for 32% of all driving fatalities. More than 10% of US children live with a parent with alcohol-related problems. More than one-half of all murders and more than one-third of all suicides are alcohol-related. Deaths as a result of alcohol abuse are two and one half times as numerous as deaths from motor vehicle crashes. In addition, people who have been drinking can be injured or suddenly develop a serious illness. As an EMR, many of the patients you encounter will be under the influence of alcohol.\n\nWhen you have a patient who appears to be under the influence of alcohol, do not always assume that the symptoms (including the smell of alcohol on someone\u2019s breath) are caused by intoxication, because the symptoms of alcohol intoxication can be similar to those of other medical illnesses or severe injuries. If you are unsure about whether a patient who appears to be intoxicated has a serious injury or illness, be extra careful with your examination. Arrange for prompt transport to an appropriate medical facility, where a physician can make a complete assessment.\n\nAlcohol is an addictive, depressant drug. A person who is physically dependent on alcohol and then is suddenly deprived of it may develop withdrawal symptoms, such as convulsions or seizures. The most severe withdrawal symptoms are called delirium tremens (DTs). The signs and symptoms of DTs include shaking, restlessness, confusion, hallucinations, gastrointestinal distress, chest pain, and fever. These signs and symptoms usually appear 3 to 4 days after the person stops drinking. Arrange for prompt transport of a person suffering from DTs to an appropriate medical facility. DTs are a serious medical emergency and can be fatal.",
        "Words of Wisdom": "Public safety personnel are not immune to the seduction that draws people into addiction to alcohol and other drugs. If you are having a problem with alcohol or other drugs, seek help through your employee assistance program or through a self-help program such as Alcoholics Anonymous.",
        "Treatment_12": "Although a person may appear intoxicated, he or she actually may be experiencing any one of a number of serious illnesses or injuries. Insulin shock, diabetic coma, head injury, traumatic shock, and drug reactions may all display the same symptoms as alcohol intoxication.",
        "Drugs": "In today\u2019s society, people of all ages abuse many different prescription and illegal street drugs. Drugs may be ingested, inhaled, injected, or absorbed into the body. As an EMR, you may not be able to identify the type of drug used, although this information will be helpful to medical providers. As you perform your scene size-up, look for clues that can indicate what type of drug was used and how it was administered. Today, the most commonly encountered drugs fall into four categories: amphetamines, opioids (painkillers), hallucinogens, and inhalants.\n\nStatistics reported 47,055 deaths from drug poisoning in 2014. Of these, 82% were unintentional poisonings, 12% were suicides, and 6% were of undetermined causes. The drug poisoning rate was highest among adults aged 45 to 54 years. From 2000 to 2014, the age-adjusted poison death rate more than doubled from 6.2 deaths per 100,000 people to 14.7 deaths per 100,000 people.\n\nIn recent years, the abuse of prescription drugs has increased. Prescription drugs can have deadly effects when taken in large quantities and when mixed with other drugs. Many overdoses are the result of mixing alcohol with other drugs.",
        "Amphetamines": "Amphetamines are drugs that stimulate the central nervous system (CNS) (the brain and spinal cord). Drugs in this category are often called uppers, speed, ice, or crystal and include the drug cocaine (coke, crack, rock). People using these mind-altering substances show signs of restlessness, irritability, and talkativeness. Patients under the influence of these drugs may need to be kept from harming themselves and should be taken to a facility where they can be monitored until the effects of the drug wear off.\n\nSynthetic stimulant-type drugs are called commonly called bath salts (synthetic cathinones). Bath salts should not be confused with products such as Epsom salt (magnesium sulfate). These drugs copy the effects of naturally occurring mind-altering drugs and can be strong and dangerous. Often labeled as \u201cnot for human consumption,\u201d these drugs can be swallowed, snorted, smoked, or injected. Bath salts can produce effects that include paranoia, panic attacks, inappropriate sexual behavior, hallucinations, and excited delirium.",
        "Pain Relievers (Opioids) and Heroin": "An opioid is a type of medication used to relieve pain by reducing the intensity of pain signals reaching the brain. Opioids also affect the areas of the brain that control emotion. This class of medications includes hydrocodone (Vicodin), oxycodone (OxyContin), morphine, and codeine. Opioids are named for the opium in poppy seeds, from which codeine and morphine are derived. When used appropriately and as prescribed, opioids are a valuable part of medical care. However, if these medications are abused (that is, taken without a prescription or used in excess quantities), dependency or overdose can occur.\n\nHeroin is an illegal street drug that is powerful and addictive. Heroin is made from morphine. According to the CDC, from 1999 to 2014, there have been more than 165,000 deaths attributed to drug poisoning caused by opioids (heroin or prescription painkillers).\n\nAn increasing number of drug overdoses are the result of taking a combination of drugs. One particularly deadly combination is heroin and fentanyl. Some drug dealers are using an illegal version of fentanyl, a drug used to induce anesthesia, to increase the potency of heroin that has been diluted. According to the Drug Enforcement Administration, fentanyl produced in illicit labs is up to 100 times more powerful than morphine and 30 to 50 times more powerful than heroin. This combination of drugs acts quickly and is deadly even in very small quantities.",
        "Signs and Symptoms of an opioid drug overdose": "Signs and symptoms of an opioid drug overdose include the following:\nSlow, difficult, shallow breathing, or no breathing\nSmall or pinpoint pupils\nWeak pulse\nLow blood pressure\nBlue nails and lips\nDrowsiness\nDisorientation\nDelirium\nComa",
        "Treating a Patient With an Opioid Overdose": "An overdose of opioid drugs can result in respiratory depression or arrest. A person who has overdosed on opioids may be breathing shallowly or not at all.\n\nIf the person is not breathing, begin mouth-to-mask resuscitation. If cardiac arrest occurs, begin CPR immediately and arrange for prompt transportation to an appropriate medical facility.\n\nAnother treatment available for opioid overdose is naloxone (Narcan). Naloxone is a medication that can rapidly reverse the effects of opioid drugs on the central nervous system. In the past, naloxone was administered exclusively by injection or through an intravenous (IV) line and the use of this drug was limited to advanced life support (ALS) providers. Recently, however, naloxone has become available in a form that can be administered by spraying it into the patient\u2019s nostrils. This method of administration is called intranasal administration.\n\nNaloxone is also available in the form of an auto-injector. In some communities, all law enforcement and EMS personnel have been trained in the use of this medication. As an EMR, you can give this medication only if you are trained in its use and have approval from your medical director.",
        "Words of Wisdom_14": "General Steps to Administer a Medication Intranasally\n1. Obtain medical direction per local protocol.\n2. Confirm correct medication and expiration date.\n3. Attempt to determine whether the patient is allergic to any medications.\n4. Prepare the medication and attach the atomizer. Never use a needle.\n5. Place the atomizer in one nostril, pointing up and slightly outward.\n6. Administer a half dose (1 mL maximum) into each nostril.\n7. Reassess the patient and document appropriately.",
        "Hallucinogens": "Hallucinogens include PCP, LSD, peyote, mescaline, and some types of mushrooms. Hallucinogens are chemicals that cause people to see things that are not there. A patient who is hallucinating may become frightened and unable to distinguish between reality and fantasy. One hallucinogen, PCP, also blocks the body\u2019s pain receptors. People taking PCP may feel no pain and may seriously injure themselves or others. Large doses of PCP can produce convulsions, coma, heart and lung failure, or stroke. Your treatment for these patients is primarily supportive. Try to reduce auditory and visual stimulation. Avoid the use of bright lights and loud noises, including sirens. Because some of the patients who have taken these drugs are prone to violent behavior, approach each emergency scene with caution. Maintain safety for yourself, other rescuers, bystanders, and the patient. Arrange for transport to an appropriate medical facility for treatment.",
        "Abused Inhalants": "Recently, the intentional inhalation of volatile chemicals (huffing) has increased, especially among teenagers who are seeking an alcohol-like high. Many of these substances can be bought in hardware stores and include gasoline, paint thinners, cleaning compounds, lacquers, and a wide variety of substances used as aerosol propellants. Users put the chemical in a plastic bag and inhale from the bag. The combination of a lack of oxygen and the effects of the poisonous substance can lead to unconsciousness and death. Some types of inhalants cause drowsiness or unresponsiveness, and others cause seizures. Some of the chemicals can overstimulate the heart and produce sudden cardiac death from ventricular fibrillation. Treat these patients carefully. Try to keep them calm and still. Support the airway, breathing, and circulation. Give high-flow oxygen as soon as it is available and if you are trained to use it. Carefully monitor their vital signs and arrange for prompt transport to an appropriate medical facility.",
        "Toxic Injection From Drugs": "Drugs that are injected into the bloodstream can result in toxic injection. The patient\u2019s reaction depends on the quantity and type of drug injected. Because street drugs such as heroin and cocaine may be diluted (cut) with sugar or other substances that should not be injected into the bloodstream, the patient may be unaware of exactly what has been injected. After a toxic injection, the patient may report weakness, dizziness, fever, or chills. This type of emergency requires you to support the patient, treat the symptoms, and provide transport to an appropriate medical facility. You should also check the injection site for redness, swelling, and increased skin temperature. The presence of any of these signs may indicate an infection that requires medical care.",
        "Safety_15": "People who use IV drugs have a high incidence of blood-borne diseases such as hepatitis B and AIDS. Use standard precautions to reduce your chances of coming in contact with blood-borne pathogens.",
        "General Treatment for a Drug Overdose": "Once you have determined that a patient is experiencing a drug overdose, your care should consist of the following:\nProvide basic life support (clear the airway and perform mouth-to-mask breathing or CPR, as necessary).\nKeep the patient from hurting himself or herself and others.\nProvide reassurance and emotional support.\nArrange for prompt transport to a medical facility for treatment.\nThe effects of some drugs can be counteracted only by other drugs administered by a paramedic or a physician.\nIf a patient is acting out, speak to him or her in a calm, reassuring tone of voice and try to keep the patient from harming anyone. If a person reports seeing things that are not there, say, \u201cI believe you are seeing those things; however, I do not see them myself.\u201d This statement lets the patient know that you understand his or her experience, but that in reality, the perceived object is not present.\nAdminister naloxone if you have been trained in its use and have the approval of your local medical director.\nPatients who are experiencing adverse reactions from a drug overdose require specialized treatment. You and other EMS personnel should be aware of local facilities equipped to deal with such cases. Keep in mind that a person experiencing a drug overdose may also have other injuries or medical conditions that require medical treatment. Avoid classifying or judging the patient.",
        "Intentional Poisoning": "Intentional self-poisoning is attempted suicide and may involve ingested poisons (such as drugs) or inhaled poisons (such as carbon monoxide). Regardless of whether the poisoning was accidental or intentional, the medical treatment you provide is the same. A patient who has attempted suicide needs both medical and emotional support; however, the patient may not want your help and may be difficult to treat. Nevertheless, you and all other EMS personnel must make every effort to preserve life and offer reassurance to the patient.",
        "Words of Wisdom_16": "Excited delirium is a condition in which the patient shows a combination of agitation, anxiety, paranoia, violent and bizarre behavior, confusion, an inability to think or talk clearly, hallucinations, disorientation, insensitivity to pain, elevated body temperature, and superhuman strength. Excited delirium can result in sudden death, usually as the result of cardiac or respiratory arrest. Excited delirium is thought to involve multiple factors, including positional asphyxia, drug toxicity, and previous mental illness. It occurs most often in men with a history of serious mental illness and/or acute or chronic drug abuse\u2014especially with cocaine, PCP, or methamphetamine. Alcohol withdrawal or head trauma may also be present. In some patients with excited delirium, a conducted electrical device may be used in an attempt to subdue the patient.\n\nAs part of the patient\u2019s health care team Your goal is to prevent the patient from going into respiratory and cardiac arrest. The use of physical restraints seems to worsen excited delirium in some patients, so try to minimize their use. ALS personnel can give medications to reduce the patient\u2019s anxiety, produce muscle relaxation, and sedate the patient. Spraying patients with a water mist or fanning their faces may help to reduce their body temperature. If the patient calms down enough for you to take vital signs, take them frequently. Arrange for prompt transportation of the patient to an appropriate medical facility.",
        "Prep Kit-Ready for Review": "This chapter discusses the signs, symptoms, and treatment of patients who have experienced accidental or intentional poisoning.\nThe four primary routes by which poisons enter the body are (1) ingestion, (2) inhalation, (3) injection, and (4) absorption.\nAn ingested poison is taken by mouth. Often, there are chemical burns, odors, or stains around the mouth. The person may also be experiencing nausea, vomiting, abdominal pain, or diarrhea.\nAn inhaled poison is breathed in and absorbed through the lungs. Some toxic substances such as carbon monoxide are very poisonous but are not irritating to the respiratory tract. Other toxic gases such as chlorine gas and ammonia are very irritating and will cause coughing and severe respiratory distress.\nThe two major causes of poisoning by injection are (1) animal bites and stings and (2) toxic injection.\nPoisoning by absorption occurs when a poisonous substance enters the body through the skin. A person experiencing absorption poisoning may have both localized and systemic signs and symptoms.\nMany nerve agents are the same types of chemicals as insecticides. Your primary role in incidents involving nerve agents is to keep yourself and others from becoming exposed.\nIt is important to pay special attention to scene safety. Do not enter a hazardous environment without the proper training and equipment.\nNaloxone (Narcan) is a medication that can rapidly reverse the effects of opioid drugs on the central nervous system.",
        "Vital Vocabulary": "acid: A chemical substance with a pH level of less than 7.0 that can cause severe burns., amphetamines: Stimulants that produce a general mood elevation, improve task performance, suppress appetite, or prevent sleepiness., anaphylactic shock: Severe shock caused by an allergic reaction to food, medicine, or insect stings., antivenin: A serum that counteracts the effect of venom from an animal or insect., base: A chemical with a pH level of greater than 7.0. Bases are also called caustics or alkalis., bath salts: , The common name for certain types of synthetic stimulant-type drugs.: , carbon monoxide: A colorless, odorless, tasteless, poisonous gas formed by incomplete combustion, such as in a fire., central nervous system (CNS): The brain and spinal cord., cocaine: A powerful stimulant that induces an extreme state of euphoria. Legitimately, it is a potent local anesthetic. On the street, it is commonly known as coke. Crack cocaine, crack, or rock is a solid, smokable form of cocaine., coma: A state of unconsciousness from which the patient cannot be aroused., delirium tremens (DTs): A severe, often fatal, complication of alcohol withdrawal that most commonly occurs 3 to 4 days after withdrawal (though it can occur as late as 10 days after withdrawal). It is characterized by restlessness, fever, sweating, confusion, disorientation, agitation, hallucinations, and convulsions., hallucinogens: Chemicals that cause a person to see visions or hear sounds that are not real., hives: An allergic skin disorder marked by patches of swelling, redness, and intense itching., nerve agents: Deadly toxic substances that attack the central nervous system., opioids: Medications that relieve pain, including prescription drugs such as morphine, oxycodone, and hydrocodone and illicit drugs such as heroin, which is produced from the morphine in poppy plants., poison: Any substance that may cause injury or death if relatively small amounts are ingested, inhaled, absorbed, applied to, or injected into the body., self-contained breathing apparatus (SCBA): A complete unit for delivery of air to a rescuer who enters a contaminated area; contains a mask, regulator, and air supply., toxic: Poisonous."
    },
    {
        "Introduction": "A geriatric patient is commonly defined as a patient who is older than 65 years. The geriatric population of the United States is the fastest growing segment of society. According to the US Census Bureau, 13% of the US population (or 40.3 million people) were age 65 years or older in 2010. This chapter addresses concerns particular to geriatric patients, including sensory changes such as hearing loss and vision impairment, changes in mobility, and changes in medical conditions. Special considerations for the care of patients with chronic conditions are addressed. Mental health conditions that commonly affect older patients, such as depression and senility, are also covered. The chapter concludes with a discussion of end-of-life issues, hospice care, advance directives, and methods of recognizing signs of elder abuse. The natural aging process results in a decline in the functioning of all body systems. This slowdown is gradual and begins shortly after the body reaches maturity. Heredity and lifestyle choices such as diet, alcohol and/or drug abuse, stress level, and amount of exercise influence the speed at which this decline occurs. As an emergency medical responder (EMR), it is important not to prejudge the physical or mental health of older patients. Some people are vibrant and healthy at age 80 years, whereas others experience chronic debilitating diseases in their 50s. The same is true of mental capacity: Although you may encounter middle-aged patients who have become senile, many older people retain their full mental capacity.\n\nBecause older patients experience health complications more frequently than younger people do, most emergency medical services (EMS) systems respond to many calls involving geriatric patients. These calls will be much easier for you to handle if you understand some of the physical and mental changes involved in the aging process. As discussed in Chapter 5, Communications and Documentation, these calls will also be less stressful for the patient and for you if you understand how to effectively communicate with older patients. You will achieve a greater rapport with older patients if you interact with each person as an individual, rather than as a member of some stereotypical group defined by age.\n\nOlder people often wear more clothing than younger people do, even during warmer months. Do not use layers of clothing as an excuse to perform an incomplete examination. It is essential that you conduct a complete full-body examination on all patients.\n\nBe especially careful as you examine geriatric patients. Their skin is thinner and more fragile than the skin of younger people. As a person ages, the layer of fat under the skin decreases. The skin becomes drier because the number of sweat glands decreases with age. These changes mean that older people have more fragile skin. They tend to bruise easily and tend to bleed more easily than younger patients. These changes also make older patients more prone to pressure sores (bedsores) if they are unable to change positions frequently or if they are left on a hard surface that is not padded.\n\nThe loss of bowel and bladder control occurs frequently in the geriatric population. This situation can be distressing and embarrassing to both you and the patient. Do not let this occurrence interfere with appropriate patient care.\n\nWhen you respond to a call for an older patient, remember the patient\u2019s spouse is probably anxious as well. Try to keep the spouse informed of what is happening to ease some of his or her anxiety.",
        "Sensory Changes": "Two of the most socializing senses are hearing and sight. Many people experience some loss of hearing as they age, and the ability to see often diminishes as well. For some older people, decreased vision results in the need to wear eyeglasses for reading, and activities such as driving and walking can become more hazardous. Impaired vision and confusion often contribute to mistakes in taking medications. Other conditions, such as cataracts (a clouding of the lens of the eye) or macular degeneration (a disease that results in blurred or no vision), may develop.",
        "Words of Wisdom": "Suspect the possibility of medication errors in patients with decreased vision or mental confusion.",
        "Patients Who Are Hard of Hearing or Deaf": "Hearing loss is an invisible disability. Hearing loss may be related to repeated exposures to loud noises or to heredity. Often hearing losses are more pronounced in the higher frequencies, meaning that a person may be able to hear a person with a low-pitched voice but not hear a person with a higher-pitched voice. Some older adults require the use of a hearing aid. As a person ages, there is also an increased chance for disorders of the inner ear. People with certain inner ear disorders are more prone to poor balance and falls than the general population.\n\nBe certain an older patient can hear and understand what you say. Identify yourself by name and title and speak slowly and clearly. If you think the patient has difficulty hearing you, do not shout. Ask the patient if he or she can hear you. Speak directly into the patient\u2019s ear or talk while facing the patient and maintaining eye contact. If you determine that a patient has a hearing aid, ask the patient or caregiver to check to make certain it is in place and is functioning properly. Many older patients read lips to help compensate for hearing loss. If you are still having difficulties communicating, write down your questions and offer paper and a pencil to the patient to respond. Consider learning sign language so you can communicate with patients who know sign language. If you do not know sign language, use gestures to communicate.",
        "Patients Who Are Visually Impaired or Blind": "During your scene size-up (initial assessment of the scene), look for signs indicating the patient may be visually impaired. These signs may include the presence of eyeglasses, a cane, or a service dog. As you approach, introduce yourself to the patient. If you think the patient is blind, ask, \u201cCan you see?\u201d\n\nA patient who is visually impaired may feel vulnerable, especially during the chaos of an emergency incident. The patient may have learned to use other senses such as hearing, touch, and smell to compensate for the loss of sight. The sounds and smells of an emergency scene may be disorienting. The patient may rely on you to make sense of everything. Tell the patient what is happening, identify noises, and describe the situation and surroundings, particularly if you must move the patient. Find out what the patient\u2019s name is and use it throughout your examination and treatment, just as you would with a sighted patient. A reaffirming, supportive touch may provide emotional support.\n\nIf an older patient wears eyeglasses, keep them with the patient if at all possible. If the eyeglasses are lost during a medical emergency, make every effort to locate them because your patient may be severely handicapped and anxious without his or her eyeglasses. Knowing that the eyeglasses are not lost will be a great relief to the patient. Imagine how you would feel if you were in an emergency situation and could not see. If you bring that understanding and empathy to your interactions with patients who are visually impaired, it will help you provide compassionate care.",
        "Words of Wisdom_0": "Techniques for communicating with older patients include the following:\nIdentify yourself by name and title.\nLook directly at the patient.\nSpeak slowly and distinctly.\nExplain what you are going to do in clear, simple language.\nListen to the patient.\nShow the patient respect.\nDo not talk about the patient in front of the patient.\nBe patient.",
        "Musculoskeletal and Mobility Issues": "As a person ages, several changes occur to the musculoskeletal system. Muscles decrease in strength. Part of this loss is the result of decreased physical activity, which can be offset by a good exercise program, and part is an inevitable outcome of the aging process. The disks between the vertebrae narrow; this change can cause a loss of height, curvature of the spine, and a loss of flexibility. The bones in the skeletal system decrease in strength because of a loss of calcium. This loss of bone strength is especially pronounced in postmenopausal women and can result in the development of osteoporosis. Osteoporosis is a decrease in the density of bone, and this condition affects both women and men. Many older people also experience some loss of balance caused by a variety of issues. Together, the loss of muscular strength, weakened bones, and decreased balance result in an increased incidence of falls among older patients. Falls in older patients result in an increased risk for brain injuries because the blood vessels are more fragile and because the brain gets smaller as a person ages. As the brain gets smaller, the amount of space in the cranium increases, resulting in an increased chance of injury to the brain as the result of trauma.",
        "Slowed Movements": "When you assist an older patient, remember that as a person ages, physical movements become slower. Lend a helping hand or supporting arm. Most older patients are afraid of falling and your support will help them overcome this fear. Allow enough time for patients to move safely; do not try to rush them.",
        "Fractures": "Fractures occur frequently in the geriatric population because the loss of bone density often results in osteoporosis. Osteoporosis affects both women and men. Be aware that a simple fall at home can result in multiple severe fractures in an older patient who has weakened bones. Fractures of the wrist, spine, and hip are particularly common. Some of these fractures can occur with little trauma\u2014even fractures of the vertebrae. Geriatric patients may also have a reduced awareness of pain. They may experience little pain, even with a major fracture, and they may not realize the seriousness of their injury. Splinting and spinal immobilization of a geriatric patient can be a challenge when a spinal curvature or osteoporosis is present. Handle these patients carefully.\n\nHip fractures are a common result of osteoporosis. They are usually caused by a fall and occur most frequently in older women. As you conduct your primary assessment, remember that other conditions may have contributed to the fall. Patients may have experienced a minor stroke, heart attack, or confusion before the fall or they may not have seen an obstacle that caused them to trip.\n\nIn a hip fracture, the injured leg is usually (but not always) shortened compared with the other leg. The toes of the injured leg are pointed outward (externally rotated), and pain may be so great that the patient cannot move the leg. An older patient who reports pain after a fall must be examined by a physician to identify any possible fractures. Splint the patient as described in Chapter 15, Injuries to Muscles and Bones, and arrange for prompt transport to an appropriate medical facility.",
        "Table 18-1 Conditions That May Occur With Age": "Hearing loss or impairment\nSight loss or impairment\nLoss of sensation\nSlowed physical movements\nFractures\nSenility\nLoss of bowel or bladder control",
        "Treatment": "Carefully examine geriatric patients for signs and symptoms of fractures.",
        "Medical Considerations": "With increasing age comes an increase in the incidence of many different medical conditions. Two types of medical conditions that cause the greatest number of deaths are cardiovascular diseases and respiratory diseases. As people get older, they are generally less able to fight off diseases. Their immune systems become less effective. They are unable to cough as effectively and may have increased difficulty handling secretions, thus increasing the need for suctioning.",
        "Cardiovascular Diseases": "Cardiovascular diseases are conditions that affect the heart and blood vessels. As a person ages, the ability of the body to speed up the rate of contractions of the heart decreases. At the same time, the blood vessels become stiffer and narrowed by fatty deposits. These changes increase the occurrence of cardiac diseases such as heart attacks, angina, and congestive heart failure in geriatric patients. Strokes and abdominal aortic aneurysms are two common conditions related to blood vessels. The incidence of these diseases also rises with age. Some patients may have experienced one of these conditions in the past. Their current medical emergency may be related to the ongoing results of a past stroke or heart attack. With other patients, the immediate cause of their medical emergency may be a heart attack or stroke that is occurring at that moment. When caring for geriatric patients, it is important to understand that the signs and symptoms of medical conditions may be different from the classic signs and symptoms you would expect in a younger patient. Remember, older patients often have a decreased awareness or sensation to the pain of a medical or trauma condition. Older patients are more likely to have a so-called silent heart attack where they do not experience acute pain; hence, they may not realize that they are experiencing a heart attack. Some patients who are experiencing a stroke will not be aware of the signs and symptoms that are present. Treat older patients with a high degree of suspicion. It is better to err on the side of overtreatment than it is to fail to treat and arrange for transport.",
        "Respiratory Diseases": "Respiratory diseases are a major cause of sickness and death in older patients. As a person ages, the alveoli have a loss of elasticity. This condition makes it harder to inhale oxygen and to exhale carbon dioxide. Older patients usually have a reduced lung capacity, which means they do not exchange as much air with each breath as they did when they were younger. Also, the muscles associated with respiration become weaker with age. This condition makes it harder for older people to cough, which makes them more susceptible to a variety of respiratory infections. There are two major types of respiratory diseases: chronic respiratory diseases and acute respiratory diseases.\n\nPatients with chronic obstructive pulmonary disease may live with this condition for many years. They call for EMS assistance when some type of change in their life causes them to experience shortness of breath. A cold or other respiratory infection can upset their normal equilibrium and result in a medical emergency.\n\nAcute respiratory diseases can strike a patient quickly. Pneumonia is a common infectious disease in older patients. Because many older patients have a weakened immune system, they are especially susceptible to pneumonia. Pneumonia frequently kills older people. Minor symptoms can become a major illness in a short period of time. A physician should examine any older patient who has congestion and a possible fever.\n\nYour role in caring for older patients with a possible respiratory condition is to carefully examine them, secure an accurate medical history (past and present), treat their presenting symptoms, and arrange for transport to an appropriate medical facility when indicated.",
        "Cancer": "Cancer is a frequent cause of disability and death in older patients. Cancer can strike any part of the body. Patients do not call EMS because they have cancer. They call for help when complications from the cancer result in acute pain, shortness of breath, shock, or some other medical condition. These patients require prehospital support and then transport to a medical facility for stabilization. Patients with cancer and their families are experiencing a major crisis. Your support and understanding will help them to get through this difficult time.",
        "Altered Mental Status": "Many of the medical conditions that commonly occur in older patients can result in altered mental status (decreased responsiveness). Recall from Chapter 10, Medical Emergencies, that patients may be confused or unresponsive for a wide variety of reasons, and knowledge of the common causes of altered mental status may help you in treating these patients. Three common causes of decreased responsiveness in older patients are (1) lack of adequate oxygen to the brain, (2) low blood glucose level, and (3) hypothermia. When you encounter a patient with an altered mental status, carefully assess the patient and provide treatment that is appropriate for his or her signs and symptoms. Ensure the patient is transported to an appropriate medical facility for further assessment and treatmenWords of Wisdomt.",
        "Words of Wisdom_2": "\nComplications with the transmission of nerve impulses can result in the loss of sensation in the arms or legs. This lack of sensation places the older patient at a higher risk for burns from hot water or from cooking accidents.",
        "Medications": "Because older patients can have a variety of chronic conditions, many of them take multiple medications every day. They may see several physicians for different conditions. If the various physicians do not communicate effectively, there is a chance that some medications may interfere with the action of other medications. Many medications have negative side effects, such as dizziness, when taken in excess quantities. Many patients with heart conditions take blood thinners (anticoagulants) to prevent blood clots, which make them more likely to bleed from even minor cuts. Older patients may not take their medications as instructed, accidentally taking the wrong dosage of a particular medication or missing doses altogether\n\nIt is important for you to determine what types of medication a patient takes, including any over-the-counter drugs or supplements. While you cannot be expected to learn all the medications that a patient might take, you can learn a lot by asking the patient directly. Often the patient knows the conditions for which he or she is taking medications; for example, \u201cThe white pill is for my high blood pressure, and the green pill is a blood thinner.\u201d If the patient is being transported to a medical facility, gather up his or her prescription medications and bring them to the hospital with the patient.",
        "Words of Wisdom_1": "In addition to medications taken by mouth, some patients receive medication through skin patches (for example, nitroglycerin). It is important to ask the patient whether he or she is using any type of skin patch for medication administration.",
        "Infections and Sepsis": "Infectious diseases are illnesses that are caused by bacteria, viruses, or fungi. They may affect different body systems or different organs of the body. Because older people have weakened immune systems, they are more susceptible to contracting infectious diseases, including pneumonia, abdominal infections, kidney infections, and urinary tract infections. Signs and symptoms of an infectious disease vary depending on the organism causing the infection and the body system primarily infected, but in general, common signs and symptoms include fever, fatigue, coughing, muscle aches, and diarrhea. A severe, potentially life-threatening complication of infection is sepsis. Sepsis occurs when chemicals are released into the bloodstream as a result of infection and trigger an inflammatory response throughout the body. Sepsis is most common in older adults and people who have weakened immune systems. If untreated, sepsis can progress to septic shock, a condition in which the blood pressure drops dramatically. Septic shock often results in death. The most common types of infections that may cause sepsis include pneumonia, abdominal infections, bloodstream infections, kidney infections, and urinary tract infections. The most effective way to prevent complications and death from infection is to recognize and treat an infection as soon as possible. As an EMR, you do not have the training and tools to diagnose or to treat patients who may have infections. Your job is to understand that older people are more likely to contract infections and develop sepsis than younger people and to recognize that older people often do not realize how sick they are. If an older patient shows signs or symptoms of an infection such as fever, diarrhea, fatigue, muscle aches, or coughing, he or she should be evaluated by a physician to rule out the possibility of an infection or sepsis.",
        "Voices of Experience": "He was struggling to breathe and had sustained numerous injuries, including chest injuries. Many years ago, I responded to a motor vehicle collision in which an older couple\u2019s car collided with a gasoline tanker truck. Thankfully, the truck was not transporting fuel, but the incident was still devastating. We rapidly extricated both patients from the vehicle. The truck had struck the car on the passenger side. The man, who had been riding on the passenger side, was injured more severely than his wife who had been driving. He was struggling to breathe and had sustained numerous injuries, including chest injuries. As a second ambulance arrived, my partner assisted me with caring for the man as the other crew took over care of his wife. I recall the older woman asking to be with her husband, and I informed her that we needed to transport them in separate ambulances to a trauma center. The man was struggling to breathe despite our aggressive care, and the curvature of his spine made it more difficult to immobilize him on the long backboard. I recall the wife begging me not to separate her from her husband. My heart went out to this couple. To this day I am not sure why I did what I did, but I am thankful that I made the decision to transport these patients in the same ambulance. I instructed the crew of the other ambulance to load my patient\u2019s wife in my ambulance and have the paramedic of that ambulance come onboard to continue her care as I cared for her husband. The other crew questioned my request because of the severity of this collision but I insisted. As we were transporting both patients to the trauma center, I continued care of the husband and I recall the wife reaching over with her right hand to hold the hand of her husband. I continued to assist ventilations of my patient as he responded to his wife\u2019s touch. Words of many years of love and companionship were spoken by the wife, and I realized that this couple had been together longer than I had been alive. They had shared many years together, and I feel sure that this older man had depended on his wife for most of his life. My patient knew his wife was by his side until the end. When we arrived at the hospital trauma center, the husband stopped breathing. His heart stopped less than 5 minutes later. Because of the extent of his injuries, resuscitative measures were unsuccessful. Before we placed our patients in the ambulance, I had no idea that this would be the last time that this gentleman would feel the love of his wife\u2019s touch. Several weeks later, I saw the wife of my patient in the local hospital where she was a volunteer. She came up to me and hugged me.",
        "Patients Who Require Long-Term Care": "Modern medical science has made great advances in treating patients with chronic conditions. In the past, most patients with serious chronic medical conditions were treated in hospitals or rehabilitation facilities; many died shortly after their conditions were diagnosed. Today, many patients are treated at home by nurses, home health aides, or family members. The life expectancy of people with chronic conditions has greatly increased. Patients with chronic conditions may be of any age. Because most patients with chronic conditions are older, this topic is being addressed in this chapter. However, remember that young children with complex chronic conditions are often treated at home as well.\n\nA variety of complex medical devices are used with patients who require long-term care. Devices that help patients breathe include ventilators that push oxygen into the patients\u2019 lungs, oxygen-enrichment devices, surgically inserted breathing tubes, and monitors that sound an alarm if a patient stops breathing. Patients with certain heart conditions may have pacemakers and automatic defibrillators inserted under their skin. Tubes inserted into a patient\u2019s arm, neck, or stomach may provide fluids or food. Catheters drain urine from the patient\u2019s bladder. To make matters even more complex, patients who require long-term care must often take a variety of medications.\n\nAs an EMR, you may be called to assist with these patients for a variety of reasons, ranging from trauma or illness to mechanical failures or transport needs. A minor illness for a healthy person can be life threatening for a patient with a chronic condition. Some patients fall and sustain musculoskeletal trauma, whereas others simply need help getting back into bed. Medical equipment may stop working because the power or backup batteries failed. Patients may need transport to a hospital for assessment and treatment.\n\nWhen you receive such a call, remember your role as an EMR is to assess the emergency and to use your training to take the appropriate steps in caring for the patient. Do not get overwhelmed or distracted by the complex equipment. You are not expected to understand how all these complex medical devices work. The people caring for the patient are familiar with the equipment they use each day. Do not be afraid to ask them about the equipment and the condition of the patient. Do not hesitate to question the patient and the patient\u2019s caregivers about the issue. They can probably tell you what the issue is and how you can help. Keep in mind the principles of your training. These patients need an open airway and adequate breathing and circulation. In most situations, you need to help stabilize the patient for only a few minutes until more highly trained EMS personnel arrive to provide care.",
        "Complex medical devices may be used to treat patients who need chronic care": "A.Ventilator.B. Feeding tube.",
        "Mental Health Considerations": "Three types of mental health conditions seen frequently in older people are depression, suicidal thoughts, and dementia or Alzheimer disease. It is helpful for you to have some understanding of why these conditions are common in older people and what you can do when you encounter them.",
        "Depression": "Depression is the most common psychiatric condition experienced by older adults. While the rates of depression are between 1% and 5%, for older people living on their own, the rates rise significantly with the loss of Independence. Fourteen percent of people receiving home health care are estimated to suffer from depression and between 29% and 52% of older people living in nursing homes suffer from depression. This condition is more common in women than in men. The recent loss of a spouse or close friend can contribute to depression. People with declining health, chronic health conditions, or terminal illnesses are especially likely to experience depression. Be aware of the high incidence of depression in older patients and be alert for signs and symptoms of persistent feelings of sadness or despair. If you observe signs or symptoms of depression, bring this to the attention of other EMS providers or other medical professionals.",
        "Special Populations": "Do not overlook signs of mental health conditions in older patients.",
        "Suicide": "Older men have the highest suicide rate of any age group in the United States, according to the American Foundation for Suicide Prevention. When older people attempt suicide, they choose more lethal means than younger people do. This factor results in more deaths from suicide than in some other age groups. Many factors contribute to the high suicide rate among older men. Physical illnesses, especially terminal ones, can lead to suicide. Loss of a loved one and alcohol abuse are also contributing factors. Listen carefully to the patient. Be alert for indications of hopelessness, depression, or attempts at suicide. If you think a patient may be considering suicide, arrange for transport to an appropriate medical facility. Be alert for your safety because weapons may be present on the scene. Contact law enforcement for assistance if needed. Know the protocols in your department for handling this type of situation.",
        "Dementia": "As people get older, some of them experience a decrease in mental function. A pattern of decline in mental function is called dementia. Dementia is a progressive and usually irreversible decline in mental functions. It is marked by impairment in memory and may result in decreases in reasoning, judgment, comprehension, and ability to communicate verbally. It is estimated that 20% to 40% of people older than age 85 have some degree of dementia. You may hear people use the term senile dementia when referring to patients with decreased mental function. Senile dementia is a general term used to describe an abnormal decline in mental functioning seen in older patients. Dementia can be caused by many different conditions including small strokes, hardening of the arteries, and/or heredity.\n\nThe most common type of dementia is Alzheimer disease. Alzheimer disease is a chronic degenerative disorder that attacks the brain and results in impaired memory, behavior, and thinking. According to the Alzheimer\u2019s Association, more than 5 million people in the United States are living with Alzheimer disease. During the course of this illness, the patient may experience mood swings and feelings that people are plotting against him or her. Patients with Alzheimer disease may wander at night and are at increased risk for falls. In the terminal stages of this disease, patients may be unable to walk, control their bowels and bladder, and swallow.\n\nWhen you care for patients with dementia, it is important to speak clearly to them and use their name. Let the patient know what you are doing at each step of your assessment and treatment. You will need to rely on family members or caregivers for a medical history. Because the patient\u2019s thought processes are impaired, communication may be difficult; therefore, inform the patient what you need to do. Be respectful and patient. Patients who are senile will pick up on your calm attitude and approach and respond accordingly. Use nonverbal communication to connect with patients who are unable to communicate verbally. Your kind and caring approach will make the patient more comfortable and will make your job easier.",
        "End-of-Life Issues": "It is important that you have an understanding of end-of-life issues when caring for geriatric patients. This section discusses the role of hospice care and advance directives.",
        "Hospice Care": "A hospice is a health care program that brings together a variety of caregivers to provide physical, emotional, spiritual, social, and economic care for patients who have terminal illnesses and who are expected to die within the next 6 months. Hospice care is provided in the patient\u2019s home or in a special facility. The hospice\u2019s interdisciplinary programs are designed to provide pain relief and other supportive care when there is no hope that the patient can recover from the illness. One of the goals of a hospice is to provide pain relief without the use of needles or intravenous (IV) lines. Pain relief is provided through oral medications, medication patches, and medicine placed in the mouth between the gum and the cheek. Most hospice patients have some type of cancer. When the hospice care is working well, EMS providers are usually not called. However, if the patient experiences unexpected conditions such as shortness of breath, EMS may be requested by a family member or by a caregiver. In the event that you are called to care for someone who is under the care of hospice, it is helpful for you to know the purpose of the hospice and the types of care being provided. Patients who are under the care of hospice may have advance directives that request that they not be resuscitated (discussed next). If there is any question about whether you should begin treatment, begin treatment and let the physician at the hospital make any further decisions.",
        "Advance Directives": "Patients who have a terminal condition may have drawn up a document to instruct physicians and other medical caregivers regarding the care they want to receive if they are unable to make their own medical decisions. These documents, called advance directives or living wills, were discussed in Chapter 4, Medical, Legal, and Ethical Issues. Recall that advance directives may include do not resuscitate (DNR) orders. A DNR order is a request to withhold cardiopulmonary resuscitation and other lifesaving measures if a person\u2019s heart stops or if he or she stops breathing. It is important for you to know the regulations and local protocols concerning these documents in your state. Some states have systems, such as bracelets, to identify patients with DNR orders. If you are unable to determine whether a DNR order is valid, begin appropriate medical care and leave the questions about living wills to physicians.",
        "Elder Abuse": "Older adults who are physically weak or mentally compromised are at high risk for abuse by a spouse, other family members, friends, or caregivers. Elder abuse is hard to detect because those who are at the highest risk of abuse are also isolated from public view if they are confined to their homes or are living in an assisted care facility. As an EMR, you may be in a position to recognize physical or emotional abuse in geriatric patients. Elder abuse may be in the form of physical abuse, sexual abuse, emotional abuse, financial abuse, or neglect. Patients with severe physical conditions or with senility may not be able to report abuse. The signs and symptoms of abuse include bruises, especially on the buttocks, lower back, genitals, cheeks, neck, and earlobes. Look for pressure bruises caused by a human hand grabbing the patient. Look for multiple bruises in different states of healing. Burns are another means of abuse. These may be caused by cigarettes or hot fluids. Suspect sexual abuse if there is trauma in the genital area. Finally, look for signs of neglect. Does the patient appear to be malnourished? If you suspect abuse, you need to report it to the proper authorities. Learn the requirements for reporting elder abuse in your state and know how to follow the protocols for reporting within your department. Many community-based programs assist in supporting geriatric patients who need physical assistance, nutritional support, or emotional help. It is only by reporting signs and symptoms of abuse to the proper authorities that the condition can be improved.",
        "Prep Kit-Ready for Review": "The natural aging process results in a decline in the functioning of all body systems, including sensory and musculoskeletal changes.\nFractures occur often in older people because of the loss of bone density that can lead to osteoporosis. A simple fall at home can result in multiple severe fractures in a geriatric patient who has weakened bones. Fractures of the wrist, spine, and hip are particularly common.\nCommon medical concerns for geriatric patients include cardiovascular and respiratory diseases.\nMany of the medical conditions that commonly occur in older patients can result in altered mental status. Three common causes of altered mental status are lack of adequate oxygen to the brain, low blood glucose level, and hypothermia.\nOlder people and people with weakened immune systems are prone to contracting infectious diseases, including pneumonia, abdominal infections, kidney infections, and urinary tract infections. A severe, potentially life-threatening complication of infection is sepsis. If untreated, sepsis can progress to septic shock.\nYou may be called to assist with patients who require long-term care for a variety of reasons, ranging from trauma or illness to mechanical failures or transport needs. A minor illness for a healthy person can be life threatening for a patient with a chronic condition.\nDo not overlook signs of mental health conditions in older patients. Three types of mental health conditions seen frequently in older people are depression, suicidal thoughts, and dementia. \nOlder people who are physically weak or mentally compromised are at high risk for abuse by a spouse, other family members, friends, or caregivers. As an emergency medical responder, you may be in a position to recognize abuse in geriatric patients. Elder abuse may be in the form of physical abuse, sexual abuse, emotional abuse, financial abuse, or neglect.",
        "Vital Vocabulary": "altered mental status: A sudden or gradual decrease in the person\u2019s level of responsiveness. Measured using the AVPU scale., Alzheimer disease: A chronic, progressive dementia that accounts for 60% of all dementia., dementia: A progressive, irreversible decline in mental functioning; marked by memory impairment and decrease in reasoning, judgment, comprehension, and ability to communicate verbally., depression: A psychiatric disorder marked by persistent feelings of sadness, hopelessness, and decreased interest in daily activities. The person may have persistent thoughts of suicide., elder abuse: An action taken by a family member or caregiver that results in the physical, emotional, financial, or sexual harm to a person older than 65 years; also includes neglect., externally rotated: Rotated outward, as a fractured hip., geriatric patient: A patient who is older than 65 years., hospice: An interdisciplinary program designed to reduce or eliminate pain and address the physical, spiritual, social, and economic needs of terminally ill patients., osteoporosis: Abnormal brittleness of the bones caused by loss of calcium; affected bones fracture easily., senile dementia: General term for dementia that occurs in older people., sepsis: A severe, potentially life-threatening complication of infection that can progress to septic shock if left untreated; occurs when chemicals are released into the bloodstream and trigger an inflammatory response throughout the body., septic shock: A condition in which the blood pressure drops dramatically as a result of severe infection; often results in death., suicide: Intentionally causing one\u2019s own death. Suicide is especially common in older and chronically ill people."
    },
    {
        "Introduction": "This chapter describes medical conditions that are caused by environmental conditions such as excessive heat, humidity, and cold and injuries and illnesses related to submersion in water. When a person is exposed to excessive heat, the body\u2019s mechanisms for controlling temperature can be overwhelmed, resulting in heat cramps, heat exhaustion, or heatstroke. Exposure to cold environments may result in conditions such as frostbite or hypothermia. You will learn about each of these conditions, including signs, symptoms, and common treatments. This chapter also discusses unintentional exposure to water leading to submersion injuries and drowning and the signs, symptoms, and treatment of these conditions. Special considerations for treating hypothermic patients in cardiac arrest are emphasized. Finally, this chapter outlines the injuries caused by lightning and emphasizes the importance of properly treating these patients.",
        "Patient Assessment for Environmental Emergencies": "Your approach to a patient who has signs and symptoms of an environmental emergency should follow the same patient assessment sequence described in Chapter 9. Review your dispatch information and evaluate it to help you consider the possible conditions or injuries the patient may be experiencing. Carefully assess the scene to determine safety issues for you and your patient. As you perform the primary assessment, first, try to form an impression of the patient\u2019s condition.\n\nDetermine the patient\u2019s level of responsiveness as you introduce yourself. Then check the patient\u2019s airway, breathing, and circulation (ABCs), and acknowledge the patient\u2019s chief complaint.\n\nUsually it is best to collect a medical history on the patient experiencing a medical problem before you perform a secondary assessment. The medical history should be complete and include all factors that may relate to the patient\u2019s current illness.\n\nUse the SAMPLE mnemonic to help you secure the medical history information you need: S Signs and symptoms A Allergies M Medications P Pertinent past medical history L Last oral intake E Events associated with or leading up to the illness or injury Although the secondary patient assessment should focus on the areas related to the patient\u2019s current illness, you should also recognize the patient may not always be aware of all the various aspects of his or her condition. It is better to perform a complete patient assessment and find all the problems than to perform a partial assessment and miss an underlying problem. Obtain the patient\u2019s vital signs and do not forget to monitor your patient through the use of ongoing reassessment if the arrival of additional emergency medical services (EMS) personnel is delayed.",
        "Exposure to Heat": "As an emergency medical responder (EMR), you will encounter patients who have been exposed to excessive heat. Next, we will discuss the signs, symptoms, and treatment for patients experiencing heat cramps, heat exhaustion, and heatstroke to help you recognize and treat these patients.",
        "Heat Cramps": "Heat cramps are painful involuntary muscle spasms. They often occur after vigorous exercise, especially in hot weather. They can also occur in factory or construction workers and even in well-conditioned athletes. The exact cause of heat cramps is not known, but it is thought to be partly related to the change in the electrolytes that occurs during exercise and partly as a result of the dehydration that accompanies exercise or working in a hot environment. A large amount of water loss occurs during vigorous physical activity. This loss of water may affect muscles that are stressed and cause them to go into spasm. Heat cramps occur most often in the leg or calf muscles. They may also occur in the abdominal muscles. When abdominal cramps occur, it may appear that the patient is having an acute abdominal problem. The first step in treating heat cramps is to move the patient to a cool place. Have the patient lie down in a comfortable position to rest the affected muscles. Give the patient water to drink. A diluted balanced electrolyte solution, such as Gatorade, can also be given if it is available. Usually with rest and fluid the cramps will go away. If the cramps do not go away, or if the patient is young, old, or has a chronic medical condition, you should arrange to have the patient transported to an appropriate medical facility for a thorough evaluation and treatment.",
        "Heat Exhaustion": "Heat exhaustion is a heat-related illness that occurs when a person is exposed to temperatures above 80\u00b0F (27\u00b0C), often in combination with high humidity. It may also occur as a result of vigorous exercise at lower temperatures. A person experiencing heat exhaustion sweats profusely and becomes light-headed, dizzy, and nauseated.\n\nCertain risk factors may make some people more susceptible to heat-related illnesses. The very young, older adults (age 65 and older), and people who have preexisting medical conditions or who are taking certain medications are more likely to experience a heat-related illness. High air temperatures reduce the body\u2019s ability to cool itself by radiation. High humidity reduces the body\u2019s ability to lose heat through evaporation. Exercise results in greater production of sweat.\n\nThe patient\u2019s blood pressure may drop (causing a weak pulse), and the patient may frequently report feeling weak. Body temperature is usually normal. The signs and symptoms of heat exhaustion are similar to the early signs of shock, and its treatment is similar as well.\n\nWhen you encounter a patient who is experiencing heat exhaustion, complete a scene size-up and a primary assessment. Patients experiencing heat exhaustion sweat heavily and are in mild shock from fluid loss. To treat heat exhaustion, move the patient to a cooler place (for example, from a baseball diamond to a shady spot under a tree) and treat him or her for shock. Unless the patient is unconscious, nauseous, or vomiting, give fluids by mouth to replace fluid loss through sweating. Drinking cool water is excellent treatment for patients experiencing heat exhaustion. Monitor the ABCs and arrange for transport to a medical facility.",
        "Signs and symptoms of heat exhaustion": "Signs and symptoms of heat exhaustion include the following:\nDizziness, light-headedness\nWeak pulse\nProfuse sweating\nNausea, vomiting\n",
        "Heatstroke": "Heatstroke occurs when the body is subjected to more heat than it can handle and the normal mechanisms for getting rid of the excessive heat, such as through sweating, are overwhelmed. The patient\u2019s body temperature rises until it reaches a level at which brain damage occurs. Without prompt and proper treatment, a patient with heatstroke will die.\n\nThe patient usually has flushed, dry skin that feels hot to the touch. Be alert for the fact that the patient\u2019s clothing may still be wet even though he or she has stopped perspiring. A person who is experiencing heatstroke may be semiconscious; however, as the body temperature rises, the patient will rapidly lose consciousness. These patients may have body temperatures in excess of 104\u00b0F (40\u00b0C).\n\nMaintain the patient\u2019s ABCs. Move the patient from the heat and into a cool place as soon as possible. Remove the patient\u2019s clothes, down to his or her underwear. Soak the patient with water. You can cool the patient with water from a garden hose, a shower in the home or factory, or a low-pressure hose from a fire truck. Ice packs can be placed on the groin and armpits. If the patient is conscious and not nauseated, give small amounts of cool water. Arrange for rapid transport to an appropriate medical facility for further treatment.",
        "signs and symptoms of heat exhaustion with those of heatstroke": "In the figure, **heat exhaustion** typically involves a normal body temperature, sweating, cool and clammy skin, and symptoms of dizziness and nausea. By contrast, **heatstroke** is characterized by a high body temperature, usually dry skin, hot and red skin, and a patient who may be semiconscious or unconscious.",
        "Treatment": "Heatstroke is an emergency that requires immediate action. The patient\u2019s body temperature must be lowered quickly!",
        "Safety": "Firefighters are at high risk for heat exhaustion and heatstroke when wearing heavy turnout gear because, in addition to working in hot environments, the turnout gear does not allow body heat to escape. Law enforcement personnel are also at high risk for heat-related conditions because of the heavy ballistic vests they wear for protection. It is important to keep hydrated and to take breaks when operating in hot environments.",
        "Exposure to Cold": "As an EMR, you will encounter patients who have been exposed to excessive cold. When you assess these patients, you should follow the steps of the patient assessment sequence discussed earlier. The signs and symptoms exhibited by the patient will guide you in your treatment. To help you recognize and treat these patients, the signs, symptoms, and treatment for frostbite and hypothermia are discussed next.",
        "Frostbite": "Frostbite can result when parts of the body are exposed to a cold environment. It can occur outside on a winter day, in a walk-in food freezer, or in a cold-storage warehouse in the middle of the summer. It can also occur through exposure to super-cooled gases. Exposed body parts actually freeze. The body parts most susceptible to frostbite are the face, ears, fingers, and toes. Depending on the temperature and wind speed, frostbite can occur in a short period. The fingers are one of the most common areas affected by frostbite. Increases in wind speed have the same effect as decreases in temperature. Imagine holding your hand outside an automobile traveling at 55 mph on a cold winter day. The combination of wind speed and low temperature produces a windchill factor. When the temperature is relatively mild, 35\u00b0F (2\u00b0C), an accompanying 20-mph wind will produce a windchill equivalent to an actual temperature of 24\u00b0F (\u22124\u00b0C). If there is a combination of low temperature and high wind, protect yourself and your patient from the dangers of windchill.\n\nPeople weakened by old age, medical conditions, exhaustion, or hunger are the most susceptible to frostbite. In superficial frostbite, sometimes called frostnip, the affected body part first becomes numb and then acquires a bright red color. Eventually the area loses its color and becomes pale. There may be a loss of feeling and sensation in the injured area. If the area is rewarmed, the patient may experience a tingling feeling.\n\nWarming a frostbitten area or body part must be done quickly and carefully. Usually, putting the fingers, toes, or ears next to a warm body part is enough. For example, place frostbitten fingers in the armpits. Do not try to warm a frostbitten area by rubbing it with your hands or a blanket, and never rub snow or ice onto a suspected frostbitten area. Doing so will only make the problem worse. Treat the frostbitten patient for shock.\n\nA patient with frostbite who has been outside for an extended period may have deep frostbite. In this situation, the patient\u2019s skin will be white and waxy, and it may be firm or frozen. Swelling and blisters may be present. If the skin has thawed, it may appear flushed with areas of purple and white color or it may be mottled and cyanotic. Follow the scene size-up, primary assessment, and secondary assessment sequence. Remove any jewelry the patient is wearing and cover the extremity with dry clothing or dry dressings. If possible, remove wet clothing and keep the patient warm to prevent hypothermia and further frostbite. Do not break blisters, rub the injured area, apply heat, or allow the patient to walk on an affected lower extremity. Patients with deep frostbite should receive prompt transport to a medical facility so they can be warmed under carefully controlled conditions. Remember, any patient with a frostbite injury may have been in the cold environment long enough to produce hypothermia.",
        "Special Populations": "Infants and small children have poorly developed heat-regulating mechanisms. They sometimes spike a fever with a minor infection. They are also susceptible to both heat and cold injuries. They are more susceptible to cold injuries because they cannot tell you when they are cold or take steps to change their environment. Also, their ability to generate and use up heat is limited. Older adults are much more susceptible to heat and cold injuries. Many older adults have decreased sensation to heat and cold. Their bodies are not capable of generating heat as efficiently as younger adults. Some of the medications taken by many older adults reduce their ability to compensate for hot and cold conditions, and older adults generally tend to drink less fluids, which makes them more susceptible to dehydration. All of these factors make geriatric patients more susceptible to heat and cold injuries. You should always be alert for the possibility of heat and cold injuries in infants, young children, and older adults.",
        "Safety_2": "Prevention is the only defense against frostbite. If you are going outside in freezing weather, dress warmly and make sure the vulnerable parts of your body are well covered and protected.",
        "Characteristics of Systemic Hypothermia Core": "Table 13-2 describes systemic hypothermia based on core temperature ranges. Between 93\u00b0F and 95\u00b0F (34\u00b0C to 35\u00b0C), the patient may exhibit shivering and foot stamping, with constricted blood vessels, rapid breathing, and a withdrawn demeanor. At 89\u00b0F to 92\u00b0F (32\u00b0C to 33\u00b0C), there is often loss of coordination and muscle stiffness, slowing respirations and pulse, and the patient may appear confused, lethargic, or sleepy. From 80\u00b0F to 88\u00b0F (27\u00b0C to 31\u00b0C), the patient may lapse into a coma, showing a weak pulse, dysrhythmias, and very slow respirations, and becomes unresponsive. Below 80\u00b0F (under 27\u00b0C), the patient shows signs of apparent death, is at risk of cardiac arrest, and remains unresponsive.",
        "Hypothermia": "When a person\u2019s body temperature falls to a subnormal range of below about 95\u00baF (35\u00baC), the condition is called hypothermia (\u201clow temperature\u201d). Hypothermia occurs when the body is not able to produce enough energy to keep the internal (core) body temperature at a satisfactory level. Hypothermia does not only occur in the winter; it can occur in temperatures as high as 50\u00baF (10\u00baC). People who become cold because they do not have enough clothing or their clothing is wet are likely to experience hypothermia, especially if they are weakened by illness. Intoxicated patients and patients who have abused drugs are at an especially high risk for developing hypothermia. The initial signs of hypothermia include feelings of being cold, shivering, decreasing level of consciousness, and sleepiness. Shivering is the body\u2019s attempt to produce more heat. As the body temperature drops and hypothermia progresses, shivering stops. A patient who is so cold that he or she cannot shiver cools down even faster. Signs of increasing hypothermia include a lack of coordination, decreased level of consciousness, mental confusion, and slowed reactions. As the body\u2019s temperature goes below about 90\u00baF (32\u00baC), the patient will lose consciousness. Patients suffering from hypothermia may have weak or very slow pulse rates. Therefore, it is important to carefully monitor their pulse for at least 30 seconds to accurately determine the underlying heart rate. Without treatment and warming to reverse the downward trend in body temperature, the patient will eventually die.\n\nIf you suspect a patient is experiencing hypothermia, move the patient to a warm (or warmer) location. Remove wet clothing and place warm blankets over and under the patient to help retain body heat and begin the warming process. If the patient is conscious, give warm fluids to drink. If you are outdoors and cannot easily take the patient inside a building, move the patient into a heated vehicle as soon as possible. If you cannot move the patient to a warmer environment, keep the patient dry and place as many blankets and insulating materials as possible around the patient. If transport is delayed or extended you may need to consider using your own body heat to warm the patient. Wrap blankets around yourself and the patient or get into a sleeping bag with the patient to use your body heat to start the warming process, even during transport. Handle the patient gently. Any patient experiencing hypothermia must be examined by a physician.",
        "Cardiac Arrest and Hypothermia": "If the patient\u2019s body temperature falls below 83\u00baF (28\u00baC), the heart may stop and you will need to begin cardiopulmonary resuscitation (CPR). As odd as it may seem, hypothermia may actually protect patients from death in some cases. Therefore, always start CPR and use an automated external defibrillator, if available, on hypothermic patients even if you believe they have been dead for several hours. Hypothermic patients should never be considered dead until they have been warmed in an appropriate medical facility.",
        "Treatment_3": "A special example of hypothermia protecting a patient from death is an apparent drowning in water colder than 70\u00baF (21\u00baC). Many children who fell in cold water and apparently drowned have been resuscitated successfully. Always start CPR on apparent drowning victims pulled from cold water.",
        "Voices of Experience": "\u201cThe National Weather Service was forecasting an additional 8 inches (20 cm) of snow, and a high of \u221220\u00baF (\u221229\u00baC).\u201d Don and Margaret had been happily married for 52 years and, as with any couple, they had had their ups and downs. Recently, things had gotten harder for Don. It seemed Margaret\u2019s dementia was getting worse. Sometimes she did not recognize Don, and sometimes she did not know where she was. But throughout it all, Don always provided for all of Margaret\u2019s needs. It was a cold, wintery night when Don got up around 0300 hours to use the bathroom. As he was getting back into bed, he looked over and realized Margaret was not in bed. Had she been there when he got up?He couldn\u2019t remember. He called her name, but heard nothing in the house. As he entered the living room, he found the worst: the front door was open. Frantically he called 9-1-1 and reported his wife missing. As emergency medical responders and law enforcement officers arrived, they began searching the area. Looking for footprints was difficult due to the rapidly falling snow. The National Weather Service was forecasting an additional 8 inches (20 cm) of snow, and a high of \u221220\u00baF (\u221229\u00baC). After approximately 8 minutes, a police officer called saying he had found her, but she was not moving. As we got over to Margaret, we found her unresponsive, but she was breathing and had a pulse. We rapidly moved her into the ambulance, turned up the heat as high as possible, and removed all of her wet clothing. Drying Margaret as much as we could, we applied hot packs to the appropriate areas and covered her with all the blankets we could find. As we were shutting the doors of the ambulance, I heard Don say, \u201cYou\u2019re all I know, Margaret. I love you and don\u2019t want to lose you.\u201d Hearing this brought tears to my eyes. I looked at Don and told him we would do everything we could to help his wife.As we were en route to the local, rural hospital, I called in a report and advised the physician that the patient was cold, really cold. Once we arrived at the emergency room, we turned over care to the waiting staff. There was a lot frantic activity and I kept hearing, \u201cMake sure the helicopter is coming.\u201d Just then we were dispatched to another call, so I could not follow up with the outcome of Margaret\u2019s care. Almost a month later, my partner and I were sitting at our station watching television when there was a knock on the door. When I opened the door, I was met by Don and Margaret, along with a large plate of cookies. We invited our guests inside and Don immediately gave me a huge embrace and broke down in tears. He told us how the events surrounding that night unfolded. The doctors suspected that Margaret had become confused, had gone outside by herself, and had become disoriented. After a 2-week stay in the intensive care unit, Margaret was discharged and came home, with no lasting effects. Don is now working with a social worker to provide a safer home for Margaret. As you study the material in this textbook, consider the following: while you may not know the patients whose life you will impact, someone deeply cares about that individual, and you need to provide the best care possible.",
        "Drowning and Submersion": "Because EMRs are often the first trained people to arrive at the scene of a drowning, it is important for you to have some understanding of drowning and submersion injuries. According to the Centers for Disease Control and Prevention, from 2005 to 2014, there was an average of 3,536 unintentional drownings annually, about 10 deaths per day. An additional 332 people died each year from drownings in boat-related incidents. An additional 12,000 people are hospitalized because of injuries resulting from submersion in water. Drowning is the second leading cause of injury and death among children 1 to 14 years. Fifty percent of the cases of infant drowning occur in the bathtub. In children ages 1 to 4 years, most drownings occur in swimming pools. For children ages 5 to 14 years, most of the drownings occur in rivers and lakes. Alcohol consumption and drug abuse are contributing factors in many cases of drowning involving teenagers and adults.\n\n Drowning is defined as suffocation because of submersion in water or in other fluids. Submersion injuries are any injuries that result from being beneath the surface of water or another liquid. \n\nFamiliarize yourself with your emergency response area; consider the places a drowning could occur. Likely locations include streams, lakes, and swimming pools. Hot tubs, wading pools, public fountains, and storm drain ponds are also potential locations for drowning. Common hazards for drowning in infants and young children that are present in every household include bathtubs, toilets, and mop buckets. Remember, young children can drown in liquids as shallow as 6 inches (15 cm).\n\nThe process of drowning progresses through several stages. Usually, the initial stage is panic as the person realizes that something is wrong, such as a strong current that is overpowering. In other instances, the person becomes fatigued, injured, and cold; becomes entangled in seaweed or kelp; experiences a loss of orientation; or becomes ill. The feeling of panic produces an inefficient breathing pattern. If a swimmer is not able to take in full breaths, the ability to float is lost, and exhaustion sets in as the person struggles to stay on the surface of the water. Small quantities of water reaching the larynx (voice box) cause a spasm of the larynx (laryngospasm), which makes it hard or impossible to breathe. If this cycle of panic is not corrected, respiratory and cardiac arrest can result. Signs and symptoms of a submersion injury include coughing, vomiting, difficulty breathing, respiratory arrest, and cardiac arrest. Some patients who have sustained submersion injuries may have broken bones or spinal injuries from hitting a hard surface. Hypothermia is an added risk when a patient is wet, especially if the water is cold or if the air temperature is low.\n\nFollow the steps of the patient assessment sequence when examining and treating a patient who has sustained a submersion injury. Begin by assessing scene safety. If the patient is still in the water, do not exceed the limits of your training in an attempt to rescue the patient. Keep yourself safe and attempt rescue only if you can do so safely. Use the reach, throw, row, and go sequence outlined in Chapter 20, Vehicle Extrication and Special Rescue. Call for additional help if needed. If there is evidence of trauma and you need to move the patient, protect the spine from further injury as described in Chapter 20. Perform a primary assessment. Correct any airway, breathing, and circulation (ABC) problems. You may need to carefully turn the patient on his or her side to allow water to drain out of the mouth. Begin CPR if indicated. If the patient is breathing adequately, administer high-flow oxygen as soon as it is available. As soon as the ABCs are stabilized, dry the patient because wet skin results in a significant loss of body heat. Then cover the patient with towels or blankets to help preserve body temperature. As soon as possible, perform a secondary assessment to check for other injuries. Obtain the patient\u2019s medical history from the patient if possible or from any family members present. Perform regular reassessments. All patients who have sustained a submersion injury should be examined by a physician. These patients may appear to be uninjured immediately after submersion, but life-threatening respiratory problems can develop hours after the incident. You must arrange to have these patients transported to an appropriate medical facility for a complete examination by a physician.",
        "Cold Water Drowning": "You should begin CPR on a drowning victim as long as the patient does not show definitive signs of death discussed in Chapter 4, Medical, Legal, and Ethical Issues. When a person is submerged in cold water, a protective mechanism called the mammalian diving reflex may be activated. This reflex slows the heart rate and metabolic rate and decreases the body\u2019s demand for oxygen. Because of the protection provided by the mammalian diving reflex, there have been cases in which a person has been in cold water for longer than 30 minutes and has been successfully resuscitated and recovered to a normal level of physical and mental functioning. Therefore, when you encounter a person who has been submerged in cold water even for an extended period, CPR should be started and continued until the person has been delivered to an appropriate medical facility. Resuscitating a cold water drowning patient often requires warming the patient in the hospital while continuing CPR.",
        "Words of Wisdom": "Do not put your life at risk by exceeding the limits of your training.",
        "Other Environmental Emergencies": "Lightning Injuries are sometimes classified as environmental emergencies because they have an environmental cause. The electrical injury resulting from a lightning strike can cause cardiac irregularities or cardiac arrest. Treat patients who have been struck by lightning by supporting their ABCs. Oxygen administration, defibrillation, and CPR may be needed for some patients. Because there is a chance of cardiac problems occurring hours after the injury, it is important that patients who have been struck by lightning are transported to an appropriate medical facility for examination and treatment. Lightning injuries also cause electrical burns. This type of burn is mainly internal and the extent of burn damage will not be visible right after the injury occurs. For this reason, it is also important to transport all patients who have been struck by lightning to an appropriate medical facility. Electrical burns are discussed in Chapter 14, Bleeding, Shock, and Soft-Tissue Injuries.",
        "Bites and Stings": "Bites and stings are sometimes classified as environmental injuries. They are discussed in detail under the topic of poisoning in Chapter 11, Poisoning and Substance Abuse.",
        "Prep Kit-Ready for Review": "Your approach to a patient who has experienced an environmental emergency should follow the patient assessment sequence.\nHeat cramps are caused by electrolyte imbalance and dehydration. They usually involve muscles in the calf, leg, or abdomen. Usually the cramps disappear with rest and the administration of water.\nA person experiencing heat exhaustion sweats profusely and becomes light-headed, dizzy, and nauseated. Certain risk factors may make some people more susceptible to heat-related illnesses.\nHeatstroke results when a person has been in a hot environment for a long period, overwhelming the body\u2019s sweating mechanism. The patient\u2019s body temperature rises until it reaches a level at which brain damage occurs.\nThe body parts most susceptible to frostbite are the face, ears, fingers, and toes. Warming the frostbitten part must be done quickly and carefully.\nHypothermia occurs when a person\u2019s body is not able to produce enough heat to keep the internal (core) body temperature at a satisfactory level. The initial signs of hypothermia include feeling cold, shivering, decreasing level of consciousness, and sleepiness. Signs of increasing hypothermia include a lack of coordination, mental confusion, and slowed reactions. Hypothermic patients should never be considered dead until they have been warmed in an appropriate medical facility.\nDrowning can occur in a variety of settings around a home and outdoors. Signs and symptoms of a submersion injury include coughing, vomiting, difficulty breathing, respiratory arrest, cardiac arrest, and trauma.\nLightning injuries are caused by a powerful jolt of electrical current that passes through part of the body. They may cause irregular heart rhythms",
        "Vital Vocabulary": "drowning: Suffocation because of submersion in water or other fluids., frostbite: Partial or complete freezing of the skin and deeper tissues caused by exposure to the cold., heat cramps: Painful muscle spasms that usually occur after vigorous exercise in hot weather and are generally relieved by rest and drinking water., heat exhaustion: A form of shock that occurs from significant fluid loss and too many electrolytes through very heavy sweating after exposure to heat., heatstroke: A condition of rapidly rising internal body temperature that occurs when the body\u2019s mechanisms for the release of heat are overwhelmed. Untreated heatstroke can result in death., hypothermia: A condition in which the internal (or core) body temperature falls below 95\u00baF (35\u00baC) after prolonged exposure to cool or freezing temperatures., laryngospasm: A spasm of the muscles of the larynx or vocal cords resulting in an inability to breathe., submersion injury: An injury resulting from being beneath the surface of water or another liquid."
    },
    {
        "Introduction": "This chapter on medical conditions has two parts. In the first part, you will learn about general medical complaints, including altered mental status and seizures. General medical complaints may result from a wide variety of medical conditions. You will learn the signs, symptoms, and common treatment steps for patients with these general medical complaints. The second part addresses some specific medical conditions you will encounter, including angina pectoris, heart attack, congestive heart failure, dyspnea, asthma, stroke, hypoglycemia, diabetic coma, and abdominal pain. You will learn the signs, symptoms, and treatment of patients with these specific medical conditions. Treating patients with medical conditions can be some of the most challenging work you perform as an emergency medical responder (EMR). By carefully studying these conditions, you will be prepared to provide reassuring and sometimes life-saving care to patients who are experiencing medical emergencies.",
        "Patient Assessment in Medical Emergencies": "Your approach to a patient who has a general medical complaint should follow the systematic approach outlined in the patient assessment sequence in Chapter 9. Review your dispatch information to help you decide on possibilities for the patient\u2019s condition. Carefully assess the scene to determine safety issues for you and your patient. As you perform the primary assessment, first try to form an impression of the patient\u2019s condition. Then determine the patient\u2019s responsiveness, introduce yourself, check the patient\u2019s airway, breathing, and circulation (ABCs), and acknowledge the patient\u2019s chief complaint.\nUsually, it is best to obtain a medical history on a patient experiencing a medical condition before you perform the secondary patient assessment. The medical history should be complete and include all factors that may relate to the patient\u2019s current illness.\nThe SAMPLE history format will help you secure the information you need: S\u2003Signs and symptoms A\u2003Allergies M\u2003Medications P\u2003Pertinent past medical history L\u2003Last oral intake E\u2003Events leading up to the illness or injury.\n\nAlthough the secondary assessment focuses on the areas related to the patient\u2019s current illness, the patient may not always be aware of all the aspects of his or her condition. It is better to perform a complete physical examination and find all the conditions than to perform a partial examination and miss an underlying condition. Obtain the patient\u2019s vital signs. Be sure to monitor your patient through ongoing reassessment if the arrival of additional emergency medical services (EMS) personnel is delayed.\n\nAs you perform the patient assessment, remember to reassure the patient. Any call for emergency medical care is a frightening experience for the patient. Stress aggravates many medical conditions. Reducing the patient\u2019s stress will go a long way toward making the patient more comfortable.",
        "General Medical Conditions": "General medical conditions may have different causes, but they result in similar signs and symptoms. By becoming skilled at recognizing the signs and symptoms of various general medical conditions and learning about general treatment guidelines, you will be able to provide immediate care for your patients even if you cannot determine the exact cause of the conditions. This initial treatment can stabilize the patient and allow other EMS and hospital personnel to diagnose and further treat the condition.",
        "Altered Mental Status": "Altered mental status is a sudden or gradual decrease in the patient\u2019s level of responsiveness. This change may range from a decrease in the level of understanding to unresponsiveness. Any patient who is unresponsive has experienced a severe change in mental status.\n\nWhen you are assessing altered mental status, remember the AVPU scale: \nA: Awake and alert. An alert patient will answer simple questions accurately and appropriately.\nV: Responsive to Verbal stimuli. A patient who is responsive to verbal stimuli will react to loud voices.\nP: Responsive to Pain. A patient who is responsive to a painful stimulus will react to the pain by moving or crying out.\nU: Unresponsive. An unresponsive patient will not respond to either verbal or painful stimuli.\n\nWhen assessing the patient\u2019s mental status, consider two factors: the patient\u2019s initial level of consciousness and any change in that level of consciousness. A patient who is initially alert but later responds only to verbal stimuli has experienced a decrease in his or her level of consciousness.\n\nMany different conditions may cause an altered level of consciousness including:\nHead injury\nShock\nDecreased level of oxygen to the brain\nStroke\nSlow heart rate\nHigh fever\nInfection\nPoisoning, including drugs and alcohol\nLow level of blood glucose (diabetic emergencies)\nInsulin reaction\nPsychiatric condition\n\nSome of the specific conditions that cause altered mental status are explained in the second part of this chapter Even if you cannot determine what is causing the patient\u2019s altered level of consciousness, you can help by treating the symptoms of the condition.",
        "Seizures": "Seizures are caused by sudden episodes of uncontrolled electrical impulses in the brain. Instead of discharging electrical impulses in a controlled manner, the brain cells keep firing impulses. Seizures that produce shaking movements and involve the entire body are called generalized seizures (formerly called grand mal seizures). These seizures usually last 1 to 2 minutes, although prolonged seizures may continue for more than 2 minutes. Patients are usually unconscious during generalized seizures and do not remember them afterwards. Although seizures are rarely life threatening, they are a serious medical emergency and may be the sign of a life-threatening condition. After a seizure, you may need to assist the patient in maintaining an open airway. The patient may have a loss of bowel or bladder control, soiling his or her clothing. One cause of generalized seizures is a sudden high fever. These seizures are called febrile seizures. Febrile seizures most commonly occur in infants and young children. Febrile seizures are discussed in Chapter 17, Pediatric Emergencies.\n\nSome seizures result in only a brief lapse of consciousness. These seizures are called absence seizures (formerly called petit mal seizures). Patients experiencing absence seizures may blink their eyes, stare vacantly, or jerk one part of their body. Because these seizures are of brief duration and severity, the family or bystanders of the patient usually do not call EMS. A physician should examine patients exhibiting signs and symptoms of an absence seizure.\n\nMany times you will find that you are not able to determine the cause of the patient\u2019s seizure. The patient\u2019s family may be able to tell you whether a physician has diagnosed the patient as having a seizure disorder. After a seizure, the patient may be sleepy, confused, upset, hostile, or out of touch with reality for up to an hour. You must monitor the patient\u2019s ABCs and arrange for transport to an appropriate medical facility.\n\nUsually, the seizure will be over by the time you arrive at the scene. If it has not ended, focus your treatment on protecting the patient from injury. Do not restrain the patient\u2019s movements. If you attempt to restrain the patient, you may cause further injury. If a patient experiences a seizure while on a hard surface, control the patient\u2019s arms by grasping them at the wrists. Allow the patient\u2019s arms to move but prevent the elbows from hitting the hard surface. To prevent the patient\u2019s head from hitting a hard surface, quickly slide the toes of your shoes under the patient\u2019s head. Move the patient only if he or she is in a dangerous location, such as in a busy street or close to something hard, hot, or sharp.\n\nDuring a seizure, the patient generally does not breathe and may turn blue. You cannot do anything about the patient\u2019s airway during the seizure, but once the seizure has stopped, it is essential that you ensure an open airway. Usually the best method to accomplish this is the head tilt\u2013chin lift maneuver. Observe the seizure activity and report your observations and assessment findings to other EMS providers. This information may be important in determining the cause of the seizure.\n\nAfter you have opened the airway, place the patient in the recovery position to help keep the airway open and to allow any secretions (saliva or blood from a bitten tongue) to drain out.\n\nMost patients start to breathe soon after the seizure ends. If the patient does not resume breathing after a seizure or if the seizure is prolonged, begin mouth-to-mask or mouth-to-mouth breathing. Supplemental oxygen should be administered as soon as it is available.\n\nFollowing a seizure, the patient will experience a state of confusion that may last for 30 to 45 minutes. The patient may also become anxious, hostile, or belligerent. Continue to monitor the patient to be sure he or she is breathing adequately. At this point, the patient needs privacy. Because the person is probably embarrassed about what happened or where it happened (perhaps in a public place such as a restaurant or shopping mall), move the patient to a more comfortable, private place if other EMS personnel have not arrived. Do not leave the patient, even if the patient insists that he or she is now awake and alert. Encourage any patient who experiences a seizure to go to a medical facility for examination and treatment\n\nThe best treatment you can provide for a patient experiencing a seizure is to protect him or her from self-injury. After the seizure, ensure that the airway is open, the patient is breathing adequately, and the mouth is clear of secretions and blood.",
        "Words of Wisdom": "There are many different types of seizures, and many factors that can cause them, including: Epilepsy, Trauma, Head injury, Stroke, Shock, Decreased level of oxygen to the brain, High fever, Infection, Poisoning, Overdose of drugs or alcohol, Brain tumor or infection, Diabetic emergencies (low blood glucose), Complication of pregnancy, Unknown causes",
        "Treatment": "Treatment for a seizure patient is as follows:\nStay calm. You cannot stop a seizure once it has started.\nDo not restrain the patient.Time the duration of the seizure.\nProtect the patient from contact with hard, sharp, or hot objects.\nLoosen ties or anything else around the neck that may obstruct breathing.\nDo not force anything between the patient\u2019s teeth.\nDo not be concerned if the patient stops breathing temporarily during the seizure.\nAfter the seizure, turn the patient on his or her side and make sure breathing is not obstructed.\nIf the patient does not begin breathing after a seizure, begin rescue breathing.\n\nAlthough you may be inclined to quickly categorize patients as \u201cmedical patients\u201d or as \u201ctrauma patients,\u201d many of the patients you encounter may have both a medical condition and a traumatic injury. For example, the altered level of consciousness experienced by a diabetic patient with severe hypoglycemia may contribute to a motor vehicle crash. As you study this chapter, try to imagine how you can use your knowledge to treat patients with a single condition or a variety of conditions. Remember to carefully assess each patient and treat the conditions that you identify",
        "Safety": "Do not attempt to put anything in the mouth of a patient who is actively seizing. Remember, a person having a seizure cannot swallow his or her tongue.",
        "Specific Medical Conditions": "In the first part of this chapter, you learned how to assess general medical complaints and treat patients based on their signs and symptoms. This is the foundation for assessing and treating patients who present with medical conditions. You will find it helpful, however, to be knowledgeable about some of the more specific medical conditions you may encounter as an EMR. These include heart conditions, dyspnea, asthma, stroke, diabetic conditions, and abdominal pain. Sometimes the patient or the patient\u2019s family will tell you that the patient has a certain medical condition. At other times, your careful assessment of the patient will reveal information that leads you to suspect a particular condition, allowing you to take specific steps to help the patient. The added knowledge you gain from the second part of this chapter will help you assess, treat, and communicate more effectively with patients who have medical conditions.",
        "Words of Wisdom_0": "Remember, many medical conditions can cause both altered mental status and seizures.",
        "Heart Conditions": "The heart must receive a constant supply of oxygen or it will die. The heart receives its oxygen through a complex system of coronary (heart) arteries. As long as these arteries continue to supply the heart with an adequate amount of oxygen, the heart can continue to function properly.\n\nAs the body ages, however, the coronary arteries may narrow as a result of a disease process called atherosclerosis. Atherosclerosis causes layers of fat to coat the inner walls of the arteries. Progressive atherosclerosis can cause angina pectoris, heart attack, and even cardiac arrest.",
        "Angina Pectoris": "As atherosclerosis progresses in the coronary arteries, it can reduce the blood (oxygen) supply to the heart enough to cause pain or pressure in the chest. This pain is known as angina pectoris or simply angina. The heart needs more oxygen than the narrowed coronary arteries can deliver.\n\nWhen a patient has chest pain, first ask the person to describe the pain. Patients often describe angina as pressure or heavy discomfort. The patient may say something like, 'It feels like an elephant is sitting on my chest.'\n\nAngina attacks are usually brought on by exertion, emotion, or eating. The patient may feel crushing pain in the chest. The pain may radiate to either or both arms, the neck, jaw, or any combination of these sites. The patient is often short of breath and sweating, extremely frightened, and has a sense of doom. The patient may experience nausea and vomiting.\n\nAsk whether the patient is already being treated for a diagnosed heart condition. If the answer is 'yes,' ask if the patient has a pill or spray to take for angina pain. A patient who has experienced previous episodes of angina usually has medication that he or she can place or spray under the tongue to relieve the pain. The most common medication of this type is nitroglycerin, and the patient may have already taken a dose by the time you arrive at the scene.\n\nIf the patient has nitroglycerin but has not taken it during the past 5 minutes, help place one of the tiny pills under the patient\u2019s tongue or help the patient administer the aerosol spray. Follow your local protocols regarding the administration of nitroglycerin. Nitroglycerin usually relieves angina pain within 5 minutes. If the pain has not diminished after 5 minutes, help the patient take a second dose. If the pain still has not lessened 5 minutes after the second dose, assume the patient is having a heart attack. Before you assist with the administration of nitroglycerin, you need to receive training and have permission from your medical director.",
        "Heart Attack": "A heart attack (myocardial infarction) results when one or more of the coronary arteries is completely blocked. The two primary causes of coronary artery blockage are severe atherosclerosis and a blood clot from somewhere else in the circulatory system that breaks free and lodges in the artery. If one of the coronary arteries becomes blocked, the part of the heart muscle served by that artery is deprived of oxygen and dies.\n\nBlockage of a coronary artery causes the patient to experience immediate and severe pain. The pain of angina pectoris and a heart attack may be similar at first. Most heart attack patients describe the pain as crushing. The pain may radiate from the chest to the left arm, or to the jaw, or to the back. Heart conditions do not cause all chest pain. Pneumonia and muscle strains to the chest wall can also cause chest pain. It is better for the patient to treat the pain as if it is a heart attack than to undertreat the symptoms. The patient is usually short of breath, weak, sweating, nauseated, and may vomit.\n\nNitroglycerin pills or spray will not relieve the pain of a heart attack. The pain will persist, unlike the pain of angina, which rarely lasts more than 5 minutes.\n\nGiving one adult aspirin (325 mg) or 2 to 4 low-dose aspirins (81 mg each) may help to reduce the chance of death from a heart attack. Instruct the patient to chew the aspirin and then swallow it. Be sure the patient is not allergic to aspirin and has not had any recent internal bleeding such as a stomach ulcer.\n\nIf the area of heart muscle supplied by the blocked artery is either critical or large, the heart may stop completely. Complete cessation of heartbeat is called cardiac arrest. Cardiopulmonary resuscitation is your first emergency treatment for cardiac arrest. To support the patient and reduce the probability of cardiac arrest, you can take the following actions:\n\nSummon additional help.\n\nTalk to the patient to relieve his or her anxiety.\n\nTouch the patient to establish a bond. Hold the person\u2019s hand.\n\nReassure the patient that you are there to help. The person is afraid that death is close, and fear can create tension and make the pain worse.\n\nMove the patient as little as possible and do not allow the person to move! You and other bystanders must move the patient if necessary.\n\nPlace the patient in the position he or she finds most comfortable. This is usually a semi-reclining or sitting position.\n\nHelp the patient take one adult aspirin (325 mg) or 2 to 4 low-dose aspirins (81 mg each). Instruct the patient to chew and then swallow the aspirin tablets.\n\nIf oxygen is available and you are trained to use it, administer it to the patient. Supplemental oxygen increases the amount of oxygen the blood can carry. The increase in oxygen reduces pain and anxiety. It also eases the minds of the patient\u2019s family and friends to see that you are doing something to relieve the patient\u2019s physical distress.\n\nBe prepared to administer cardiopulmonary resuscitation, if necessary. If an automated external defibrillator is available, have it brought to the patient and make sure it is ready for use if needed.\n\nBecause you do not have extensive equipment available to help a patient experiencing a heart attack, your primary role is to provide emotional support and arrange for prompt transport to an appropriate medical facility. Because the patient\u2019s emotional state can affect his or her physical condition, emotional support is valuable. It can help prevent cardiac arrest.",
        "Words of Wisdom_1": "Recent research has shown that the administration of one adult aspirin (325 mg) or 2 to 4 low-dose aspirins (81 mg each) may help to reduce the chance of death from a heart attack by reducing the size of the blood clot in the heart. The American Heart Association recommends that patients experiencing chest pain take aspirin as soon as possible. The patient should chew and then swallow the aspirin tablets. Check to be sure your patient is not allergic to aspirin and has not had any recent internal bleeding such as a stomach ulcer. Check with your supervisor or medical director to see if your department recommends aspirin administration in patients with chest pain.",
        "The signs and symptoms of cardiac arrest": "The signs and symptoms of cardiac arrest are as follows:\nUnconsciousness\nAbsence of respirations or only gasping\nAbsence of a carotid pulse",
        "Treatment_2": "Not everyone having a heart attack has severe chest pain. Older women and people with diabetes are more likely to have silent heart attacks. People experiencing silent heart attacks may report vague feelings of discomfort and not feel the classic chest pain associated with heart attacks. Do not discount vague complaints in these patients. The only way to rule out a heart attack is to have a thorough examination by a physician.\n\nWithin the last 20 years, the use of clot-buster drugs and nonsurgical treatments, such as percutaneous coronary intervention (PCI), has been an important advance in treating patients experiencing a heart attack. Clot-buster drugs or PCI can often open the blocked coronary vessels and prevent the need for costly and painful surgery. A specially trained physician must administer these treatments within a few hours of the start of a heart attack to be effective. Your prompt response and attentive care of a patient experiencing a heart attack may be the first step in returning that patient to a comfortable, healthy, and productive life.",
        "Congestive Heart Failure": "Congestive heart failure (CHF) is not directly caused by narrow or blocked coronary arteries, but by failure of the heart to pump adequately. As explained in Chapter 6, The Human Body, and Chapter 8, Professional Rescuer CPR, the heart has two sides. The right side receives deoxygenated blood from the body and sends it to the lungs; the left side receives fresh oxygenated blood from the lungs and pumps it to the body. If one side of the heart becomes weak and cannot pump as well as the other side, the circulatory system becomes unbalanced, resulting in circulatory congestion. In CHF, the failure is in the heart muscle, but the congestion is in the blood vessels. Figure 10-6 shows what happens if CHF occurs on the left side of the heart, which sends blood to the body. Because the left side cannot send blood to the body as efficiently as the right side can send blood to the lungs, more blood goes to the lungs than to the body. This results in congestion (overload) in the blood vessels of the lungs.\n\nThe major symptom of CHF is breathing difficulty, not chest pain. If you are assisting a patient who has respiratory difficulty but no airway obstruction or signs of injury, look for the signs and symptoms of CHF. As blood pressure builds in the vessels of the lungs, fluid is forced into the lung tissue, causing it to swell. The patient may make a gurgling sound when breathing and start spitting up a white or pink froth or foamy fluid. At this point, the patient is actually \u201cdrowning\u201d in his or her own body fluids. The patient is very anxious but is usually in little or no pain (unless he or she is experiencing a heart attack coupled with CHF).\n\nAs soon as you determine that your patient is experiencing CHF, take these simple, life saving actions: \n1.Place the patient in a sitting position, preferably on a bed or chair. Having the legs hang down over the edge of the bed or chair helps drain some of the fluid back into the lower parts of the body and may improve breathing.\n2.Administer oxygen (if it is available and you are trained to give it) in large quantities and at a high flow rate.\n3.Summon additional help.\n4.Arrange for prompt transport to an appropriate medical facility. \n\nThe most important action you can perform is to place the patient in a sitting position with the legs down. This position helps relieve CHF symptoms until more highly trained EMS personnel arrive.",
        "Signs and symptoms of congestive heart failure": "Signs and symptoms of congestive heart failure include the following:\nShortness of breath\nRapid, shallow breathing\nMoist or gurgling respirations\nProfuse sweating\nEnlarged neck veins\nSwollen ankles\nAnxiety",
        "Dyspnea": "Dyspnea means shortness of breath or difficulty breathing. Although healthy people may experience shortness of breath during intense physical exertion or at high altitudes, this condition is not usually associated with serious heart or lung disease. Heart-related causes of dyspnea include angina pectoris, heart attack, and CHF. Pulmonary (lung) diseases such as chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, pneumonia, and asthma can also cause dyspnea.\nCOPD and emphysema are caused by damage to the small air sacs (alveoli) in the lungs. This damage decreases the amount of working lung capacity, resulting in shortness of breath. Chronic bronchitis is caused by an inflammation of the airways in the lungs. Pneumonia is caused by an infection in the lungs. Asthma is caused by a clamping down or spasm of the smaller air passages.\nAs an EMR, you will not always be able to determine what is causing a patient to be short of breath. Do not spend too much time trying to determine the specific cause. Focus on treating the symptoms of dyspnea.\n\nGeneral treatment for patients with dyspnea consists of the following steps\n1. Check the patient\u2019s airway to be sure it is not obstructed.\n2. Check the rate and depth of the patient\u2019s breathing. If the rate is less than 8 breaths per minute or more than 40 breaths per minute, be prepared to assist with mouth-to-mask or mouth-to-barrier device rescue breathing.\n3. Place the patient in a comfortable position. A conscious patient is usually most comfortable when sitting.\n4. Provide reassurance.\n5. Loosen any tight clothing.\n6. Administer oxygen if it is available and you are trained to do so.",
        "Asthma": "One common cause of dyspnea is asthma. Asthma is an acute spasm of the smaller air passages associated with excess mucus production and swelling of the lining of the respiratory passages. A type of allergic reaction can cause an asthma attack. Severe emotional stress, exercise, or a respiratory infection can also cause an asthma attack. Asthma is a common condition. According to the Centers for Disease Control and Prevention (CDC), more than 24 million people in the United States have asthma. It killed 3,630 people in the United States in 2013. Patients experiencing an asthma attack have great difficulty exhaling through partially obstructed air passages. A patient experiencing an asthma attack is like a person trying to exhale though a narrow straw. You will hear a wheezing sound during exhalation. If there is a limited amount of air moving through the small air passages, wheezing may be absent. Fatigued patients may be so short of breath that they are unable to talk. Many patients with asthma will have taken medications before your arrival.\n\nPatients can die during asthma attacks. It is important that you follow the steps just listed for treating dyspnea. In addition to these steps, you can instruct the patient to perform pursed-lip breathing. Ask the patient to purse his or her lips as if blowing up a balloon when exhaling. Tell the patient to blow out with force. Pursed-lip breathing relieves some of the internal lung pressures that cause the asthma attack. Treatment by paramedics or in the hospital includes medications that help to relax the constricted air passages. If advanced life support is not available, arrange for prompt transport to an appropriate medical facility.",
        "Treatment_7": "Patients who are short of breath or receiving oxygen should have their breathing and pulse monitored at least every 5 minutes. Underlying illness or trauma may cause certain patients to stop breathing and require you to begin rescue breathing.",
        "Stroke": "Strokes are the fifth leading cause of death in the United States. Many more people suffer brain injury and disability as the result of strokes. According to the CDC, each year about 795,000 adults experience strokes, and approximately 130,000 of them die. Strokes are a leading cause of long-term disability. Most strokes (87%) are caused by a blood clot that lodges in an artery of the brain. The clot blocks the blood supply to a part of the brain. Without treatment, that part of the brain will be damaged or die. Think of a stroke as a 'brain attack,' similar to a heart attack. People with high blood pressure have an increased risk of having a stroke.\n\nThe signs and symptoms of a stroke vary depending on what portion of the brain is affected. They can be similar to the signs and symptoms of a head injury, hypoglycemia, or seizures. When you are caring for a stroke patient, the person may be alert, confused, or unresponsive. Responsive patients may not be aware that they have signs of a stroke. Some stroke patients are unable to speak; others are unable to move one side of their body. The patient may have a headache and may describe it as 'the worst headache of my life.' Some stroke patients experience seizures.\n\nThe Cincinnati Prehospital Stroke Scale is an easy-to-administer and accurate tool that you can use to determine whether a patient may have experienced a stroke. It requires no special equipment to administer. This test consists of three assessments: assessment of the facial muscles by having the patient smile, assessment of arm drift by having the patient hold his or her arms in front of him or her, and speech assessment by having the patient repeat a simple phrase. If the patient is not able to complete one or more of these tasks, suspect a stroke.\n\nYour first priority is to maintain an open airway. Administer oxygen (if it is available and you are trained to use it) using a nasal cannula. If the patient is having a seizure, try to prevent further injury from occurring. Be prepared to administer rescue breathing if the patient stops breathing. Place an unresponsive patient in the recovery position to help maintain an open airway. This is especially important because some stroke patients are unable to swallow. Give emotional support by talking to and touching the patient. Be especially careful if you must move a patient because some patients may not be able to feel one side of their body.\n\nSome stroke patients can be treated with special drugs to dissolve the blood clot in their brain. These clot-buster drugs must be administered in the hospital within the first few hours after the stroke. For this reason, it is important for you to determine the time the stroke began by questioning the patient, family, or bystanders. If the patient has signs or symptoms of a stroke, it is important for you to arrange for prompt transport of the patient to a medical facility that is equipped to treat stroke patients.",
        "The Cincinnati Prehospital Stroke Scale": "The Cincinnati Prehospital Stroke Scale is a quick assessment tool for identifying a high likelihood of stroke by checking three indicators: (1) **Facial Droop**\u2014ask the patient to show their teeth or smile; observe whether both sides of the face move equally or if one side moves less; (2) **Arm Drift**\u2014with the patient\u2019s eyes closed, have them hold both arms straight out for 10 seconds and see whether both arms move equally (or not at all) or if one arm drifts downward compared with the other; and (3) **Abnormal Speech**\u2014have the patient say \u201cYou can\u2019t teach an old dog new tricks,\u201d then note whether they use the correct words without slurring, or if they slur, use the wrong words, or cannot speak. If any of these three signs is abnormal, there is a 72% probability that the patient is experiencing a stroke.",
        "The signs and symptoms of stroke": "The signs and symptoms of stroke include the following: Headache, Numbness or paralysis on one side of the body, Dizziness, Confusion, Drooling, Inability to speak, Difficulty seeing, Unequal pupil size, Unconsciousness, Seizures, Respiratory arrest, Incontinence, Unresponsiveness.",
        "Words of Wisdom_9": "A stroke patient may be able to hear what you are saying even if he or she cannot speak or appears to be unconscious. Be careful not to say anything that would increase the patient\u2019s anxiety.",
        "Voices of Experience": "It was a little overwhelming to see someone writhing on the floor uncontrollably, and it took me a second to absorb what was happening.\n\nSome people end up attracting the same type of call throughout their shift or even series of shifts. That was me when I first started in EMS; I was almost guaranteed a seizure call.\n\nPrior to my involvement with EMS, I had never witnessed a seizure. The terms generalized seizure, status epilepticus, and postictal were foreign.\n\nWe were dispatched to a community center for a male having a seizure. Seizures can have a variety of causes, but this patient was known to have epilepsy. When we arrived, people had cleared the area around him and he was still seizing. It was a little overwhelming to see someone writhing uncontrollably on the floor, and it took me a second to absorb what was happening. Then, the training kicked in. One of several concerns is the patient\u2019s airway, which is virtually impossible to assess while the patient is actively seizing. The patient\u2019s respiratory rate and tidal volume are compromised while he or she is in a seizure. The patient may vomit during and after the seizure, presenting the possibility of aspiration. We had suction ready along with a bag valve mask, high-flow oxygen, and an airway. The paramedic was prepared to start an IV line for both fluid and medication administration. Drugs like diazepam (Valium) are used to break or stop seriously prolonged seizure activity in a condition known as status epilepticus.\n\nAs the muscular activity subsided, the patient lay still. His breathing was shallow but present. We opened his airway, verified there were not any secretions, put a nonrebreathing mask on him, providing high-flow oxygen, and placed him on his side in the recovery position. He began to show purposeful movement and mumble a little. Seizure patients in their postictal phase (after the seizure, when the body is recovering) often are not able to communicate for some time, so it is our responsibility as EMRs to look out for what they may need. The paramedic started the IV line and we prepared to load the patient onto the gurney for our 35-minute transport to the nearest hospital.\n\nSome patients will have a medical bracelet indicating their condition; some scenes will have family or friends available to give us a medical history. Other times, we have to wait until the patient is able to provide us with information, but obtaining a SAMPLE history helps us to provide the best care possible. It is also important to keep in mind that, while someone who has been prone to seizures might be a little more comfortable in communicating with us after a seizure, someone who has experienced one for the first time could be embarrassed or confused, complicating the information-gathering process. Either way, be patient and understanding. The worst part is over. Give the patient a gentle, comforting ride to the hospital.",
        "Diabetes": "Diabetes is caused by the body\u2019s inability to process and use glucose (sugar) that is carried by the bloodstream to the body\u2019s cells. Glucose is an essential nutrient. The body\u2019s cells need both oxygen and glucose to survive. The body produces a hormone (chemical) called insulin that enables glucose carried by the blood to move into individual cells, which use it as fuel. If the body does not produce enough insulin, the cells become \u201cstarved\u201d for glucose. This condition is called diabetes. Many people with diabetes must take supplemental insulin injections to bring their insulin levels up to normal. Oral medicine rather than insulin is sometimes used to treat mild diabetes. Diabetes is a serious medical condition. Therefore, all patients with diabetes who are sick must be evaluated and treated in an appropriate medical facility. Two specific medical conditions can occur in patients in the course of managing their diabetes: hypoglycemia and diabetic coma. Consider both of these conditions as medical emergencies.",
        "Hypoglycemia": "Hypoglycemia, or low blood sugar, occurs if the body has enough insulin but not enough blood glucose. An older term for hypoglycemia is insulin shock. A person with diabetes may take insulin in the morning and then alter his or her usual routine by not eating or by exercising vigorously. In either case, the level of blood glucose drops and the patient experiences hypoglycemia. The signs and symptoms of hypoglycemia (insulin shock) are similar to those of other types of shock. Suspect low blood sugar if your patient has a history of diabetes or is wearing medical emergency information, such as a medical alert necklace or bracelet. Hypoglycemia is a serious medical emergency that can occur quickly, often within a few minutes. With very low levels of blood sugar, a person with diabetes may become unresponsive. If hypoglycemia is not diagnosed and corrected by the rapid administration of glucose in some form, the patient may die or experience permanent brain injury. A person experiencing hypoglycemia may appear to be drunk or confused. This is an important fact for you to keep in mind. EMS personnel who misinterpreted hypoglycemia as intoxication have made mistakes. If you suspect that a patient is experiencing hypoglycemia, try to get answers to the following questions:\nDo you have diabetes?\nDid you take your insulin today?\nHave you eaten today?\nIf the patient has diabetes and has taken insulin that day, but has not yet eaten, suspect that the patient is going into hypoglycemia. If the patient is able to swallow, attempt to get the patient to eat or drink something sweet. For example, you could use a drink that has a high sugar concentration such as a cola or orange juice. Honey is another possibility. Do not give a diet beverage to these patients. Diet beverages do not contain the necessary sugar.\n\nIf the patient is unconscious, do not try to administer fluids by mouth because the patient may choke and aspirate the fluid into the lungs. Summon help immediately. Open the patient\u2019s airway, and assist breathing and circulation, if necessary. The patient must have glucose administered intravenously as soon as possible. A paramedic or a physician can do this.\nSome EMRs carry glucose tablets or a tube of oral glucose gel. The preferred route for oral glucose administration is for the patient to swallow oral glucose tablets. If the patient is not able to safely swallow these, some people place a tablet or glucose gel inside the cheek. Some glucose will be absorbed through the inside of the patient\u2019s cheek. Glucose can be administered orally to patients who are able to swallow. Even though the patient\u2019s body may absorb only a small amount of glucose, it may be enough to prolong consciousness until the patient receives further medical treatment.",
        "Signs and symptoms of hypoglycemia": "Signs and symptoms of hypoglycemia include the following:\nPale, moist, cool skin\nRapid, weak pulse\nDizziness or headache\nConfusion or unconsciousness\nSweating\nHunger\nRapid onset of symptoms (within minutes)\n",
        "Words of Wisdom_11": "Progression into hypoglycemia is rapid and may be fatal; progression into diabetic coma usually takes several days.",
        "Diabetic Coma": "Diabetic coma occurs when the body has too much blood glucose and not enough insulin. For example, a person with diabetes may fail to take insulin for several days, resulting in blood glucose levels that build to higher and higher levels, but there is no insulin to process it for use by the body\u2019s cells. The patient may be unresponsive or unconscious. A patient experiencing a diabetic coma may appear to have the flu (influenza) or a severe cold. As with hypoglycemia, misdiagnosis is common. It is not always easy to tell the difference between hypoglycemia and diabetic coma.\n\nIf the patient is conscious and you cannot get definite answers to your questions to determine whether the patient is experiencing hypoglycemia or diabetic coma, you can do no harm by administering a liquid substance that contains sugar. In a patient who is experiencing low blood sugar, the sugar may improve the patient\u2019s condition. If the patient is experiencing a diabetic coma, the sugar will not raise blood glucose levels enough to do any further harm to the patient. In general, give conscious patients with diabetes sugar by mouth and arrange for prompt transport to an appropriate medical facility.",
        "Comparing Hypoglycemia and Diabetic Coma": "This table compares **hypoglycemia** (low blood sugar) with **diabetic coma** (high blood sugar). Hypoglycemia usually presents with **pale, moist, cool skin**, a **rapid, weak pulse**, and **normal breathing**, as well as **dizziness or headache**, **confusion or unresponsiveness**, and a **rapid onset of symptoms** measured in minutes. By contrast, diabetic coma often involves **warm, dry skin**, a **rapid pulse**, **deep, rapid breathing**, and, similarly, **confusion or unresponsiveness**, but it has a **slow onset of symptoms** over days rather than minutes.",
        "Treatment_12": "During your initial examination of every patient, look for an emergency medical alert device (such as a necklace or bracelet) to find out whether the patient has a preexisting medical condition, such as diabetes.\n\nIf the patient with diabetes is unconscious, arrange for prompt transport to an appropriate medical facility. An ambulance must transport every patient with diabetes who is experiencing illness to an appropriate medical facility for further treatment and examination.",
        "Signs and symptoms of diabetic coma": "Signs and symptoms of diabetic coma include the following:\n\nHistory of diabetes\nWarm, dry skin\nRapid pulse\nDeep, rapid breathing\nFruity or acetone odor on the patient\u2019s breath\nWeakness, nausea, and vomiting\nIncreased hunger, thirst, and urination\nSlow onset of symptoms (days)",
        "Abdominal Pain": "The abdomen is separated from the chest by the diaphragm. It is a crossroads for several body systems, including the circulatory, skeletal, nervous, digestive, and genitourinary systems. For example, the aorta carries blood from the heart through the abdomen to the lower parts of the body. Conversely, a large vein, the vena cava, carries blood back to the heart. The spine, with its large trunks of nerves, runs through this area. Parts of the rib cage surround the abdominal cavity. Most of the digestive system, including the stomach, small intestine, large intestine, liver, gallbladder, and pancreas, are in the abdomen. The kidneys and ureters are located in the abdominal area, as are parts of the male and female reproductive systems.\n\nThere are hollow and solid structures in the abdomen. Hollow structures, such as the small intestine, are really tubes through which contents pass. Solid structures, such as the pancreas and the liver, produce various substances used by the body. The structures in the abdomen are sometimes identified by quadrant, according to their location. As an EMR, you do not have to learn the names, types, and locations of all the abdominal structures, but it is helpful for you to have a basic understanding of the abdominal anatomy.\n\nThe abdomen occupies a large part of the body, and abdominal pain is a common complaint. Because of the number of body systems and organs located in the abdomen, even physicians may have a difficult time identifying the cause of abdominal pain. As an EMR, you need to be able to recognize that a patient has an abdominal condition. You do not have to determine the cause of the abdominal pain.\n\nOne condition you may encounter is called an acute abdomen. Irritation of the abdominal wall causes an acute abdomen. This irritation may be the result of infection or caused by the presence of blood in the abdominal cavity as the result of disease or trauma. A patient with an acute abdomen may have referred pain in other parts of the body such as the shoulder. The abdomen may feel as hard as a board. These patients may have nausea and vomiting, fever, and diarrhea as well as pain.\n\nSome patients with abdominal pain will vomit blood because they are bleeding from the esophagus or the stomach. Bleeding from the lower part of the gastrointestinal tract may produce bloody stools that contain bright red blood or the stools may be black and tarry. Treat these patients for shock. Arrange for prompt transport to an appropriate medical facility. \n\nIf a patient has abdominal pain, monitor vital signs, treat symptoms of shock, keep the patient comfortable, and arrange for transport to an appropriate medical facility. It is important for a physician to examine these patients.\n\nOne cause of an acute abdomen is an abdominal aortic aneurysm (AAA). An abdominal aortic aneurysm occurs when one or more layers of the aorta become weak and separate from other layers of the aorta. Patients who have diabetes, high blood pressure, or atherosclerosis, as well as heavy smokers, are at high risk for developing an AAA. The weakening of the aorta causes a ballooning of the vessel, much like a weak spot on thin rubber tubing. If this weak spot or aneurysm ruptures, the patient will rapidly lose large quantities of blood into his or her abdomen. This massive internal blood loss will cause profound shock.\n\nPatients with an AAA may report pain in the abdomen. Some patients describe this pain as a tearing sensation. They may have pain referred to the shoulder. If an AAA ruptures, the patient will experience severe pain and profound shock from the blood spilling into the abdomen.\n\nPlace any patient who experiences these signs and symptoms in a comfortable position. This is often a side-lying position with the legs drawn up. Treat the patient for shock. Handle these patients gently and arrange for prompt transport to an appropriate medical facility. The sooner these patients receive medical care, the better their chance of survival will be.",
        "Signs and symptoms of an acute abdomen": "Signs and symptoms of an acute abdomen include the following: Nausea and vomiting Loss of appetite Pain in the abdomen Rigid abdomen Distention Shock",
        "Kidney Dialysis Patients": "People with certain types of kidney disease are unable to filter waste products from their bloodstream. Many patients with chronic renal (kidney) failure must undergo a treatment called hemodialysis two or three times a week. During hemodialysis, the patient\u2019s blood passes through a machine that filters out the waste products and returns the cleansed blood to the patient. Most hemodialysis patients have a special device called a shunt implanted in their arm or leg. The shunt is a surgically created connection between an artery and a vein. The shunt is used to connect the patient to the hemodialysis machine. A shunt looks like a raised bump on the patient\u2019s arm or leg. If you have a patient who is on dialysis, find out if he or she has a shunt. If a shunt is in place, be sure to take the patient\u2019s blood pressure in the arm without the shunt to prevent damaging it.\n\nPatients who are receiving dialysis treatment may experience medical emergencies related to the treatment. During or shortly after dialysis treatment, patients may experience a drop in blood pressure caused by the changes in their body from the treatment. This decrease in blood pressure can produce shock. Patients receiving dialysis treatment are also at risk for internal bleeding. Bleeding from stomach ulcers may result in the patient vomiting blood or having bloody stools. If the tubing that connects the patient\u2019s shunt to the dialysis machine separates, the patient can lose a significant amount of blood externally. Hemodialysis patients may also experience abnormal levels of electrolytes in their blood that can cause cardiac arrhythmias that sometimes result in cardiac arrest. For these conditions, treat the symptoms presented by the patient. Remember that the patient can most likely supply you with information about these situations. If not, question the patient\u2019s companions and caregivers because they are with the patient for many hours each week.",
        "Prep Kit-Ready for Review": "Your approach to a patient who has a general medical complaint should follow the systematic patient assessment sequence. Usually, it is best to collect a medical history on the patient experiencing a medical condition before you perform a physical examination. The SAMPLE history format will help you secure the information you need.\nGeneral medical conditions may have different causes, but they result in similar signs and symp-toms. By becoming skilled at recognizing the signs and symptoms of various general medical conditions and learning about general treatment guidelines, you will be able to provide immediate care for patients even if you cannot determine the exact cause of the condition.\nAltered mental status is a sudden or gradual decrease in the patient\u2019s level of responsiveness. When you are assessing altered mental status in a patient, remember the AVPU scale. Complete the patient assessment sequence to ensure scene safety and proper assessment. Initial treatment should consist of maintaining the patient\u2019s ABCs and normal body temperature and keeping the patient safe from incurring any additional harm. If the patient is unconscious and has not sustained trauma, place the patient in the recovery position or use an airway adjunct to help maintain an open airway.\nSeizures are caused by sudden episodes of uncontrolled electrical impulses in the brain. Usually, the seizure will be over by the time you arrive at the scene. If it has not ended, focus your treatment on protecting the patient from injury. Do not restrain the patient\u2019s movements. You cannot do anything about the patient\u2019s airway during the seizure, but once the seizure has stopped, it is essential that you ensure an open airway. After you have opened the airway, place the patient in the recovery position and arrange for transport to an appropriate medical facility.\nThe second part of this chapter covers some specific medical conditions: angina pectoris, heart attack, congestive heart failure, dyspnea, asthma, stroke, hypoglycemia, diabetic coma, and abdominal pain. By learning the causes and knowing the signs and symptoms of these conditions, you may be able to provide specific care for the patient. Although a physician must diagnose and treat these conditions, you can greatly improve the patient\u2019s chances of survival by taking the simple actions described here until more highly trained EMS personnel arrive on the scene to assist you.",
        "Vital Vocabulary": "abdominal aortic aneurysm (AAA): A condition in which the layers of the aorta in the abdomen weaken. This causes blood to leak between the layers of the artery, causing it to bulge and sometimes rupture., absence seizures: Seizures that are characterized by a brief lapse of attention. The patient may stare and not respond; formerly known as petit mal seizures., acute abdomen: The sudden onset of abdominal pain caused by disease or trauma that irritates the lining of the abdominal cavity and requires immediate medical or surgical treatment., angina pectoris: Chest pain with squeezing or tightness in the chest caused by an inadequate flow of blood to the heart muscle., asthma: A disease in which the airway becomes narrowed and inflamed, resulting in episodes of shortness of breath because of air being trapped in the small air sacs of the lungs., atherosclerosis: A disease characterized by thickening and destruction of the arterial walls and caused by fatty deposits within them; the arteries lose the ability to dilate and carry blood., bronchitis: Inflammation of the airways in the lungs., cardiac arrest: Sudden cessation of heart function., chronic obstructive pulmonary disease (COPD): A slow process of destruction of the airways, alveoli, and pulmonary blood vessels caused by chronic bronchial obstruction (emphysema)., diabetes: A disease in which the body is unable to use glucose normally because of a deficiency or total lack of insulin., diabetic coma: A state of unconsciousness that occurs when the body has too much glucose and not enough insulin., dyspnea: Shortness of breath or difficulty breathing., generalized seizures: Seizures characterized by contractions of all the body\u2019s muscle groups that may last for 1 to 2 minutes; formerly known as grand mal seizures., hypoglycemia: A condition of low blood sugar that occurs in a person with diabetes who has taken too much insulin or has not eaten enough food., nitroglycerin: A medication used to treat angina pectoris; increases blood flow and oxygen supply to the heart muscle and reduces or eliminates the pain of angina pectoris., stroke: A brain attack caused by a blood clot or a broken blood vessel in the brain. Strokes can result in trouble speaking, inability to move parts of the body, confusion, or unconsciousness."
    },
    {
        "Introduction": "Every emergency situation, whether it is an illness or an injury, has emotional and psychological effects on everyone involved\u2014you, the patient, the patient\u2019s family and friends, and even bystanders. When you respond to the scene of a behavioral emergency, you will need to give psychological support as well as the necessary emergency medical care to your patient. This chapter explains the five major factors that cause behavioral emergencies: medical conditions, physical trauma conditions, psychiatric illnesses, mind-altering substances, and situational stresses.\n\nThe simple intervention techniques addressed in this chapter will help prepare you to care for patients and their families during the stressful experience of a medical emergency. Also, you will be better able to identify and understand the reactions to the grief that you observe.\n\nMany patients experience high anxiety, denial, anger, remorse, and grief during a situational crisis. Three skills that are useful to you when communicating with patients in crisis are restatement, redirection, and empathy. This chapter provides information on how to deal with crowd control, domestic violence, violent patients, armed patients, suicide crises, sexual assault, posttraumatic stress disorder, and death and dying. Medical and legal considerations and the role of critical incident stress debriefings are also covered.",
        "Patient Assessment in Behavioral Emergencies": "When you are assessing a patient who appears to be experiencing a behavioral emergency, you should follow the steps of the patient assessment sequence. You should complete a scene size-up, being especially careful to ensure the scene is safe for you and for the patient. If the patient is oriented and responsive, you can complete your primary assessment by observing the patient\u2019s responsiveness, airway, breathing, and measuring the pulse to determine the rate and strength of the heartbeat. Use the SAMPLE mnemonic to aid you when obtaining the patient\u2019s past medical history. You may need to ask additional questions about the events leading up to the call for assistance. Do not neglect to ask about medical problems. Many of the calls you receive for situations that appear to be behavioral will have a medical cause or a medical component. It is important that you do not overlook this part of your examination.\n\nThe secondary assessment should rule out any obvious injuries and focus on signs of medical illnesses. Some patients experiencing a behavioral crisis may not be aware of injuries or illnesses that might contribute to their condition. Complete your secondary assessment by taking a set of vital signs. As you are performing your patient assessment, inform the patient what you are doing at each step of the way. Complete the last step of the patient assessment by reassessing the patient every 15 minutes for a stable patient and every 5 minutes for an unstable patient. Some patients will not let you assess them. In this case, try to help the patient understand that you are trying to help. However, in cases where you cannot complete the assessment, be sure to document your assessment findings and the reason for not completing all the steps.",
        "Patient assessment sequence.": "Scene Size-up, primary Assessment, History Taking, Secondary Assessment, Reassessment",
        "Behavioral Crises": "As an emergency medical responder (EMR), you will encounter situations in which patients exhibit abnormal behavior. Sometimes this abnormal behavior is the primary reason that you have been called to the scene, and sometimes it is a secondary reaction to another situation such as an accident or illness. A behavioral emergency is a situation in which the patient exhibits abnormal behavior that is unacceptable or cannot be tolerated by the patient himself or herself or by family, friends, or the community. Some behavioral emergencies involve your patient, and others involve the patient\u2019s family or friends.\n\nFive main factors contribute to behavioral changes. They are:\n1. Medical conditions such as uncontrolled diabetes that cause low blood glucose, respiratory conditions that prevent the patient\u2019s brain from receiving enough oxygen, strokes, head injuries, high fevers, infections, and excessively low body temperature.\n2. Physical trauma conditions such as head injuries and injuries that result in shock and an inadequate blood supply to the brain.\n3. Psychiatric illnesses such as depression, panic disorders, or psychotic behavior (mental disturbance characterized by abnormal thought processes and/or the loss of contact with reality).\n4. Mind-altering substances such as alcohol and a wide variety of chemical substances.\n5. Situational stresses from a variety of emotional traumas such as death or serious injury to a loved one.\nTo better understand a behavioral crisis, you need to look at the phases a person experiences during a situational crisis.",
        "What Is a Situational Crisis?": "Simply put, a situational crisis is a state of emotional upset or turmoil. The crisis is caused by a sudden disruptive event such as a physical illness, a traumatic injury, or the death of a loved one. Every emergency creates some form of situational crisis for the patient and those people close to the patient. You will often encounter this type of crisis as an EMR. Some of the concepts covered here are similar to the concepts covered in Chapter 2, Workforce Safety and Wellness. Most situational crises are sudden and unexpected (such as a motor vehicle crash), cannot be handled by the person\u2019s usual coping mechanisms, last only a short time, and can cause socially unacceptable, self-destructive, or dangerous behavior.",
        "Phases of a Situational Crisis": "There are four emotional phases to each situational crisis. Although a person may not experience every phase during a crisis, he or she will certainly experience one or more of the phases. If you understand what these phases are and why they occur, you can better understand how to help the people who are experiencing a behavioral crisis.",
        "High Anxiety or Emotional Shock": "In the first phase of a situational crisis, a person exhibits high anxiety or emotional shock. High anxiety is characterized by rather obvious signs and symptoms: flushed (red) face, rapid breathing, rapid speech, increased activity, loud or screaming voice, and general agitation. Emotional shock is often the result of a sudden illness or accident or the sudden death of a loved one. Like most other types of shock, emotional shock is characterized by signs and symptoms including cool, clammy skin; a rapid, weak pulse; vomiting and nausea; and general inactivity and weakness.",
        "Words of Wisdom": "The emotional phases of a situational crisis are: High anxiety or emotional shock Denial Anger Remorse and grief",
        "Denial": "The next phase of a situational crisis may be denial or a refusal to accept the fact that an event has occurred. For example, a child who has just suffered the loss of a parent may refuse to accept the death by telling everyone that the parent is sleeping or has gone away. Allow the patient to express denial. Do not argue with the patient, but try to understand the emotional and psychological trauma that he or she is experiencing.",
        "Anger": "Anger is a normal human response to emotional overload or frustration. Anger may follow denial or, in some cases, may occur instead of denial. For example, the spouse of a patient may, for no apparent reason, begin screaming at you, calling you incompetent, or using foul language or racial slurs. Although it may be difficult, you should remain calm and not respond angrily as well. In crisis situations, it is often easier to vent angry feelings on an unknown person (the EMR) or an authority figure (a law enforcement officer) than on a friend or family member. Anger is perhaps the most difficult emotion to deal with objectively because the angry person seems to be directing his or her anger at you. Do not take the person\u2019s anger personally, but acknowledge that it is a reaction to stress. Frustration and a sense of helplessness can often build to anger. If these emotions are not released, the anger may be expressed by aggressive physical behavior. For example, in a serious crash involving a school bus, you may have to demonstrate to bystanders that you and other rescue personnel are indeed removing children from the bus. If little activity is apparent to the bystanders, leading them to believe that nothing is being done, they may become angry, hostile, and even violent. In such situations, you must show confidence. Demonstrate that you are making progress. Always be professional and do not react to anger by becoming angry yourself. Remain calm and deliberate in your actions to prevent the escalation of violence. If necessary, a member of the emergency medical services (EMS) team may have to explain the situation\u2014what is being done and why it appears to be taking so long. Acknowledge anger by saying something like, \u201cWhat\u2019s the matter? Can you tell me what I can do to help?\u201d Then allow the person to express his or her anger.",
        "Treatment": "Virtually every emergency call requires some degree of psychological intervention.\n\nRemorse or Grief\nAn acceptance of the situation may lead to remorse or grief\nPeople may feel guilty or sorry about their behavior or actions during an incident. They may also express grief about the incident itself.",
        "Crisis Management": "As an EMR, you should consider how you can best manage a patient\u2019s emotional concerns or crises. When you have a patient who is experiencing a behavioral or situational crisis, you need to approach the situation using the same general framework for patient assessment that applies to other types of patients. In this section, you will learn about some additional skills that you can use for patients who are exhibiting behavioral crises or emotional stress.",
        "Role of the Emergency Medical Responder": "Remember, as an EMR, your approach to a patient who may be exhibiting abnormal behavior is to follow the steps of your patient assessment sequence: 1. Perform a scene size-up. 2. Perform a primary assessment. 3. Obtain the patient\u2019s medical history (SAMPLE). 4. Perform a secondary assessment. 5. Provide ongoing reassessment. After you complete the primary assessment, you may need to obtain the patient\u2019s medical history or perform a physical examination, depending on the needs of that individual patient. As you perform these steps, it is important that you remain calm and reassure the patient. Your most important assessment skill may be your ability to communicate with the patient. Your communication skills will help you obtain needed information from the patient as you calm and reassure the patient.",
        "Communicating With the Patient": "The first and most important step you can take in crisis management is to talk with the person. Talking lets the person know that someone cares. Introduce yourself to the patient, ask the patient his or her name, and ask what you can do to help. When you communicate with the patient, be honest, warm, caring, and understanding. When you begin talking with the patient, your body language is as important as your words. Try to position yourself at eye level with the patient. If the person is lying down, kneel beside him or her. If the person is sitting, move down to his or her level. Do not stand above the person with your hands on your hips. This is a threatening position and communicates an uncaring attitude and indifference to the patient\u2019s problem. \n\nWhen you establish eye contact with the person, you are assuring him or her that you are, indeed, interested in helping. Use a calm, steady voice when you talk to the person and provide honest reassurance. Avoid making false statements or giving false assurances. The patient does not want to be told that everything is all right when it obviously is not.\n\nTry not to let negative personal feelings about the person or about the person\u2019s behavior interfere with your attempt to assist. Your function is to help the person cope with the events that caused the crisis. You should remain neutral and avoid taking sides in any situation or argument.\n\nSometimes a simple act, such as offering a tissue or a warm blanket, defuses the person\u2019s reaction to the immediate crisis. Simple acts of kindness can comfort and reassure the person that you are there to help. Some patients are comforted by your touch during an emergency. It provides a sense of presence, reassurance, and comfort to them. Other patients may find your touch offensive and may become upset or violent if you touch them without their permission. Be observant in determining when touch is approprWords of Wisdomiate.",
        "Words of Wisdom_0": "The following crisis intervention tips may help you at the scene of a behavioral emergency:\nTake your time.\nRemain calm.\nReassure the patient.\nUse eye contact.\nTouch the patient, if appropriate.\nTalk in a calm, steady voice.\nDemonstrate confidence.\nDo not take the patient\u2019s comments personally.",
        "Restatement": "To show the person that you understand what he or she is saying, you can use a technique known as restatement. This means you rephrase a person\u2019s own words and thoughts and repeat them back to the person. Here is an example:\n\nPatient:\n I just don\u2019t think I can go on anymore. Nobody cares.\nEMR:\n You sound like you are very discouraged. Why do you feel you can\u2019t go on and that nobody cares?\n\nThese communication techniques can also be effective with patients who have sustained trauma or are experiencing a medical illness. Here is another example of restatement with an injured patient who is experiencing a crisis:\n\nPatient with a broken arm:\n I can\u2019t take any more of this pain!\nEMR:\n The pain may seem unbearable to you right now, but it will ease up when we finish applying this splint.\n\nIt is not usually helpful to say, \u201cI know what you mean,\u201d or, \u201cI know how you feel.\u201d You do not know exactly how the patient is feeling, even though you may have been through a similar experience. Be honest and give the patient hope, but do not give false hope.",
        "Redirection": "Sometimes, a patient may be embarrassed about being the center of attention or may be concerned about others involved in the situation. Redirection helps focus a patient\u2019s attention on the immediate situation or crisis. You should use redirection in an attempt to lessen the concerns the patient expressed and draw his or her attention back to the immediate situation. An example of redirection follows:\n\nPatient involved in a motor vehicle crash:\n Oh my God! Where are my children? What\u2019s wrong with my children?\nEMR:\n Your children are being taken care of by my partner; they are in good hands. Now, we must take care of you.\n\nIf the patient is in a public place such as on a sidewalk or in the lobby of a building, move the patient to a location that is quieter and more private, if the injury or illness permits.",
        "Empathy": "The ability to empathize involves the ability to sense someone else\u2019s emotions and to imagine what he or she might be thinking and feeling. Empathy helps you understand the emotional or psychological trauma the patient is experiencing. Ask yourself, \u201cHow would I feel if I was lying on the sidewalk with my clothes all torn and bloody and strangers were looking down at me?\u201d Empathy is one of the most helpful concepts you can use when caring for patients in crisis situations. To show empathy and to reassure the patient, you need to use a calm and caring approach.",
        "Communication Skills": "By using these various communication skills, you will be able to more effectively manage the patient\u2019s conditions. Practice these skills with another person until you are comfortable using them. Some principles you can use when assessing patients with a behavioral crisis are listed here:\n1. Identify yourself and let the patient know you are there to help.\n2. Inform the patient of what you are doing.\n3. Ask questions in a calm, reassuring voice.\n4. Allow the patient to tell you what happened. Do not be judgmental.\n5. Show you are listening by using restatement and redirection.\n6. Acknowledge the patient\u2019s feelings.\n7. Assess the patient\u2019s mental status:\nAppearance\nActivity\nSpeech\nOrientation to person, place, and time\nMood\nThought process\nMemory",
        "Special Populations-Communicating With Patients With Developmental Disabilities": "Data from the Centers for Disease Control and Prevention indicate that 1 in 6 children have some type of developmental disability.\nDevelopmental disabilities range from learning disabilities and developmental delays to autism spectrum disorder. Some patients with developmental disabilities will present a challenge for you during an emergency. For example, patients with autism spectrum disorder might:\nAvoid eye contact and want to be alone.\nNot look at objects when another person points to them.\nHave trouble expressing their needs using typical words or motions.\nAppear to be unaware when people talk to them but respond to other sounds.\nHave trouble adapting when a routine changes.\nPrefer not to be held or cuddled.\nSome of the behaviors listed above may make it difficult for you to determine the patient\u2019s illness or injury. These behaviors may make it harder to assess the patient and more difficult to provide needed treatment. If a family member or caregiver is present with the patient, he or she is often helpful. He or she can supply helpful information about the patient, help you determine the patient\u2019s problem, and he or she can often communicate more effectively with the patient. If no caregiver or relative is present, use the communication skills described. Remain calm, speak in a reassuring tone, and allow only one person to communicate with the patient",
        "Crowd Control": "Performing simple crowd control may help reduce a patient\u2019s anxiety when there are too many people around. Encourage bystanders to leave. Sometimes too many emergency personnel have been dispatched to the scene. The presence of many uniformed personnel in a small apartment, for instance, is overwhelming or threatening to some people. Any emergency personnel who are not needed right away should leave the room or immediate area until the patient calms down. During your initial overview of the emergency scene, look to see if there is a crowd that may become hostile. If you feel the potential exists, it is better to ask for assistance early on to deal with an unhappy crowd than it is to wait until the situation is unsafe for you and your patient.",
        "Domestic Violence": "Domestic violence is common in today\u2019s society. It takes on different forms, including elder abuse, child abuse, and spousal and domestic partner abuse. As an EMR, you need to recognize the signs and symptoms of abuse and to understand the three phases in the cycle of abuse. Protecting yourself at the scene is also very important. When you respond to a situation involving domestic violence, you know how to maintain safety for yourself and for the patient and how to conduct an effective assessment and treatment in what could be a volatile situation. Finally, understand the requirements for reporting abuse in your state. The signs of abuse include physical injuries, the emotional state of the patient, and the personality indicators of the abuser. Physical injuries from domestic violence include broken bones, cuts, head injuries, bruises, burns, and scars from old injuries. Internal injuries may also be caused by abuse. In some cases, injuries will be in varying stages of healing. The abused person\u2019s emotional scars and symptoms may include depression, suicide attempts, and abuse of alcohol or drugs. The patient may have feelings of anxiety, distress.and hopelessness. People who are abusers may be paranoid, overly sensitive, obsessive, or threatening. They often abuse alcohol or drugs and have access to weapons. If you suspect abuse, your responsibility is to maintain safety for yourself and for the patient. Dealing with a violent person is covered later in this chapter. To defuse a tense situation, try to separate the patient from the person who may have been the abuser. This will create a safe place for the patient, give you a chance to gather needed information, and allow you to treat the patient\u2019s injuries. As you question the patient, express your concern. Ask the patient if she or he is all right. Avoid judging the patient. If the patient refuses to be transported, some agencies provide information about domestic abuse shelters. In some cases, the presence of law enforcement personnel will be helpful. Finally, learn the requirements for reporting cases of suspected abuse in your state.",
        "Cycles of Abuse": "Abuse has been described as a three-part cycle. In the tension-building phase, the abuser becomes angry and often blames the victim. If the victim has been in the relationship for some time, he or she may recognize the tension buildup and react by trying to calm the abuser. The victim may also try to minimize or deny the abuse. The tension phase is usually the longest part of the abuse cycle. The second stage is the explosive, or acute battery, phase, when the abuser becomes enraged and loses control as well as the ability to think clearly. Most injuries to the victim occur during this stage. The third phase is the honeymoon or makeup phase. During this stage, the abuser may make all sorts of promises, which are seldom kept. This phase helps keep the abused person in the relationship with the abuser. As an EMR, you may enter a domestic scene anywhere in this cycle. Understanding this cycle will help you to anticipate the actions of both the abuser and the person being abused.",
        "Violent Patients": "If you must treat an unarmed patient who is or may become violent, immediately attempt to establish verbal and eye contact with the patient. This begins the process of establishing rapport with the patient, which is important for communicating with a potentially violent person. If family members or friends are present, ask them about the patient\u2019s history of violence. A patient with a history of violence is more likely to become violent again. Is the patient yelling or issuing verbal threats? Loud, obscene, or bizarre speech indicates emotional instability. Assess the patient\u2019s posture to determine whether he or she is showing threatening behavior. A person who is pacing, cannot sit still, or tries to protect his or her personal space is more likely to become violent. Patients who have been abusing alcohol or drugs are also at a high risk for developing violent behavior. Do not force the patient into a corner, and do not allow yourself to be cut off from a route of retreat. \n\nIn these situations, it is usually best to have only one person talk with the patient. Having more than one rescuer attempt conversation is often very threatening. The communicator should be the rescuer with whom the patient seems to have the best initial rapport.\n\nIf all other means of approach and intervention fail, it may be necessary for you to summon law enforcement personnel to control a violent patient.",
        "Voices of Experience": "Be willing to look beyond the situation at hand.\n\nHow many of us have experienced a personal behavioral situation when responding to an incident? We may also have family members, friends, or a coworker with some type of a personal situation we don\u2019t talk about. As responders, we should not forget that a patient in a behavioral emergency may be crying out for help or just need someone to talk to.\n\nIn the late 1990s, we responded to a call of a man cutting himself with glass. We were told to hold short until the Sheriff\u2019s Officer had secured the scene. The scene was declared safe within a few minutes. (Let\u2019s all remember that our safety comes first.) We arrived on scene and found a man in his late 20s stabbing himself in his upper legs with broken bottles.\n\nAfter obtaining a brief history from family members, we found out that the patient was taking medications for mental illness and that he had had an argument with his father earlier that day. The family stated he had been off his medication for around a week. We convinced the patient to stop hurting himself after a few minutes. He continued saying no one wanted him. He was transported to the local emergency department for treatment. During his stay in the emergency department, a nurse turned her back, and the patient left the emergency department and went to the woods across the street from the hospital. He was found there less than an hour later, stabbing himself with tree branches.\n\nA second incident occurred about 3 months later, at the same residence. This time the patient had taken two broken beer bottles and had walked to the interstate near his home. He was found sitting on the guardrail with the necks of the bottles around his thumbs and resting at his neck veins. Several bystanders had stopped and were trying to convince him to remove them from his neck. This was making the situation worse.\n\nAfter obtaining a history report, we found out that he and his father had been arguing again. After talking with him, I managed to convince him to be treated for small cuts to his neck. He kept saying no one liked him; we had to convince him to believe in himself. He was later removed from the family setting and hospitalized. After about 2 years of hospitalization he was released. We see him from time to time, and he is a changed person. His family lives in the area but will not see him. We have not had a call to his residence in several years. Sometimes family members can contribute to a behavioral illness.When confronted with this type of situation, the responder has to remember that this could be his or her own family member. Be willing to look beyond the situation at hand. What caused this person to react this way? Remember, your safety comes first, then your crew\u2019s safety, and then the patient\u2019s safety.",
        "Violence Against EMRs": "According to the National Institute for Occupational Safety and Health, the following factors increase the risk of violence in the workplace: \nWorking alone or in small numbers\nWorking late at night or early in the morning hours\nWorking in high-crime areas\nWorking in community settings\nAll of these factors describe your job as an EMR. You come in contact with all kinds of people at all hours of the day and night. You work in the community and may be called to high-crime areas. You should be alert when you respond to a call that has an increased chance for violence. These include crime scenes, incidents involving gangs, large gatherings of hostile or potentially hostile people, and domestic disputes (previously discussed). However, even though you are more likely than the average citizen to be involved in potentially violent situations, there are steps you can take to minimize the chance of injury to you and to your patients. Take steps to keep yourself and other rescuers safe at these scenes. Remember, always keep an escape route between you and the patient at scenes that may become dangerous.",
        "Prevention": "Prevention is the best way to avoid violence. It is far better to avoid or prevent an incident of violence than to have actual violence erupt and then have to deal with it. You may have several different opportunities for preventing violence. Can you learn anything from the dispatch information you received about the incident? As you arrive at the scene, use your personal antenna to pick up any signs that you may be approaching a violent situation. Make sure you have an escape route in mind as you approach any suspicious scene.\n\nYour ability to use good interpersonal communication skills will help prevent many situations from becoming violent. Empathy can often defuse tense situations. Practice the communication skills discussed in this chapter. If you think you need backup or law enforcement personnel, request it early. If you are unable to handle a situation by yourself, remember your escape route. Learn your local protocols for violent situations and take part in additional safety training for handling this type of situation.",
        "Safety": "If you have any doubts about your safety at a scene, wait at a safe distance and request assistance from law enforcement officials.",
        "The Armed Patient": "You may encounter a person who is armed with a gun, knife, or other weapon. It is not your role to handle this situation unless you are a law enforcement officer. Be alert for potentially threatening situations and summon assistance if you think the person is armed. Do not proceed into an area where there may be an armed person without assistance from law enforcement personnel. If you must wait for law enforcement personnel to arrive, stay with your vehicle in a safe location. If, despite caution, you are confronted by an armed person, immediately attempt to withdraw. Your best defense is to avoid confronting a person who is armed! Work with the law enforcement personnel in your area to learn what your role is in cases that might involve an armed person.",
        "Safety_2": "If you cannot withdraw from a dangerous scene:\nStay calm.\nDo not turn your back on the patient.\nDo not make threatening moves.\nTry to talk with the person and explain that you are there to give emergency medical assistance.",
        "Medical and Legal Considerations": "To protect the rights of the patient and to protect yourself from any possible legal action, you must understand the laws of your state and community that relate to dealing with patients experiencing a behavioral emergency. If a patient agrees to be treated, there should be few legal issues. However, if a patient who appears to be disturbed refuses to accept treatment, it may be necessary to provide care against the patient\u2019s will. To do this, you must have a reasonable belief that the patient will harm himself, herself, or others. Usually, if patients are a threat to themselves or to others, it is possible to treat and transport them without their consent. As an EMR, you usually will not be responsible for transporting the patient, but you should know what the laws in your state permit you to do. This direction should come from your medical director and from legal counsel.\nThere may be times when it is necessary for you to apply reasonable force to keep a patient from injuring himself, herself, or others. If you are required to restrain a patient, you should consider the following factors: the patient\u2019s size and apparent strength, the sex of the patient, the type of abnormal behavior, the mental state of the patient, and the method of restraint. Whenever possible, you should avoid acts of physical force that may injure the patient. You may, however, use reasonable force to defend yourself against an attack by a behaviorally impaired patient.\nTo prevent legal issues if you must restrain a patient, seek assistance from law enforcement officials and from your medical director. It is also important to document the conditions present in cases where you must restrain or subdue a patient. To prevent accusations of sexual misconduct by behaviorally impaired patients, a caregiver of the same sex should take primary responsibility for the care of the patient, whenever possible.",
        "Other Types of Emotional Crises": "Four other types of emotional crises\u2014attempted suicide, posttraumatic stress disorder, sexual assault, and death and dying\u2014also require you to have good communication skills. Each of these situations is difficult for the patient and for the EMR.",
        "Attempted Suicide": "Each year, thousands of people, from teenagers to older adults, attempt suicide (self-inflicted death). People attempt suicide by ingesting poisons, jumping from heights or in front of motor vehicles or trains, cutting their wrists or neck, and shooting or hanging themselves. Not all suicide attempts result in death, and many patients who fail on their first attempt will try again to commit suicide. Most people who attempt suicide have a serious psychiatric illness, such as depression or alcohol or drug abuse. Many people attempt suicide while under the influence of alcohol or drugs. The underlying psychiatric disease is usually treatable, however, and with proper treatment the patient will no longer be suicidal. However, until that treatment is carried out, the patient must at all times be considered suicidal. All suicide attempts should be taken seriously. Do not be afraid to ask the patient questions about suicide such as: Do you feel depressed? Have you ever been prescribed medication for depression? Have you ever thought about suicide?\n\nManagement of an attempted suicide consists of the following steps\n1. Protect yourself and the patient from further harm.\n2.Obtain a complete history of the incident.\n3.Determine whether the patient still has a weapon or drugs on him or her.\n3.Support the patient\u2019s airway, breathing, and circulation (ABCs), as needed.\n3.Dress open wounds.\n4.Treat the patient for spinal injuries, if indicated.\n5.Do not judge the patient. Treat him or her for the injuries or conditions you discover.\n5.Provide emotional support for the patient and family.\n\nTalk with the patient as you are providing treatment. Remember, many suicide attempts are cries for help. In addition to treating the patient, you should provide emotional support for the patient\u2019s family. Help the family understand that a suicide attempt usually indicates an underlying psychiatric illness and that it is not the fault of the family or friends. It is not your role as an EMR to pass judgment on a patient; it is your role to provide a caring attitude and good medical care",
        "Special Populations_3": "One of the main causes of suicide in older adults is terminal disease. A person who knows he or she is going to die from an incurable condition may choose to commit suicide to avoid the final disability and suffering associated with that disease. In these cases, the patient\u2019s family will be coping with the grief from the diagnosis of the terminal disease as well as the patient\u2019s suicide. This is a time when they need your comfort and understanding. A second age group at high risk for attempted suicide is teenagers. For many teenagers, this is a difficult time of adjustment to growth and change. Stressors in this age group include school, interpersonal relationships, problems at home, and experimentation with drugs and alcohol. The rate of suicide among teenagers is high. Be especially alert for signs of depression and attempted suicide in teenage patients.",
        "Posttraumatic Stress Disorder": "Posttraumatic stress disorder (PTSD) is a mental health or behavioral condition triggered by experiencing or witnessing a terrifying event. Although many people who experience traumatic events have difficulty coping and adjusting for a while, most get better with time and by taking care of themselves. However, people experiencing PTSD get worse with time, and their anxiety often interferes with their normal day-to-day activities. General symptoms of posttraumatic stress disorder include severe anxiety, nightmares, flashbacks, and uncontrollable thoughts about the event. Symptoms may be broken into four different groups: 1. Intrusive memories. Includes unwanted distressing memories of the traumatic event, unsettling dreams, emotional distress when reminded of the event, or reliving the event. 2. Avoidance. People experiencing PTSD avoid places, activities, or people that remind them of the traumatic event. 3. Negative feelings. People with PTSD have negative changes in mood or thinking, such as the inability to experience positive emotions, experiencing negative feelings about themselves or others, a lack of interest in activities once enjoyed, difficulty maintaining close relationships, or feelings of hopelessness. 4. Emotional reactions. Being easily frightened, having difficulty sleeping, having trouble concentrating, engaging in self-destructive behavior, becoming irritable, or feeling overwhelmed with shame or grief. Physicians are not sure why some people develop PTSD and others do not. It may be caused by a mixture of multiple factors, and certain risk factors may make some people more likely to develop PTSD. These risk factors include having a job that increases the risk of being exposed to traumatic events (such as military personnel or first responders), having a preexisting mental health condition, lacking a good support system or coping mechanisms, or having experienced a trauma earlier in life. Traumatic events that may lead to PTSD include physical attack, sexual assault, childhood neglect, military combat exposure, or being threatened with a weapon.\n\nPeople experiencing PTSD may develop self-destructive behaviors including suicidal thoughts, eating disorders, or abuse of alcohol or drugs. They may also suffer from anxiety and depression or exhibit violent behaviors. Patients exhibiting any of these possible symptoms of PTSD need to receive appropriate medical care. PTSD is treated with a combination of psychotherapy and medications. It is important that these patients do not self-medicate and that they have a good support system to help them cope with their illness. As an EMR, you need to practice good communication skills when working with PTSD patients, always ensure your safety and the safety of your partner and your patient, and ensure your patient is transported to a facility where he or she can receive the necessary treatment.",
        "Sexual Assault": "Special consideration should be given to any person who has been sexually assaulted. These patients may be a man or a woman, old or young. Because sexual assault creates an emotional crisis, the psychological aspects of treatment are important. The patient may have a hard time coping with a rescuer who is the same sex as the person who committed the assault. You may have to delay all but the most essential treatment until a responder of the same sex as the patient arrives. Your first priority is the medical well-being of the patient, so treat any injuries the person may have (knife wounds, gunshot wounds, and so forth). However, because sexual assault is a crime, you should not remove any of the patient\u2019s clothing except to give medical care. Try to convince the patient not to bathe or use the toilet. Keep the scene and any evidence as undisturbed and intact as possible, and avoid aggressively questioning the patient as to what happened. In addition to giving medical care, treat the patient with empathy. Maintain the patient\u2019s privacy by covering her or him with a sheet or blanket, and do not leave the patient alone. Contact your local law enforcement agency and the organization designated as the rape crisis center in your community.",
        "Death and Dying": "As an EMR, you will encounter death and dying from natural, accidental, and intentional causes. How well you can help the dying patient and the person\u2019s family or friends largely depends on your own feelings about death. The material presented here expands on the material introduced in Chapter 2, Workforce Safety and Wellness. In some situations, there is nothing you can do and the patient dies. In other situations, the patient dies despite everyone\u2019s best efforts. In yet other situations, the patient\u2019s death is completely unexpected. In every case, you must do whatever you can to meet the patient\u2019s medical needs. Your attempts to save or give comfort to the patient help everyone (the patient, the family, and you) to cope emotionally with the patient\u2019s death.\n\nMost people are afraid of dying. Witnessing the death of another person brings that fear to the forefront, if only for a brief time. You must work through your personal feelings about death so you can confront it in the field. Although you may be somewhat uncomfortable bringing up the subject, it helps to discuss it with others in the emergency care field. If you are uncomfortable talking with your peers, talk to a member of your hospital\u2019s emergency department staff. Once you have done everything you can to medically treat a patient, consider the psychological needs of the patient and his or her family. Being there as an empathetic caregiver is helpful. Do not be afraid to touch. Putting an arm around a shoulder or holding the hand of the patient or a member of the family helps everyone, including you. Do not make false statements about the situation, but it is just as important not to destroy hope. Even if, in your judgment, the situation is hopeless, try to give comfort by making such positive statements as, \u201cWe are here to help you, and we are doing everything we can. The ambulance is on its way, and you will be at the hospital as soon as possible.\u201d\n\nAs unfortunate as it may seem, coping with the deaths of others is a routine aspect of your job as an EMR. Therefore, you must constantly be on guard to prevent any callousness from entering into your interactions with patients and their families. For every call you respond to, always deliver compassionate medical care.",
        "Signs and Symptoms of extreme stress": "Signs and symptoms of extreme stress include: Depression, Inability to sleep, Weight changes, Increased alcohol consumption or drug abuse, Inability to get along with family and coworkers, Lack of interest in food or sex.",
        "Critical Incident Stress Debriefing": "Providing emergency care is stressful for you as well as for the patient. As an EMR, you will encounter patients experiencing high levels of stress and anxiety. In emergency situations, there may be times when you may not always be able to help patients. Some types of situations, such as rescue missions involving children or mass-casualty incidents, tend to produce more stress than others. You may need counseling to cope with these stressors. If you let stress build up without releasing it in healthy ways, it can begin to have negative effects on you and your performance.\n\nTo help prevent excess stress and to relieve stress caused by critical incidents, some departments use a process called critical incident stress debriefing (CISD). CISD brings rescuers and a trained professional together to talk about the rescuers\u2019 feelings. CISD may help rescuers understand the signs and symptoms of stress and receive reassurance from the group leader. It also allows people to obtain more help from trained professionals, if needed. Some public safety agencies have set up CISD teams to handle stressful events. These teams may be helpful to rescuers who have been through an overwhelming or stressful event. Other departments have trained professionals available to counsel members who have experienced a highly stressful event. Additional information about critical incident stress debriefing is presented in Chapter 2, Workforce Safety and Wellness. Check with your agency to see what types of counseling and CISD resources are available.",
        "Prep Kit-Ready for Review": "Only a small percentage of the patients you treat are severely mentally ill, but almost every patient you care for is experiencing some degree of a behavioral and emotional crisis. No matter what type of incident or crisis is taking place, your response must be to help the patient.\nBehavioral emergencies are situations in which a person exhibits abnormal, unacceptable behavior that cannot be tolerated by the patients themselves or by family, friends, or the community.\nThe five major factors that contribute to behavioral crises: medical conditions, physical trauma conditions, psychiatric illnesses, mind-altering substances, and situational stresses.\nThe four emotional phases to each crisis include high anxiety or emotional shock, denial, anger, and remorse or grief. Although a person may not experience every phase during a crisis, he or she will certainly experience one or more of the phases\nYour role as an EMR consists of assessing the patient and providing physical and emotional care. Your most important assessment skill may be your ability to communicate with the patient. You must understand the laws of your state and community that relate to caring for patients experiencing a behavioral emergency. If a patient who is experiencing a behavioral emergency agrees to be treated, there should be few legal issues. However, if a patient who appears to be disturbed refuses to accept treatment, it may be necessary to provide care against the patient\u2019s will. To do this, you must have a reasonable belief that the patient would harm himself, herself, or others. Usually, if patients are a threat to themselves or to others, it is possible to treat and transport them without their consent.\nEven when you have thoroughly mastered the processes and tools for managing behavioral crises, it is important to remember that sometimes the best approach is to ask yourself, \u201cHow would I like to be treated if I were in this situation?\u201d",
        "Vital Vocabulary": "behavioral emergency: A situation in which the patient exhibits abnormal behavior that is unacceptable or cannot be tolerated by the patient him- or herself or by family, friends, or the community., critical incident stress debriefing (CISD): A system of psychological support designed to reduce stress on emergency personnel., emotional shock: A state of shock caused by a sudden illness, an accident, or the death of a loved one., empathy: The ability to share another person\u2019s feelings or ideas., posttraumatic stress disorder (PTSD): A mental health or behavioral condition triggered by experiencing or witnessing a terrifying event., psychotic behavior: Mental disturbance characterized by abnormal thought processes and/or the loss of contact with reality., redirection: A means of focusing the patient\u2019s attention on the immediate situation or crisis., restatement: Rephrasing a patient\u2019s own statement to show that he or she is being heard and understood by the rescuer., situational crisis: A state of emotional upset or turmoil caused by a sudden and disruptive event., suicide: Self-inflicted death."
    },
    {
        "Introduction": "As an emergency medical responder (EMR), you must sometimes assist in the birth of a child. A planned childbirth is an exciting, dramatic, and stressful event in itself. An unplanned childbirth, where you are called to assist, can be even more dramatic and stressful. However, if you remember some easy steps, you can effectively assist in the birth process and offer comfort and support to both the mother and the newborn. Childbirth is a normal and natural part of life. If you are concerned about your ability to handle such a situation, just remember that hundreds of thousands of deliveries occur in the world each day and result in healthy babies. In many countries, medical assistance at childbirth is the exception, not the rule. You may not have the time or necessary assistance to transport the pregnant woman to the hospital. Therefore, you must be prepared to help your patient deliver the newborn wherever she is. In most cases, during the birth process, the newborn is literally being pushed out of the body; therefore, your part involves helping, guiding, and supporting the newborn as he or she is born. Following the birth, ensure that the newborn is breathing adequately and being kept warm. Generally, pregnancy is not a surprise for the mother and she may be knowledgeable and well prepared for the birth process. However, there will be times when the timing of the childbirth catches everyone by surprise or a complication has developed, thus requiring a call to emergency medical services (EMS). In this chapter, you will learn about the three stages of the birth process. The two key indicators of an impending birth are the frequency of the contractions and the appearance of the newborn\u2019s head during a contraction, or crowning.",
        "The Anatomy and Function of the Female Reproductive System": "The major female reproductive organs are the ovaries, which produce eggs, and the uterus (womb), which holds the fertilized egg as it develops during a pregnancy (the usual gestational period is 40 weeks). The egg released by the ovaries travels through the fallopian tube to the uterus. The external opening of the female reproductive system is called the birth canal, which includes the lower part of the uterus and the vagina. The developing newborn (fetus) is covered in an amniotic sac for support and floats in amniotic fluid. The placenta, or afterbirth, draws nutrients from the wall of the woman\u2019s uterus. These nutrients and oxygen are delivered to the fetus through the umbilical cord.",
        "Assessing the Birth Situation": "Should you help deliver the newborn on the scene or arrange to transport the pregnant woman to the hospital? To make this decision, you need to understand that labor (the process of delivering a newborn) consists of three distinct stages.",
        "Stages of Labor": "The first stage of labor is when the pregnant woman\u2019s body prepares for birth. This stage is characterized by the following conditions: initial contractions occur, the bag of waters breaks (rupture of the amniotic sac, which is the fluid in which the fetus floats), the bloody show (a plug of mucus often mixed with blood) occurs, but the newborn\u2019s head does not appear during the contractions. Check the woman\u2019s vaginal opening to determine whether the newborn is crowning. Report your findings to the responding ambulance crew so that they can make a decision on whether the woman is close to delivery or transport to the hospital is necessary.\n\nThe second stage involves the birth of the newborn. You will see the newborn\u2019s head crowning during contractions, at which time you must prepare to assist the woman with delivery.\n\nThe third stage is the final stage. It involves delivery of the placenta (afterbirth). You must assist in stabilizing the condition of the mother and newborn and delivering the placenta",
        "Is There Time to Reach the Hospital?": "The following questions will help you to determine how close the pregnant woman is to delivery and whether there is time to transport her to the hospital or whether you need to prepare for a delivery.\n\n1. Is this the woman\u2019s first pregnancy?: The length of labor for a first-time mother is usually longer than for a woman who has had children. A woman who is experiencing her first labor will usually have more time to reach the hospital. It is also helpful to ask the woman the newborn\u2019s due date, although labor can start before this date.\n\n2. Has the woman experienced a bloody show?: As the newborn starts to descend toward the birth canal, the bloody show is expelled from the cervix and discharged from the vaginal opening. This occurs as the first stage of labor is about to begin.\n\n3. Has the bag of waters broken?: The bag of waters usually breaks toward the end of the first stage of labor and may give some idea of the progress of the birth process. In some women, the bag of waters may not break until the birth is actually occurring (discussed later in the chapter).\n\n4. How frequent are the contractions?: If the contractions are more than 5 minutes apart, you can usually transport the woman to the hospital. Contractions less than 2 minutes apart usually indicate that delivery will occur soon and you need to prepare for delivery. If the contractions are 3 to 4 minutes apart, take the other factors listed here into account to make your decision.\n\n5. Does the woman feel an urge to move her bowels?: When the newborn\u2019s head is in the birth canal, it presses against the rectum and the woman may feel the urge to move her bowels. Do not allow her to go to the toilet. This urge is an indication that she is close to delivery.\n\n6. Is the newborn\u2019s head crowning?: Crowning indicates that the newborn will be born in the next few minutes and you need to be ready.\n\n7. Is transportation available?: Find out whether the ambulance is responding and how far it is to the hospital. Will bad weather, a natural disaster, or rush hour traffic prevent prompt arrival of transportation?",
        "Timing Contraction Cycles": "When you care for a patient in labor, time the contraction cycles from the beginning of one contraction to the beginning of the next. If contractions are less than 3 minutes apart, delivery is close.",
        "Detecting Crowning": "To determine whether the newborn\u2019s head is crowning, you must observe the vaginal opening during a contraction. If you see the head crowning during the contraction, prepare for delivery. Do not risk transporting the woman to the hospital.",
        "Words of Wisdom": "Do not forget that pregnant women can experience trauma or medical emergencies too! It is important to perform a patient assessment to determine whether your patient has any additional medical conditions or has sustained a recent injury. It is easy to focus on the pregnancy and neglect other conditions.",
        "Preparing for Delivery": "As you prepare to assist the patient in the delivery, keep these two things in mind:\n1. Calm the woman. Delivery is a natural process.\n2. Calm yourself. You are there to help.\nBecause you are not in a hospital, you will not be able to maintain sterile conditions. However, be as clean as possible. Wash your hands thoroughly. If you do not have a sterile delivery kit, use the gloves from your emergency medical responder (EMR) life support kit (or even clean kitchen gloves, if they are available). Place the patient on a firm surface that is padded with blankets, folded sheets, or towels. Elevate her hips 2 inches to 4 inches (5 cm to 10 cm) with pillows and blankets. Allow the patient to get in a comfortable position. This is often on her back with knees bent and feet flat on the surface beneath her.\n\nHave plenty of clean towels ready to cover the newborn and to clean the mother after delivery has occurred. Childbirth involves blood and body fluids, so place towels or sheets on the floor around the delivery area to help soak up the fluids and to protect the mother and the newborn.",
        "Standard Precautions and Childbirth": "As the woman\u2019s contractions become more forceful, the newborn is gradually pushed down the birth canal. Because a woman in childbirth will expel both blood and body fluids, take standard precautions during the delivery. Try not to get any more blood or fluids on you than is absolutely necessary. Use sterile gloves during any delivery whenever possible. Sterile gloves protect not only the woman and newborn from infection but also protect you from any blood-borne diseases the woman might have.\n\nSkill Drill 16-1: Carefully open the sterile glove package without touching the gloves Step 1. Pick up the first glove by grasping one edge Step 2. Pull on the first glove, being careful not to touch the outside of the glove Step 3. Grasp the second glove by sliding two fingers of your gloved hand into the rolled edge Step 4. Put on the second glove Step 5. Keep the gloves as sterile as possible Step 6.\n\nBecause body fluids could splatter on your face during the delivery process, wear face and eye protection to keep possible splatter out of your eyes, nose, and mouth.\n\n Wearing a surgical gown can help keep fluids off your body. As an EMR, you will not have all the protective equipment that is available in a hospital. Do what you can to prevent unnecessary exposure to body fluids and report all direct exposures of blood or fluids to the emergency physician or to your medical director.",
        "Equipment": "You should have a prepackaged obstetric (OB) delivery kit in your emergency care equipment. The delivery kit includes the following materials:\nSterile gloves\nUmbilical cord clamp\nSterile drapes and towels\nSanitary pads\nGauze pads (4 inch \u00d7 4 inch [10 cm \u00d7 10 cm])\nTowel or blanket for the newborn\nBulb syringe\nPlastic placenta bag\nIn addition, you will need the following:\nSheets or towels for the mother\nSuction (if available)\nOxygen (if available and if you are trained to use it)\nNewborn-sized face mask\nIf you do not have an OB delivery kit, look for appropriate substitute materials. You can find most of these items in your EMR life support kit or in most homes. Even if you do not have any equipment, remember that you can still assist in delivering a newborn with only common sense and gloved hands.",
        "Assisting With Delivery": "As you prepare to assist with delivery, remember that there are two lives to be considered in this situation: the life of the mother and the life of the newborn. Do not neglect to perform a patient assessment on the woman. Determine whether she has any medical conditions. Obtain a baseline set of vital signs and repeat them at least every 15 minutes. Throughout the delivery process, continue to monitor her airway, breathing, and circulation.\n\nRemember, your primary purpose is to assist in the delivery of the newborn. The woman is going to feel pressure in the vaginal area, as if she has to move her bowels. This feeling is normal during the delivery process. Do not let her go to the bathroom and do not hold her legs together.\n\nBe as clean as possible during the entire delivery process. Take standard precautions. Do not touch the vaginal area except during the delivery. If you have a partner, have him or her stay with you during the delivery.\n\nThe newborn\u2019s head should emerge slowly to prevent undue stress on the newborn and tearing of the vaginal tissues. As the head emerges, support the newborn\u2019s head and tell the woman to stop pushing. To help her stop pushing, tell her to take quick, short breaths (advise her to blow like she is blowing out a candle). Some EMS systems advise their personnel to use the palm of the hand to provide slight counterpressure over the newborn\u2019s head to slow down the birth process. Be sure to check with your medical director and follow your local protocols for the appropriate treatment in this situation.\n\nDo not attempt to pull the newborn during the delivery. In a normal birth, the newborn will turn to the side by himself or herself after the head emerges, and the rest of the body will be delivered spontaneously. Usually, the upper shoulder will deliver first. Continue to support the newborn\u2019s head and be ready to grasp the newborn in a clean towel. Remember, the newborn will be wet and slippery. As the torso and the legs are delivered, support the newborn with both hands. Grasp the newborn\u2019s feet as they are delivered. Keep the newborn\u2019s head at about the level of the woman\u2019s vagina. If the amniotic sac has not broken as the newborn\u2019s head starts to deliver, tear it with your fingers and push it away from the newborn\u2019s head and mouth. As the head emerges, check to make sure the umbilical cord is not wrapped around the newborn\u2019s neck. If the cord is wrapped around the neck, attempt to slip the cord over the newborn\u2019s head. If you cannot slip the cord over the head, attempt to reduce the pressure on the cord. Never pull on the umbilical cord; it is extremely fragile. In a normal delivery, there is no need for you to cut the umbilical cord.",
        "Caring for the Newborn": "As soon as you are holding the newborn in a clean towel, lay him or her down between the mother\u2019s legs and immediately clear blood and mucus from the newborn\u2019s mouth and nose using a gauze pad or the cleanest object available. \n Many newborns will begin to breathe or cry without further assistance. If the baby does not begin to breathe spontaneously within a few seconds, suction the newborn\u2019s mouth and nose. Use a bulb syringe from the delivery kit if one is available. Suction the mouth first and then the nostrils. Be careful not to reach all the way to the back of the newborn\u2019s mouth. Discard the fluid into a towel, and repeat the procedure two to three times until the mouth and nostrils are clear. If a bulb syringe is not available, wipe the newborn\u2019s mouth and nose with a gauze pad. Drying and suctioning the newborn usually provides enough stimulation to induce breathing.\n\nSuction the mouth and nose to clear the airway of mucus and amniotic fluid. Use a bulb syringe in a newborn\u2019s mouth first, then use the bulb syringe to suction the newborn\u2019s nose.\n\nPlace the newborn on the mother\u2019s abdomen if the mother and the newborn are breathing adequately. This step allows skin-to-skin contact and will help keep the newborn warm. Wipe blood and mucus from the newborn\u2019s mouth and nose with sterile gauze or with the cleanest object available.\n\nIf the newborn is still not breathing, suction the newborn\u2019s mouth and nose again.\n\nRub the newborn\u2019s back or flick the soles of the newborn\u2019s feet to stimulate breathing. Use the towel to dry the newborn and then wrap the newborn in a blanket to keep him or her warm. Place the newborn on his or her side with the head slightly lower than the trunk. This step will aid in the drainage of secretions from the airway. Gently flick your fingers against the soles of the feet to stimulate breathing in the newborn.\n\nWhen the umbilical cord stops pulsating, clamp it with an umbilical cord clamp or tie it with gauze between the mother and the newborn. Remember, there is no need for you to cut the umbilical cord in a normal delivery. However, if you have sterile equipment and are trained to use it, you can cut the cord with sterile supplies. Keep the newborn warm and wait until more highly trained EMS personnel arrive. They will have the proper equipment to clamp and cut the umbilical cord in an approved manner. Note the time of the delivery so it can be properly reported on the newborn\u2019s birth certificate. In the rare event of multiple births, prepare for the second delivery.",
        "Delivery of the Placenta": "The placenta will deliver on its own, usually within 30 minutes after delivery. Never pull on the umbilical cord to help deliver the placenta. The safest and best method for the mother and the newborn is to leave the umbilical cord uncut and attached to the placenta and the newborn\u2014at least until the transporting EMS unit arrives. After the placenta is delivered, wrap it in a towel or newspaper with three-quarters of the umbilical cord, place it in a plastic bag, and transport it to the hospital with the mother and newborn so it can be examined by a physician. Try to keep the placenta at the same level as the newborn to help prevent any blood from the newborn flowing back out into the placenta. This step is especially important if you are unable to tie the umbilical cord The mother can be transported to the hospital before the placenta is delivered, if necessary. \n\nBleeding usually stops after the placenta is delivered. If bleeding does not stop, you can massage the uterus to help stop the bleeding. To massage the uterus, place one hand with fingers fully extended just above the mother\u2019s pubic bone. Use your other hand to press down into the abdomen and, using a circular motion, gently massage the uterus until it becomes firm. This process should take 3 to 5 minutes. As the uterus firms up, it should feel about the size of a softball or large grapefruit. If sterile supplies are unavailable and you cannot cut the umbilical cord, keep the placenta, still attached at the cord, at the same level as the newborn during transport to the hospital.",
        "Aftercare of the Mother and Newborn": "Continue to observe the mother and newborn carefully and keep them both warm. Cover the newborn\u2019s head and body to prevent the loss of body heat. About every 3 to 5 minutes, recheck the uterus for firmness. Also recheck the vagina for any excessive bleeding. In a normal delivery, the mother will have about 10 fluid ounces to 16 fluid ounces, or 1 cup to 2 cups (300 mL to 500 mL) of blood loss. Continue to massage the uterus using a circular motion if it is not firm or if bleeding continues. Allowing the newborn to nurse at the mother\u2019s breast causes a hormone to be released that helps to contract the uterus and reduce bleeding after childbirth.\n\nClean the mother with clean, moist towels or cloths. Cover the vaginal opening with a clean sanitary pad or large dressing, but do not pack any materials in the vagina. Replace the used towels or sheets with clean ones, if possible. If the mother is thirsty, you can give her small amounts of water to drink.",
        "Special Populations": "The newborn should begin to cry right after birth. You should observe the following vital signs in a healthy, conscious newborn:\n\nA respiratory rate of greater than 40 breaths per minute\nA pulse rate of greater than 100 beats per minute (Check the brachial pulse located at the inside of the infant\u2019s upper arm. Even for experienced health care providers, it is hard to accurately measure rapid heart rates.)",
        "Resuscitating the Newborn": "If the newborn does not cry and breathe on his or her own within the first minute after birth, proceed with the steps listed in \nSkill Drill 16-2\n.\n1. \nTilt the newborn\u2019s head down and to the side to encourage drainage of\nmucus \nStep 1\n. Use a gauze pad to clear secretions from the\nnewborn\u2019s mouth and nose.\n2. \nSuction the mouth and nose with a bulb syringe (if available). Other\nways to stimulate breathing include gently flicking your fingers against\nthe soles of the newborn\u2019s feet and/or rubbing the newborn\u2019s back. Do\nnot handle the newborn roughly. A newborn responds best to simple,\ngentle techniques, but if the newborn is still not breathing, proceed to\nthe next step \nStep 2\n.\n3. \nBegin mouth-to-mouth-and-nose or mouth-to-mask breathing by gently\npuffing twice into the newborn\u2019s mouth and nose with only enough\nforce to cause the newborn\u2019s chest to rise \nStep 3\n. If the newborn\nbegins to cry and breathe on his or her own, support and assist\nrespirations and recheck the airway to be sure it remains clear (see\nChapter 7\n, \nAirway Management\n).\n4. \nIf the newborn is still not breathing, continue mouth-to-mouth-and-nose\nor mouth-to-mask breathing and check for a brachial pulse \nStep 4\n.\n5. \nIf you cannot feel a brachial pulse or if the heart rate is less than 60\nbeats per minute, begin closed-chest cardiac compressions. \nUse your two middle fingers to depress the newborn\u2019s chest\n\n Step 5\nContinue cardiopulmonary resuscitation (CPR) until the newborn begins breathing adequately and has a strong pulse of over 60 beats per minute or until the newborn is pronounced dead by a physician. Provide rapid transport to the hospital. Do not give up! Throughout this process, try to dry the newborn and wrap the newborn in a blanket to keep him or her warm.",
        "Special Populations_0": "Newborns must be kept warm. Dry the newborn and keep the body and head covered to prevent loss of body heat and hypothermia.",
        "Complications of Pregnancy and Childbirth": "Although most pregnancies and births are normal, be aware of possible complications that can occur any time between early in the pregnancy until after the delivery. These complications include ectopic pregnancy and shock, miscarriage and vaginal bleeding, premature birth, unbroken bag of waters, prolapse of the umbilical cord, breech birth, stillborn delivery, multiple births, and excessive bleeding after delivery.",
        "Ectopic Pregnancy and Shock": "Any woman of childbearing age who presents with severe abdominal pain or signs and symptoms of shock (pale skin, dizziness, rapid pulse, decreased blood pressure, fainting) needs to be evaluated by a physician to determine whether she has experienced a ruptured ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg becomes implanted in the fallopian tube rather than in the uterus. As the embryo starts to grow, it expands and causes the fallopian tube to rupture. This rupture causes sudden abdominal pain, internal bleeding, and shock. You will not be able to determine that an ectopic pregnancy has occurred, but you must be able to recognize this life-threatening condition if you encounter a woman of childbearing age who reports the sudden development of severe abdominal pain and has signs and symptoms of shock. As an EMR, your treatment begins with a complete patient assessment. Be sure to measure the patient\u2019s vital signs. Treat the woman for shock and arrange for prompt transport to an appropriate medical facility.",
        "Miscarriage and Vaginal Bleeding": "A miscarriage (spontaneous abortion) is the delivery of an incomplete or underdeveloped fetus. A fetus before 20 weeks of pregnancy cannot survive outside the womb. If a miscarriage occurs, save the fetus and all the tissues that pass from the vagina. Control the woman\u2019s bleeding by placing a sanitary pad or other large dressing at the vaginal opening. Also treat her for shock. Arrange for prompt transport to a hospital so that a physician can examine her and the fetal tissues and control any additional bleeding. Vaginal bleeding in a pregnant woman is often the first sign of a miscarriage. It can also indicate a variety of other complications with the pregnancy. Anytime a pregnant woman experiences vaginal bleeding, perform a patient assessment, obtain a good medical history, and obtain a set of vital signs to determine whether she is experiencing shock. A pregnant woman who experiences vaginal bleeding should be examined by a physician. Arrange for transport to an appropriate medical facility for further treatment. A woman who miscarries will be upset about the loss of the newborn and will need your emotional support as well as emergency medical care. Be sensitive to the needs and concerns of the woman and other members of the family.",
        "Words of Wisdom_1": "When you conduct a patient assessment on a pregnant woman, be sure to check her blood pressure. Recall from Chapter 6, The Human Body, that the normal systolic blood pressure for adults is 90 mm Hg to 140 mm Hg. High blood pressure in pregnant women can be a sign of a serious condition (preeclampsia) that leads to seizures and can be life threatening to the woman and fetus. If you obtain a high blood pressure reading in a pregnant woman in labor, arrange for prompt transportation to an appropriate medical facility. Also, be sure to communicate this information to other emergency medical providers.",
        "Premature Birth": "Any newborn weighing less than 5 pounds (2 kg) or delivered before 36 weeks of pregnancy is called premature. A premature newborn is smaller, thinner, and usually has redder skin than a full-term newborn. You must keep premature newborns warm because loss of body heat occurs rapidly. Wrap the newborn in a clean towel or sheet and cover the head. Wrapping a premature newborn in an additional length of aluminum foil can also help maintain body temperature. Arrange for prompt transport to a medical facility.",
        "Unbroken Bag of Waters": "In rare instances, the bag of amniotic fluid that surrounds the newborn does not break. If the newborn is surrounded by the bag of waters, carefully break the bag and push it away from the nose and mouth so the newborn can breathe. Be careful not to injure the newborn in the process. Then suction the newborn\u2019s mouth, followed by the nose, to help the newborn begin to breathe.",
        "Voices of Experience": "There are a number of things that it could have been, but one thing was coming out on the top of my list: an ectopic pregnancy. It was the morning of the 2004 Super Bowl; I was ending a 24-hour shift at the fire station and was looking forward to going home for a day of rest, relaxation, and football. We were finishing up the station duties when the dispatcher came on the radio and dispatched us for a 23-year-old woman who was reporting abdominal pain. As the address came across the radio, I could not help but think that it seemed oddly familiar. It took me a moment to process it; the address was mine. I was hit with a whirlwind of emotions and thought, \u201cIs this really happening?\u201d My wife and I had just found out that she was pregnant the previous week. As we responded, I began running through the possible causes of her abdominal pain. There are a number of things that it could have been, but one thing was coming out on the top of my list: an ectopic pregnancy. We arrived to find my wife experiencing severe abdominal pain at 9/10 on a 0 to 10 scale. We placed her on oxygen, started an intravenous line (IV), loaded her into the ambulance, and began the drive to the hospital. We were fortunate that day. After having a battery of tests, we found out the baby was fine; the reason for her pain was a kidney stone. The next 8 months went by and she and the baby were doing well, until the 38th week. Suddenly, she began experiencing the signs and symptoms of preeclampsia; she started having some unusual swelling in her hands and lower legs and said she just was not feeling quite right. Her obstetrician ordered bed rest. Two weeks later, my wife woke me up in the middle of the night; her water had broken. Because it was her first pregnancy we knew we did not have to rush to the hospital. We contacted our physician and patiently waited and timed her contractions. Suddenly, she started complaining of a headache and began having tremors in her arms. I called 9-1-1, and within a few moments paramedics arrived. I explained that she had been diagnosed with preeclampsia 2 weeks earlier. They took her blood pressure and it was 190/110 mm Hg. We again loaded her into the ambulance for the drive to the hospital. I had never been so scared, but I knew I needed to be calm so that she did not become alarmed and risk making her situation worse. The last thing a patient with preeclampsia needs is extra stress. We were lucky for a second time when she delivered a healthy 6 pound 5 ounce (3 kg) baby boy. As we progress through our training and then into our careers, we should always keep something in mind: you just never know who is going to benefit from the knowledge you gain and the lives that you will touch.",
        "Prolapse of the Umbilical Cord": "On rare occasions, the umbilical cord appears from the vaginal opening before the fetus is delivered. This condition is called a prolapsed umbilical cord. The cord may be compressed between the newborn and the woman\u2019s pelvis during contractions, cutting off the newborn\u2019s blood supply. This condition is a serious emergency that requires immediate transport to a hospital.\n\nPlace the patient on her back and prop her hips and legs higher than the rest of her body with pillows, blankets, or articles of clothing. Keep the umbilical cord covered and moist, and do not try to push it back into the vagina. Administer oxygen to the patient if it is available and you are trained to use it. Arrange for rapid transport to the hospital.\n\nSome EMS systems recommend placing the woman in a kneeling position (knee-chest position) to take the pressure off the umbilical cord. Check with your medical director regarding local procedures.",
        "Breech Birth": "In a breech birth, the newborn\u2019s buttocks come down the birth canal first, rather than the head. This abnormal delivery can result in injury to the newborn and the woman.\n\nIf, instead of the normal crowning, you see a breech presentation, make every attempt to arrange for prompt transport to a medical facility. A breech birth slows the labor, so there will be more time for transport to the emergency department. If you are stranded and cannot transport the patient to the emergency department, you will have to assist with the breech birth.\n\nSupport the newborn\u2019s buttocks and legs as they are delivered; the head usually follows on its own. If the head does not deliver within 3 minutes, arrange for prompt transport to a hospital. Insert a gloved hand into the vagina and use your fingers to keep the newborn\u2019s airway open by forming a pocket over the newborn\u2019s nose and mouth.\n\nIn very rare cases, the arm or the leg is the first part of the newborn to appear in the birth canal. This circumstance, called limb presentation, is an extreme emergency that cannot be handled in the field. You must arrange for rapid transport to the hospital by ambulance.",
        "Safety": "When a newborn is in the breech position, do not attempt to pull the newborn out of the vagina!",
        "Stillborn Delivery": "Start and continue resuscitation on all newborns who are not breathing. However, sometimes a newborn dies in the uterus long before labor. The fetus will generally have an unpleasant odor and will not exhibit any signs of life. A lifeless fetus is referred to as a stillborn. In a situation like this, carefully wrap the stillborn newborn in a blanket and turn your attention to the mother to provide physical care and emotional support.",
        "Multiple Births": "In the event of multiple births (such as twins), another set of labor contractions will begin shortly after the delivery of the first newborn. A pregnant woman generally knows of a multiple birth in advance. However, there are times when a multiple birth has not been previously diagnosed. Do not worry\u2014just get ready to repeat the procedures you completed for delivering the first newborn.",
        "Excessive Bleeding After Delivery": "In addition to the early bloody show that precedes birth, about 1 cup or 2 cups (300 mL to 500 mL) of blood loss occurs during normal childbirth. If the mother is bleeding severely, place one or more clean sanitary pads at the opening of the vagina, treat her for shock, and arrange for rapid transport to the hospital by ambulance. Remember to encourage the newborn to nurse at the mother\u2019s breast because nursing contracts the uterus and can often help stop the bleeding. Massage the uterus with your hand, as described earlier in this chapter. If the area between the mother\u2019s vagina and anus is torn and bleeding, treat it as you would an open wound. Apply direct pressure using sanitary pads or gauze dressings.",
        "Safety_2": "Pregnant women showing signs and symptoms of shock should be transported while lying on the left side to prevent putting pressure on the major abdominal organs and vein, the inferior vena cava.",
        "Vehicle Collisions and Pregnant Women": "A pregnant woman who is involved in a motor vehicle crash or who has sustained other trauma should be examined by a physician. The forces involved in even a minor crash may be great enough to injure the woman or the unborn child, even though the fetus is usually well protected in the uterus. Promptly assess and transport a pregnant woman who has been involved in a motor vehicle crash to the hospital. If the woman exhibits signs or symptoms of shock, monitor the airway, breathing, and circulation. Arrange for administration of high-flow oxygen if available and if you are trained to use it. Have the woman lie on her left side rather than on her back. This position will relieve pressure on the uterus and the abdominal organs and will allow blood to return through the major veins in the abdomen. In rare circumstances, a crash can be severe enough to kill the pregnant woman but not the fetus. Provide CPR to the woman while transporting her to the closest medical facility.",
        "Words of Wisdom_3": "As part of your patient assessment, check to see whether the patient was wearing a seat belt. Pregnant women are at lower risk for injury to the fetus and to themselves if they wear a seat belt.",
        "Prep Kit-Ready for Review": "Childbirth is usually a happy event. As an emergency medical responder (EMR), your role is to assist in the delivery and offer comfort and support to the mother and newborn. In most cases, deliveries result in healthy babies.\nTo estimate how soon a delivery will occur, assess the time between contractions and whether the newborn\u2019s head appears during a contraction (crowning). By using these two key indicators, you can determine whether to transport the woman to a medical facility or whether the birth will occur outside the hospital.\nNormal labor consists of three distinct stages: Stage one is characterized by the following conditions: initial contractions occur; the bag of waters breaks; the bloody show occurs, but the newborn\u2019s head does not appear. Stage two involves the actual birth. You will see the newborn\u2019s head crowning during contractions, at which time you must prepare to assist the woman with delivery. Stage three involves delivery of the placenta. You must assist in stabilizing the condition of the mother and newborn and delivering the placenta.\nTake standard precautions when assisting with delivery of a newborn.\nAfter the delivery, you have two patients to care for\u2014the mother and the newborn. If the infant does not breathe on his or her own within the first minute after birth, proceed with the steps to resuscitate.\nAlthough most pregnancies and births are uneventful, be aware of possible complications, including ectopic pregnancy and shock, vaginal bleeding and miscarriage, premature birth, unbroken bag of waters, prolapse of the umbilical cord, breech birth, stillborn delivery, multiple births, and excessive bleeding after delivery.\nPromptly assess and arrange transport for a pregnant woman who has been involved in a motor vehicle crash to the hospital.",
        "Vital Vocabulary": "anus: The distal or terminal ending of the gastrointestinal tract., bag of waters: The amniotic sac and fluid that surround the fetus before birth., birth canal: The vagina and the lower part of the uterus., bloody show: The plug of mucus that is discharged from the vagina when labor begins., breech presentation: A delivery in which the newborn\u2019s buttocks appear in the birth canal first, rather than the head., contractions: Muscular movements of the uterus that push the newborn out of the birth canal., crowning: Appearance of the newborn\u2019s head during a contraction as he or she is pushed outward through the birth canal., ectopic pregnancy: A pregnancy that occurs outside the uterus, usually in a fallopian tube; usually terminates with the rupture of the fallopian tube., fetus: A developing newborn in the uterus or womb., labor: The process of delivering a newborn., miscarriage: Delivery of an incomplete or underdeveloped fetus before it is mature enough to survive outside the womb (about 20 weeks of pregnancy); also called spontaneous abortion., placenta: Life-support system of the fetus; also called the afterbirth., premature newborn: A newborn delivered before 36 weeks of gestation or who weighs less than 5 pounds (2 kg) at birth., prolapsed umbilical cord: A condition in which the umbilical cord appears before the newborn does; the newborn\u2019s head may compress the cord and cut off all circulation., suction: To aspirate (suck out) fluid by mechanical means., umbilical cord: Ropelike attachment between the pregnant woman and fetus; nourishment and waste products pass to and from the fetus and the woman through this cord., uterus (womb): Muscular organ that holds and nourishes the developing fetus., vagina: The opening through which the newborn emerges."
    },
    {
        "National EMS Education Standard Competencies": "Special Patient Populations\nApplies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs. Geriatrics\nImpact of age-related changes on assessment and care Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies\nCardiovascular diseases\nRespiratory diseases\nNeurologic diseases Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies (cont\u2019d)\nEndocrine diseases\nAlzheimer disease\nDementia Patients With Special Challenges\nRecognizing and reporting abuse and neglect\nHealth care implications of\nAbuse\nNeglect Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Special Considerations in Trauma\nRecognition and management of trauma in the\nGeriatric patient\nPathophysiology, assessment, and management of trauma in the\nGeriatric patient",
        "Introduction Geriatrics is the assessment and treatment of disease in a person 65 years of age or older.": "Geriatric patients present as a special challenge for health care providers. \nInjuries and illness are affected by chronic conditions, multiple medications, and the physiology of aging.",
        "Generational Considerations": "It is important to understand and appreciate how the life of an older person might differ from yours.\nIt takes time and patience to interact with an older person.\nTreat the patient with respect. Make every attempt to avoid ageism.\nNot all older people have dementia.\nNot all older people are hard of hearing.\nNot all older people are sedentary or immobile.",
        "Communication and Older Adults": "Effective verbal communication skills are essential.\nCommunication techniques\nSpeak respectfully.\nIdentify yourself.\nBe aware of how you present yourself.\nLook directly at the patient at eye level.\nSpeak slowly and distinctly. Communication techniques (cont\u2019d)\nHave one person talk to the patient, and ask only one question at a time.\nDo not assume that all older patients are hard of hearing.\nGive the patient time to respond.\nListen to the answer.\nExplain what you will do before you do it.",
        "The geriatric population is predisposed to a host of problems not seen in youth.": "Hip fractures are common.\nMore likely to occur when bones are weakened by osteoporosis or infection\nSedentary behavior can lead to pneumonia and blood clots.",
        "Common Complaints and the Leading Causes of Death in Older People": "",
        "Changes in the Body The aging process is accompanied by changes in physiologic function.": "All tissues in the body undergo aging.\nDecrease in the functional capacity of various organ systems is normal, but can affect the way a patient responds to illness.",
        "Changes in the Respiratory System": "Age-related changes can predispose an older adult to respiratory illness.\nAirway musculature becomes weakened.\nAlveoli in the lung tissue become enlarged and the elasticity decreases.\nThe body\u2019s chemoreceptors slow with age.\nDecreased cough and gag reflexes Pneumonia\nInflammation/infection of the lung from bacterial, viral, or fungal causes\nLeading cause of death from infection in Americans older than 65 years\nAging causes some immune suppression and increases the risk of contracting infections like pneumonia. Pneumonia (cont\u2019d)\nIncreased mucus production, pulmonary secretions, and infection all interfere with the ability of the alveoli to oxygenate the blood. \nManagement of pneumonia is the same for any patient. Pulmonary embolism\nSudden blockage of an artery by a venous clot\nA patient will present with shortness of breath and sometimes chest pain.\nCan be confused with a cardiac, lung, or musculoskeletal problem Pulmonary embolism risk factors:\nLiving in a nursing home \nRecent surgery\nHistory of blood clots or heart failure\nPresence of a pacemaker or central venous catheter \nObesity or sedentary behavior\nRecent long-distance travel\nTrauma, cancer, or paralyzed extremities Pulmonary embolism presents with:\nTachycardia\nSudden onset of dyspnea\nShoulder, back, or chest pain\nCough\nSyncope in patients in whom the clot is larger\nAnxiety Pulmonary embolism presents with (cont\u2019d):\nApprehension\nLow-grade fever\nHemoptysis\nLeg pain, redness, and unilateral pedal edema\nFatigue\nCardiac arrest (worst-case scenario)",
        "Changes in the Cardiovascular System": "The heart hypertrophies with age.\nCardiac output declines.\nArteriosclerosis contributes to systolic hypertension. Geriatric patients are at risk for atherosclerosis.\nAccumulation of fat and cholesterol in the arteries\nMajor complications include myocardial infarction and stroke. FIGURE 36-2 Atherosclerosis is characterized by the\nbuildup of fat and cholesterol on arterial walls. \u00a9 Jones & Bartlett Learning. Older people are at increased risk for formation of an aneurysm.\nAbnormal, blood-filled dilation of the blood vessel wall\nSevere blood loss can occur.\nBlood vessels and heart valves become stiff and degenerate.\nHeart rate becomes too fast, too slow, or too erratic. Another vessel-related problem is venous stasis.\nLoss of proper function of the veins in the legs that carry blood back to the heart\nCauses blood clots\nDeep vein thrombosis can lead to pulmonary embolism. \nPeople usually exhibit edema of the legs and ankles.",
        "The classic symptoms of a heart attack are often not present in geriatric patients.": "\u201cSilent\u201d heart attacks are particularly common in women and people with diabetes. Manifestations of acute cardiac disease:\nDyspnea\nEpigastric and abdominal pain\nLoss of bladder or bowel control\nNausea and vomiting\nWeakness, dizziness, light-headedness, syncope\nFatigue or confusion Other signs and symptoms include:\nIssues with circulation\nDiaphoresis\nPale, cyanotic, or mottled skin\nAbnormal or decreased breath sounds\nIncreased peripheral edema",
        "The signs and symptoms will differ depending on whether the right or left side of the heart is not functioning correctly. Right-sided heart failure occurs when the fluid backs up into the body.": "Causes jugular vein distention, ascites, peripheral edema, and an enlarged liver\nRight-sided heart failure is often caused by left-sided heart failure, so it is common to see signs of both. With left-sided heart failure, fluid backs up into the lungs.\nCauses a condition called pulmonary edema and shortness of breath\nThe patient will have severe shortness of breath and hypoxia with crackles in the lungs. Paroxysmal nocturnal dyspnea\nCharacterized by a sudden attack of respiratory distress that wakes the person when he or she is reclining\nCaused by fluid accumulation in the lungs\nPatients report coughing, feeling suffocated, and cold sweats.\nYou will notice tachycardia.",
        "Leading cause of death in older people": "Preventable risk factors: smoking, hypertension, diabetes, atrial fibrillation, obesity, and a sedentary lifestyle\nUncontrollable factors: age, race, and gender Signs and symptoms\nAcute altered level of consciousness\nNumbness, weakness, or paralysis on one side \nSlurred speech, difficulty speaking\nVisual disturbances\nHeadache and dizziness\nIncontinence\nSeizure Hemorrhagic strokes are less common and more likely to be fatal.\nIschemic strokes occur when a blood clot blocks the flow of blood to a portion of the brain. The treatment goal is to salvage as much of the surrounding brain tissue as possible.\nIf the symptoms occurred within the past few hours, the patient will be a candidate for stroke center therapy. \nTransient ischemic attack (TIA) can present with the same signs and symptoms as a stroke.",
        "Changes in the Nervous System": "Changing in thinking speed, memory, and posture stability are the most common findings.\nThe brain decreases in weight and volume.\nThere is a 5% to 50% loss of neurons in older people.\nThe performance of most of the sense organs declines with increasing age. Vision\nVisual acuity, depth perception, and ability to accommodate to light change with age.\nCataracts interfere with vision.\nDecreased tear production leads to drier eyes. FIGURE 36-3 Changes in vision, hearing, posture, and motor ability predispose older people to a greater risk of being struck by a vehicle or being involved in a motor vehicle crash. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Vision (cont\u2019d)\nInability to differentiate colors\nDecreased night vision\nInability to see up close (presbyopia)\nOther diseases:\nGlaucoma\nMacular degeneration\nRetinal detachment Hearing\nChanges in the inner ear make hearing high-frequency sounds difficult.\nProblems with balance make falls more likely.\nPresbycusis is a gradual hearing loss.\nHeredity and long-term exposure to loud noises are the main factors. Taste\nDecrease in the number of taste buds\nNegative result might be lessened interest in eating, which can lead to:\nWeight loss\nMalnutrition\nComplaints of fatigue Touch\nDecreased sense of touch and pain perception from the loss of the end nerve fibers\nAn older person may be injured and not know it.\nDecreased sensation of hot and cold",
        "Slow onset of progressive disorientation, shortened attention span, and loss of cognitive function": "Chronic, generally irreversible condition that causes a progressive loss of:\nCognitive abilities\nPsychomotor skills\nSocial skills Dementia is the result of many neurologic diseases, and may be caused by:\nAlzheimer disease\nParkinson disease\nCerebrovascular accidents\nGenetic factors On assessment, patients may:\nHave short- and long-term memory loss\nHave a decreased attention span\nBe unable to perform daily routines\nShow a decreased ability to communicate\nAppear confused or angry\nHave impaired judgment\nBe unable to vocalize pain",
        "Delirium": "Sudden change in mental status, consciousness, or cognitive processes\nMarked by the inability to focus, think logically, and maintain attention\nAffects 15% to 50% of hospitalized people aged 70 years or older\nAcute anxiety may be present. Generally the result of a reversible physical ailment, such as tumors, fever, or metabolic causes\nIn the history, look for:\nWithdrawal from alcohol or sedatives\nMedical conditions\nDepression\nMalnutrition or vitamin deficiencies\nEnvironmental emergencies Assess and manage the patient for:\nHypoxia\nHypovolemia\nHypoglycemia\nHypothermia\nYou may see changes in circulation, breath sounds, motor function, and pupillary response.",
        "Syncope Assume this is a life-threatening problem until proven otherwise.": "Often caused by an interruption of blood flow to the brain",
        "Neuropathy Disorder of the nerves of the peripheral nervous system": "Function and structure of the peripheral motor, sensory, and autonomic neurons are impaired.\nSymptoms depend on which nerves are affected and where they are located.",
        "Changes in the Gastrointestinal System": "Reduction in the volume of saliva\nDental loss\nGastric secretions are reduced.\nChanges in gastric motility occur.\nIncidence of certain diseases involving the bowel increases.\nBlood flow to the liver declines. Age-related changes in the GI system:\nIssues with dental problems\nDecrease in saliva and sense of taste\nPoor muscle tone of the sphincter between the esophagus and stomach\nDecrease in hydrochloric acid\nAlterations in absorption of nutrients\nWeakening of the rectal sphincter GI bleeding can be caused by inflammation, infection, or obstruction of the upper or lower GI tract.\nUsually heralded by hematemesis\nBleeding that travels through the lower digestive tract usually manifests as melena.\nRed blood usually means a local source of bleeding, such as hemorrhoids.\nA patient with GI bleeding may experience weakness, dizziness, or syncope. Specific GI problems in older patients include:\nDiverticulitis\nBleeding in the upper and lower GI system\nPeptic ulcer disease\nGallbladder disease\nBowel obstruction When assessing patients, ask about NSAID and alcohol use.\nOrthostatic vital signs can help determine if a patient is hypovolemic.\nTreatment consists of airway, ventilatory, and circulatory support.",
        "Acute Abdomen\u2014Nongastrointestinal Complaints Extremely difficult to assess in the prehospital setting": "Most serious threat from abdominal complaints is blood loss\nAbdominal aortic aneurysm (AAA) is one of the most rapidly fatal conditions.",
        "Changes in the Renal System": "Age brings changes in the kidneys.\nReduction in renal function\nReduction in renal blood flow\nTubule degeneration Changes in the genitourinary system:\nDecreased bladder capacity\nDecline in sphincter muscle control\nDecline in voiding senses\nIncrease in nocturnal voiding\nBenign prostatic hypertrophy (enlarged prostate) Incontinence is not a normal part of aging and can lead to skin irritation, skin breakdown, and urinary tract infections.\nStress incontinence occurs during activities such as coughing, laughing, sneezing, lifting, and exercise.\nUrge incontinence is triggered by hot or cold fluids, running water, or thinking about going to the bathroom. The opposite of incontinence is urinary retention or difficulty urinating.\nIn men, enlargement of the prostate can place pressure on the urethra, making voiding difficult.\nBladder and urinary tract infections can also cause inflammation.\nIn severe cases of urinary retention, patients may experience renal failure.",
        "Changes in the Endocrine System": "Reduction in thyroid hormones (thyroxine)\nSigns and symptoms:\nSlower heart rate\nFatigue\nDrier skin and hair\nCold intolerance\nWeight gain Other endocrine changes include:\nAn increase in the secretion of antidiuretic hormone, causing fluid imbalance\nHyperglycemia\nIncreases in the levels of norepinephrine, possibly having a harmful effect on the cardiovascular system Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a type 2 diabetic complication in older people.\nOn assessment, you may see:\nWarm, flushed skin\nPoor skin turgor\nPale, dry, oral mucosa\nFurrowed tongue\nSigns of shock Assessment of the patient should include:\nObtaining blood pressure\nDistal pulses\nAuscultation of breath sounds \nTemperature\nAssessment of blood glucose level (if permitted by local protocol) \nTreatment should include airway, ventilatory, and circulatory support.",
        "Changes in the Immune System Infections are commonly seen in older people because of their increased risk.": "Less able to fight infections\nAnorexia, fatigue, weight loss, falls, or changes in mental status may be the primary symptoms.\nPneumonia and UTIs are common in patients who are bedridden.\nSigns and symptoms may be decreased because of loss of sensation, lack of awareness, or fear of being hospitalized.",
        "Changes in the Musculoskeletal System": "Decrease in bone mass\nEspecially in postmenopausal women\nBones become more brittle and tend to break more easily.\nJoints lose their flexibility.\nA decrease in the amount of muscle mass often results in less strength. Changes in physical abilities can affect older adults\u2019 confidence in mobility.\nMuscle fibers become smaller and fewer.\nMotor neurons decrease in number.\nStrength declines.\nLigaments and cartilage of the joints lose their elasticity.\nCartilage goes through degenerative change. Osteoporosis is characterized by a decrease in bone mass.\nReduction in bone strength and greater susceptibility to fracture\nExtent of bone loss depends on:\nGenetics, body weight\nSmoking, alcohol consumption\nLevel of activity, diet Osteoarthritis is a progressive disease of the joints that destroys cartilage, promotes the formation of bone spurs, and leads to joint stiffness.\nResults from wear and tear\nAffects joints in the hands, knees, hips, and spine",
        "Changes in Skin": "Proteins that make the skin pliable decline with age. \nLayer of fat under the skin becomes thinner.\nBruising becomes more common.\nSweat glands do not respond as readily to heat. Pressure ulcers become a problem.\nSometimes referred to as bedsores or decubitus ulcers\nThe pressure from the weight of the body cuts off the blood flow to the area of skin.\nWith no blood flow, a sore develops. Stages of ulcer development:\nStage I: Nonblanching redness with damage under the skin\nStage II: Blister or ulcer that can affect the dermis and epidermis\nStage III: Invasion of the fat layer through to the fascia\nStage IV: Invasion to muscle or bone",
        "Toxicology": "Older people are more susceptible to toxicity.\nKidneys undergo many changes with age.\nDecreased liver function makes it harder for the liver to detoxify the blood and eliminate medications and alcohol. Typical OTC medications can have negative effects when mixed with each other or with herbal substances, alcohol, and prescription medications. FIGURE 36-4 Over-the-counter medications such as aspirin, antacids, cough syrups, and decongestants can interact negatively with some prescription medications. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS Polypharmacy refers to the use of multiple prescription medications by one patient.\nNegative effects can include overdosing and negative medication interaction.\nMedication noncompliance occurs due to:\nFinancial challenges\nInability to open containers\nImpaired cognitive, vision, and hearing ability",
        "Depression is not part of normal aging, but a medical disease.": "Treatable with medication and therapy\nIf depression goes unrecognized or untreated, it is associated with a higher suicide rate in the geriatric population. Risk factors include history of depression, chronic disease, and loss.\nThe following conditions contribute to the onset of significant depression:\nSubstance abuse\nIsolation\nPrescription medication use\nChronic medical condition",
        "Older men have the highest suicide rate of any age group in the United States.": "Older persons choose much more lethal means than younger victims.\nGenerally have diminished recuperative capacity to survive an attempt Common predisposing events and conditions include:\nDeath of a loved one\nPhysical illness\nDepression and hopelessness\nAlcohol abuse\nAlcohol dependence\nLoss of meaningful life roles When assessing the patient who is displaying signs of depression, it is appropriate to ask if he or she is considering suicide. \nIf the answer is \u201cyes,\u201d the next question should be, \u201cDo you have a plan?\u201d \nInclude this information in your report.",
        "The GEMS Diamond": "Created to help you remember what is different about older patients\nNot intended to be a format for the approach to geriatric patients or replace the ABCs of care\nServes as an acronym for the issues to be considered when assessing every older patient Geriatric patient\nOlder patients may present atypically.\nBe familiar with the normal changes of aging.\nEnvironmental assessment\nThe environment can help give clues to the patient\u2019s condition and the cause of the emergency. Medical assessment\nOlder patients tend to have a variety of medical problems and numerous medications.\nObtain a thorough medical history. Social assessment\nOlder people may have less of a social network.\nThey may need assistance with activities of daily living.\nConsider obtaining information pamphlets about some of the agencies for older people in your area.",
        "Special Considerations in Assessing a Geriatric Medical Patient Assessing an older person can be challenging because of:": "Communication issues\nHearing and vision deficits\nAlterations in consciousness\nComplicated medical histories\nEffects of medications",
        "Geriatric patients are commonly found in their own homes, retirement homes, or skilled nursing facilities.": "Many older people live alone.\nAccess may be hampered if their condition prevents them from getting to the door.\nTake note of negative or unsafe conditions. Mechanism of injury/nature of illness\nMay be difficult to determine in older people with altered mental status or dementia\nAsk the family member, caregiver, or bystander why he or she called.\nMultiple and chronic disease processes may also complicate the determination of the NOI.\nChest pain, shortness of breath, and an altered level of consciousness should always be considered serious. Scene Size-up Look for clues that indicate your patient\u2019s traumatic incident may have been preceded by a medical incident.\nBystander information may help.\nMOI is important in establishing whether an injury is considered critical, and it affects treatment and transport considerations.",
        "Primary Assessment": "Address life threats.\nDetermine the transport priority.\nForm a general impression.\nYou should be able to tell if the patient is generally in stable or unstable condition.\nUse the AVPU scale to determine the patient\u2019s level of consciousness. Airway and breathing\nAnatomic changes that occur as a person ages predispose geriatric patients to airway problems.\nEnsure that the patient\u2019s airway is open and not obstructed by dentures, vomitus, fluid, or blood. Airway and breathing (cont\u2019d)\nAnatomic changes affect a person\u2019s ability to breathe effectively.\nLoss of mechanisms that protect the upper airway cause a decreased ability to clear secretions.\nAirway and breathing issues should be treated with oxygen as soon as possible. Circulation\nPoor perfusion is a serious issue in the older adult.\nPhysiologic changes may negatively affect circulation.\nVascular changes and circulatory compromise might make it difficult to feel a pulse. Transport decision\nAny complaints that compromise the ABCs should result in prompt transport.\nDetermine conditions that are life threatening.\nTreat them to the best of your ability.\nProvide transport to priority patients. Address life threats.\nDetermine the transport priority.\nRecommended that older trauma patients be transported to a trauma center\nForm a general impression.\nIs patient\u2019s condition is stable or unstable?\nUse AVPU and the Glasgow Coma Scale to determine mental status. Airway and breathing\nOlder patients may have a diminished ability to cough, so suctioning is important.\nAssess for the presence of dentures. Circulation\nManage any external bleeding immediately.\nDrinking alcohol and taking anticoagulant medications can make internal bleeding worse or external bleeding more difficult to control. \nOlder patients can more easily go into shock.\nPatients who were hypertensive prior to injury may have a normal blood pressure when they are actually in shock.",
        "Investigate the chief complaint.": "Find and account for all medications.\nObtain a thorough patient history.\nDetermine early whether the altered LOC is acute or chronic.\nMultiple disease processes and multiple and/or vague complaints can make assessment complicated. Collect a SAMPLE history.\nYou may have to rely on a relative or caregiver to help you.\nList the patient\u2019s medications or take the medications with you to the hospital. \nThe last meal is particularly important in patients with diabetes.\nTransport to a facility that knows the patient\u2019s medical history, if possible. History Taking Investigate the chief complaint.\nConsiderations in your assessment must include past medical conditions, even if they are not currently acute or symptomatic.",
        "Secondary Assessment": "Physical examinations\nAn older patient may not be comfortable with being exposed.\nProtect his or her modesty.\nConsider the need to keep your patient warm during exam. Vital signs\nThe heart rate should be in the normal adult range but may be compromised by medications such as beta-blockers.\nWeaker and irregular pulses are common.\nCirculatory compromise may make it difficult to feel a radial pulse; consider other pulse points. Vital signs (cont\u2019d)\nBlood pressure tends to be higher.\nCapillary refill is not a good assessment.\nThe respiratory rate should be in the same range as in a younger adult.\nBe sure to auscultate breath sounds.\nCarefully assess pulse oximetry data. Physical examinations\nPerformed in the same manner as for any adult but with consideration of the higher likelihood of damage from trauma\nAny head injury can be life threatening.\nCheck lung sounds.\nLook for bruising and other evidence of trauma. Vital signs\nAssess the pulse, blood pressure, and skin signs.\nCapillary refill is unreliable because of compromised circulation.\nRemember that some older people take beta-blockers, which will inhibit their heart from becoming tachycardic.",
        "Reassessment": "Reassess the geriatric patient often.\nReassess the vital signs.\nReassess the patient\u2019s complaint.\nRecheck interventions.\nIdentify and treat changes in the patient\u2019s condition. Communication and documentation\nCommunicate your findings and the interventions you used to emergency department personnel. \nDocument all history, medication, assessment, and intervention information. Repeat the primary assessment.\nA geriatric patient has a higher likelihood of decompensating after trauma.\nInterventions\nBroken bones are common and should be splinted. Interventions (cont\u2019d)\nDo not force a patient with joint flexion or kyphosis into a \u201cnormal\u201d position.\nProvide blankets and heat to prevent hypothermia. FIGURE 36-7 Placing padding in the void space between the patient\u2019s body and the backboard is an important component of achieving spinal motion restriction in a geriatric patient. Place blankets and pillows under an injured extremity to provide support to a fracture site. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Communications and documentation\nCommunication can be challenging.\nProvide psychological support as well as medical treatment.",
        "Trauma and Geriatric Patients": "Conditions that create risk and complicate assessment:\nSlower homeostatic compensatory mechanisms\nLimited physiologic reserves\nNormal effects of aging on the body\nExisting medical issues Physical findings in an older adult may be more subtle and easily missed.\nMechanisms are much more minimal.\nRecuperation from trauma is longer and often less successful.\nMany injuries are undertriaged and undertreated. Older pedestrians are more likely to have life-threatening complications after being struck by a vehicle.\nCommonly suffer injury to the legs and arms\nSecondary impacts can also cause serious injuries. Older people are more likely to experience burns because of altered mental status, inattention, and a compromised neurologic status.\nRisk of mortality is increased when:\nPreexisting medical conditions exist.\nThe immune system is weakened.\nFluid replacement is complicated by renal compromise. Higher mortality from penetrating trauma in older adults, especially gunshot wounds\nFalls are the leading cause of fatal and nonfatal injuries in older adults.\nNearly half of fatal falls in geriatric patients result in traumatic brain injury. Anatomic changes and trauma\nChanges in pulmonary, cardiovascular, neurologic, and musculoskeletal systems make older patients more susceptible to trauma.\nA geriatric patient\u2019s overall physical condition may lessen the body\u2019s ability to compensate for simple injuries. Osteoporosis predisposes older people to hip and pelvic fractures.\nContributing factors:\nStresses of ordinary activity\nA standing fall\nVitamin D and calcium deficiencies\nMetabolic bone diseases\nTumors With age, the spine stiffens as a result of shrinkage of disk spaces, and vertebrae become brittle.\nCompression fractures of the spine occur. Because brain tissue shrinks with age, older patients are more likely to sustain closed head injuries.\nAcute subdural hematomas are among the deadliest of all head injuries.\nSerious head injuries are often missed because the mechanism may seem relatively minor. Other factors that predispose an older patient to a serious head injury include:\nLong-term abuse of alcohol\nRecurrent falls or repeated head injury\nAnticoagulant medication",
        "Environmental Injury Internal temperature regulation is slowed.": "Half of all deaths from hypothermia occur in older people.\nIncluding most indoor hypothermia deaths\nDeath rates from hyperthermia are more than doubled in older people.\nPeople older than 85 years are at highest risk.",
        "Special Considerations in Assessing Geriatric Trauma Patients": "Special Considerations in Assessing Geriatric Trauma Patients Trauma is never isolated to a single issue when you are assessing and caring for a geriatric patient.",
        "Response to Nursing and Skilled Care Facilities": "Many calls will occur at a nursing home or other skilled care facility. \nCalls can be challenging.\nPatients often have an altered level of consciousness.\nStaff may be spread thin and may not know how to assist you.\nAsk, \u201cWhat is wrong with the patient that is new or different today?\u201d Infection control needs to be a high priority for EMTs.\nMethicillin-resistant Staphylococcus aureus (MRSA) infections are common.\nMany infections in hospitals are caused by vancomycin-resistant enterococci.\nThe respiratory syncytial virus causes an infection of the upper and lower respiratory tracts. Infection control (cont\u2019d)\nClostridium difficile is a bacterium responsible for the most common cause of hospital-acquired infectious diarrhea.\nTypical alcohol-based hand sanitizers do not inactivate or kill C difficile. Infection control (cont\u2019d)\nSARS-CoV-2\nAffects older, more vulnerable people\nSpreads from person-to-person through airborne droplets created by speaking, coughing, and sneezing",
        "Dying Patients More patients are choosing to die at home rather than in a hospital.": "Dying patients receive palliative care.\nBe understanding, sensitive, and compassionate.\nDetermine if the family wishes for the patient to go to the hospital or stay in the home.",
        "Advance Directives": "Specific legal papers that direct relatives and caregivers about what kind of medical treatment may be given to patients who cannot speak for themselves. May take the form of a do not resuscitate (DNR) order\nGives you permission not to attempt resuscitation for a patient in cardiac arrest\nDNR does not mean \u201cdo not treat.\u201d\nBasic ABCs should still be provided. Another type of order is the POLST (Physician Orders for Life Sustaining Treatment), which gives medical orders in addition to the advanced directives.\nIf there is any question regarding orders or when there are no written orders, initiate resuscitation.",
        "Elder Abuse and Neglect": "Any action on the part of an older person\u2019s family member, caregiver, or other person that takes advantage of the older person\u2019s:\nPerson\nProperty\nEmotional state\nIncludes acts of commission and acts of omission Has been largely hidden from society.\nDefinitions of abuse and neglect among the geriatric population vary.\nVictims are often hesitant to report the problem. The abused person may feel traumatized by the situation or be afraid that the abuser will punish him or her for reporting the abuse. \nElder abuse occurs more often in women older than 75 years.\nAbusers of older people are sometimes products of child abuse themselves. Take note of the environment and conditions a patient lives in, and of soft-tissue injuries that cannot be explained by the person\u2019s lifestyle and physical condition.\nSuspect abuse when answers are concealed or avoided.\nSuspect abuse when you are given unbelievable answers. Information that may be important in assessing abuse includes:\nCaregiver apathy about the patient\u2019s condition\nOverly defensive reaction by caregiver\nCaregiver does not allow patient to answer questions.\nRepeated visits to the ED or clinic\nA history of being accident-prone\nUnbelievable or vague explanations of injuries Information that may be important in assessing abuse includes (cont\u2019d):\nPsychosomatic complaints \nChronic pain without medical explanation\nSelf-destructive behavior\nEating and sleep disorders\nDepression or a lack of energy\nSubstance and/or sexual abuse history",
        "Signs of Physical Abuse": "Inflicted bruises are usually found on the buttocks and lower back, genitals, inner thighs, face, and ears.\nPressure bruises caused by the human hand may be identified by oval grab marks, pinch marks, or handprints.\nHuman bites are typically inflicted on the upper extremities and can cause lacerations and infection. Typical abuse from burns is caused by contact with:\nCigarettes\nMatches\nHeated metal\nForced immersion in hot liquids\nChemicals\nElectrical power sources Check for signs of neglect, such as:\nLack of hygiene\nPoor dental hygiene\nPoor temperature regulation\nLack of reasonable amenities in the home FIGURE 36-8 Signs of neglect include evidence of a lack of hygiene, poor dental hygiene, poor temperature regulation, or lack of reasonable amenities in the home. \u00a9 wrangler/Shutterstock. Regard injuries to the genitals or rectum with no reported trauma as evidence of sexual abuse in any patient.\nGeriatric patients with altered mental status may never be able to report sexual abuse.\nMany women do not report cases of sexual abuse because of shame and the pressure to forget."
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Toxicology\nRecognition and management of\nCarbon monoxide poisoning\nNerve agent poisoning\nHow and when to contact a poison control center Anatomy, physiology, pathophysiology, assessment, and management of\nInhaled poisons\nIngested poisons\nInjected poisons\nAbsorbed poisons\nAlcohol intoxication and withdrawal",
        "Introduction": "Every day, we come into contact with potentially poisonous things.\nAcute poisoning affects over 2 million people each year.\nChronic poisoning is more common. Deaths caused by poisoning are fairly rare.\nPoisoning in children has decreased steadily since the 1960s due to child-resistant caps.\nDeaths caused by chronic poisoning in adults have been rising as a result of drug abuse.",
        "Identifying the Patient and the Poison": "Toxicology is the study of toxic or poisonous substances.\nPoison: any substance whose chemical action can damage body structures or impair body function\nToxin: a poisonous substance produced by bacteria, animals, or plants \nSubstance abuse: the misuse of any substance to produce a desired effect.\nOverdose: a toxic dose of a drug. Your primary responsibility to the patient is to recognize that a poisoning has occurred.\nPay attention to your surroundings. \nVery small amounts of some poisons can cause considerable damage or death.\nThe signs and symptoms of poisoning vary according to the specific agent. If possible, ask the patient:\nWhat substance did you take?\nWhen did you take it (or become exposed to it)?\nHow much did you ingest?\nDid you have anything to eat or drink before or after you took it?\nHas anyone given you an antidote or any substance orally since you ingested it? \nHow much do you weigh? Try to determine the nature of the poison.\nLook around the immediate area for clues.\nTake any suspicious material with you.\nContainers at the scene can provide critical information. If the patient vomits, examine the contents for pill fragments.\nNote and document anything unusual that you see.",
        "How Poisons Enter the Body": "How you provide treatment depends on how the poison got into the patient\u2019s body. \nFour routes to consider:\nInhalation\nAbsorption\nIngestion\nInjection\nAll four routes can lead to life-threatening conditions. FIGURE 22-2 There are four routes by which a poison can enter the body. A. Inhalation. B. Absorption (surface contact). C. Ingestion. D. Injection. A: \u00a9 Jones & Bartlett Learning. Photographed by Kimberly Potvin; B: \u00a9 Jones & Bartlett Learning; \nC: \u00a9 Jaimie Duplass/Shutterstock; D: \u00a9 Cate Frost/Shutterstock.",
        "Move the patient into fresh air immediately.": "The patient may require supplemental oxygen.\nIf you suspect the presence of a toxic gas, call for specialized resources such as the hazmat team. Some patients may need decontamination by the hazmat team after removal from the toxic environment.\nAll patients who have inhaled poison require immediate transport.\nBe prepared to use supplemental oxygen.\nMake sure a suctioning unit is available. Some patients use inhaled poisons to commit suicide in a vehicle.\nExhaust fumes contain high levels of carbon monoxide.",
        "Absorbed and Surface Contact Poisons": "Can affect the patient in many ways:\nSkin, mucous membrane, or eye damage\nChemical burns\nRashes or lesions\nSystemic effects\nIt is important to distinguish between contact burns and contact absorption. Signs and symptoms include:\nA history of exposure\nLiquid or powder on a patient\u2019s skin\nBurns\nItching\nIrritation\nRedness of skin\nTypical odors of the substance Emergency treatment:\nAvoid contaminating yourself or others.\nRemove the substance from patient as rapidly as possible.\nRemove all contaminated clothing.\nFlush and wash the skin. If dry powder has been spilled, brush off the powder, flood the area with water for 15 to 20 minutes, then wash skin with soap and water. \nIf liquid has been spilled onto the skin, flood for 15 to 20 minutes. If a chemical agent is introduced to the eyes, irrigate them quickly and thoroughly. FIGURE 22-4 If chemical agents are in the patient\u2019s eyes, irrigate the eyes quickly and thoroughly, ensuring that the irrigation fluid runs from the bridge of the nose outward. (Use of a nasal cannula is shown.). \u00a9 American Academy of Orthopaedic Surgeons. Many chemical burns occur in an industrial setting.\nSafety showers and specific protocols for handling surface burns may be available. \nHazmat team should be available to assist you. \nAfter decontamination, promptly transport to the ED for definitive care.\nObtain material safety data sheets.",
        "Ingested Poisons": "About 80% of poisoning is by mouth.\nLiquids\nHousehold cleaners\nContaminated food\nPlants\nDrugs Usually accidental in children and deliberate in adults\nSigns and symptoms include burns around the mouth, gastrointestinal pain, vomiting, cardiac dysrhythmias, and seizures. Treat signs and symptoms and notify the poison center and medical control of the patient\u2019s condition.\nConsider whether there is unabsorbed poison remaining in the gastrointestinal tract and whether you can safely and effectively prevent its absorption. Some EMS systems allow EMTs to administer activated charcoal.\nAlways immediately assess the ABCs of every patient who has been poisoned. FIGURE 22-7 Activated charcoal comes as a premixed suspension. \u00a9 American Academy of Orthopaedic Surgeons.",
        "Injected Poisons": "Exposure includes intravenous drug abuse and envenomation by insects, arachnids, and reptiles. \nUsually absorbed quickly into the body or cause intense local tissue destruction \nCannot be diluted or removed from the body in the field Signs and symptoms may include weakness, dizziness, fever/chills, unresponsiveness, and excitability.\nMonitor the airway, provide high-flow oxygen, and be alert for nausea and vomiting.\nRemove rings, watches, and bracelets from areas around the injection site if swelling occurs.",
        "Scene Size-up Take standard precautions and look for clues:": "Is there an odor in the room? Is the scene safe? \nAre there medication bottles lying around? Is there medication missing that might indicate an overdose?\nAre alcoholic beverage containers present?\nAre there syringes or other drug paraphernalia?\nIs there a suspicious odor that may indicate the presence of a drug laboratory?",
        "Primary Assessment": "Determine the severity of the patient\u2019s condition. \nObtain a general impression.\nAssess the level of consciousness.\nDetermine any life threats.\nDo not assume a conscious, alert, and oriented patient is in stable condition. Airway and breathing\nEnsure that the patient has an open airway and adequate ventilation.\nIf patient has difficulty breathing or an inhalation injury, begin oxygen therapy.\nHave suction available; these patients are susceptible to vomiting. \nCirculation\nAssess the pulse and skin condition.\nWill vary depending on the substance involved Transport decision\nConsider prompt transport for patients with obvious alterations in the XABCs or for patients you have determined have a poor general impression.\nEveryone who is exposed to the hazardous material must be thoroughly decontaminated by the hazmat team before leaving the scene.",
        "History Taking": "Investigate the chief complaint.\nIf your patient is responsive, begin with an evaluation of the exposure and the SAMPLE history.\nIf your patient is unresponsive, obtain the history from other sources. In addition to SAMPLE, ask the following questions:\nWhat is the substance involved?\nWhen did the patient become exposed to it?\nHow much did the patient ingest or what was the level of exposure? Questions (cont\u2019d):\nOver what period did the patient take or was exposed to the substance?\nHas the patient or a bystander performed any intervention?\nHow much does the patient weigh?",
        "Secondary Assessment Physical examinations": "Focus on the area of the body involved with the poisoning or the route of exposure.\nA general review of all body systems may help to identify systemic problems.\nA complete set of baseline vital signs is important.",
        "Reassessment": "Reassess the adequacy of the XABCs.\nRepeat vital signs; compare them with the baseline set. \nEvaluate your interventions.\nEvery 15 minutes for a stable patient\nEvery 5 minutes, or constantly, for a patient who has consumed a harmful or lethal dose Treatment\nSupporting the XABCs is your most important task.\nContact medical control or a poison center to discuss treatment options.\nManage airborne exposures with oxygen.\nRemove contact exposures with water.\nConsider activated charcoal for ingestions. Communication and documentation\nReport as much information as you have about the poison or chemical to the hospital.\nBring the material data sheet to the hospital if the poisoning occurred in a work setting.",
        "Emergency Medical Care": "Ensure scene safety.\nRemove tablets or fragments from the patient\u2019s mouth.\nWash or brush the poison from the patient\u2019s skin. Assess and maintain the patient\u2019s XABCs.\nProvide oxygen and perform assisted ventilations if necessary.\nTreat for shock and transport the patient promptly to the nearest hospital.\nSome EMS systems allow EMTs to give activated charcoal by mouth. Activated charcoal binds to specific toxins, which are then carried out of the body in the stool. \nContraindicated in patients who have:\nIngested alkali poisons, cyanide, ethanol, iron, lithium, methanol, mineral acids, or organic solvents \nA decreased LOC and cannot protect their airway If local protocol permits, you may carry a premixed suspension of 50 g of activated charcoal.\nThe usual dose for an adult or child is 1 g per kilogram of body weight. Before you give a patient charcoal, obtain approval from medical control.\nShake the bottle vigorously.\nYou may need to convince the patient to drink it, but never force it.\nRecord the time when you administered activated charcoal.\nIf the patient refuses activated charcoal, document the refusal and transport the patient for further evaluation. Side effects are constipation and black stools.\nIf the patient has ingested a poison that causes nausea, he or she may vomit after taking charcoal.",
        "Specific Poisons": "Over time, a person who routinely misuses a substance may need increasing amounts of it to achieve the same result.\nThis is called developing a tolerance.\nA person with an addiction has an overwhelming need to continue using the substance, at whatever cost.\nAlmost any substance can be abused. The importance of safety awareness and standard precautions cannot be overemphasized.\nKnown drug abusers have a fairly high incidence of serious and undiagnosed infections, including HIV and hepatitis.",
        "Many calls for service have a connection to alcohol use. FIGURE 22-8 Alcohol intoxication causes altered mental status, slowed reflexes, and impaired reaction time. \u00a9 David R. Frazier/Photo Researchers, Inc. Alcohol can damage the liver, whether thorough chronic overuse or occasional heavy use (binge drinking).": "Binge use can be more damaging than chronic use, depending on the frequency of the binging and the surrounding circumstances. Alcohol is a powerful CNS depressant.\nDecreases activity and excitement\nInduces sleep\nDulls the sense of awareness, slows reflexes, and reduces reaction time\nMay cause aggressive and inappropriate behavior and lack of coordination\nAlcohol increases the effects of other drugs and is commonly taken with other substances. If a patient exhibits signs of serious CNS depression, provide respiratory support.\nMay cause vomiting\nPatients may experience frightening hallucinations, or delirium tremens (DTs). DTs are characterized by:\nAgitation and restlessness\nFever\nSweating\nTremors\nConfusion/disorientation\nDelusions/hallucinations\nSeizures",
        "An opioid is a type of narcotic medication used to relieve pain.": "An opiate is a subset of the opioid family, and refers to natural, nonsynthetic opioids.\nNamed for the opium in poppy seeds, from which codeine and morphine are derived Prescription opioid drugs are among the most commonly abused drugs in the United States.\nSome people become physically dependent on opioids after taking an appropriate medical prescription. These agents are CNS depressants and can cause severe respiratory depression and then cardiac arrest if not treated promptly.\nTolerance develops quickly.\nSome users may require massive doses to experience the same high.\nOften cause nausea and vomiting\nMay lead to hypotension Although seizures are uncommon, they can occur. \nPatients typically appear sedated or unconscious and cyanotic with pinpoint pupils. Naloxone reverses the effects of opiate or opioid overdose. \nCan be given intravenously, intramuscularly, or intranasally \nIn many EMS systems, EMTs administer naloxone by the intranasal route. \nShould only be used when the patient has agonal respirations or is apneic Naloxone (cont\u2019d)\nIn some areas, lay people are permitted to administer naloxone.\nFind out from bystanders if the patient was given naloxone.",
        "Barbiturates and benzodiazepines are CNS depressants.": "Alter the level of consciousness. \nPatient may appear drowsy, peaceful, or intoxicated. These agents are generally taken by mouth.\nOccasionally, they are dissolved in water and injected.\nIV sedative-hypnotic drugs quickly induce tolerance.\nThese drugs may be given to people as a \u201cknock-out\u201d drink.\nTreatment is to ensure airway is patent, assist ventilation, and provide prompt transport.",
        "Abused Inhalants": "These agents are inhaled.\nAcetone, toluene, xylene, hexane\nFound in glues, cleaning compounds, paint thinners, and lacquers\nGasoline and halogenated hydrocarbons are also abused.\nCommonly abused by teenagers Always use special care.\nHalogenated hydrocarbon solvents can make the heart hypersensitive to the patient\u2019s own adrenaline.\nKeep patients from struggling or exerting themselves.\nUse a stretcher to move the patient, give oxygen, and transport to the hospital.",
        "Hydrogen sulfide": "A highly toxic, colorless, and flammable gas with a distinctive rotten-egg odor\nAffects all organs, but it has the most impact on the lungs and CNS.\nUsed to commit suicide\nIf you suspect the presence of a toxic gas, wait for a hazmat team to tell you the scene is safe. Signs and symptoms: \nNausea and vomiting, confusion, dyspnea, a loss of consciousness, seizures, shock, coma, and cardiopulmonary arrest\nOnce the patient has been decontaminated, management is largely supportive. \nMonitor and assist the patient\u2019s respiratory and cardiovascular functions.\nProvide rapid transport.",
        "Sympathomimetics": "CNS stimulants that mimic the effects of the sympathetic nervous system Produce an excited state.\nFrequently cause hypertension, tachycardia, and dilated pupils\nIncludes amphetamines, methamphetamines, phentermine hydrochloride, and Benzedrine\nDesigner drugs, such as MDMA, are also frequently abused.\nCommonly taken by mouth; also injected by drug abusers Cocaine may be taken in a number of different ways.\nCan be absorbed through all mucous membranes and even across the skin\nImmediate effects include excitement and euphoria and last less than an hour.\nSmoked crack is the most potent. Acute overdose is a genuine emergency.\nPatients have a high risk of seizures, cardiac dysrhythmias, and stroke. \nPatients may experience hallucinations or paranoia.\nDo not leave the patient unattended.\nProvide prompt transport.",
        "Synthetic Cathinones": "An emerging class of drugs similar to MDMA.\nProduce euphoria, increased mental clarity, and sexual arousal. \nMost users of this drug snort or insufflate the powder nasally. \nEffects reportedly last as long as 48 hours. Adverse effects include: \nTeeth grinding, appetite loss, muscle twitching, lip-smacking, confusion, gastrointestinal conditions, paranoia, headache, elevated heart rate, and hallucinations\nKeep the patient calm and transport. \nConsider ALS assistance.",
        "Marijuana is abused throughout the world.": "THC is the chemical in the marijuana plant that produces its high.\nProduces euphoria, relaxation, and drowsiness\nImpairs short-term memory and the capacity to do complex thinking\nCould progress to depression and confusion With very high doses, patients may experience hallucinations or become very anxious or paranoid.\nReassure the patient and transport with a minimum amount of excitement.\nMarijuana is often used as a vehicle to get other drugs into the body. Several states have legalized the recreational use of marijuana, and others allow for the medical use of marijuana and products that contain THC.\n\u201cEdibles\u201d infused with marijuana\nIngestion can lead to cannabinoid hyperemesis syndrome. Synthetic marijuana or \u201cSpice\u201d \nA variety of herbal incense or smoking blends that resemble THC and produce a similar high\nPowerful and unpredictable effects may result, ranging from simple euphoria to complete loss of consciousness.",
        "Hallucinogens alter a person\u2019s sensory perceptions.": "Classic example is LSD. These agents:\nCause visual hallucinations\nIntensify vision and hearing\nGenerally separate the user from reality\nPatients experiencing a \u201cbad trip\u201d have hypertension, tachycardia, anxiety, and paranoia. Use a calm, professional manner.\nProvide emotional support.\nDo not use restraints unless you or the patient is in danger of injury.\nWatch the patient carefully throughout transport and do not leave unattended.\nRequest ALS assistance when appropriate.",
        "Anticholinergic Agents": "Have properties that block the parasympathetic nerve.\n\u201cHot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter.\u201d\nCommon drugs include atropine, Benadryl, jimsonweed, and amitriptyline. Some tricyclic antidepressants have significant anticholinergic effects.\nDeath from these agents can be rapid.\nThe patient can go from \u201cnormal\u201d to seizure and death within 30 minutes.\nTransport immediately.\nConsider ALS backup.",
        "Cholinergic Agents": "Overstimulate normal body functions that are controlled by the parasympathetic nerves. \nInclude \u201cnerve gases\u201d designed for chemical warfare and organophosphate insecticides Use the mnemonic DUMBELS to remember the signs and symptoms:\nDiarrhea \nUrination\nMiosis\nBradycardia, bronchospasm, bronchorrhea\nEmesis\nLacrimation\nSeizures, salivation, sweating Or, you can use SLUDGEM:\nSalivation, sweating \nLacrimation\nUrination\nDefecation, drooling, diarrhea \nGastric upset and cramps\nEmesis \nMuscle twitching/miosis The most important consideration is to avoid exposure yourself.\nDecontamination may take priority over immediate transport.\nHazmat team will provide decontamination and contain the exposure chemical. \nAfter decontamination:\nDecrease the secretions in the mouth and trachea.\nProvide airway support. Antidote kit may be available.\nDuoDote Auto-Injector\nThe kit consists of a single auto-injector containing atropine and pralidoxime.\nIf a known exposure to nerve agents with manifestation of signs and symptoms has occurred, use the antidote kit on yourself.",
        "Miscellaneous Drugs": "Accidental or intentional overdose with cardiac medications has become common.\nChildren \nOlder patients Signs and symptoms depend on the medication ingested.\nContact the poison center as soon as possible. Aspirin poisoning remains a potentially lethal condition.\nIngesting too many aspirin may result in:\nNausea\nVomiting\nHyperventilation\nRinging in the ears Patients with this problem have:\nAnxiety\nConfusion\nTachypnea\nHyperthermia\nDanger of having seizures Overdosing with acetaminophen is also very common.\nSome alcohols, including methyl alcohol and ethylene glycol, are even more toxic than ethyl alcohol (drinking alcohol).",
        "Almost always caused by eating food contaminated by bacteria": "Two main types:\nOrganism itself may cause disease.\nOrganism may produce toxins that cause disease. One organism that produces direct effects of food poisoning is the Salmonella bacterium. Causes salmonellosis\nCharacterized by severe GI symptoms within 72 hours of ingestion, including nausea, vomiting, abdominal pain, and diarrhea\nProper cooking kills bacteria, and proper cleanliness in the kitchen prevents the contamination of uncooked foods. The more common cause of food poisoning is the ingestion of powerful toxins produced by bacteria, often in leftovers.\nThe bacterium Staphylococcus is quick to grow and produce toxins in food.\nFoods left unrefrigerated are a common vehicle.\nSymptoms usually within start 2 to 3 hours or as long as 8 to 12 hours after ingestion. The most severe form of toxin ingestion is botulism.\nCan result from eating improperly canned food\nSymptoms are neurologic:\nBlurring of vision\nWeakness\nDifficulty in speaking and breathing Do not try to determine the specific cause of acute GI problems.\nGather as much history as possible from the patient.\nWhen two or more persons have the same illness, take along the suspected food.",
        "There are tens of thousands of cases of plant poisoning annually.": "Many household plants are poisonous if ingested. It is impossible to memorize every plant or poison, let alone their effects.\nAssess the patient\u2019s airway and vital signs.\nNotify the regional poison center.\nTake the plant to the emergency department. FIGURE 22-10 The toxins in these common poisonous plants are often ingested or absorbed through the skin. A. Dieffenbachia. B. Mistletoe. C. Castor bean. \nD. Nightshade. E. Foxglove. F. Rhododendron A: \u00a9 Andriy Doriy/Shutterstock; B: \u00a9 Robert Johnson/Shutterstock; \nC: Courtesy of Brian Prechtel/USDA. D: \u00a9 H. Brauer/Shutterstock; \nE: \u00a9 Jean Ann Fitzhugh/Shutterstock; F: \u00a9 Kateryna  hyzhnyak/Dreamstime.com G. Jimsonweed. H. Death camas. I. Poison ivy. J. Poison oak.\nK. Pokeweed. L. Rosary pea. M. Poison sumac. G: \u00a9 Travis Klein/Shutterstock; H: Courtesy of Walter Siegmund; \nI: \u00a9 LianeM/Shutterstock; J: \u00a9 Forest & Kim Starr [http://www.hear.org/starr/plants/]. Used with permission;  K: \u00a9 Thomas Photography LLC/Alamy; L: \u00a9 Thomas J. Peterson/Alamy; M: Courtesy of U.S. Fish & Wildlife Service."
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Medical Overview\nAssessment and management of a\nMedical complaint\nPathophysiology, assessment, and management of medical complaints to include\nTransport mode\nDestination decisions Infectious Diseases\nAwareness of\nA patient who may have an infectious disease\nAssessment and management of\nA patient who may have an infectious disease",
        "Introduction Patients who need EMS assistance generally have experienced a medical emergency, a trauma emergency, or both.": "Trauma emergencies involve injuries resulting from physical forces applied to the body.\nMedical emergencies involve illnesses or conditions caused by disease.",
        "Types of Medical Emergencies": "Respiratory emergencies: patients have trouble breathing or the amount of oxygen supplied to the tissues is inadequate\nCardiovascular emergencies: caused by conditions affecting the circulatory system\nNeurologic emergencies: involve the brain\nGastrointestinal conditions: appendicitis, diverticulitis, pancreatitis, and many others Urologic emergency: kidney stones\nEndocrine emergencies: most commonly caused by complications of diabetes mellitus\nHematologic emergencies: may be the result of sickle cell disease or blood-clotting disorders Immunologic emergencies: involve the body\u2019s response to foreign substances\nToxicologic emergencies: include poisoning and substance abuse\nSome medical emergencies are caused by psychological or behavioral problems.\nGynecologic emergencies: involve female reproductive organs",
        "Patient Assessment": "Similar to the assessment of the trauma patient, but with a different focus\nFocused on:\nNature of illness (NOI)\nSymptoms\nChief complaint Establish an accurate medical history.\nUse dispatch information to guide initial response.\nDo not get locked into a preconceived idea of the patient\u2019s condition. Assessment may be difficult with uncooperative or hostile patients.\nMaintain a professional, calm, nonjudgmental demeanor.\nRefrain from labeling patients.\nA frequent caller may have a different complaint this time.",
        "Scene Size-up Scene safety": "Make certain the scene is safe.\nUse standard precautions.\nDetermine the number of patients and whether you need additional help.\nNature of illness (NOI)\nIndex of suspicion: your awareness of potentially serious underlying injuries or illness",
        "Primary Assessment": "Develop a general impression.\nPerform a rapid examination of the patient.\nQuickly determine the patient\u2019s level of consciousness. Airway and breathing\nIn conscious patients, ensure the airway is open and they are breathing adequately.\nCheck respiratory rate, depth, and quality.\nConsider applying oxygen if breathing has been affected.\nFor unconscious patients, make sure to open the airway using the proper technique. Apply oxygen to patients:\nIn shock\nWith difficulty breathing\nWhen low oxygen saturations are measured \nUnconscious patients may need airway adjuncts and ventilatory assistance with a bag-mask device. Circulation\nIn a conscious patient by check the radial pulse and observe the patient\u2019s skin color, temperature, and condition.\nFor unconscious patients, assess circulation at the carotid artery. Transport decision\nPatients in need of rapid transport:\nUnconscious or have an altered mental status\nAirway or breathing problems\nObvious circulation problems such as severe bleeding or signs of shock",
        "History Taking": "Determine what the problem is or what may be causing the problem.\nGather a thorough history.\nFor an unconscious patient, survey the scene for medication containers or medical devices. Obtain a SAMPLE history and use the OPQRST mnemonic.\nRecord any allergies, medical conditions, and medications.\nSome patients take numerous medications; take the medications with you to the hospital.",
        "May occur on scene or en route to the ED": "In some cases you may not have time.\nPhysical examination\nAll conscious patients should undergo a limited or detailed physical examination.\nFor unconscious patients, always perform a secondary assessment of the entire body or head-to-toe examination. Physical examination (cont\u2019d)\nExamine the head, scalp, and face.\nExamine the neck closely.\nAssess the chest and abdomen.\nPalpate the legs and arms.\nExamine the patient\u2019s back. Vital signs\nAssess the pulse for rate, quality, and regularity.\nIdentify the rate, quality, and regularity of the respirations.\nObtain an initial blood pressure.\nConsider obtaining a blood glucose level and a pulse oximetry reading.",
        "Reassessment Performed once the assessment and treatment have been completed": "Begins and continues throughout transport\nConsider the need for ALS backup.\nReassess interventions.\nDocument any developed changes.",
        "Management: Transport and Destination": "Most medical emergencies require a level of treatment beyond that available in the prehospital setting.\nMay require advanced testing available in a hospital\nMay be beyond the scope of the EMT to administer medications to a patient\nEMTs can use the AED. Scene time\nMay be longer for medical patients than for trauma patients\nGather as much information as possible to transmit to the ED.\nCritical patients always need rapid transport. Type of transport\nLife-threatening condition: lights and siren\nNon\u2013life-threatening condition: consider nonemergency transport.\nModes of transport ultimately come in one of two categories: ground or air. Ground transport EMS units are generally staffed by EMTs and paramedics. FIGURE 15-4 Ground transport. \u00a9 2p2play/Shutterstock. Air transport EMS units are generally staffed by critical care transport professionals and paramedics. FIGURE 15-5 Air transport. LindaCharlton/iStock. Destination selection\nGenerally, the closest hospital should be your destination.\nSometimes the patient will benefit from going to another hospital capable of handling his or her particular condition.",
        "Infectious Diseases": "General assessment principles:\nApproach like any other medical patient.\nPerform scene size-up, take standard precautions, and complete primary assessment.\nGather patient history using OPQRST to elaborate on the patient\u2019s chief complaint. General assessment principles (cont\u2019d):\nObtain a SAMPLE history and a set of baseline vital signs.\nAsk whether the patient has recently traveled or has come in contact with someone who has traveled. General management principles:\nFocus on any life-threatening conditions identified in the primary assessment.\nBe empathetic.\nPlace the patient in the position of comfort on the stretcher and keep them warm.\nUse standard precautions.",
        "Epidemic and Pandemic Considerations Epidemic: new cases of a disease in a human population substantially exceed what is expected.": "Pandemic: a disease outbreak that occurs on a global scale",
        "Those with chronic medical conditions, compromised immune systems, and the very young and the very old are most susceptible to complications of influenza.": "Transmitted by direct contact with nasal secretions and aerosolized droplets from coughing and sneezing by infected people. For diseases that can be passed by the respiratory route: \nAlways wear PPE (gloves, eye protection, and HEPA respirator or N95 mask).\nPlace a surgical mask on patients with suspected or confirmed respiratory disease.\nAnnual influenza immunization is important for EMS personnel to protect providers and patients.",
        "Herpes Simplex Common virus strain carried by humans": "Symptomatic infections cause vesicles that appear on the lips or genitals. \nCan cause more serious illnesses in susceptible patients\nPrimary mode of infection is through close personal contact.",
        "HIV Infection": "EMTs face a risk of exposure. \nNo vaccine yet exists.\nAIDS can still be fatal; however, with treatment, patients can expect a near-normal lifespan. \nNot easily transmitted in the work setting\nYour risk of infection is limited to exposure to an infected patient\u2019s blood or body fluids. Many patients with HIV show no symptoms.\nAlways wear the proper type of gloves.\nTake great care in handling and disposing of needles.\nCover any open wounds.\nIf you think a patient\u2019s blood or secretions may have entered your system, seek medical advice and notify your infectious disease officer.",
        "Inflammation (and often infection) of the liver": "Can be caused by viruses and toxins\nThere is no sure way to tell which hepatitis patients are contagious.\nVaccination with hepatitis B vaccine is highly recommended for EMTs.",
        "Meningitis Inflammation of the meningeal coverings of the brain and spinal cord": "Most forms of meningitis are not contagious.\nTake standard precautions.\nCan be treated at the ED with antibiotics.\nAfter treating a meningitis patient, contact your employer health representative.",
        "Most infected patients are well most of the time.": "Chronic mycobacterial disease that usually strikes the lungs\nPatients who pose the highest risk almost always have a cough.\nN95 or HEPA mask is required to stop droplet nuclei. Absolute protection from the tubercle bacillus does not exist.\nOne-third of the world\u2019s population is infected with tuberculosis.\nHave tuberculin skin tests regularly.\nPreventive therapy is almost 100% effective.",
        "Whooping Cough Also called pertussis": "Mostly affects children younger than 6 years\nSymptoms include fever and a \u201cwhoop\u201d sound that occurs when inhaling after a coughing attack.\nThe best way to prevent exposure is to be vaccinated.\nPlace a mask on the patient and yourself.",
        "Methicillin-Resistant Staphylococcus aureus": "MRSA is a bacterium that causes infections.\nResistant to many antibiotics\nIn health care settings, MRSA is transmitted from patient to patient by health care providers\u2019 unwashed hands. Factors that increase the risk of MRSA:\nAntibiotic therapy\nProlonged hospital stays\nA stay in an intensive care or burn unit\nExposure to an infected patient\nMRSA results in soft-tissue infections.",
        "Global Health Issues": "COVID-19\nOriginated in Wuhan, Hubei Province, China\nQuickly spread, infecting millions, killing hundreds of thousands\nControlling the virus: social distancing\nSymptoms include fever, cough, shortness of breath that appear 2\u201314 days after exposure\nCDC website (www.cdc.gov) MERS-CoV (Middle East respiratory syndrome coronavirus)\nFirst human case discovered in 2012 in Saudi Arabia \nNo cure or vaccines for this virus at present\nPlace a surgical mask on the patient if MERS-CoV is suspected. Ebola\n2014 outbreak of the Ebola virus in West Africa\nIncubation period: 6 to 12 days after exposure\nSymptoms may not appear for as long as 21 days after infection. \nFatality rate can be as high as 70% if treatment in an ICU is not initiated promptly.",
        "Travel Medicine": "Be aware of travel-acquired infections when assessing a patient who was recently outside of the United States. \nPatients can present with a variety of symptoms. \nWhen you encounter an ill patient with a recent travel history, place a mask on the patient and gather as much information as possible. Important questions to ask include: \nWhere did you recently travel?\nDid you receive any vaccinations before your trip?\nWere you exposed to any infectious diseases?\nIs there anyone else in your travel party who is sick?\nWhat types of foods did you eat?\nWhat was your source of drinking water?",
        "Conclusion Assessment and treatment of medical patients can be challenging and interesting because of the nature of medical conditions.": "The condition of a medical patient may not be as apparent as in a trauma patient and treatment may not be as straightforward. \nPatients sometimes have more than one isolated problem."
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Abdominal and Gastrointestinal Disorders\nAnatomy, presentations, and management of shock associated with abdominal emergencies\nGastrointestinal bleeding Abdominal and Gastrointestinal Disorders (cont\u2019d)\nAnatomy, physiology, pathophysiology, assessment, and management of\nAcute and chronic gastrointestinal hemorrhage\nPeritonitis\nUlcerative diseases Genitourinary/Renal\nBlood pressure assessment in hemodialysis patients\nAnatomy, physiology, pathophysiology, assessment, and management of\nComplications related to\nRenal dialysis\nUrinary catheter management (not insertion)\nKidney stones",
        "Introduction Abdominal pain is a common complaint.": "Cause of abdominal pain is often difficult to determine.\nAs an EMT:\nYou do not need to determine the exact cause.\nYou should be able to recognize a life-threatening problem and act.",
        "Anatomy and Physiology": "Abdominal cavity contains:\nGastrointestinal system\nGenital system\nUrinary system\nMade up of solid and hollow organs Injury to a solid organ can cause shock and bleeding.\nBreach of a hollow organ causes its contents to leak and contaminate the abdominal cavity. FIGURE 19-1 The solid and hollow organs of the abdomen. A. Solid organs include the liver, spleen, pancreas, kidneys, and ovaries (in women). B. Hollow organs include the gallbladder, stomach, small intestine, large intestine, and bladder. A, B: \u00a9 Jones & Bartlett Learning.",
        "The Gastrointestinal System": "Responsible for digestion process\nDigestion begins when food is chewed.\nThe stomach is the main digestive organ.\nGastric juices break food down. The liver assists in digestion.\nSecretes bile and aids in digestion of fats\nFilters toxic substances\nCreates glucose stores\nThe gallbladder is a reservoir for bile. Small intestine \nDuodenum\nDigestive juices from pancreas and liver mix.\nPancreas releases amylase, bicarbonate, and insulin.\nJejunum\nAbsorbs digestive products\nDoes most of the work Small intestine (cont\u2019d)\nIleum\nAbsorbs nutrients that were not absorbed earlier\nAbsorbs bile acids so they can be returned to the liver for future use and vitamin B12 for making nerve cells and red blood cells Colon (large intestine)\nFood that is not broken down comes here.\nWater is absorbed.\nStool is formed. Spleen\nLocated in abdomen\nNo digestive function",
        "The Genital System": "Male reproductive system:\nTesticles\nEpididymis\nVasa deferentia\nSeminal vesicles\nProstate gland\nPenis Female reproductive system:\nOvaries\nFallopian tubes\nUterus\nCervix\nVagina",
        "Controls discharge of waste materials filtered from blood by kidneys": "The kidneys are solid organs.\nThere are two kidneys, one on each side of the body. Ureters join each kidney to the bladder.\nThe bladder is located behind the pubic symphysis.\nThe bladder empties urine outside body through the urethra.\n1.5 to 2 L of urine per day FIGURE 19-2 The urinary system lies in the retroperitoneal space behind the organs of the digestive system. The urinary system in men and women includes the kidneys, ureters, bladder, and urethra. This diagram shows the male urinary system. \u00a9 Jones & Bartlett Learning.",
        "Pathophysiology": "The abdominal cavity is lined by the peritoneum.\nParietal peritoneum lines the walls of the abdominal cavity.\nVisceral peritoneum covers organs.\nForeign material such as blood, pus, or bile can irritate the peritoneum.\nCauses peritonitis \u201cAcute abdomen\u201d refers to the sudden onset of abdominal pain.\nOften associated with severe, progressive problems Peritonitis \nInflammation of peritoneum \nTypically causes ileus\nIleus\nParalysis of muscular contractions\nRetained gas and feces cause distention.\nStomach empties by emesis. Diverticulitis \nInflammation of small pockets at weak areas in the muscle walls\nCholecystitis \nInflammation of the gallbladder\nAcute appendicitis",
        "Abdominal Pain Two types of nerves supply the peritoneum.": "Parietal peritoneum: supplied by the same nerves that supply the skin of the abdomen\nVisceral peritoneum: supplied by the autonomic nervous system",
        "Causes of Acute Abdomen": "Ulcers\nProtective layer of mucus erodes, allowing acid to eat into the organ\nMay lead to gastric bleeding and peritonitis Gallstones\nGallstones may form and block its outlet.\nCause pain\nLead to cholecystitis Pancreatitis\nInflammation of the pancreas\nCaused by obstructing gallstone, alcohol abuse, or other diseases\nSigns and symptoms include pain in upper left and right quadrants, nausea, vomiting, and abdominal distention.\nSepsis or hemorrhage may occur. Appendicitis\nInflammation or infection in the appendix\nNausea, vomiting, anorexia, fever, chills, rebound tenderness \nGastrointestinal hemorrhage\nBleeding within gastrointestinal tract\nMay be acute or chronic Esophagitis\nLining of the esophagus becomes inflamed by infection or acids from the stomach.\nPain in swallowing, heartburn, nausea, vomiting, sores in mouth\nEsophageal varices\nCapillary network in the esophagus leaks.\nFatigue, weight loss, jaundice, anorexia, edema, abdominal pain Mallory-Weiss syndrome\nJunction between esophagus and stomach tears. \nPrincipal symptom: vomiting\nGastroenteritis\nInfection from bacterial or viral organisms or caused by noninfectious conditions \nPrincipal symptom: diarrhea Diverticulitis\nFecal matter becomes caught in colon walls, causing inflammation and infection.\nFever, malaise, body aches, chills\nHemorrhoids\nCreated by swelling and inflammation of blood vessels surrounding rectum\nBright red blood during defecation",
        "Urinary System Cystitis (bladder infection) is common.": "Also called urinary tract infection (UTI)\nCaused by bacterial infection\nBecomes serious if infection spreads to kidneys\nReports of urgency and frequency of urination",
        "Play a major role in maintaining homeostasis": "When the kidneys fail, uremia results.\nKidney stones can grow over time and cause blockage. Acute kidney failure\nSudden decrease in kidney function\nReversible with prompt diagnosis and treatment\nChronic kidney failure\nIrreversible\nProgressive, develops over months/years\nEventually dialysis or transplant is required.",
        "Female Reproductive Organs Gynecologic problems are a common cause of acute abdominal pain.": "Lower quadrant pain may relate to the ovaries, fallopian tubes, or uterus.",
        "Other Organ Systems": "The aorta lies immediately behind the peritoneum.\nWeak areas can result in abdominal aortic aneurysm (AAA).\nAAA is difficult to detect. \nUse extreme caution when assessing or detecting AAA. Hernias \nProtrusion of an organ or tissue through an opening into a body cavity where it does not belong\nMay not always produce noticeable mass or lump\nStrangulation is a serious medical emergency. Serious hernia signs and symptoms:\nA formerly reducible mass that is no longer reducible\nPain at the hernia site\nTenderness when the hernia is palpated\nRed or blue skin discoloration",
        "Scene Size-up Scene safety and standard precautions": "Mechanism of injury/nature of illness\nMay be the result of violence\nUse assessment results to develop an early index of suspicion for life threats.",
        "Primary Assessment Airway and breathing": "May cause shallow, inadequate respirations\nCirculation\nAsk about blood in vomit or black, tarry stools.\nCheck pulses in both feet.\nTransport decision\nImmediate transport is needed if there are signs of significant illness.",
        "History Taking SAMPLE history": "Nausea and vomiting\nChange in bowel habits and urination\nWeight loss\nBelching or flatulence \nPain\nConcurrent chest pain\nOther signs or symptoms",
        "Secondary Assessment": "Physical examination\nNormal abdomen is soft and not tender.\nPain/tenderness: signs of acute abdomen\nExpose and assess abdomen.\nPalpate gently. FIGURE 19-4 Check for tenderness or rigidity by gently palpating the abdomen. \u00a9 Jones & Bartlett Learning. Vital signs\nCheck respiratory rate and pulse rate.\nAvoid taking a blood pressure in the same arm where a dialysis shunt is.",
        "Reassessment Frequent reassessment is important.": "Assess interventions, including treatment for shock and emotional support.\nTransport the patient in the most comfortable position.",
        "Emergency Medical Care You cannot treat causes of acute abdomen.": "Take steps to provide comfort and lessen effects of shock.\nTreat for shock even when obvious signs are not apparent.\nLow-flow oxygen may decrease nausea and anxiety.",
        "Dialysis Emergencies": "Dialysis is the only definitive treatment for chronic kidney failure.\nDialysis filters blood, cleans it of toxins, and returns it to body.\nIf the patient misses dialysis treatment, pulmonary edema can occur.\nSome services transport patients to and from dialysis centers. The dialysis machine functions much like normal kidneys.\nAdverse effects of dialysis:\nHypotension\nDysrhythmias\nMuscle cramps\nNausea and vomiting\nHemorrhage from access site\nInfection at access site",
        "Emergency care:": "Manage XABCs.\nProvide high-flow oxygen if indicated.\nManage any bleeding from access site.\nPosition the patient:\nUpright in cases of pulmonary edema\nSupine if the patient is in shock\nTransport promptly"
    },
    {
        "National EMS Education Standard Competencies": "Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Environmental Emergencies\nRecognition and management of\nSubmersion incidents\nTemperature-related illness\nPathophysiology, assessment, and management of\nNear drowning\nTemperature-related illness\nBites and envenomations Pathophysiology, assessment, and management of (cont\u2019d)\nDysbarism\nHigh altitude\nDiving injuries\nElectrical injury",
        "Introduction": "Medical emergencies can result from environmental factors.\nCertain populations are at higher risk:\nChildren\nOlder people\nPeople with chronic illnesses\nYoung adults who overexert themselves Environmental emergencies include:\nHeat- and cold-related emergencies\nWater emergencies\nPressure-related injuries\nInjuries caused by lightning\nEnvenomation",
        "Factors Affecting Exposure": "Physical condition\nPatients who are ill or in poor physical condition will not tolerate extreme temperatures well.\nAge\nInfants, children, and older adults are more likely to experience temperature-related illness. Nutrition and hydration\nA lack of food or water will aggravate hot or cold stress.\nAlcohol will change the body\u2019s ability to regulate temperature. Environmental conditions\nConditions that can complicate environmental situations:\nAir temperature\nHumidity level\nWind\nExtremes in temperature and humidity are not needed to produce injuries.",
        "Cold exposure may cause injury to:": "Feet\nHands\nEars\nNose\nWhole body (hypothermia)\nThere are five ways the body can lose heat. Conduction\nTransfer of heat from a part of the body to a colder object by direct contact\nHeat can also be gained if the substance being touched is warm.\nConvection\nTransfer of heat to circulating air\nWhen cool air moves across the body Evaporation\nConversion of any liquid to a gas\nNatural mechanism by which sweating cools the body\nRadiation\nTransfer of heat by radiant energy\nHeat loss caused when a person stands in a cold room Respiration\nBody heat loss as warm air in the lungs is exhaled into the atmosphere and cooler air is inhaled. The rate and amount of heat loss or gain by the body can be modified in three ways:\nIncrease or decrease in heat production\nMove to an area where heat loss can be decreased or increased.\nWear the appropriate clothing for the environment.",
        "Core temperature falls below 95\u00b0F (35\u00b0C)": "Body loses the ability to regulate its temperature and generate body heat.\nEventually, key organs such as the heart begin to slow down, and mental status deteriorates.\nCan lead to death Air temperature does not have to be below freezing for it to occur.\nCan develop quickly or gradually\nPeople at risk:\nHomeless people and those whose homes lack heating\nSwimmers\nGeriatric, pediatric, and ill individuals Signs and symptoms become more severe as the core temperature falls.\nProgresses through four stages Assess general temperature.\nPull back your gloves and place the back of your hand on the patient\u2019s abdomen. FIGURE 33-1 To assess a patient\u2019s core body temperature,\npull back your glove and place the back of your hand on\nthe patient\u2019s skin at the abdomen. \u00a9 Jones & Bartlett Learning. Mild hypothermia\nOccurs when the core temperature is greater than 93.2\u00b0F (34\u00b0C) but less than 98\u00b0F (36.7\u00b0C).\nPatient is usually alert and shivering.\nPulse rate and respirations are rapid.\nSkin may appear red, pale, or cyanotic. Moderate hypothermia exists when the core temperature is 86\u00b0F to 93.2\u00b0F (30\u00b0C to 34\u00b0C).\nShivering stops.\nMuscular activity decreases.\nSevere hypothermia occurs when the core temperature is less than 86\u00b0F (30\u00b0C).\nThe patient becomes lethargic and stops fighting. If body temperature is 80\u00b0F or less \nPulse becomes slower and weaker.\nCardiac dysrhythmias may occur.\nPatient may appear dead (or in a coma).\nNever assume a cold, pulseless patient is dead.",
        "Local Cold Injuries": "Most injuries from cold are confined to exposed parts of the body.\nFrostnip\nImmersion foot (trench foot)\nFrostbite FIGURE 33-2 The (A) hands, (B) nose, and (C) feet are\nparticularly susceptible to frostbite. A: Courtesy of Neil Malcom Winkelmann; B: \u00a9 Dr. P. Marazzi/Science Source; C: \u00a9 Chuck Stewart, MD. Important factors in determining the severity of a local cold injury\nDuration of the exposure\nTemperature to which the body part was exposed\nWind velocity during exposure Consider underlying factors.\nExposure to wet conditions\nInadequate insulation from cold or wind\nRestricted circulation from tight clothing or shoes or circulatory disease\nFatigue\nPoor nutrition Underlying factors (cont\u2019d)\nAlcohol or drug abuse\nHypothermia\nDiabetes\nCardiovascular disease\nAge",
        "Frostnip and Immersion Foot": "Frostnip\nAfter prolonged exposure to the cold, skin may freeze while deeper tissues are unaffected.\nUsually affects the ear, nose, and fingers\nUsually not painful, so the patient often is unaware that a cold injury has occurred. Immersion foot\nOccurs after prolonged exposure to cold water\nCommon in hikers and hunters Signs and symptoms \nPale, cool skin\nNormal color does not return after palpation of the skin.\nThe skin of the foot may be wrinkled.\nLoss of feeling and sensation in the injured area",
        "Most serious local cold injury because the tissues are actually frozen.": "Gangrene requires surgical removal of dead tissue. FIGURE 33-3 Gangrene (necrosis), or permanent cell\ndeath, occurs when tissue is frozen and destructive\nchemical changes occur in the cells. Courtesy of Dr. Jack Poland/CDC. Signs and symptoms\nHard, waxy feel of the affected tissues\nThe injured part feels firm.\nBlisters and swelling may be present. The depth of skin damage will vary.\nWith superficial frostbite, only the skin is frozen.\nWith deep frostbite, deeper tissues are frozen.\nYou may not be able to tell superficial from deep frostbite in the field.",
        "Scene safety": "Note the environmental conditions.\nEnsure that the scene is safe for you and other responders.\nIdentify safety hazards such as icy roads, mud, or wet grass.\nUse appropriate standard precautions. Scene safety (cont\u2019d)\nConsider the number of patients.\nSummon additional help as quickly as possible.\nMechanism of injury/nature of illness\nLook for indicators of the MOI. Scene Size-up Scene safety\nPerform an environmental assessment.\nThe heat emergency may be secondary to a medical or trauma emergency.\nConsider calling ALS.\nLook for indicators of MOI.\nStay hydrated.\nUse appropriate standard precautions, including gloves and eye protection. Scene Size-up Scene safety\nGloves and eye protection\nNever drive through moving water; be cautious driving through still water.\nNever attempt a water rescue without proper training and equipment.\nConsider trauma and spinal immobilization.\nCheck for additional patients.",
        "Primary Assessment": "Form a general impression.\nPerform a rapid scan.\nIf a life threat exists, treat it.\nCheck core temperature.\nEvaluate mental status using the AVPU scale.\nAn altered mental status can be affected by the intensity of the cold injury. If the patient is in cardiac arrest, begin compressions.\nAirway and breathing\nEnsure that the patient has an adequate airway and is breathing.\nWarmed, humidified oxygen helps warm the patient from the inside out. Circulation \nPalpate for a carotid pulse and wait for up to 60 seconds to decide if the patient is pulseless.\nThe AHA recommends that CPR be started on a patient who has no detectable pulse or breathing.\nPerfusion will be compromised.\nBleeding may be difficult to find. Transport decision\nComplications can include cardiac dysrhythmias and blood clotting abnormalities.\nAll patients with hypothermia require immediate transport.\nRough handling of a hypothermic patient may cause a cold, slow, weak heart to fibrillate. Form a general impression.\nObserve how the patient interacts with you and the environment.\nIntroduce yourself and ask about the chief complaint.\nPerform a rapid scan, and avoid tunnel vision.\nAssess mental status using AVPU. Airway and breathing\nUnless the patient is unresponsive, the airway should be patent.\nNausea and vomiting may occur.\nPosition the patient to protect the airway.\nConsider spinal immobilization.\nIf unresponsive, insert an airway and provide bag-mask ventilations. Circulation\nIf adequate, assess for perfusion and bleeding.\nAssess the patient\u2019s skin condition.\nTreat for shock. Form a general impression.\nPay attention to chest pain, dyspnea, and complaints of sensory changes.\nDetermine level of consciousness using the AVPU scale.\nBe suspicious of drug or alcohol use.\nAirway and breathing\nOpen the airway and assess breathing in unresponsive patients. Airway and breathing (cont\u2019d)\nConsider spinal trauma and take appropriate actions.\nSuction if the patient has vomited.\nProvide ventilations with a bag-mask for inadequate breathing. \nIf the patient is responsive, provide high-flow oxygen with a nonrebreathing mask.\nAuscultate and monitor breath sounds. Circulation\nIt may be difficult to find a pulse.\nBegin CPR, and apply your AED.\nEvaluate for shock and perfusion.\nIf the MOI suggests trauma, assess for bleeding and treat appropriately. Transport decision\nAlways transport near-drowning patients to the hospital.\nInhalation of any amount of fluid can lead to delayed complications.\nDecompression sickness and air embolism must be treated in a recompression chamber.",
        "History Taking Investigate the chief complaint.": "Obtain a medical history.\nBe alert for injury-specific signs and symptoms and any pertinent negatives.\nSAMPLE history\nFind out how long your patient has been exposed to the cold environment.\nExposures may be short or prolonged. Investigate the chief complaint.\nBe alert for injury-specific signs and symptoms. \nAbsence of perspiration\nDecreased level of consciousness\nConfusion\nMuscle cramping\nNausea\nVomiting SAMPLE History\nNote any activities, conditions, or medications.\nInadequate oral intake\nDiuretics\nMedications\nDetermine exposure to heat and humidity and activities prior to onset. History Taking Investigate the chief complaint.\nObtain a medical history.\nBe alert for injury-specific signs and symptoms.\nSAMPLE history\nDetermine the depth of the dive, length of time the patient was underwater, time of onset of symptoms, and previous diving activity.",
        "Secondary Assessment": "Physical examinations\nFocus on the severity of hypothermia.\nAssess the areas of the body directly affected by cold exposure.\nAssess the degree and extent of damage. Vital signs\nMay be altered by the effects of hypothermia and can be an indicator of its severity\nRespirations may be slow and shallow.\nLow blood pressure and a slow pulse indicate moderate to severe hypothermia.\nEvaluate for changes in mental status. Monitoring devices\nDetermine a core body temperature using a hypothermia thermometer.\nPulse oximetry will often be inaccurate. Physical examinations\nAssess the patient for muscle cramps or confusion.\nExamine the patient\u2019s mental status and vital signs.\nPay special attention to skin temperature, turgor, and level of moisture. \nPerform a careful neurologic examination. Vital signs\nPatients who are hyperthermic will be tachycardic and tachypneic.\nFalling blood pressure indicates that the patient is going into shock.\nIn heat exhaustion, the skin temperature may be normal or cool and clammy.\nIn heatstroke, the skin is hot. Physical examinations\nExamine lungs and breath sounds.\nLook for hidden life threats and trauma, indications of the bends or air embolism, and signs of hypothermia. \nComplete a detailed full-body scan en route to the hospital. Assess for:\nPeripheral pulses\nSkin color and discoloration\nItching\nPain\nParesthesia (numbness and tingling) Vital signs\nCheck pulse rate, quality, and rhythm.\nCheck respiratory rate, quality, and rhythm, and listen for lung sounds.\nAssess pupil size and reactivity.\nMonitoring devices\nOxygen saturation readings may be inaccurate.",
        "Reassessment": "Repeat the primary assessment.\nReassess vital signs and the chief complaint.\nMonitor the patient\u2019s level of consciousness and vital signs.\nRewarming can lead to cardiac dysrhythmias. Communicate all of the information you have gathered to the receiving facility.\nPatient\u2019s physical status\nConditions at the scene\nAny changes in the patient\u2019s mental status during treatment and transport Watch for deterioration.\nPatients with symptoms of heatstroke should be transported immediately.\nMonitor vital signs at least every 5 minutes.\nEvaluate the effectiveness of interventions. \nBe careful not to overcool a patient. Communication and documentation\nInform the staff at the receiving facility early on that your patient is experiencing heatstroke.\nAdditional resources may be required.\nDocument environmental conditions and the activities the patient was performing prior to onset. Repeat the primary assessment.\nDrowning patients may deteriorate rapidly due to:\nPulmonary injury\nFluid shifts in the body\nCerebral hypoxia\nHypothermia\nPneumothorax, air embolism, or decompression sickness patients may decompensate quickly. Document\nCircumstances of drowning and extrication\nTime submerged\nTemperature and clarity of the water\nPossible spinal injury\nBring all dive equipment to the hospital, including dive log or dive computer",
        "General Management of Cold Emergencies": "Move the patient from the cold environment.\nRemove any wet clothing.\nPlace dry blankets over and under the patient. FIGURE 33-5 Place dry blankets over and under the patient with hypothermia; give warm, humidified oxygen, if available. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. If available, give the patient warm, humidified oxygen.\nHandle the patient gently.\nDo not massage the extremities.\nDo not allow the patient to eat or use any stimulants. Mild hypothermia\nPatient is alert, shivering, and responds appropriately.\nPlace the patient in a warm environment, and remove wet clothing.\nApply heat packs or hot water bottles to the groin, axillary, and cervical regions.\nGive warm fluids by mouth. Moderate or severe hypothermia\nDo not try to actively rewarm the patient.\nThe goal is to prevent further heat loss.\nRemove the patient from the cold environment.\nRemove wet clothing, cover with a blanket, and transport.",
        "Emergency Care of Local Cold Injuries": "Remove the patient from further exposure to the cold.\nHandle the injured part gently and protect it from further injury.\nRemove any wet or restricting clothing over the injured part. If transport will be delayed, consider active rewarming.\nWith frostnip, contact with a warm object may be all that is needed.\nWith immersion foot, remove wet shoes, boots, and socks, and rewarm the foot gradually.\nWith a late or deep cold injury, do not apply heat or rewarm the part.\nNever rub or massage injured tissues. Rewarming in the field\nImmerse the frostbitten part in water between 102\u00b0F and 104\u00b0F.\nDress the area with dry, sterile dressings.\nIf blisters have formed, do not break them.\nNever attempt rewarming if there is any chance that the part may freeze again.",
        "Cold Exposure and You You are at risk for hypothermia if you work in a cold environment.": "If cold weather search-and-rescue is possible in your area, you need:\nSurvival training\nPrecautionary tips\nWear appropriate clothing.",
        "Heat Exposure": "In a hot environment, the body tries to rid itself of excess heat.\nSweating and dilation of skin blood vessels\nRemoval of clothing and relocation to a cooler environment",
        "Hyperthermia is a core temperature of 101\u00b0F (38.3\u00b0C) or higher.": "Risk factors of heat illness:\nHigh air temperature (reduces radiation)\nHigh humidity (reduces evaporation)\nLack of acclimation to the heat\nVigorous exercise (loss of fluid and electrolytes)",
        "Persons at greatest risk for heat illnesses are:": "Children (especially newborns and infants)\nGeriatric patients\nPatients with heart disease, COPD, diabetes, dehydration, and obesity\nPatients with limited mobility",
        "Heat Cramps Painful muscle spasms that occur after vigorous exercise": "Do not occur only when it is hot outdoors\nExact cause is not well understood.\nUsually occur in the leg or abdominal muscles",
        "Heat Exhaustion": "Most common illness caused by heat\nCauses:\nHypovolemia as the result of the loss of water and electrolytes\nHigh humidity\nExertion in poorly ventilated areas Signs and symptoms\nDizziness, weakness, or syncope\nNausea, vomiting, or headache\nCold, clammy skin with ashen pallor\nDry tongue and thirst\nNormal vital signs\nNormal or slightly elevated body temperature",
        "Least common but most serious illness caused by heat exposure": "Occurs when the body is subjected to more heat than it can handle, and normal mechanisms are overwhelmed.\nUntreated heatstroke always results in death. Typical onset situations\nDuring vigorous physical activity \nOutdoors or in a closed, poorly ventilated, humid space\nDuring heat waves without sufficient air conditioning or poor ventilation\nChildren left unattended in a locked car on a hot day Signs and symptoms\nHot, dry, flushed skin\nQuickly rising body temperature\nChange in behavior\nUnresponsiveness and seizures\nRapid, weak pulse\nIncreased respiratory rate\nCessation of perspiring",
        "Management of Heat Emergencies": "Heat cramps\nRemove the patient from the hot environment and loosen clothing.\nAdminister high-flow oxygen if indicated.\nRest the cramping muscles. \nReplace fluids by mouth.\nCool the patient with water spray or mist. Heatstroke\nMove the patient out of the hot environment and into the ambulance.\nSet air conditioning to maximum cooling.\nRemove the patient\u2019s clothing.\nAdminister high-flow oxygen if indicated.\nAssist ventilations as needed. Heatstroke (cont\u2019d)\nCover the patient with wet towels or sheets.\nAggressively fan the patient.\nExclude other causes of altered mental status.\nCheck blood glucose level if possible.\nTransport immediately to the hospital.\nNotify the hospital.\nCall for ALS if the patient begins to shiver.",
        "Process of experiencing respiratory impairment from submersion or immersion in liquid": "Some agencies may still use the term \u201cnear drowning\u201d to refer to a patient who survives at least 24 hours after suffocation in water. Risk factors\nAlcohol consumption\nPreexisting seizure disorders\nGeriatric patients with cardiovascular disease\nUnsupervised access to water\nLaryngospasm\nInhaling water causes the muscles of the larynx and vocal cords to spasm.",
        "Spinal Injuries in Submersion Incidents": "Submersion incidents may be complicated by spinal fractures and spinal cord injuries.\nAssume spinal injury if:\nSubmersion resulted from a diving mishap or fall.\nThe patient is unconscious.\nThe patient complains of weakness, paralysis, or numbness.",
        "Most spinal injuries in diving incidents affect the cervical spine.": "Stabilize the suspected injury while the patient is still in the water.",
        "Safety Water rescues are usually handled by specialized rescue personnel.": "\u201cReach, throw, and row, and only then go.\u201d FIGURE 33-9 Basic rules of water rescue. A. Reach for the person from shore. If you cannot reach the person from shore, wade closer. B. If an object that floats is available, throw it to the person. C. Use a boat if one is available. D. If you must swim to the person, use a towel or board for him or her to hold onto. Do not let the person grab you. \u00a9 Jones & Bartlett Learning.",
        "Recovery Techniques If the patient is not floating or visible in the water, an organized rescue effort is necessary.": "Specialized personnel are required, with snorkel, mask, and scuba gear.",
        "Resuscitation Efforts Never give up on resuscitating a cold-water drowning victim.": "Hypothermia can protect vital organs from the lack of oxygen.\nThe diving reflex may cause immediate bradycardia.\nSlowing of the heart rate caused by submersion in cold water",
        "Descent Emergencies": "Caused by the sudden increase in pressure as the person dives deeper into the water\nTypical areas affected\nLungs\nSinus cavities\nMiddle ear\nTeeth\nFace The pain forces the diver to return to the surface to equalize the pressures, and the problem clears up by itself.\nPerforated tympanic membrane\nCold water may enter the middle ear through a ruptured eardrum.\nThe diver may lose his or her balance, shoot to the surface, and run into ascent problems.",
        "Emergencies at the Bottom Rarely occur": "Caused by faulty connections in the diving gear\nInadequate mixing of oxygen and carbon dioxide in the air the diver breathes\nAccidental feeding of poisonous carbon monoxide into the breathing apparatus\nCan cause drowning or rapid ascent",
        "Ascent Emergencies": "Usually requires aggressive resuscitation\nAir embolism\nMost dangerous and most common scuba diving emergency\nBubbles of air in the blood vessels\nAir pressure in the lungs remains at a high level while pressure on the chest decreases. Decompression sickness\n\u201cThe bends\u201d\nBubbles of gas, especially nitrogen, obstruct the blood vessels.\nConditions that can cause the bends:\nToo rapid an ascent from a dive\nToo long of a dive at too deep of a depth\nRepeated dives within a short period Decompression sickness (cont\u2019d)\nComplications\nBlockage of tiny blood vessels\nDepriving parts of the body of their normal blood supply\nSevere pain in certain tissues or spaces\nSigns and symptoms\nAbdominal/joint pain so severe that the patient doubles up You may find it difficult to distinguish between air embolism and decompression sickness.\nAir embolism generally occurs immediately on return to the surface.\nSymptoms of decompression sickness may not occur for several hours. Treatment is the same for both.\nBasic life support (BLS)\nRecompression in a hyperbaric chamber FIGURE 33-11 A hyperbaric chamber, usually a small\nroom, is pressurized to a level higher than atmospheric\npressure and used in the treatment of decompression\nsickness and air embolism. Courtesy of Perry Baromedical Corporation.",
        "Emergency Care for Drowning or Diving Emergencies": "Immobilize and protect the patient\u2019s spine if a fall or diving injury is possible.\nIf the patient is not breathing:\nAssist ventilations with a bag-mask device or pocket mask.\nProvide chest compressions and use the AED if indicated.\nTreat for hypothermia. For air embolism or decompression sickness in a conscious patient:\nRemove the patient from the water.\nTry to keep the patient calm.\nAdminister oxygen.\nConsider the possibility of pneumothorax, and monitor breath sounds.\nProvide prompt transport.",
        "Other Water Hazards Pay close attention to the body temperature of a person who is rescued from cold water.": "Breath-holding syncope\nA person swimming in shallow water may experience a loss of consciousness caused by a decreased stimulus for breathing.\nTreatment is the same as a drowning patient.",
        "Prevention Appropriate precautions can prevent most immersion incidents.": "All pools should be surrounded by a fence.\nThe most common problem in child drownings is lack of adult supervision.\nHalf of all teenage and adult drownings are associated with the use of alcohol.",
        "Dysbarism injuries": "Caused by the difference between the surrounding atmospheric pressure and the total gas pressure in the body\nAltitude illness\nCaused by diminished oxygen in the air at high altitudes\nAffects the central nervous system and pulmonary system",
        "Acute mountain sickness": "Diminished oxygen in the air at higher altitudes\nCaused by ascending too high, too fast or not being acclimatized to high altitudes\nSigns and symptoms\nHeadache\nLight-headedness\nFatigue",
        "Acute mountain sickness signs and symptoms (cont\u2019d)": "Loss of appetite\nNausea\nDifficulty sleeping\nShortness of breath during physical exertion\nSwollen face",
        "High-altitude pulmonary edema (HAPE)": "Fluid collects in the lungs, hindering the passage of oxygen into the bloodstream.\nSigns and symptoms\nShortness of breath\nCough with pink sputum\nCyanosis\nRapid pulse",
        "High-altitude cerebral edema (HACE)": "May accompany HAPE and can quickly become life threatening\nSigns and symptoms\nSevere, constant, throbbing headache\nAtaxia\nExtreme fatigue\nVomiting\nLoss of consciousness",
        "High Altitude": "Treatment of HAPE and/or HACE\nProvide oxygen.\nDescend from the height. \nTransport promptly.\nProvide positive pressure ventilation with a bag-mask device for inadequate respirations.",
        "Lightning is the fifth most common cause of death from isolated environmental phenomena.": "Targets of direct lightning strikes:\nPeople engaged in outdoor activities\nAnyone in a large, open area Many individuals are indirectly struck when standing near an object that has been struck by lightning, such as a tree.\nThe cardiovascular and nervous systems are most commonly injured.\nRespiratory or cardiac arrest is the most common cause of lightning-related deaths. Categories of lightning injuries\nMild\nLoss of consciousness, amnesia, confusion, tingling, superficial burns\nModerate\nSeizures, respiratory arrest, dysrhythmias, superficial burns\nSevere\nCardiopulmonary arrest Emergency medical care\nProtect yourself.\nMove the patient to a sheltered area.\nUse reverse triage.\nTreatment\nStabilize the spine, and open the airway.\nAssist ventilations or use an AED.\nControl bleeding and transport.",
        "Spider Bites Spiders are numerous and widespread in the United States.": "Many species of spiders bite.\nOnly the female black widow spider and the brown recluse spider deliver serious or life-threatening bites.",
        "The female is fairly large, measuring approximately 2 inches across.": "Usually black with a distinctive, bright red-orange marking in the shape of an hourglass on its abdomen FIGURE 33-12 Black widow spiders are distinguished by their glossy black color and bright red-orange hourglass marking on the abdomen. \u00a9 Crystal Kirk/Shutterstock. Found in every state except Alaska\nPrefer dry, dim places\nThe bite is sometimes overlooked.\nMost bites cause localized pain and symptoms, including agonizing muscle spasms.\nThe main danger is the venom, which is poisonous to nerve tissues. Other systemic symptoms include:\nDizziness\nSweating\nNausea\nVomiting\nRashes\nTightness in the chest\nSevere cramps Generally, these symptoms subside over 48 hours.\nEmergency treatment consists of BLS for the patient in respiratory distress.\nTransport as soon as possible.",
        "Dull brown in color and 1 inch long": "Violin-shaped mark on its back\nLives mostly in the southern and central parts of the country FIGURE 33-13 Brown recluse spiders are dull brown and have a dark, violin-shaped mark on the back. Courtesy of Kenneth Cramer, Monmouth College. Tends to live in dark areas\nThe venom is cytotoxic.\nIt causes severe local tissue damage.\nTypically, the bite is not painful at first but becomes so within hours.\nThe area becomes swollen and tender, developing a pale, mottled, cyanotic center.",
        "Hymenoptera Stings Bees, wasps, yellow jackets, ants": "Stings are painful but are not a medical emergency.\nRemove the stinger and venom sac using a firm-edged item such as a credit card to scrape the stinger and sac off the skin.\nAnaphylaxis may occur if the patient is allergic to the venom.",
        "Snakebites": "Of the approximately 115 different species of snakes in the United States, only 19 are venomous.\nRattlesnake, copperhead, cottonmouth or water moccasin, and coral snakes FIGURE 33-15 A. Rattlesnake. B. Copperhead. C. Cottonmouth (water moccasin). D. Coral snake. A: \u00a9 Photos.com; B: Courtesy of Ray Rauch/US Fish & Wildlife Service; C: \u00a9 SuperStock/Alamy; D: Courtesy of Luther C. Goldman/US Fish & Wildlife Service. Snakes usually do not bite unless provoked, angered, or accidentally injured.\nProtect yourself from getting bitten.\nUse extreme caution and wear proper PPE.\nThe classic appearance of the poisonous snakebite is two small puncture wounds, with discoloration, swelling, and pain.",
        "Rattlesnakes, copperheads, and cottonmouths are all pit vipers, with triangular-shaped, flat heads.": "Named for small pits located just behind each nostril and in front of each eye FIGURE 33-17 Pit vipers have small, heat-sensing organs (pits) located in front of their eyes that allow them to strike at warm targets, even in the dark. \u00a9 Jones & Bartlett Learning. Rattlesnakes\nMost common form of pit viper\nMany patterns of color, diamond pattern\nCan grow to 6 feet or longer\nCopperheads\nUsually 2 to 3 feet long\nRed-copper color crossed with brown and red bands Copperheads (cont\u2019d)\nTheir bites are almost never fatal, but the venom can cause significant damage to extremities.\nCottonmouths\nOlive or brown with black cross-bands and a yellow undersurface\nWater snakes with aggressive behavior\nTissue destruction may be severe. Signs of envenomation\nSevere burning pain at the site of injury\nSwelling and blue discoloration\nWeakness\nNausea and vomiting\nSweating\nSeizures\nFainting Signs of envenomation (cont\u2019d)\nVision problems\nChanges in level of consciousness\nShock\nIf swelling has occurred, use a pen to mark its edges on the skin. Treatment\nCalm the patient, and place in a supine position.\nLocate the bite area and clean it gently with soap and water.\nBe alert for an anaphylactic reaction and treat with an epinephrine auto-injector as appropriate.\nDo not give anything by mouth and be alert for vomiting. Treatment (cont\u2019d)\nIf the bite occurred on the trunk, keep the patient supine and quiet, and transport as quickly as possible.\nIf there are any signs of shock, treat for it.\nIf the snake has been killed, bring it with you.\nNotify the hospital that you are bringing in a patient with a snakebite.\nTransport promptly.",
        "Coral Snakes": "Small reptile with a series of bright red, yellow, and black bands completely encircling the body\nLives in most southern states\nInjects the venom with its teeth and tiny fangs by a chewing motion, leaving puncture wounds Coral snake venom is a powerful toxin that causes paralysis of the nervous system.\nWithin a few hours of being bitten, a patient will exhibit bizarre behavior, followed by progressive paralysis of eye movements and respiration.\nAntivenin is available, but most hospitals do not stock it.\nEmergency care is the same as for a pit viper bite.",
        "Scorpion Stings": "Scorpions are eight-legged arachnids with a venom gland and a stinger at the end of their tail.\nThey are rare and live primarily in the southwestern United States and in deserts.\nWith one exception, a scorpion\u2019s sting is usually very painful, but not dangerous. FIGURE 33-18 The sting of a scorpion is usually more painful than it is dangerous, causing localized swelling and discoloration. \u00a9 Visual & Written SL/Alamy. The exception is the Centruroides sculpturatus.\nThe venom may cause:\nCirculatory collapse\nSevere muscle contractions\nExcessive salivation\nHypertension\nConvulsions and cardiac failure",
        "Tiny insects that usually attach themselves directly to the skin": "Found most often in brush, shrubs, trees, sand dunes, or other animals\nOnly a fraction of an inch long\nInfectious diseases can be spread through the tick\u2019s saliva FIGURE 33-19 Ticks typically attach themselves directly to the skin. \u00a9 Joao Estevao A. Freitas (jefras)/Shutterstock. FIGURE 33-20 The rash associated with Lyme disease has a characteristic bull\u2019s-eye pattern \u00a9 E. M. Singletary, MD. Used with permission. Rocky mountain spotted fever\nOccurs within 7 to 10 days after the bite\nSymptoms\nNausea\nVomiting\nHeadache\nWeakness\nParalysis\nCardiorespiratory collapse Lyme disease\nReported in all states except Hawaii\nThe first symptoms are generally fever and flulike symptoms, sometimes associated with a bull\u2019s-eye rash that may spread to several parts of the body.\nPainful swelling of the joints occurs.\nMay be confused with rheumatoid arthritis Tick bites occur most commonly during the summer months.\nIf transport will be delayed, remove the tick by using fine tweezers to grasp the head and pull it straight out of the skin.\nOnce the tick is removed, cleanse the area with antiseptic and save the tick for identification.",
        "Injuries From Marine Animals": "Coelenterates are responsible for more envenomations than any other marine animals.\nFire coral, Portuguese man-of-war, sea wasp, sea nettles, true jellyfish, sea anemones, true coral, and soft coral FIGURE 33-21 Coelenterates are responsible for many marine envenomations. A. Jellyfish. B. Portuguese manof-war. C. Sea anemone A: \u00a9 Creatas/Alamy; B: Courtesy of NOAA; C: Photos.com. Signs and symptoms\nVery painful, red lesions in light-skinned individuals\nHeadache\nDizziness\nMuscle cramps\nFainting Emergency treatment\nLimit further discharge of nematocysts by avoiding fresh water, wet sand, showers, or careless manipulation of the tentacles. \nKeep the patient calm. \nReduce motion of the affected extremity.\nRemove the remaining tentacles by scraping them off with the edge of a sharp, stiff object.\nProvide transport to the emergency department."
    },
    {
        "National EMS Education Standard Competencies": "Special Patient Populations\nApplies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs. Obstetrics\nRecognition and management of\nNormal delivery\nVaginal bleeding in the pregnant patient\nAnatomy and physiology of normal pregnancy\nPathophysiology of complications of pregnancy Obstetrics (cont\u2019d)\nAssessment of the pregnant patient\nManagement of\nNormal delivery\nAbnormal delivery\nNuchal cord\nProlapsed cord\nBreech delivery Management of (cont\u2019d)\nThird trimester bleeding\nPlacenta previa\nAbruptio placenta\nSpontaneous abortion/miscarriage\nEctopic pregnancy\nPreeclampsia/eclampsia Neonatal Care\nAssessment and management of\nNewborn care\nNeonatal resuscitation Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Special Considerations in Trauma\nRecognition and management of trauma in the\nPregnant patient\nPathophysiology, assessment, and management of trauma in the\nPregnant patient",
        "Introduction Most deliveries occur in a hospital.": "Occasionally, the pregnant woman is unable to get to a hospital.\nYou must then decide whether to:\nAssist the delivery on scene.\nTransport the patient to the hospital.",
        "Anatomy and Physiology of the Female Reproductive System": "The ovaries are two glands, one on each side of the uterus.\nSimilar in function to the male testes\nEach ovary contains thousands of follicles, and each follicle contains an egg.\nOvulation occurs approximately 2 weeks prior to menstruation. The fallopian tubes extend out laterally from the uterus, with one tube associated with each ovary.\nFertilization usually occurs when the egg is inside the fallopian tube.\nThe fertilized egg continues to the uterus where implantation occurs. The uterus is a muscular organ that encloses and protects the fetus as it grows.\nProduces contractions during labor\nHelps to push the fetus through the birth canal\nThe birth canal is made up of the vagina and the lower third of the uterus, called the cervix. FIGURE 34-1 Anatomic structures of the pregnant woman. \u00a9 Jones & Bartlett Learning.",
        "The vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal.": "Completes the passageway from the uterus to the outside world\nThe perineum is the area of skin between the vagina and the anus.",
        "The breasts produce milk that is carried through small ducts to the nipple to provide nourishment to the newborn once it is born.": "Early signs of pregnancy in the breasts include increased size and tenderness.",
        "The placenta attaches to the uterine wall and connects to the fetus by the umbilical cord.": "The placenta attaches to the uterine wall and connects to the fetus by the umbilical cord. FIGURE 34-2 The placental barrier keeps the maternal and fetal blood separate but allows nutrients, oxygen, waste, carbon dioxide, toxins, and most medications to pass between the fetus and pregnant woman. \u00a9 Jones & Bartlett Learning.",
        "After delivery, the placenta separates from the uterus and delivers.": "The umbilical cord is the lifeline of the fetus.\nThe umbilical vein carries oxygenated blood from the placenta to the fetus.\nThe umbilical arteries carry deoxygenated blood from the fetus to the placenta.",
        "The fetus develops inside a fluid-filled, baglike membrane called the amniotic sac.": "Contains about 500 to 1,000 mL of amniotic fluid\nHelps insulate and protect the fetus\nFluid is released in a gush when the sac ruptures, usually at the beginning of labor.",
        "Normal Changes in Pregnancy": "Many normal changes occur in the body that are not all directly related to the reproductive system.\nRespiratory \nCardiovascular \nMusculoskeletal Hormone levels increase.\nTo support fetal development and prepare the body for childbirth\nUterus is displaced from its protected position within the pelvis.\nThis increases the chance of direct fetal injury in trauma. Rapid uterine growth occurs during the second trimester.\nAs the uterus grows, it pushes up on the diaphragm and displaces it.\nRespiratory capacity changes, with increased respiratory rates and decreased minute volumes. Blood volume gradually increases to:\nAllow for adequate perfusion of the uterus\nPrepare for the blood loss during childbirth\nNumber of red blood cells increases.\nSpeed of clotting increases.\nPatient\u2019s heart rate increases up to 20%. Changes in the GI tract cause an increased risk for:\nGastroesophageal reflux\nNausea\nVomiting\nPotential aspiration Weight gain during pregnancy is normal.\nWeight gain will challenge the heart and impact the musculoskeletal system.\nThe joints become \u201clooser\u201d or less stable.\nChanges in the body\u2019s center of gravity increase the risk of slips and falls.",
        "Complications of Pregnancy Most pregnant women are healthy.": "Some may be ill when they conceive or become ill during pregnancy.\nUse oxygen to treat any heart or lung disease in a pregnant patient.",
        "Diabetes Develops during pregnancy in many women who have not had it previously": "Gestational diabetes usually resolves after delivery.\nTreatment is the same as for any other patient with diabetes.",
        "Hypertensive Disorders": "Gestational hypertension\nThe presence of high blood pressure in the absence of other systemic effects\nSystolic pressure higher than 140 mm Hg and diastolic pressure higher than 90 mm Hg\nConsidered severe with systolic pressure is higher than 160 mm Hg and/or diastolic pressure higher than 110 mm Hg Preeclampsia is pregnancy-induced hypertension.\nCan develop after the 20th week of gestation\nSigns and symptoms include severe hypertension, severe or persistent headache, visual abnormalities, swelling in the hands and feet, and anxiety. Eclampsia is characterized by seizures that occur as a result of hypertension.\nTo treat seizures caused by eclampsia:\nLie the patient on her left side.\nMaintain her airway.\nAdminister supplemental oxygen if necessary.\nIf vomiting occurs, suction the airway.\nProvide rapid transport and call for ALS. Transporting the patient on her left side can also prevent supine hypotensive syndrome.\nCaused by compression of the descending aorta and the inferior vena cava by the pregnant uterus when the patient lies supine",
        "Internal bleeding may be a sign of an ectopic pregnancy.": "An embryo develops outside the uterus, most often in a fallopian tube. FIGURE 34-3 In an ectopic pregnancy, a fertilized egg implants somewhere other than in the uterus. Here, it is implanted in one of the fallopian tubes, the most common location for an ectopic pregnancy. \u00a9 Jones & Bartlett Learning. Consider an ectopic pregnancy in the presence of severe abdominal pain and vaginal bleeding during the first trimester.\nConsider the possibility in a woman who has missed a menstrual cycle and complains of sudden, severe pain in the lower abdomen. Hemorrhage from the vagina that occurs before labor begins may be very serious.\nMay be a sign of spontaneous abortion, or miscarriage.\nIn abruptio placenta, the placenta separates prematurely from the wall of the uterus.\nIn placenta previa, the placenta develops over and covers the cervix. FIGURE 34-4 In abruptio placentae, the placenta\nseparates prematurely from the wall of the uterus. \u00a9 Jones & Bartlett Learning. \u00a9 Jones & Bartlett Learning. FIGURE 34-5 In placenta previa, the placenta develops over and covers the cervix.",
        "Abortion Passage of the fetus and placenta before 20 weeks": "May be spontaneous or induced\nMost serious complications are bleeding and infection.\nIf the woman is in shock, treat and transport her promptly to the hospital.",
        "Pregnant women have an increased chance of being victims of domestic violence and abuse.": "Abuse increases the chance of:\nSpontaneous abortion\nPremature delivery\nLow birth weight The woman is at risk from bleeding, infection, and uterine rupture.\nPay attention to the environment for any signs of abuse.\nTalk to the patient in a private area, away from the potential abuser if possible.",
        "Substance Abuse": "Effects of addiction on the fetus include:\nPrematurity\nLow birth weight\nSevere respiratory distress\nDeath\nFetal alcohol syndrome describes the condition of infants born to women who have abused alcohol. Pay special attention to your safety.\nLook for clues that you are dealing with an addicted patient.\nThe newborn will probably need immediate resuscitation.",
        "Special Considerations for Trauma and Pregnancy": "With a trauma call involving a pregnant woman, you have two patients:\nThe woman\nThe unborn fetus\nTrauma to a pregnant woman may have a direct effect on the fetus. Pregnant women also have an increased risk of falling.\nLoosened joints in the musculoskeletal system\nIncreased weight of the uterus and displacement of abdominal organs can affect balance. Pregnant women have an increased amount of overall total blood volume and a 20% increase in heart rate.\nMay experience a significant amount of blood loss before you will see signs of shock\nFetus may be in trouble before signs of shock appear. When a pregnant woman is involved in a motor vehicle crash, severe hemorrhage may occur from injuries to the uterus.\nTrauma is one of the leading causes of abruptio placenta.\nCommon symptoms include vaginal bleeding and severe abdominal pain. Improper positioning of the seat belt can result in injury to a pregnant woman and the fetus. \nCarefully assess a pregnant woman\u2019s abdomen and chest for seat belt marks, bruising, and obvious trauma. Cardiac arrest\nYour focus is the same as with other patients.\nPerform CPR and provide transport.\nNotify the receiving facility personnel that you are en route with a pregnant trauma patient in cardiac arrest. Assessment and management\nYour focus is on the woman.\nSuspect shock based on the MOI.\nBe prepared for vomiting and aspiration.\nAttempt to determine the gestational age to assist you with determining the size of the fetus and the position of the uterus. Follow these guidelines when treating a pregnant trauma patient:\nMaintain an open airway.\nAdminister high-flow oxygen.\nEnsure adequate ventilation.\nAssess circulation.\nTransport the patient on her left side.",
        "Cultural Value Considerations": "Cultural sensitivity is important. \nWomen of some cultures may have a value system that will affect:\nThe choice of how they care for themselves during pregnancy\nHow they have planned the childbirth process Some cultures may not permit a male health care provider to assess or examine a female patient.\nRespect these differences and honor requests from the patient.",
        "Teenage Pregnancy The United States has one of the highest teenage pregnancy rates.": "Pregnant teenagers may not know they are pregnant or may be in denial.\nRespect the teenager\u2019s privacy.\nAssess and obtain her history away from her parents.",
        "Patient Assessment": "Patient Assessment Childbirth is seldom an unexpected event, but there are occasions when it becomes an emergency.",
        "Scene Size-up": "Scene safety\nTake standard precautions.\nGloves and eye and face protection are a minimum if delivery is already begun or is complete.\nIf time allows, a gown should also be used.\nConsider calling for additional resources. Mechanism of injury/nature of illness\nDetermine the MOI or NOI.\nDo not develop tunnel vision during a call.\nFalls and necessity for spinal immobilization must be considered.",
        "Primary Assessment": "Form a general impression.\nShould tell you whether the patient is in active labor or whether you have time to assess and address other possible life threats\nPerform a rapid examination.\nWhen trauma or other medical problems present, evaluate these first. Airway and breathing\nLife-threatening conditions with the woman\u2019s airway and breathing are usually not an issue during a birth.\nA motor vehicle crash, assault, or a medical condition may cause a life threat.\nAssess the airway and breathing to ensure they are adequate. Circulation\nExternal and internal bleeding are potential life threats and should be assessed early.\nBlood loss after delivery is expected, but significant bleeding is not.\nAssess for and treat life-threatening bleeding. \nIf signs of shock are present, control the bleeding, give oxygen, and keep the patient warm. Transport decision\nIf delivery is imminent, prepare to deliver at the scene.\nIdeal place to deliver is in the ambulance or the woman\u2019s home.\nIf delivery is not imminent, prepare the patient for transport. Provide rapid transport for pregnant patients who:\nHave significant bleeding and pain\nAre hypertensive\nAre having a seizure\nHave an altered mental status",
        "History Taking": "Obtain a thorough obstetric history:\nHer expected due date\nAny complications that she is aware of\nIf she has been receiving prenatal care\nA complete medical history Obtain a SAMPLE history.\nPertinent history should include questions related specifically to prenatal care.\nDetermine the due date, frequency of contractions, a history of previous pregnancies and deliveries, the possibility of multiples, and if she has taken any drugs or medications.\nIf her water has broken, ask whether the fluid was green (due to meconium).",
        "Secondary Assessment": "Physical examinations\nAssess the major body systems as needed.\nEmphasis on the chief complaint\nAssess for fetal movement.\nIf the patient is in labor, focus on contractions and possible delivery.\nIf you suspect that delivery is imminent, check for crowning. Vital signs \nObtain a complete set of vital signs and pulse oximetry.\nBe especially alert for tachycardia and hypo- or hypertension.\nHypertension, even mild, may indicate more serious problems.",
        "Reassessment": "Repeat the primary assessment.\nObtain another set of vital signs.\nCheck interventions and treatments Communication and documentation\nIf delivery is imminent, notify staff at the receiving hospital.\nProvide an update on the status of the woman and the newborn after delivery.\nIf delivery does not occur within 30 minutes, provide rapid transport. Communication and documentation (cont\u2019d)\nFor a pregnant patient with a complaint unrelated to childbirth, be sure to include the pregnancy status in your radio report.\nIf delivery occurs in the field, you will have two patient care reports to complete.",
        "Stages of Labor Dilation of the cervix": "Delivery of the fetus\nDelivery of the placenta",
        "First Stage": "Begins with the onset of contractions and ends when the cervix is fully dilated\nUsually the longest stage, lasting an average of 16 hours\nUterine contractions become more regular and last about 30 to 60 seconds each.\nFrequency and intensity increase. Labor is generally longer in a primigravida (first pregnancy) than in a multigravida.\nA woman may experience preterm or false labor, or Braxton-Hicks contractions. Some women experience a premature rupture of the amniotic sac.\nPatient may or may not go into labor.\nProvide supportive care and transport.\nThe head of the fetus descends into the woman\u2019s pelvis as it positions for delivery.\nThis descent is called lightening.",
        "Second Stage Begins when the fetus begins to encounter the birth canal": "Ends when the newborn is born \nUterine contractions are usually closer together and last longer.\nThe perineum will bulge significantly, and the top of the fetus\u2019s head will appear at the vaginal opening (crowning).",
        "Third Stage Begins with the birth of the newborn and ends with the delivery of the placenta": "The placenta must completely separate from the uterine wall.\nMay take up to 30 minutes",
        "Preparing for Delivery": "Consider delivery at the scene when:\nDelivery is imminent (will occur within a few minutes)\nA natural disaster, inclement weather, or other environmental factor makes it impossible to reach the hospital. To determine if delivery is imminent, ask the patient:\nHow long have you been pregnant?\nWhen are you due?\nIs this your first baby?\nAre you having contractions?\nHow far apart?\nHow long do they last? To determine if delivery is imminent, ask the patient (cont\u2019d):\nHave you had spotting or bleeding?\nHas your water broken?\nDo you feel as though you need to have a bowel movement?\nDo you feel the need to push? To determine potential complications, ask:\nWere any of your previous deliveries by cesarean section? \nHave you had problems in this or any previous pregnancies? \nDo you use drugs, drink alcohol, or take any medications?\nIs there a chance of multiple deliveries?\nDoes your physician expect complications? If the patient says that she is about to deliver, she has to move her bowels, or feels the need to push, you should prepare for delivery.\nVisually inspect the vagina to check for crowning.\nDo not touch the vaginal area unless delivery is imminent Once labor has begun, it cannot be slowed or stopped.\nNever attempt to hold the patient\u2019s legs together.\nDo not let her go to the bathroom.\nRemember, if you deliver at the scene, you are only assisting the woman with the delivery. Your emergency vehicle should always be equipped with a sterile emergency obstetric (OB) kit. FIGURE 34-6 Your unit should contain a sterile obstetric kit. \u00a9 Jones & Bartlett Learning. Patient position\nPreserve the patient\u2019s privacy.\nPlace the patient on a firm surface padded with blankets, sheets, and towels.\nElevate the hips about 2 to 4 inches.\nSupport the head, neck, and upper back.\nHave her keep her legs and hips  flexed, with her feet flat and her knees spread apart. Preparing the delivery field\nPlace towels or sheets on the floor around the delivery area.\nOpen the OB kit carefully.\nPut on sterile gloves.\nUse the sterile sheets and drapes from the OB kit to make a sterile delivery field. FIGURE 34-7 Preparing the delivery field. A. Use sterile sheets and drapes from the OB kit to make a clean delivery field. Place one sheet under the woman\u2019s buttocks. Wrap another sheet behind her back with either end draped over the thighs.\nB. Drape another sheet over the woman\u2019s abdomen A, B: \u00a9 Jones & Bartlett Learning.",
        "Your partner should be at the patient\u2019s head to comfort, soothe, and reassure.": "If the patient will allow it, apply oxygen.\nContinually check for crowning.\nSome patients experience precipitous labor and birth.\nPosition yourself so that you can see the perineal area at all times. Time the patient\u2019s contractions.\nRemind the patient to take quick, short breaths during each contraction but not to strain.\nBetween contractions, encourage the patient to rest and breathe deeply through her mouth.\nDelivering the head\nObserve the head as it exits the vagina.\nSupport the head with your gloved hand as it rotates. Delivering the head (cont\u2019d)\nApply gentle pressure across the perineum with a sterile gauze pad to reduce the risk of perineal tearing. \nBe prepared for the possibility of the patient having a bowel movement.\nDo not poke your fingers into the newborn\u2019s eyes or fontanelles. Unruptured amniotic sac\nIf the amniotic sac does not rupture by the time the head is crowning, it will appear as a fluid-filled sac emerging from the vagina.\nIt will suffocate the fetus if not removed.\nYou may puncture the sac with a clamp or tear it by twisting it between your fingers.\nClear the newborn\u2019s mouth and nose immediately. Umbilical cord around the neck\nAs soon as the head is delivered, use one finger to feel whether the umbilical cord is wrapped around the neck.\nUsually, you can slip the cord gently over the delivered head.\nIf not, you must cut it.\nOnce the cord is cut, attempt to speed delivery. Delivering the body\nOnce the head is born, the body usually delivers easily.\nSupport the head and upper body as the shoulders deliver.\nDo not pull the fetus from the birth canal.\nThe newborn will be slippery and covered in vernix caseosa.",
        "Postdelivery Care": "If the mother is able and willing, place the newborn on her abdomen so skin-to-skin contact can begin immediately. \nDry off the newborn and wrap him or her in a blanket or towel.\nWrap the newborn so only the face is exposed. Wipe the mouth with a sterile gauze pad as needed.\nClamp and cut the umbilical cord after approximately 60 seconds.\nObtain the 1-minute Apgar score. Delivery of the placenta\nYour job is only to assist.\nThe placenta delivers itself, usually within a few minutes of the birth.\nNever pull on the end of the umbilical cord. You can help to slow bleeding by gently massaging the woman\u2019s abdomen with a firm, circular, \u201ckneading\u201d motion. FIGURE 34-9 After delivery, massage the woman\u2019s abdomen in a firm, circular motion. \u00a9 Jones & Bartlett Learning. Record the time of birth in your patient care report.\nThe following are emergency situations:\nMore than 30 minutes elapse and the placenta has not delivered\nThere is more than 500 mL of bleeding before delivery of the placenta.\nThere is significant bleeding after the delivery of the placenta.",
        "Neonatal Assessment and Resuscitation": "The first minute after birth is the \u201cgolden minute.\u201d\nDuring this time perform the initial steps of newborn care:\nAirway positioning and suctioning, if needed\nDrying\nWarming\nTactile stimulation Normally the newborn will begin breathing within 30 seconds after birth, and the heart rate will be 100 beats/min or higher.\nIf not, positive pressure ventilation may be needed\nMany newborns require some form of stimulation, including:\nPositioning the airway, drying, warming, suctioning, or tactile stimulation",
        "Additional Resuscitation Efforts": "Observe the newborn for spontaneous respirations, skin color, and movement of the extremities.\nEvaluate the heart rate at the base of the umbilical cord or brachial artery or by listening to the newborn\u2019s chest with a stethoscope. If chest compressions are required, use the hand-encircling technique for two-person resuscitation.\nPerform bag-mask ventilation during a pause after every third compression, using a ratio of 3:1.\n120 actions per minute (90 compressions and 30 ventilations)\nHands-only CPR is not as effective as ventilation with CPR. FIGURE 34-11 A. Chest compressions should be given with the hands encircling the newborn and thumbs side by side. B. In very small newborns, you may need to overlap the thumbs. A, B: \u00a9 Jones & Bartlett Learning. If meconium is present and the newborn is not breathing:\nQuickly suction the newborn\u2019s mouth then nose after delivery before providing rescue ventilations.",
        "Standard scoring system used to assess the status of a newborn": "Assigns a number value to five areas:\nAppearance\nPulse\nGrimace or irritability\nActivity or muscle tone\nRespirations The total of the five numbers is the Apgar score.\nA perfect score is 10.\nCalculate the Apgar score at 1 minute and 5 minutes after birth. Assessing a newborn\nCalculate the Apgar score.\nStimulation should result in an immediate increase in respirations.\nIf the newborn is breathing well, assess the pulse.\nAssess oxygenation via pulse oximetry and observe for central cyanosis. Request a second unit if the newborn is in distress and will require resuscitation.\nIn situations where assisted ventilation is required, use a newborn bag-mask device.\nIf the newborn does not begin breathing on his or her own or does not have an adequate heart rate, continue CPR and rapidly transport.",
        "Most infants are born headfirst.": "Occasionally, the buttocks are delivered first.\nCalled a breech presentation FIGURE 34-13 In a breech presentation, the buttocks are delivered first. Breech deliveries are usually slow, so you will often have time to transport the woman to the hospital. \u00a9 Jones & Bartlett Learning. Breech deliveries usually take longer, so you will often have time to transport the pregnant woman to the hospital.\nIf the buttocks have passed through the vagina, the delivery has begun.\nProvide emergency care and call for ALS backup.\nConsult medical control to guide you. Preparing for a breech delivery is the same as for a normal childbirth.\nPosition the pregnant woman.\nPrepare the OB kit.\nPlace yourself and your partner as you would normally.\nAllow the buttocks and legs to deliver spontaneously, supporting them with your hand. Preparing for a breech delivery (cont\u2019d)\nThe head is almost always facedown and should be allowed to deliver spontaneously.\nMake a \u201cV\u201d with your gloved fingers and position them in the vagina to keep the walls from compressing the fetus\u2019s airway.",
        "Presentation Complications": "On rare occasions, the presenting part of the fetus is a single arm, leg, or foot.\nCalled a limb presentation FIGURE 34-14 In rare cases, a limb, usually a single arm or leg, presents first. This is a life-threatening situation, and you must provide prompt transport for hospital delivery. \u00a9 Jones & Bartlett Learning. A fetus with a limb presentation cannot be delivered in the field.\nUsually surgery is needed.\nTransport immediately.\nIf a limb is protruding, cover it with a sterile towel.\nNever try to push it in or pull on it.\nPlace the patient on her back, with her head down and pelvis elevated. Prolapse of the umbilical cord must be treated in the hospital.\nThe umbilical cord comes out of the vagina before the fetus. FIGURE 34-15 A prolapsed umbilical cord is a\nlife-threatening situation for the fetus and must be treated at the hospital. \u00a9 Jones & Bartlett Learning. The fetus\u2019s head will compress the cord and cut off circulation.\nDo not push the cord back into the vagina.\nInsert your gloved hand into the vagina and push the fetus\u2019s head away from the umbilical cord.\nPlace the pregnant woman supine with the foot of the cot raised higher than the head, with her hips elevated or in the knee-chest position.\nTransport rapidly.",
        "Spina Bifida Developmental defect in which a portion of the spinal cord or meninges may protrude outside of the vertebrae": "Cover the open area of the spinal cord with a sterile, moist dressing.\nMaintenance of body temperature is important when applying moist dressings.",
        "Multiple Gestation": "Twins occur once in every 30 births.\nTwins are smaller than single fetuses, and delivery is typically not difficult.\nAbout 10 minutes after the first birth, contractions will begin again, and the birth process will repeat itself.\nSecond one is usually born within 45 minutes of the first. The procedure is the same as that for a single fetus.\nRecord the time of birth of each twin separately.\nTwins may be so small that they look premature.",
        "Premature Birth": "A normal, full-term, single newborn will weigh about 7 lb at birth.\nAny newborn who delivers before 8 months (36 weeks) or weighs less than 5 lb at birth is considered premature. A premature newborn is smaller and thinner, and the head is proportionately larger.\nThe vernix caseosa will be absent or minimal.\nThere will be less body hair. FIGURE 34-16 Premature newborns (right) are smaller and thinner than full-term newborns. \u00a9 American Academy of Orthopaedic Surgeons. Premature newborns require special care to survive.\nOften require resuscitation efforts, which should be performed unless it is physically impossible\nWith such care, premature newborns as small as 1 lb have survived and developed normally.",
        "Postterm Pregnancy": "Pregnancies lasting longer than 41 weeks\nFetuses can be larger, sometimes weighing 10 lb or more.\nCan lead to problems with the woman and fetus\nA more difficult labor and delivery Problems (cont\u2019d):\nIncreased chance of injury to the fetus\nIncreased likelihood of cesarean section\nWoman is at risk for perineal tears and infection.\nPostterm newborns have increased risks of meconium aspirations, infection, and being stillborn.\nNewborns may not have developed normally.",
        "Fetal Demise You may deliver a fetus who died in the woman\u2019s uterus before labor.": "Onset of labor may be premature, but labor will progress normally in most cases.\nIf an intrauterine infection caused the demise, you may note a foul odor.\nDo not attempt to resuscitate an obviously dead neonate.",
        "Postpartum Complications": "If bleeding continues after delivery of the placenta:\nContinue to massage the uterus.\nCheck your technique and hand placement if bleeding continues.\nExcessive bleeding is usually caused by the uterine muscles not fully contracting. Cover the vagina with a sterile pad.\nChange the pad as often as possible.\nDo not discard any blood-soaked pads.\nAdminister oxygen, monitor vital signs, and transport the patient immediately. Postpartum patients are at an increased risk of an embolism.\nMost commonly a pulmonary embolism\nResults from a clot that travels through the bloodstream and becomes lodged in the pulmonary circulation\nConsider when a woman complains of sudden difficulty breathing or shortness of breath following delivery"
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Psychiatric\nRecognition of\nBehaviors that pose a risk to the EMT, patient, or others\nBasic principles of the mental health system\nAssessment and management of\nAcute psychosis\nSuicidal/risk\nAgitated delirium",
        "Introduction EMTs often care for patients experiencing behavioral health emergencies.": "Crisis may be the result of:\nAcute medical situation\nMental illness\nMind-altering substances\nStress\nOther causes",
        "Myth and Reality": "At some point, most people experience an emotional crisis.\nThis does not mean that everyone develops mental illness.\nDo not jump to conclusions. The most common misconception is that if you are feeling bad or depressed, you must be \u201csick.\u201d\nThere are many justifiable reasons for feeling depressed:\nDivorce\nDeath of a relative or friend Some people believe that all individuals with mental health disorders are dangerous, violent, or unmanageable.\nOnly a small percentage fall into these categories.\nEMTs may be exposed to a higher proportion of violent patients.\nCommunication is key. \nYou may be able to predict violence.",
        "Defining a Behavioral Crisis": "Behavior is what you can see of a person\u2019s response to the environment: his or her actions.\nOver time, people learn to adapt to stress.\nSometimes stress is so great that the normal ways of coping do not work.\nReactions to stress that are acute and those that develop over time can create a crisis. A behavioral crisis includes patients who exhibit agitated, violent, or uncooperative behavior or who are a danger to themselves or others. If an abnormal or disturbing pattern of behavior lasts for a month or more, it is a matter of concern.\nWhen a behavioral health emergency arises, the patient:\nMay show agitation or violence\nMay become a threat to self or others",
        "The Magnitude of Mental Health Disorders": "Mental disorders are common throughout the United States, affecting tens of millions of people each year.\nA psychiatric disorder is an illness with psychological or behavioral symptoms that may result in impaired functioning.\nAnxiety disorders are among the most common. Anxiety disorders include:\nGeneralized anxiety disorder\nPanic disorder\nSocial and other phobias\nPosttraumatic stress disorder (PTSD)\nObsessive\u2013compulsive disorder The US mental health system provides many levels of assistance.\nProfessional counselors are available for marital conflict and parenting issues.\nMore serious issues are often handled by a psychologist.\nSevere psychological conditions require a psychiatrist. The US mental health system provides many levels of assistance. (cont\u2019d)\nMost psychological disorders can be handled through outpatient visits.\nSome people require hospitalization in specialized behavioral health units. Behavioral health disorders have many underlying causes:\nSocial and situational stress\nDiseases such as schizophrenia\nPhysical illnesses such as diabetic emergencies\nChemical problems such as alcohol or drug use\nBiological disturbances such as electrolyte imbalances",
        "Pathophysiology": "An EMT is not responsible for diagnosing the underlying cause of a behavioral crisis or emergency.\nYou should understand the two basic categories of diagnosis a physician will use: organic and functional. Organic disorders\nOrganic brain syndrome is a temporary or permanent dysfunction of the brain caused by a disturbance in the physical or physiologic functioning of the brain tissue.\nCauses: sudden illness, traumatic brain injury (TBI), seizure disorders, drug and alcohol abuse, overdose, or withdrawal, and diseases of the brain. Organic disorders (cont\u2019d)\nAltered mental status can arise from:\nHypoglycemia\nHypoxia\nImpaired cerebral blood flow\nHyperthermia or hypothermia Functional disorders\nPhysiologic disorder that impair bodily functions when the body seems to be structurally normal\nExamples: schizophrenia, anxiety conditions, and depression",
        "Safe Approach to a Behavioral Crisis All regular EMT skills are used in a behavioral crisis. FIGURE 23-1 When working with a potentially volatile": "patient, position yourself at a 45\u00b0 angle, but be aware this position could hinder your movements. \u00a9 PEDRO PARDO/AFP/Getty Images.",
        "Scene Size-up": "Scene safety\nIs the situation potentially dangerous for you and your partner?\nDo you need immediate law enforcement backup?\nShould you stage until law enforcement personnel have secured the scene? Scene safety (cont\u2019d)\nDoes the patient\u2019s behavior seem typical or normal for the circumstances?\nAre there legal issues involved (crime scene, consent, refusal)?\nTake standard precautions and request additional resources early. Mechanism of injury/nature of illness\nDetermine the mechanism of injury and/or nature of illness.\nNote any medications or substances that may contribute to the complaint or be treatment of a relevant medical condition.",
        "Primary Assessment": "Form a general impression.\nBegin your assessment from the doorway or from a distance.\nPerform a rapid physical exam.\nObserve the patient closely using the AVPU scale to check for alertness.\nEstablish a rapport with the patient.\nMost medical or trauma situations will include a behavioral component. Airway and breathing\nAssess the airway to make sure it is patent and adequate.\nEvaluate the patient\u2019s breathing.\nUse pulse oximetry if available.\nProvide the appropriate interventions. Circulation\nAssess the pulse rate, quality, and rhythm.\nEvaluate for the presence of shock and bleeding.\nEvaluate skin color, temperature, and capillary refill. Transport decision\nUnless the patient is unstable from a medical problem or trauma, prepare to spend time with the patient.",
        "History Taking": "Investigate the chief complaint and obtain a SAMPLE history.\nConsider four major areas as contributors:\nIs the patient\u2019s central nervous system functioning properly?\nAre hallucinogens or other drugs or alcohol a factor?\nAre significant life changes, symptoms, or illness involved?\nIs there a history of behavioral health illness? SAMPLE history\nYou may be able to elicit information that would be helpful to the hospital staff.\nIn geriatric patients, consider Alzheimer disease and dementia.\nUse reflective listening.",
        "Secondary Assessment": "Physical examination\nIn an unconscious patient, begin with a physical exam.\nA conscious patient may not respond to your questions. Physical examination (cont\u2019d)\nYou can tell a lot about a patient\u2019s emotional state from:\nFacial expressions\nPulse rate\nRespirations\nA blank gaze or rapidly moving eyes could mean central nervous system dysfunction. Transport decision\nHave law enforcement or firefighters accompany you if possible.\nThere may be a specific facility to which patients with behavioral health emergencies are transported.\nTransport by ground.\nMake the patient comfortable.",
        "Reassessment": "Never let your guard down.\nIf restraints are necessary, reassess and document every 5 minutes:\nRespirations\nPulse, motor, and sensory function in all restrained extremities Interventions\nDefuse and control the situation.\nThe best treatment may be to be a good listener.\nIntervene only as much as it takes to accomplish tasks.\nIf you think a pharmacologic restraint is necessary, request ALS as early as possible. Communication and documentation\nGive the receiving hospital advance warning of the behavioral health emergency.\nDocument thoroughly and carefully.\nIf restraints are used, say which types and why they were used.",
        "Acute Psychosis": "Psychosis is a state of delusion in which the person is out of touch with reality.\nCauses:\nMind-altering substances\nIntense stress\nDelusional disorders\nSchizophrenia Schizophrenia is a complex disorder that is not easily defined or treated.\nTypical onset occurs during adulthood.\nInfluences thought to contribute include:\nBrain damage\nGenetics\nPsychologic and social influences Symptoms of schizophrenia:\nDelusions\nHallucinations\nA lack of interest in pleasure\nErratic speech Guidelines for dealing with a psychotic patient:\nDetermine if the situation is dangerous.\nClearly identify yourself.\nBe calm, direct, and straightforward.\nMaintain an emotional distance. Guidelines (cont\u2019d)\nDo not argue.\nExplain what you would like to do.\nInvolve people whom the patient trusts, such as family or friends, to gain the patient\u2019s cooperation.",
        "Delirium is a condition of impairment in cognitive function that can present with disorientation, hallucinations, or delusions.": "Agitation is characterized by restless and irregular physical activity. Symptoms of delirium:\nHyperactive irrational behavior\nVivid hallucinations\nHypertension\nTachycardia\nDiaphoresis\nDilated pupils Be calm, supportive, and empathetic.\nApproach the patient slowly and respect the patient\u2019s personal space.\nLimit physical contact.\nDo not leave the patient unattended. Use careful interviewing to assess the patient\u2019s cognitive functioning.\nDetermine the patient\u2019s ability to communicate early.\nObserve the patient\u2019s appearance, dress, and personal hygiene. If the patient has overdosed, take all medication bottles or illegal substances to the medical facility.\nTransport the patient to a hospital with behavioral health facilities.\nRefrain from using lights and siren. If the patient\u2019s agitation continues, request ALS assistance so chemical restraint can be considered.\nExcited delirium can lead to sudden death.",
        "Every prehospital care transport provider should create and follow a prehospital patient restraint protocol.": "Protocols vary throughout the country.\nThe restraint chosen should be the least restrictive that ensures the safety of the patient and providers. Personnel must be properly trained.\nIf you restrain a person without authority in a nonemergency situation, you expose yourself to a possible lawsuit.\nAssault\nBattery\nFalse imprisonment \nViolation of civil rights Involve law enforcement if the patient is in a severe behavioral crisis or behavioral health emergency.\nBefore considering physical restraint, use verbal deescalation techniques. Process of restraining a patient\nCarry the decision out quickly.\nThere should be 5 people to help, one for each extremity and one for the head.\nThere should be a team leader and plan of action.\nUse the minimum force necessary. Level of force will vary, depending on these factors:\nThe degree of force that is necessary to keep the patient from injuring self and others\nThe patient\u2019s sex, size, strength, and mental status\nThe type of abnormal behavior the patient is exhibiting Talk to the patient throughout the process.\nTreat the patient with dignity and respect.\nIf possible, a provider of same gender should attend to the patient.\nWear appropriate barrier protection. Avoid direct eye contact and respect personal space.\nNever leave a restrained person unattended.\nFour-point restraints (both arms and both legs) are preferred. Monitor the patient for:\nVomiting\nAirway obstruction\nRespiratory status\nCirculatory status (blood pressure)\nChanges in level of consciousness",
        "You may use restraints only:": "To protect yourself or others from bodily harm\nTo prevent the patient from injuring himself or herself FIGURE 23-3 Restraints should be used when necessary only to prevent injury and in the least restrictive manner that achieves the needed result. \u00a9 Jones & Bartlett Learning.",
        "The Potentially Violent Patient": "Violent patients account for only a small percentage of patients undergoing a behavioral crisis. History\nHas the patient previously exhibited hostile, overly aggressive, or violent behavior?\nPosture\nHow is the patient sitting or standing?\nIs the patient tense, rigid, or sitting on the edge of his or her seat? The scene\nIs the patient holding or near potentially lethal objects?\nVocal activity\nWhich kind of speech is the patient using?\nLoud, obscene, erratic, and bizarre speech patterns usually indicate emotional distress. Physical activity\nMost telling factor of all\nA patient requiring careful watching is one who:\nHas tense muscles, clenched fists, or glaring eyes\nIs pacing\nCannot sit still\nIs fiercely protecting personal space Other factors to consider:\nPoor impulse control\nA history of truancy, fighting, and uncontrollable temper\nHistory of substance abuse\nDepression\nFunctional disorder",
        "Depression is the single most significant factor that contributes to suicide.": "It is a common misconception that people who threaten suicide never commit it.\nSuicide is a cry for help.\nSomeone is in a crisis that he or she cannot handle alone.\nImmediate intervention is necessary. Be alert to these warning signs:\nAir of tearfulness, sadness, deep despair, or hopelessness\nAvoiding eye contact, speaking slowly, and projecting a sense of vacancy\nUnable to talk about the future\nSuggestion of suicide\nHaving any plans related to death Consider these additional risks:\nAre there any unsafe objects nearby?\nIs the environment unsafe?\nIs there evidence of self-destructive behavior?\nIs there an imminent threat to the patient or others? Additional risks (cont\u2019d)\nIs there an underlying medical problem?\nAre there cultural or religious beliefs promoting suicide?\nHas there been trauma?\nA suicidal patient may be homicidal.",
        "PTSD occurs after exposure to, or injury from, a traumatic event.": "Example events:\nSexual and physical assault\nChild abuse\nSerious accidents",
        "Example events (cont\u2019d):": "Natural disasters\nWar\nLoss of a loved one\nStressful life changes",
        "Not necessarily the result of one event": "An estimated 7% to 8% of the general population will experience PTSD at some point in their lives.\nMilitary personnel with combat experience have a high incidence.",
        "Posttraumatic Stress Disorder and Returning Combat Veterans": "Symptoms of PTSD include feelings of:\nHelplessness\nAnxiety\nAnger\nFear People with PTSD:\nFrequently avoid reminders of the trauma, loud noises or smells, interactions with people\nSuffer constant nervous system arousal\nCan relive the traumatic event through thoughts, nightmares, and flashbacks",
        "Combat veterans are prone to:": "Early heart disease\nHigher incidence of type 2 diabetes\nLoss of brain gray matter\nHigher incidence of traumatic brain injury (TBI)",
        "Caring for the combat veteran": "Requires a unique level of understanding\nBe careful how you phrase your questions.\nUse a calm, firm voice, but be in charge. \nRespect a veteran\u2019s personal space.\nLimit the number of people involved. \nAsk about suicidal intentions.\n\nEnsure that there is nothing the patient can access and use as a weapon.\nPhysical restraints may simply escalate the problem.",
        "Medicolegal Considerations": "The medicolegal aspects of EMS are more complicated with patients undergoing behavioral health emergency.\nLegal problems are reduced when the patient consents to care. You must decide whether the patient needs immediate emergency medical care.\nThe patient may resist your attempt to provide care.\nNever leave the patient alone.\nRequest law enforcement personnel to handle the patient. Consent\nImplied consent is assumed with a patient who is not mentally competent to grant consent.\nConsent matters are not always clear-cut in behavioral health emergencies.\nIf you are not sure, request the assistance of law enforcement personnel or guidance from medical control. Limited legal authority\nThe EMT has limited legal authority to require a patient to undergo emergency medical care when no life-threatening emergency exists.\nCompetent adults have the right to refuse care. In psychiatric cases, a court of law would probably consider your actions in providing life-saving care to be appropriate.\nA patient who is in any way impaired may not be considered competent.\nMaintain a high index of suspicion about the patient\u2019s condition.\nErr on the side of treatment and transport."
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Awareness that\nDiabetic emergencies cause altered mental status\nAnatomy, physiology, pathophysiology, assessment, and management of\nAcute diabetic emergencies Anatomy, physiology, pathophysiology, assessment, and management of\nSickle cell crisis\nClotting disorders",
        "Introduction": "Endocrine system influences nearly every: \nCell\nOrgan\nFunction of the body\nEndocrine disorders can have many signs and symptoms. Hematologic emergencies\nDifficult to assess and treat",
        "Endocrine system is a communication system that controls functions inside the body.": "Glands secrete messenger hormones.\nHormones affect end organs, tissues, or cells.\nEndocrine disorders are caused by an internal communication problem. Glucose metabolism \nBrain needs glucose and oxygen. \nInsulin is necessary for glucose to enter cells. \nWithout enough insulin, cells do not get fed. Glucose metabolism (cont\u2019d)\nThe pancreas produces and stores glucagon and insulin.\nIn the pancreas, islets of Langerhans have alpha and beta cells. \nAlpha cells produce glucagon.\nBeta cells produce insulin. Anatomy and Physiology Blood is made up of four components.\nRed blood cells contain hemoglobin, which carries oxygen to the tissues.\nWhite blood cells collect dead cells and provide for their correct disposal.\nPlatelets are essential for clot formation.\nPlasma serves as the transportation medium.",
        "Pathophysiology": "Diabetes mellitus impairs body\u2019s ability to use glucose for fuel.\nWithout treatment, blood glucose levels become too high.\nComplications include blindness, cardiovascular disease, and kidney failure. You need to know signs and symptoms of blood glucose that is:\nHigh (hyperglycemia)\nLow (hypoglycemia)\nHyperglycemia and hypoglycemia can occur with diabetes mellitus type 1 and type 2. \nAll hypoglycemic patients require prompt treatment. Sickle cell disease\nInherited disorder, affects red blood cells\nPredominantly in people of African, Caribbean, and South American ancestry \nMisshapen RBCs lead to dysfunction in oxygen binding and unintentional clot formation. Sickle cell disease (cont\u2019d)\nSickled cells have a short life span, resulting in more cellular waste products and contributing to sludging of the blood.  \nComplications include:\nAnemia\nGallstones\nJaundice\nSplenic dysfunction Sickle cell disease (cont\u2019d)\nVascular occlusion with ischemia:\nAcute chest syndrome \nStroke\nJoint necrosis\nPain crises\nAcute and chronic organ dysfunction/failure\nRetinal hemorrhages\nIncreased risk of infection Sickle cell disease (cont\u2019d)\nMany of these complications are very painful and potentially life threatening. FIGURE 20-8  Sickle cells. \u00a9 Science Picture Co/Science Source. Clotting disorders\u2014hemophilia\nRare: only about 20,000 Americans have the disorder. \nHemophilia A affects mostly males. Clotting disorders\u2014hemophilia (cont\u2019d)\nDecreased ability to create a clot after an injury, which can be life threatening\nPatients can be prescribed medications to replace missing clotting factors, release stored clotting factors, or prevent the breakdown of blood clots. Clotting disorders\u2014hemophilia (cont\u2019d)\nCommon complications of hemophilia A include:\nLong-term joint problems that may require a joint replacement\nBleeding in the brain \nThrombosis due to treatment Clotting disorders\u2014thrombophilia \nDisorder in the body\u2019s ability to maintain the smooth flow of blood through the venous and arterial systems\nConcentration of particular elements in the blood creates clogging or blockage issues Clotting disorders\u2014thrombophilia (cont\u2019d)\nGeneral term for conditions that result in blood clotting more easily than normal \nClots can spontaneously develop in the blood of the patient. Clotting disorders\u2014deep vein thrombosis (DVT) \nCommon medical problem in sedentary patients and in patients who have had recent injury or surgery \nMethods to prevent blood clot formation: \nBlood-thinning medications\nCompression stockings\nMechanical devices Clotting disorders\u2014DVT (cont\u2019d) \nRisk factors include\nJoint replacement surgery\nRemaining sedentary for long periods of time Clotting disorders\u2014DVT (cont\u2019d) \nTreatment\nAnticoagulation therapy \nMedications are typically administered for at least 3 months after diagnosis of a DVT. \nA clot from the DVT can travel from the patient\u2019s lower extremity to the lung, causing a pulmonary embolus. Clotting disorders\u2014Anemia\nAn abnormally low number of RBCs\nBlood is unable to deliver adequate amounts of oxygen to the tissues.\nPulse oximetry may indicate an adequate saturation, even though the tissues are hypoxic.",
        "Diabetes Mellitus Type 1": "Autoimmune disorder where the immune system produces antibodies against pancreatic beta cells\nMissing the pancreatic hormone insulin\nWithout insulin, glucose cannot enter the cell, and the cell cannot produce energy. Onset usually happens from early childhood through the fourth decade of life. \nImmune system destroys the ability of the pancreas to produce insulin.\nPatient must obtain insulin from an external source.\nPatients with type 1 diabetes cannot survive without insulin. Many people with type 1 diabetes have an implanted insulin pump.\nContinuously measures glucose levels and provides insulin.\nLimits the number of times patients have to check their fingerstick glucose level\nCan malfunction and diabetic emergencies can develop.\nAlways inquire about the presence of an insulin pump. Most common metabolic disease of childhood\nNew-onset patient will have symptoms related to eating and drinking:\nPolyuria\nPolydipsia\nPolyphagia\nWeight loss\nFatigue Normal blood glucose is between 80 to 120 mg/dL.\nWhen a patient\u2019s blood glucose level is above normal, the kidney\u2019s filtration system becomes overwhelmed and glucose spills into the urine. When glucose is unavailable to cells, the body turns to burning fat.\nThis produces acid waste (ketones).\nAs ketone levels go up in the blood, they spill into the urine.\nKidneys cannot maintain acid\u2013base balance.\nPatient breathes faster and deeper (Kussmaul respirations). If fat metabolism and ketone production continue, diabetic ketoacidosis (DKA) can develop.\nMay present as generalized illness plus:\nAbdominal pain\nBody aches\nNausea\nVomiting\nAltered mental status or unconsciousness If not recognized and treated, DKA can result in death.\nObtain a glucose level with a fingerstick using a lancet and a glucometer.\nGenerally higher than 400 mg/dL",
        "Diabetes Mellitus Type 2": "Caused by resistance to the effects of insulin at the cellular level\nObesity predisposes patients to type 2 diabetes.\nPancreas produces more insulin.\nInsulin resistance can sometimes be improved by exercise and dietary modification. Oral medications used to treat type 2 diabetes\nInjectable medications and insulin are also used for type 2 diabetes. Often diagnosed at a yearly medical examination from complaints related to high blood glucose levels, including:\nRecurrent infection\nChange in vision\nNumbness in the feet",
        "Symptomatic Hyperglycemia": "Occurs when blood glucose levels are high \nPatient is in a state of altered mental status resulting from several combined problems. \nIn type 1 diabetes, leads to ketoacidosis with dehydration from excessive urination \nIn type 2 diabetes, leads to a nonketotic hyperosmolar state of dehydration If an individual has hyperglycemia for a protracted length of time, consequences of diabetes may present:\nWounds that do not heal\nNumbness in the hands and feet\nBlindness\nRenal failure\nGastric motility problems When blood glucose levels are not controlled in diabetes mellitus type 2, HHNS can develop. \nKey signs and symptoms of HHNS include:\nHyperglycemia\nAltered mental status, drowsiness, lethargy\nSevere dehydration, thirst, dark urine\nVisual or sensory deficits\nPartial paralysis or muscle weakness\nSeizures Higher glucose levels in the blood cause the excretion of glucose in the urine. \nIncreased fluid intake causing polyuria. \nUrine becomes dark and concentrated. \nPatient may become unconscious or have seizure activity due to severe dehydration.",
        "Symptomatic Hypoglycemia": "A patient\u2019s blood glucose level drops and must be corrected swiftly.\nCan occur in patients who inject insulin or use oral medications that stimulate the pancreas to produce more insulin\nWhen insulin levels remain high, glucose is rapidly taken out of the blood. \nIf glucose levels fall, there may be an insufficient amount to supply the brain. Mental status of the patient declines.\nPatient may become aggressive or display unusual behavior. \nUnconsciousness and permanent brain damage can quickly follow. Common reasons for a low blood glucose level to develop:  \nCorrect dose of insulin with change in routine \nMore insulin than necessary \nCorrect dose of insulin without eating a sufficient amount\nCorrect dose of insulin and the patient developed an acute illness Signs and symptoms of hypoglycemia:\nNormal to shallow or rapid respirations\nPale, moist skin\nDiaphoresis \nDizziness, headache\nRapid pulse\nNormal to low blood pressure Signs and symptoms of hypoglycemia (cont\u2019d):\nAltered mental status \nAnxious or combative behavior\nSeizure, fainting, or coma\nWeakness on one side of the body \nRapid changes in mental status Hypoglycemia is quickly reversed by giving the patient glucose. \nWithout glucose, the patient can sustain permanent brain damage. FIGURE 20-3 The left column illustrates blood glucose levels; the right column illustrates the conditions associated with that particular level of blood glucose. Notice that the normal range is rather small in comparison to the other ranges.Abbreviations: DKA, diabetic ketoacidosis; HHNS, hyperosmolar hyperglycemic nonketotic syndrome. \u00a9 Jones & Bartlett Learning.",
        "Scene Size-up Scene safety": "Patients with diabetes may use syringes.\nBe alert for clues.\nUse standard precautions.\nQuestion bystanders on events leading to your arrival.\nKeep open the possibility that trauma may have occurred.\nDetermine MOI/NOI. Scene Size-up Scene safety\nMost sickle cell patients will have had a crisis before.\nWear gloves and eye protection at a minimum.\nConsider ALS support.",
        "Primary Assessment": "Form a general impression.\nAirway and breathing\nPatients showing signs of inadequate breathing, a pulse oximetry level less than or equal to 94%, or altered mental status should receive high-flow oxygen (12 to 15 L/min via nonrebreathing mask) Airway and breathing (cont\u2019d)\nHyperglycemic patients may have Kussmaul respirations and sweet, fruity breath.\nHypoglycemic patients will have normal or shallow to rapid respirations. Circulation\nDry, warm skin: hyperglycemia\nMoist, pale skin: hypoglycemia\nRapid, weak pulse: symptomatic hypoglycemia Transport decision\nProvide prompt transport for patients with altered mental status and inability to swallow.\nFurther evaluate conscious patients capable of swallowing and able to maintain airway. Perform cervical spine immobilization, if necessary. \nForm a general impression.\nAirway and breathing\nInadequate breathing or altered mental status:\nHigh-flow oxygen at 12 to 15 L/min via nonrebreathing mask Airway and breathing (cont\u2019d)\nSickle cell crisis patients may have increased respirations or signs of pneumonia.\nManage respiratory distress. Circulation\nSickle cell patients: increased heart rate\nSuspected hemophilia patients:\nBe alert for signs of acute blood loss.\nNote bleeding of unknown origin.\nBe alert for signs of hypoxia.\nMake a transport decision.",
        "History Taking": "Investigate chief complaint\nObtain history of present illness from responsive patient, family, or bystanders.\nIf patient has eaten but not taken insulin, hyperglycemia is more likely.\nIf patient has taken insulin but not eaten, hypoglycemia is more likely. SAMPLE history\u2014ask the patient:\nDo you take insulin or pills to lower blood sugar?\nDo you wear an insulin pump? Is it working properly?\nHave you taken your usual insulin dose (or pills) today?\nHave you eaten normally today?\nHave you had any illnesses, unusual amount of activity, or stress? Investigate chief complaint.\nObtain history of present illness from responsive patients, family, or bystanders.\nPhysical signs indicating sickle cell crisis:\nSwelling of fingers and toes\nPriapism\nJaundice Ask about:\nSingle location or felt throughout body?\nVisual disturbances?\nNausea, vomiting, or abdominal cramping?\nChest pain or shortness of breath? Obtain SAMPLE history from responsive patient or family member.\nHave you had a crisis before?\nWhen was the last time you had a crisis?\nHow did your last crisis resolve?\nRecent illness, unusual amount of activity, or stress?",
        "Physical examination": "Assess unresponsive patients from head to toe. \nWhen you suspect a diabetes-related problem, focus on mental status, ability to swallow, and ability to protect airway. Vital signs\nUse a glucometer, if available and protocols allow. \nHypoglycemia: respirations are normal to rapid, pulse is weak and rapid, and skin is typically pale and clammy with a low blood pressure \nHyperglycemia: respirations may be deep and rapid; pulse may be rapid, weak, and thready; and skin may be warm and dry with a normal blood pressure Portable glucometer\nStudy the operator\u2019s manual for proper use in the field.\nKnow the upper and lower ranges at which your glucometer functions.\nNormal nonfasting adult and child blood glucose level range: 80 to 120 mg/dL; neonates should be above 70 mg/dL Secondary Assessment Physical examination\nFocus on major joints.\nEvaluate and document mental status using (AVPU).\nVital signs\nObtain complete set of vital signs.\nLook for signs of sickle cell crisis.\nUse pulse oximeter, if available.",
        "Reassess frequently.": "Provide indicated interventions.\nHypoglycemic, conscious, can swallow:\nEncourage patient to take glucose tablets or drink juice containing sugar.\nAdminister highly concentrated sugar gel.\nProvide rapid transport. Interventions (cont\u2019d)\nHypoglycemic, unconscious, risk of aspiration:\nPatient needs intravenous (IV) glucose or intramuscular (IM or IN) glucagon.\nWhen in doubt, consult medical control. If unable to test for a blood glucose value:\nPerform a thorough assessment.\nContact the hospital to help sort out the signs and symptoms. Communication and documentation\nPatients who refuse transport after symptoms improve may require even more through documentation. Reassessment Reassess vital signs frequently.\nEvaluate interventions.\nAdjust or change the interventions as needed. \nDocument each assessment. \nCommunicate with hospital staff for continuity of care and document clearly.",
        "Emergency Medical Care for Diabetic Emergencies": "Giving oral glucose\nThree types of oral glucose:\nRapidly dissolving gel\nLarge chewable tablets\nLiquid formulation FIGURE 20-7 Oral glucose is commercially available in gel and tablet form. One tube of gel equals one 15-gram dose. Courtesy of Paddock Laboratories, Inc. Oral glucose (cont\u2019d)\nContraindications: inability to swallow and unconsciousness\nWear gloves before putting anything in patient\u2019s mouth.\nFollow local protocols for glucose administration.\nReassess frequently. \nProvide transport.",
        "The Presentation of Hypoglycemia": "Seizures:\nConsider hypoglycemia or an underlying condition.\nEnsure airway is clear.\nPlace patient on side.\nPut nothing in patient\u2019s mouth.\nHave suctioning equipment ready.\nProvide oxygen or artificial ventilations for inadequate breathing or cyanosis.\nTransport promptly. Altered mental status\nMay be caused by diabetes complications\nUse the mnemonic AEIOU-TIPS. \nAlways suspect and check for hypoglycemia in a patient with altered mental status. Altered mental status (cont\u2019d)\nEnsure airway is clear.\nBe prepared to provide artificial ventilations and suctioning if patient vomits.\nProvide prompt transport.\nMisdiagnosis of neurologic dysfunction \nSymptoms mistaken for intoxication Misdiagnosis (cont\u2019d)\nA diabetic patient confined by police is at risk.\nLook for emergency medical identification bracelet, necklace, or card.\nPerform blood glucose test at scene (if protocols allow) or ED.\nDiabetes and alcoholism can coexist in a patient. Relationship to airway management\nPatients with altered mental status can lose gag reflex.\nVomit or tongue may obstruct airway.\nCarefully monitor airway.\nPlace patient in lateral recumbent position.\nMake sure suction is available.",
        "Hematologic Emergencies Hematology is the study of blood-related diseases.": "Four disorders that can create a prehospital emergency:\nSickle cell disease\nHemophilia A\nThrombophilia \nAnemia",
        "Emergency Medical Care for Hematologic Disorders Mainly supportive and symptomatic": "Patients with inadequate breathing or altered mental status:\nAdminister high-flow oxygen at 12 to 15 L/min via nonrebreathing mask.\nPlace in a position of comfort.\nTransport rapidly to hospital.",
        "Answer: D": "Rationale: SAMPLE is the mnemonic used in taking the history of all patients. In addition to asking the SAMPLE, EMTs should also ask about past crises."
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Gynecology\nRecognition and management of shock associated with\nVaginal bleeding Anatomy, physiology, assessment findings, and management of\nVaginal bleeding\nSexual assault (to include appropriate emotional support)\nInfections",
        "Introduction Women are uniquely designed to conceive and give birth.": "Women are susceptible to problems that do not occur in men.",
        "Anatomy and Physiology": "External female genitalia\nVaginal opening\nLabia majora and labia minora\nClitoris\nPerineum FIGURE 24-1 The external genitalia of the female reproductive system. \u00a9 Jones & Bartlett Learning. Ovaries are a primary internal female reproductive organ.\nLie on each side of lower abdomen\nProduce ovum (egg)\nFallopian tubes connect each ovary with the uterus. Uterus is a muscular organ where the fetus grows.\nNarrowest part of uterus is the cervix\nCervix opens into the vagina\nVagina is outermost cavity of woman\u2019s reproductive system.\nForms the lower part of birth canal FIGURE 24-2 Anterior and lateral views of the female reproductive system. \u00a9 Jones & Bartlett Learning Ovulation and menstruation begin in puberty.\nOnset of menstruation is called menarche.\nOccurs between age 11 and 16 years\nWomen continue ovulation and menstruation until menopause.\nOccurs around age 50 Each ovary produces an ovum in alternating months (ovulation).\nThe process of fertilization begins in the vagina. \nSperm are deposited from the male penis, passes through cervix to uterus, and up the fallopian tubes.\nEmbryo travels into the uterus, attaches to the uterine wall, and continues to grow. If fertilization does not occur within about 14 days of ovulation:\nThe lining of the uterus begins to separate, and menstruation occurs for about a week.\nProcess of ovulation and menstruation is controlled by female hormones.",
        "Pathophysiology Causes of gynecologic emergencies are varied.": "Range from sexually transmitted diseases to trauma",
        "Pelvic Inflammatory Disease (PID) Infection of upper organs of reproduction": "Occurs almost exclusively in sexually active women\nCan result in increased risk of ectopic pregnancy or sterility\nMost common sign is generalized lower abdominal pain",
        "Sexually Transmitted Diseases": "STDs can lead to more serious conditions, such as PID.\nChlamydia\nMost common STD\nCaused by bacteria\nUsually mild or absent symptoms\nCan spread to rectum and progress to PID Bacterial vaginosis\nMost common vaginal infection\nAffects women ages 15 to 44 years\nNormal bacteria in vagina are replaced by an overgrowth of other bacteria.\nUntreated, it can progress to premature birth or low birth weight in pregnancy, and PID. Gonorrhea\nGrows and multiplies rapidly in warm, moist areas of reproductive tract\nCervix, uterus, fallopian tubes in women\nUrethra in men and women\nIf untreated, can enter bloodstream and spread to other parts of body",
        "Vaginal Bleeding Possible causes include:": "Abnormal menstruation\nVaginal trauma\nEctopic pregnancy\nSpontaneous abortion\nCervical polyps or cancer",
        "Patient Assessment Obtaining an accurate and detailed assessment is critical.": "You will be able to gain only a primary impression of the problem in the field. \nThorough patient assessment will help determine how sick the patient is and whether life-saving measures are needed.",
        "Scene Size-up": "Scene safety\nGynecologic emergencies can involve large amounts of blood and body fluid.\nInvolve police if assault is suspected.\nIn sexual assault, it is important to have a female EMT provide care. Sometimes the MOI may be easily understood from the dispatch information, such as sexual assault.\nIn other patients, patient history may reveal the nature of the condition.",
        "Primary Assessment": "Form a general impression.\nIs the patient stable or unstable?\nUse AVPU scale.\nAirway and breathing\nAlways evaluate first to ensure adequacy.\nCirculation\nPulse and skin color, temperature, and moisture can help identify blood loss. Most gynecologic emergencies are not life threatening.\nIf the patient has signs of shock, rapid transport is warranted.",
        "History Taking": "Investigate chief complaint.\nSome questions are extremely personal.\nEnsure the patient\u2019s privacy and dignity are protected. For abdominal pain, ask about: \nOnset, duration, quality, and radiation \nProvoking or relieving factors \nAssociated symptoms such as syncope, light-headedness, nausea, vomiting, and fever For vaginal bleeding, ask about:\nOnset\nDuration \nQuantity (number of sanitary pads soaked) \nAssociated symptoms such as syncope and light-headedness SAMPLE History\nAsk about birth control pills or devices.\nAsk about medical conditions and last menstrual cycle.",
        "Pertinent secondary assessment findings should include:": "Vital signs: blood pressure, pulse, skin color, orthostatic vital signs\nAbdomen: distention and tenderness\nGenitourinary: visible bleeding\nNeurologic: mental status Physical examinations\nShould be limited and professional\nOnly examine the genitalia if necessary to treat the patient.\nPatients age 65+ may have concerns related to hormone replacement therapy, cancer, pelvic floor collapse, or urinary incontinence. Vaginal bleeding: \nVisualize the bleeding and ask about quality and quantity. \nUse external pads to control bleeding.\nObserve for vaginal discharge.\nSyncope, fever, nausea, and vomiting are significant in gynecologic emergencies. Vital signs\nAssess patient\u2019s:\nHeart rate, rhythm, and quality\nRespiratory rate, rhythm, and quality\nSkin color, temperature, and condition\nCapillary refill time\nBlood pressure\nConsider orthostatic vital signs\nConsider noninvasive blood pressure monitoring to continuously track patient\u2019s blood pressure.",
        "Reassessment": "Repeat the primary assessment.\nThere are very few interventions with a gynecologic emergency. Communication and documentation\nCommunicate all relevant information to staff at receiving hospital.\nInclude possibility of pregnancy\nCarefully document everything, especially in cases of sexual assault.",
        "Emergency Medical Care": "Maintain patient\u2019s privacy as much as possible.\nIf in a public place, move to ambulance.\nHave a female EMT participate in the patient\u2019s care if possible. Use sanitary pads on the external genitalia to absorb blood.\nDocument the number of pads saturated in blood.\nExternal genitals have a rich nerve supply.\nMakes injuries very painful Treat external lacerations with moist, sterile compresses.\nDo not pack or place dressings in the vagina.",
        "Assessment and Management of Specific Conditions Pelvic inflammatory disease (PID)": "A patient with PID will complain of abdominal pain.\nUsually starts during or after menstruation\nMay be made worse by walking\nPrehospital treatment is limited.\nNonemergency transport is usually recommended.",
        "Sexual assault and rape are common.": "1 of 5 women has reported being raped.\n1 of 3 women will be sexually molested.\nEMTs treating victims of sexual assault face many complex issues. You may be first person victim has contact with after the encounter.\nProfessionalism, tact, kindness, and sensitivity, are important. Be aware of drugs used to facilitate sexual assault or rape.\nIf possible, give the patient the option of being treated by a female EMT. Your focus should be:\nProvide medical treatment of patient.\nOffer psychological care of patient.\nPreserve evidence.\nTake history.\nProduce a patient care report."
    },
    {
        "National EMS Education Standard Competencies": "Preparatory\nApplies fundamental knowledge of the emergency medical services (EMS) system; safety/well-being of the emergency medical technician (EMT), medical/legal, and ethical issues to the provision of emergency care. Life Span Development\nApplies fundamental knowledge of life span development to patient assessment and management.",
        "Introduction Humans develop throughout their lives.": "EMTs must be aware of the physical changes a person undergoes at various stages of life.\nMay affect the approach to patient care",
        "Neonates and Infants": "Neonates\nBirth to 1 month\nInfants\n1 month to 1 year\nDevelop at a startling rate FIGURE 7-1 An infant is 1 month to 1 year of age. \u00a9 Johanna Goodyear/ShutterStock. Weight\nNeonate weighs 6 to 8 lb (3 to 3.5 kg) at birth.\nThe head accounts for 25% of body weight.\nGrowth of about 1 oz per day\nWeight triples by the end of the first year Cardiovascular system\nAt birth, neonate makes transition from fetal to independent circulation.\nPulmonary system\nInfants younger than 6 months are prone to nasal congestion.\nInfants have larger tongues and shorter, narrower airways, so airway obstruction is more common than in older children or adults. Nervous system\nEvolution continues after birth.\nMoro reflex: neonate opens arms wide, spreads fingers, and seems to grab at things.\nPalmar grasp: occurs when an object is placed into the neonate\u2019s palm\nRooting reflex: neonate instinctively turns head when something touches its cheek.\nSucking reflex: occurs when a neonate\u2019s lips are stroked Fontanelles\nSpaces between the bones that eventually fuse to form the skull\nPosterior fontanelle fuses by 3 months.\nAnterior fontanelle fuses between age 9 and 18 months. FIGURE 7-2 Fontanelles. \u00a9 Jones & Bartlett Learning. Nervous system (cont\u2019d)\n2 months of age: tracking objects with their eyes and recognize familiar faces\n6 months of age: sitting upright and babbling\n12 months of age: walking with minimal assistance Immune system\nMaintains some of the mother\u2019s immunities\nInfants can also receive antibodies via breastfeeding. Psychosocial changes\nBegin at birth and evolve as the infant interacts with the environment Psychosocial changes (cont\u2019d)\nCrying is the main method of communicating distress.\nInfants develop relationships with their parents or caregivers at different rates. Psychosocial changes (cont\u2019d)\nBonding is based on a secure attachment.\nAnxious-avoidant attachment is found in infants who are repeatedly rejected.\nSeparation anxiety is common in older infants.\nTrust and mistrust involves an infant\u2019s needs being met.",
        "Toddlers and Preschoolers": "The cardiovascular system of a toddler (1 to 3 years) or preschooler (4 to 6 years) is not dramatically different from an adult. FIGURE 7-4 A toddler is 1 to 3 years of age. \u00a9 EML/Shutterstock. Preschoolers (3 to 6 years)\nPulse: 80 to 140 beats/min\nRespiratory rate: 20 to 25 breaths/min\nSystolic blood pressure: 80 to 100 mm Hg FIGURE 7-5 A preschooler is 3 to 6 years of age. \u00a9 Maxim Bolotnikov/Shutterstock. Preschoolers (cont\u2019d)\nDo not have well-developed lung musculature\nWeight gain should level off.\nPassive immunity is lost.\nNeuromuscular growth also makes considerable progress at this age.\nAverage age for completion of toilet training is 28 months. Psychosocial changes\nLearn to speak and express themselves\nMaster basic language \nInteract and play games with other children\nBegin to understand cause and effect\nLearn to recognize gender differences by observing role models",
        "School-Age Children": "6 to 12 years\nPhysical traits and functions continue to mature at a rapid rate FIGURE 7-7 A school-age child is 6 to 12 years of age. \u00a9 Trout55/Shutterstock. Growth of 4 lb and 2.5 inches each year\nPermanent teeth come in.\nBrain activity increases in both hemispheres. Psychosocial changes\nPreconventional reasoning: children act to avoid punishment and get what they want.\nConventional reasoning: children look for approval from peers and society.\nPostconventional reasoning: children make decisions guided by their conscience.\nSelf-concept and self-esteem develop.",
        "12 to 18 years": "Vital signs level off.\nPulse: 60 to 100 beats/min\nRespirations: 12 to 20 breaths/min\nSystolic blood pressure: 90 to 110 mm Hg FIGURE 7-8 An adolescent is 12 to 18 years of age. \u00a9 Jamie Wilson/Shutterstock. 2- to 3-year growth spurt\nGirls finish by 16 years; boys by 18 years.\nReproductive system matures.\nSecondary sexual development takes place.\nVoices start to change.\nMenstruation begins.\nAcne can occur. Psychosocial changes\nAdolescents and their families often deal with conflict.\nPrivacy becomes an issue.\nSelf-consciousness increases.\nAdolescents may struggle to create their own identity. Psychosocial changes (cont\u2019d)\nAntisocial behavior and peer pressure peak at age 14 to 16 years.\nSmoking, illicit drug use, unprotected sex\nEating disorders\nCode of ethics develops.\nHigh risk of suicide and depression",
        "Early Adults": "19 to 40 years\nVital signs do not vary greatly.\nPulse: 60 to 100 beats/min\nRespiratory rate: 12 to 20 breaths/min\nSystolic blood pressure: 90 to 120 mm Hg FIGURE 7-10 An early adult is 19 to 40 years of age. \u00a9 Rubberball Productions. From age 19 to 25 years, the body should be functioning at its optimal level.\nLifelong habits are solidified.\nPsychosocial changes\nLife centers on work, family, and stress.\nSettling down, marriage, and family\nOne of the more stable periods of life",
        "Middle Adults": "41 to 60 years\nVital signs remain the same.\nPulse: 60 to 100 beats/min\nRespiratory rate: 12 to 20 breaths/min\nSystolic blood pressure: 90 to 140 mm Hg FIGURE 7-11 A middle adult is 41 to 60 years of age. \u00a9 Photodisc. Vulnerable to vision and hearing loss\nCancer incidence increases.\nMenopause occurs in late 40s or early 50s.\nDiabetes, hypertension, and weight problems are common.\nExercise and healthy diet can diminish the effects of aging. Psychosocial changes\nFocus on achieving life goals\nReadjust lifestyle as children leave home\nGenerally have the physical, emotional, and spiritual reserves to handle life\u2019s issues\nFinances become a concern.\nMay be caring for both children leaving for college and aging parents",
        "61 years and older": "Life expectancy is constantly changing.\nNow approximately 78 years FIGURE 7-12 An older adult is 61 years of age or older. \u00a9 Photodisc. Cardiovascular system\nDeclines with age largely due to atherosclerosis\nHeart rate and cardiac output decrease.\nVascular system becomes stiff.\nAbility to produce replacement blood cells declines, as does blood volume. Respiratory system\nSize of airway increases.\nSurface area of alveoli decreases.\nNatural elasticity of the lungs decreases.\nBreathing becomes more labor intensive. Respiratory system (cont\u2019d)\nVital capacity decreases.\nChest becomes more rigid and fragile.\nCough and gag reflex diminish.\nGreater risk for aspiration and airway obstruction\nMore susceptible to lung infections Endocrine system\nInsulin production drops off.\nMetabolism decreases.\nThe reproductive system changes to some extent. Digestive system\nTaste sensations decrease.\nSaliva secretion decreases.\nAbility of the intestines to contract and move food diminishes.\nGallstones become increasingly common.\nAnal sphincter changes can produce fecal incontinence. Renal system\nFiltration function declines.\nKidney mass decreases by 20%.\nDiminished blood flow to the kidneys\nDecreased ability to clear wastes from the body and ability to conserve fluids when needed Nervous system\nMotor and sensory neural networks become slower.\nNeurons are lost but there is no loss of knowledge or skill.\nSleep patterns change. Nervous system (cont\u2019d)\nAge-related shrinkage creates a void between the brain and the outermost layer of the meninges. FIGURE 7-14 Age-related atrophy or shrinkage of the brain\ncreates space between the brain and dura mater (subdural\nspace). When the bridging veins are stretched and torn,\nblood may accumulate in this area. \u00a9 Jones & Bartlett Learning. Nervous system (cont\u2019d)\nPeripheral nerve sensation is diminished.\nIncreased reaction times cause longer delays between stimulation and motion.\nSlowdown in reflexes and decreased kinesthetic sense may contribute to falls and trauma. Sensory changes\nMost older adults can see and hear well.\nMay need glasses or hearing aids\nVisual distortions are common.\nHearing loss is four times more common than vision loss. Psychosocial changes\nUntil about 5 years before death, most people retain high brain function.\nStatistics indicate that 95% of the elderly live at home.\nFinancial limits may restrict access to health care or medications. Psychosocial changes (cont\u2019d)\nMore than 50% of all single women in the United States who are 60 years of age or older are living at or below the poverty line.\nElderly need to face their own mortality.\nIsolation and depression can be challenges."
    },
    {
        "National EMS Education Standard Competencies": "Special Patient Populations\nApplies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs. Patients With Special Challenges\nHealth care implications of\nHomelessness\nPoverty\nBariatrics\nTechnology dependent Patients With Special Challenges (cont\u2019d)\nHealth care implications of (cont\u2019d)\nHospice/terminally ill\nTracheostomy care/dysfunction\nHome care\nSensory deficit/loss\nDevelopmental disability Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Special Considerations in Trauma\nPathophysiology, assessment, and management of trauma in the\nCognitively impaired patient",
        "Introduction": "Today, more people with chronic diseases live at home.\nShorter hospitalization\nImprovements in medicine and technology\nPatients with special challenges:\nPatients with diseases resulting in altered body function\nPatients with sensory deficits\nGeriatric patients with chronic diseases Some patients depend on mechanical ventilation, intravenous pumps, and other devices.\nDo not be distracted by the equipment!\nFocus on the patient.",
        "Developmental disability": "Conditions that may impair development with physical ability, learning, language development, or behavioral coping skills.\nIntellectual disability\nSubset of developmental disability\nSignificant limitations in intellectual functioning and skills needed for daily living Possible causes\nGenetic factors\nCongenital infections\nMalnutrition\nEnvironmental factors\nFetal alcohol syndrome\nTraumatic brain injury \nPoisoning Rely on patients and family members for information. \nPatient may have difficulty adjusting to change or a break in routine.\nPatients with intellectual disabilities are susceptible to the same diseases as other patients.",
        "Autism Spectrum Disorder": "Intellectual disability characterized deficits in social communication along with restrictive, repetitive patterns of behavior, interests, and activities. Often have abnormal sensory responses\nMay not feel cold, heat, or pain as others do\nMay respond to pain by laughing, humming, singing, or removing clothing\nMay have increased sensitivity to noise or physical stimulation\nKeep the environment calm and minimize stimulation. Increased sensitivity to noise or physical stimulation (cont\u2019d)\nDemonstration of examination techniques on a trusted individual may comfort the patient.\nUse short, direct and simple phrases when communicating.\nAllow extra time for the patient to process the communication if possible.",
        "A genetic chromosomal defect that can occur during fetal development": "Results in mild to severe intellectual impairment\nIncreased maternal age and family history are known risk factors. Physical abnormalities\nRound head with flat occiput\nEnlarged, protruding tongue\nSlanted, wide-set eyes FIGURE 37-1 A child with Down syndrome. \u00a9 PhotoCreate/Shutterstock. Increased risk for medical complications\nLeukemia\nCongenital heart defects\nIntubation may be difficult due to large tongues and small oral and nasal cavities.\nMask ventilation can be challenging.\nJaw-thrust maneuver or a nasopharyngeal airway may be necessary. Management of seizures is the same for any other patent.\nThe atlantoaxial joint is unstable in approximately 15% of patients with Down syndrome. \nIncreased risk of complications when they experience trauma",
        "Patient Interaction Approach in a calm, friendly manner.": "Establish rapport.\nIntroduce your team members.\nExplain what you are doing.\nMove slowly but deliberately.\nStay at eye level with the patient.",
        "Brain Injury Patients with a prior brain injury may be difficult to treat.": "Talk with patient and family. \nEstablish what is considered normal for the patient.\nExplain procedures and reassure patient.",
        "Possible causes": "Congenital defect\nDisease\nInjury\nDegeneration of the eyeball optic nerve or nerve pathway Range in degree of visual impairment \nSome patients lose peripheral or central vision.\nSome can distinguish light from dark or shapes.\nVisual impairments may be difficult to recognize. Patient interaction\nMake yourself known when you enter.\nIntroduce yourself and your team.\nRetrieve any visual aids and give them to your patient.\nPatient may feel vulnerable and disoriented.\nDescribe the situation and surroundings to the patient. Transport considerations\nTake cane or walker, if used.\nMake arrangements for care or accompaniment of service animal.\nPatients should be gently guided, never pulled or pushed. \nCommunicate obstacles in advance.",
        "Hearing Impairment": "Problems range from slight hearing loss to total deafness.\nMany older people have some hearing loss.\nSensorineural deafness is caused by nerve damage.\nConductive hearing loss is caused by faulty transmission of sound waves. Clues that a person could be hearing impaired \nPresence of hearing aids\nPoor pronunciation of words\nFailure to respond to your presence or questions",
        "Communication With Hearing Impaired Patient": "Assist the patient with finding and inserting any hearing aids.\nFace the patient while you communicate.\nDo not exaggerate your lip movements or look away.\nPosition yourself approximately 18 inches directly in front of the patient. Do not speak louder; try lowering the pitch of your voice. \nAmerican Sign Language may be useful.\nProvide paper and a pencil.\nOnly one person ask questions.\n\u201cReverse stethoscope\u201d FIGURE 37-3 Consider learning common terms in American Sign Language related to illness and injury. A. Sick. B. Hurt. C. Help A, B, C: \u00a9 Jones & Bartlett Learning. Photographed by Glen E. Ellman.",
        "Hearing aids make sound louder.": "May be external or internal\nSeveral types are available.\nBehind-the-ear, conventional body, in-the-canal, in-the-ear\nDevice should fit snugly.\nIf whistling occurs, it may not be in far enough. FIGURE 37-4 Different types of hearing aids. A. Behind-the-ear. B. Conventional body. C. In-the-canal. D. In-the-ear.\nE. Completely in-the-canal. A: \u00a9 Piotr Marcinski/Shutterstock; B: \u00a9 Stine Lise Nielsen/Shutterstock; C: \u00a9 Steve Hamblin/Alamy; \nD: \u00a9 Terry Smith Images/Alamy; E: \u00a9 Jiri Hera/Shutterstock.",
        "Group of disorders characterized by poorly controlled body movement": "Possible causes\nDamage to the developing brain in utero\nOxygen deprivation at birth\nTraumatic brain injury \nInfection such as meningitis during early childhood Symptoms\nPoor posture \nUncontrolled, spastic movements\nVisual and hearing impairments\nDifficulty communicating\nUnsteady gait FIGURE 37-5 A person with cerebral palsy. \u00a9 Sally and Richard Greenhill/Alamy. Considerations\nObserve airway closely and suction as needed. \nDo not assume intellectual disability.\nUnderdeveloped limbs are prone to injury.\nAtaxic or unsteady gait makes patients prone to falls. \nPatient may have special pillow or chair. Considerations (cont\u2019d)\nPad the patient to ensure comfort.\nNever force extremities into position. \nWhenever possible, take walkers or wheelchairs along during transport. \nBe prepared for a seizure, and keep suctioning available.",
        "Birth defect caused by incomplete closure of spinal column": "Spinal cord is exposed. \nOpening can be closed surgically, but often leaves spinal damage. FIGURE 37-6 Spina bifida is one of the most common\ndisabling birth defects in the United States. \u00a9 Biophoto Associates/Photo Researchers, Inc. Associated conditions\nHydrocephalus (requires shunt)\nPartial or full paralysis of the lower extremities\nLoss of bowel and bladder control\nExtreme latex allergy",
        "Paralysis": "Inability to voluntarily move body parts\nCauses: stroke, trauma, birth defects\nMay have normal sensation or hyperesthesia\nMay cause communication challenges\nDiaphragm may not function correctly (requires ventilator). Specialized equipment \nUrinary catheters\nTracheostomy tubes\nColostomy bags\nFeeding tubes\nDifficulty swallowing may require suctioning.\nAsk patients how it is best to move them before you transport them.",
        "Bariatric Patients": "Obesity: person has excessive body fat.\nObese: 30% over ideal body weight\nSevere obesity: 2\u20133 times over the ideal weight\nImbalance between calories consumed and calories used\nMay be attributed to low metabolic rate or genetic predisposition Quality of life is negatively affected.\nAssociated health problems\nMobility difficulties\nDiabetes\nHypertension\nHeart disease\nStroke",
        "Interaction with Patients with Obesity": "Patient may be embarrassed.\nPlan early for extra help or equipment.\nFind easiest and safest exit.\nDo not risk dropping the patient or injuring a team member. Treat the patient with dignity and respect.\nAsk your patient how it is best to move him or her before attempting to do so. \nAvoid trying to lift the patient by one limb, which would risk injury to overtaxed joints. \nCoordinate and communicate all moves to all team members prior to starting to lift. If the move becomes uncontrolled at any point, stop, reposition, and resume. \nLook for pinch or pressure points from equipment (deep venous thrombosis).\nLarge patients may have difficulty breathing if you lay them in a supine position. Specialized equipment is available.\nBecome familiar with the resources available in your area. \nPlan egress routes.\nNotify the receiving facility early.",
        "Tracheostomy Tubes": "Tracheal stoma provides a path between the neck and the trachea.\nKept open by plastic tracheostomy tube  \nTubes bypass nose and mouth\nTemporary or permanent\nFor patients who depend on home automatic ventilators and have chronic pulmonary illness Tubes are prone to obstruction by mucus or foreign bodies\nEmergency event FIGURE 37-7 Some patients require a tracheostomy tube to breathe. Portex\u00ae Blue Line\u00ae Ultra Tracheostomy courtesy of Smiths Medical. DOPE mnemonic helps recognize causes of obstruction.\nDisplacement, dislodged, or damaged tube\nObstruction of the tube \nPneumothorax\nEquipment failure Common problems\nBleeding or air leaking around the tube\nTube can become loose or dislodged.\nOpening around the tube may become infected. Management\nMaintain an open airway.\nSuction tube if necessary to clear a mucus plug.\nMaintain the patient in a position of comfort.\nAdminister supplemental oxygen.\nProvide transport to the hospital.",
        "Two types of oxygen delivery devices": "Oxygen from a gas cylinder\nOxygen concentrator\nCompressed oxygen cylinders\nDo not require oxygen or complex machinery\nHeavy, bulky, and can be difficult to transport\nWill run out of gas\nPatients coordinate pickup and delivery of cylinders. Home oxygen concentrator\nTakes ambient air and scrubs out the nitrogen\nCan provide an unlimited supply of oxygen\nRequires a reliable source of electricity\nPatient must have a backup compressed gas cylinder in case of power failure. Ask the patient:\nWhy they are on home oxygen\nHow long they have been on home oxygen\nBaseline home oxygen requirement\nBaseline oxygen saturation",
        "Mechanical Ventilators": "Used when patients cannot breathe without assistance\nPossible causes\nCongenital defect\nChronic lung disease\nTraumatic brain injury\nMuscular dystrophy If ventilator malfunctions:\nRemove patient from ventilator.\nApply a tracheostomy collar.\nDesigned to cover the tracheostomy hole\nMay not be available in prehospital setting\nCan improvise by placing a face mask over the stoma Caregivers will know how the equipment works. FIGURE 37-10 A home ventilator. \u00a9 ResMed 2010. Used with permission.",
        "Apnea Monitors": "Used for infants who:\nAre premature and have severe gastroesophageal reflux \nHave family history of SIDS \nExperienced a life-threatening event Used 2 weeks to 2 months after birth to monitor the respiratory system\nSounds an alarm if the infant experiences bradycardia or apnea\nAttached with electrodes or belt around the infant\u2019s chest or stomach\nProvides a pulse oximetry reading",
        "Internal Cardiac Pacemakers Implanted under skin to regulate heart rate": "On nondominant side of the patient\u2019s chest \nMay include automated implanted defibrillator \nNever place defibrillator paddles or pacing patches directly over the implanted device.\nGather information about the type of cardiac pacemaker when obtaining history.",
        "Left Ventricular Assist Devices Takes over the function of either one or both heart ventricles": "Typically used as a bridge to heart transplantation\nMay be difficult to palpate a pulse\nProvide support measures and basic care.\nUse the caregiver as a resource.\nBe prepared to provide CPR.",
        "External Defibrillator Vest Vest with built-in monitoring electrodes and defibrillation pads": "Worn by the patient under his or her clothing \nAttached to a monitor that provides alerts and delivers a shock\nIf patient is in cardiac arrest, vest should remain in place while you perform CPR.",
        "Central Venous Catheter": "Catheter with its tip placed in vena cava to provide venous access\nUsed for many types of home care patients \nCommon locations\nChest\nUpper arm\nSubclavicular area FIGURE 37-13 Patients who require frequent intravenous\nmedications may have a central line in place. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Common problems \nBroken lines\nInfections around the lines\nClotted lines\nBleeding around the line or from the tubing attached to the line",
        "Gastrostomy Tubes": "Placed into the stomach for patients who cannot ingest fluids, food, or medication by mouth \nMay be inserted through the nose or mouth into the stomach\nMay be placed surgically directly into the stomach through the abdominal wall FIGURE 37-14 Gastric tubes may be placed through the\nskin into the stomach for children or adults who cannot be\nfed by mouth. \u00a9 DELOCHE/age fotostock. May become dislodged \nImmediately stop the flow of any fluids.\nAssess for signs or symptoms of bleeding into the stomach.\nVague abdominal discomfort\nNausea\nVomiting (especially \u201ccoffee ground\u201d emesis)\nBlood in emesis Increased risk of aspiration\nAlways have suction readily available.\nPatients with difficulty breathing should be transported while sitting or lying on their right side with head elevated 30\u00b0.\nContinue tube feeding unless the tube is dysfunctional, dislodged, or partially dislodged.",
        "Shunts": "For patients with chronic neurologic conditions \nTubes that drain excess cerebrospinal fluid \nFluid reservoir\nDevice beneath skin on side of head, behind the ear\nShould alert you to the presence of a shunt Types \nVentricular peritoneum shunt\nVentricular atrium shunt\nBlocked/infected shunt may cause changes in mental status and respiratory arrest.\nInfection may occur within 2 months of insertion. Signs of distress\nHigh-pitched cry or bulging fontanelles\nHeadache\nProjectile vomiting\nAltered mental status\nIrritability\nFever\nNausea Signs of distress (cont\u2019d)\nDifficulty with coordination (walking)\nBlurred vision\nSeizures\nRedness along shunt track\nBradycardia\nHeart dysrhythmias",
        "Vagus Nerve Stimulators": "Treatment for seizures not controlled with medication\nSurgically implanted \nStimulate the vagus nerve to prevent seizure activity Used in children older than 12 years\nLocated under the patient\u2019s skin \nAbout the size of a silver dollar\nIf you encounter a patient with this device, contact medical control or follow your local protocols.",
        "Colostomy or ileostomy": "Procedure that creates opening between the small or large intestine and the surface of the body \nAllows for elimination of waste products into a clear, external bag or pouch \nEmptied or changed frequently",
        "Assess for dehydration if the patient has been complaining of diarrhea or vomiting.": "Area around the stoma is prone to infection. \nSigns of infection:\nRedness\nWarm skin around the stoma\nTenderness over the colostomy or ileostomy site",
        "Urostomy": "Surgical procedure that connects the urinary system to the surface of the skin\nAllows urine to drain through a stoma in the abdominal wall\nContact medical control or follow local protocols for care of a patient with a colostomy, ileostomy, or urostomy bag.",
        "Patient Assessment Guidelines Interaction with caregiver is an important part of patient assessment process.": "They are experts on caring for these patients.\nDetermine patient\u2019s normal baseline status before assessment.\nAsk, \u201cWhat is different today?\u201d",
        "Occurs within home environment": "Represents a spectrum of populations\nInfants, older adults, chronic illness, developmental disabilities\nServices: delivering meals, cleaning, laundry, maintenance, physical therapy, personal care EMS may be called to residence by home care provider.\nObtain baseline health status and history from home care provider.",
        "Hospice Care and Terminally Ill Patients": "Terminally ill may receive hospice care at a hospice facility or at home.\nMost have DNR order.\nMay have medical orders for scope of treatment Comfort care \nPalliative care (pain medications)\nImproves quality of life before patient dies\nFollow local protocol, patient\u2019s wishes, legal documents. \nBring documentation to the hospital. \nShow compassion, understanding, and sensitivity. Ascertain the family\u2019s wishes regarding transport.\nAllow family member to accompany the patient.\nFollow local protocols for handling the death of a patient.",
        "Poverty and Homelessness": "Unable to provide for basic needs\nDisease prevention strategies are absent.\nLeads to increased probability of disease\nHomeless population includes:\nPatients with mental illness or prior brain trauma\nDomestic violence victims\nAddicts\nImpoverished families Advocate for all patients. \nAll health care facilities must provide assessment and treatment regardless of the patient\u2019s ability to pay.\nBecome familiar with social services resources within your community."
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Neurology\nAnatomy, presentations, and management of\nDecreased level of responsiveness\nSeizure\nStroke Neurology (cont\u2019d)\nAnatomy, physiology, pathophysiology, assessment, and management of\nStroke/transient ischemic attack\nSeizure\nStatus epilepticus\nHeadache",
        "Introduction": "Stroke is the fifth-leading cause of death and the leading cause of adult disability in the United States.\nCommon in geriatric patients\nContributing factors for stroke include family history and race.\nNew treatments are available. Seizures and altered mental status may also occur.\nSeizures may occur as a result of:\nRecent or prior head injury\nA brain tumor\nMetabolic problems\nFever\nA genetic disposition Possible causes of altered mental status include:\nIntoxication\nHead injury\nHypoxia\nStroke\nMetabolic disturbances\nTreatment varies widely.",
        "Anatomy and Physiology": "The brain is the body\u2019s computer.\nControls breathing, speech, and all body functions\nThree major parts: brainstem, cerebellum, and cerebrum\nThe cerebrum is the largest part. FIGURE 18-1 The brain is well protected within the skull. The brain\u2019s major parts are the cerebrum, the cerebellum, and the brainstem \u00a9 Jones & Bartlett Learning. The brainstem controls the most basic functions.\nBreathing, blood pressure, swallowing, pupil constriction\nThe cerebellum controls muscle and body coordination. The cerebrum is divided into right and left hemispheres.\nEach controls activities on the opposite side of the body.\nThe front of the cerebrum controls emotion and thought.\nThe middle controls sensation and movement.\nThe back processes sight. In most people, speech is controlled on the left side of the brain near the middle of the cerebrum.\nMessages sent to and from the brain travel through nerves.\nTwelve cranial nerves run directly from the brain to parts of the head. The rest of the nerves join in the spinal cord and exit the brain through a large opening in the base of the skull called the foramen magnum.\nAt each vertebra in the neck and back, two nerves branch out (spinal nerves).\nThese carry signals to and from the body. FIGURE 18-2 The spinal cord is the continuation of the\nbrainstem. It exits the skull at the foramen magnum and\nextends down to the level of the second lumbar vertebra. \u00a9 Jones & Bartlett Learning.",
        "Pathophysiology Many different disorders may cause brain dysfunction.": "May affect the patient\u2019s level of consciousness, speech, and voluntary muscle control\nThe brain is sensitive to changes in oxygen, glucose, and temperature.",
        "One of the most common complaints": "Can be a symptom of another condition or a neurologic condition on its own\nOnly a small percentage of headaches are caused by a serious medical condition. \nTension headaches, migraines, and sinus headaches are the most common. Tension headaches \nCaused by muscle contractions in the head and neck\nAttributed to stress\nPain is usually described as squeezing, dull, or as an ache.\nUsually do not require medical attention Migraine headaches \nThought to be caused by changes in blood vessel size in the base of the brain.\nPain is usually described as pounding, throbbing, and pulsating.\nOften associated with nausea and vomiting, and may be preceded by visual changes\nCan last for several hours or days Sinus headaches\nCaused by pressure that is the result of fluid accumulation in the sinus cavities\nPatients may also have cold-like symptoms of nasal congestion, cough, and fever.\nPrehospital emergency care is not required. Serious conditions that include headache as a symptom are hemorrhagic stroke, brain tumor, and meningitis.",
        "Stroke Also called a cerebrovascular accident (CVA)": "Interruption of blood flow to an area within the brain\nResults in the loss of brain function\nThere are two main types of stroke: ischemic and hemorrhagic.",
        "Ischemic Stroke": "Most common, accounting for 87% of strokes\nResults from thrombosis or an embolus\nSymptoms may range from nothing at all to complete paralysis.\nAtherosclerosis in the blood vessels is often the cause. FIGURE 18-3 Atherosclerosis can damage the wall of a\ncerebral artery, producing narrowing and/or a blood clot.\nWhen a vessel is narrowed or completely blocked, blood\nflow to part of the brain may be blocked, causing brain\ncells to die because of the lack of adequate oxygenation. \u00a9 Jones & Bartlett Learning.",
        "Hemorrhagic Stroke": "Accounts for 13% of strokes\nResults from bleeding inside the brain\nCerebral hemorrhages are often fatal. \nPeople at high risk include those experiencing stress or exertion.\nPeople at highest risk are those who have very high blood pressure. Aneurysm \nSwelling or enlargement of the wall of an artery resulting from a defect or weakening of the arterial wall FIGURE 18-5 An angiogram showing a cerebral aneurysm \u00a9 Living Art Enterprises/Photo Researchers, Inc.",
        "Transient Ischemic Attack (TIA) Stroke-like symptoms go away on their own in less than 24 hours.": "May be a warning sign of a larger stroke to come\nAbout one-third of patients who have a TIA will experience a stroke.",
        "Signs and Symptoms of Stroke": "Facial drooping\nSudden weakness or numbness in the face, arm, leg, or one side of body\nDecreased or absent movement and sensation on one side of the body\nLack of muscle coordination (ataxia) or loss of balance Sudden vision loss in one eye\nBlurred and double vision\nDifficulty swallowing\nDecreased level of responsiveness\nSpeech disorders Aphasia\nSlurred speech (dysarthria)\nSudden and severe headache\nConfusion\nDizziness Weakness\nCombativeness\nRestlessness\nTongue deviation\nComa",
        "Left Hemisphere Stroke in the left cerebral hemisphere may cause aphasia.": "Inability to produce or understand speech\nSpeech problems can vary widely.\nMay also cause paralysis of the right side of the body",
        "Right Hemisphere Stroke may cause paralysis of the left side of the body.": "Usually, patients can understand language and are able to speak.\nPatients may be oblivious to their problem (neglect).\nNeglect and lack of pain cause many patients to delay seeking help.",
        "Bleeding in the Brain Patients may have high blood pressure.": "May be the cause of the bleeding\nMay be caused by the bleeding, as a compensatory response\nIncreasing blood pressure is an important sign. \nSignificant drops in blood pressure may occur as the patient\u2019s condition worsens.",
        "Hypoglycemia": "Postictal state \nSubdural or epidural bleeding",
        "Conditions That May Mimic Stroke": "FIGURE 18-6 Trauma to the head may result in intracranial bleeding. A. Bleeding outside the dura and under the skull is called epidural bleeding. B. Bleeding beneath the dura but outside the brain is called subdural bleeding. A, B: \u00a9 Jones & Bartlett Learning.",
        "Seizures A neurologic episode caused by a surge of electrical activity in the brain": "Can take the form of a convulsion and/or can be associated with a temporary alteration in consciousness.\nTwo basic groups: generalized and partial (focal)",
        "Results from abnormal electrical discharges from large areas of the brain": "Typically characterized by unconsciousness and a generalized severe twitching of all muscles lasting several minutes or longer Generalized Seizure",
        "Does not involve any changes in motor activity": "Characterized by a brief lapse of consciousness in which the patient seems to stare and not respond Absence Seizure",
        "Partial": "Focal-onset aware seizure\nNo change in the patient\u2019s level of consciousness\nMay have numbness, weakness, dizziness, visual changes, or unusual smells/tastes\nMay have some twitching or brief paralysis Focal-onset, impaired awareness seizure\nAltered mental status\nResults from abnormal discharges from the temporal lobe of the brain\nLip smacking, eye blinking, isolated jerking\nUnpleasant smells, visual hallucinations, uncontrollable fear, repetitive physical behavior",
        "Aura Patients may experience an aura prior to a seizure.": "Can include visual changes or hallucinations\nPeople with a history of seizures recognize their auras and usually take steps to minimize injury.\nAuras do not occur prior to every seizure, and not all patients with a seizure disorder experience an aura.",
        "Generalized Seizure Characterized by sudden loss of consciousness, chaotic muscle movement and tone, and apnea.": "May exhibit bilateral muscle movement characterized by a cycle of muscle rigidity and relaxation\nTypically lasts less than 5 minutes\nFollowed by a postictal state",
        "Absence Seizure Formerly called petit mal": "May last for seconds\nPatient fully recovers with a brief lapse of memory",
        "Status Epilepticus Seizures lasting more than 5 minutes are likely to progress to status epilepticus.": "Seizures that continue every few minutes without the person regaining consciousness or last longer than 30 minutes",
        "Causes of Seizures": "Epileptic seizures usually can be controlled by medications.\nLevetiracetam (Keppra)\nPhenytoin (Dilantin)\nPhenobarbital\nCarbamazepine (Tegretol)\nValproate (Depakote)\nTopiramate (Topamax)\nClonazepam (Klonopin)",
        "The Importance of Recognizing Seizures Recognize when a seizure is occurring and whether this episode differs from previous ones.": "Recognize the postictal state and complications of seizures.\nIdentify other problems associated with seizures.",
        "The Postictal State After a seizure, the muscles relax and breathing becomes labored.": "May be characterized by hemiparesis\nMost commonly characterized by lethargy and confusion\nIf the patient does not improve, consider other possible underlying conditions.",
        "Syncope Seizures are often mistaken for syncope, or fainting.": "Fainting typically occurs while the patient is standing.\nSeizures may occur in any position.\nFainting is not associated with a postictal state.",
        "Altered Mental Status Aside from stroke and seizures, the most common neurologic emergency": "Patient is not thinking clearly or is incapable of being aroused.\nIn some cases, the patient will be unconscious; in others, the patient may be alert but confused.",
        "Causes of AMS": "Hypoglycemia\nHypoxemia\nIntoxication\nDelirium\nDrug overdose\nUnrecognized head injury Brain infection\nBody temperature abnormality\nBrain tumor\nOverdose and/or poisoning",
        "Scene Size-up Make an early determination whether the cause is medical or trauma.": "Look for threats to safety.\nFollow standard precautions.\nConsider the need for spinal motion restriction.\nCall for additional resources early.",
        "Primary Assessment Look for and treat life-threatening conditions.": "Perform a rapid exam.\nEstablish priorities of care based on assessment of the patient\u2019s LOC and XABCs.",
        "History Taking Investigate the chief complaint.": "For unresponsive patients, gather any history from family or bystanders.\nIf no one is around, quickly look for explanations for the AMS.\nTry to determine the events leading up to the incident.\nObtain a SAMPLE history.",
        "Secondary Assessment": "Vital signs\nSignificant intracranial bleeding leads to a great deal of pressure in the skull, compressing the brain.\nSlow pulse and erratic respirations\nHigh blood pressure\nChanges in pupil size\nIf the patient has an AMS, check the blood glucose level. Stroke assessment\nStroke scales evaluate the face, arms, and speech.\nBE-FAST mnemonic\nCincinnati Prehospital Stroke Scale\nLos Angeles Prehospital Stroke Screen\n3-Item Stroke Severity Scale (LAG)\nGlasgow Coma Scale (GCS) score All patients with an altered mental status should also have a Glasgow Coma Scale (GCS) score calculated.",
        "Reassessment Focus on reassessing the ABCs, vital signs, and interventions.": "Compare baseline findings with updated information.\nWatch carefully for changes in pulse, blood pressure, respirations, and GCS scores.\nNotify the receiving facility of patient\u2019s chief complaint and assessment findings.",
        "Emergency Medical Care": "ED physicians determine if there is bleeding in the brain for patients with a suspected stroke with a CT scan of the head.\nIf no bleeding is present, the patient may be a candidate for blood clot dissolving medication.\nNotify the hospital regarding the last time the patient was known to be without their current signs and symptoms of stroke. Patients who have had a seizure require definitive evaluation and treatment.\nSupplemental oxygen is strongly advised.\nFor patients who are having a seizure:\nProtect them from harm.\nMaintain a clear airway by suctioning.\nProvide oxygen as quickly as possible.\nIf head or neck trauma is suspected, provide spinal immobilization. For patients who continue to have a seizure, as in status epilepticus:\nSuction the airway.\nProvide positive pressure ventilations.\nTransport quickly to the hospital.\nRendezvous with ALS, if possible.",
        "Emergency Medical Care: Headache You should be concerned if the patient complains of:": "A sudden-onset, severe headache\nA sudden headache with fever, seizures, altered mental status, or following trauma",
        "Emergency Medical Care: Migraine Always assess the patient for other signs and symptoms that might indicate a more serious condition.": "Apply high-flow oxygen, if tolerated.\nProvide a darkened, quiet environment.\nDo not use lights and siren during transport.",
        "Emergency Medical Care: Stroke Support XABCs and provide rapid transport to a stroke center.": "Maintain a SpO2 level of at least 94%.\nOxygen therapy not recommended unless the patient is in respiratory distress or is hypoxic.\nIf possible, transport to a designated stroke center.",
        "Emergency Medical Care: Seizure": "The patient may be in a postictal state upon your arrival.\nThe patient may still be having a seizure:\nContinue to assess and treat XABCs.\nProtect the patient from harm. If the patient refuses transport after a seizure:\nContact medical control.\nFollow local protocols.",
        "Emergency Medical Care: Altered Mental Status Determine the cause.": "Provide spinal motion restriction.\nProvide airway and ventilation support. \nTransport to the appropriate facility."
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Immunology\nRecognition and management of shock and difficulty breathing related to\nAnaphylactic reactions\nAnatomy, physiology, pathophysiology, assessment, and management of\nHypersensitivity disorders and/or emergencies\nAnaphylactic reactions",
        "Introduction": "EMTs often respond to calls involving allergic reactions.\nAllergy-related emergencies may involve:\nAcute airway obstruction\nCardiovascular collapse You must be able to: \nTreat these life-threatening complications\nDistinguish between the body\u2019s usual response to an allergen and an allergic reaction \nImmunology is the study of the body\u2019s immune system.\nFive categories of stimuli that may provoke an allergic reaction.",
        "Anatomy and Physiology The immune system protects the body from foreign substances and organisms.": "When a foreign substance invades the body:\nThe body initiates a series of responses to inactivate the invader.",
        "Pathophysiology": "An allergic reaction is an exaggerated immune response to any substance.\nNot caused directly by an outside stimulus\nCaused by the body\u2019s immune system\nReleases chemicals to combat stimulus\nIncludes histamines and leukotrienes Some patients may not know what is causing their reaction, so you must:\nRecognize the signs and symptoms.\nMaintain a high index of suspicion.\nAn allergic reaction may be mild and local or severe and systemic. Anaphylaxis is an extreme, life-threatening allergic reaction.\nInvolves multiple organ systems\nCan rapidly result in shock and death FIGURE 21-1 The sequence of events in anaphylaxis. A. The antigen is introduced into the body. B. The antigen\u2013antibody reaction at the surface of a mast cell. C. The release of mast cell chemical mediators. D. Specific antibody reacts with its corresponding antigen. E. Chemical mediators exert their effects on end organs. \u00a9 Jones & Bartlett Learning. Three common signs of anaphylaxis:\nUrticaria (hives)\nSmall areas of generalized itching or burning that appear as multiple, small, raised areas on the skin FIGURE 21-2 Urticaria, or hives, may appear following\nexposure to an allergen and is characterized by multiple\nsmall, raised areas on the skin. Urticaria may be one of the warning signs of an impending anaphylactic reaction. \u00a9 Charles Stewart MD, EMDM MPH. Three common signs of anaphylaxis (cont\u2019d):\nAngioedema\nAreas of localized swelling\nWheezing\nHigh-pitched, whistling breath on expiration FIGURE 21-3 Angioedema is localized swelling associated with allergic reactions. If the site of swelling includes the lips, tongue, larynx, or other such structures, airway obstruction may occur. \u00a9 E.M. Singletary, MD. Used with permission. You may also note:\nStridor on inspiration due to upper airway narrowing\nHypotension due to vasodilation and increased capillary permeability\nNausea, vomiting, and abdominal cramps",
        "Common Allergens": "Food\nMay take more than 30 minutes to appear\nShellfish, nuts\nMedication\nAntibiotics (eg, penicillin)\nNonsteroidal anti-inflammatory drugs (NSAIDs) Medication (cont\u2019d)\nIf medication is injected, the reaction may be immediate and severe.\nReactions to oral medications may take more than 30 minutes to appear but can also be very severe. FIGURE 21-4 A severe allergic reaction to medication. Courtesy of Carol B. Guerrero.",
        "Plants": "Dusts, pollens, and other plant materials\nRagweed, ryegrass, maple, and oak\nChemicals\nMakeup, soap, and hair dye\nLatex is of particular concern to health care providers\nNitrile gloves are an alternative.",
        "Insect bites and stings": "Envenomation: the process of an insect injecting its venom\nReaction can be localized or may be severe and systemic.",
        "Approximately 2 million Americans are allergic to the venom of bees, wasps, and hornets.": "Allergic reactions to insect stings cause at least 62 deaths/year in the United States.\nIn about half of these deaths, the victim had never experienced a reaction to prior stings. Signs and symptoms:\nSudden pain\nSwelling\nLocalized heat\nUrticaria\nRedness in light-skinned individuals\nItching and a wheal FIGURE 21-7 A wheal is a whitish, firm elevation of the skin that occurs after an insect sting or bite \u00a9 Simon Krzic/Shutterstock.",
        "The stinging organ of most insects is a small hollow spine projecting from the abdomen.": "The stinging organ of most insects is a small hollow spine projecting from the abdomen.",
        "Honeybees cannot withdraw their stinger.": "Wasps and hornets can sting multiple times. FIGURE 21-5 Most stinging insects inject venom through\na small, hollow spine that projects from the abdomen.\nA. The stinger of the honeybee is barbed; the honeybee\ncannot withdraw its stinger once it has stung someone.\nB. The wasp\u2019s stinger is unbarbed, meaning that it can\ninflict multiple stings. A: \u00a9 manfredxy/Shutterstock; B: \u00a9 Heintje Joseph T. Lee/Shutterstock.",
        "Some ants, especially the fire ant, strike repeatedly. FIGURE 21-6 A. The fire ant. B. Fire ants inject an irritating": "toxin at multiple sites. Bites are generally found on the feet\nand the legs and appear as multiple small, raised pustules. A: Courtesy of Scott Bauer/USDA; B: \u00a9 Scott Camazine/Alamy Stock Photo.",
        "In severe (anaphylactic) cases, patients may experience:": "Stridor\nBronchospasm and wheezing\nChest tightness and coughing\nDyspnea\nAnxiety\nGastrointestinal complaints\nHypotension",
        "Patients may occasionally experience respiratory failure.": "If untreated, anaphylactic reaction can proceed rapidly to death.\nMore than two-thirds of patients who die of anaphylaxis do so within the first 30 minutes.",
        "Patient Assessment in an Immunologic Emergency": "Scene size-up\nScene safety\nThe patient\u2019s environment or recent activity may indicate the source of the reaction.\nSting or bite\nFood allergy\nNew medication regimen Scene safety (cont\u2019d)\nBe mindful of other potential causes of respiratory distress.\nTraumatic injury may also be present.\nFollow standard precautions, with a minimum of gloves and eye protection.\nConsider the need for additional resources, such as ALS personnel.",
        "Primary Assessment": "Quickly identify and treat any immediate or potential life threats.\nForm a general impression.\nMay present as respiratory or cardiovascular distress in the form of shock\nPatients often appear very anxious.\nCall for ALS backup if available.\nLook for a medical identification tag. Airway and breathing\nAnaphylaxis can cause rapid swelling of the upper airway.\nYou have only a few minutes to assess the airway and provide lifesaving measures.\nWork quickly to determine the severity of the symptoms. Airway and breathing (cont\u2019d)\nQuickly assess for: \nIncreased work of breathing\nUse of accessory muscles\nHead bobbing\nTripod positioning\nNostril flaring\nAbnormal breath sounds Airway and breathing (cont\u2019d)\nAssist the patient into high Fowler position to maximize ventilations.\nIf signs of shock, place the patient in supine position.\nDo not hesitate to initiate high-flow oxygen.\nIn severe situations, assist using bag-mask device, attached to oxygen. Circulation\nMay present with hypotension\nPalpate for presence and quality of radial pulse.\nAssess for rapid pulse rate; cool, cyanotic, or red, moist skin; delayed capillary refill.\nMay indicate hypoperfusion Treat for shock.\nDefinitive treatment for anaphylactic shock is epinephrine. Transport decision\nAlways provide prompt transport for any patient who may be having an allergic reaction.\nIf the patient does not exhibit severe symptoms, consider continuing the assessment; err on the side of emergency transport.",
        "History Taking": "Investigate:\nChief complaint\nHistory of present illness\nIdentify:\nAssociated signs and symptoms SAMPLE history \nIf possible, ask the following questions:\nHave any interventions already been completed?\nHas the patient experienced a severe allergic reaction in the past? Be alert for any statements regarding ingestion of foods that cause allergic reactions.\nAsk about gastrointestinal complaints (nausea or vomiting).",
        "Secondary Assessment": "Physical examination\nSystematic head-to-toe or focused assessment\nAuscultate for abnormal breath sounds:\nWheezing or stridor\nInspect the skin \nSwelling, rashes, or urticaria Physical examination (cont\u2019d)\nAssess baseline vital signs\nPulse and respiratory rates\nBlood pressure\nPupillary response\nOxygen saturation\nSkin signs may be unreliable. Monitoring devices\nPulse oximetry can be a useful method to assess the patient\u2019s perfusion status.\nDecision to apply oxygen should be based on:\nAirway patency\nWork of breathing\nAbnormal lung sounds",
        "Reassessment": "Repeat the primary assessment, reassess the patient\u2019s vital signs, and repeat the focused physical exam.\nIf patient is unstable, reassess every 5 minutes; if stable, every 15 minutes.\nWatch for signs of shock. Interventions\nDetermine the severity of the reaction.\nMild reactions require supportive care and monitoring.\nAnaphylaxis requires epinephrine and ventilatory support.\nTransport to a medical facility.\nRecheck your interventions. Communication and documentation\nDocumentation should include:\nSigns and symptoms\nReasons why you chose to provide the care you did\nPatient\u2019s response to the treatment",
        "If patient appears to be having a severe allergic (or anaphylactic) reaction:": "Administer BLS.\nProvide prompt transport to the hospital.",
        "If a stinger is present, scrape the skin with the edge of a sharp, stiff object such as a credit card.": "Do not use tweezers or forceps. FIGURE 21-8 To remove the stinger of a honeybee, gently scrape the skin with the edge of a sharp, stiff object such as a credit card. \u00a9 Jones & Bartlett Learning.",
        "Wash the area with soap or antiseptic.": "Remove any jewelry from the area.\nPosition the injection site below the heart.\nApply ice or cold packs.",
        "Be alert for signs of airway swelling and other signs of anaphylaxis.": "Place the patient in supine position, and give oxygen as needed.\nMonitor the patient\u2019s vital signs.",
        "Epinephrine": "Mimics the sympathetic (fight-or-flight) response\nCauses the blood vessels to constrict\nReverses vasodilation and hypotension\nIncreases cardiac contractility and relieves bronchospasm\nRapidly reverses the effects of anaphylaxis",
        "Epinephrine is prescribed by a physician and comes pre-dosed in an epinephrine injector (EpiPen).": "Your EMS service may or may not allow you to assist the patient in the administration of epinephrine. \nRefer to local protocols or consult medical control.",
        "Emergency Medical Care of Immunologic Emergencies": "All kits should contain a prepared, auto-injectable syringe of epinephrine.\nAdult EpiPen delivers 0.3 mg of epinephrine; infant\u2013child system delivers 0.15 mg FIGURE 21-9 Patients who experience severe allergic reactions often carry their own prescription epinephrine, which comes predosed in an \nauto-injector or a prefilled syringe. \u00a9 Jones and Bartlett Learning. Courtesy of MIEMSS",
        "Side effects of epinephrine:": "High blood pressure\nIncreased pulse rate\nAnxiety\nCardiac arrhythmias\nPallor\nDizziness\nChest pain\nHeadache\nNausea\nVomiting",
        "Do not give epinephrine to:": "Patients without signs of respiratory compromise or hypotension \nThose who do not meet the criteria for a diagnosis of anaphylaxis"
    },
    {
        "dialysis defined": "filtration and purification of blood in a clinical setting, in place of the kidneys",
        "the two types of dialysis": "peritoneal dialysis, and hemodialysis",
        "peritoneal dialysis": "bathing the peritoneal cavity in a fluid that waste products diffused into. the fluid is then drained two hours later, along with the diffused waste products.",
        "hemodialysis": "blood is drawn out of the patient and filtered via a machine (in place of the kidney) and then the blood is returned clean of waste products.",
        "cause of hypotension in dialysis": "caused by excreting too much fluid from the blood during the dialysis process",
        "true or false: peritoneal dialysis is as effective as hemodialysis": "true",
        "cause of air embolism in a dialysis patient": "if the tubing being used in the dialysis machine has any leaks, it may pump air back to the patient",
        "how often do patient need dialysis?": "generally every 2-3 days, 4 hours at a time",
        "when measuring the bp of a dialysis patient...": "use the arm that does not have a fistula, shunt, or graft in it",
        "uremic frost": "small, white and yellow urea crystals deposited on the surface of the skin",
        "risk factors while on dialysis": "uremic pericarditis \nair embolism \ndisequilibrium syndrome \nhypo/hyperkalemia \nhypo/hypertension\nchf\nshock",
        "arteriovenous graft": "surgical graft created to form a joining of both an artery and vein, required for hemodialysis",
        "disequilibrium syndrome": "syndrome characterized by increased intracranial pressure caused by a fluid shift into the csf during dialysis. often subsides in a few hours.",
        "signs/symptoms of disequilibrium syndrome": "nausea and vomiting, confusion, and headache.",
        "cause of hyperkalemia in kidney disease": "diseased kidneys cannot excrete potassium, so potassium levels rise",
        "ecg t wave changes may occur in dialysis patients due to...": "hyperkalemia - peaked t waves\nhypokalemia - flattened or inverted t waves",
        "cause of hypokalemia in dialysis": "can occur due to overaggressive dialysis, removing too much potassium in the blood",
        "uremic pericarditis": "caused by high levels of urea in the blood, found in patients with chronic kidney disease",
        "signs/symptoms of a patient who missed dialysis": "muscle cramping\nweakness\nuremic frost\npulmonary edema",
        "disequlibrium syndrome can present similarly to...": "stroke\nsubdural hematoma"
    },
    {
        "c": "celsius",
        "cc": "cubic centimeter",
        "ci": "curie",
        "cm": "centimeter",
        "db": "decibel",
        "dl": "deciliter",
        "fl": "fluid",
        "f": "fahrenheit",
        "fl oz": "fluid ounce",
        "g": "gram",
        "hz": "hertz",
        "kg": "kilogram",
        "km": "kilometer",
        "l": "liter",
        "l/min": "liters per minute",
        "lb": "pound",
        "m": "thousand, meter, molar",
        "mcg": "microgram",
        "meq": "milliequivalent",
        "mg": "milligram",
        "ml": "milliliter",
        "mmhg": "millimeters of mercury",
        "mol wt (mw)": "molecular weight",
        "oz": "ounce",
        "ppm": "parts per million",
        "pt": "pint",
        "rad": "radiation-absorbed dose",
        "rev/min, rpm": "revolutions per minute",
        "u": "unit",
        "mu, u": "micron",
        "v": "volt",
        "vol %": "volume percent",
        "v/v": "volume per volume",
        "w": "watt",
        "w/v": "weight per volume"
    },
    {
        "kussmaul respirations": "rapid and deep breaths",
        "polydipsia": "excessive thirst",
        "polyphagia": "excessive hunger or increased appetite",
        "polyuria": "increased/excessive urination",
        "pancreas function": "produces/releases the hormones insulin and glucagon",
        "pituitary gland function": "to release antidiuretic hormone (adh) and oxytocin",
        "thyroid function": "cellular metabolism stimulation",
        "parathyroid function": "increase calcium (ca2+) levels in the bloodstream",
        "thymus function": "helps stimulate the production of t-lymphocytes (helper t cells)",
        "adrenal gland function": "stimulates the sympathetic nervous system (think: adrenaline, fight or flight)"
    },
    {
        "hypoglycemia": "when levels of circulating blood glucose fall below normal resulting in lethargy, changes in mentation, and/or altered levels of consciousness. also, called low blood sugar.",
        "hyperglycemia": "when levels of circulating blood glucose are higher than normal (typically far exceed normal levels before a patient becomes symptomatic). symptoms include excessive thirst, increased appetite, and frequent urination",
        "endocrine glands": "glands that produce and distribute chemical messengers (hormones), largely via the circulatory system, to affect change in target organs and tissues",
        "hormone": "a chemical messenger molecule that affects other organs and tissues",
        "homeostasis": "maintaining internal balance. the endocrine system and nervous system coordinate, enabling organ systems to communicate with each other and adapt to constant stimuli.",
        "types of glands": "endocrine and exocrine. endocrine glands are those that secrete hormones into the bloodstream while exocrine glands are those that secrete hormones through ducts.",
        "hormone is defined as:": "a chemical substance that acts as a messenger molecule in the body.",
        "what is the primary function of the endocrine system?": "helps to control mood, growth and development, the way our organs work, metabolism, and reproduction.",
        "what is a goiter an indicator of?": "an enlarged thyroid",
        "insulin resistance": "the body needs more insulin than normal to control blood sugar, increasing the risk of diabetes and heart disease.",
        "graves disease": "an autoimmune disease characterized by excessive production of thyroid hormone; one of the most common diseases of hyperthyroidism",
        "hashimoto's thyroiditis": "a disease characterized by damage to the cells of the thyroid gland following an autoimmune attack. this hypothyroid condition may result in goiter development, weight gain, fatigue, constipation, etc.",
        "a disease characterized by excessive growth hormone production": "acromegaly; a condition caused by overactivity of the pituitary gland",
        "hypothalamus": "this structure serves as the primary link between the nervous system and the endocrine system. the central function of the hypothalamus is to coordinate nervous system activity with endocrine function to maintain homeostasis within the body",
        "adrenal glands": "located above the kidneys. the cortex (outer portion) secretes hormones such as cortisol. the medulla (inner portion) secretes adrenaline.",
        "pancreas": "secretes hormones involved in the regulation of blood sugar as well as enzymes involved in digestion.",
        "type 1 diabetes": "an autoimmune disease characterized by the destrution of beta cells in the pancreas, resulting in the cessation of insulin production",
        "type 2 diabetes": "chronically high levels of circulating blood glucose result in a gradual increase in insulin resistance. this prevents the uptake of glucose into the cells and complicates fluid and nutrient balance, placing further strain on the cardiovascular system",
        "hyperthyroidism": "a condition where the thyroid gland produces excess thyroid hormone. it can cause weight loss, nervousness, and a fast heart rate",
        "hypothyroidism": "a condition in which the thyroid gland produces insufficient amounts of thyroid hormone. it can cause fatigue, depression, constipation, and skin problems",
        "gigantism": "also known as acromegaly, is a growth hormone disorder that causes excessive growth at an early age. it can be seen by the abnormal height of a person.",
        "dwarfism": "is a growth hormone deficiency disease. individuals with dwarfism are noted for their short stature.",
        "ketoacidosis": "extreme hyperglycemia associated with type 1 diabetes. involves the breakdown of ketone bodies for energy resulting in metabolic acidosis.",
        "which gland is the smallest in the endocrine system? what is its primary known function?": "the pineal gland; secretes melatonin, which is understood to be involved in regulating sleep.",
        "which gland is responsible for controlling sleep, appetite, and temperature?": "the hypothalamus",
        "the most common cause of cushing\u2019s syndrome": "the overuse of a cortisol medication, or excess production of cortisol in the body",
        "common signs and symptoms of cushing\u2019s syndrome": "a fatty hump between the shoulders and a rounded face are both classic signs of cushing's syndrome",
        "common signs and symptoms of hypothyroidism": "tiredness, sensitivity to cold temperatures, weight gain, constipation",
        "common signs and symptoms of hyperthyroidism": "weight loss, tiredness, sensitivity to warm temperatures, diarrhea",
        "describe the relationship between the thyroid and parathyroid glands.": "one function of the thyroid is to decrease blood calcium levels by storing excess calcium primarily in the bone tissue. the parathyroid glands, on the other hand, help to raise blood calcium levels by breaking down stored calcium in the bone tissue.",
        "these two hormones are stored and released by the posterior pituitary gland": "oxytocin and antidiuretic hormone (adh)/vasopressin",
        "oxytocin": "found in both the male and female reproductive systems; is involved in bonding for both males and females, as well as labor and milk production in females",
        "antidiuretic hormone (adh)": "this hormone helps to maintain and control blood pressure by regulating the excretion and reabsorption of water",
        "addison's disease": "a hormone disease characterized by adrenal insufficiency (specifically a lack of cortisol and aldosterone) that leads to fatigue, extreme weakness, and dehydration",
        "provide an example of a positive feedback loop": "blood clotting is a positive feedback loop. as a small number of platelets are triggered, they send signals to increase platelet aggregation",
        "provide an example of a negative feedback loop": "thermoregulation is an example of a negative feedback loop. for example, if the body gets too hot, it begins sweating, this cools the body and ceases the production of sweat",
        "aldosterone": "produced in the cortex of the adrenal gland, this hormone regulates fluid and electrolyte balance through water and sodium reabsorption",
        "hormone(s) produced by the adrenal cortex": "aldosterone, cortisol, androgens, estrogen",
        "cretinism": "commonly referred to as congenital hypothyroidism, this disease is characterized by a deficiency of thyroid hormone in early development. may affect physical growth, cognitive development, and neurological function",
        "thyroid storm": "a rare and life-threatening condition stemming from an extreme overproduction of thyroid hormone. symptoms include rapid heartbeat, high fever, ams, loc",
        "diabetes insipidus": "an uncommon disorder that causes an imbalance of fluids in the body and a constant feeling of thirst. this disorder is not related to diabetes mellitus.",
        "thyroidectomy": "surgical removal of the thyroid gland",
        "how often do endocrine cells in the pancreas regenerate?": "approximately once every year.",
        "this gland serves as the connection between the endocrine and nervous systems": "the hypothalamus",
        "steroid vs. non-steroid hormones": "steroid hormones utilize lipids and phospholipids as building blocks, meaning they are able to pass through the cell membrane on their own to affect change on the cell; non-steroid hormones utilize amino acids as their building blocks, meaning they require receptors and sometimes other chemical messengers to affect change on the cell",
        "pancreatitis defined": "inflammation of pancreas, often due to gallstones or repeated alcohol abuse",
        "graves' disease defined": "excess production/release of thyroid hormones",
        "thyroid storm defined": "acute onset, life threatening condition characterized by overproduction of thyroid hormones causing a severe hypermetabolic state",
        "myxedema defined": "advanced hypothyroidism causing a low metabolic state and abnormal growth of connective tissue",
        "cushing's syndrome defined": "adrenal gland disorder characterized by high cortisol levels\ncan be caused by prolonged exposure to glucocorticoid medication",
        "addison's disease defined": "adrenal disorder characterized by low production of hormones by the adrenal glands",
        "pancreatitis signs/symptoms": "constant flank pain (may worsen if supine)\nfever\njaundice (skin/eyes turn yellow)\nnausea/vomiting",
        "graves' disease signs/symptoms": "emotional changes\nweight loss\ninability to sleep well (insomnia)\nweakness/fatigue\nrapid heart rate\nacute atrial fibrillation\nprotruding eyes\ngoiter\nsensitivity to heat",
        "thyroid storm signs/symptoms": "increased stimulation of sns\nfever\naltered mental status \nrapid heart rate\nhypotension\nvomiting\ndiarrhea",
        "addison's disease signs/symptoms": "weakness, fatigue\ndecreased appetite\nunexplained weight loss\ndarkening of skin\nvomiting, diarrhea\nlow mood\ncardiac dysrhythmias"
    },
    {
        "hyperglycemia defined": "high blood sugar level, 140 mg/dl and above",
        "cause of rapid hyperglycemia": "intake of sugar or carbohydrate rich foods",
        "cause of gradual hyperglycemia": "infection or illness",
        "dka defined": "dka - diabetic ketoacidosis - is characterized by high blood sugar levels (350 mg/dl or more) and the build up of acids in the body because of the absence of insulin",
        "signs/symptoms of dka": "polyuria\npolydipsia\npolyphagia\nnausea & vomiting\ntachycardia\nkussmaul respirations\nfruity odor of breath\nabd pain",
        "ketones": "waste product of the body metabolizing fat for energy",
        "hormones that elevate blood sugar level": "cortisol, catecholamines, glucagon",
        "hhs defined": "hhs - hyperosmolar hyperglycemic syndrome - is characterized by very high blood sugar levels, highly concentrated blood as a result of dehydration, but no significant ketosis",
        "onset of hhs vs. dka": "dka is a more rapid onset, progressing over a few hours or a few days\nhhs is slower in onset, progressing over days to weeks",
        "why are kussmaul respirations found in a patient with dka?": "kussmaul respirations allow for the body to more effectively exhale off co2, decreasing the acidosis",
        "what type of diabetic is more likely to be found in dka?": "type 1 diabetic, due to the total absence of insulin production",
        "ketonemia": "excess amount of ketone bodies in the blood",
        "most common electrolytes lost during dka": "sodium and potassium",
        "field treatment of dka": "begin fluid re-hydration at 1l/hour or as per local protocol\nmonitor closely for hypotension, and pulmonary edema\nmonitor for cardiac rhythm abnormalities \n*note: insulin therapy will almost always take place in the hospital setting",
        "signs/symptoms of hhs": "high blood glucose\naltered loc\nfatigue, lethargy\nsevere dehydration\npolydipsia\ndark urine\nvisual/sensory deficits\nmuscle weakness\nseizures, in extreme cases",
        "what kind of diabetic is more likely to be found in hhs?": "a type 2 diabetic",
        "factors that can exacerbate hhs": "infection\nlife stresses\ndehydration",
        "bgl often seen in hhs": "600 mg/dl or higher",
        "arterial ph of hhs vs. dka": "dka - lower than 7.3\nhhs - higher than 7.3",
        "hhs management in the field": "fluid replacement with ns using a large bore iv if possible\nobtain bgl\nmonitor for change in loc\nrapid transport"
    },
    {
        "the most common cause of vaginal bleeding during pregnancy is?": "abortion/miscarriage",
        "abortion": "the expulsion of the fetus prior to 20 weeks gestation. also called a miscarriage.",
        "signs and symptoms of a spontaneous abortion": "vaginal bleeding with clots and tissue, cramping abdominal pain or backache. if it is late in the first trimester or later, a fetus may be passed which may remain attached by the umbilical cord.",
        "ectopic pregnancy": "abnormal implantation of fertilized egg outside of he uterus.",
        "signs and symptoms of a ectopic pregnancy": "abdominal pain, diffuse tenderness moving to specific unilateral sharp pain lower abdominal quadrant. missing a period, decreased menstrual flow with brownish color, shorter in duration. a rigid abdomen may be present and pain may be referred to a shoulder on the affected side. vaginal bleeding, signs of shock/hypoperfusion along with syncope may be present.",
        "placenta previa": "placenta implants on the lower half of the uterus, either partially or completely blocking the cervical opening.",
        "signs and symptoms of a placenta previa": "bright red vaginal bleeding without pain. may be spotting or recurrent hemorrhage. may be precipitated by recent intercourse or vaginal examination and is normally seen in the third trimester.",
        "abruptio placenta": "premature separation of the placenta from the uterine wall.",
        "signs and symptoms of abruptio placenta": "vaginal bleeding may be present or may not be depending on the location of separation. sudden sharp tearing pain and a stiff, board-like abdomen. if complete separation occurs, significant hemorrhage and hypoperfusion/shock will occur. this may occur during labor.",
        "preeclampsia": "increase in systolic blood pressure by 30 mmhg and/or a diastolic increase by 15 mmhg over patient's baseline on two occasions within a 6 hour time period and protein in patient's urine (damage to organs). occurs after 20 weeks of gestation, most commonly seen in the last trimester and may rarely occur postpartum.",
        "signs and symptoms of preeclampsia": "hypertension, edema, headache, visual disturbances, pulmonary edema, and significant decrease in urine output.",
        "eclampsia": "generalized tonic-clonic seizures in a patient who is pregnant and likely has a history of preeclampsia.",
        "signs and symptoms of eclampsia": "seizures that may be preceded by visual disturbances (flashing lights or dark spots). pain in the epigastric or right upper abdominal quadrant may also precede a seizure. edema and hypertension are likely present.",
        "braxton-hicks contractions": "intermittent contraction of the uterus that are painless with no dilation or effacement (thinning/shortening) of the cervix. this sometimes termed \"false labor\". virtually impossible to distinguish in the field.",
        "stage 1 of labor": "the first stage begins when true contractions occur (dilation and effacement begin) and ends with the complete dilation/effacement of the cervix.",
        "stage 2 of labor": "begins at complete dilation of the cervix and ends when the fetus is delivered.",
        "stage 3 of labor": "begins with the delivery of the fetus and ends with the delivery fo the placenta.",
        "average normal maternal blood loss with delivery": "500 ml or 1 pint",
        "acrocyanosis": "dusky colored extremities with pink central color in a neonate. common in the first hours of life.",
        "apgar score": "appearance. pulse. grimace. activity. respirations.",
        "other than normal signs of respiratory distress/arrest or hypoxia, when should respiration be given to a neonate?": "if the heart rate falls below 100 bpm.",
        "other than in cardiac arrest, when should chest compression be given to a neonate?": "if the heart rate falls below 60 bpm with no response to ventilatory support.",
        "breech presentation": "a condition in which the buttocks or both feet of the fetus present first in birth instead of the cranium.",
        "prolapsed cord": "when the umbilical cord presents during birth before the fetus.",
        "complications of a prolapsed cord": "compression of the cord can cause fetal distress due cessation of fetal circulation.",
        "limb presentation": "a single arm or leg presents during birth before the cranium of the fetus.",
        "standard limb presentation guidelines": "do not touch the limb. do not attempt birth. transport to closest capable facility. assist mother into knee to chest position if possible.",
        "shoulder dystocia": "during labor, the infant shoulders become stuck at the pubic symphysis. the head delivers normally and then sucks back into the vagina.",
        "meconium staining": "the fetus passes feces into the amniotic fluid. this suggest the fetus had a hypoxic episode. there is a risk of aspiration of stain fluid, respiratory distress, and later pulmonary infection. instead of a clear fluid/ light straw color, the amniotic fluid is light yellowish green to dark green.",
        "postpartum hemorrhage": "the loss of more than 500 ml of blood by the mother immediately after birth."
    },
    {
        "erythr/o (color)": "red",
        "cyan (color)": "blue",
        "xanth (color)": "yellow",
        "polio (color)": "gray",
        "melano (color)": "black",
        "chlor/o (color)": "green",
        "cirrh/o (color)": "yellow, tawny",
        "alb, albin/o, leuk/o (color)": "white",
        "acar/o": "mites",
        "arachn/o": "spiders",
        "bacteri/o": "bacteria",
        "coccus": "berry shaped bacterium",
        "fung/i": "fungus or mushroom",
        "helminth/o": "worm",
        "hirud/i": "leech",
        "ixod/i": "ticks",
        "myc/o": "fungus/mushroom",
        "parasit/o": "parasite",
        "pedicul/o": "louse",
        "scolec/o": "worm",
        "verm/i": "worm",
        "vir/o": "virus",
        "acous/o (sense)": "hearing",
        "acoust/o (sense)": "hearing",
        "audi/o (sense)": "hearing",
        "audit/o (sense)": "hearing",
        "cusis (sense)": "hearing",
        "olfact (sense)": "smell",
        "osmia (sense)": "smell",
        "osm/o (sense)": "smell",
        "osphresia (sense)": "smell",
        "osphresi/o (sense)": "smell",
        "haph/e (sense)": "touch",
        "pselaphes/o (sense)": "touch",
        "tact/o (sense)": "touch",
        "thigm (sense)": "touch",
        "geusia (sense)": "taste",
        "gustat/o (sense)": "taste",
        "gust/o (sense)": "taste",
        "opia (sense)": "vision",
        "opsia (sense)": "vision",
        "opt/o (senses)": "vision"
    },
    {
        "thrombocytosis": "condition characterized by overproduction of platelets, causing increased likelihood of coagulation/clotting problems - especially thrombosis",
        "thrombosis": "occurs when clotting partially or fully occludes a vein or artery",
        "sickle cell disease (scd)": "a group of red blood cell (rbc) disorders that are inherited, characterized by the production of abnormally \"sickle\" or \"c\" shaped red blood cells.",
        "common disorders caused by scd": "vasoocclusive crisis\nanemia \nleukocytosis",
        "scd red blood cell complications": "thrombosis\nhypoxia\nshort rbc lifespan",
        "anemia": "reduced hemoglobin or rbc levels in the blood",
        "hemophilia": "the blood has the inability to the clot well, or at all",
        "s/s of anemia": "fatigue, weakness\npale skin \ndifficulty catching breath\nin rare cases, angina",
        "s/s of scd": "pale skin\nhypotension\ndehydration\nin some cases, jaundice\nsob\nbody aches\nfever",
        "what other diseases may scd mimic?": "opiate withdrawal, and appendicitis",
        "leukocytosis": "high leukocyte (wbc) count in the blood",
        "leukemia": "cancer of wbcs, causing excessive wbc production",
        "general prehospital management of blood disorders": "airway monitoring, o2 therapy, fluids and analgesics for pain as needed",
        "thrombocytopenia": "decreased platelet level in the blood",
        "polycythemia": "overproduction of rbcs, causing increased viscosity and volume in the blood",
        "disseminated intravascular coagulation": "(dic) characterized by decreased clotting ability due to fibrin breakdown, and uncontrolled internal hemorrhage. high mortality rate.",
        "causes of dic": "injuries and hypotension due to trauma, as well as obstetrics and septic complications",
        "blood transfusion reactions": "caused by a patients poor reaction to a blood transfusion, often presenting similar to anaphylaxis",
        "lymphoma": "disease process that originates in the lymphatic system",
        "both types of lymphoma": "hodgkin and non-hodgkin lymphoma"
    },
    {
        "prenatal period": "the time from conception until delivery of the fetus.",
        "placenta": "known as the organ of pregnancy. it is a temporary structure that is vital to the development of a fetus.",
        "umbilical cord": "a rope-like structure that is ~ 2 feet long and connects the fetus to the placenta, transporting oxygenated blood/nutrients to the fetus and deoxygenated blood away from the fetus.",
        "at how many weeks is a fetus considered full term?": "38 to 40 weeks",
        "gravidity refers to the number of  times a woman has ___.": "been pregnant",
        "parity refers to the number of times a woman has ___.": "given birth (fetus grater than 24 weeks) regardless of the survival of the fetus/neonate.",
        "what important landmark occurs at 28 weeks gestation?": "the fetus develops surfactant, a lubricating substance vital to the normal function of the lungs.",
        "what is fundal height?": "the distance in cm from the pubic symphysis to the uterine fundus or top of the uterus. after ~24 weeks gestation, the height of the fundus corresponds to gestational age in weeks.",
        "if fetal movement is felt during an assessment, the fetus must be at least ___ weeks old.": "20",
        "at what gestational age is a premature fetus considered to have a chance (greater than 50%) of survival?": "24 weeks"
    },
    {
        "diabetes defined": "metabolic disease characterized by inadequate insulin production and higher than normal blood sugar levels",
        "types 1 diabetes defined": "the pancreas does not produce insulin, requiring blood glucose levels to be controlled via insulin that originates outside of the body, commonly referred to as insulin dependent diabetes",
        "type 2 diabetes defined": "commonly referred to as adult onset diabetes, this type of diabetes is caused by underproduction of insulin by the pancreas to adequately control blood sugar levels, and lack of cell sensitivity to the insulin produced.",
        "differences between type 1 and type 2 diabetes": "type 1 - autoimmune caused, insulin dependent, often happens earlier in life\ntype 2 - lifestyle or genetically caused, can be either managed with diet/exercise, medication, or insulin, often happens later in life",
        "normal blood sugar range": "70 - 140\nbetween 70 and 140 mg/dl",
        "hypoglycemia": "low blood sugar, generally below 70 mg/dl",
        "hyperglycemia": "high blood sugar, generally above 140 mg/dl",
        "prediabetes": "a condition in which a patient shows risk factors for diabetes and elevated bgl, but does not have elevated enough blood sugar to be diagnosed with diabetes. a1c range: 5.7%-6.4%.",
        "gestational diabetes": "diabetes that can occur during pregnancy, characterized by insulin resistance and higher than normal bgl during gestation",
        "common complications in a patient with diabetes": "kidney disease\nhypertension\nnerve damage (neuropathy)\neye damage/problems  (retinopathy)\nstroke\nheart disease",
        "type 1 diabetes cause": "though not entirely understood, the consensus on the cause of type 1 diabetes is that it is an autoimmune disorder that starts from an external trigger i.e. viral, environmental, etc.",
        "type 2 diabetes cause": "lack of consistent exercise, poor/unbalanced diet, family history, and obesity are all risk factors that can cause type 2 diabetes.",
        "type of diabetes previously called \"juvenile diabetes\"": "type 1 diabetes (now called \"insulin dependent diabetes\")",
        "cells that produce insulin in the pancreas": "beta cells - of the islets of langerhans",
        "the two kinds of insulin a type 1 diabetic will take": "short acting insulin - taken at meals or when carbohydrates/sugars are eaten\nlong acting insulin - taken once a day to allow for fewer fluctuations in blood sugar level",
        "oral antihyperglycemics": "medication a type 2 diabetic may take to help control blood sugar level without needing to take insulin",
        "insulin resistance": "occurs when body produces insulin, but cannot utilize it effectively.  a main characterization of type 2 diabetes.",
        "why polyuria occurs during hyperglycemia": "the body is combating the elevated blood sugar level by increasing urine output, essentially attempting to flush the bloodstream of the excess sugar",
        "why polydipsia occurs during hyperglycemia": "the body is increasing urine output (polyuria) in order to flush out the excess sugar in the bloodstream. excessive thirst will occur in order to replenish the fluids that are needed during this process.",
        "hemoglobin a1c": "blood test revealing a patients average blood sugar readings for the last 3 months. healthy range: 5.7% or lower."
    },
    {
        "hypoglycemia defined": "low blood sugar level, generally characterized by a bgl of less than 60 mg/dl. in extreme cases referred to as \"insulin shock.\"",
        "causes of hypoglycemia": "taking too much insulin\nnot eating enough food\nexercise without fuel replenishment",
        "signs/symptoms of hypoglycemia": "hunger\nagitation or irritability \nelevated heart rate\ncool, clammy skin\naltered loc\nin rare cases a patient can be combative \nweakness, fatigue\nnausea \ncoma (in extreme cases)",
        "hormone that elevates blood sugar level": "glucagon, released by the pancreas",
        "field test done on all diabetics": "blood glucose test via a glucometer",
        "oral glucose/tabs contraindication during hypoglycemia": "patient cannot manage their own airway",
        "examples of household carbohydrate options after hypoglycemia treated": "peanut butter and jelly sandwich\nbowl of granola and milk\n*any carbohydrate rich meal that can be eaten to stabilize bgl long term",
        "oral glucose dose": "15-30 g",
        "alternatives to oral glucose/tabs": "cup of orange juice or non-diet soda",
        "medical event that can be confused with hypoglycemia": "cerebrovascular accident (cva), aka stroke",
        "gluconeogenesis": "a process in the liver that allows for production of new glucose in the body",
        "cause of tachycardia and diaphoresis in hypoglycemia": "epinephrine and norepineprhine secretion to combat the falling blood sugar level",
        "field treatment for hypoglycemia - no iv access": "glucagon im - 0.5-1 mg (or as per protocol)",
        "field treatment for hypoglycemia - iv access": "dextrose administration as per local protocol - often 12.5-25 g over 3 minutes",
        "risk factor of dextrose 50% (d50)": "iv line infiltration and vein extravisation, potentially resulting in local tissue death",
        "volume of dextrose 10%": "250 ml - 25 g dose\n1g/10ml",
        "volume of dextrose 50%": "50 ml - 25 g dose\n1g/2ml",
        "hypoglycemic unawareness": "a condition caused by repeated, chronic hypoglycemia, eventually preventing the patient from being aware of low bgl, and them subsequently not self treating.",
        "appropriate size iv when administering dextrose": "18 gauge or larger"
    },
    {
        "geriatric defined": "an individual aged 65 years or older",
        "incontinence defined": "the inability to control bladder or bowel movements",
        "common chief complaints of geriatric patients": "dizziness\nfatigue, weakness\nfalls\npoor ability to sleep or rest\nbody temperature, too hot or cold\nheadache\nloss of appetite\ngi problems",
        "\"gems\" geriatric assessment defined": "geriatric patient \nenvironmental assessment \nmedical assessment \nsocial assessment",
        "polypharmacy defined": "the use of multiple medications at one time\n4-6 medications prescribed at one time is not uncommon for patients of the geriatric population",
        "most common fractures from a fall": "hip or pelvic fractures",
        "risk factors for a fall": "in poor health\nin poor living conditions\nin group living conditions with less frequent monitoring \npolypharmacy\npoor reaction to medication",
        "syncope": "indicates serious need for thorough assessment\nrule out fall secondary to syncope",
        "bereavement defined": "sadness over loss of loved ones, can be exacerbated by old age",
        "when interviewing a geriatric patient, it is important to...": "speak to them directly, not surrounding family\nuse their name, not a nickname or common expression",
        "signs/symptoms of sepsis": "tachycardia\nhot, flushed skin\ntachypnea\nfever\naltered mental status\nlow etco2",
        "herpes zoster defined": "painful rash that causes blisters, also known as shingles\ncommon in geriatric patients who had chickenpox when they were younger",
        "pressure ulcers defined": "sores that are the results of lying in one position in bed for extended periods of time\nin extreme cases necrotic tissue can be found at the site of the sores",
        "consider hypovolemia in geriatric patient if...": "systolic bp less than 120\nthink: dehydration, fluid replacement",
        "presbycusis defined": "progressive inability to hear high frequency noise, or distinguish between different noises",
        "proprioception defined": "sense of body movement and position, independent of vision",
        "more than half of geriatric patients will be...": "hypertensive",
        "osteoporosis defined": "reduction in bone mass as part of the aging process. results in decreased bone strength and greater risk of fractures",
        "ra defined": "ra - rheumatoid arthritis - is the inflammation of  joints and subsequent tissue. it is an autoimmune disorder. hands and feet commonly affected first.",
        "hospice defined": "organization that provides end of life care for a patient, and provides resources to the patients family"
    },
    {
        "what happens to bladder capacity with aging?": "bladder capacity decreases",
        "sickle cell disease can result in what condition of the penis?": "priapism: a prolonged and painful erection",
        "what function does a ureter serve?": "ureters drain urine from the kidneys to the urinary bladder",
        "where are the kidney's located?": "left kidney: behind the spleen, just inferior to the rib cage\nright kidney: behind the liver, just inferior to the rib cage",
        "what structures are shared between the urinary and reproductive systems in men?": "the testes, epididymis and vas deferens, prostate gland, and penis",
        "what is the functional unit of the kidney called?": "the nephron",
        "what is the common name for a renal calculi?": "kidney stone",
        "what is renal colic?": "flank pain",
        "define: nocturia": "night time urination",
        "define: hematuria": "blood in urine",
        "oliguria": "reduced urine output",
        "anuria": "no urine output",
        "acute renal failure": "sudden onset drop in urine output, caused by the kidneys inability to filter waste products in blood. seen in very ill/injured patients.",
        "acute renal failure signs/symptoms": "oliguria, anuria, painful and full bladder, edema",
        "chronic renal failure": "inadequate kidney function with slow onset",
        "risk factors for renal failure": "hypertension, diabetes",
        "renal calculi": "aka kidney stones, hardened cluster of calcium in kidney",
        "renal calculi signs/symptoms": "severe flank pain\nsever groin pain\npainful urine flow\ninability to urinate \nblood in urine",
        "uti": "urinary tract infection, occurs most often in females and those who are bed ridden",
        "uti signs/symptoms": "odorous urine\ndark color urine\npainful urination\nhaving the urge to urinate frequently\ndifficulty urinating\nflank pain",
        "components of the excretory system": "kidneys, ureters, bladder, urethra",
        "purpose of the excretory system": "to excrete waste filtered from the bloodstream",
        "function of the excretory system": "to regulate acid-base balance in blood, osmolarity in blood, and blood pressure",
        "what does water follow in the body?": "sodium",
        "pyelonephritis": "inflammation of the kidney linings",
        "more advanced utis can cause...": "pyelonephritis",
        "extracorporeal lithotripsy": "common treatment for renal calculi. consists of high energy shock waves breaking up the kidney stone into smaller pieces, making it easier to pass.",
        "epididymitis": "inflammation/swelling of the epididymis on the back of the testicle",
        "orchitis": "inflammation/swelling of the testicles",
        "testicular torsion": "twisting of the testicles"
    },
    {
        "autoimmune disorder": "disorder in which the body's immune system attacks its own tissue and systems",
        "encourage patients to wear these when they have a serious allergy": "allergy alert tags or bracelets",
        "immunosuppressants": "medication that a patient will take to temporarily or permanently suppress their immune system from being active",
        "most common organs to be transplanted": "heart, liver, kidney, lung, or pancreas",
        "early s/s of organ transplant rejection": "flu like symptoms - general fatigue, weakness, fever",
        "it is important for all patients with immune disorders to have": "a good relationship with a physician that is most familiar with their case",
        "systemic lupus erythematosus": "aka sle or lupus - multisystem autoimmune disease that can present in many different ways, occurs more commonly in women",
        "common s/s of lupus": "fever\nfatigue\njoint pain\nrash\nskin lesions that worsen in the sun",
        "collagen vascular diseases": "body perceives its own collagen tissue as a foreign threat and attacks it",
        "two most common types of collagen vascular diseases": "systemic lupus erythematosus \nscleroderma",
        "scleroderma": "characterized by tightening, thickening and scarring of tissue, particularly the skin",
        "scleroderma s/s": "chronically cold extremities\nhypertension\nskin covered in scar/scar tissue\nheart palpitations",
        "common physiological effects of scleroderma": "renal damage/failure\npulmonary hypertension\nheart dysrhythmias \npulmonary fibrosis",
        "patients with collagen vascular disease or who have recently gone through an organ transplant are often taking these kinds of medications": "immunosuppressants",
        "in heart transplants, this nerve is not connected to the new heart": "vagus nerve"
    },
    {
        "what is an allergic reaction?": "a hypersensitivity reaction to a previously encountered allergen.",
        "what is anaphylaxis?": "a systemic and life threatening reaction to an antigen.",
        "what is a local reaction and the common symptoms": "does not involve the whole body\nconjunctivitis (swelling of the eyes), rhinitis (runny nose), angioedema (swelling), urticaria (hives), pruritis (itching).",
        "common symptoms of anaphylaxis": "a. respiratory system\u2014severe respiratory distress, wheezing to silent chest\nb. cardiovascular\u2014rapid pulse, hypotension\nc. skin\u2014pale, red, or cyanotic\nd. other\u2014decreasing mental status",
        "what is a systemic reaction?": "a widespread and life threatening reaction (anaphylaxis).",
        "management of anaphylaxis": "abcs, position of comfort, oxygen, emotional support, vitals, assist with the patients auto injector if they have their own, and remove the allergen if possible.",
        "immediate reaction": "a reaction occurring within minutes of exposure",
        "delayed reaction": "a reaction occurring 48-72 hours after exposure",
        "what is an antigen?": "a cell marker to identify self and non-self viruses or bacteria.",
        "what is an antibody?": "a protein produced by b cells designed to eliminate foreign substances.",
        "anaphylactoid reaction": "an anaphylactic reaction not mediated through ige, does not require a previous exposure.",
        "anaphylaxis symptoms: upper airway": "stridor, hoarseness or muffled voice, laryngeal or epiglottic edema, rhinorrhea",
        "anaphylaxis symptoms: lower airway": "accessory muscle use, bronchospasm, decreased breath sounds, increased mucus production, wheezing",
        "anaphylaxis symptoms: cardiovascular": "vasodilation, hypoperfusion, tachycardia, chest tightness",
        "anaphylaxis symptoms: cutaneous": "angioedema, edema, erythema, pallor, pruritus, tearing of eyes, urticaria",
        "anaphylaxis symptoms: gi": "stomach pain, diarrhea, n/v",
        "anaphylaxis symptoms: neurological": "anxiety, coma, dizziness, headache, seizure, syncope, weakness",
        "first line medication in managing anaphylaxis": "epinephrine",
        "effect of histamine in anaphylaxis": "causes vasodilation with the ultimate goal being increased blood flow, but in turn also causing hypoperfusion and tachycardia.",
        "mechanism of action: beta agonists": "beta-2 adrenergic bronchodilator thus increasing bronchodilation. albuterol is also an occasional beta 1 stimulant, causing an increase in cardiovascular stimulation. \n(levalbuterol, albuterol)",
        "b-cell lymphocytes": "create cells to defend from potential pathogens such as plasma cells and memory cells:\n-memory cells can identify previously seen pathogens and destroy them\n-plasma cells will release antigens in response to a pathogen, a fully matured plasma cell can release 2,000 antigens a second",
        "t-cell lymphocytes": "t-cell lymphocyte- eliminates potential pathogens and assists in coordinating immune response. releases:\n-cytotoxic t-cells to eliminate infected cells.\n-helper t-cells which will direct other antibodies.",
        "stages of shock": "compensated shock\ndecompensated shock\nirreversible shock",
        "what type of shock does anaphylaxis qualify as?": "distributive shock- is shock based off of widespread vasodilation causing hypoperfusion to patients organs, and causes capillaries to leak. (septic shock, neurogenic shock, and anaphylactic shock)",
        "indication for glucagon in anaphylaxis?": "indicated in patient who are on beta blockers in anaphylaxis.",
        "mechanism of action: corticosteroids": "decrease acute and chronic inflammation in the lungs. \n(methylprednisolone, hydrocortisone, and dexamethasone)",
        "mechanism of action: antihistamines": "reduce or stop the release of histamine. \n (diphenhydramine, hydroxyzine, promethazine, cimetidine, ranitidine, and famotidine)",
        "mechanism of action: anticholinergic bronchodilator": "used to increase bronchodilation effects of beta-agonists such as albuterol. \n(ipratropium)",
        "allergic reaction": "a hypersensitivity reaction to a previously encountered allergen.",
        "anaphylaxis": "a systemic and life threatening response to an antigen",
        "common substances that cause anaphylaxis": "drugs, insect bites, stings, foods, latex, animals, pollens and mold.",
        "signs and symptoms of anaphylaxis": "a. respiratory system - severe respiratory distress, wheezing\nb. cardiovascular - rapid pulse, low blood pressure\nc. skin -- pale, red, or cyanotic; hives, itching, swelling around eyes, mouth, tongue\nd. other - altered mental status, nausea, vomiting"
    },
    {
        "what are the routes of exposure?": "absorption, inhalation, ingestion, and injection",
        "what accounts for the majority of accidental ingestion overdoses?": "pediatric patients, aged one to three.",
        "what are toxins?": "harmful substances produced by exterior sources, such as plants, animals, and bacteria",
        "what is an overdose?": "the result of having taken a hazardous dose of a drug or medication, leading to dangerous or potentially lethal outcomes.",
        "what is the most common source of fatal gas poisonings?": "carbon monoxide, through smoke inhalation.",
        "why should a patient who's ingested caustic agents avoid attempting to throw them up?": "caustic agents can burn and traumatize the soft tissues of the esophagus and airway, causing further damage.",
        "what is the most important part of treating a patient with an organophosphate exposure?": "proper decontamination prior to treatment.",
        "what is the mechanism of action that activated charcoal uses to treat patients?": "adsorption of the stomach's contents.",
        "what national resource can be contacted for questions about overdosing and poisoning, even in the emergency setting?": "poison control (1\u2010800\u2010222\u20101222)",
        "which patient age group is most vulnerable to alcoholism and drug dependency?": "geriatric patients.",
        "why are patients overdosing on drugs of abuse potentially dangerous?": "they can be unpredictable due to the mind altering and mood altering effects of the drug involved.",
        "through which route of exposure do transdermal patches work?": "absorption",
        "through which route of exposure do wasps or snakes envenom patients?": "injection",
        "through which route of exposure does carbon monoxide attach to hemoglobin?": "inhalation",
        "through which route of exposure does a patient overdose on over counter pain meds, such as asa or nsaids?": "ingestion",
        "what is a toxidrome?": "a collection of signs and symptoms that consistently occurs after exposure to a particular toxin or drug class.",
        "what drug class includes organophosphates?": "cholinergics",
        "what collection of symptoms are included with the sludgem mnemonic?": "salivation, lacrimation,  urination, defectation, gi upset, emesis, and miosis",
        "what are anticholinergics?": "pharmacological agents that block the body's ability to receive acetylcholine neurotransmissions.",
        "patients overdosing on a stimulant might enter a dangerous mental state known as _____ _____.": "excited delirium",
        "why is the use of naloxone on a opioid overdose patient considered potentially hazardous?": "the patient may become aggressive and unpredictable.",
        "is discussing a patient's medical condition and suspicion of overdose with law enforcement without the patient's consent a potential violation of hippa?": "yes",
        "carbon monoxide has how much more affinity for hemoglobin than oxygen?": "240x greater affinity",
        "what condition can long term alcohol use lead to?": "alcohol dependency",
        "what are the two different kinds of medication overdoses?": "intentional and unintentional.",
        "what does pharmacokinetics study?": "the path of drugs within the body, how it is absorbed, and eventually metabolized.",
        "what symptoms can present in the cholinergic toxidrome?": "respiratory distress, tremors, flaccid paralysis, symptomatic bradycardia, bronchoconstriction, comas, seizures, and sludge.",
        "what symptoms can present in the anticholinergic toxidrome?": "dry mouth, constipation, urinary retention, bowel obstructions, dilated pupils, increased heart rate, and decreased sweating. in more serious cases, delirium, seizures, and memory loss.",
        "what symptoms can present in the cannaboid toxidrome?": "judgement impairment, fatigue, paranoia, and increased hunger.",
        "what symptoms can present in the sympathomimetic/stimulant toxidrome?": "manic behavior, tremors, restlessness, dilated pupils, lack of sleep and appetite, and mood swings.",
        "what symptoms can present in the barbiturate/sedative/hypnotic toxidrome?": "respiratory depression, extreme lethargy, and comas.",
        "what symptoms can present in the hallucinogenic toxidrome?": "hallucinations, effects on mood, sensory perception, body temperature, emotion, and pain perception.",
        "what symptoms can present in the opiate toxidrome?": "changes in mentation and unresponsiveness, seizures, nausea, shallow breathing and reduced respiratory drive, cyanosis, pinpoint pupils, bradycardia, and hypotension.",
        "what symptoms can present in the huffing agent toxidrome?": "mentation changes, cardiovascular collapse, seizures, and psychosis",
        "what symptoms can present in the alcohol toxidrome?": "cns changes such as aggression or fatigue, motor skills depression, respiratory depression, nausea/vomiting, and lack of coordination",
        "what sort of poisoning is sodium bicarbonate used to treat?": "sodium channel blocker overdoses and tricyclic antidepressant overdoses.",
        "what sort of poisoning is atropine used to treat?": "organophosphate exposures",
        "what is the roll of sedatives in treating poisoning patients?": "seizures, anxiety, and the therapeutic chemical restraint of patients that have become potentially dangerous, second to a mind-altering drug exposure.",
        "what sort of poisoning is glucagon used to treat?": "beta blocker and calcium channel blocker overdoses.",
        "what sort of poisoning is calcium gluconate used to treat?": "calcium channel blocker overdoses",
        "through which membrane must an inhaled toxin pass before being absorbed by the blood stream and metabolized by the body?": "the alveolocapillary membrane.",
        "what symptoms can present during alcohol withdrawal?": "tremors, weakness, nausea, seizures, and even hallucinations.",
        "which two patient groups are most vulnerable to accidental poisonings?": "pediatric and geriatric patients",
        "what sort of poisoning is sodium thiosulfate used to treat?": "cyanide",
        "how does narcan treat narcotic overdoses?": "it is a narcotic antagonist that binds to narcotic receptor sites, reversing respiratory depression and altered mentation."
    },
    {
        "dementia defined": "irreversible brain failure caused by brain disease or injury",
        "disorders that cause dementia": "alzheimer's disease, huntington disease, parkinson's disease, wernicke encephalopathy, or brain tumor are among the most common",
        "it is of the utmost importance to determine the ___________ loc of a dementia patient.": "*baseline* determining the baseline loc of a dementia patient will help the provider determine the best course of treatment and care",
        "onset of dementia": "months to years",
        "dementia patients are at an increased risk for...": "victimization and abuse",
        "prehospital treatment for dementia": "supportive care, patient assessment, treating the symptoms, ascertaining a baseline loc, and coordinating with family about a transport decision",
        "signs/symptoms of dementia": "loss of short or long term memory\nloss of cognition\nincreased tendency to become lost\nincreased confusion\nincreasing frustration/anger\nsocial withdraw",
        "most significant risk factor alzheimer's disease": "old age",
        "dyskinesia defined": "involuntary movements or tremors that can affect one or both sides of the body",
        "jargon aphasia": "talking nonsense",
        "alzheimer's disease": "form of dementia that is causes progressive loss of brain function. initial signs are confusion, severe signs are complete memory loss of loved ones or inability to speak.",
        "huntington disease": "form of dementia that is genetic, causing slow declines in one's spontaneous movement, emotional state, and memory.",
        "parkinson's disease": "form of dementia characterized by extremity tremors, abnormally slow movement, loss of balance, and stiffness of trunk and/or extremities in addition to confusion and memory loss",
        "wernicke encephalopathy": "form of dementia caused by chronic alcohol abuse and thiamine deficiency causing memory loss/confusion",
        "correlating risk factors of dementia": "low level of education, african american ethnicity, and being of the female sex",
        "dementia diagnosis criteria": "loss or impairment of two or more of the following skills: language, memory, personality, cognitive, emotional, and visual perception.",
        "method of confirming presence of alzheimer's disease": "brain tissue analysis postmortem",
        "fifth leading cause of death in the u.s.": "alzheimer's disease",
        "bradykinesia defined": "slowness of movement",
        "senile plaque": "deposits of dead neurons in the brain that form clusters around proteins"
    },
    {
        "what is the normal ph range of the exracellular fluid in the human body?": "7.35-7.45",
        "the byproducts of normal bodily funciton cause the ecf ph to _____?": "decrease, become more acidic",
        "what is the primary buffer against acidosis in the ecf?": "carbonic acid and bicarbonate buffer system",
        "does the buffer system remove acids from the ecf?": "it does not, it only temporarily neutralizes them",
        "what is the relationship between h+ and ph?": "inverse relationship. the more available  h+ the lower the ph.",
        "what is the relationship between co2 and ph?": "inverse relationship. the more available co2 the lower the ph.",
        "if there are high co2 levels in the ecf, how will a healthy respiratory center respond?": "by increasing the breathing rate to offload more co2",
        "what system takes the longest to respond to help maintain homeostasis in the ecf?": "the renal system",
        "what is the underlying problem in respiratory acidosis?": "a build up of co2 caused by an interuption in the normal ventilatory process, causing a decrease in the ecf ph.",
        "what is the underlying problem in repiratory alkalosis?": "too much co2 has been offload by an overworking ventilatory system (hyperventilation). leads to an increase in ecf ph.",
        "what is the underlying problem in metabolic acidosis?": "insufficient bicarbonate availability, caused by either reduced bicarbonate production or increased h+ production, leads to an decrease in ecf ph.",
        "what is the underyling problem in metabolic alkalosis?": "increased availability of bicarbonate ions, either due to increased bicarb levels or a decrease in natural acids in the ecf, leading to a increase in ecf ph.",
        "between acidosis (respiratory or metabolic) and alkalosis, which one is more frequently encountered?": "a state of acidosis is more likely to be encountered due to the relatively common causes and natural trend of the body to become acidodic when systems fail.",
        "what is the normal range of end tidal co2?": "35-45 mmhg",
        "will a pulmonary embolism (pe) cause respiratory acidosis or respiratory alkalosis?": "depends. anxiety and hyperventilation are common with pulmonary emboli and can cause respiraotry alkalosis. at the same time, pe decrease the ability of the body to offload co2 which could lead to an acidodic state.",
        "what condition could be caused by excessive or inappropriate administration of bicarbonate?": "metabolic alkalosis.",
        "when chemically sedating a patient, we are increasing the patient's risk for ___?": "respiratory acidosis. monitor respirations and end tidal co2.",
        "if we encounter a patient with deep, rapid, respirations and we choose rsi/dsi this patient, what is a potential consequence of our intervention?": "deep, rapid, respirations (kussmal respirations) are a conpesatory response to metabolic acidosis in a diabetic. interupting this response and not adapting for it could potentially worsen the pt.'s acidotic state.",
        "why is cardiac monitoring an important step for patient presenting in any of these conditions?": "arrhythmias can develop associated with these conditions including rhythms associated with hyperkalemia and hypokalemia. theses state may be associated with an underlying problem such as renal failure or be precipitated by a metabolic shift between the icf and the ecf due to alkalosis or acidosis."
    },
    {
        "renal cortex": "kidneys most outer layer",
        "renal medulla": "sits within the renal cortex of the kidney",
        "functional unit of the kidney": "the nephron",
        "nephrons primary function": "filtration",
        "two main goals of the kidney": "keep what the body needs, and pass the rest\nconserve water by concentrating urine",
        "three main kidney processes": "filtration, secretion, reabsorption",
        "secretion defined": "a substance being discharged for a particular function",
        "excretion defined": "expelling waste matter",
        "pathway for urine to travel from the kidney to the bladder": "ureter",
        "nephrons secrete...": "salts, acids, bases, and urea",
        "detrusor muscle": "muscular lining of the bladder",
        "where in the body is ammonia converted to urea?": "the liver",
        "substances commonly reabsorbed by the renal system": "glucose, amino acids, and vitamins",
        "aldosterone": "hormone secreted by the adrenal gland when blood pressure drops too low",
        "renin": "released by the kidney to facilitate production of angiotensin 1",
        "angiotensin converting enzyme": "\"ace\" - convertes angiotensin 1 to angiotensin 2",
        "angiotensin 2": "promotes release of aldosterone, in order to raise blood pressure",
        "bicarbonate buffer system": "major component ph regulation in the blood\nfound in the kidneys",
        "distal convoluted tubule": "\"dct\" - responds to the hormone aldosterone, promoting sodium reabsorption",
        "adh": "\"anti-diuretic hormone\" - promotes reabsorption of water, aka vasopressin"
    },
    {
        "sepsis": "when an infection occurs and its toxic products enter the blood stream",
        "s/s of sepsis": "hot, flushed skins signs\ntachycardia\ntachypneic\nfever of 100.4 f\nreduced body temp\netco2 of less than 32 mmhg\naltered mental status",
        "sepsis alert": "an alert notifying the receiving hospital that the ems provider caring for the patient believes they are septic",
        "sepsis alert function": "alerting the receiving facility early of potential sepsis will increase positive patient outcomes and decrease sepsis related complications",
        "patients at highest risk for sepsis": "patients 65 y/o or older, patients younger than 1 year, and patients that have a compromised immune system",
        "septic shock": "occurs due to widespread infection, and can be deadly. severe cases cause mods - multiple organ dysfunction syndrome",
        "multiple organ dysfunction syndrome": "mods - the progressive dysfunction of multiple organs or organ systems, if untreated will cause death",
        "ssc": "surviving sepsis campaign - a campaign started to improve awareness, diagnosis, and management of sepsis",
        "true or false: sepsis can progress quickly and suddenly": "true\nthis is why a sepsis alert protocol is important",
        "general sepsis management in the field": "monitoring mental status, blood pressure, and respiratory rate are of utmost importance. \nstabilizing bp and rr will be vital."
    },
    {
        "hematemesis": "vomiting blood",
        "melena": "dark stool, tar like appearance. indicates blood in stool.",
        "visceral pain": "aka diffuse pain. vague, dull, cramping pain",
        "upper gi tract": "mouth to stomach",
        "lower gi tract": "intestines to anus",
        "gastroenteritis vs. gastritis": "gastroenteritis - inflammation of stomach and intestines \ngastritis - stomach inflammation only",
        "appendicitis": "inflammation of appendix. very common surgical emergency seen in the prehospital setting.",
        "peptic ulcer": "erosion from gastric acid along the gi tract, often referred to as \"stomach ulcer.\" can be seen in patients under high stress in mid-life.",
        "diverticulitis": "inflammation of small sacs or pouches that line the intestines",
        "cholecystitis": "inflammation of the gall bladder",
        "cullen's sign": "bruising around umbilicus",
        "somatic pain": "localized, sharp \"pin point\" pain",
        "grey turner's sign": "flank (side of body) bruising",
        "mallory-weiss syndrome": "a lacerated esophagus, often from excessive vomiting",
        "referred pain": "pain felt anywhere other than where the pain originates",
        "peritonitis": "inflammation of peritoneum",
        "crohn's disease": "inflammatory bowel disorder, often seen in white females under stress",
        "esophageal varices": "swollen veins in the esophagus. often from excessive alcohol abuse. can cause massive, life threatening hemorrhage.",
        "hepatitis": "inflamed liver, often associated with alcohol abuse",
        "ibs": "irritable bowel syndrome, occurs due to genetic factors, stress, bacterial infection, viral infection."
    },
    {
        "ab (prefix)": "away from",
        "ante (prefix)": "before, in front",
        "bi (prefix)": "two, double",
        "circum (prefix)": "around",
        "co (prefix)": "together",
        "demi (prefix)": "half",
        "en (prefix)": "into, in, within",
        "ex (prefix)": "out, away from, outside",
        "extra (prefix)": "outside, beyond",
        "fore (prefix)": "before, in front of",
        "hypo (prefix)": "under, below, beneath, less than normal",
        "inter (prefix)": "between",
        "in (prefix)": "inside, within, not",
        "intra (prefix)": "within",
        "justa (prefix)": "near, beside",
        "medio (prefix)": "middle",
        "ob (prefix)": "against, in front of",
        "para (prefix)": "near, beside, beyond",
        "post (prefix)": "after, behind",
        "pre (prefix)": "before, in front",
        "quadri (prefix)": "four",
        "re (prefix)": "back, again",
        "retro (prefix)": "backward, behind",
        "semi (prefix)": "half",
        "sub (prefix)": "under, below",
        "super (prefix)": "above, excess",
        "supra (prefix)": "above, over",
        "trans (prefix)": "across, through",
        "ultra (prefix)": "beyond, excess",
        "uni (prefix)": "one",
        "de (prefix)": "down, from",
        "ecto (prefix)": "outside",
        "dia (prefix)": "through",
        "endo (prefix)": "within, inner",
        "latero (prefix)": "the side",
        "ventro (prefix)": "front part of body",
        "anterior": "the front of the body (anatomic position) (synonym = ventral)",
        "ventral": "the front of the body (anatomic position) (synonym = anterior)",
        "posterior": "the back of the body (anatomic position) (synonym = dorsal)",
        "dorsal": "the back of the body (anatomic position) (synonym = posterior)",
        "superior": "upper or higher relative to another body part (synonym = cranial)",
        "cranial": "upper or higher, relative to another body part (synonym = superior)",
        "inferior": "lower or below, relative to another body part (synonym = caudal)",
        "caudal": "lower or below, relative to another body part (synonym = inferior)",
        "lateral": "at the side or toward the side of the body",
        "medial": "towards the middle of the body, opposite of lateral",
        "superficial": "refers to a position which is closest to the body\u2019s surface",
        "deep": "a position which is distant or away from the body\u2019s surface"
    },
    {
        "immune system function": "protects the human body from invading organisms or substances that are foreign, or considered foreign",
        "allergen": "substance that triggers allergic symptoms in an individual",
        "antibody": "aka immunoglobulin, a protein that recognizes an antigen and counteracts its effects",
        "antigen": "foreign substance or organism that triggers an immune response, will trigger antibody response",
        "systemic reaction": "reaction that effects the entire body, usually involving multiple body systems",
        "allergic reaction": "abnormal immune response that occurs after the body has been exposed to an allergen",
        "anaphylaxis": "a severe, potentially life threatening allergic reaction that occurs after the body has been exposed to an allergen that it has a hypersensitivity to",
        "innate immunity": "immunity the body is naturally born with",
        "adaptive immunity": "immunity that is specific to a pathogen, allowing for the immune system to form memory around the invader and the response",
        "integument": "the skin - the body's first line of defense against a threat to health",
        "hypersensitivity": "immune system overreaction to something that is perceived as harmful",
        "biphasic reaction": "an allergic reaction that happens in two phases, once directly after exposure to an allergen, and then later after the initial symptoms have subsided",
        "prolonged reaction": "symptoms of anaphylaxis that can last hours, up to days, at a time",
        "anaphylactoid reaction": "allergic reaction that is clinically similar to anaphylaxis, but is caused by a non-immune mediated response",
        "macrophage cell": "cells that specialize in the identification and destruction of harmful bacteria in the body",
        "natural killer cell": "cells that are the defense against both cancerous and vitally infected cells",
        "chemical mediators": "function to reduce inflammation and promote healing",
        "hematopoiesis": "blood cell production, specifically wbcs, that occurs in the bone marrow",
        "leukocytes": "white blood cells (wbcs) - responsible for counteracting disease and foreign substances",
        "interferon cell": "protein that prevents viral replication, released by virally infected cells"
    },
    {
        "what happens to bladder capacity with aging?": "bladder capacity decreases",
        "what function does a ureter serve?": "ureters drain urine from the kidneys to the urinary bladder",
        "where are the kidney's located?": "left kidney: behind the spleen, just inferior to the rib cage\nright kidney: behind the liver, just inferior to the rib cage",
        "what structures are shared between the urinary and reproductive systems in men?": "the testes, epididymis and vas deferens, prostate gland, and penis",
        "what is the functional unit of the kidney called?": "what is the functional unit of the kidney called?",
        "what is the common name for a renal calculi?": "kidney stone",
        "define: nocturia": "night time urination",
        "define: hematuria": "blood in urine",
        "define: polyuria": "excessive urination",
        "define: dysuria": "discomfort or burning with urination",
        "s/s of kidney stones": "renal colic (severe flank pain) and back pain\nabdominal pain\nmay start as vague visceral pain, progressing to extremely sharp, radiating to pelvis, groin, or genitals\nincreased pain, urgency, and frequency of urination\nhematuria \nfever\npale, cool, clammy skin",
        "what is benign prostate hypertrophy?": "noncancerous enlargement of the prostate",
        "what structures do the female reproductive system share with the urinary system?": "none",
        "what are the main functions of the urinary system?": "regulation of blood volume\nregulation of ph (acid/base) \nregulation of water/electrolyte balance\nblood filtration\nremoving waste and toxins\nregulating arterial blood pressure\nproduction of red blood cells\nregulation of glucose",
        "is the urinary bladder classified as a solid or hollow organ?": "",
        "define: renal colic": "a severe form of sudden onset flank pain",
        "s/s: epididymitis": "1. swelling and pain in the scrotum \n2. enlarged testes\n3. swollen groin on affected side\n4. testicular pain that worsens with bowel movement\n5. fever\nf. urethral discharge",
        "s/s: fourmier\u2019s gangrene": "1. crepitus of skin\n2. grey/black color of tissues with significant drainage \n3. fever\n4. pain",
        "define: phimosis": "condition where the foreskin is too tight to be pulled around the head of the penis",
        "define: priapism": "painful and prolonged erection",
        "four categories of uti (based on location)": "urethritis: in the urethra\ncystitis: in the urinary bladder\nprostatitis: prostate gland (men)\npyelonephritis: kidney",
        "define: pyelonephritis": "a type of uti, specifically an infection in the kidney",
        "define: nephron": "the functional unit of the kidney",
        "define: ureter": "structure that drains urine from the kidney to the bladder",
        "preferred analgesic for flank pain": "tordol (ketorolac) has been shown to be most effective for renal colic (flank pain)\nnarcotics are the second choice, if tordol isn't available",
        "most common ph issue that arises from a gu disorder": "metabolic acidosis",
        "at what age is testicular torsion most likely to occur?": "can occur at any age, however more common in early adolescence and infancy",
        "changes to gu system in elderly (8)": "1. reduction in renal function\n2. reduction in renal blood flow\n3. tubule degeneration\n4. decreased bladder capacity \n5. decline in sphincter muscle control\n6. decline in voiding senses\n7. increase nocturia\n8. benign prostatic hypertrophy (males)",
        "define: benign prostatic hypertrophy (bph)": "noncancerous enlargement of the prostate",
        "s/s: testicular torsion": "1. sudden onset of severe pain in one testis\n2. swelling on one side of scrotum\n3. testicular lump\n4. blood in semen",
        "how does the urinary system regulate arterial blood pressure?": "urine formation\nrenin-angiotensin system"
    },
    {
        "which three electrolytes are primarily responsible for cardiac muscle contraction?": "sodium (na+), potassium (k+), and calcium (ca2+)",
        "you notice a fistula on the patient\u2019s left arm. what does this tell you about the patient\u2019s medical history?": "renal failure",
        "your patient complains of severe cramping in their hands and feet. name two conditions that could present this way.": "hyponatremia, hyperkalemia (dehydration also)",
        "on a patient\u2019s medication list, you see amlodipine. what class of medication is this?": "calcium channel blocker",
        "your patient is in torsades des pointes on the monitor, but still has a pulse. what treatments are indicated?": "asa 324mg chewable, iv access, 12-lead, place defibrillator pads",
        "you are working a cardiac arrest, and at the rhythm check, the patient is in torsades des pointes. is this a \u201cshockable\u201d rhythm?": "yes, follow vf/vt arrest algorithm",
        "what drug(s) are indicated at the aemt level for a patient in cardiac arrest with torsades des pointes as the presenting rhythm?": "epinepherine 1mg 1:10,000 iv",
        "most electrolytes are removed from the blood by which organ? how are they excreted?": "kidneys, as urine",
        "where is excess calcium stored in the body?": "in the bones/as bone tissue",
        "what aemt drug would help address hyperkalemia?": "albuterol",
        "in the event of an overdose, what 2 pieces of information should be collected before leaving the scene (if possible)?": "dose/quantity ingested (number of pills and dose per pill, for example), time ingested",
        "what is the emergency responder\u2019s top priority when responding to an overdose?": "responder/scene safety",
        "what cardiac rhythms would be expected in a calcium channel blocker overdose?": "bradycardic rhythms, av blocks",
        "the parathyroid gland is primarily responsible for regulating levels of which electrolyte in the blood?": "calcium"
    },
    {
        "average menstral cycle length": "commonly around 28 days but can range between 21-30. what is \"normal\" depends on the woman/patient.",
        "what female sex hormones are involved in the menstral cycle?": "progesterone and estrogen",
        "what are the four phases of menstruation?": "1) proliferation stage 2) secretory stage 3) ischemic phase 4) menstrual phase",
        "premenstrual symptoms (pms)": "a set of symptoms and physical signs some women experience just prior to the onset of their menstrual period. these can include fluid retention, fatigue, cravings, headaches, irritability, anxiety, and or depression.",
        "menopause": "this is the cessation of ovarian function and the cessation of estrogen secretion. usually menstrual periods decrease in frequency around ages 45-55 and then completely stop. mood swings, hot flashes and night sweats may occur due to low hormone levels.",
        "at what age do menstrual cycles normally begin?": "around 10-14 years old. at first, they may be irregular.",
        "what does lmp or lnmp stand for?": "last menstrual period or last normal menstrual period"
    },
    {
        "what maternal cardiac changes would you expect during pregnancy?": "1) heart rate increases by 10-15 bpm. \n2) cardiac output increases by 30-50%.",
        "what changes to maternal blood volume occur during pregnancy?": "maternal blood volume increases 45%, increasing plasma and red blood cell availability.",
        "how does maternal blood pressure change during pregnancy?": "during the first two trimesters, bp decreases. during the last trimester, bp rises to almost normal levels.",
        "what changes to the respiratory system occur during pregnancy?": "1) 20% increase in oxygen consumption. \n2) 40% increase in tidal volume. \n3) slight increase in respiratory rate",
        "what is supine hypotension syndrome?": "a mother with a gravid (pregnant) uterus in the supine position will compress the inferior vena cava, resulting in decreased in blood pressure. abdominal aorta may also be compressed along with other major vessels.",
        "what amount (%) of blood loss can a pregnant woman suffer without significant alteration in vital signs?": "30-35%",
        "what position should a pregnant woman (greater than 24 weeks gestation) while acquiring vital signs?": "left side. alleviates the effects of supine hypotension syndrome."
    },
    {
        "pelvic inflammatory disease (pid)": "infection of the female reproductive tract by a fungus, bacteria or virus.",
        "pelvic inflammatory disease (pid) (signs and symptoms)": "can be asymptomatic. normally see abdominal pain (diffuse, lower abdomen),  increased pain during intercourse, shuffling gait due to pain on ambulation. in severe cases, fever and sepsis can develop and foul-smelling yellow discharge.",
        "ovarian cyst": "fluid-filled pockets on the ovary. can be asymptotic if they do not rupture.",
        "ovarian cyst rupture": "rupture of an ovarian cyst which releases blood into the abdomen causing abdominal pain.",
        "ovarian cyst rupture (signs and symptoms)": "rebound tenderness with moderate to severe unilateral abdominal pain. rupture can occur secondary to exercise or intercourse. pain comes on suddenly and may radiate to back. history of dyspareunia (pain during intercourse), irregular bleeding, and delayed menstrual period. vaginal bleeding possible.",
        "urinary tract infection (cystitis)": "infection of the urinary tract.",
        "urinary tract infection (signs and symptoms)": "abdominal pain (frequently around pubic symphysis). urinary frequency, pain or burning on urination or dysuria, low-grade fever.  urine may be cloudy and patient may appear with altered mental status.",
        "endometritis": "infection of the uterine lining. occasional complication of abnormal or normal pregnancy or surgical intervention.",
        "endometritis (signs and symptoms)": "mild to severe lower abdominal pain. blood and foul-smelling discharge and a fever. normally take a few days to develop after birth/procedure. can be fatal or result in sterility. sepsis is possible.",
        "endometriosis": "endometrial tissue is found outside the uterus. most common locations are the abdomen and/or pelvis but can occur virtually anywhere. tissue responds to hormonal changes during menstruation causing bleeding in that region.",
        "endometriosis (signs and symptoms)": "dull, ramping pelvic pain is common but location depends on the location of the tissue. dyspareunia (pain during intercourse), abnormal vaginal bleeding, painful bowel movement (tissue in gi tract).",
        "ectopic pregnancy": "implantation of the fetus in a location outside of the uterus. most commonly a fallopian tube. risk of rupture makes this a surgical emergency.",
        "ectopic pregnancy (signs and symptoms)": "unilateral abdominal pain (radiation to shoulder of the same side), later or missed menstrual period, occasional vaginal bleeding."
    },
    {
        "kussmaul respirations": "rapid and deep breaths",
        "polydipsia": "excessive thirst",
        "polyphagia": "excessive hunger or increased appetite",
        "polyuria": "increased/excessive urination",
        "hypothalamus location": "cerebrum of the brain",
        "hypothalamus function": "-bridge between endocrine system and central ns\n-causes release of growth hormone (gh)",
        "pituitary gland location": "below hypothalamus in cerebrum of the brain",
        "pituitary gland function": "to release antidiuretic hormone (adh) and oxytocin",
        "thyroid location": "neck",
        "thyroid function": "cellular metabolism stimulation",
        "parathyroid location": "on thyroid",
        "parathyroid function": "increase calcium (ca2+) levels in the bloodstream",
        "thymus location": "in the mediastinum (a division of the thoracic cavity)",
        "thymus function": "helps stimulate the production of t-lymphocytes (helper t cells)",
        "adrenal gland location": "on top of the kidneys",
        "adrenal gland function": "stimulates the sympathetic nervous system (think: adrenaline, fight or flight)",
        "pancreas location": "behind stomach",
        "pancreas function": "produces/releases the hormones insulin and glucagon",
        "gonadal glands location": "ovaries - on either side of the uterus \ntestes - within the scrotum",
        "gonadal glands function": "ovaries - produce/release hormones estrogen and progesterone \ntestes - produce/release hormone testosterone"
    },
    {
        "drug class": "hormone",
        "mechanism of action": "directly stimulates contraction of uterine smooth muscle by increasing the sodium permeability of uterine myofibrils. produces intense uterine contractions.",
        "pharmacokinetics": "onset: immediate\nduration: 1 hour",
        "indications": "postpartum bleeding after expulsion of the placenta",
        "contraindications": "sbp<100, ed medication use in last 24 hours, right sided ami",
        "precautions": "od can cause uterine rupture. the absence of additional fetuses must be established, placenta must be delivered before administration",
        "side effects": "cardiac dysrhythmias, htn",
        "dosing": "adult: 10-40 units in 1,000 ml titrated to uterine response 10 units im"
    },
    {
        "peaked t waves are the hallmark 12-lead finding for what condition?": "hyperkalemia",
        "what is the treatment for tricyclic antidepressant overdose?": "sodium bicarbonate",
        "in which group of cardiac muscle cells does calcium play the primary role in depolarization?": "pacemaker cells",
        "in skeletal muscle at rest, where is the greatest concentration of potassium?": "inside the cells",
        "your patient says they missed dialysis yesterday to attend a family event. what condition is common after missed dialysis sessions?": "hyperkalemia",
        "name 2 ecg findings that might indicate hyperkalemia.": "peaked t waves, sine wave morphology",
        "on a patient\u2019s medication list, you see they are taking amitriptyline. what class of medication is this?": "tricyclic antidepressant (sodium channel blocking effects in overdose)",
        "on a patient\u2019s medication list, you see they are taking nicardipine. what class of medication is this?": "calcium channel blocker (other common examples: diltiazem/cardizem, amlodipine/norvasc)",
        "what is the antidisrhythmic of choice and dose for torsades des pointes?": "magnesium sulfate, 2g over 10 min (or iv push in arrest)",
        "you are working a cardiac arrest, and the presenting rhythm is torsades des pointes. should you follow the vf/vt algorithm, or the pea/asystole algorithm? what is the difference?": "vf/vt, defibrillation is the difference.",
        "which medications are indicated for hyperkalemia?": "calcium chloride or gluconate, continuous albuterol nebulizer",
        "what is the usual dose of calcium gluconate? what about calcium chloride?": "gluconate: 10ml (1 gram, 4.6 meq)\nchloride: 10ml (1 gram, 13.6 meq)",
        "name three potential causes of hyperkalemia.": "missed dialysis, rhabdomyolysis, large burns/crush injuries",
        "when is a dialysis patient most likely to be hypokalemic?": "immediately following a dialysis treatment",
        "which organ is most responsible for the regulation of electrolytes in the body?": "the kidneys",
        "which gland is associated with the management of blood calcium levels?": "parathyroid glands",
        "nystagmus in the vertical plane (as opposed to the horizontal plane, which is commonly checked) is indicative of what condition?": "hypomagnesemia",
        "what is the primary ecg change present in hypocalcemia?": "long qt segment",
        "what is the primary ecg change present in hypercalcemia? what other condition is this ecg finding associated with?": "j waves (osborn waves), hypothermia.",
        "lasix/furosemide and hydrochlorothiazide (hctz) are two common diuretics. which one is sometimes called a \u201cpotassium-sparing\u201d diuretic?": "hctz",
        "in what anatomical part of the nephron does lasix/furosemide primarily act?": "loop of henle (ascending loop to be more specific)"
    },
    {
        "sexually transmitted infections": "sti - aka std (sexually transmitted diseases) - an infection passed from one person to another through sexual contact",
        "gonorrhea": "sti caused by the gonococcal bacteria neisseria gonorrhoeae. treatable with antibiotics.",
        "s/s of gonorrhea": "male: pus discharge from urethra, and dysuria \nfemale: inflammation of the urethra cervix, can potentially cause pelvic inflammatory disease (pid)",
        "pelvic inflammatory disease": "pid - infection of female reproductive organs",
        "dysuria": "pain during urination",
        "s/s of pid": "pelvic pain\nfever\nvaginal discharge",
        "best practices to prevent transmission during exposure to an sti": "simply standard precautions and thorough hand washing.",
        "syphilis": "sti that has three stages of infection, each progressing in severity, treated with penicillin",
        "syphilis - primary infection": "chancres, or ulcerative sores, can be found at site of infection",
        "syphilis - secondary infection": "rash present on skin, swollen lymph nodes, and patches of hair being lost",
        "syphilis - tertiary infection": "heart, eye site, auditory, and nervous system complications arise, as well as widespread lesions",
        "genital herpes": "chronic and recurrent infection that is caused by the herpes simplex virus, characterized by lesions at the site of infection. there is no cure.",
        "chlamydia": "most frequently reported sti in the u.s. \ntreated by antibiotics",
        "chlamydia s/s": "female: pid, or preemptive symptoms of pid\nmale: swelling of urethra and epididymis, possible discharge",
        "scabies": "a parasitic sti that is transmitted by skin to skin contact",
        "scabicides": "products used to treat scabies that kill scabies mites and their eggs",
        "scabies s/s": "a rash of small red bumps where the mites have burrowed in the skin. \nintense itching.",
        "genital warts": "caused by the human papillomavirus  (hpv) - characterized by growths that appear at the genital areas of men and women",
        "human papillomavirus": "hpv - most common sti, with millions of cases reported per year. can vary from being harmless, to being a contributor for different types of cancer.",
        "lice": "small insects that are housed in hair and feed on blood through skin. acquired by direct contact. treatable via permethrin cream."
    },
    {
        "drug class": "adsorbent",
        "mechanism of action": "adsorbs toxin molecules to the outside surface of the charcoal. the combined complex is then excreted from the body.",
        "pharmacokinetics": "usually not indicated unless ingestion has been less than 2 hours",
        "indications": "select ingestions. will not bind certain ionic compounds such as iron, lithium, alcohol, or petroleum products.",
        "contraindications": "ams, unless given through ng tube with ett in place",
        "side effects": "abdominal cramping, constipation",
        "dosing": "adult: 1g/kg \ncomes supplied in 25-50 gram tubes"
    },
    {
        "introduction": "hematology refers, as the name implies, to the study of blood and its many components. these include red blood cells (rbcs), white blood cells (wbcs), platelets, and other proteins involved in the bleeding and clotting cascades. this subject also includes the hemopoietic system - a collection of tissues and organs that are involved with the generation of blood components.",
        "hematologic emergencies": "hematologic emergencies are emergencies related to blood conditions (not including exsanguination). it's important to note that ems rarely responds to true hematologic emergencies and that many of these conditions are characterized by chronic, long-standing medical health issues. a hematologic disorder is any disorder that specifically affects the blood.",
        "hematologic anatomy and physiology": "a review of hematologic anatomy and physiology will be required before exploring the depths of pathology and epidemiology.",
        "key points": "blood is a connective tissue, suspended in liquid plasma, and is comprised of cells and cell fragments. it accounts for approximately 8% of body weight in the average adult body or approximately 5-6 liters.\nplasma is the liquid portion of blood. it is comprised mostly of water, with a small percentage of electrolytes, solutes, proteins, glucose, and clotting factors.\nblood-forming organs there are several origins for the formulation of blood's many components, but the three primary organ sources are the liver, the spleen, and bone marrow.\nnormal red cell production, function, and destruction the lifespan of an rbc, also known as an erythrocyte, starts with stem cells, which serve as the building blocks for all cells within the body.\nnormal white cell production and function wbcs are a key component of the body's immunological system and are utilized as defenses against pathogens and foreign substances.\nimmunity refers to the means by which the body protects itself from antigens, pathogens, and other foreign undesirables.\nblood groups are how rbc types are categorized. unlike wbcs, all rbcs serve the same purpose and, at a physiological level, are identical in their method of action.\nhemostasis refers to the body's inherent blood-clotting ability.",
        "general assessment findings and symptoms": "the assessment of a patient with a potential hematologic disorder, at its basics, is fundamentally no different than the assessment of any other patient. however, there are some specific signs and symptoms the responder should be on the lookout for; unusual bleeding being chief among these.",
        "general management": "airway, ventilation, and circulation always remain the fundamental basics in the treatment of any patient, particularly those suffering a hematological emergency.",
        "sickle cell disease": "sickle cell disease gets a special focus in this review of hematological emergencies because it is, by far, the most commonly inherited blood disorder in america.",
        "hematological conditions": "anemia: anemia is characterized by an unusually low rbc or hemoglobin count.\nleukopenia: a condition in which the body suffers a decrease specifically in disease-fighting cells, such as wbcs.\nthrombocytopenia: a condition in which the blood platelet count is too low to maintain proper homeostasis.\nleukemia: leukemia is a form of cancer that forms in and is directly related to the lymphatic system - the system from which the wbcs are formed.\nlymphomas: a lymphoma is a form of cancer of the lymphatic system that comes in two different forms: non-hodgkins lymphomas and hodgkin lymphoma.\npolycythemia: polycythemia is a condition in which the body produces and circulates an excessive amount of rbcs.\ndisseminated intravascular coagulopathy (dic): dic is a rare condition that causes systemic abnormal blood clotting and is usually triggered by some other initiating event.\nhemophilia: hemophilia is a disorder in which the blood of the body cannot properly clot.\nmultiple myeloma: multiple myeloma is another form of cancer that forms in the plasma cells in the bone marrow.",
        "blood transfusion complications": "blood transfusions are a regular procedure that's common during surgery or emergency treatment. however, there are oftentimes reactions to transfusions that can lead to a medical emergency.",
        "background understanding": "in the field interventions for these disorders are going to be largely limited, but a background understanding of these issues will assist in being a quality responder, capable of advocating for a patient with specific conditions. a review of hematologic anatomy and physiology will be required before exploring the depths of pathology and epidemiology.",
        "general management for a patient with a hematological condition or emergency": "airway, ventilation, and circulation always remain the fundamental basics in the treatment of any patient, particularly those suffering a hematological emergency. the inherent purpose of blood as an oxygen-carrying substance means that any compromise to its ability in transportation, gas exchange, or any other interruption could fundamentally alter the patient's ability to maintain homeostasis. respiratory issues should continue to be treated with oxygen and, if necessary, ventilation. circulation can be managed on an outside bleed with pressure and bandaging. internal bleeding can, by its nature, be more difficult to treat; refer to local protocols for fluid boluses to help patients maintain pressure with an isotonic solution.",
        "pharmacological interventions": "pharmacological interventions are fairly limited in the ems system, as they are often dependent on a patient's lab values and specific complaints. however, some symptoms may be managed pharmacologically, such as through pain control medications or antiemetics.",
        "non-pharmacological interventions": "non-pharmacological often include comfort measures and obtaining a solid assessment for a quality and effective hand-off report. a lot of the patient's complaints may stem from chronic, long-term issues which need to be handled at a higher level of care, but that doesn't mean that the quality of the first responder's treatment and management has to be of any less quality.",
        "patient management for sickle cell disease": "the treatment of a patient with sickle cell crisis in the emergency setting is most frequently going to fall back on addressing immediate symptoms, as there is little the ems provider can do to address their patient's chronic, underlying condition. that said, there are many tools in the first responder's kit to keep the patient stable during transport to definitive care. chief among these will be the administration of high-concentration oxygen. the nature of sickle cell disease means that many of its affected patients are chronically hypoxic. iv and fluids therapy can also be used to attend to a patient's hypovolemia and flush damaged rbcs from organs in which they've been secluded, and peripheral tissues.",
        "importance of understanding hematologic emergencies": "in the field interventions for these disorders are going to be largely limited, but a background understanding of these issues will assist in being a quality responder, capable of advocating for a patient with specific conditions.",
        "review of hematologic anatomy and physiology": "a review of hematologic anatomy and physiology will be required before exploring the depths of pathology and epidemiology.",
        "blood composition": "1. blood is a connective tissue, suspended in liquid plasma, and is comprised of cells and cell fragments. it accounts for approximately 8% of body weight in the average adult body or approximately 5-6 liters. the primary duties of blood include supplying oxygen and nutrients to the body's cells and tissues, transporting endocrine hormones, transporting carbon dioxide and other wastes to be expelled from the body, regulating body temperature, regulating body's acidity, regulating electrolyte levels, assisting the immune system by transporting wbc's, and forming clots to stop breaches in the vascular system.",
        "plasma": "2. plasma is the liquid portion of blood. it is comprised mostly of water, with a small percentage of electrolytes, solutes, proteins, glucose, and clotting factors. it accounts for approximately half of blood's volume, while the other portion is made up of the formed elements, which include rbcs, wbcs, and platelets.",
        "blood-forming organs": "3. blood-forming organs there are several origins for the formulation of blood's many components, but the three primary organ sources are the liver, the spleen, and bone marrow. the liver works by helping build clotting factors in the blood, though it also filters the blood and cleanses it of wastes. the liver breaks down old rbcs, transforming them into bile. the liver also has very large deposits of capillary beds, where blood is stored when not circulating through the rest of the body. the spleen, which is also highly vascularized, filters and breaks down old rbcs, assists in forming new wbcs, and stores roughly 1/3rd of the body's platelet count. bone marrow remains one of the body's primary cell production sites, including the production of rbcs. these 'cell factories' are most commonly found in the marrow of long bones, as well as the pelvis, skull, and vertebrae.",
        "normal red cell production, function, and destruction": "4. normal red cell production, function, and destruction the lifespan of an rbc, also known as an erythrocyte, starts with stem cells, which serve as the building blocks for all cells within the body. it is stimulated by a protein called erythropoietin that is secreted by the kidneys as often as the body requires. rbcs will mature over the course of approximately 5 days and then circulate in the body for ~120 days. an rbc's function is to carry oxygen and other chemicals, to be delivered to different tissues of the body. oxygen binds to the iron-rich hemoglobin molecules within the rbcs during transport. in fact, oxygen attaching to the hemoglobin is what gives blood its characteristic red color. the exchange of oxygen for carbon dioxide occurs when oxygen-rich blood cells enter carbon dioxide-rich environments. this change in equilibrium is what drives the exchange across the cell membrane and is known as the bohr effect.",
        "normal white cell production and function": "5. normal white cell production and function wbcs are a key component of the body's immunological system and are utilized as defenses against pathogens and foreign substances. similar to rbcs, they are formed from stem cells, though, unlike rbcs, there are many different'versions' of wbcs, each of which is created for a very specialized purpose for the body's defense.",
        "immunity": "6. immunity refers to the means by which the body protects itself from antigens, pathogens, and other foreign undesirables. it is its own separate body system and has many organs and system-specific cells that are dedicated to its purpose. the immune system can be categorized into one of two different forms: cellular immunity and humoral immunity. cellular immunity, also known as cell-mediated immunity, involves pathogens and foreign substances that are attacked and destroyed by wbcs, such as t-cells and macrophages. it is a very 'active' form of immunity. humoral immunity is a 'passive' form of immunity, in which antibodies, called immunoglobulins, are secreted with the purpose of recognizing specific antigens. this creates a'memory' for certain foreign undesirables for the body to catalog, recognize, target, and destroy with an active immune response. autoimmune diseases are severe reactions to a pathogen or perceived pathogen in which, in the attempt to destroy its target, the immune system attacks and harms the body. normally, the immune system is able to identify the difference between the body's own cells and foreign cells, however, during an autoimmune response, the immune system attacks the body's own cells and tissues. some autoimmune diseases have a localized reaction and target only a single organ, such as in the case of the pancreas and type 1 diabetes.",
        "blood groups": "7. blood groups are how rbc types are categorized. unlike wbcs, all rbcs serve the same purpose and, at a physiological level, are identical in their method of action. however, rbcs carry different antigen marker patterns on their surface. antibodies, which are tasked with identifying foreign antigens, will recognize the surface antigen pattern on the surface rbcs and be able to differentiate them from other foreign bodies. this prevents an autoimmune response that targets the body's own rbcs. this pattern of antigens is how hematologists also classify rbcs, separating them into different groups based on the pattern, using the abo system. this system classifies rbcs into one of 4 different types, a, b, o, and ab. it is important to know the classification of a patient's rbcs during blood transfusion because if the blood of the wrong type is administered, the body's immune system will attack the foreign rbcs. a secondary antigen can also be found in rbcs, known as the rh antigen. a patient with rh factor in their blood is known as rh-positive. a patient without the rh factor is known as rh-negative.",
        "hemostasis": "8. hemostasis refers to the body's inherent blood-clotting ability. it is a highly complex process that includes three main steps that occur in rapid succession: (1) vascular spasms, platelet plugging, and coagulation. vascular components of hemostasis refer, specifically, to the vascular spasms that occur after a vessel has suffered trauma and the actions of the endothelial cells found within the blood vessels. when intact, blood vessels are filled with endothelial cells that prevent clotting by secreting a fibrinolytic heparin molecule. however, when an endothelial injury occurs, the cells stop the secretion of the coagulation inhibitors and instead secrete a different chemical that causes platelet adherence, which initiates a clot. the vasoconstriction itself is a reflexive contraction, causing a reduction of blood flow to the injured area. coagulation mechanisms include the actions of platelets and clotting factors, second to vascular injury. almost immediately after a vessel has been damaged, platelets will form a 'platelet plug' around the site. shortly after this, a stiff and hardy connective tissue known as fibrin will begin to interlace with the platelet plug, hardening the site and filling in gaps. this is a near-immediate response that lays the groundwork for the clotting cascade to build atop, usually starting within twenty seconds of the initial injury. sometimes, particularly in minor injuries, the platelet plug alone is enough to stop the bleed if the platelet plug alone cannot stop the bleeding, a third stage is initiated: coagulation. chemicals are known as 'clotting factors' will begin to be released in the area, which breaks down the cell walls of the rbcs, turning the blood into something like a 'gel' rather than a liquid. eventually, this hardens into a blood clot, otherwise known as a thrombus, and is the final product of hemostasis.",
        "anemia": "anemia is characterized by an unusually low rbc or hemoglobin count. this can severely affect the body's ability to transport oxygen and other important molecules to and from the body's tissues. it is usually associated with some other underlying condition or illness, but also be a result of chronic or acute blood loss.",
        "leukopenia": "a condition in which the body suffers a decrease specifically in disease-fighting cells, such as wbcs.",
        "thrombocytopenia": "a condition in which the blood platelet count is too low to maintain proper homeostasis. if the condition becomes bad enough, it will prevent the patient's blood from clotting appropriately, reducing the body's ability to heal and making injuries significantly more dangerous.",
        "leukemia": "leukemia is a form of cancer that forms in and is directly related to the lymphatic system - the system from which the wbcs are formed. in leukemia, many cells develop abnormally or unnecessarily. wbcs are particularly affected by this condition and can lead to problems such as anemia, an unhealthy decrease in platelets, or an excessive increase in wbcs.",
        "lymphomas": "a lymphoma is a form of cancer of the lymphatic system that comes in two different forms: non-hodgkins lymphomas and hodgkin lymphoma.",
        "polycythemia": "polycythemia is a condition in which the body produces and circulates an excessive amount of rbcs. this extracellular tissue has a direct effect on the viscosity of the blood, which in turn can lead to other health issues, including an increased risk of thrombus formation.",
        "disseminated intravascular coagulopathy (dic)": "dic is a rare condition that causes systemic abnormal blood clotting and is usually triggered by some other initiating event, such as major trauma, sepsis, or obstetric complications.",
        "hemophilia": "hemophilia is a disorder in which the blood of the body cannot properly clot. it is usually inherited via the x chromosome, meaning that it most often manifests in men through hereditary inheritance patterns.",
        "multiple myeloma": "multiple myeloma is another form of cancer that forms in the plasma cells in the bone marrow.",
        "patient management for sickle cell crisis": "the treatment of a patient with sickle cell crisis in the emergency setting is most frequently going to fall back on addressing immediate symptoms, as there is little the ems provider can do to address their patient's chronic, underlying condition. that said, there are many tools in the first responder's kit to keep the patient stable during transport to definitive care. chief among these will be the administration of high-concentration oxygen. the nature of sickle cell disease means that many of its affected patients are chronically hypoxic. iv and fluids therapy can also be used to attend to a patient's hypovolemia and flush damaged rbcs from organs in which they've been secluded, and peripheral tissues."
    },
    {
        "introduction": "a stroke is an interruption of blood flow to the brain. there are two main types of strokes: hemorrhagic strokes and ischemic strokes. strokes are the third leading cause of death in the united states and are the leading cause of disability in the united states.",
        "ischemic stroke": "ischemic strokes are caused by blot clots that inhibit blood flow to the brain. due to lack of oxygen and nutrients, brain cells die the longer blood flow is occluded. ischemic strokes can be further divided into thrombotic strokes and embolic strokes. thrombotic strokes occur when a blood clot forms inside the brain whereas embolic strokes occur when a blood clot forms elsewhere in the body and lodges itself in the brain. ischemic strokes make up around 87% of all strokes.",
        "hemorrhagic stroke": "hemorrhagic strokes occur when there is a rupture of a blood vessel in the brain or a blood vessel that supplies the brain with blood. this stops the brain from being delivered oxygen or nutrients and causes death of brain tissue. this bleeding can also cause increased icp (inter-cranial pressure) leading to brain swelling and further anoxic brain injury. hemorrhagic strokes make up about 13% of all strokes.",
        "stroke screening tools": "strokes fall under the large umbrella of altered mental status. the key symptoms of a stroke are: sudden onset of confusion, altered mental status, lack of coordination, vision or balance issues, weakness in the arm, leg, or face, specifically in one side. sometimes right before the change in mentation or strength, the patient will report a splitting headache. there are specific algorithms used to help determine the likelihood of a stroke and one of them is the cincinnati prehospital stroke scale (cpss). the cpss evaluates facial droop, arm drift, and speech on a normal or abnormal scale. this scale has been built upon by many local protocols, with an example being the portland prehospital stroke screen. the portland prehospital screen accounts for altered mental status being a signature symptom of a stroke by ruling out other common causes of altered mental status prior to prehospital providers calling a stroke alert and mobilizing the stroke team at the receiving hospital. after ruling out causes of altered mental status and acute onset of the condition, the screening process moves to an evaluation similar to the cpss.",
        "prehospital treatment": "as usual, start with a scene size-up and provider safety first. do a primary assessment to make sure the patient is alive and for assessment of abss. stroke patients are generally altered so start an evaluation of altered mental status right away, with no delay as every minute counts when it comes to preserving brain tissue. if you have a high index of suspicion for a stroke, do a quick cpss right away and look for deficits. get capillary blood glucose, blood pressure, oxygen saturation, and cardiac rhythm to investigate other possible causes of altered mental status. work through the stroke screening tools while also considering trauma, infection/sepsis, and drug ingestion or poisoning as well. if the patient is determined to have a stroke, definitive care is at the hospital. emts and paramedics do not have the tools to fix the stroke in the field so rapid transport to the hospital is necessary. making sure to choose the best destination is important, specifically based on your local protocols. different hospitals will have different capabilities including some that are able to handle cstat negative strokes but not cstat positive strokes. it is important to understand the capabilities of the facilities within the area you work and serve. if als capabilities are available, establishing a large bore (generally 18ga or larger) iv, allows the hospital to use the iv for ct and speed up the patient treatment course.",
        "scenario": "a construction manager called 911 for a 55-year-old male on his staff with a sudden onset of slurred speech and weakness. scene size up and primary survey: scene is safe and patient is altered, but abcs appear to be intact perform a quick and complete altered mental status assessment. oxygen: 96% cbg: 130 cardiac: sinus rhythm at a rate of 85 stroke scale: the patient has a left-sided facial droop and is slurring speech you ask the manager if the patient has been sick recently (possible infection) and he says no. no signs of trauma on physical assessment and no signs of drug use as well. stroke scale now determined to be positive initiate rapid transport: gather all necessary information for the patient and initiate rapid transport. cstat test shows patient unable to hold arms up and unable to follow commands cstat positive transport to nearest stroke center as local protocols allow monitor vital signs en route and establish iv access (18ga or larger if possible) reassess symptoms throughout transport",
        "final thoughts": "ems do not have the ability to provide definitive care for stroke patients. the most important thing ems providers can do is quick and complete assessments of altered mental status patients to catch strokes as quickly as possible. then scene time should be minimized such that almost all interventions are done en-route to the hospital. this decreases time the patient has lack of oxygen to the brain and increases the patient\u2019s chances at having a positive outcome."
    },
    {
        "introduction": "hemodialysis remains the primary treatment for kidney failure, short of a kidney transplant, and allows the body to perform all its necessary functions after renal failure has reached a point where the kidneys can no longer perform their duties. this includes waste excretion, urine concentration, electrolyte balance, ph balance, and blood pressure stabilization.",
        "the process of hemodialysis": "the process of hemodialysis itself involves being attached to a hemodialysis machine for several hours a few times a week, where the blood is filtered through a machine that rids the body of toxic wastes it otherwise couldn't. during the process of dialysis, a patient's blood is transferred out of the body with a machine known as a dialyzer, taken to a secondary container where it is purified and filtered before being returned to the body, cleansed of wastes and electrolytes balanced.",
        "importance of dialysis appointments": "patients needed to be transported to a dialysis appointment are, generally, not experiencing an emergency. however, if a patient misses one or more dialysis appointments, they might start experiencing a true life-threatening emergency.",
        "dialysis vascular access": "a dialysis shunt is used to connect the hemodialysis access point to a major artery. the shunt itself is just the means of connection. an atrioventricular (av) fistula is a surgically connected artery and vein, utilized for dialysis access. the access point needs to be durable enough to withstand frequent access, several times a week, without becoming structurally compromised. the placement of an av fistula is an operation in itself and changes the anatomical structure of the patient's extremity (usually the arm). the av fistula is often considered the best long-term solution for dialysis patients because of its low rates of infection. however, it can take some time for them to properly mature and be utilized for hemodialysis.",
        "alternative access options": "alternatively, a patient might have an av graft which is a surgical connection of an artery and vein created by interposing graft materials, biological or synthetic, between them. unlike fistulas, grafts require no maturation stage, meaning they are ready to perform their duty shortly after placement. grafts are chosen over fistulas on a case-by-case basis, often related to life expectancy, and other factors. they are also used for secondary access while waiting for a fistula to heal or develop, or while waiting for a kidney transplant.",
        "the dialysis process": "once a suitable shunt has been selected, a patient may submit to hemodialysis, during which the patient's blood is filtered through a solution known as dialysate. after being removed into the dialyzer, the blood is exposed to dialysate which, through a chemical process, separates the blood from its wastes, before being returned to the body. dialysate is a fluid composed of water, electrolytes, and salt.",
        "peritoneal dialysis": "peritoneal dialysis is an alternative method of artificially reproducing the kidney's duties artificially. during peritoneal dialysis, the abdominal cavity is saturated with large amounts of dialysis fluid. the fluid will remain in the cavity for 1-2 hours, to allow for waste to be absorbed completely, and is then drained. peritoneal dialysis has the advantage of being able to be performed at home, unlike hemodialysis, which requires a clinic, however, it also comes with a significantly increased risk of peritonitis.",
        "special considerations": "overhandling of a patient with an extremity graft or fistula can result in damaging the access point. blood pressures and iv access should only be done on an extremity that has no shunt, or damage can occur, requiring the patient to undergo further surgery for a new, secondary access point. many of these patients have a central line, a permanently fixed iv access port, meaning that secondary iv access is not always mandatory for these patients. review your protocols and consult with the patient before utilizing this established access point.",
        "complications/adverse reactions to dialysis": "dialysis is an effective procedure that extends the life of many patients by years and even paves the way to full recovery in some patients. however, that does not mean it is not without drawbacks, and not every patient responds positively to the treatment. some common problems and even medical emergencies associated with dialysis treatment in of itself include hypotension, hemorrhage from a fistula or shunt, access site infection, potassium/electrolyte imbalances, air embolisms, even machine dysfunctions, or disequilibrium syndrome (which is a collection of its own symptoms, including nausea, fatigue, headaches, convulsions, and disturbed consciousness). further, patients undergoing regular dialysis treatment are more at risk for other chronic health issues, including heart failure, myocardial infarction with cardiac dysrhythmias, hypertension, pericardial tamponade, and uremic pericarditis.",
        "consequences of missed dialysis appointments": "these are potentially serious symptoms and conditions that the dialysis patient could suffer, however, the alternative isn't much better. missed dialysis appointments, even one missed appointment in particularly frail patients, could lead to hyperkalemia with associated ecg changes, severe weakness, and pulmonary edema. if they continue to go without dialysis, they will go into total renal failure, which has its own collection of very dire symptoms, up to and including death.",
        "management of the patient with a dialysis emergency": "first and foremost, manage the basics: airway, breathing, and circulation. in a highly acute dialysis emergency, one of these fundamentals could be compromised, so never fail to return to these. if the patient is suffering from hypotension, consider administering fluids. if the patient is hemorrhaging from a fistula or shunt, apply direct pressure to control the bleeding, and consider using a clamp - a common tool found at most dialysis clinics.",
        "treatment of electrolyte imbalance": "in the case of an electrolyte imbalance, treat any ekg changes as protocols indicate. typically, hypokalemic bradycardia is treated with atropine, while symptomatic hyperkalemia is treated with calcium or sodium bicarbonate - but as always, refer to your standing orders.",
        "treatment of pulmonary edema and hypoperfusion": "if the patient is experiencing severe pulmonary edema, treat with positive pressure if needed and elevate the patient's torso. conversely, if the patient is presenting with hypoperfusion symptoms, consider laying the patient flat.",
        "supportive care and transport": "however, as in most cases, the dialysis patient requires supportive care and transport to a system that can manage their long-term health needs.",
        "treatment of electrolyte imbalance and other complications": "in the case of an electrolyte imbalance, treat any ekg changes as protocols indicate. typically, hypokalemic bradycardia is treated with atropine, while symptomatic hyperkalemia is treated with calcium or sodium bicarbonate - but as always, refer to your standing orders.",
        "transport and supportive care": "if the patient is experiencing severe pulmonary edema, treat with positive pressure if needed and elevate the patient's torso. conversely, if the patient is presenting with hypoperfusion symptoms, consider laying the patient flat. however, as in most cases, the dialysis patient requires supportive care and transport to a system that can manage their long-term health needs.",
        "importance of regular dialysis appointments": "patients needed to be transported to a dialysis appointment are, generally, not experiencing an emergency. however, if a patient misses one or more dialysis appointments, they might start experiencing a true life-threatening emergency."
    },
    {
        "introduction": "the recognition and management of hemorrhage in medical and trauma patients are vital for decreasing mobility and mortality. there is a significant emphasis on hemorrhage management in trauma that should be managed after, or at the same time if resources allow, airway management is completed.",
        "anatomy & physiology": "structures of the heart located inside the thoracic cavity behind the sternum with about two thirds of the heart lying in part of the left aspect of the mediastinum. consisting of the right atrium and ventricle that supplys blood to the lungs and receives the blood from the systemic vasculature. also containing the left atrium and ventricle that supplys blood to the systemic circulation and receives the blood from the pulmonary circulation. blood will pass between the right atrium and right ventricle via the tricuspid valve. where the right ventricle will pump the blood up through the pulmonary semilunar valve. blood will pass between the left atrium and left ventricle via the mitral valve. where the left ventricle will pump the blood up through the aortic semilunar valve.",
        "blood flow within the heart and lungs": "the superior and inferior vena cava return blood from the systemic circulation that is deoxygenated to the right atrium. from here the blood will pass between the right atrium into the ventricle to be pumped into the pulmonary circulation. once the blood is in the pulmonary circulation the blood will offload the carbon dioxide and on-load oxygen for perfusion of the bodies cells. blood will be returned to the left side of the heart to then be pumped around to systemic circulation.",
        "the cardiac cycle": "is used to describe the continual progressive and repetitive pumping of the heart. it is important to remember that is is controlled by the sa and av node. starting with the depolarization of the right atrium and left atrium that forces the blood into the prospective ventricles. with the next aspect being the depolarization of the right ventricle and left ventricle forcing the blood into the prospective section of circulation. preload is at the amount of blood that is returned to the heart to be pumped out. this directly affects the after-load. after-load is the pressure in the aorta or peripheral vasculature that the left ventricle must pump against. the greater the after-load the harder it is for the ventricle to eject blood. stoke volume is the amount of blood ejected per contraction. this can be reduced in the presence of high after-load. cardiac output is the amount of blood pumped through the circulatory system in 1 minute. this is calculated by multiplying the stroke volume and pulse rate.",
        "blood": "plasma is the straw colored fluid that counts for more than half of the total blood volume. consisting of 92% of water and 8% of dissolved chemicals, minerals, and nutrients. red blood cells (rbcs) make up about 45% of the blood volume. the purpose of the cells are to carry oxygen, glucose, proteins, fats, and electrolytes to the tissues and then carry away cellular waste products. these cells are also known as erythrocytes. hemoglobin is contained on the cells and binds to oxygen. each is able to bind up to four gaseous molecules. white blood cells (wbcs) combined with platelets only makes up about 1% of the blood volume. help to fight infections. also know as leukocytes. there are several types and they all sever different functions. platelets is import for controlling bleeding. these small cells are vital for coagulation to take place. working with clotting proteins, calcium, and other proteins in order to stop the hemorrhage. hematocrit tests are vital in order to ensure the patient has the appropriate level of rbcs that can indicate disease states or conditions. normal range for males of any age is 40.7-50.3% for females of any age it is 36.1-44.3%.",
        "blood circulation and perfusion": "it is important to remember that arteries carry blood away from the heart while veins carry blood to the heart. the vasculature that is spread throughout the body is extensive with varying branches and connection points supplying vital nutrients to the body that is needed for life. perfusion is the actual circulation of blood within an organ or tissue in adequate amounts to meet the cells needs. the autonomic nervous system monitors the bodies needs and adjust the blood flow accordingly.",
        "pathophysiology of hemorrhage": "external hemorrhage the severity of hemorrhage is linked to the wound type and the types of vascular that have been injured. capillary bleeding is typically described as oozing and hemorrhage can be of a significant amount in the present of a large abrasion and varicose veins. arterial bleeding is typically described as spurring (initially), with the progression of loss of blood the bleeding may continue to a simple continual flow of blood. the blood is typically described as bright red due to being of high concentration of oxygen. this type of bleeding changes along with blood pressure. arterial incisions directed across or transverse will often recoil in an attempt to slow the bleeding. if the artery is cut vertically it will continue to bleed and no longer has the mechanism to attempt to self control. venous bleeding is typically described as dark red due to the low oxygen concentration and is a steady flow.",
        "internal hemorrhage": "internal hemorrhage may occur in any location of the body, with some being contained within a small space and other being able to freely bleed. fractures of the long bones can still lose blood, but is confined into the space surround the bones and between the muscle tissues. occupying a limited space. hemorrhage into the trunk of the body can be considerable and develop rapidly. leading too severe and uncontrollable bleeding in the out of hospital setting. non trauma induced hemorrhage usually occurs in the gi system. but can also occur in the pelvic cavity or abdominal cavity due to ectopic pregnancy, abdominal cavity and thoracic cavity or inside the cranium due to ruptured aneurysms.",
        "the significance of hemorrhage": "the adult male has approximately 70ml of blood per kg of body weight, adult females contain approximately 65ml of blood per kg. the body cannot tolerate more than 20% of the total blood volume. if the body loses more than 20% of blood, vital signs will change leading to increased heart rate, respiratory rate, and a decrease in blood pressure. with pediatrics, they have a significantly less blood volume meaning that with even a small amount of blood loss could lead to significant changes.",
        "physiologic response to hemorrhage": "with arterial bleeding it can be difficult to control due to the pressure that cause the bleeding to spurt. as the bleeding continues the amount of blood available decreases causing the patient blood pressure to drop. this can be seen when the spurring diminishes. venous bleeding is easier to manage due to having less pressure. capillary bleeding is typically relatively easy to slow and stop.",
        "hemorrhagic shock": "there is significant risk of developing hemorrhagic shock in patients with both external and internal hemorrhage. with an increased risk of development in patients with trauma and internal hemorrhage. penetrating injuries to the heart, thoracic vascular system, abdominal vascular system, venous system, and liver have a high potential for development of hemorrhagic shock.",
        "management for hemorrhage and hemorrhagic shock": "external hemorrhage initially management includes applying direct pressure over the site of bleeding and maintaining said pressure. it is important to recognize the need for a secondary method of hemorrhage control included below. rapid transport is recommended for patients who are presenting with hypopurfusion with shock management."
    },
    {
        "introduction": "suicide is when an individual kills themself. this is the third leading cause of death among individuals 15-24 years of age and the second leading cause of death of individuals 25-34 years of age. suicide is the fifth leading cause of death in individuals between 45-54 years of age. suicide is more common among caucasian males who are single, widowed, or divorced. also, individuals suffering from depression are at increased risk of suicide with one-sixth of attempts at suicide being successful.",
        "risk factors": "alcoholism is another significant risk factor for suicide as it is a depressant agent. risk factors for suicide also include depression, or sudden improvement in depression; alcohol or other drug abuse; recent loss of a spouse or significant relationship; chronic, debilitation illness; schizophrenia; expressed suicidal thoughts and concrete plans for carrying them out; social isolation; previous suicide attempt; financial setback or loss of a job; and family history of suicide.",
        "suicide attempts": "suicide attempts typically occur when a person feels that emotional attachments are endangered or when a significant loss has occurred. a suicidal person may experience feels like worthlessness, lack of self-esteem, and a sense of loss of control.",
        "assessment": "every patient with depression should be assessed for the risk of suicide. most patients are relieved when being asked about suicidal thoughts because it allows them the opportunity to talk about it, you may need to ask about suicide in a stepwise fashion. it is important to remember that patients who have previously attempted suicide, those with a detailed plan for suicide, and those who are at high risk for suicide must be evaluated in the hospital. in some situations, patients may make last-minute efforts to communicate their suicidal intentions. when someone relays their plans for suicide you should encourage them to continue the conversation until able to get the patient to definitive care or until help can arrive on scene.",
        "management": "do not leave the patient alone. it is your responsibility to look after the patients well being until the patient has been transferred to the care of another medical professional. collect and bring any method of self harm that you found on the scene to the hospital with the patient. acknowledge the patients feelings and do not argue or try to dismiss the patients desires to die. talking about it and having one person provide honest reassurance can be beneficial. encourage that the patient is transported to the hospital. if the patient refuses make an attempt to get others involved who can convince the patient to go to the hospital."
    },
    {
        "introduction": "conditions that are affecting the female reproductive system that can be life threatening to the life of the woman affected by these conditions. unfortunately these emergencies are relatively common and can leave long lasting affects on the health of the individual.",
        "anatomy & physiology": "external\nmons pubis is the anatomic landmark that is a rounded pad of fatty adipose tissue atop the symphysis pubis.\nprepuce is the layer of skin above the clitoris where the labia minor anteriorly joins.\nthe clitoris is a cylindrical collection of erectile tissue and nerves.\nlabia majora (has pubic hair) and labia minora surround the vaginal opening and the anterior opening of the urethra that provides protection\nperineum is the space between the vaginal opening and anus.\nvestibule is the cleft between the labia minor.\nthis is where the urethral orifice, vaginal opening, and the hymen are located.\nthe vagina is the lower potation of the birth canal and severs as a passage for menstrual flow and sexual intercourse.\ninside the lower vagina are two openings to the bartholin glands that secrete mucus for lubrication during intercourse.\ninternal\ncervix is the lower potation of the uterus that is the start of the birth canal.\nuterus is also known as the womb. this muscular organ is where the embryo will grow once the fertilized oocyte attaches to the wall.\nis responsible for contractions during labor that helps to facilitate the delivery of the infant through the birth canal.\nuterine (fallopian) tubes is the passage between the ovary and the uterus. typically there is only one associated with each ovary. this is where the oocyte will travel throughout. fertilization of the oocyte will occur here.\novaries are located on both side of the uterus and contains thousands of follicles that house an oocytes.",
        "gynecologic conditions": "imperforate hymen may occur if the hymen completely covers the vaginal orifice. if undetected until puberty it can cause the flow of the first menses to become blocked, causing acute pain with severe constipation and low back pain. this can lead to endometriosis or cause other secondary painful effects. this also can be caused by child sexual abuse due to imperforation from scarring due to digital or penile penetration.\nmenstruation (menses, period, menstrual cycle) is a cycle of periodic vaginal discharge of 25-65ml of blood, epithelial cells, mucus, and tissue. this cycle differs for each and ranges from an average of 24-35 days. hormone changes occur during this time. the patient may experience weight gain due to the accumulation of extracellular edema that tends to be centralized to the abdomen, fingers, and ankles. muscle sensitivity may also occur due to hypertonicity. vascular changes also occur and can lead to increase bruising. breast pain and tenderness, mild to severe headache, menstrual migraine due to hormone dumping, severe cramping, and emotional changes may also occur.",
        "ovarian cycle": "the follicular phase is the first phase that lasts from days 1-13. marks as the time from the first day of menstruation until ovulation. the luteal phase is the second phase lasting from days 14-28. this is the time that ovulation occurs until the first day of menstruation.\nduring ovulation, only one follicle will be successful in maturing and is able to release an oocyte. follicles that are unsuccessful will die and be reabsorbed by the body. this is brought on by the stimulated release of specific hormones inside the female body.",
        "uterine cycle": "the proliferative phase is when the uterine lining increases significantly in thickness in order to become implanted with the fertilized oocyte. lasting days 5-14. the secretory phase occurs after ovulation until menstruation when the oocyte is not fertilized. estrogen and progesterone levels will decrease and the thick lining of the uterus is shed. occurs days 14-28.",
        "menarche": "is the first occurrence of menses. once the individual reaches childbearing age, the first menses will occur. genetics, socioeconomic factors, and individual health can affect when this occurs. anywhere between the age of 11-14.",
        "menopause": "occurs once the woman is reaching the end of childbearing age and is the last menses. typically occurring between the ages of 40- 50. the menstrual cycles become less frequent. a decrease of production in estrogen and other hormones can lead to normal imbalance causing a range of symptoms. copious diaphoresis, hair loss, hot flashes (tachycardia may occur), severe muscle aches and pains, headache, dyspnea, vertigo, digestive problems, and emotional instability may occur and may vary in severity. these patients can still become pregnant. postmenopausal women no longer deal with monthly menses leading to less irritation and discomfort. menopause can make them more susceptible to atherosclerosis, osteoporosis, and coronary heart disease. this can also lead to atrophy of genitourinary organs causing vaginal dryness and discomfort. atrophy of the bladder and urethral mucosa can cause urinary frequency, nocturne, and incontinence.",
        "premenstrual syndrome (pms)": "normally occurs 7-14 days before the onset of menstrual flow and then generally subsides once the flow begins.\naffects about one third of all premenopausal women in there 30-40s.\ncan be debilitation. stress, diet, alcohol use, prescriptions, and nonprescription use can all affect the severity of symptoms.\nsymptoms from the menstrual cycle, reactive hypoglycemia, fatigue, and anxiety may occur.",
        "mittelschmerz": "abdominal pain and cramping about 2 weeks prior to the beginning of menses. is usually not severe and can last from a few minutes to 48 hours. the patient may also experience minor blood spotting.\ndescribed as sharp and cramping pain in the lower abdomen that is localized to one side that has occurred during previous periods in the beginning of ovulation. the pain may switch sides month to month.\ndue to the ovulatory processes and may start at any time during ovulation.\naffects about 20% of women.",
        "amenorrhea": "is when the absence or cessation of menses occurs. this can be caused by multiple things but is commonly caused by pregnancy. exercise-induced amenorrhea is common in athletes. this can occur when a woman's body fat drops below a certain percentage. emotional problems or extreme stress can also cause this to occur. in young adults and adolescents, it can be caused by anorexia nervosa.",
        "emergent conditions": "gynecologic trauma\nthe female genitalia has high levels of vascular blood supply and is extremely susceptible to trauma leading to hemorrhage.\nmvc, sport accidents, assault, and consensual sex can all cause trauma to the genitalia.\nmay have significant pain and hemorrhage, this can make it difficult to differentiate between menstrual pain and bleed if the patient is currently having her period.\nhemorrhage from more interior structures can be difficult to examine the extent of the injury and harder to control.",
        "vaginal bleeding": "if trauma is not present, most treatment will be supportive.",
        "dysfunctional uterine bleeding": "can occur at any age and is irregular bleeding that is not from pregnancy, infection, or tumors.\nhypermenorrhea is when bleeding lasts several days longer that normal or there is more bleeding than normal.\npolymenorrhea is if the menstrual bleeding occurs more frequently than 24 days interval. can be caused by physical or emotional stress.\nmetrorrhagia is when the bleeding is intermittent spotting that is irregular but frequent in occurrence.\ncan be from a large variety of causes that can be difficult to identify.",
        "ectopic pregnancy": "always treat for shock in any woman presenting with abdominal pain and vaginal bleeding even off they are not actively showing signs of shock.",
        "endometritis": "treated with antibiotics.",
        "endometriosis": "treatment is based on the signs and symptoms of the patient.",
        "pelvic inflammatory disease (pid)": "treatment in the field is minimal and focused on comfort.",
        "vaginitis": "can lead to infertility, preterm birth, endometritis, pid, and increases risk of std development if left untreated.",
        "gardnerella vaginitis": "the patient may not present as being in acute distress, but should be evaluated. most likely will be corrected with antibiotics.",
        "bartholin abscess": "will need to be examined, if the cyst is filled with puss a physician will need to drain the floor or remove the cyst.",
        "ruptured ovarian cyst, ovarian torsion, and tube-ovarian abscess": "treat similarly to that of an ectopic pregnancy with treatment for shock and supportive care.",
        "prolapsed uterus": "our care is limited to pain management and shock management if noted to be in shock.",
        "toxic shock syndrome (tss)": "the patient needs to be rapidly transported to definitive care.",
        "sexually transmitted diseases": "care focuses on protecting patient's privacy and modesty.",
        "chancroid": "haemophilus ducreyi bacterial infection that is highly contagious. is a curable disease.\nhas been linked to help with the transmission of hiv.",
        "chlamydia": "most common std caused by chlamydia trachomatis infection.\nsymptoms may be mild or absent but include lower abdominal pain, low back pain, nausea, fever, painful intercourse, or bleeding between menstrual periods.",
        "cytomegalovirus (cmv)": "viral infection of the herpesvirus family with no know cure.\ncan remain dormant in the body for years and is a common viral infection.",
        "genital herpes": "can occur in the genitals, buttocks, or anal area due to the herpes simplex virus. occurs more frequently in women than in men.",
        "gonorrhea": "bacterial infection from neisseria gonorrhoeae that rapidly grows in the warm moist environment of the reproductive tract.",
        "genital warts": "also known as condylomata acuminata and venereal warts but is caused by hpv. there is more than 100 types of hpv and 30 types are spread through sexual contact.",
        "syphilis": "treponema pallidum bacterial infection that can mimic other disease processes. comprised of three stages of infection.",
        "trichomoniasis": "trichomonas vaginalis parasitic infection that is transmitted through sexual contact.\npatients can present asymptomatic or have signs and symptoms.",
        "sexual assault": "a female rape victim should be given the option of being treated by a female paramedic.",
        "vaginal foreign bodies": "keep the patient calm, protect their dignity, and transport.",
        "prehospital treatments": "gynecologic trauma\nensure the patient has a patent airway and is oxygenating. if you are seeing signs that these are not occurring, treat accordingly.",
        "other important information": "it is important to determine if the patient is using any tampons or sanitary pads.",
        "internal": "cervix is the lower potation of the uterus that is the start of the birth canal. uterus is also known as the womb. this muscular organ is where the embryo will grow once the fertilized oocyte attaches to the wall. is responsible for contractions during labor that helps to facilitate the delivery of the infant through the birth canal. uterine (fallopian) tubes is the passage between the ovary and the uterus. typically there is only one associated with each ovary. this is where the oocyte will travel throughout. fertilization of the oocyte will occur here. ovaries are located on both side of the uterus and contains thousands of follicles that house an oocytes.",
        "menarche and menopause": "menarche is the first occurrence of menses. once the individual reaches childbearing age, the first menses will occur. genetics, socioeconomic factors, and individual health can affect when this occurs. anywhere between the age of 11-14. menopause occurs once the woman is reaching the end of childbearing age and is the last menses. typically occurring between the ages of 40- 50. the menstrual cycles become less frequent. a decrease of production in estrogen and other hormones can lead to normal imbalance causing a range of symptoms. copious diaphoresis, hair loss, hot flashes (tachycardia may occur), severe muscle aches and pains, headache, dyspnea, vertigo, digestive problems, and emotional instability may occur and may vary in severity.",
        "toxic shock syndrome": "the patient needs to be rapidly transported to definitive care. ultimate care needed is antibiotic therapy and potentially surgery."
    },
    {
        "introduction": "mood disorders were known as affective disorders and are among the most prevalent psychiatric disorders. affecting at least 10% of the population. mood disorders differ from normal bouts of sadness or happiness. affecting a person's ability to function.",
        "manic behavior": "when a patient has abnormally exaggerated happiness, joy, or euphoria with her activity and insomnia. these patients are typically awake and alert but are easily distracted, with hyperactivity and difficulty concentrating. most patients will report having a decreased need for sleep and they may have gone days without sleeping. these patients may present as being talkative with pressured and rapid speech. also, might have erratic ideas or delusions, racing thoughts are very common. patients experiencing an acute manic episode have an increased risk of putting themselves in a high-risk situation that could get them into trouble or lead to injury. most patients may not believe that they are experiencing a mental health crisis and may not be receptive to treatment.",
        "depression": "depression is the leading cause of disability in patients between the age of 15-44. this affects women more frequently than men and may occur at any age with the mean being around the age of 32. can be identified by a sad expression, bouts of crying, and listless or empathetic behavior. patients may experience feeling of worthlessness, guilt, and pessimism. isolation is common due to the patient feels like no one understands or cares. can occur in episodes with a sudden onset and limited duration. commonly seen in major depressive disorder. the person may feel substantial suffering and pain that interfere with social or occupational functioning. the onset of depression may also be insidious and chronic in nature. experiencing signs and symptoms of depression for more days than not for a period of at least 2 years may have a chronic form of depression. this is known as dysthymic disorder. these patients with experience not only experience social and occupational distress but may require hospitalization in the event the patient becomes suicidal.",
        "diagnostic features of depression": "mnemonic: gas pipes\nfeatures: ['guilt and self blaming are characteristic features of depression', 'appetite is abnormal and varies', 'sleep disturbances may develop with the most common being insomnia', 'paying attention is no longer able to be achieved', 'interest in things that were once important becomes lost', 'psychomotor abnormalities like being slowed down or may increase physical repetitive activities', 'energy levels are typically low and the patient may feel tired all the time', 'suicidal thoughts may develop.']"
    },
    {
        "introduction": "psychiatric and behavioral emergencies are difficult to navigate due to the wide variety of presentation, cause, and treatments that can be found. it is important to note that this is not an all-encompassing overview, but rather an important aspect to understand. individuals experiencing these issues are in higher numbers than what was previously believed.",
        "pathophysiology": "causes of abnormal behavior. biologic or organic causes an interference with normal cerebral functions. some patients are classified as having organic brain syndrome. examples include conditions like chronic hypoxia, seizure, traumatic brain injury, chronic alcohol and drug abuse, and brain tumors. environmental causes are this that exerts a tremendous influence on behavior. affecting both psychosocial and sociocultural influences on behavior. when exposed to stressful psychosocial events or developmental influences in high frequency it can affect ones ability to display normal reactions.",
        "causes of abnormal behavior": "injury and illness caused are when a person is overwhelmed with acute illness that causes changes in their behavior. severe infections, electrolyte abnormalities, and metabolic disorders can cause stress on coping mechanisms and lead to abnormal behaviors. traumatic events can also lead to changes in the patients ability to handle stress and lead to the development of mental health issues. substance-related causes are typically due to the use of alcohol, cigarettes, illicit drugs, and other chemicals that affects the persons emotions, behaviors, and thought processes.",
        "psychiatric signs of symptoms": "signs and symptoms are grouped to the systems they affect and are due to the bodys attempt to maintain balance. disorders of consciousness can presents with distractibility and inattention, confusion, delirium, stupor, and potentially coma. disorders of motor activity can present as restlessness, repetitive movements that do not serve any purpose, repetitive actions use to relieve anxiety of obsessive thoughts, and slow movements.",
        "disorders of speech and thinking": "disorders of speech can present as low speech, accelerated or pressured speech, neologisms, echolalia, and mutism. disorders of thinking can present as disordered thought progressions and disordered thought content.",
        "disorders of mood and affect": "disorders of mood and affect can present with anxiety, euphoria, depression, inappropriate affect, and flat affect. disorders of memory may present as amnesia or confabulation. disorders of orientation may present with being disoriented to person, place, and time. disorders of perception my present with illusions and hallucinations.",
        "safety guidelines": "assess the scene for potential harmful objects or a potentially violent patient. if able to removed the objects do so. if the situation appears to be unsafe, leave immediately and call for back up. be prepared to spend a longer amount of time on these types of calls, and have a plan of action that may need to be done in order to manage the patient.",
        "specific emergencies": "acute psychosis is when the patient is in a state of delusion and is out of touch with reality and the line between reality and fantasy is blurred. this can be caused by many different things from organic, biologic, and some due to mental illness, or drug abuse.",
        "agitated delirium": "occurs when the patient is in an acute state of global cognitive impairment of mental status. this is associated with behavioral changes, inattention, disorganized thinking, and an altered level of consciousness.",
        "suicide": "for information about suicide, please see our suicide outline.",
        "patterns of violence, abuse, and neglect": "it takes a significant amount of maturity and experience to understand your own personal feelings and remain professional, positive, and provide the best care that you can in the following situations",
        "abuse and neglect": "it is important to remember that both victims and perpetrators of violence and abuse may having mental illnesses that can add to the situation at hand.",
        "violence": "most patients who are angry or agitated can be calmed by a trained person who can relay an impression of confidence that the patient will behave well by asking what is causing them to feel this way.",
        "risk factors for violence": "violent actions are more likely to occur in situations where there is alcohol or illicit drugs are being used, in large crowds, and incidents in chick violent acts have already occurred.",
        "management of the violent patient": "assess the situation as a whole and determine what can be removed to make the situation calmer and what could be the cause of the patients presentation.",
        "psychiatric disorders": "mood disorders: for information regarding mood disorders, please refer to our mood disorder outline.",
        "schizophrenia": "this complex disorder is neither easily defined nor readily treated.",
        "neurotic disorders": "a collection of psychiatric disorders without psychotic symptoms and lacking the intense psychopathology of other mood disorders.",
        "substance-related disorders and addictive behavior": "these types of behavioral disorders typically develop and evolve over a long period of time.",
        "eating disorders": "have been around for a long time and cases increased rapidly in the 1950-1960s.",
        "somatoform disorders": "when one is overly concerned about their physical head and appearance when it is dominating their life.",
        "factitious disorders (munchausen syndrome)": "when one intentionally produces or creates physical or psychological signs or symptoms by a variety of means.",
        "impulse control disorders": "patients with this diagnosis have a lack in the ability to resist a temptation or cannot avoid acting on a drive.",
        "personality disorders": "defined as enduring patterns of perceiving, related to, and thinking about the environment and ones self that are exhibited in a wide range of social and personal contexts from the american psychiatric association.",
        "medications for psychiatric disorders and behavioral emergencies": "it is important to know that patients may be taking a variety of medications to assist in the regulation of their mental health.",
        "medication types": "antidepressants, benzodiazepines, antipsychotics, amphetamines",
        "medication noncompliance": "dulling of the senses and slowed thinking are common reasons that the patient may experience noncompliance.",
        "emergency medications": "situations in which medications are needed to be utilized are once the situation leads to potential violence.",
        "communication techniques": "begin with an open-ended question, let the patient talk, listen, and show that you are listening, do not be afraid of silence",
        "crisis intervention skills": "be as calm and direct as possible, exclude disruptive people, sit down, maintain a non-judgmental attitude, provide honest reassurance",
        "types of restraint": "environmental restraints, physical restraints, chemical restraints",
        "specific populations": "pediatric, geriatric",
        "chemical restraints": "typically used is situations where there is significant risk of crew and patient for injury due to the patient being aggressive and psychotic behavior.",
        "disorders of perception and intelligence": "disorders of perception my present with illusions and hallucinations. disorders of intelligence my present with difficulty learning.",
        "identifying yourself and staying with the patient": "identify yourself calmly and display a calm and trustworthy appearance, but at the same time, be direct in you intentions and what you expect from the patient. stay with the patient unless it is unsafe to do so, it is okay to leave the patient in the presence of law enforcement once contact has been made.",
        "encouraging purposeful movement": "encourage purposeful movement to help the patient get the help they need.",
        "expressing interest and keeping a safe distance": "express interest in what the patient is going thought. keep a safe distance from the patient with the ability to escape quickly.",
        "avoiding fighting and being honest": "avoid fighting with the patient as this can make matters worse and lead to injury. be honest and reassuring to the patient and that what they are going through is valid and that it is important to address.",
        "suicide and patterns of violence, abuse, and neglect": "suicide: for information about suicide, please see our suicide outline. patterns of violence, abuse, and neglect: it takes a significant amount of maturity and experience to understand your own personal feelings and remain professional, positive, and provide the best care that you can in the following situations",
        "antipsychotics": "introduced in the 1950s for schizophrenia and other psychoses.",
        "amphetamines": "work on the cns and pns.",
        "physical restraints": "physical restraints are typically applied to the wrists and ankles to prevent movements.",
        "geriatric": "changes in experiences and alterations in routines that have been well established throughout time can lead to physical and psychological changes in this population.",
        "benzodiazepines": "may be prescribed to a patient experiencing severe emotional distress even if the patient is not psychotic or an imminent threat to themselves or to others."
    },
    {
        "introduction": "a seizure is a disruption or alteration of neurologic function caused by abnormal discharge of neurons in the brain. generally there are two large categories of seizures: epileptic seizures and non-epileptic seizures. epileptic seizures are caused by abnormal neuronal firing whereas non-epileptic seizures have an outside cause such as drug use, febrile seizures, brain trauma, etc.",
        "pathophysiology behind a seizure/statistics": "around 1% of the world population will have an epileptic seizure in their lifetime. in brain function, there is a balance between excitation and inhibition of nerve impulses. in patients with seizures, that neural balance is thrown out of control, and the electrical activity and neural firing of the brain deviates from that balance. as for these neurons fire, generally, with too much frequency/activity, alters the neurologic function and the symptoms of seizure occur.",
        "types of seizure": "there are three primary types of seizures: generalized seizures, focal seizures, and unknown seizures. generalized seizures affect both the left and right sides of the brain. these seizures can be either motor or non-motor. when these seizures have a motor component, the patients usually have jerking movements (tonic-clonic) along with muscle twitching and tense muscles. when generalized seizures do not have a motor component they are usually called absence seizures. symptoms of absence seizures may include staring into space, minor muscle twitches, and fluttering eyelids. focal seizures only affect one part of the brain. similar to generalized seizures they can have motor or non-motor symptoms, or both. common symptoms include repetitive actions, spasms, and muscle contractions. non-motor symptoms may include lack of movement or even change in emotion or temperament. focal seizures can change locations of seizures and therefore the location of symptoms throughout the seizure event. combination seizures can present with symptoms from both generalized and focal seizures. unknown seizures present with symptoms of with generalize or focal seizures, but have no known etiology for the cause of the seizure.",
        "prehospital seizure presentation/cause": "epileptic: genetic cause trauma: injury to brain or brainstem causes misfiring of neurons and seizure to occur chemical: recreational use of some drugs can cause seizures pregnancy/eclampsia: seizures later in pregnancy. there is no one cause but lifestyle factors such and weight and hypertension have correlation with greater risk of seizure.",
        "prehospital seizure treatment": "right away/bls: turn patients on their side to prepare for possible vomitus and monitor airway status cushion the patient and remove their glasses time the seizure remove any items nearby the patient could hit or injure themselves with during the seizure check for medical wrist bands/obvious signs of seizure if als capabilities (always check your personal local protocols): administer 10mg of midazolam im if iv access is established administer 2.5-5mg midazolam iv monitor pt respiratory status closely after midazolam administration note: if the seizure is suspected to be eclampsia, olmc can be contacted for potential administration of magnesium sulfate. normal dosing is 4g iv over 15-20 minutes.",
        "transport decision": "all first-time seizures should be transported. once the seizure has broken, the patient can be transported code 1 or code 3 depending of the suspected etiology of the seizure, transport time to the nearest hospital, patient medical history, etc. if the patient is in status seizure (seizure more than 5 minutes unresponsive to medication) the patient should be transported code 3. transport may become unnecessary if the patient becomes fully oriented, is taking anti-seizure medication as prescribed, has a health care provider, and this is a typical seizure for the patient."
    },
    {
        "introduction": "organophosphate poisonings are an important part and topic in understanding and learning about toxicology emergencies. you may encounter a patient who has been exposed to organophosphates.",
        "facts": "major components in many insecticides for agricultural and household products. chemicals that are organophosphates include acephate (orthene), diazinon (basin, knox out, spectracide), dalathion (celthion, python), carbamates, warfarin, and pyrethrums (raid). carbamates was used as a replacement for organophosphates and is linked to thousands of cares of poisoning each year. leading to 10% of individuals being hospitalized. death rate of organophosphate poisoning in adults is 10% while pediatrics is nearly 50%. similar chemical structures can be used in chemical warfare. suicide attempts is one of the highest reasons why organophosphate poisoning occurs, and is usually ingested orally. agricultural accidental exposures are also common followed by the manufacturing of organophosphates and similar compounds.",
        "pathophysiology": "in the autonomic nervous system, organophosphates cause toxic effects of the synapses of the nerve cells. our neurotransmitter acetylcholine is used for the activation of our nerve cells be being released from one synapse to the next. once the acetylcholine has caused the second nerve to fire, it needs to be deactivated in order to not contuse to stimulate the target nerve cell. if this does not occur the target nerve cell will no longer be able to receive another message from the brain. the deactivation of acetylcholine is achieved by the help of the enzyme acetylcholinesterase. breaking it down into acetate and choline. when organophosphate coming into the body it causes an inactivation of the enzyme of acetylcholinesterase. this is due to phosphoraliting of the acetylcholinesterase leading to the deactivation of the enzyme. leading to the acetylcholine continuing to stimulate the nerve.",
        "signs & symptoms": "regardless of route of exposure, the signs and symptoms will present within the first 8 hours of exposure. this includes anxiety, restlessness, headache, dizziness, confusion, tremoring, seizures, dyspnea, wheezing, respiratory depression, and loss of consciousness. additional cns signs and symptoms include salivation, lacrimation, urination, dedication, gastric upset, and emesis.",
        "assessment and management": "decontamination along with the removal of all contaminated clothing has to be done before initiating care or loading the patient into the ambulance. place contaminated clothing in a plastic back and should be disposed of as hazardous materials. patients should be showered and scrubbed with soap and clean water when able to be done. an airway needs to be established and maintained. you should also consider the use of advanced airway adjuncts as needed. suctioning may be needed due to vomiting and hypersalivation. breathing may need to be assisted if signs of respiratory compromise are present. etco2 and spo2 monitoring need to be placed on the patient. deliver oxygen in order to achieve and maintain spo2 levels of 95%. circulation status needs to be monitored with 4-lead ekg. be alert for bradycardia and other cardiac arrhythmias. vascular access should be established for fluid and medication administration. 0.1 mg of atropine via iv push should be administered every 3-5 minutes until symptoms have resolved, and 1-2 g of pralidoxime (2-pam) should be infused with normal saline for 5-10 minutes. transport the patient to the appropriate facility and provide the hospital with an early warning so they may have treatments and resources available."
    },
    {
        "introduction": "the human body functions properly under a certain range of internal physical and chemical conditions. these conditions are maintained by biological processes that respond to deviations from this range. this is known as homeostasis. one of these ranges is the acid-base balance. important tip: the human body has a ph balance of 7.35-7.45 acids (<7) are byproducts of multiple different body processes. consequently, the body must constantly adjust to maintain an extracellular fluid (ecf) ph between 7.35 -7.45 (slightly basic). there are three ways in which the body accomplishes this maintenance.",
        "the three ways to maintain acid-base balance": "1. buffer systems 2. respiratory system 3. renal system important tip: h+ has an inverse relationship with the ph. a rise in h+ in the ecf means a decrease in ph and a more acidic ecf. the same relationship is true for co2 and ph. a rise in co2 means a decrease in ph",
        "the processes": "buffer system: this system can be thought of as the front-line defense against increases in acidity. it is distributed throughout the body and reacts immediately to an increase in acidity. the primary buffer of the ecf is the carbonic acid-bicarbonate (hco3-). this molecule binds with excess h+ ions and removes neutralizes their effect on ecf ph. the h+ remains in the ecf during this process, making this a temporary fix. if the production of h+ is greater than the availability/production of buffers, this system can be overwhelmed. respiratory system: here is the second line response to increases in acidity. the respiratory system is later to respond to changes in ph than the buffer system. it works with the buffer system though to remove acidic components. this is achieved during expiration, when co2 and h20 are expelled along with other waste products. remember, co2 and h+ have inverse relationships with ph. by removing these molecules, ph would increase, making the ecf less acidic. this system also reacts to co2 levels in the ecf. if the levels are high, respiratory rate increases, offloading more co2. if the levels are low, the respiratory rate decreases, offloading less co2. renal system: the final line of defense against an acidic environment is the renal system. this system takes the longest to respond to changes in ph. once it responds to a decrease in ph, this system is capable of selectively excreting products such as h+ from the body. the renal system will also selectively reabsorb bicarbonate (hco-) to help maintain the buffer system. if the body is alkalotic, the kidneys will respond in the inverse, offloading bicarbonate and reabsorbing h+.",
        "system failure?": "if these systems are interrupted or cannot keep up with the production of acid in the body, they will result in two different acidotic states. respiratory acidosis: the respiratory system fails to remove sufficient levels of co2 to prevent a decrease in ph. any condition that interferes with the offloading of co2 at the alveoli can lead to this condition. respiratory depression or interruption: anesthesia, overdose, increase in icp, injury to cns (stroke or trauma), insufficient artificial ventilation, and severe obesity. airway obstruction, copd, asthma, and pneumonia. pulmonary embolism. rapid shallow respirations or hypoventilation, decreased loc, pallor or cyanosis, increase in etco2, and hypotension. dyspnea, wheezes, and headache. important tip: the acidotic state exists throughout the body (ecf), not simply in the respiratory system. the name of this conditions refers to the cause of the acidosis, not the location in which the acidosis occurs. metabolic acidosis: insufficient levels of bicarbonate result in an acidotic state. this is most commonly caused by increases in metabolic acid production. it may also be caused by the removal of or an interruption in the production of bicarbonate.",
        "symptoms of acidosis": "respiratory acidosis: rapid shallow respirations or hypoventilation, decreased loc, pallor or cyanosis, increase in etco2, and hypotension. dyspnea, wheezes, and headache. metabolic acidosis: symptoms include headache, warm, flushed skin, nausea and vomiting, decreased loc, decreased coordination, compensatory hyperventilation (kussmaul respirations).",
        "what about the base?": "because the body constantly produces acids as byproducts of biological processes, the body primarily functions to adjust to the threat of an acidic environment. under different conditions, alkalotic or basic conditions may threaten homeostasis as well. respiratory alkalosis: this condition occurs when the body offloads an excessive amount of co2. hyperventilation due to anxiety, fear, or mechanical ventilation. may also occur in the context of a pulmonary embolism. symptoms include deep, rapid breathing, numbness or tingling of extremities, nausea and vomiting, altered loc, seizures, and hypotension or normal bp. metabolic alkalosis: this is caused by an excess of circulating bicarbonate ions or a decrease in the acids in the ecf. cyclical vomiting (loss of acids), diuretics, nasogastric suctioning, or excessive bicarbonate administration. symptoms include tachycardia, compensatory hypoventilation, altered loc, nausea, vomiting, diarrhea, and tremors/muscle cramps.",
        "important tip": "while the causes of alkalotic conditions are less common and potentially more benign, it is important to not let your guard down. there can be serious causes of both of these conditions that cannot be easily identified in the field and they may have overlapping symptoms with acidotic conditions that further complicate prehospital differentiation.",
        "basic life support interventions": "airway: maintain a patent airway (altered loc) breathing: consider supplemental oxygenation and mechanical ventilation. important tip: understand that interruption of adaptive hyperventilation in the case of dka will worsen the patient's condition circulation: identify perfusion status acquire baseline set of vital signs physical assessment and sign/symptom identification sample and opqrst identify any potential conditions that could lead to a metabolic or respiratory abnormality treat underlying condition or chief complaint",
        "scenario": "dispatch information: bls unit is on a sick person code 1. scene information: the scene is safe. you arrive at a single-family home and find a 17-year-old female, 65 kg, who is accompanied by her mother who appears anxious. she states that her daughter was out all day at the lake the day before with her friends. she awoke to find her daughter sick this morning, lethargic, and vomiting. patient chief complaint: patient states that she does not feel good, has a headache, abdominal pain, and has been unable to keep water or food since this started early this morning.",
        "patient assessment": "airway is patent. breathing is rapid and deep. circulation; regular radial pulse, possible tachycardic. when checking for a pulse you notice that the patient's skin is moist and warm. the patient appears flush. pulse oximetry is 99% on room air with a pulse of 121. your partner gets a blood pressure of 95/60. lung sounds are clear and rr of 22. the patient is alert though lethargic, to person, place, time, and event.",
        "the human body: 7.35-7.45": "acids (<7) are byproducts of multiple different body process including aerobic and anaerobic respiration. consequently, the body must constantly adjust to maintain an extracellular fluid (ecf) ph between 7.35 -7.45 (slightly basic). there are three ways in which the body accomplishes this maintenance.",
        "buffer system details": "co2 + h2o <- -> h2co3 <- -> h+ + hco3 [left side] [right side] h2co3 = carbonic acid hco3 = bicarbonate (h2o plays a vital role in this reaction. for simplicity, not shown) bicarbonate binds with excess h+ ions (see the right side equation above) and removes/neutralizes their effect on ecf ph by differentiating them into co2 and h2o.",
        "respiratory system": "as the second line of defense to changes in ph, the respiratory system takes more time to respond to changes in ph than the buffer system. unlike the buffer system, it effectively removes acidic components during expiration: co2 and h20. if co2 and h2o were allowed to build up, they would push the reaction below to the right, increasing available h+ and decreasing ph.",
        "respiratory system details": "co2 + h2o <- -> h2co3 <- -> h+ + hco3 [left side] [right side] fortunately, there are chemoreceptors throughout the body that react to changes in co2 within the ecf. if the levels are high, respiratory rate increases, offloading more co2, pushing the equation to the left. if the levels are low, the respiratory rate decreases, offloading less co2 and pushing the equation to the right.",
        "renal system": "the final line of defense against an acidic environment is the renal system. this system takes the longest to respond ph changes. once it responds to a decrease in ph, this system is capable of selectively excreting products such as h+ from the body. the renal system will also selectively reabsorb bicarbonate (hco-) to help maintain the buffer system. if the body is alkalotic, the kidneys will respond in the inverse, offloading bicarbonate and reabsorbing h+.",
        "respiratory acidosis": "the respiratory system fails to remove sufficient levels of co2 to prevent a decrease in ph. any condition that interferes with the offloading of co2 at the alveoli can lead to this condition.",
        "respiratory acidosis causes": "respiratory depression/interruption: anesthesia, overdose, increase in icp, injury to cns (stroke or trauma), insufficient artificial ventilation and severe obesity. airway obstruction, copd, asthma, and pneumonia. pulmonary embolism.",
        "respiratory acidosis symptoms": "rapid shallow respirations or hypoventilation, decreased loc (level of consciousness), pallor or cyanosis, increase in etco2, and hypotension. dyspnea, wheezes, and headache.",
        "metabolic acidosis": "insufficient levels of bicarbonate results in an acidotic state. this is most commonly caused by increases in metabolic acid production. it may also be cause by the removal or an interruption in the production of bicarbonate.",
        "metabolic acidosis causes": "renal failure, diabetes (dka), hyperthyroidism or hypermetabolism, loss of bicarbonate (diarrhea), bicarbonate production failure (dehydration or liver failure).",
        "metabolic acidosis symptoms": "headache, warm, flushed skin, nausea and vomiting, decreased loc, decreased coordination, compensatory hyperventilation (kussmaul respirations).",
        "respiratory alkalosis": "this condition occurs when the body offloads an excessive amount of co2. hyperventilation due to anxiety, fear, or mechanical ventilation. may also occur in the context of a pulmonary embolism.",
        "respiratory alkalosis symptoms": "deep, rapid breathing, numbness or tingling of extremities, nausea and vomiting, altered loc, seizures, and hypotension or normal bp.",
        "metabolic alkalosis": "this is caused by an excess of circulating bicarbonate ions or a decrease in the acids in the ecf. cyclical vomiting (loss of acids), diuretics, nasogastric suctioning, or excessive/inappropriate bicarbonate administration.",
        "metabolic alkalosis symptoms": "tachycardia, compensatory hypoventilation, altered loc, nausea, vomiting, diarrhea, and tremors/muscle cramps.",
        "basic life support and advanced interventions": "airway: maintain a patent airway (altered loc) breathing: consider supplemental oxygenation and mechanical ventilation understand that interruption of adaptive hyperventilation (slowing a patient\u2019s respirations down) in the case of dka will worsen the patient\u2019s condition circulation: identify perfusion status acquire baseline set of vital signs physical assessment and sign/symptom identification sample and opqrst identify any potential conditions that could lead to a metabolic or respiratory abnormality iv access administer supplemental fluids for hypotension or acidotic/alkalotic state consider antiemetic for nausea/vomiting monitor end tidal capnography treat underlying condition or chief complaint",
        "acid-base balance": "the human body: 7.35-7.45. acids (<7) are byproducts of multiple different body processes including aerobic and anaerobic respiration. consequently, the body must constantly adjust to maintain an extracellular fluid (ecf) ph between 7.35 -7.45 (slightly basic). there are three ways in which the body accomplishes this maintenance.",
        "maintenance methods": "1. buffer systems, 2. respiratory system, 3. renal system. important tip: h+ has an inverse relationship with the ph. a rise in h+ in the ecf means a decrease in ph and a more acidic ecf. the same relationship is true for co2 and ph. a rise in co2 means a decrease in ph.",
        "system failure": "if these systems are interrupted or cannot keep up with the production of acid in the body, they will result in two different acidotic states. respiratory acidosis: the respiratory system fails to remove sufficient levels of co2 to prevent a decrease in ph.",
        "respiratory acidosis details": "any condition that interferes with the offloading of co2 at the alveoli can lead to this condition. symptoms: depend on the cause. rapid shallow respirations or hypoventilation, decreased loc, pallor or cyanosis, increase in etco2, and hypotension. dyspnea, wheezes, and headache. hyperkalemia and associated arrhythmias.",
        "metabolic acidosis details": "symptoms include headache, warm, flushed skin, nausea and vomiting, decreased loc, decreased coordination, compensatory hyperventilation (kussmaul respirations).",
        "alkalotic conditions": "because the body constantly produces acids as byproducts of biological processes, the body primarily functions to adjust to the threat of an acidic environment. under different conditions, alkalotic or basic conditions may threaten homeostasis as well.",
        "basic life support and advanced life support interventions": "airway: maintain a patent airway (altered loc). breathing: consider supplemental oxygenation and mechanical ventilation. *interruption of adaptive hyperventilation in the case of dka will worsen the patient\u2019s condition (slowing the patient\u2019s respirations down).",
        "treatment and transport": "you acquire a baseline set of vital signs. physical assessment and sign/symptom identification. sample and opqrst. identify any potential conditions that could lead to a metabolic or respiratory abnormality. identify and monitor cardiac rhythm."
    },
    {
        "introduction": "toxicology refers to the study of toxic or poisonous substances. a poison is a substance that can cause harm to the body through a series of chemical reactions after being introduced. even a small amount of poison might cause serious damage and when this happens, it is called poisoning. in contrast to this, a drug is usually a medication meant for therapeutic purposes, but can also cause harm if misused. toxins are harmful substances produced by exterior sources, such as plants, animals, and bacteria. an overdose is a term used to describe what happens when someone has taken a hazardous dose of a drug or medication, leading to dangerous or potentially lethal outcomes. the drug may be legal or illegal and the overdose itself may be accidental or on purpose. if the substance is a legal drug, it may be prescription or over-the-counter. toxic exposure can affect a populace on the local scale, referring to a small area with either a single or few numbers of individuals in the given area (overdoses), a regional scale, referring to a larger area, and exposing many hundreds or thousands of people in a compact area (gas leak), or a national scale, which could potentially affect anyone anywhere in the nation (epidemics).",
        "types of toxicological emergencies": "unintentional poisonings are a frequent and tragic occurrence. they are not always deadly and there are many causes for them, but on occasion can have fatal outcomes. two population groups, particularly at risk for unintentional overdoses, are pediatric and geriatric patients. pediatric patients often consume any medications they can get access to, not understanding the dangers. geriatric patients often have large quantities of medications they are expected to take daily; combine this with the risk for memory loss and dementia, and it is not unusual at all for an elderly patient to have accidentally taken too much of prescription medication. patients might also be unintentionally poisoned by exposure to dangerous chemicals, or environmental threats such as toxic plants, or in rare cases, idiosyncratic response to a medication that has caused unexpected potentially dangerous side effects. drugs of abuse such as alcohol, stimulants, and other mind/mood-altering drugs can, unsurprisingly, lead to overdoses. it is important to be cautious about the mood and behavior of these patients, as they can become unpredictable or even dangerous.",
        "intentional poisonings": "intentional poisonings can either be self-inflicted or afflicted on another. some sources of intentional poisonings could be from a chemical warfare attack or attempted homicide using a biological weapon. more often though, intentional overdoses are self-inflicted. these could be genuine suicide attempts or cries for help; regardless of their nature, its important to treat both the patients medical needs and emotional needs as best you can.",
        "routes of exposure": "much like all ems medications have a route for administration, all drugs/poisons in an overdose have a route or mechanism to exposure. the typical routes are ingestion, inhalation, injection, and absorption",
        "ingestion": "this route of exposure involves swallowing the drug/poison, bringing it from the mouth, down the esophagus, and into the stomach. from here, the body is exposed after the toxin is ingested through the lining of the stomach or intestines. it should be noted this route of exposure can have a delayed onset because of the nature of ingestion. examples could include prescription medications and alkalis/bleaches. treatments could potentially include activated charcoal, if the response time was appropriate, as well as other generalized monitoring and drug-specific treatments.",
        "inhalation": "this route of exposure means breathing in the toxins as a gas or aerosol. from here, the toxin is absorbed through the alveoli of the lungs and the blood-gas barrier. examples could include smoke inhalation, carbon monoxide poison, and aerosol products. common treatment would include oxygen administration, fresh air exposure, or in some cases, hyperbaric chamber treatment.",
        "injection": "this route of exposure requires needles or other penetrating devices to administer the drug either intravenously, intramuscularly, or subcutaneously. this might also be the route of environmental exposure, if it comes from a venomous insect or animal, such as snakes or bees. this is a particularly dangerous route of drug use because its effects can be immediate and intense. further, use of a needle itself can be dangerous and lead to exposure to bloodborne disease transmission, infection of the injection site, and be a potential hazard for responders if it is still with the patient on arrival. examples could include illicit iv drugs, such as heroin or fentanyl, and bee stings.",
        "absorption": "transdermal application of medication is usually one that is exposed through the skin or mucous membranes of the body (rectal, sublingual, etc.) this sort of exposure must be absorbed through the epithelial tissues of the body before they can move to the circulatory system and cause a systemic effect. examples could include transdermal medications, such as nitro or fentanyl patches, nasal sprays, or rectal medications. also includes some industrial chemical exposures, such as pesticides and other organophosphates. treatment should include removing the source of the exposure as soon as possible, by either removing the patches or washing/wiping the chemical off the skin.",
        "drugs of abuse": "drugs of abuse are drugs that are frequently used by individuals to alter the mind, often recreationally. some of them are legal, though many of them are not. all of them are dangerous if used in inappropriate amounts.",
        "cannabis": "cannabis is a mind-altering medication that can be used for medical or recreational purposes. although the drug itself may not cause as much physiological damage as some other drugs, it can cause judgment impairment and is a cns depressant. other side effects might include fatigue, paranoia, and increased hunger. it can be administered in the ointment, ingested, or inhaled forms. treatment will include supportive care and rapid transport if their symptoms are severe enough for intervention.",
        "stimulants": "stimulants, sometimes known as uppers, are highly addictive, mind-altering medications that increase cns activity. this can include more benign versions, such as caffeine, to more intense, such as adderall or cocaine. one of the most dangerous versions of this drug is known as methamphetamine. toxidrome symptoms of a stimulant overdose can resemble manic behavior, tremors, restlessness, dilated pupils, lack of sleep and appetite, and mood swings. treatment will include rapid transport and management of abcs. occasionally these patients can become aggressive, entering a state known as excited delirium, especially if mixing their stimulants with other drugs - be prepared to use chemical sedation or physical restraints in order to protect yourself, others, and these patients from themselves.",
        "barbiturates/sedatives": "barbiturates/sedatives, sometimes also known as downers, are drugs that slow down brain activity. medically, they're often used to treat seizure disorders, sleep disorders, or chronic anxiety; these can include medications such as versed, benzodiazepines, or any medication with the -bital suffix. the toxidrome of an overdose on these meds includes respiratory depression, extreme lethargy, and even comas. these patients may require immediate airway support, up to and including rsi, as well as management of other symptoms and rapid transport.",
        "hallucinogens": "hallucinogens are mind-altering medications that can, as the name implies, cause the user to experience hallucinations. they are classified into classic hallucinogens, such as lysergic acid diethylamide (lsd) and psilocybin mushrooms, and dissociative hallucinogens, such as phencyclidine (pcp) and ketamine. hallucinogens can have intense effects on mood, sensory perception, body temperature, emotion, pain perception. patients under the influence of hallucinogens can be unpredictable and if they provide no other alternatives, occasionally need to be restrained for their own, and other's safety. beyond this, carefully manage this patient's airways as the effects may lead to catatonic states as easily as they lead to delirium. rapid transport is, as always, highly advised.",
        "opioids": "opioids, otherwise known as narcotics, are very effective and highly addictive pain killers. opioids can be either a prescribed medication, such as oxycodone, codeine, or vicodin, or an illicit substance, such as heroin. besides bringing pleasure and reducing pain, the opiate toxidrome includes changes in mentation and unresponsiveness, seizures, nausea, shallow breathing, and reduced respiratory drive, cyanosis, pinpoint pupils, bradycardia, and hypotension. interventions should include management of abcs and timely administration of narcan, which is an opiate antagonist and can temporarily reverse symptoms.",
        "huffing agents": "huffing agents or hydrocarbons are typically inhaled to produce a euphoric high that is fleeting but generates a buzz that leads to high abuse potential; particularly combined with the fact that these can be purchased cheaply at many hardware or even convenience stores in the forms of aerosol and paint. overexposure to hydrocarbons can lead to cardiovascular collapse, seizures, and psychosis, so these patients must be closely monitored. be prepared for compromises to the airway and peripheral vascular resistance, and initiate rapid transport while treating these symptoms.",
        "alcohol": "alcohol is a legal mind-altering intoxicant that can have severe long-term effects if abused, leading to conditions including alcohol dependence syndrome. symptoms of alcohol intoxication include cns changes such as aggression or fatigue, motor skills depression, respiratory depression, nausea/vomiting, and lack of coordination; these symptoms, particularly the judgment impairment frequently associated with intoxication, can lead to other medical and trauma-related emergencies.",
        "poisoning and exposure": "poisoning and exposure patients require extra vigilance regarding scene safety. this should always be paramount on every ems call, but it's particularly important when exposure to dangerous substances is possible. without appropriate ppe or vigilance in the treatment of patients suffering from poisoning, the ems responder can easily become exposed as well.",
        "carbon monoxide": "carbon monoxide is the most common cause of fatal gas poisonings, through exposure to smoke inhalations. it is a colorless, odorless, tasteless gas that has a 240 times greater affinity for hemoglobin than oxygen (carboxyhemoglobin). exposure to carbon monoxide can cause severe hypoxia, which leads to shock and unresponsiveness. treatment includes fresh air, 100% o, or in extreme cases, hyperbaric oxygen may be required.",
        "chlorine gas": "chlorine gas poisonings can occur in the household by accident after mixing a strong cleaning agent, like bleach, with a strong acid or ammonia in a misguided attempt at cleaning. the chemical reaction that results from this creates chlorine gas. patients can also be exposed to gas leaks at industrial centers and if the leak is big enough, could cause an mci. the symptoms involved depend on the level of exposure; chlorine gas is a natural irritant to the mucous membranes, which can cause discomfort in mild cases, but more toxic exposures can lead to headaches, choking, coughing, nausea and vomiting. the most dangerous exposures can lead to cyanosis, pulmonary edema, seizures, and loss of consciousness. treatment should include removal from the exposure and rapid transport.",
        "cyanide": "cyanide is a chemical byproduct of the combustion of synthetic materials that contain carbon and nitrogen. this might include many household items, such as insulation, carpeting, and upholstery, making modern-day house fires an extremely toxic environment. it is often characterized by the bitter smell of almonds. cyanide can also be found in manufacturing centers, the seeds of some plants, and has a history of being used as a method of suicide or execution. it is a rapid-acting and deadly poison that impairs and blocks the use of oxygen at the cellular level, preventing it from being taken up by the body's tissues even if it is being transported by the red blood cells. treatment includes oxygen treatments, antidote administration if available, and rapid transport.",
        "acids/alkalis": "acids/alkalis are caustic substances that cause intraoral burns, painful swallowing, or burning/painful regurgitation. common acids include hydrochloric acid, sulfuric acid, acetic acid, and phenol. common alkalis (bases) include lye, drain pipe cleaner, bleach, ammonia, polishes, dyes, and jewelry cleaner. while vomiting may be ideal for overdose patients who have ingested other medications, this is not preferred for patients who have ingested caustic substances, because of the potential damage they do to the esophagus. rapid transport is the priority for this class of overdose.",
        "organophosphates": "organophosphates, as discussed earlier in the cholinergic toxidromes, are a very dangerous chemical to come into contact with and are the main chemical component in many pesticides we use today. remember that the number one risk in treating these patients is accidentally exposing yourself to the chemical as well, so make sure proper decontamination has been accomplished before starting an intimate assessment on these patients, lest you become a victim to poisoning yourself.",
        "poisonous plants": "poisonous plants are rarely fatal to humans, but can cause severe discomfort; in 2014, only four fatal poisonings were recorded in 44,000 reported cases (nancy carolines ems in the streets, 2018). curiously, many plants that are poisonous can commonly be found in ornamental garden shrubs and houseplants. it is because of this, perhaps, that approximately 65% of poison plant exposures occur among children younger than five. exposure to plants like poison ivy, oak, and sumac, can cause severe, painful rashes that last for weeks and in worst-case scenarios, anaphylactic reactions. some common plants involved with poisoning include chinaberry, foxglove, mistletoe, dieffenbachia; always consult your local nature guides before consumption of native or unrecognized vegetation.",
        "medication overdoses": "medication overdoses are among the most frequent overdoses you'll encounter in ems. these include both intentional and unintentional exposures so be prepared not only to manage a patient's symptoms but their emotions as well. when taken unintentionally, it is not unusual for a patient who takes several medications to occasionally get them confused, this is also true for geriatric patients who might suffer from cognitive disabilities. medications can harm rather than help, if not used therapeutically.",
        "cardiac medication": "cardiac medication overdoses can be dangerous because of the specific system they are intended to treat. common cardiac medications can include nitroglycerin, digoxin, metoprolol, lisinopril, and several others. an overdose on these medications can cause severe changes in heart rhythm patterns, rates, and blood pressures, which can lead to other critical symptoms. patients suffering from a suspected cardiac medication overdose will need constant cardiac monitoring, iv access, fluids therapy, and rapid transport.",
        "psychiatric medications": "psychiatric medications are designed to treat alter irregularities in mood and affect (most commonly depression). because of the nature of patients prescribed psychiatric medications, suspicion (but never presumption) of intentional overdose should always be present in the first responders mind. according to the aapccs national poison data system, antidepressants accounted for over 75,000 adult exposures and were the fourth most common pharmaceutical involved in fatal exposures in 2014, (nancy caroline, 2018).",
        "non-prescription pain medications": "non-prescription pain medications can still be toxic if overindulged, despite not requiring a doctor's note to obtain them. the most common of these are salicylic acids, an organic pain reliever and the main component of aspirin, and nonsteroidal anti-inflammatory drugs (nsaids), or acetaminophen, which can reduce inflammation, fever, and treat pain. asa/acetaminophen overdoses are particularly common among children and adolescents and might be either intentional or accidental. if the prehospital provider makes contact with a patient experiencing an asa/acetaminophen overdose within one hour of ingestion, activated charcoal may be used to adsorb the contents of the drug inside the stomach.",
        "treatment of overdoses in pre-hospital setting": "if the overdosed patient is showing signs of altered mental status, treat with the appropriate protocol, with a priority on keeping yourself and your patient safe. manage the patient's airway as needed, obtain iv access, and provide oxygen/ventilation if the patient has no respiratory drive. do not hesitate to contact olmc or the poison control hotline (1-800-222-1222) for immediate recommendations on treatment and information on risk factors.",
        "special patient considerations": "pediatric patients and children aged one through three accounts for a significant majority of accidental ingestion poisonings. these could include medications or toxins, such as poisonous plants or dangerous chemicals. young adults and teenagers are at particular risk for experimenting with drugs of abuse. children are frequent patients of unintentional ingested poisons and medications. geriatric patients and the elderly are more prone to alcoholism and drug addiction. drug dependency is also a common condition among the elderly and many of these patients also have chronic pain issues and have been using narcotics such as vicodin or oxycodone for years.",
        "documentation and communication": "when transferring care to hospital staff it is very important to be as accurate and honest as you can be, both in what the patient told you, the evidence you found on the scene, and your own instincts regarding a patient who is suffering from an overdose. many patients who have used drugs intentionally are not forthcoming about their history or condition, or have an altered sense of perception due to their condition; keep aware that there may be more to a patients condition than simply what they are telling you.",
        "toxidromes": "toxidromes, or toxic syndromes, are collections of signs and symptoms that consistently occur after exposure to a particular toxin or drug class.",
        "cannabinoids": "cannabis is a mind-altering medication that can be used for medical or recreational purposes.",
        "hydrocarbons": "hydrocarbons, or huffing agents, are typically inhaled to produce a euphoric high that is fleeting but generates a buzz that leads to high abuse potential;",
        "cholinergics": "cholinergics are drugs that affect the body's acetylcholine receptors and its toxidrome is mostly associated with organophosphates which are found most commonly in pesticides used in agricultural areas but are also a component in chemical weapons, such as sarin gas, and a first responder should be highly cautious in the treatment of patients suffering from this exposure.",
        "anticholinergics": "anticholinergics are pharmacological agents that block the body's ability to receive acetylcholine neurotransmissions.",
        "antidote therapies": "some substances a patient has overdosed on are responsive to 'antidotes' which can reverse the symptoms caused by the overdose. the method of action by which they do this is unique to the administered medication and there is no 'catch-all' pharmaceutical treatment for substance overdoses or exposures. some of these are regularly found in the first responder's field kit, but many aren't utilized until the patient has moved to a higher level of care. methylene blue, cyanide antidotes, physostigmine, sodium bicarbonate, atropine and pralidoxime (2-pam), narcan, sedatives, solu-medrol and decadron, beta agonist, ipecac, haldol, glucagon, flumazenil, dimercaprol, digibind, and calcium gluconate are all examples of antidote therapies.",
        "decontamination": "one of the most critical parts of treating and protecting a patient is also making sure that you and your crew remain safe. if a patient has been exposed to a dangerous chemical or substance that is still transferable, ensure the patient has gone through a rigorous and appropriate decontamination process before you treat them. this may be as simple as rinsing out their eyes or separating them from a hazardous sharp needle, or as involved as removing all clothing and being scrubbed down by a crew in appropriate ppe. whatever the needs are, make sure you do not incidentally turn yourself into another patient."
    },
    {
        "introduction": "genitourinary disorders the urinary system functions to filter blood and create urine to eliminate waste. it provides a number of functions vital to homeostasis many severe medical disorders affecting the urinary system involve the renal system. renal is the adjective used to describe kidneys and kidney function urologic and renal disorders are common, and often very serious. due to the sensitive nature of the organs involved, care must be taken to preserve patient dignity and privacy, while also being forward and direct to identify potentially serious issues origins of urinary system problems can be traumatic and nontraumatic, and difficult to identify",
        "anatomy and physiology": "the urinary system in women shares no structures with the reproductive system, they are completely distinct. the male urinary system, however, shares some structures with the reproductive system. structures include the testes, epididymis and vas deferens, prostate gland, and penis",
        "kidneys": "left kidney is located behind the spleen, right kidney is behind the liver. blood is supplied through the renal artery/vein the functional unit of the kidney is called the nephron blood that enters through the renal artery flows through successively smaller vessels until it reaches a glomerulus, a cluster of capillaries surrounded by bowman's capsule. water and chemical substances enter the tubule through the bowman's capsule, and after passage through the tubule, urine eventually moves to the ureter to exit the kidneys",
        "ureters": "urine drains from the kidneys into the ureter, a long duct that runs from the kidney to the urinary bladder",
        "urinary bladder": "most anterior organ in the pelvis of men and women stores urine",
        "urethra": "the duct that carries urine from the bladder to the exterior of the body.",
        "prostate gland": "surrounds the male urinary bladder neck, and the first part of the urethra runs through it. any enlargement of the prostate can narrow or obstruct the urethra, blocking urine flow and creating a potential medical emergency",
        "functions of the urinary system": "the urinary system\u2019s key functions are regulation of blood volume ph (acid/base), water/electrolyte balance blood filtration retaining key substances such as glucose, removing waste and toxins, such as metabolic byproducts ammonia (after being converted to urea by the liver), foreign chemicals (eg drug metabolites) regulating arterial blood pressure through urine formation and the renin-angiotensin system production of red blood cells regulation of glucose glucose is completely reabsorbed by the nephrons until blood glucose level reaches approx 180 mg/dl, above which glucose begins to be lost in urine",
        "urinary system conditions": "gu emergencies can be difficult to discern in the field, especially when abdominal pain is the sole complaint. often, it is unimportant to discern the specific cause of abdominal pain as pre hospital treatment is often the same regardless of origin. emphasis should be placed on a thorough assessment, history, and management for any life threatening issues.",
        "renal calculi (kidney stones)": "consist of small, insoluble substances (mineral ions, uric acid, etc) that aggregate into stones and travel from the kidneys, through the ureters to the bladder, and eliminated through urine can cause severe pain, which may result in brief hospitalization. overall mortality and morbidity is low, unless a (rare) complication such as hemorrhage or obstruction results",
        "s/s": "focused hx usually centers on pain renal colic (severe flank pain) and back pain abdominal pain may start as vague visceral pain, progressing to extremely sharp, radiating to pelvis, groin, or genitals increased pain, urgency, and frequency of urination hematuria fever pale, cool, clammy skin",
        "male genital tract conditions": "benign prostate hypertrophy noncancerous enlargement of the prostate occurs in approx 60% of men by age 50 if bph obstructs urine flow, pain and an inability to urinate requires evaluation by a physician priapism painful and prolonged erection associated with sickle cell disease, certain cancers, drug use (both prescribed and recreational) and environmental issues. requires intervention by physician",
        "age related gu considerations": "a healthy kidney in a young adult is approx the size of a fist, containing 1 million nephrons with age comes normal loss of nephrons, approx 10% per decade after 40. compromised kidney function should be included in differential diagnosis in elderly patients bed bound or even sedentary lifestyles associated with the elderly can result in numerous urinary system conditions with aging comes a decrease in bladder capacity, decline in sphincter muscle control, decline in voiding sense, and an increase in nocturia"
    },
    {
        "introduction": "the function, parts, and disorders of the endocrine system will be covered.",
        "lessons and concepts": "the job of the endocrine system is to release hormones into the bloodstream. hormones are chemical messengers that bind with specific receptors to stimulate change in those cells. the body maintains homeostasis by using hormones to regulate the behavior of all the organ systems. hormones are typically regulated by feedback loops, which adjust the amount of hormones released based on conditions in the body.",
        "key terms": "endocrine system: the organ system of glands that release hormones into the blood. hormone: a chemical messenger molecule. hypothalamus: a part of the brain that secretes hormones. these hormones tell the pituitary gland to either begin secreting or stop secreting hormones. provides a link between the nervous and endocrine system. target cell: the type of cell on which a hormone has an effect.",
        "major glands in the endocrine system": "adrenal glands: located above the kidneys. each gland has an inner and outer part. the outer part, called the cortex, secretes hormones such as cortisol. the inner part, called the medulla, secretes fight-or-flight hormones such as adrenaline. gonads: secrete sex hormones. the male gonads are called testes, and they secrete the male sex hormone testosterone. the female gonads are called ovaries, and they secrete the female sex hormone estrogen. they affect growth and development and also regulate reproductive cycles and behaviors. hypothalamus: links the endocrine and nervous system. the hypothalamus drives the endocrine system and plays an important role in thermoregulation, behavioral and emotional responses, regulation of appetite, coordination of the autonomic nervous system. pancreas: located near the stomach. its hormones include insulin and glucagon which work together to control the level of glucose in the blood. it is a vital organ in both the digestive and endocrine systems residing in the u-shaped loop of the duodenum. pineal gland: a tiny gland located at the base of the brain. secretes the hormone melatonin, which is involved in the sleep-wake cycle (and likely several other processes, though a lot is still unknown). pituitary glands: attached to the hypothalamus by a thin stalk. the pituitary gland receives signals from the hypothalamus. this gland has two lobes, the posterior and anterior lobes. the posterior (back) lobe stores hormones from the hypothalamus. the anterior (front) lobe produces its own hormones. often referred to as the \"master\" gland. thyroid gland: a large gland in the neck. it is a bilobed (two-lobed) organ that resembles a bow tie in shape. thyroid hormones increase the rate of metabolism in cells throughout the body and help control how quickly cells use energy and make proteins. parathyroid glands: located behind (on the posterior aspect of) the thyroid gland. parathyroid hormone helps keep the level of calcium in the blood within a narrow range. most people have four parathyroid glands.",
        "how hormones work": "the endocrine system is a messenger-relaying system that uses hormones. compared to the fast transmission of electrical nerve impulses by the nervous system, hormones travel more slowly. a hormone travels through the bloodstream until it finds a target cell with a matching receptor to which it can bind. when the hormone binds to a receptor, it stimulates change within the cell.",
        "steroid hormones": "made of lipids such as phospholipids and cholesterol. they are fat soluble, so they can diffuse across the plasma membrane of target cells and bind with receptors in the cytoplasm of the cell. the steroid hormone and receptor form a complex that moves into the nucleus and influences gene expression. examples: cortisol, estrogen, testosterone.",
        "non-steroid hormones": "made of amino acids. non-fat soluble; cannot diffuse across the cell membrane of target cells to deliver its message, rather it activates an enzyme inside the cell membrane. this activated enzyme then signals another molecule, called a second messenger, which causes changes in the cell based on the hormone message. examples: insulin, thyroid hormones.",
        "hormone regulation": "feedback mechanism hormones are regulated by feedback mechanisms, where a hormone produces feedback to control its own production based on conditions in the body. negative feedback loop: when a hormone feeds back to decrease its own production. this brings things back to normal when conditions become too extreme. negative feedback is the most common feedback mechanism. example: when blood sugar levels get too high, insulin is released to decrease blood sugar levels. once blood sugar levels are back to normal again, signals are sent to the brain to decrease the amount of insulin released. positive feedback loop: when a hormone feeds back to increase its own production, which causes conditions to become increasingly extreme. example: during childbirth, progesterone is released to start uterine contractions. increased uterine contractions stimulate an increased release of progesterone. this increases uterus contractions even more, which in turn calls for even more progesterone. thus, the level of progesterone in the body keeps increasing and doesn't stop until the child is born.",
        "recognition": "endocrine system disorders: hypersecretion: when too much of a hormone is released - usually caused by a tumor. hyposecretion: when not enough of a hormone is released - usually caused when cells that secrete hormones are destroyed. hormone resistance: when target cells become resistant to hormones and don't respond to them.",
        "endocrine system disorders": "addison's disease - a hormone disease that leads to fatigue, extreme weakness, and dehydration. it is caused by adrenal insufficiency, which is lowered production of hormones such as corticosteroids. cushing's disease - a condition that occurs from exposure to chronically high cortisol levels. the most common cause is the use of steroid drugs, but it can also occur from an overproduction of cortisol by the adrenal glands. gigantism - also known as acromegaly, is a growth hormone disorder that causes excessive growth at an early age. growth hormone, which is produced by the pituitary gland, is necessary for the growth of the body in childhood. in excess, it causes kids to grow abnormally fast and reach above-normal height. although it is rare, it can be seen on the outside by the abnormal height of the person. dwarfism - a hormone deficiency disease. it is caused by growth hormone deficiency in children and can be easily noticed by its short stature. thyroid disease- hyperthyroidism and hypothyroidism are caused by the imbalance in the production of the thyroid hormone. hyperthyroidism is a condition of excess thyroid hormone production. it can cause weight loss, nervousness, and tachycardia. hypothyroidism is a condition of inadequate thyroid hormone production. it can cause fatigue, depression, constipation, and skin problems. diabetes mellitus- the most commonly occurring endocrine disorder. it can be divided into type 1 and type 2. type 1 is an autoimmune disease where the destruction of the beta cells means the pancreas stops producing insulin completely. type 2 occurs when the body develops insulin resistance, meaning it has little-to-no-effect on the cells, and its production slows. both types lead to poor regulation of blood glucose levels and long-term complications.",
        "four endocrine emergencies to know": "thyroid storm: occurs when the body is overwhelmed by very high levels of circulating thyroxine. signs include altered mental status, hypertension, tachycardia, tachypnea, and hyperthermia with hot, diaphoretic skin. blood sugar levels may be low, and the patient may be dehydrated due to nausea, vomiting and diarrhea. myxedema coma: severe, and life-threatening, hypothyroidism. signs include profound bradycardia, hypotension, and hypothermia. respirations will be slow, shallow, and, in extreme cases, will cease altogether. mental status might range from confusion and lethargy to profound unconsciousness (coma). diabetic ketoacidosis: occurs when the body becomes hyperglycemic because the absence of insulin prevents glucose from entering the cells. the body turns to metabolizing proteins and fats (lipolysis) as the primary source of energy. this mechanism creates ketone bodies as a byproduct of metabolism, which lowers the ph of the body. dka occurs more frequently in type i diabetics due to the complete absence of insulin. classic findings include the three \"polys\": increased urination (polyuria), excessive thirst (polydipsia), and excessive hunger (polyphagia). kussmaul breathing (increasing rate and depth of breathing to resolve acidosis) and a fruity odor to the breath are also likely in this state. acute adrenal crisis: this may occur in a patient with a condition such as addison's disease who suddenly stops corticosteroid therapy. sepsis, surgery, or trauma to the kidneys may also initiate an acute adrenal crisis. these patients will present in a hypotensive state with altered mental status. it can also produce hyponatremia (low sodium levels) and hyperkalemia (high potassium levels), causing nausea, vomiting, weakness and/or fatigue.",
        "treatment and management": "thyroid storm - provide a cooling blanket and rapid transport to the emergency department. myxedema coma - support the patient's airway, assisting ventilations if necessary, and supporting perfusion. an airway adjunct may be required to maintain airway patency. monitor oxygen saturation (spo2) and exhaled carbon dioxide levels (etco2) and provide positive pressure ventilation. diabetic ketoacidosis - airway management and assisting ventilation as necessary. acute adrenal crisis - treatment is mostly supportive. hypoglycemia - glucose. hyperglycemia - transport.",
        "scenario": "dispatch info: you are dispatched to a 48 yo female with cc of ams. scene info: upon arrival your scene is safe. you find a female sitting on the couch semi-conscious and confused. patient info: the family states she was fine about 30 minutes ago. you begin your assessment and check all vitals. your initial bp is 140/70, pulse is 68, rr is 8, spo2 is 94%, and cbg is 24. treatment info: you immediately ensure the patient can protect her own airway and begin assisting her ventilations with high-flow oxygen. due to her semi-unconscious state, you will have to call for als assistance. the patient needs to be given glucose in some form. if the patient is conscious enough to follow commands and protect her airway, oral glucose can be given along with a meal. once a patient is stable she should be packaged and made ready for transport. transport info: her cbg should be monitored en route as glucose and dextrose are metabolized quickly and she likely needs a more complex sugar. in the meantime, you may need to administer additional glucose.",
        "tips and tricks": "adrenal hypofunction = addison's. adrenal hyperfunction = cushing's. thyroid hyperfunction = graves. thyroid hypofunciton = myxedema.",
        "additional info": "hormone: growth hormone (gh), antidiuretic hormone (adh), thyroid hormone (t3/t4), parathyroid hormone (pth), cortisol, insulin. gland: anterior pituitary, posterior pituitary, thyroid, parathyroid, adrenal, pancreas. underproduced?: growth hormone deficiency (i.e. dwarfism), diabetes insipidous (polyuria), hypoparathyroidism (low blood calcium levels). overproduced?: acromegaly (gigantism), syndrome of inappropriate adh secretion (siadh) (fluid retention), graves disease, hyperparathyroidism (high blood calcium levels), cushing's syndrome, diabetes mellitus, hyperinsulinemia.",
        "how do hormones work?": "the endocrine system is a message-relaying system that uses hormones as its messengers compared to the fast-transmission of electrical nerve impulses by the nervous system, hormones travel more slowly a hormone will travel through the bloodstream until it finds target cells with a matching receptor to which it can bind when a hormone binds to a receptor, it affects change within a cell",
        "additional information": "hormone gland underproduced? overproduced? growth hormone (gh) anterior pituitary growth hormone deficiency (i.e. dwarfism) acromegaly (gigantism) antidiuretic hormone (adh) posterior pituitary diabetes insipidus (polyuria) syndrome of inappropriate adh secretion (siadh) (fluid retention) thyroid hormone (t3/t4) thyroid myxedema coma grave's disease parathyroid hormone (pth) parathyroid hypoparathyroidism (low blood calcium levels) hyperparathyroidism (high blood calcium levels) cortisol adrenal addison's cushing's insulin pancreas diabetes mellitus hyperinsulinemia"
    },
    {
        "introduction": "hypoglycemia/hyperglycemia",
        "anatomy, physiology, and pathophysiology": "anatomy: pancreas, adrenal glands. pancreas: located in the upper retroperitoneum behind the stomach and between the duodenum and the spleen. contains both endocrine glands and exocrine glands",
        "pancreas": "endocrine: islets of langerhans, which consists of 25% alpha cells. 60% beta cells, and 15% delta cells.1 alpha cells produce glucagon. when blood sugar drops too low, glucagon is released. glucagon will stimulate the breakdown of stored glycogen and turn it into glucose. the process is called glycogenolysis. glucagon can also stimulate the liver to break down fats or proteins into sugar. this process is called gluconeogenesis.",
        "beta cells": "beta cells produce the hormone insulin. insulin decreases blood glucose by increasing the uptake of glucose in the cells. insulin is constantly secreted due to the liver removing circulating insulin within 10-15 minutes. this results in a steady amount of glucose being used for energy. insulin also promotes energy storage in the body by the synthesis of glycogen, protein, and fat. in type one diabetes, beta cells are destroyed and produce very low levels of insulin, leading to hyperglycemia.",
        "delta cells": "10-15 % of cells in the pancreas are delta cells. delta cells produce somatostatin which inhibits the secretion of insulin and glucagon. somatostatin can also retard nutrient absorption from the intestines.",
        "adrenal glands": "adrenal glands play a small role in blood sugar. within the adrenal gland, lies the adrenal cortex which secretes glucocorticoids. glucocorticoids: most important hormone is cortisol. cortisol acts similar to glucagon by increasing the blood sugar by promoting gluconeogenesis and decreasing glucose utilization as an energy source",
        "pathophysiology": "type one diabetes and dka/hypoglycemia: in type one diabetes, the body does not produce enough insulin to meet the body's demand. elevated levels of glucose, can lead to diabetic ketoacidosis (dka)",
        "type one diabetes": "most often diagnosed early in age (commonly referred to as juvenile diabetes). also known as iddm (insulin-dependent diabetes mellitus). often is hereditary. these patients rely on insulin injections regularly to maintain glucose homeostasis",
        "type two diabetes": "in type two diabetes, there is a decline in insulin production, as well as a deficient response to insulin (insulin resistance). sometimes referred to as adult-onset diabetes, or niddm (non-insulin-dependent diabetes). hereditary might play a small role, but the biggest cause of type two diabetes is obesity. as fat increases in the body, there becomes a deficiency in the number of insulin receptors on the cell.",
        "symptoms": "hypoglycemia: diaphoresis, clamminess, confusion, tachycardia, hungry, pallor, weakness, irritability, slurred speech, seizures, coordination problems, nausea\ndka: onset: sudden, polydipsia, polyuria, kussmaul respirations, dry skin/mucous membranes, nausea/vomiting, abdominal pain, ketones (fruity breath), weakness, confusion\nhyperglycemia: high ketones in the urine, hypotension, tachycardia\nhhnk: onset: gradual days- weeks, polyuria, polydipsia, altered mental status/unconsciousness, dry skin/mucous membranes, hyperglycemia, tachycardia",
        "treatment and management": "insulin shock/hypoglycemia: maintain airway and breathing as needed. vitals including cbg. if the patient is on an insulin pump, stop the insulin pump or have the family stop the insulin pump. if the patient is awake and can follow commands, administer 15g of oral glucose.\ndka/hhnk: maintain airway and breathing as needed. vitals including cbg. call for als intercept or transport immediately to the hospital for a higher level of care.",
        "scenario 1": "you are being dispatched to a 20-year-old female for altered mental status. boyfriend reports that he came over to visit his girlfriend and found her sitting on the chair not acting like herself. boyfriend informs you that the patient is a diabetic and has an insulin pump.",
        "scenario 2": "you are dispatched to an unconscious patient found this morning by his son. patient was last seen normal was two days ago at 0800. son reports that he visits the patient every two days to check on him.",
        "tips and tricks": "remember, dka is categorized by ketones. kussmaul respirations can be seen. acetone may also be noted on the breath. in hhnk, the ph in the body will not change, so there will be no change in respiration. if the patient is hypoglycemic and can protect their airway, administer 15g of oral glucose.",
        "oral glucose drug card": "supplied: 15-24 grams in a tube of gel. pharmacology: glucose is one of the body's important fuel sources. when administer, glucose will absorb into the bloodstream thereby increasing blood glucose.",
        "alpha cells": "alpha cells produce glucagon. when blood sugar drops too low, glucagon is released. glucagon will stimulate the breakdown of stored glycogen and turn it into glucose. the process is called glycogenolysis. glucagon can also stimulate the liver to break down fats or proteins into sugar. this process is called gluconeogenesis.",
        "glucocorticoids": "most important hormone is cortisol. cortisol acts similar to glucagon by increasing the blood sugar by promoting gluconeogenesis and decreasing glucose utilization as an energy source",
        "recognition": "hypoglycemia: diaphoresis, clamminess confusion tachycardia hungry pallor weakness irritability slurred speech seizures coordination problems nausea dka: onset: sudden polydipsia polyuria kussmaul respirations dry skin/mucous membranes nausea/ vomiting abdominal pain ketones (fruity breath) weakness confusion hyperglycemia high ketones in the urine hypotension tachycardia hhnk: onset: gradual days- weeks polyuria polydipsia altered mental status/ unconsciousness dry skin/mucous membranes hyperglycemia tachycardia",
        "dka/hhnk": "maintain airway and breathing as needed. vitals including cbg iv therapy and fluid resuscitation. consider als intercept if needed, or transport immediately to the nearest appropriate facility.",
        "glucagon drug card": "supplied: 1mg vial of powder/ 1 ml vial of diluent pharmacology: glucagon is a hormone that breaks down glycogen into glucose. effects should kick within 15 minutes",
        "dextrose": "supplied: 25g/50 ml prefilled syringe (50%) or 25g/250ml bag (10%) pharmacology: glucose is the body's basic fuel. it is regulated by insulin which stimulates excess glucose and glucagon, which mobilizes stored glucose.",
        "hhnk/hhs": "hyperosmolar hyperglycemia state (hyperglycemic hyperosmolar nonketoic coma). sustained hyperglycemia causes osmotic diuresis which causes the body to become dehydrated."
    },
    {
        "introduction": "pneumonia is a lower airway infection that most often targets the bronchi, bronchioles, and alveoli. pneumonia infections may result from bacteria, fungi, or viruses1, but regardless of cause, they often present with airway irritation and eventual respiratory complications.",
        "pneumonia statistics": "\u2022 from the american thoracic society2\n\u2022 in the united states, over 1 million adults seek hospital care for pneumonia every year\n\u2022 in the u.s., 50,000 adults die yearly from pneumonia\n\u2022 worldwide, there are approximately 120 million cases per year in children, accounting for 16% of all deaths in children under five years of age\n\u2022 pneumonia is the suspected cause for 50% of all sepsis cases\n\u2022 financially, pneumonia is one of the top 10 most expensive hospitalizations in the u.s.\n\u2022 any single microbe causing pneumonia is not responsible for more than 10% of all diagnosed cases",
        "lessons and concepts": "physiology of pneumonia\n\u2022 rooted in the lower airway\n\u2022 microbes enter the respiratory tract and end up in the alveoli\n\u2022 the body launches an immune response to the foreign microbes\n\u2022 as a result of the immune response, localized swelling, fluid build-up, and airway irritation occur\n\u2022 due to the immune response, respiratory function is diminished due to the impedance of portions of the airway",
        "common sources of pneumonia": "\u2022 there are three main etiologies of pneumonia\n\u2022 bacterial infection3\n\u2022 the most common cause of pneumonia\n\u2022 viral infection3\n\u2022 influenza (flu)\n\u2022 rhinovirus (common cold)\n\u2022 respiratory syncytial virus (rsv)\n\u2022 sars-cov-2 (covid-19)\n\u2022 fungal infection3",
        "routes of infection": "\u2022 \u201ctype\u201d of pneumonia varies\n\u2022 defined by infection origin\n\u2022 there are two main \u201csources\u201d of infection, with one sub-source4\n\u2022 community-acquired pneumonia (cap)\n\u2022 exposure and development outside of a hospital/healthcare setting\n\u2022 transmission through common methods\n\u2022 airborne & aerosolized (person-to-person)\n\u2022 surface contamination\n\u2022 residing in environments harmful to respiratory health\n\u2022 smoke\n\u2022 dust\n\u2022 fine particulates and other pollutants\n\u2022 increased chance of infection with other health conditions\n\u2022 asthma\n\u2022 diabetes\n\u2022 heart disease\n\u2022 lung disease\n\u2022 immunocompromised\n\u2022 age, younger than 2, greater than 65",
        "hospital-associated pneumonia (hap) and ventilator-associated pneumonia (vap)": "\u2022 hospital-associated pneumonia (hap)\n\u2022 develops during or after hospital admission, long-term-care facility, or dialysis center\n\u2022 defined as developing 48 hours after admission without incubation occurring/in progress at the time of admission5\n\u2022 ventilator-associated pneumonia (vap)\n\u2022 pneumonia occurring 48-72 hours after tracheal intubation5\n\u2022 affects 10-20% of patients who receive mechanical ventilation for over 48 hours",
        "risk factors for hap and vap": "\u2022 iv antibiotic use in the previous 90 days\n\u2022 septic shock at the time of intubation\n\u2022 acute respiratory distress syndrome (ards) before intubation\n\u2022 hospital admission of 5 days or longer\n\u2022 acute renal replacement therapy",
        "recognition": "signs and symptoms\n\u2022 generalized\n\u2022 chest pain during inspiration or coughing\n\u2022 chills\n\u2022 cough with or without mucus production\n\u2022 fever\n\u2022 hypoxia\n\u2022 shortness of breath at rest or with exertion\n\u2022 headache\n\u2022 muscle pain\n\u2022 weakness\n\u2022 tiredness\n\u2022 nausea\n\u2022 vomiting\n\u2022 diarrhea\n\u2022 diminished lung sounds\n\u2022 ronchi",
        "geriatric and pediatric patients": "\u2022 geriatric patients may present with low body temperature instead of fever and altered mental status, typically sudden in onset1\n\u2022 pediatric patients may also exhibit1:\n\u2022 cyanosis\n\u2022 grunting\n\u2022 intercostal retractions\n\u2022 tachypnea\n\u2022 nostril flaring",
        "advanced complications": "\u2022 septicemia or septic shock\n\u2022 lung abscess\n\u2022 pleural disorders\n\u2022 respiratory failure",
        "diagnosis": "\u2022 physical assessment\n\u2022 lung auscultation\n\u2022 medical history questioning\n\u2022 blood work\n\u2022 complete blood count (cbc)\n\u2022 blood cultures\n\u2022 blood gas\n\u2022 imaging\n\u2022 chest x-ray\n\u2022 chest ct scan\n\u2022 sputum sample",
        "treatment": "out-of-hospital\n\u2022 oxygen therapy\n\u2022 titrate to need\n\u2022 treat any other associated signs and symptoms\nin-hospital\n\u2022 mild cases\n\u2022 for cases of bacterial or fungal pneumonia, antibiotics are prescribed, and the patient is discharged home\n\u2022 for some viral pneumonias, antiviral medication is prescribed but is less effective and, therefore, less common",
        "scenario": "dispatch: emergent response to a senior living facility for \u201cbreathing problems\u201d for a 79 yof\nscene info: you and your partner arrive at a senior living facility and are led to the patient room by staff.\npatient info: the patient tells you she has been having a hard time breathing, with increased effort on exertion.",
        "scenario cont.": "treatment: quality physical assessment and in-depth pmh questioning on scene.\nreassessment: while transporting, the patient\u2019s spo2 has risen to 100%, and she states she feels like she is breathing much better.",
        "history": "atrial fibrillation, hypertension, arthritis, asthma \nmedications: cardizem, metoprolol, prn mdi, dietary supplements \nvitals: hr: 80-87 irregular, rr: 16 at rest, 28 and labored on exertion, bp: 142/79, spo2: 91% ra, temp: 96.3f temporal, ecg: a-fib",
        "treatment cont.": "quality physical assessment and in-depth pmh questioning on scene. recent hospital admission for 1 week raises concerns about potential for a cardiac event. after loading the patient on the gurney, you place her on a simple oxygen mask at 6 lpm and see an immediate improvement in spo2 by the time you reattach telemetry in the ambulance. the nearest hospital is a 10 minute drive.",
        "reassessment": "while transporting, the patient\u2019s spo2 has risen to 100%, and she states she feels like she is breathing much better. all other vital signs remain the same. you arrive at the ed and transfer patient care to the ed staff, giving your report to the er nurse. later in the day you check-in on the patient, and she tells you she has pneumonia. she states the md suspects she acquired it from her hospital stay, and is going to prescribe a course of antibiotics for her. patient says they are preparing to discharge her home with supplemental oxygen."
    },
    {
        "introduction": "there are 4 main electrolytes in the body: sodium (na+), potassium (k+), chloride (cl-), and calcium (ca2+). magnesium (mg+) is another ion present in trace amounts. these electrolytes are used in many processes, but especially in contraction of muscles (including the heart). an imbalance of electrolytes could be an immediate life threat if it causes an arrhythmia in the heart.",
        "lessons and concepts": "the primary job of electrolytes in the body is in cellular action potentials. recall that in skeletal muscles at rest, na+ ions are outside the cell and k+ ions are mostly inside the cell. when the cell contracts, na+ floods the cell first, then k+ exits the cell to end the contraction. pumps in the cell walls return the cell to its resting state. in cardiac tissue, ca2+ plays an increased role. in pacemaker cells, ca2+ is responsible for the majority of depolarization. in contractile cells, ca2+ enters the cell after depolarization is complete (initiated by na+) to keep the cell depolarized longer. this prevents the contraction from proceeding the wrong way back up the heart. k+ still plays a role in returning both types of cells to their baseline, or resting potential.",
        "recognition": "most of the time, the body does a decent job of managing the balance of electrolytes through the kidneys. a history of renal disease or failure is almost always present for patients with an electrolyte imbalance. an imbalance can also arise from the loss of electrolytes, for example after prolonged exertion without adequate replacement. finally, toxicological mechanisms (such as an overdose) could lead to a true or relative electrolyte imbalance. for example, a calcium channel blocker overdose might lead to similar symptoms as hypocalcemia.",
        "potassium (k+)": "hyperkalemia is sometimes called the great imitator, because it can mimic other arrhythmias like v-tach on the monitor. any time you see kidney problems in a patient's medical history, this is a red flag for potential electrolyte imbalances, but especially potassium. at a dialysis center, patients at least slightly hyperkalemic, are dialyzed, and leave somewhat hypokalemic. missed dialysis treatments or incomplete treatments are a good indicator that someone could be hyperkalemic. peaked t waves are the hallmark sign on an ekg strip, but this is a late changing sign. other signs to look for include: sine wave morphology, a rhythm that looks like v-tach, but is slower than 130 bpm, may present with a sensation of cramping, especially in the feet and hands.",
        "hypokalemia": "typically associated with hypomagnesemia. ecg changes include larger p waves, longer pri, and development of u waves. look for atrial arrhythmias, possibly leading to ventricular arrhythmias (including torsades des pointes) in later stages.",
        "sodium (na+)": "hyponatremia typically presents as cramping, especially in the feet and hands. early signs are nausea/vomiting, lethargy, and confusion. late signs include seizures, coma, and eventually death. usually brought on by extensive exercise or exertion. for example, an ultramarathon runner or someone performing manual labor outdoors in the summer heat might be at increased risk for hyponatremia. hypernatremia chronically has long term health effects, but few in the short term. in severe cases, can still lead to seizures/coma. neonates/infants are more susceptible.",
        "calcium (ca2+)": "blood calcium levels are regulated by the parathyroid glands, so if a patient has a problem with this gland, it could lead to a calcium imbalance, but otherwise calcium is generally well managed by the body. as blood calcium levels get low, calcium is released from bones. when there is an excess of calcium in the blood, it is stored in bone tissue. hypocalcemia chronically low calcium can contribute to more brittle bones (since calcium is removed from bones to balance blood calcium levels). a calcium channel blocker overdose may present as relative hypocalcemia of the heart, since the calcium isn\u2019t able to have its necessary effect.",
        "magnesium (mg+)": "hypomagnesemia thought to be associated with torsades des pointes, which is why magnesium sulfate (mgso4) is given to correct torsades. could lead to weakness, seizures, or cardiac arrest (in the case of torsades).",
        "treatment and management": "most of these conditions will need to be confirmed by a blood test and corrected at the hospital, but a few might be discernible in the field. hyperkalemia: continuous albuterol neb (if allowed per protocol), request als if not already en route, establish iv access and obtain a 12-lead ecg if not done already. calcium channel blocker overdose: scene safety considerations for overdoses, wait for police to clear scene, back out and request police if scene is unsecured or scene becomes unsafe.",
        "scenario": "you are dispatched as a first response (non-transport) unit for chest pain. the patient is a 62-year-old male who says he just doesn't feel right today. the scene is a single family residence in a mobile home park. you notice a wheelchair accessible van parked in the carport.",
        "key takeaways": "potassium problems are common for dialysis patients, especially when a treatment is missed or there are other complications with their dialysis treatment. having the iv established already allowed the paramedic to administer drugs which addressed the underlying problem. once a patient loses their pulse, treatment falls into the acls algorithms with few deviations start compressions, and get the defibrillator pads attached right away.",
        "tips and tricks": "ask your opqrst questions on every patient, even if they are unresponsive and you have to ask a bystander. when testing, these questions are worth a total of 8 points\u2014more than any other category on the medical patient assessment skill station. electrolyte imbalances are fairly rare to begin with, and almost always have some preceding event or underlying condition. when you see dialysis patients, think potassium problems. when you see overexertion, think sodium problems. when your patient says they have a parathyroid problem, it could mean they have a calcium problem too."
    },
    {
        "introduction": "the urinary system functions to filter blood and create urine to eliminate waste. it provides a number of functions vital to homeostasis. many severe medical disorders affecting the urinary system involve the renal system. renal is the adjective used to describe kidneys and kidney function. urologic and renal disorders are common, and often very serious. due to the sensitive nature of the organs involved, care must be taken to preserve patient dignity and privacy, while also being forward and direct to identify potentially serious issues. origins of urinary system problems can be traumatic and nontraumatic, and difficult to identify.",
        "anatomy and physiology": "the urinary system in women shares no structures with the reproductive system, they are completely distinct. the male urinary system, however, shares some structures with the reproductive system. structures include the testes, epididymis and vas deferens, prostate gland, and penis.",
        "kidneys": "left kidney is located behind the spleen, right kidney is behind the liver. blood is supplied through the renal artery/vein. the functional unit of the kidney is called the nephron. blood that enters through the renal artery flows through successively smaller vessels until it reaches a glomerulus, a cluster of capillaries surrounded by bowman's capsule. water and chemical substances enter the tubule through the bowman's capsule, and after passage through the tubule, urine eventually moves to the ureter to exit the kidneys.",
        "ureters": "urine drains from the kidneys into the ureter, a long duct that runs from the kidney to the urinary bladder.",
        "urinary bladder": "most anterior organ in the pelvis of men and women. stores urine.",
        "urethra": "the duct that carries urine from the bladder to the exterior of the body. significantly shorter in women than men (3-4 cm in women vs approx 20 cm in men). this difference in length contributes to why women are more susceptible to bacterial infection (uti's). male urethra carries both urine and reproductive fluids, thus can be an entry point for sti's.",
        "prostate gland": "surrounds the male urinary bladder neck, and the first part of the urethra runs through it. any enlargement of the prostate can narrow or obstruct the urethra, blocking urine flow and creating a potential medical emergency.",
        "functions of the urinary system": "the urinary system's key functions are: regulation of blood volume, ph (acid/base), water/electrolyte balance. blood filtration. retaining key substances such as glucose. removing waste and toxins, such as metabolic byproducts, ammonia (after being converted to urea by the liver), foreign chemicals (eg drug metabolites). regulating arterial blood pressure. through urine formation and the renin-angiotensin system. production of red blood cells. kidneys produce 90% of the body's erythropoietin, the hormone that stimulates erythrocytes (rbc) growth in bone marrow. regulation of glucose. glucose is completely reabsorbed by the nephrons until blood glucose level reaches approx 180 mg/dl, above which glucose begins to be lost in urine.",
        "urinary system conditions": "gu emergencies can be difficult to discern in the field, especially when abdominal pain is the sole complaint. often, it is unimportant to discern the specific cause of abdominal pain as pre hospital treatment is often the same regardless of origin. emphasis should be placed on a thorough assessment, history, and management for any life threatening issues.",
        "renal calculi (kidney stones)": "consist of small, insoluble substances (mineral ions, uric acid, etc) that aggregate into stones and travel from the kidneys, through the ureters to the bladder, and eliminated through urine. can cause severe pain, which may result in brief hospitalization. overall mortality and morbidity is low, unless a (rare) complication such as hemorrhage or obstruction results.",
        "symptoms of renal calculi": "focused hx usually centers on pain. renal colic (severe flank pain) and back pain. abdominal pain. may start as vague visceral pain, progressing to extremely sharp, radiating to pelvis, groin, or genitals. increased pain, urgency, and frequency of urination. hematuria. fever. pale, cool, clammy skin.",
        "male genital tract conditions": "benign prostate hypertrophy. noncancerous enlargement of the prostate. occurs in approx 60% of men by age 50. if bph obstructs urine flow, pain and an inability to urinate requires evaluation by a physician. priapism. painful and prolonged erection. associated with sickle cell disease, certain cancers, drug use (both prescribed and recreational) and environmental issues. requires intervention by physician.",
        "age related gu considerations": "a healthy kidney in a young adult is approx the size of a fist, containing 1 million nephrons. with age comes normal loss of nephrons, approx 10% per decade after 40. compromised kidney function should be included in differential diagnosis in elderly patients. bed bound or even sedentary lifestyles associated with the elderly can result in numerous urinary system conditions. with aging comes a decrease in bladder capacity, decline in sphincter muscle control, decline in voiding sense, and an increase in nocturia.",
        "urinary retention": "inability to void, either partially or completely. results from a variety of etiologies, including physical obstruction, neurogenic issues, medication, infectious diseases, etc. urine that stays in the body for too long can grow bacteria, resulting in infection. s/s: unable to urinate, bladder distention, abdominal pain. aloc. particularly common in the elderly. focus on support and transport. iv tko if indicated (altered, severe pain, etc).",
        "urinary tract infection (uti)": "extremely common, especially those with urinary stasis (incomplete urination that leaves urine in the bladder that can serve as a nutrient pool for bacteria). at risk groups include: females more than men (due in part to shorter urethra). particularly pregnant and elderly. neurogenically impaired individuals. divided into categories based on location of the infection: urethritis: in the urethra, cystitis: in the urinary bladder, prostatitis: prostate gland (men), pyelonephritis: kidney.",
        "symptoms of uti": "pain/burning sensation with urination, increased urge and frequency when urinating, difficulty starting/continuing to urinate, cloudy/rust colored urine, strong smell to urine, back/flank pain, hematuria (blood in urine), abdominal pain.",
        "fluid, electrolyte, and acid/base disturbances": "the urinary system works to excrete waste, including water and electrolytes (na+, k+, phosphate ions), excess h+ ions and bicarbonate (a powerful buffer used to regulate ph in the body). if this system isn't working properly, metabolic acidosis or metabolic alkalosis can result.",
        "water/electrolyte imbalances": "causes: most commonly related to inadequate kidney function, excessive vomiting/diarrhea. can also result from inadequate fluid or electrolyte replacement following ingestion of large quantities of water or excessive exercise.",
        "metabolic acidosis": "causes include: diabetic ketoacidosis, lactic acidosis, hyperkalemia, poor renal function and certain overdoses (eg. tricyclic antidepressants). s/s: n/v, increased rr (due to trying to correct acidosis through off gassing, or compensatory respiratory alkalosis), general malaise.",
        "metabolic alkalosis": "rare compared to acidosis. causes include: hypovolemia, massive vomiting or diarrhea, or ingestion of large quantities of alkalizing agents. s/s: headache, lethargy, chest pain, seizures, muscle spasms.",
        "epididymitis": "infection of the epididymis. most commonly associated with sti's in young men (gonorrhea and chlamydia), in older men it is seen with bladder infections or invasive procedures (surgical or catheter placement).",
        "fourmier's gangrene": "type of necrotizing fasciitis. typically seen in diabetic men. alcoholism and immunosuppressed men are also predisposed. rare, but has severe complications and significant mortality rate.",
        "structural conditions": "phimosis: condition where the foreskin is too tight to be pulled around the head of the penis. normal in babies and toddlers. if present in older children, or if there's significant pain, bleeding, or pain upon urination, needs to be evaluated by physician.",
        "priapism": "painful and prolonged erection. associated with sickle cell disease, certain cancers, drug use (both prescribed and recreational) and environmental issues. requires intervention by physician.",
        "benign prostate hypertrophy": "noncancerous enlargement of the prostate. occurs in approx 60% of men by age 50. if bph obstructs urine flow, pain and an inability to urinate requires evaluation by a physician.",
        "testicular torsion": "twisting of the spermatic cord, cutting off blood supply to the testicle and surrounding structures in the scrotum. can occur at any age, however more common in early adolescence and infancy."
    },
    {
        "introduction": "sepsis is the body's response to an infection and it's a life-threatening emergency. sepsis happens when an existing infection triggers a chain reaction throughout your body. without treatment, sepsis will progress to tissue and organ damage, and even death. often, infections that lead to sepsis begin in the lung, urinary tract, or gastrointestinal tract.",
        "sepsis statistics": "per the cdc: at least 1.7 million adults in america develop sepsis. nearly 270,000 die as a result of sepsis. 1 in 3 patients who die in a hospital has sepsis. although nearly 87% of cases of sepsis, or the infection causing sepsis, start outside of the hospital setting.",
        "who is at risk for sepsis?": "adults 65 or older, people with weakened immune systems, people with chronic medical conditions (diabetes, lung disease, cancer, kidney disease, etc.), sepsis survivors, people with recent severe illness or hospitalization, children younger than one.",
        "ways to reduce risks of sepsis?": "prevent infections: take care of chronic conditions, get recommended vaccines, practice good hygiene: wash your hands, keep cuts clean and covered until healed, know the signs and symptoms of sepsis (will be discussed later in the \"recognition\" section). act fast: sepsis is a medical emergency. if an infection is not getting better or is getting worse, act fast.",
        "what specifically occurs during sepsis?": "1. your body has an infection present somewhere. 2. if the infection does not improve and instead begins to spread, the immune system becomes overwhelmed. 3. widespread release of chemical mediators attempting to fight off the infection. 4. this triggers an inflammatory response throughout the entire body causing loss of vessel fluid volume resulting in hypovolemia and hypotension.",
        "physiology of sepsis": "as stated above, sepsis is the body's response to an infection. though more specifically, it is an extreme response that may result in serious health concerns and even death.",
        "recognition": "early sepsis recognition can be a key factor in survivability in patients. understanding key signs/symptoms can help pre-hospital care providers better treat the condition and get patients to definitive care faster.",
        "signs and symptoms of sepsis": "s/s vary based on the extent of the condition and causal illness or injury, however, general symptoms include: general malaise, fatigue, or weakness, nasal congestion, cough, irregular body temperature (can be elevated or lower than normal), wounds/surgical sites that are swollen, red, and hot to the touch or do not appear to be healing with proper wound care and/or antibiotic usage.",
        "assessment findings": "a full-body assessment truly is key in helping determine or increase the suspicion of infection and/or sepsis.",
        "treatment and management": "consider any scene safety concerns, need for additional resources, and response to the scene (emergent/non-emergent). assessment: as you approach the patient, note: is the patient conscious? are they tracking you or talking as your approach? do you hear or see any audible coughing, sniffling, or presence of tissues, cold medicine, etc.",
        "transport considerations": "most facilities should be able to initially stabilize a sepsis patient, however, long-term and extended care requires an icu.",
        "scenario": "dispatch info: dispatch relays your patient is an 82 y/o female complaining of ams. the caller states the patient has rapidly declined over the last 12 hours.",
        "key takeaways": "know the signs and symptoms of sepsis! patients may present with varying degrees of symptoms, be prepared for patients to decompensate and know the next treatments that are needed.",
        "tips and tricks": "testing tips: always remember scene safety, request additional resources, c-spine, and abc's take first priority (in that order)!"
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "General \u2013 Pain Control",
        "overview": "The practice of pre-hospital emergency medicine requires expertise in a wide variety of pharmacological and non-pharmacological techniques to treat acute pain resulting from a myriad of injuries and illness. One of the most essential missions for all healthcare providers should be the relief and/or prevention of pain and suffering. Approaches to pain relief must be designed to be safe and effective in the organized chaos of the pre-hospital environment. The degree of pain and the hemodynamic status of the patient will determine the rapidity of care.",
        "hpi": "* Age\n* Location\n* Duration\n* Severity (1 - 10)\n* Past medical history\n* Medications\n* Drug allergies",
        "considerations": "* Severity (pain scale)\n* Quality (sharp, dull, etc)\n* Radiation\n* Relation to movement, respiration\n* Increased with palpation of area\n* Musculoskeletal\n* Visceral (abdominal)\n* Cardiac\n* Pleural, respiratory\n* Neurogenic\n* Renal (colic)",
        "procedure": "1. Perform general patient management.     \n2. Administer oxygen to maintain SpO2 94 - 99%     \n3. Determine patient\u2019s pain score assessment using a standardized scoring system. Refer to Universal Pain Assessment tool on this protocol.     \n4. Place patient on cardiac monitor per patient assessment.  \n5. Determine if pain is acute or chronic (3 weeks or more). If chronic, attempt to identify cause (cancer/palliative care)    \n6. If pain is mild, moderate, or chronic (cancer/palliative care excluded), consider use of non-opioid treatment. If age > 10 yrs, may alternatively consider one of the following, if available:\n   a. Nitronox (via patient-administered dosing system)\n   b. Acetaminophen 650 mg PO\n   c. Nonsteroidal such as ibuprofen 400 mg PO (avoid in pts with open fractures or suspected hip/femur fractures)\nOMD Option OMD Option OMD Option OMD Option\n7. If NO nonsteroidal administered, for mild, moderate, or chronic pain (cancer/palliative care excluded), consider TORADOL 15 mg IV or 30 mg IM. Avoid use If age less than 10 years, older than 65 years of age, or patients with history of renal disease.   \n8. If pain rated 7 or above and/or chronic pain from cancer/palliative car, establish IV of normal saline if indicated for medication administration.   \n9. If pain rated 7 or above, administer fentanyl 2 mcg/kg INTRANASAL (max first dose of 100 mcg) half dose in each nostril. May consider additional dose of up to 100mcg after 5 minutes if pain persists \u2013OR- fentanyl 1 mcg/kg IV, or IM (max single dose of 100 mcg). *** There are no documented cases of chest rigidity with the administration of fentanyl INTRANASALLY ***   \n10. If fentanyl unavailable, administer morphine sulfate 0.1 mg/kg IV or IM (max single dose of 5.0 mg). Sickle cell patients may be given higher doses up to 10 mg IV or IM.   \n11. Repeat the patient\u2019s pain score assessment.     \n12. Consider Ondansetron (ZOFRAN) 0.1 mg/kg IV up to 4 mg over 2 to 5 minutes for nausea or to prevent nausea. Can also be given 4mg PO tablet for EMT and above in adult patients.    \n13. If indicated based on pain assessment, repeat pain medication administration after 10 minutes of the previous dose. Maximum total dose of fentanyl is 200 mcg and morphine sulfate is 20 mg for non-sickle cell patients. Sickle cell patients may have up to a total of 400 mcg of fentanyl or 40 mg of morphine sulfate.   \n14. Transport in position of comfort and reassess as indicated.",
        "universal pain assessment tool": "Verbal Descriptor Scale\nNo pain\nMild pain\nModerate pain\nSevere pain\nVery severe pain\nExcruciating pain\n\nWong - Baker Scale\nAlert\nSmiling\nNo humor\nSerious, flat\nFurrowed brow\nPursed lips\nBreath holding\nWrinkled nose\nRaised upper lip\nRapid breathing\nSlow blink\nOpen mouth\nEyes closed\nMoaning\nCrying\n\nActivity Tolerance Scale\nNo pain\nCan be ignored\nInterferes with tasks\nInterferes with concentration\nInterferes with basic needs\nBed rest required\n\nSpanish\nNada de dolor\nUn poquito de dolor\nUn dolor leve\nDolor fuerte\nDolor demasiado fuerte\nUn dolor insoportable",
        "pearls": "1. Pain severity (0 - 10) is a vital sign that should be recorded before and after IV or IM medication administration and upon arrival at destination.\n2. Contraindications to narcotic medication administration include hypotension, head injury, respiratory depression, and severe COPD.\n3. All patients should have drug allergies ascertained prior to administration of pain medication.\n4. Patients receiving narcotic analgesics should be administered oxygen.\n5. Narcotic analgesia was historically contraindicated in the pre-hospital setting for abdominal pain of unknown etiology. It was thought that analgesia would hinder the ER physician or surgeon\u2019s evaluation. Recent studies have demonstrated opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors.1\n6. Fentanyl is contraindicated for patients who have taken MAOIs within past 14 days, and used with caution in patients with head injuries, increased ICP, COPD, and liver or kidney dysfunction.",
        "reference": "1. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006; 296(14):1764 -74 (ISSN: 1538- 3598) Ranji SR; Goldman LE; Simel DL; Shojania KG"
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Medical \u2013 Diabetic - Hypoglycemia",
        "overview": "Symptomatic hypoglycemia is defined as a blood glucose level < 60 mg / dL with signs of altered mental status and/or unconsciousness. The many signs and symptoms that are associated with hypoglycemia can be divided into two broad categories: adrenergic and neurologic. Adrenergic stimulation is due to the increased epinephrine levels and neurologic is due to central nervous system dysfunction from the decreased glucose levels.",
        "hpi": "- History of diabetes\n- Onset of symptoms\n- Medications\n- Fever or recent infection\n- Alcohol consumption\n- Last meal",
        "signs and symptoms": "- Anxiety, agitation, and / or confusion\n- Cool, clammy skin\n- Diaphoresis\n- Seizure\n- Decreased visual acuity, blindness\n- Abnormal/ hostile behavior\n- Tachycardia\n- Hypertension\n- Dizziness, headache, weakness",
        "considerations": "- Hypoxia\n- Seizure\n- Stroke\n- Brain trauma\n- Alcohol intoxication\n- Toxin / substance abuse\n- Medication effect / overdose",
        "procedure": "1. Perform general patient management. \u2022 \u2022 \u2022 \u2022 \u2022\n2. Support life-threatening problems. \u2022 \u2022 \u2022 \u2022 \u2022\n3. Assess for signs of trauma. Provide spinal immobilization as necessary. \u2022 \u2022 \u2022 \u2022 \u2022\n4. Administer oxygen to maintain SPO2 94 - 99% \u2022 \u2022 \u2022 \u2022 \u2022\n5. For altered mental status, perform rapid glucose determination. \u2022 \u2022 \u2022 \u2022\n6. If glucose less than 60 mg / dL or clinical signs and symptoms indicate hypoglycemia and the patient is awake and able to swallow:\n   a. If the patient can protect airway, give Oral Glucose15 grams. Repeat in 15 minutes if necessary. \u2022 \u2022 \u2022 \u2022\n7. If glucose less than 60 mg / dL or clinical signs and symptoms indicate hypoglycemia and oral glucose is contraindicated or patient is unconscious:\n   a. If BLS, administer Glucagon 1 mg IM/IN\n   b. Once desired effect is obtained and patient is able to swallow, administer oral glucose 15 grams.\n   c. Do not delay transport if long transport time or delayed ALS response expected. \u2022 \u2022 \u2022 \u2022\n   d. If ALS, may consider use of Glucagon prior to dextrose administration. If Patient > 40 kg: Give DEXTROSE 10% 100mL bolus. Titrate to consciousness and/or normal glucose levels.\n   e. If DEXTROSE 10% is unavailable, administer DEXTROSE 50% 1G / kg up to 25 G IV\n   f. If unable to establish an IV, alternatively administer GLUCAGON 1 mg IM / IN. \u2022 \u2022 \u2022\n8. For signs and symptoms of hypovolemic shock or dehydration, follow the Medical \u2013 Hypotension/Shock (Non -trauma) protocol. \u2022 \u2022 \u2022 \u2022 \u2022\n9. Place on cardiac monitor per patient assessment. \u2022 \u2022\n10. Transport and perform ongoing assessment as indicated. \u2022 \u2022 \u2022 \u2022",
        "possible causes of pulseless arrest": "A Alcohol, Abuse, Acidosis T Toxidromes, Trauma, Temperature, Tumor\nE Endocrine, Electrolytes, Encephalopathy I Infection, Intussusception\nI Insulin P Psychogenic, Porphyria, Pharmacological\nO Oxygenation, Overdose, Opiates S Space occupying lesion, Sepsis, Seizure, Shock\nU Uremia",
        "pearls": "1. Use aseptic techniques to draw blood from finger. Allow alcohol to dry completely prior to puncturing finger for blood glucose level. Alcohol may cause inaccurate readings. Do not blow on, or fan site, to dry faster.\n2. Blood glucose levels should be taken from extremity opposite IV and medication administration for most accurate reading.\n3. After puncturing finger, use only moderate pressure to obtain blood. Excessive pressure may cause rupture of cells causing inaccurate results. Know your specific agency\u2019s glucometer parameters for a \u201cHI\u201d and \u201cLO\u201d reading.\n4. When administering IV fluids, a minimum amount should be delivered as large amounts may lower blood glucose level and impede original goal of administering Dextrose.\n5. An inadequate amount of glucose for heat production, combined with profound diaphoresis, may place a hypoglycemic patient at greater risk for hypothermia. Keep patient warm as needed.\n6. Patients who are consuming aspirin, acetaminophen, anti -psychotic drugs, beta-blockers, oral diabetic medications, or antibiotics such as sulfa- based, tetracycline, and amoxicillin that experience a hypoglycemic episode are at a greater risk for relapse. These patients should be strongly encouraged to seek additional medical intervention and, as such should be transported. If you (and / or Medical Control) are unable to influence the patient into accepting transport, to, the extent practical, advise the patient to stay with a responsible party who can remain with the patient for several hours.\n7. Glucagon causes a breakdown of stored glycogen to glucose. Glucagon may not work if glycogen stores are previously depleted due to liver dysfunction, alcoholism, or malnutrition. Effects of Glucagon may take up to 30 minutes.\n8. Any patient that has been administered Glucagon should be transported for further evaluation.\n9. Any patient, who has had a hypoglycemic episode without clear reason / cause, should be transported for further evaluation."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Medical - Seizure (Protocol 3-12)",
        "overview": "A seizure is a period of altered neurologic function caused by abnormal neuronal electrical discharges. Generalized seizures begin with an abrupt loss of consciousness. If motor activity is present, it symmetrically involves all four extremities. Episodes that develop over minutes to hours are less likely to be seizures; generally seizures only last one to two minutes. Patients with seizure disorders tend to have stereotype, or similar, seizures with each episode and are less likely to have inconsistent or highly variable attacks. True seizures are usually not provoked by emotional stress. Most seizures are followed by a postictal state of lethargy and confusion.",
        "hpi": "- Reported, witnessed seizure activity description\n- Previous seizure history\n- Medic alert tag information\n- Seizure medications\n- History of trauma\n- History of diabetes mellitus\n- History of pregnancy",
        "signs and symptoms": "- Decreased mental status\n- Sleepiness\n- Incontinence\n- Observed seizure activity\n- Evidence of trauma",
        "considerations": "- CNS (head) trauma\n- Brain tumor\n- Metabolic, hepatic, renal failure\n- Diabetic\n- Hypoxia\n- Electrolyte abnormality\n- Drugs, medications, non-compliance\n- Infection, fever, meningitis\n- Alcohol withdrawal\n- Eclampsia\n- Stroke\n- Hyperthermia",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n   a. Suction the oro/nasopharynx as necessary.\n   b. Place a nasopharyngeal airway as necessary (avoid in head trauma).\n3. Administer oxygen to maintain SPO2 94-99%. Support respirations as necessary with a BVM.\n4. Do not restrain the patient. Let the seizure take its course but protect patient from injury.\n5. Perform rapid glucose determination. If glucose less than 60 mg/dL or clinical signs and symptoms indicate hypoglycemia, refer to the Medical - Diabetic - Hypoglycemia protocol.\n6. Establish an IV of normal saline at KVO.\n7. If the seizure persists and the rapid glucose determination is greater than 60 mg/dL, give MIDAZOLAM 0.2 mg / kg INTRANASAL (max single dose 10 mg) -OR- give MIDAZOLAM 0.1 mg / kg IV / IM (max single dose 5 mg)\n   a. Repeat dose in 5 minutes if seizure persists.\n   b. If midazolam is unavailable, administer DIAZEPAM 0.25 mg / kg up to 5 mg slow IV push. Repeat once as necessary.\n8. Place patient on cardiac monitor (life-threatening dysrhythmias may cause seizure-like activity).\n9. Consider placing the patient in the recovery position during the postictal period.\n10. Transport and perform ongoing assessment as indicated.",
        "types of seizures": "Generalized\n- Absence (Petit-Mal)\n- Atonic (Drop Attack)\n- Myoclonic (Brief bilateral jerking)\n- Tonic-Clonic (Grand-Mal)\n\nSimple Partial\n- Focal/Local: Localized twitching of hand, arm, leg, face, or eyes. Patient may be conscious or unconscious\n\nComplex Partial\n- Temporal Lobe\n- Psychomotor",
        "pearls": "1. Status epilepticus is defined as two or more consecutive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment, and transport.\n2. Grand Mal seizures are generalized in nature and associated with loss of consciousness, incontinence, and tongue trauma.\n3. Focal seizures affect only a specific part of the body and are not usually associated with loss of consciousness.\n4. Jacksonian seizures are seizures that start as focal in nature and become generalized.\n5. Petit Mal seizures may be localized to a single muscle group or may not involve visible seizure activity at all. Always examine pupils for nystagmus, which would alert the provider to continued seizure activity.\n6. Respirations during an active seizure should be considered ineffective and airway maintenance should occur per assessment.\n7. Be prepared for airway problems and continued seizures.\n8. Investigate possibility of trauma and substance abuse.\n9. Be prepared to assist ventilations as dosage Midazolam or Valium is repeated and/or increased."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Medical \u2013 Sickle Cell Anemia/Crisis (Sickle Cell Anemia/Crisis)",
        "overview": "Sickle cell anemia is a recessive genetic illness that primarily affects African-Americans, but also people with African, Arab, India, Greek, Italian, and Latin American heritage. Although rare, Caucasians can also have sickle cell disease or sickle cell trait. In patients with sickle cell anemia, the beta hemoglobin chain of red blood cells are produced abnormally, hemoglobin S, which has an inferior oxygen-carrying ability. These mutated molecules do not have the smooth motion needed for oxygenation and de-oxygenation. When these hemoglobin S cells are exposed to low-oxygen states, they crystallize, distorting the RBC into a fragile, stiff, and rigid crescent (sickle) shape, stopping the smooth passage of the cell through the narrow blood vessels. As a result, blood vessels can sometimes become clogged causing occlusions within the vessels. As fewer RBCs pass through congested vessels, tissues and joints receive less oxygen, causing excruciating pain from the buildup of waste products in the hypoxic areas. Pain may range from mild transient attacks with duration of minutes to severe pain lasting days to weeks and requiring hospitalization.",
        "hpi": "Duration of current crisis\n Last crisis\n Normal crisis symptoms\n Medications (out of meds vs. meds no longer working)\n Allergies",
        "signsandsymptoms": "Increased weakness\n Body aches\n Pain\n Shortness of breath\n Abdominal pain\n Chest pain\n Back pain\n Extremity pain",
        "considerations": "Angina\n Gout\n Drug abuse\n Fibromyalgia\n Lupus\n Electrolyte imbalance\n Dehydration",
        "procedure": "1. Perform general patient management.     \n2. Administer oxygen to maintain SPO2 94 - 99%     \n3. Determine patient\u2019s pain score assessment.     \n4. Consider differential diagnoses for patient\u2019s pain.     \n5. Establish IV of Normal Saline per patient assessment.\nAdminister bolus if needed.   \n6. If significant pain, refer to General \u2013 Pain Control protocol.\nSickle cell patients may be given higher doses of FENTANYL and MORPHINE SULFATE.   \n7. Repeat the patient\u2019s pain score assessment.     \n8. Transport in position of comfort and reassess as indicated.",
        "pearls": "1. Oxygen should be administered if necessary to maintain an O2 saturation above 94% to sickle cell patients to fully oxygenate all normal RBCs and to decrease the sickling of RBCs that occurs during hypoxic states.\n2. Several factors causing sickle cell crises include an infection such as a cold or the flu, cold weather, fatigue, over exercising, and dehydration.\n3. Symptoms of sickle cell disease may start in children as young as six months old. Babies suffering from sickle cell symptoms may be irritable or cranky and cry, even when their parents do everything they can to comfort them. A thorough assessment may include determining the parent\u2019s history when dispatched to a patient complaining of these vague symptoms.\n4. Sickle cell disease is inherited. A patient must inherit two sickle cell genes, one from each parent, to develop sickle cell disease. When only one gene is present, the condition is known as a sickle cell trait. Patients with sickle cell trait often do not have crises."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "PROTOCOL TITLE: Medical \u2013 Hypotension/Shock (Non-trauma)",
        "overview section": "OVERVIEW:\nShock is defined as a state of inadequate tissue perfusion. This may result in acidosis, derangements of cellular metabolism, potential end-organ damage, and death. Early in the shock process, patients are able to compensate for decreased perfusion by increased stimulation of the sympathetic nervous system, leading to tachycardia and tachypnea. Later, compensatory mechanisms fail, causing a decreased mental status, hypotension, and death. Early cellular injury may be reversible if definitive therapy is delivered promptly.",
        "hpi section": "HPI\n* Blood loss (vaginal or gastrointestinal)\n* Fluid loss (vomiting, diarrhea)\n* Fever\n* Infection\n* Cardiac ischemia (MI, HF)\n* Medications\n* Allergic Reaction\n* Pregnancy",
        "signs and symptoms section": "Signs and Symptoms\n* Restlessness, confusion\n* Weakness, dizziness\n* Weak, rapid pulse\n* Pale, cool, clammy skin\n* Delayed capillary refill\n* Hypotension\n* Coffee-ground emesis\n* Tarry stools",
        "considerations section": "Considerations\n* AAA, ectopic pregnancy\n* Shock\n   * Hypovolemic\n   * Cardiogenic\n   * Septic\n   * Neurogenic\n   * Anaphylactic\n* Ectopic pregnancy\n* Dysrhythmia\n* Pulmonary embolus\n* Tension pneumothorax\n* Medication effect, overdose\n* Vaso-vagal\n* Physiologic (pregnancy)",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Assess for signs of shock including, but not limited to:\n   * Restlessness, altered mental status, hypoperfusion (cool, pale, moist skin), tachypnea (rapid breathing), rapid, weak pulse, orthostatic hypotension (blood pressure suddenly drops on standing up), nausea and thirst.\n4. Administer oxygen per patient assessment to maintain SpO2 between 94-99%. Support respirations as necessary with a BVM.\n5. Transport as soon as possible.\n6. Control external bleeding with direct pressure, then tourniquet if direct pressure is inadequate.\n7. If pregnant (uterine fundus above umbilicus), place the patient on her left side.\n8. Maintain body temperature by protecting the patient from the environment, removing wet clothing and covering the patient with a blanket.\n9. Establish a large bore IV or IO of Normal Saline. If time permits, establish second access.\n10. Give a 20 mL/kg bolus. If no improvement after the first 20 mL/kg bolus, may repeat once. While administering a fluid bolus, frequently reassess perfusion for improvement. If perfusion improves, slow the IV to KVO and monitor closely. If patient develops fluid overload respiratory distress (dyspnea, crackles, rhonchi, decreasing SpO2), slow the IV to KVO.\n11. If patient tachycardic and/or hypotensive after IV fluid bolus, consider:\n    a. Administration of Norepinephrine Infusion 0.1-0.5 mcg/kg/minute for hypotension. Titrate to MAP > 65 mmHg.\n    b. If Norepinephrine unavailable, consider Dopamine 5-20 mcg/kg/min for hypotension that remains after fluid bolus. Titrate to MAP > 65 mmHg.\n***DO NOT USE PRESSORS ON HYPOVOLEMIC PATIENTS!***\n12. Transport and perform ongoing assessment as indicated.",
        "pearls section": "PEARLS:\n1. Trendelenburg is no longer believed to increase BP and/or cardiac output in most patients, does not improve tissue oxygenation, results in displacement of only a very small amount of total blood volume, and actually decreases cardiac output in the hypotensive patient. It has also been proven to produce right ventricular stress and deterioration of pulmonary function.\n2. GI bleeding may be a less obvious cause of hypovolemic shock if it has been gradual. Ask patient about possible melena, hematemesis, and hematochezia.\n3. Ectopic pregnancy may be a less obvious cause of hypovolemic shock. Consider this diagnosis in all women of child-bearing age if there is a complaint of abdominal, back or pelvic pain.\n4. Abdominal aneurysm may be a less obvious cause of hypovolemic shock. Consider this diagnosis in patients whose age is \u2265 50, and who have a cardiac/hypertensive history if there is a complaint of abdominal or back pain.",
        "classes of shock section": "Classes of Shock\n\n**Hypovolemic Distributive Cardiogenic Obstructive**\n\nCaused by hemorrhage, Caused by Maldistribution of Caused by necrosis Caused by impairment of\nburns, or dehydration. blood, caused by poor of the myocardial cardiac filling, found in\nvasomotor tone in tissue, or by pulmonary embolism,\nneurogenic shock, arrhythmias. tension pneumothorax, or\nsepsis, anaphylaxis, cardiac tamponade.\nsevere hypoxia, or\nmetabolic shock."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Medical - Respiratory Distress/Asthma/COPD/Croup/Reactive Airway Disease (Respiratory Distress \u2013 Asthma/COPD)",
        "overview": "**OVERVIEW:**\nRespiratory distress, or dyspnea, is one of the most common medical complaints witnessed in pre-hospital medicine. Most patients describe it as a sensation of shortness of breath or a feeling of \u201cair hunger\u201d accompanied by labored breathing. Dyspnea may be caused by pulmonary or cardiac disease or by any mechanism that causes hypoxia. It may be mild, manifesting only on exertion, or severe, occurring at rest. The most common causes of non-cardiac dyspnea in the pre-hospital environment involve asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and bronchitis. The wheezing patient may present in different ways, some may not even complain of wheezing, but rather just of shortness of breath, cough, or chest tightness. Wheezing patients are often apprehensive and distressed, at times, so severe that they may not be able to speak in complete sentences. Oxygenation may be compromised to the point that there is a decrease in the patient\u2019s level of consciousness. These signs are clues that the patient needs immediate and aggressive therapy. Treatment is aimed at maintaining the patient\u2019s SpO2 to > 90%. Remember, not all wheezing is from asthma.",
        "hpi": "**HPI**\n* Asthma, COPD, chronic bronchitis, emphysema, heart failure\n* Home treatment (oxygen, inhaler, nebulizer)\n* Medications (Theophylline, steroids, bronchodilators)\n* Toxic exposure, smoke inhalation",
        "signs and symptoms": "**Signs and Symptoms**\n* Shortness of breath\n* Purse lip respirations\n* Decreased ability to speak\n* Increased respiratory rate and effort\n* Use of accessory muscles\n* Tripoding\n* Wheezing, rhonchi, rales\n* Fever, cough\n* Tachycardia",
        "considerations": "**Considerations**\n* Asthma\n* Anaphylaxis\n* Aspiration\n* COPD (emphysema, bronchitis)\n* Pleural effusion\n* Pulmonary embolism\n* Pneumothorax\n* Cardiac (MI, HF)\n* Pericardial Tamponade\n* Upper respiratory infection\n* Hyperventilation, anxiety\n* Inhaled toxins",
        "procedure": "**EMR EMT A I P**\n1. Perform general patient management.     \n2. Support life-threatening problems associated with airway, breathing, and circulation.     \n3. Administer oxygen to maintain SPO2 94 - 99%. Support respirations as necessary with a BVM.     \n4. Place patient in a position of comfort, typically sitting upright.     \n5. Monitor Capnography, if available.    \n6. Assist patient with prescribed BRONCHODILATOR METERED DOSE INHALER (MDI). If no dosing schedule is prescribed, repeat in 5 to 10 minutes as needed.    \n7. If in critical respiratory distress, provide BVM ventilation with patient\u2019s spontaneous efforts. If patient becomes unresponsive, perform BVM ventilation with an airway adjunct. If BVM ventilation is inadequate, secure airway with a definitive airway (Supraglottic/glottic/dual lumen) or ENDOTRACHEAL TUBE [Level I and P only].     \nFor patients in respiratory distress:\n8. Give ALBUTEROL 2.5 to 5.0 mg and IPRATOPRIUM 0.5 mg via small volume nebulizer.    \na. Repeat ALBUTEROL ONLY every 10 minutes up to 4 treatments if respiratory distress persists and no contraindications develop. Note: IPRATOPRIUM bromide is only administered with the first treatment.    \n9. Establish venous access as needed.   \n10. Administer DEXAMETHASONE IV/IM/PO 10 mg.   \n11. Administer CPAP with 5 \u2013 10 cm H20 PEEP for moderate to severe dyspnea. For levels I and P, if the CPAP device allows, begin at 5.0 mmHg and titrate to effect.    \n12. In the asthmatic patient, for severe respiratory distress that is non-responsive to standard medications, consider administration of MAGNESIUM SULFATE 40 mg/kg IV over 20 minutes (max dose of 2 grams).  \n13. In the asthmatic patient, for severe respiratory distress that is non-responsive to standard medications, contact Medical Control to consider administration of EPINEPHRINE 1:1,000 0.01 mg/kg up to 0.3 mg IM. MC MC\n14. Place on cardiac monitor and obtain 12 lead ECG per assessment.    \n15. Transport and perform ongoing assessment as indicated.",
        "pearls": "**PEARLS:**\n1. Status asthmaticus is defined as a severe prolonged asthma attack, non-responsive to therapy.\n2. A silent chest in respiratory distress is a pre-respiratory arrest sign.\n3. Magnesium Sulfate and Epinephrine should only be used for patents in severe, non-responsive distress that is refractory to initial treatments."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "General \u2013 Behavioral/Patient Restraint",
        "overview": "Psychiatric patients may have an illness that presents with symptoms such as delusions, hallucinations, depression, or significant trauma. The patient\u2019s symptoms demand immediate response as they may appear intense, raise the anxiety levels of those around the patient to an intolerable level, or create problems in the immediate environment. The patient may perceive their life to be at immediate risk, either from suicide or their current inability to make logical decisions. Remember that personal safety takes priority over patient intervention. Patient care should be focused with preventing / mitigating hyperthermia, agitated delirium, positional asphyxia, hypoxia, and physical harm.",
        "hpi": "* Situational crisis\n* Psychiatric illness / medications\n* Injury to self or threats to others\n* Plan\n* History of suicide attempts\n* Substance abuse / overdose\n* Diabetes",
        "signs and symptoms": "* Anxiety, agitation, and/ or confusion\n* Affect change\n* Auditory and / or visual hallucinations\n* Delusional thoughts, bizarre behavior\n* Combative and / or violent\n* Expression of suicidal / homicidal thoughts",
        "considerations": "* See Unconscious / Syncope / AMS\n* Diabetic\n* Hypoxia\n* Stroke\n* Brain trauma\n* Alcohol intoxication\n* Toxin / substance abuse\n* Medication effect / overdose\n* Withdrawal Syndromes\n* Depression\n* Bipolar (manic - depressive), schizophrenia, anxiety disorders",
        "procedure": "For Non-violent and Non-aggressive Patients:\n1. Scene safety is a priority. Maintain scene and provider safety. Request police if indicated.\n2. Perform general patient management.\n3. Develop rapport with the patient. Speak in a calm, non-judgmental / non-confrontational manner. Be aware of your own and the patient\u2019s posture, body language, and position.\n4. Remove disturbing persons and/ or objects from the environment.\n5. Encourage the patient to sit, relax, and talk. Do not touch the patient without permission.\n6. Transport and Reassess if indicated.",
        "management violent or aggressive patients": "For Violent or Aggressive Patients:\n1. Assure scene safety. Request Police department if needed. Do not engage patient without police unless benefits outweigh risks to patient and providers.\n2. Perform general patient management.\n3. Support life-threatening problems associated with airway, breathing, and circulation.\n4. Assess for signs of trauma.\n5. Administer oxygen to maintain SPO2 94 - 99%\n6. For altered mental status, perform rapid glucose determination.\n7. Control environmental factors; attempt to move patient to a private area free of family and bystanders. MAINTAIN ESCAPE ROUTE.\n8. Attempt de-escalation, utilize an empathetic approach. Ensure patient safety and comfort. AVOID CONFRONTATION.\n9. Ensure patient capacity to make decisions. If patient has capacity, consent to treat is required. If patient lacks capacity, consent to treat is not required.\n10. Physically restrain. Refer to Clinical Procedures: Patient Restraint.\n11. Chemical Restraint:\n    a. If chemical agitation or alcohol withdrawal is suspected, refer to the appropriate Medical \u2013 Overdose/Poisoning protocol.\n    b. If behavioral or alcohol related agitation is suspected, give MIDAZOLAM 0.1 mg / kg IV / IM (max single dose of 5 mg). If midazolam is unavailable, administer DIAZEPAM 0.25 mg / kg IV / IM (max single dose of 5 mg or a max dose of 10 mg). Contact Medical Control for repeat dosing.\n    c. In adult patients, if behavioral or alcohol related agitation continues or escalates, give GEODON 20 mg IM if greater than 50 kg weight (10 mg IM if weight less than 50 kg). If Geodon unavailable, use Haldol:\n      -For Moderate agitation give 5 mg Haldol IM\n      -For Severe agitation give 10 mg Haldol IM\n12. Transport as soon as possible.",
        "pearls": "1. Do not leave patient alone once patient contact has been made unless your safety has been compromised. Your safety is the primary concern. If necessary, leave equipment on scene.\n2. Every suicide act, gesture, or verbal threat must be taken seriously. In the Commonwealth of Virginia, patients are unable to refuse care under these circumstances and shall be placed in emergency custody as needed with police assistance, VA Code 3 7.2-808.\n3. Always have police search patient for weapons or items that could be used as weapons prior to placing patient in ambulance. Patient belongings that are secured should be transported in the front of the ambulance, or an outside compartment, for safety and given to hospital staff on arrival.\n4. If a patient must be transported using handcuffs or police flexible wrist restraints, a police officer should ride in the ambulance with the patient to the receiving hospital.\n5. Patient\u2019s taking medications long term for the treatment of seizures may have resurgence of seizure activity as Haldol can decrease the idd"
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Airway - Failed",
        "overview": "The purpose of these guidelines is to facilitate the management of the difficult airway and to reduce the likelihood of adverse outcomes. The principal adverse outcomes associated with the difficult airway include, but are not limited to, death, brain injury, myocardial injury, and airway trauma.",
        "hpi": "* Age\n* Past medical, surgical history\n* Medications\n* Reason for airway failure\n* Duration of symptoms\n* Last meal\n* Menstrual history, pregnancy",
        "signs and symptoms": "* Hypercarbia\n* Stridor\n* Trismus\n* Pooling of secretions\n* Hypoxia",
        "considerations": "* Congenital abnormalities\n* Previous tracheostomy\n* Previous neck surgeries\n* Previous mouth / throat surgeries\n* Known head / neck cancers and masses\n* Trauma",
        "medication facilitated intubation and surgical airway": "Medication Facilitated Intubation and Surgical Airway are skills that are only approved when:\n* Proper medications and equipment are available for procedures; AND\n* The ALS Provider has been trained in those procedures; AND\n* The provider's OMD has authorized the performance of the procedures for the provider.",
        "procedure": "1. Perform general patient management.     \n2. Assess mechanism of injury and/or nature of illness. Protect C-spine if necessary.     \n3. Administer Oxygen to maintain SpO2 94 - 99%     \n4. Assess patient ability to control airway and adequacy of ventilations. Do not hypo or hyperventilate.     \n5. Use head-tilt-chin-lift or jaw thrust as appropriate to open airway. Use oral or nasal airway adjuncts to support as appropriate.     \n6. Support ventilations with two-man bag-valve-mask ventilations if personnel is available.     \n7. If unable to maintain airway, consider oral (I or P) or nasal (P only) intubation.  \n8. If unable to successfully intubate, attempt to use an alternative airway to secure airway.    \n9. If still unable to maintain airway, consider medication facilitated intubation* or use alternative airway as a rescue device. \n10. If still unable to maintain airway, consider surgical airway or Needle Cricothyrotomy. \n11. Transport promptly.    \n12. Continuously monitor patient's airway."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Medical \u2013 Nausea/Vomiting",
        "overview": "The pre-hospital provider should be very careful to ensure that patients who present with vague complaints such as nausea and vomiting are thoroughly assessed. All patients presenting with nausea and vomiting should be screened for potential life-threats initially. Anti-emetic treatment should be considered a treatment of a symptom of an underlying illness or injury. The patient\u2019s symptoms and recent history must determine the most appropriate care. Frequently, treatment of an underlying cause and limiting movement may resolve or greatly reduce these complaints. However, persistent nausea and vomiting of unknown etiology may respond well to pharmaceutical therapy. Do not overlook the possibility of cardiac origin complaints, with atypical presentation of nausea/vomiting (i.e., diabetic and female patients).",
        "hpi": "* Age\n* Time of last meal\n* Last bowel movement, emesis\n* Improvement, worsening with food or activity\n* Duration of signs and symptoms\n* Other sick contacts\n* Past medical, surgical history\n* Medications\n* Menstrual history (pregnancy)\n* Travel history\n* Recent trauma",
        "signs and symptoms": "Pain\n* Character of pain (constant, intermittent, sharp, dull, etc)\n* Distention\n* Constipation\n* Diarrhea\n* Anorexia\n* Radiation\n* Associated symptoms (helpful to localize source): Fever, headache, blurred vision, weakness, malaise, myalgias, cough, dysuria, mental status changes, rash",
        "considerations": "* CNS (increased pressure, headache, stroke, lesions, trauma, hemorrhage, vestibular)\n* Myocardial infarction\n* Drugs (NSAIDs, antibiotics, narcotics, chemotherapy)\n* GI or renal disorders\n* Gynecological disease (ovarian cyst, PID)\n* Infections (pneumonia, influenza)\n* Electrolyte abnormalities\n* Food or toxin induced\n* Medications, substance abuse\n* Pregnancy\n* Psychologic",
        "procedure": "1. Perform general patient management.     \n2. Support life-threatening problems associated with airway, breathing, and circulation.     \n3. Administer oxygen to maintain SPO2 94 - 99%     \n4. Allow the patient to lie in a comfortable position.     \n5. Establish an IV of normal saline per patient assessment.   \n6. Assess for signs of shock. If shock is suspected, follow the Medical \u2013 Hypotension/Shock (non-trauma) protocol.     \n7. Place the patient on the cardiac monitor and obtain / interpret 12 lead ECG.    \n8. For severe nausea or vomiting, if available, give ONDANSETRON (ZOFRAN) administer 0.1 mg / kg IV / IM up to 4 mg over 2 to 5 minutes.*   \n9. If moderate to severe nausea or vomiting in adults only, consider administering ONDANSETRON (ZOFRAN) ODT 4 mg tablet.    \n10. May repeat ONDANSETRON dosing in adult after 5 minutes if needed    \n11. Transport and perform ongoing assessment as indicated.",
        "pearls": "1. Nausea and vomiting has many subtle, sometimes life-threatening causes. Do not minimize its importance as a symptom of a serious life-threatening illness or injury.\n2. Atypical CVAs and vertebrobasilar artery compromise may present as benign vertigo or labyrinthitis. Therefore, it is recommended that all cases of vertigo should be transported for physician evaluation whenever possible.\n3. Ondansetron (Zofran) may not be as effective for vertigo and labyrinthitis-related nausea and vomiting.\n4. For nausea and vomiting associated with dehydration, fluid replenishment may be sufficient in improving patient comfort and reduce the need for medication administration.\n5. Performing an appropriate history and physical will identify life-threats and concerns that should receive priority over anti-emetic treatment.\n6. In cases of toxic ingestion, including alcohol, poisons, and drug overdoses, vomiting is an internal protective mechanism and should not be prevented with pharmacological therapy in the pre-hospital environment. Care should be given to prevent aspiration.\n7. Ondansetron (Zofran) is also safe and effective for nausea and vomiting in trauma patients and can be used in conjunction with pain management.\n8. Proper documentation should include the mental status and vital signs before and after medication administration."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Medical \u2013 Dystonic/ Extrapyramidal Reaction",
        "overview": "Dystonic or extrapyramidal reactions are characterized by an unusual posture, change in muscle tone, drooling, and/or uncontrolled movements. Although dystonic reactions are occasionally dose related, these reactions are more often idiosyncratic and not predictable. Dystonia results from drug-induced alteration of the dopaminergic-cholinergic balance in the basal ganglia. Risk factors include, but are not limited to, family history of dystonia, recent history of cocaine or alcohol use, or treatment with a potent dopamine D2 receptor antagonist such as fluphenazine and almost every antipsychotic medication. Diphenhydramine, when administered, usually causes marked improvement, if not total resolution of symptoms.",
        "hpi": "* Onset of symptoms\n* Medications\n* Illicit drug use\n* History of past reaction",
        "signs and symptoms": "* Eye deviation in all directions\n* Protrusion of the tongue\n* Forced jaw opening or spasms\n* Facial grimacing\n* Deviation of the head\n* Difficulty speaking",
        "considerations": "* Conversion disorder\n* Mandible dislocation\n* Hypocalcemia\n* Hypomagnesemia\n* Meningitis\n* Status Epilepticus\n* Stroke\n* Tetanus\n* Drug toxicity (Anticholinergic, Carbamazepine, Phenytoin, Valproate)",
        "procedure": "1. Perform general patient management. \u2502 \u2502 \u2502 \u2502 \u2502\n2. Administer oxygen to maintain SpO2 94-99% \u2502 \u2502 \u2502 \u2502 \u2502\n3. If patient is having a seizure, refer to the Seizure protocol. \u2502 \u2502 \u2502 \u2502 \u2502\n4. Obtain a blood glucose sample. If < 60 mg/dl or > 300 mg/dL, refer to Hypoglycemia or Hyperglycemia protocol. \u2502 \u2502 \u2502 \u2502\n5. Place patient on cardiac monitor and obtain 12-lead ECG if indicated. \u2502 \u2502 \u2502 \u2502\n6. Establish IV of Normal Saline, titrate to maintain systolic BP > 90 mmHg; alternatively may establish NaCl lock. \u2502 \u2502 \u2502\n7. Administer DIPHENHYDRAMINE (Benadryl) 25-50 mg IV or IM. \u2502 \u2502 \u2502\n8. Transport in position of comfort and reassess. \u2502 \u2502 \u2502 \u2502",
        "common types of dystonia": "* Spasmodic Torticollis \u2013 Commonly called wry neck or cervical dystonia, is the most common form of focal dystonia. This form affects the muscles in the neck, causing the head to assume unnatural postures or turn uncontrollably. The head may turn (laterocollis), twist to one side (rotational torticollis), tilt forward (anterocollis), or tilt backward (retrocollis).\n* Blepharospasm \u2013 This is the second most common form of focal dystonia causing involuntary contraction of the eyelids, leading to uncontrollable blinking and closure of the eyes.",
        "common medications causing dystonia": "**Anti-depressants** **Neuroleptic Agents** **Miscellaneous Agents**\n* Amitriptyline\n* Amoxapine (Asendis)\n* Bupropion\n* Clomipramide (Anafranil)\n* Doxepin (Sinequan)\n* Trimipramine (Surmontil)\n* Trazadone (Desyrel)\n* Chlorpromazine (Largactil)\n* Clozapine (Clozaril)\n* Fluphenazine (Prolixin)\n* Haloperidol (Haldol)\n* Perphenazine (Fentazin)\n* Promazine\n* Trifluoperazine (Stelazine)\n* Lithium (Priadel)\n* Midazolam\n* Phenytoin (Dilantin)\n* Promethazine (Phenergan)\n* Verapamil (Calan)\n**Anti-anxiety Agents** **Anti-nausea/ Vomiting agents**\n* Alprazolam (Xanax)\n* Buspirone (Buspar)\n* Metoclopramide (Reglan)\n* Prochlorperazine (Stemetil)",
        "pearls": "1. Incidence of acute dystonic reactions vary according to individual susceptibility, drug identity, dose, and duration of therapy.\n2. A small population of all patients on neuroleptic medications have dystonic reactions.\n3. In rare instances, although abnormal, airway management may be needed.\n4. Dystonic reactions are rarely life-threatening and result in no long-term effects.\n5. Risk of reaction typically decreases with age and tends to be most common in children, teens, and young adults (<45 years old)."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Sepsis",
        "overview": "Sepsis is an illness that affects all parts of the body that can happen in response to an\ninfection and can quickly become life-threatening. Sepsis is a systemic inflammatory\nresponse syndrome or (SIRS) caused by severe infection. In severe cases of sepsis,\none or more organs fail. In the worst cases, sepsis causes the blood pressure to drop\nand the heart to weaken, leading to septic shock. Once this happens, multiple organs\nmay quickly fail and the patient can die. Sepsis is a serious illness that is very difficult to\npredict, diagnose, and treat. Patients who develop sepsis have an increased risk of\ncomplications and death and face higher healthcare costs and longer treatment. The\nmortality rate can range from 10% to 60%. Early recognition combined with aggressive\nfluid resuscitation and finding the source of infection are the keys to greatly reducing the\nmortality rate.",
        "hpi": "Recent antibiotic use",
        "signs and symptoms": "Fever, chills, sweats\n Cough\n SOB\n Rash\n Headache, neck pain\n Restlessness, confusion\n Weakness, dizziness\n Weak, rapid pulse\n Pale, cool, clammy skin\n Delayed capillary refill\n Difficulty breathing\n Hypotension\n Febrile",
        "considerations": "Shock\n Hypovolemic\n Cardiogenic\n Septic\n Neurogenic\n Anaphylactic\n Ectopic pregnancy\n Dysrhythmia\n Pulmonary embolus",
        "general inclusion criteria at least two of the following specific findings": "18 years old and NOT pregnant\n History consistent with infection;\n Signs of hypoperfusion or hypotension\n Temperature greater than 38\u00baC (100.4\u00baF) or lower than 36\u00baC (96\u00baF)\n Pulse greater than 90 bpm\n Respiratory rate greater than 20/min\n Known abnormal white blood cell count (>12,000 or <4,000 cells/mm)\n Hypoperfusion, as manifested by one of the following:\n  1. Systolic BP less than 90 or MAP less than 65\n  2. If known, Lactate level greater than 4mmol/L\n  3. Altered mental status\n  4. Pulse Ox <94% despite high flow oxygen",
        "procedure": "EMR EMT AIP\n1. Perform general patient management. Obtain patient\u2019s temperature, if possible      \n2. Identify criteria for sepsis. If meets general inclusion criteria and two or more specific findings, continue with this protocol. If not, refer to appropriate protocol. \n3. Administer oxygen to maintain SPO2 94-99%.     \n4. Obtain 12 lead ECG.    \n5. Interpret 12 lead ECG and place on cardiac monitor  \n6. Initiate IV of Normal Saline KVO. Establish second IV if time permits.   \n7. Administer Normal Saline 30 mL / kg bolus.   \n8. If patient is hypotensive after IV initial fluid bolus, consider\n   a. Administration of Norepinephrine (13-27) infusion 0.1-0.5 mcg / kg / minute for hypotension. Titrate to MAP > 65 mmHg.\n   b. If Norepinephrine unavailable, consider Dopamine (13-14) infusion 5 - 20 mcg / kg / min for hypotension that remains after fluid bolus. Titrate to MAP > 65 mmHg.  \n9. If patient is tachycardic and/or hypotensive after initial bolus, administer bolus of Normal Saline 20 ml / kg bolus.  \n10. Notify receiving hospital of potential of \u201csepsis alert\u201d patient    \n11. Transport promptly in position of comfort. Reassess as needed.",
        "classes of shock": "Hypovolemic Distributive Cardiogenic Obstructive\nCaused by hemorrhage, burns, or dehydration. Maldistribution of blood, caused by poor vasomotor tone in neurogenic shock, sepsis, anaphylaxis, severe hypoxia, or metabolic shock. Caused by necrosis of the myocardial tissue, or by arrhythmias. Caused by impairment of cardiac filling, found in pulmonary embolism, tension pneumothorax, or cardiac tamponade.",
        "pearls": "1. Sometimes patients may present with complaints of weakness, malaise, altered mental status, or simply \"not eating.\" The source of infection may be readily apparent (cellulitis), may require extensive testing (intra-abdominal abscess), or may be completely obscure (subacute endocarditis).\n2. Up to 15% of infected elderly patients with normal oral temperatures will have an elevated rectal temperature.\n3. Norepinephrine reference is available at 13-27.\n4. Dopamine reference is available at 13-14."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Medical - Altered Mental Status",
        "overview": "The unconscious patient can be a difficult patient to manage. There are many potential causes for a change in mentation or syncope. These causes range from benign problems to potentially life-threatening cardiopulmonary or central nervous system disorders. When approaching the patient that has experienced a change in mental status, or syncope, be alert for clues that may indicate the potential cause \u2013 diligently obtain a thorough patient history and perform a complete physical exam. Obtaining an adequate physical assessment and assessing for the presence of common causes of the episode can quickly aid you in determining the proper sequence of care to provide to the patient. Focus on managing any life-threatening conditions that may have led to the episode and correcting any found.",
        "signs and symptoms": "Loss of consciousness with recovery\n Lightheadedness, dizziness\n Palpitations, slow or rapid pulse\n Pulse irregularity\n Decreased blood pressure",
        "hpi": "Complaint prior to event",
        "considerations": "Cardiac history, stroke, seizures\n Occult blood loss (GI, ectopic)\n Females (LMP, vaginal bleeding)\n Fluid loss (nausea, vomiting, diarrhea)\n Past medical history\n Recent trauma",
        "procedure": "1. Perform general patient management.      \n2. Maintain patient in a supine position.      \n3. Administer oxygen to maintain SPO2 94 - 99% and glucose check.      \n4. If the patient has altered mental status, refer to the appropriate protocol per assessment. If no obvious etiology is identified, refer to Medical \u2013 Stroke/TIA protocol.      \n5. If the patient age is \u2265 25 years of age or has a cardiac history, place on cardiac monitor and obtain / interpret 12 lead ECG. If interpretation is consistent with STEMI, notify and transport to the closest appropriate Emergency PCI hospital.     \n6. Establish IV of Normal Saline. Keep at KVO rate unless hypotensive. If hypotensive, refer to Medical \u2013 Hypotension/Shock (Non -trauma) protocol.    \n7. Transport and reassess as needed.",
        "possible causes of unconsciousness syncope ams": "A Alcohol, Abuse, Acidosis\nE Endocrine, Electrolytes, Encephalopathy\nI Insulin\nO Oxygenation, Overdose, Opiates\nU Uremia\n\nT Toxidromes, Trauma, Temperature, Tumor\nI Infection, Intussusception\nP Psychogenic, Porphyria, Pharmacological\nS Space occupying lesion, Sepsis, Seizure, Shock",
        "pearls": "1. In patient that has experienced a syncopal episode, assess for signs or symptoms of injury and take appropriate precautions if there is reason to suspect trauma, or traumatic injury that cannot be ruled out.\n2. In patients with a cardiac history, or in the elderly, be suspicious of cardiac arrhythmia as the cause of syncope."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Abdominal Pain",
        "overview": "Abdominal pain is one of the most common presenting complaints in emergency medicine. In up to 42% of patients, the etiology remains obscure. Recalling the differences between generalized types of pain can be helpful diagnostically.\n\n* Visceral abdominal pain results from stretching of the autonomic nerve fibers. The pain may be described as cramp-like, colicky, or gaseous and is often intermittent. Obstruction is often the cause.\n* Somatic pain occurs when pain fibers located in the parietal peritoneum are irritated by chemical or bacterial inflammation. The pain is described as sharp, more constant, and more precisely located.\n* Referred pain is any pain felt at a distance from a diseased organ. Referred pain generally follows certain classic patterns, for example, diaphragmatic irritation often radiates to the supra-clavicular area.",
        "hpi": "* Age\n* Past medical, surgical history\n* Medications\n* Time of onset\n* Palliation, provocation\n* Quality (crampy, constant, sharp, dull, etc)\n* Region, radiation, referred\n* Severity (1-10)\n* Duration, repetition\n* Fever\n* Last meal\n* Last bowel movement, consistency\n* Menstrual history, pregnancy",
        "signs and symptoms": "* Pain (location, migration)\n* Distension, rigidity\n* Unequal, absent femoral pulses\n* Diaphoresis\n* Orthostatic changes\n* Tenderness\n* Nausea, vomiting, diarrhea\n* Dysuria\n* Constipation\n* Vaginal bleeding, discharge\n* Pregnancy\n* Associated symptoms (helpful to localize source) Fever, headache, weakness, malaise, myalgias, cough, mental status changes, rash",
        "differential diagnosis": "* Pneumonia, CHF\n* Pulmonary embolus\n* Liver (hepatitis)\n* Peptic ulcer disease, gastritis\n* Gallbladder\n* Myocardial infarction\n* Pancreatitis\n* Kidney stone\n* Abdominal aneurysm\n* Mesenteric Arterial Tear\n* Appendicitis\n* Bladder, prostate disorder\n* Pelvic (PID, ectopic pregnancy, ovarian cyst)\n* Spleen enlargement\n* Bowel obstruction\n* Gastroenteritis (infectious)",
        "bls": "* Perform initial assessment (General impression, Airway, Breathing, Circulation, and LOC).\n* Place patient on pulse oximetry and administer Oxygen per patient assessment.\n* Place patient on a cardiac monitor.\n* Assess abdomen for pulsating masses, if noted refer to Aortic Dissection/ AAA Patient Care Protocol.\n* Use distraction (through conversation, etc) and breathing techniques to help patient alleviate pain.\n* If shock is present, without pulsating masses, refer to Hypovolemic Shock (Non-Cardiac) Patient Care Protocol.",
        "als": "* Place patient on a cardiac monitor.\n* (A-Skill) Establish IV of Normal Saline at KVO rate or NS lock, per patient assessment.\n* Obtain and interpret 12-Lead ECG, refer to appropriate Cardiac Patient Care Protocol as needed.\n* (A-Skill) Administer ONDANSETRON (Zofran) 0.1 mg/kg slow IVP over 2-5 minutes, max 4.0 mg per dose, or 4 mg orally dissolving tablet (ODT) as needed, per Nausea and Vomiting Patient Care Protocol.\n* Transport promptly in a position of comfort and reassess vital signs as indicated.",
        "pearls": "1. Abdominal pain may be the first sign of an impending rupture of the appendix, liver, spleen, ectopic pregnancy, or an aneurysm. Monitor for signs of hypovolemic shock.\n2. If a pulsating mass is felt, suspect an abdominal aneurysm and discontinue palpation.\n3. Abdominal pain in women of childbearing age should be treated as an ectopic pregnancy until proven otherwise.\n4. Appendicitis presents with vague, periumbilical pain that migrates to the RLQ over time.\n5. Kidney stones present with flank pain that migrates to the lower quadrants.\n6. Ask the patient to point to the pain. The farther from the umbilicus the patient points, the more likely the pain is to be organic in origin.\n7. Simple pain management techniques include oxygen administration, splinting, speaking in a calm, reassuring voice, and placing the patient in their position of comfort.\n8. If primary medication unavailable, use provided alternative medication and refer to Medication Reference Section, as needed."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Medical  Stroke/TIA",
        "overview": "Stroke is a major cause of disability and a leading cause of death in the U.S. There are two main mechanisms of stroke: (1) Blood vessel occlusion and (2) Blood vessel rupture. Ischemic strokes are most often caused by large vessel thrombosis, although embolism or hypoperfusion can cause them. Causes of thrombosis include atherosclerosis, vessel dissection, and some infectious diseases. Hemorrhagic strokes are divided into intracerebral (ICH) and subarachnoid (SAH) hemorrhages. Risk factors for ICH include heart disease, hypertension, smoking, diabetes, elevated cholesterol, older age, prior stoke, family history, and cocaine use. Stroke symptoms will present according to which area of the brain is being inadequately perfused.",
        "hpi": "Previous CVA/ TIA\u2019s\n Previous cardiac / vascular surgery\n Associated diseases; diabetes, hypertension, CAD, atrial fibrillation\n Medications (blood thinners)\n History of trauma",
        "signs and symptoms": "Altered mental status\n Weakness, paralysis\n Blindness or other sensory loss\n Aphasia, dysarthria\n Syncope\n Vertigo, dizziness\n Vomiting\n Headache\n Seizures\n Respiratory pattern change\n Hypertension, hypotension",
        "considerations": "TIA\n Seizure\n Hypoglycemia\n Stroke\n Thrombotic\n Embolic\n Hemorrhagic\n Tumor\n Trauma",
        "procedure": "1. Perform general patient management.     \n2. Support life-threatening problems associated with airway, breathing, and circulation. Be alert for aspiration, upper airway obstruction and hypoventilation.     \n3. Administer oxygen to maintain SPO2 94 - 99%. Support respirations as necessary with a BVM.     \n4. Perform and document Cincinnati or FAST stroke evaluation and if positive, perform VAN     \n5. Determine last known well time     \n6. If positive BE FAST /FAST , notify hospital of stroke alert. If positive VAN test, notify hospital of stroke alert with positive VAN.    \n7. Perform rapid glucose determination. If glucose less than 60 mg / dL or clinical signs and symptoms indicate hypoglycemia, refer to the Medical  Diabetic  Hypoglycemia protocol.    \n8. Ensure that a witness accompanies the patient to the hospital or obtain contact telephone for the hospital     \n9. Establish an IV of normal saline at KVO. If possible, establish secondary IV as well.   \n10. Place patient on cardiac monitor and obtain 12 lead ECG (and interpret if ALS) within 10 minutes of patient contact.    \n11. Perform ongoing assessment as indicated.    \n12. Transport to closest appropriate hospital with capabilities to provide the appropriate level of treatment based on time from last known well to estimated time of arrival at facility and positive stroke scale\n    a. less than 3.5 hrs with weakness and negative VAN  transport to any stroke certified hospital or stroke capable facility    \n    b. less than 3.5 hrs with weakness and positive VAN (or any wake-up stroke)  transport to comprehensive stroke center or primary stroke center with endovascular capabilities    \n    c. between 3.5 hrs and 24 hours (any stroke)  transport to comprehensive stroke center or primary stroke center with endovascular capabilities    \n    d. greater than 24 hours (any stroke)  transport to any stroke certified hospital or stroke capable facility    \n13. Consider not bypassing stroke capable/primary stroke centers if time to higher level of care is greater than 15 minutes    \n14. Consider air medical transport if ground transport time >30 minutes",
        "befast stroke scale 2": "B - Balance. Is there a sudden loss of balance or coordination?\n Normal  the person can walk unassisted and upright\n Abnormal  unbalanced, difficulty ambulating, unable to coordinate gait\nE - Eyes. Are there sudden vision changes?\n Normal  vision acuity is normal for patient\n Abnormal  blurry vision, deficits in vision, unable to track with eyes\nF - Face. Does one side of the face droop?\n Normal \u2014 both sides of face move equally\n Abnormal \u2014 one side of face does not move as well as the other side\nA - Arm. Does one arm drift downward?\n Normal \u2014 both arms move the same or both arms do not move at all (other findings, such as pronator drift, may be helpful)\n Abnormal \u2014 one arm does not move or one arm drifts down compared with the other\nS - Speech. Are the words slurred? Is speech confused?\n Normal \u2014 patient uses correct words with no slurring\n Abnormal \u2014 patient slurs words, uses the wrong words, or is unable to speak\nT - Time. What time did the symptoms begin? When was the person last seen looking or acting normally?",
        "van stroke scale": "V  Vision. Ask the patient to look left, right, up, and down\n Normal  No changes in vision\n Abnormal  Field cut (which side) (4 quadrants), double vision, blind new onset\nA  Aphasia. Can the patient understand and speak coherently?\n Normal  Patient can understand language\n Abnormal  inability to speak or periphrastic errors, unreceptive (not understanding or following commands such as close eyes, make fist)\nN  Neglect. Is the patient forcibly gazing to the right or left and not acknowledging the other side\n Normal  Able to maintain vision fields\n Abnormal  Forced gaze or inability to track to one side, unable to feel both sides at the same time, or unable to identify own arm, Ignoring one side",
        "pearls": "1. Every hospital and free standing emergency department in the region is an \u201cAcute Stroke Capable Hospital.\u201d Primary Stroke Centers (PSC) are (in alphabetical order) : Chippenham, HDH- F, Johnston- Willis, JRMC, MRMC , PDH, Richmond Community Hospital , SRMC , SFMC , VCU Medical Center .\n2. Onset of symptoms is defined as the last witnessed time the patient was symptom free (i.e. , a patient awakening with stroke symptoms would be defined as an onset time of the previous night when the patient was symptom free).\n3. The differentials listed in the Unconscious / Syncope / AMS Patient Care Protocol should also be considered.\n4. Be alert for airway problems (difficulty swallowing, vomiting, aspiration, etc).\n5. Hypoglycemia can present as a localized neurological deficit in the elderly.\n6. There is an increased risk of stroke after a myocardial infarction (MI). Positive predictors of stroke after MI include: advanced age; diabetes ; hypertension; history of prior stroke ; anterior location of index MI ; prior MI, atrial fibrillation ; heart failure; and nonwhite race.1\n7. Scene and transport times should be minimized so the patient may receive the maximum benefit of intravenous thrombolytic therapy or endovascular intervention.\n8. Wake-up strokes may be treated as acute strokes, even up to 24 hrs. Studies indicate improvement with intervention.\n1 Am J Med. 2006 Apr;119(4):354.e1- 9. The incidence of stroke after myocardial infarction: a meta- analysis. Witt BJ, Ballman KV, Brown RD Jr, Meverden RA, Jacobsen SJ, Roger VL.",
        "possible causes of unconsciousness": "A Alcohol, Abuse, Acidosis\nT Toxidromes, Trauma, Temperature, Tumor\nE Endocrine, Electrolytes, Encephalopathy\nI Infection, Intussusception\nI Insulin\nP Psychogenic, Porphyria, Pharmacological\nO Oxygenation, Overdose, Opiates\nU Uremia\nS Space occupying lesion, Sepsis, Seizure, Shock"
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Medical \u2013 Diabetic \u2013 Hyperglycemia",
        "overview": "Symptomatic hyperglycemia can be described as an elevated blood glucose level with signs of severe dehydration, altered mental status, and/or shock. For the purpose of these protocols, the glucose level for symptomatic hyperglycemia is 300 mg/dL.\n\nHyperglycemia is usually the result of an inadequate supply of insulin to meet the body\u2019s needs. Most pre-hospital care should be focused around the treatment of severe dehydration and support of vital functions.",
        "hpi": "\uf0b7 History of diabetes\n\uf0b7 Onset of symptoms\n\uf0b7 Medications",
        "signs and symptoms": "\uf0b7 Anxiety, agitation, and/or confusion\n\uf0b7 Dry, red, and/or warm skin\n\uf0b7 Acetone (fruity) smell on breath\n\uf0b7 Kussmaul respirations\n\uf0b7 Dry mouth, intensive thirst\n\uf0b7 Abnormal/hostile behavior\n\uf0b7 Tachycardia\n\uf0b7 Dizziness/headache",
        "considerations": "\uf0b7 Hypoxia\n\uf0b7 Stroke\n\uf0b7 Brain trauma\n\uf0b7 Alcohol intoxication\n\uf0b7 Toxin/substance abuse\n\uf0b7 Medication effect/overdose",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Assess for signs of trauma. Provide spinal immobilization as necessary.\n4. Administer oxygen to maintain SPO2 94-99%\n5. For altered mental status, perform rapid glucose determination.\n6. If glucose greater than 300 mg/dL, start an IV of normal saline.\n7. For signs and symptoms of hypovolemic shock or dehydration, follow the Medical \u2013 Hypotension/Shock (non-trauma) protocol.\n8. Place on cardiac monitor and obtain/interpret 12 lead ECG as indicated.\n9. Transport and perform ongoing assessment as indicated.",
        "possible causes of pulseless arrest": "A Alcohol, Abuse, Acidosis\nT Toxidromes, Trauma, Temperature, Tumor\nE Endocrine, Electrolytes, Encephalopathy\nI Infection, Intussusception\nI Insulin\nO Oxygenation, Overdose, Opiates\nS Space occupying lesion, Sepsis, Seizure, Shock\nU Uremia",
        "pearls": "1. Use aseptic techniques to draw blood from finger.\n2. Allow alcohol to dry completely prior to puncturing finger for blood glucose level. Alcohol may cause inaccurate readings. Do not blow on, or fan site, to dry faster.\n3. After puncturing finger, use only moderate pressure to obtain blood. Excessive pressure may cause rupture of cells causing inaccurate results.\n4. Know your specific agency\u2019s glucometer\u2019s parameters for a \u201cHI\u201d and \u201cLO\u201d reading."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "Medical \u2013 Allergic Reaction and Anaphylaxis",
        "overview": "Anaphylaxis allergic reactions are serious and potentially life-threatening medical emergencies. It is the body\u2019s adverse reaction to a foreign protein, (i.e., food, medicine, pollen, insect sting, or any ingested, inhaled, or injected substance). Patients with allergic reactions frequently present only with local or generalized swelling; in contrast, anaphylaxis is characterized by wheezing, significant airway compromise, and/or systolic BP < 90 mmHg. Common to both disorders are urticaria and Angioedema, which when isolated are best treated with simple antihistamine therapy. It is when respiratory symptoms, such as upper airway edema, dyspnea, and wheezing are present, EMS personnel should attribute these findings to anaphylaxis, and subsequently move to more aggressive therapy. Cardiovascular collapse may occur abruptly, without the prior development of skin or respiratory symptoms. Constant monitoring of the patient\u2019s airway and breathing is mandatory.",
        "allergic reaction vs anaphylaxis": "* Symptoms involving only one organ system (i.e., localized edema, hives, or vomiting)\n* A more severe reaction characterized by the acute involvement of two or more organ systems (i.e., hives and respiratory distress, decreased BP and nausea/vomiting, etc.)",
        "hpi": "* Onset and location\n* Insect sting or bite\n* Food allergy/exposure\n* New clothing, soap, detergent\n* Past history of reactions\n* Medication history",
        "signs and symptoms": "* Itching or hives\n* Coughing, wheezing, or respiratory distress\n* Chest or throat constriction\n* Difficulty swallowing\n* Hypotension or shock\n* Edema",
        "considerations": "* Urticaria (rash only)\n* Anaphylaxis (systemic effect)\n* Shock (vascular effect)\n* Angioedema (drug induced)\n* Aspiration/airway obstruction\n* Vaso-vagal event\n* Asthma or COPD\n* Heart failure",
        "procedure": "1. Perform general patient management. \n2. Support life-threatening problems associated with airway, breathing, and circulation. \n3. Administer oxygen to maintain SPO2 94-99% \n4. If signs of anaphylaxis, go to section 5. If localized allergic reaction, go to section 9. \n5. If signs of Anaphylaxis and autoinjector or approved dose-limiting system available, administer epinephrine. \n6. If no autoinjector or approved device available, administer EPINEPHERINE 1 mg/ml 0.01 mg/kg up to 0.5 mg IM. \n7. Administer DIPHENHYDRAMINE 1 mg/kg up to 50 mg IM or IV. The IV route is preferred for the patient in severe shock. If an IV cannot be readily established, give diphenhydramine via the IM route. If Benadryl injection not available, give one (1) 25mg PO capsule if the patient is 25-49kg. If 50 kg or larger, give Benadryl two (2) capsules PO. During shortages, refer to medication references 13- 39 or 13- 40 for alternative medications and dosing recommendations. \n8. If hypoperfusion persists following the first dose of epinephrine, consider administration of 20 mL/kg normal saline IV. While administering a fluid bolus, frequently reassess perfusion for improvement. If perfusion improves, slow the IV to KVO and monitor closely. If the patient develops fluid overload respiratory distress (dyspnea, crackles, rhonchi, decreasing SpO2), slow the IV to KVO. \n9. For Allergic Reaction administer DIPHENHYDRAMINE 1 mg/kg up to 50 mg IM or IV. The IV route is preferred for the patient in severe shock. If an IV cannot be readily established, give diphenhydramine via the IM route. If Benadryl injection not available, give one (1) 25mg PO capsule if patient is 25-49kg. If 50 kg or larger, give Benadryl two (2) capsules PO. During shortages, refer to medication references 13-39 or 13-40 for alternative medications and dosing recommendations.\n10. Assess for development of anaphylaxis and refer to section 5.\n11. If the patient is experiencing respiratory distress with wheezing, refer to the Respiratory Distress protocol.\n12. Transport as soon as possible.\n13. Establish an IV of normal saline at KVO.\n14. Transport and perform ongoing assessment as indicated.",
        "pearls": "1. A thorough assessment and a high index of suspicion are required for all potential allergic reaction patients.\n2. Individuals with asthma, atopic dermatitis (eczema), prior anaphylactic history, and those who delay treatment can be at greater risk for a fatal reaction.\n3. It is strongly recommended that all patients receiving anti-cholinergic medications should be transported for observation following treatment for return of symptoms.\n4. Gastrointestinal symptoms occur most commonly in food-induced anaphylaxis, but can occur with other causes. Oral pruritus is often the first symptom observed in patients experiencing food-induced anaphylaxis. Abdominal cramping is also common, but nausea, vomiting, and diarrhea are frequently observed as well.\n5. Contrary to common belief that all cases of anaphylaxis present with cutaneous manifestations, such as hives or mucocutaneous swelling, a significant portion of anaphylactic episodes may not involve these signs and symptoms on initial presentation. Moreover, most fatal reactions to food-induced anaphylaxis in children were not associated with cutaneous manifestations.\n6. Dose limiting systems are color coded syringes and other devices that do not require medication math to give the dose as approved by Virginia state medical control committee."
    },
    {
        "document title": "Adult General Medical Emergencies",
        "protocol title": "General \u2013 Universal Patient Care/Initial Patient Contact (Medical Patient Assessment)",
        "overview": "The ability to perform an accurate assessment is one of the most important skills in EMS. The information gained during the assessment is used to make decisions regarding emergency interventions, such as the need for immediate airway management and ventilation; to formulate a differential field diagnosis; and to provide continued and advanced pre-hospital care enroute to a receiving facility. Since this information is used in clinical decision-making, it is important that the assessment findings are interpreted correctly and efficiently",
        "scene survey": "Scene evaluation is one of the most important parts of pre-hospital EMS. Maintaining you and you crew's safety is paramount, and begins from the moment of dispatch to a call. The communications center begins obtaining information with each 911 call about possible problems and circumstances the pre-hospital provider may confront. The general rule is to never compromise the rescuers to aid the victim Upon entering a scene, a general impression should be formed, typically prior to any physical contact with the patient. Patients are usually categorized as either medical or trauma during the scene survey and general impression. At times, a patient may be both, as one may have led to the other. Until the condition is identified or the possibility of spine injury is ruled out, manual in-line spinal stabilization must be established and maintained.\n\nSummary of Scene Survey and Management: Obtain overview and evaluate scene for safety hazards.\nWear personal protective equipment.\nGain access to the patient.\nDetermine number of patients and additional resources needed.\nProvide life-sustaining care.\nPrepare and remove patient from scene.\nPrepare patient for transport.\nNotify intended receiving facility.",
        "primary assessment": "The primary assessment is based on assessment of the patient's airway, breathing, circulation, neurologic disability, and exposure. During the primary assessment, as patient problems are identified, critical interventions are initiated. The basic steps remain the same, whether at a scene or during an inter-facility transport.\n\nAIRWAY:\nThe patient\u2019s airway should be assessed to determine whether it is patent, maintainable, or not maintainable. For any patient who may have a traumatic injury, cervical spine precautions should be utilized while the airway is evaluated. Assessment of the patient\u2019s level of consciousness, in conjunction with assessment of the airway status, provides an impression of the effectiveness of the patient\u2019s current airway status. If an airway problem is identified, the appropriate intervention should be initiated. The decision to use a particular intervention depends on the nature of the patient\u2019s problem and the potential for complications during transport. The ability of patient to speak with a clear unobstructed voice is strong evidence of both airway patency and protection. However, if the patient that has lost protective airway reflexes, the assessment stops, and immediate action should be taken to establish airway patency. Supplemental oxygen, per assessment, should be given to all patients before transport. Specific equipment, such as a pulse oximeter or CO2 detector, help provide continuous airway evaluation during transport.\nBREATHING:The assessment of ventilation begins with noting whether the patient is breathing. If the patient is either apneic or in severe respiratory distress, immediate interventions are required. If the patient has any difficulty with ventilation, the problem must be identified and the appropriate intervention initiated. Emergent interventions may include manual ventilation of the patient via bag valve mask, endotracheal intubation, and / or needle thoracentesis.\nCIRCULATION:Palpation of both the peripheral and the central pulse provides information about the patient\u2019s circulatory status. The quality, location, and rate of the patient\u2019s pulses should be noted along with the temperature of the patient\u2019s skin being assessed while obtaining the pulses. Observation of the patient\u2019s level of consciousness may also help evaluate the patient\u2019s perfusion status initially. \nActive bleeding should be quickly controlled with direct pressure and/ or tourniquet per assessment. The patient should also be observed for indications of circulatory compromise. Skin color and temperature, diaphoresis, and capillary refill are all indicators of circulatory compromise during an assessment. Intravenous access should be obtained for administration of fluid, blood, or medications per assessment. Depending on the patient\u2019s location and the accessibility veins, peripheral, central, or intraosseous access may be used as necessary. Regardless of type of access, fluid resuscitation must always be guided by the patient\u2019s response.\n\nDISABILITY:The basic, primary neurological assessment includes assessment of the level of consciousness; the size, shape, and response of the pupils; and motor sensory function. The simple method if AVPU should be used to evaluate the patient\u2019s overall level of consciousness.\nThe Glasgow Coma Scale (GCS) provides assessment of the patient\u2019s level of consciousness and motor function and may serve as a predictor of morbidity and mortality after brain injury.\nIf the patient has an altered mental status, it must be determined whether the patient has ingested any toxic substances, such as alcohol or other drugs, or may be hypoxic because of illness or injury. A patient with an altered mental status may pose a safety problem during transport. Use of chemical sedation, or physical restraint, may be necessary to ensure safe transport of the patient and EMS providers.\n\nEXPOSURE:As much of the patient\u2019s body as possible should exposed for examination, depending on complaint. Keep in mind the effects of the environment on the patient. Discovery of hidden problems before the patient is loaded for transport may allow time to intervene and avoid disastrous complications. Although exposure for examination is emphasized most frequently in care of the trauma patient, it is equally important in the primary assessment of the patient with a medical illness.\nThe pre-hospital provider should always look under dressings or clothing, which may hide complications or potential problems. Clothing may hide bleeding that occurs as a result of thrombolytic therapy or rashes that may indicate potentially contagious conditions. During inter-facility transport, intravenous access can be wrongly assumed underneath a bulky cover. Once patient assessment has been completed, keep in mind that the patient must be kept warm. Hypothermia can cause cardiac arrhythmias, increased stress response, and hypoxia.",
        "summary of primary airway assessment": "Airway: Patent, maintainable, un-maintainable\nLevel of consciousness\nSkin appearance: Ashen, pale, gray, cyanotic, or mottled\nPreferred posture to maintain airway\nAirway clearance\nSounds of obstruction",
        "summary of primary breathing assessment": "Rate and depth of respirations\nCyanosis\nPosition of the trachea\nPresence of obvious injury or deformity\nWork of breathing\nUse of accessory muscles\nFlaring of nostrils\nPresence of bilateral breath sounds\nPresence of adventitious breath sounds\nAsymmetric chest movements\nPalpation of crepitus\nIntegrity of chest wall\nOxygen saturation measured with pulse oximetry",
        "summary of primary circulation assessment": "Pulse rate and quality\nSkin appearance: Color\nPeripheral pulses\nSkin temperature\nLevel of consciousness\nUrinary output\nBlood Pressure\nCardiac monitor\nInvasive monitor",
        "summary of primary disability (neurological) assessment": "A.V.P.U:A - Alert, V - Responds to verbal stimuli, P - Responds to painful stimuli, U - Unresponsive\n\nGlasgow Coma Scale (GCS): Eye Opening: Spontaneous (4), To voice (3), To pain (2), No response (1)\nVerbal Response: Oriented(5), Confused(4), Inappropriate words (3), Incomprehensible (2), No response (1).\nMotor Response: Obeys commands (6), Localizes (pain) (5), Withdraws (pain) (4), Flexion (pain) (3), Extension (pain) (2), No response (1)",
        "summary of primary exposure assessment": "Identification of injury, active bleeding, or indication of a serious illness\nAppropriate tube placement: Endotracheal tubes, chest tubes, feeding tubes, naso-gastric or oro-gastric tubes, and urinary catheters.\nIntravenous access: Peripheral, central, and Intraosseous.",
        "secondary (focused) assessment:": "The secondary (focused) assessment is performed after the primary assessment is completed and involves evaluation of the patient from head to toe. Illness specific information is collected by means of inspection, palpation, and auscultation during the secondary assessment. Whether the patient has had an injury or is critically ill, the prehospital provider should observe, and listen to the patient. \nThe secondary (focused) assessment begins with an evaluation of the patient\u2019s general appearance. The pre-hospital provider should observe the surrounding environment and evaluate its effects on the patient. Is the patient aware of the environment? Is there appropriate interaction between the patient and the environment? Determination of the amount of pain the patient has as a result of illness or injury is also an important component of the patient assessment. Baseline information should be obtained about the pain the patient has so that the effectiveness of interventions can be assessed during transport. Pain relief is one of the most important interventions for prehospital patient care providers.",
        "assessment acronyms:": "S.A.M.P.L.E.: Signs, Allergies, Medications, Pertinent history, Last oral intake, Events\nO.P.Q.R.S.T.: Onset, Provocation, Quality, Radiation, Severity, Time",
        "summary of secondary assessment": "Skin: Petechia, rashes, abnormal turgor, temperature, color\nHead and Neck: Pupils, extraocular movements, mental status, neck veins, swallow, lymphadenopathy, scars\nEars, Nose, and Throat: Hemorrhage, obstruction, foreign body\nMouth and Throat: Mucous membranes, drooling, tongue, airway obstruction, scars\nThorax, Lungs, and Cardiovascular System: Breath sounds, heart sounds, pulse\nAbdomen: Shape, bowel sounds, tenderness, masses\nGenitourinary: Rectal bleeding, urine color, frequency\nExtremities and Back: Gross motor function, pulses, wounds, deformity"
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN \u2013 Post-Partum Hemorrhage",
        "overview": "Post-partum hemorrhage is defined as the loss of more than 500 mL of blood loss following vaginal delivery or more than 1,000 mL following a Cesarean delivery. However, many women tolerate losses of up to 1,000 mL of blood. It can cause debilitation and diminished immunity, which can subsequently lead to post-partum infection, another leading cause of maternal death. Post-partum hemorrhage can occur up to 6 weeks after delivery. It is imperative that hemorrhage is diagnosed early, and treated aggressively.",
        "hpi": "* Time, amount of any vaginal bleeding\n* Twins, triplets, etc.\n* Past medical and delivery history\n* Medications\n* Trauma\n* Recent infection\n* Drug use and / or smoking",
        "signs and symptoms": "* Abdominal pain\n* Uterine contractions\n* Vaginal bleeding\n* Uterine tenderness to palpation\n* Rigid, board-like abdomen on palpation\n* Shock",
        "considerations": "* Abdominal trauma\n* Twins, triplets, etc.\n* Disseminated intravascular coagulation (DIC)\n* Ovarian cysts or torsion\n* Placenta previa\n* Preeclampsia\n* Shock (Hemorrhagic, Hypovolemic)",
        "procedure": "1. Perform general patient management. (EMR, EMT, A, I, P)\n2. Support life-threatening problems associated with airway, breathing, and circulation. (EMR, EMT, A, I, P)\n3. Administer oxygen to maintain SPO2 94 - 99%. (EMR, EMT, A, I, P)\n4. If atonic uterus is noted, firmly massage fundus. (EMR, EMT, A, I, P)\n5. Place patient on cardiac monitor. (A, I)\n6. Establish an IV of Normal Saline. Establish a second IV if clinically indicated. Do not delay transport to start a second IV. (A, I, P)\n7. If the patient is exhibiting symptoms of shock, refer to the Medical \u2013 Hypotension/Shock protocol. (EMR, EMT, A, I, P)\n8. Transport promptly and reassess as indicated. (EMR, EMT, A, I)",
        "pearls": "1. Many times, the estimated blood loss is only about half of the actual blood loss.\n2. Uterine atony, birth canal lacerations, and retention of placental fragments are the three leading causes of post-partum hemorrhage. Other causes include uterine inversion, and retained placenta. These all usually occur during the immediate post-partum period.\n3. Post-partum hemorrhage can occur up to 6 weeks after delivery. The causes of delayed or late post-partum hemorrhage include sub-involution of the placental site, retained placental tissue, and infection.\n4. Uterine atony is usually caused by over-distention of the uterus from multiple pregnancies, polyhydramnios, or an abnormally large fetus. The large blood vessels in the uterus become open and gaping when the placenta separates from the uterine wall. If the uterus fails to contract, as with uterine atony, large blood loss can occur from those blood vessels.\n5. Small, retained fragments of the placenta may interfere with proper uterine contraction, leading to hemorrhage. The placenta should be inspected at delivery to ensure that no pieces are missing. This is rarely a cause of immediate post-partum hemorrhage, but can be the cause of sudden profuse bleeding one week or more post-partum.\n6. Sub-involution of the placental site in the uterus, or failure for it to return to normal size, can cause late post-partum hemorrhage. It takes about 42 days for these cells to epithelialize. During this healing time, clots can slough off and cause bleeding."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN \u2013 Pregnancy Related Emergencies (Delivery \u2013 Shoulder Dystocia)",
        "overview": "Shoulder dystocia is a labor complication caused by difficulty delivering the fetal shoulders. After delivery of the head, the fetus seems to try to withdraw back into the birth canal (Turtle Sign). Further birth of the infant is prevented by impaction of the fetal shoulders within the maternal pelvis. Digital exam reveals that the anterior shoulder is stuck behind the pubic symphysis. In more severe cases, the posterior shoulder may be stuck at the level of the sacral promontory. Although this is more common among women with gestational diabetes and those with very large fetuses, it can occur with babies of any size. Unfortunately, it cannot be predicted or prevented. Improperly relieving the dystocia can result in unilateral or bilateral clavicular fractures.",
        "hpi": "* Due date\n* Time contractions started\n* Duration and time between contractions\n* Time, amount of any vaginal bleeding\n* Sensation of fetal activity\n* Past medical and delivery history\n* Medications\n* Trauma\n* Recent infection\n* Drug use and/or smoking",
        "signs and symptoms": "* \u201cTurtle sign\u201d of infants head protruding and withdrawing into the birth canal",
        "considerations": "* Breech delivery\n* Spontaneous abortion",
        "procedure": "1. Perform patient assessment.\n2. Administer Oxygen to maintain SPO2 94 - 99%.\n3. Assess for presence of nuchal cord (around the baby\u2019s neck). If present, remove by slipping over the neck or by cutting and clamping.\n4. Keep the patient\u2018s knees pushed back to her abdomen / chest.\n5. Do not apply excessive downward traction on the head. Initially apply gently downward traction on the chest and back to try and free the shoulder. If this has no effect, do not exert increasing pressure.\n6. Place the mother in MacRobert\u2019s position and apply gently downward traction on the baby again.\n7. If MacRobert\u2019s maneuver fails, have an assistant apply downward, suprapubic pressure to drive the fetal shoulder downward and clear the pubic bone. Apply coordinated, gentle downward traction on the baby.\n8. If pressure straight down is ineffective, have assistant apply it in a more lateral direction. This should nudge the shoulder into a better position.\n9. If newborn continues not to progress, transport immediately to closed appropriate facility."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN \u2013 Pregnancy Related Emergencies (Placenta Abruptio)",
        "overview": "Abruptio placenta (placental abruption) refers to premature separation of the normally implanted placenta from the uterine wall after the 20th week of gestation and prior to birth. Patients with abruptio placenta typically present with bleeding, uterine contractions, and fetal distress. A significant cause of third-trimester bleeding associated with both fetal and maternal morbidity and mortality, abruptio placenta must be considered whenever bleeding is encountered in the second half of pregnancy. The frequency of placental abruption in the United States is approximately 1% of all pregnancies, and a severe abruption leading to fetal death occurs in 0.12% of pregnancies (1:830). This mortality rate approaches 100% when > 50% of the placenta is involved. Placental Abruption begins with arterial hemorrhaging into the deciduas basalis. A hematoma is formed and progresses in size causing the expanding abruption. As the abruption continues, more vessels become involved, further contributing to the expanding retro-placental hematoma. Abruptio placenta is a surgical emergency and should be transported without delay with interventions completed during transport.",
        "hpi": "* Due date\n* Time contractions started\n* Duration and time between contractions\n* Time, amount of any vaginal bleeding\n* Sensation of fetal activity\n* Past medical and delivery history\n* Medications\n* Trauma",
        "signs and symptoms": "* Abdominal pain\n* Uterine contractions\n* Vaginal bleeding\n* Uterine tenderness to palpation\n* Rigid, board-like abdomen on palpation\n* Back pain\n* Signs of shock\n* Lack of fetal heart tones\n* Fetal demise",
        "considerations": "* Abdominal trauma\n* Appendicitis\n* Ovarian cysts or torsion\n* Placenta previa\n* Pre-eclampsia\n* Preterm labor\n* Spontaneous abortion\n* Shock (Hemorrhagic, Hypovolemic)",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%\n4. Place patient in a position of comfort. The preferred position for pregnant patients is on their left side.\n5. Establish an IV of Normal Saline .\n6. If the patient is exhibiting symptoms of shock, refer to the Medical \u2013 Hypotension/Shock protocol .\n7. Transport promptly, in the preferred left lateral recumbent position (if tolerated) and reassess as indicated.",
        "pearls": "1. The uterus will often contract during an episode of abruption and the separation of the placenta can be partial (marginal) or complete.\n2. 90% of all abruptions involve vaginal bleeding and are teamed with external hemorrhage; while the remaining 10% may have no vaginal bleeding noted and are called a \u201cconcealed\u201d abruption. In these cases, the bleeding is contained by the part of the placenta attached to the uterine wall and may be diagnosed mistakenly as premature labor. Shock eventually ensues from the concealed blood loss.\n3. Abruptio placenta associated with trauma is less common and is usually due to direct trauma to the abdomen. However, it is a complication in 1 - 5% of minor injuries that occur during pregnancy and up to 40 - 50% of major trauma injuries that occur during pregnancy.\n4. Placental abruption is more common in African American women than in either white or Latin American women.\n5. An increased risk of placental abruption has been demonstrated in patients younger than 20 years and those older than 35 years."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN - Eclampsia",
        "overview": "Pre-eclampsia is characterized by elevated BP, proteinuria, and edema after the 20th week of pregnancy in a patient who previously has been normal in these respects. The risk of pre-eclampsia / eclampsia is thought to continue through six (6) weeks post-partum. Unless the pre-eclamptic process is halted, seizure activity (eclampsia) may occur. Once the first eclamptic seizure occurs, the infant / fetal mortality rate soars. Once the seizure process is established, the ultimate patient outcome can be coma and death. The actual cause of the disease process is unknown.\n\nHELLP Syndrome (HELLPS) is a variant of severe PIH in which hematologic abnormalities exist with severe pre-eclampsia or eclampsia. HELLP is an acronym for Hemolysis, Elevated Liver enzymes, and Low Platelets, which are the hallmark signs of this syndrome.",
        "hpi": "Due date\n Time contractions started\n Duration and time between contractions\n Time, amount of any vaginal bleeding\n Sensation of fetal activity\n Past medical and delivery history\n Medications\n Trauma\n Recent infection\n Drug use and / or smoking",
        "signs and symptoms": "Seizures\n Hypertension\n Proteinuria\n Edema\n Headache\n Visual disturbances or changes\n Abdominal pain\n Epigastric pain\n Hyper -reflexia\n Anxiety\n Shock\n Coma",
        "considerations": "Pre-eclampsia\n Eclampsia\n Idiopathic thrombocytopenia\n Pre-existing seizure disorder\n Withdrawal :\n    o Drug\n    o Alcohol",
        "procedure": "1. Perform general patient management.     \n2. Support life-threatening problems associated with airway, breathing, and circulation.  Suction the oropharynx if needed.     \n3. Administer oxygen to maintain SPO 2 94 - 99%     \n4. Obtain blood glucose sample. If < 60 mg / dL or > 300 mg / dL refer to Hypoglycemia or Hyperglycemia protocol.     \n5. Establish an IV of Normal Saline. If signs of shock are present, refer to the Medical \u2013 Hypotension/Shock protocol.   \n6. If eclampsia is noted (characterized by seizures, hypertension,  / or coma), administer bolus of MAGNESIUM SULFATE 2-4, Gm IV over 5 - 10 minutes. (4 Gm preferred)  \n7. If seizure persists, administer MIDAZOLAM 0.1 mg / kg IN / IV / IM (max single dose 5 mg). If midazolam is unavailable, give DIAZEPAM 0.25 mg / kg up to 5 mg slow IV.  \n8. Transport promptly to an appropriate facility with obstetrical services and reassess as indicated.",
        "pearls": "1. Magnesium may be given IM if IV cannot be established. For IM administration, divide dose into 1.0 gm injections and inject into separate locations.\n2. Respirations during an active seizure should be considered ineffective and airway maintenance should occur per assessment.\n3. Be prepared to assist ventilations as dosage of midazolam or Valium is increased.\n4. The predominant during pregnancy risk factors for development of preeclampsia include: age extremes (< 20 years or > 35 years), primigravida, glomerulonephritis, multiple gestation, hydramnios, large fetus, hydatidiform mole, and fetal hydrops.\n5. HELLPS patients may also present with epigastric or upper quadrant abdominal pain resulting from liver distention and many patients will not meet the standard hypertension criteria for severe preeclampsia. Approximately 15% will have a diastolic BP \u2264 90 mmHg.\n6. One explanation of HELLPS is that platelet disposition at the sites of endothelial damage caused by intense vasospasm may amount for the depleted platelet levels.\n7. Definitive treatment can only be accomplished through delivery of the fetus(es).\n8. Eclampsia can occur after birth for up to six weeks until hormone levels return to pre-pregnancy levels."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "Medical - Newborn/Neonatal Resuscitation",
        "overview": "The majority of newborns will require only warmth, stimulation, and occasionally some oxygen after birth. That treatment is recommended before attempting the more aggressive interventions of Positive-Pressure Ventilation (PPV) and chest compressions. Remember that a newborn\u2019s cardiac output is rate dependent. Bradycardia usually is the result of hypoxia. Once the hypoxia is corrected, the heart rate may spontaneously correct itself. A \u201cnewborn\u201d is defined as within one month of age post-delivery.",
        "neonatal resuscitation procedure": "1. If obvious obstruction to spontaneous breathing or requires positive pressure ventilation, gently suction the newborn\u2019s mouth, then nostrils, with a bulb syringe for 3 to 5 seconds. Don\u2019t routinely suction an active baby.\n2. Evaluate respirations, heart rate (apical pulse or pulse at the base of the umbilical cord), and state of oxygenation. Obtain 1 minute APGAR.\n3. If respirations are inadequate, HR > 100 bpm:a. Initiate positive-pressure ventilation with a BVM NOT attached to oxygen. Deliver 40 to 60 breaths per minute. Use only enough volume to make the newborn\u2019s chest rise. b. If the newborn is vigorous (strong respiratory effort, good muscle tone, and a heart rate greater than 100 bpm), no routine suctioning is required.\n4. If respirations are inadequate and HR less than 100 bpm: a. If the newborn is NOT vigorous (poor or absent respiratory effort, flaccid, lethargic), consider immediate meconium aspiration via endotracheal suctioning. Suctioning of meconium should not distract from the need for emergent oxygenation and ventilation of the newly born. In the patient with meconium aspiration and respiratory failure or apnea, quickly suction meconium and then begin BVM ventilations. b. Initiate positive-pressure ventilation with a BVM on room air. If no increase in HR after 90 seconds, administer 100% oxygen. c. If HR is below 60 bpm, begin compressions",
        "apgar score \u2013 1st and 5th minute post birth": "|Sign|0 Points|1 Point|2 Points|\n|:---|:---|:---|:---|\n|Activity (Muscle Tone)|Flaccid|Some Flexion|Active Motion|\n|Pulse|Absent|< 100|> 100|\n|Grimace (Reflex Irritability)|No Response|Some|Vigorous|\n|Appearance (Skin Color)|Blue, Pale|Blue Extremities|Fully Pink|\n|Respirations|Absent|Slow, Irregular|Strong Cry|",
        "supportive care": "Maintain airway. Suction as needed with bulb syringe. Obtain blood glucose sample. If BGL is < 40 mg / dL, administer Dextrose 10% 2cc / kg (0.5 g / kg) slow IV / IO push. Repeat as necessary. Maintain warmth via blankets and / or skin-to-skin.",
        "procedure for making dextrose 10% if iv bag not available": "In 50 ml syringe, mix 10 ml of Dextrose 50% with 40 ml Normal Saline. Mixture will yield 50 ml of Dextrose 10%",
        "neonataldosagestable": "Age Pre-Term Term\nWeight (lb / kg)\n3.3 lbs\n1.5 kg\n6.6 lbs\n3.0 kg\nEpinephrine 1:10,000\n(1 mg / 10 ml)\n0.01 mg / kg\n0.015 mg 0.03 mg\nDextrose 10%\n2.0 ml / kg 3.0 ml 6.0 ml",
        "pearls": "1. The primary measure of adequate initial ventilation is prompt improvement in heart rate.\n2. In the presence of thick meconium and an infant who is limp, aggressive suctioning is required.\n3. A 3:1 ratio of compressions to ventilations with 90 compressions and 30 breaths should be used to achieve approximately 120 events per minute to maximize ventilation at an achievable rate. Each event should be allotted approximately \u00bd second, with exhalation occurring during the first compression following ventilation.\n4. Arterial saturations of a term infant at birth can be as low as 60% and can require more than 10 minutes to reach saturations of > 90%. Hyperoxia can be toxic, particularly to the preterm baby."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN \u2013 Pregnancy Related Emergencies (Pre-term Labor)",
        "overview": "Pre-term labor is defined as regular and rhythmic contractions of the uterus that produce cervical changes after the 20th week of gestation but prior to the 36th week of gestation. Of all pregnant patients, some patients will experience contractions without being in preterm labor, known as Braxton-Hicks contractions. Regular uterine contractions with rupture of the membranes are the hallmark sign for pre-term labor diagnosis.",
        "hpi": "* Due date\n* Time contractions started\n* Duration and time between contractions\n* Past medical and delivery history\n* Medications\n* Trauma\n* Recent infection\n* Drug use and/or smoking\n* History of cervical dilation",
        "signs and symptoms": "* Time, amount of any vaginal bleeding\n* Sensation of fetal activity\n* Rhythmic uterine contractions\n* Rupture of membranes\n* Passage of blood-stained mucous (mucous plug)",
        "considerations": "* Abruptio placenta\n* Ectopic pregnancy\n* Placenta previa\n* Spontaneous abortion",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%\n4. Place patient in left lateral recumbent position.\n5. Determine if patient is in labor and monitor frequency, intensity, and durations of contractions.\n6. Prepare for delivery.\n7. Establish an IV of Normal Saline if clinically indicated.\n8. If the patient is exhibiting symptoms of shock, refer to the Medical \u2013 Hypotension/Shock protocol.\n9. Transport promptly and reassess as indicated.",
        "known causes of pre term labor": "Decreased Blood Flow to the Uterus\n* Dehydration secondary to viral illness with nausea, vomiting, and diarrhea\n* PIH with arterial vasospasm\n* Diabetes\n* Cardiovascular or renal disease\n* Over-distension of the uterus with multiple gestation or tumors\n\nIncreased Hormonal Levels\n* Heavy smoking\n* Abruptio placenta or placenta previa\n* Prostaglandin production with PROM, bacterial infection, abdominal trauma, or over-distension of the uterus\n* Oxytocin levels found in meconium stained fluid\n\nCervical Incompetence\n* Traumatic\n* Congenital anomalies",
        "pearls": "1. Early signs and symptoms of pre-term labor may be as unspecific as abdominal, intestinal, or menstrual-like cramps, pelvic pressure, diarrhea, low back pain, and increased vaginal discharge.\n2. In general, resuscitation of infants with gestations less than 20 weeks is futile. However, due to varying birth weights, growth progression, and developmental changes differing in every baby and pregnancy, a specific week of gestation cannot be identified as a point of viability."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN- Pregnancy Related Emergencies (Ectopic Pregnancy/Rupture)",
        "overview": "An ectopic pregnancy implants outside the uterus, typically in the fallopian tubes. Symptoms usually appear 3-5 weeks after a missed period and include cramping and dull abdominal pain. If the pregnancy ruptures, sudden, sharp abdominal pain may occur. Vaginal bleeding may or may not be present. Concealed blood loss in the pelvic cavity can cause referred shoulder pain and a blue tinge around the umbilicus (Cullen's sign). The patient may exhibit signs of shock if blood loss is significant.",
        "hpi signs symptoms": "Due date\nVaginal bleeding\nSensation of fetal activity\nPast medical and delivery history\nMedications\nTrauma\nRecent infection\nDrug use and/or smoking",
        "considerations": "Abdominal pain\nVaginal bleeding\nUterine tenderness to palpation\nFetal demise\nRigid, board-like abdomen on palpation\nShock\nAbdominal trauma\nAppendicitis\nOvarian cysts or torsion",
        "procedure": "1. Perform general patient management.     \n2. Support life-threatening problems with airway, breathing, and circulation.     \n3. Administer oxygen to maintain SpO2 94-99%.     \n4. Place patient in a position of comfort.     \n5. Establish an IV of Normal Saline.     \n6. If symptoms of shock, refer to Medical \u2013 Hypotension/Shock protocol.     \n7. Transport promptly and reassess as indicated.",
        "pearls": "Risk factors for ectopic pregnancy include pelvic inflammatory disease, endometriosis, and previous tubal surgeries.\nIf the fetus dies early, harm to the fallopian tube is unlikely. However, ongoing fetal growth can rupture the tube, causing bleeding.\nSlow blood loss causes pain and lower abdominal pressure.\nRapid blood loss can lead to shock and death."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN \u2013 Pregnancy Related Emergencies (Delivery \u2013 Breech Presentation)",
        "considerations": "Although most babies are born without difficulty, complications may occur. Breech presentation is an abnormality in which the buttocks or legs of the fetus, rather than the head, appear first in the birth canal. This is the most common atypical birth presentation, occurring in approximately 4% of all full-term deliveries, and up to 25% of all premature births. In any breech birth, there are increased risks of umbilical cord prolapse or compression and delivery of the feet through an incompletely dilated cervix, leading to arm or head entrapment. These risks are greatest when a foot is presenting (\u201cfootling breech\u201d). Delivery may be prolonged for these newborns, which are at great risk of delivery trauma. Birth trauma can occur from forceful delivery management, such as cervical spine trauma, injury to the brachial plexus, and fractures to the humerus, clavicle, skull, and neck. The cause of breech presentation is only known in approximately half of the cases. Predisposing factors can include fetal and uterine anomalies, abnormal placental implantation, uterine over-distention, previous breech, multiple gestation, high parity, and pelvic obstruction (from placenta previa or tumors).",
        "procedure": "1. Place mother in delivery position, elevate pelvis with pillows (modified Trendelenburg). Figure 1\n2. If possible, allow the infant to deliver until the buttock appears.\n3. When providing traction, grasp the baby so that your thumbs are over the baby\u2019s hips (iliac crests). Do not pull on the legs or apply pressure to the soft lower back.\n4. Rotate the torso so the baby is face down in the birth canal. Figure 2\n5. If possible, extract a 4 - 6 inch loop of umbilical cord for slack.\n6. Apply gentle downward traction until the hairline is visible.\n7. Place one hand under the trunk, so that the infant\u2019s body rests on the palm, and the index and middle finger of that same hand support the mouth and chin.\n8. Place the other hand on the infant\u2019s back and shoulders, with the middle and index finger of that hand resting on the infant\u2019s shoulders, supporting the posterior neck.\n9. A towel can be wrapped around the lower body to provide a more stable grip, as needed.\n10. Have your assistant apply suprapubic pressure to keep the fetal head flexed, expedite delivery, and reduce risk of spinal injury. Figure 3\n11. Continue light downward traction until shoulder blades or armpits appear.\n12. If resistance is felt, arms may need to be freed prior to continuing. Exert gentle outward traction on the baby while rotating the baby clockwise and then counterclockwise a few degrees to free the arms.\n13. If the arms are trapped in the birth canal, you may need to reach up along the side of the baby and sweep them one at a time, across the chest and out of the vagina.\n14. After the shoulders have delivered, rotate the infant so that the back is anterior. Figure 4\n15. Apply gentle downward traction until the hairline is visible.\n16. Place one hand under the trunk, so that the infant\u2019s body rests on the palm, and the index and middle finger of that same hand support the mouth and chin.\n17. Place the other hand on the infant\u2019s back and shoulders, with the middle and index finger of that hand resting on the infant\u2019s shoulders, supporting the posterior neck.\n18. Slowly bring the body upward, while a second person applies suprapubic pressure to facilitate the delivery of the head.\n19. Slowly allow the chin, face, and then brow to be delivered. Try not to let the head \u201cpop\u201d out of the birth canal. A slower, controlled delivery is less traumatic.\n20. Perform post birth procedures and/or neonatal resuscitation per normal patient care protocol.\n21. If unable to deliver head, place gloved index and middle finger in the vagina with the palm towards the baby\u2019s face to maintain airway and pushing the infant up to relieve pressure on the cord.\n22. Transport immediately."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN \u2013 Childbirth/Labor/Delivery",
        "overview": "Labor is the progressive dilation of the uterine cervix accompanied by uterine contractions, resulting in dilation (10 cm) and effacement (thinning) of the cervix. Vertex (head-first) presentation is ideal for delivery. Crowning occurs as the second stage of labor begins.",
        "hpi signs and symptoms": "* Due date\n* Time contractions started\n* Duration and time between contractions\n* Time and amount of vaginal bleeding\n* Sensation of fetal activity\n* Past medical and delivery history\n* Medications\n* Trauma\n* Recent infection\n* Drug use and/or smoking",
        "considerations": "* Childbirth\n* Spontaneous abortion",
        "procedure": "1. General patient management\n2. Oxygen to maintain SpO2 > 94%\n3. IV of Normal Saline at KVO if time permits\n4. Infection control precautions (gloves, mask, gown, eye protection)\n5. Mother lying with knees drawn up and spread apart\n6. Elevate buttocks (blankets or pillow)\n7. Sterile field around vaginal opening\n8. Puncturing amniotic sac if not broken\n9. Gentle pressure on skull during crowning to prevent explosive delivery\n10. Determine if umbilical cord is around the neck and address it\n11. Support head after birth (no suctioning)\n12. Support newborn with both hands as body is born\n13. Grasp feet as they are born\n14. Wipe blood and mucus from newborn's mouth and nose\n15. Keep newborn level with vagina until cord is cut\n16. Clamp, tie, and cut umbilical cord when pulsations cease\n17. 1- and 5-minute APGAR scores\n18. Monitor newborn and refer to Neonatal Resuscitation Protocol\n19. Observe for placental delivery\n20. Wrap placenta and transport to hospital\n21. Place sterile pad over vaginal opening\n22. Record time of delivery and transport mother, newborn, and placenta to hospital",
        "apgar score \u2013 1st & 5th minute post birth": "| Sign | 0 Points | 1 Point | 2 Points |\n|---|---|---|---|\n| Activity (Muscle Tone) | Flaccid | Some Flexion | Active Motion |\n| Pulse | Absent | < 100 | > 100 |\n| Grimace (Reflex Irritability) | No Response | Some | Vigorous |\n| Appearance (Skin Color) | Blue, Pale | Blue Extremities | Fully Pink |\n| Respirations | Absent | Slow, Irregular | Strong Cry |",
        "pearls": "* Normal umbilical cord has three vessels (two arteries, one vein).\n* Delaying cord clamping for at least one minute is beneficial for non-resuscitation term and preterm infants.\n* EDC = Add 7 days to the first day of last normal menses and subtract 3 months."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN \u2013 Pregnancy Related Emergencies (Premature Rupture of Membranes (PROM))",
        "overview": "**OVERVIEW:**\nPremature Rupture of Membranes (PROM) is the leakage of amniotic fluid at least one (1) hour before the onset of labor. This can occur at any gestational age, and occurs in approximately 10% of all pregnancies. The exact cause of PROM is not known and can lead to premature labor, umbilical cord prolapse, and intrauterine infection. The patient usually reports a gush of fluid from the vagina. There may also be a continual leak of fluid, suggestive of a small tear in the amniotic sac.",
        "hpi": "Due date\n Time contractions started\n Duration and time between contractions\n Time, amount of any vaginal bleeding\n Sensation of fetal activity\n Past medical and delivery history\n Medications\n Trauma\n Drug use and/ or smoking",
        "signs and symptoms": "Abdominal pain\n Uterine contractions\n Vaginal bleeding\n Uterine tenderness to palpation",
        "considerations": "Fetal demise\n Abdominal trauma\n Preeclampsia\n Pregnant\n Delivery",
        "procedure": "1. Perform general patient management. \n2. Support life -threatening problems associated with airway, breathing, and circulation. \n3. Administer oxygen to maintain SPO2 94 - 99%\n4. Place patient in the left lateral recumbent position. \n5. Observe for signs of preterm labor, refer to Pre-term Labor protocol.\n6. Establish an IV of Normal Saline if clinically indicated .    \n7. Transport promptly and reassess as indicated."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN \u2013 Pregnancy Related Emergencies (Prolapsed Umbilical Cord)",
        "overview": "Although most babies are born without difficulty, complications may occur. Umbilical Cord Prolapse (UCP) is a condition when the umbilical cord presents through the birth canal after the amniotic sac ruptures before delivery of the head. If the umbilical cord presents in front of the fetal presenting part and the membranes rupture, the risk that the cord will prolapse through the cervix into the vagina is significant. Occult prolapse occurs when the cord lies alongside the presenting part. The risk is increased with abnormal fetal presentations, especially when the presenting part does not fill the lower uterine segment, as is the case with incomplete breech presentations, premature infants, and multi-parous women. This presents a serious medical emergency, endangering the life of the unborn fetus. In this situation, the umbilical cord may get compressed against the vaginal walls by the pressure of the infant's head. As a result, the infant's supply of oxygenated blood can be cut off.",
        "considerations": "* Due date\n* Time contractions started\n* Duration and time between contractions\n* Rupture of membranes\n* Time, amount of any vaginal bleeding\n* Sensation of fetal activity\n* Past medical and delivery history\n* Medications",
        "signs and symptoms": "* Spasmodic pain\n* Vaginal discharge, bleeding\n* Crowning, urge to push\n* Lower back, pelvis pain\n* Meconium\n* *Asymptomatic: Sometimes visual inspection is the only sign of UCP\n* Abnormal presentation\n    * Buttock\n    * Foot\n    * Hand\n* Premature labor\n* PROM (premature rupture of membrane)",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation. Do not delay immediate transport. Early hospital notification is indicated.\n3. Administer oxygen to maintain SpO2 94 - 99%\n4. If the umbilical cord presents externally or can be visualized in the vagina, use two fingers of a gloved hand to prevent any presenting part of the delivering fetus from occluding/compressing the cord. Pressure-relieving maneuvers must be maintained throughout transport.\n5. Check cord for pulsation.\n6. Keep the cord warm and moist.\n7. Establish an IV of Normal Saline.\n8. Place the patient in the knee-chest position.\n9. Transport emergently to an appropriate facility with obstetrical services and reassess as indicated.",
        "types of umbilical cord prolapse": "Occult Prolapse Funic Presentation Overt Prolapse",
        "pearls": "1. Once you have relieved pressure on the cord, you must keep the pressure off the cord.\n2. The knee-chest position uses gravity to shift the fetus out of the pelvis. The woman's thighs should be at right angles to the stretcher and her chest flat on the stretcher."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "OB/GYN \u2013 Pregnancy Related Emergencies (Placenta Previa)",
        "overview": "Placenta previa is an obstetric complication that occurs in the second and third trimesters of pregnancy and accounts for 20% of vaginal bleeding during these last trimesters. Placenta previa occurs when the placenta is implanted low in the uterus and covers the cervical canal in varying amounts. The placenta may be marginally, partially, or completely covering the internal cervical opening. Risk factors for placenta previa include prior placenta previa, first pregnancy following a cesarean delivery, multi-parity, age > 30 years, multiple gestations, prior induced abortions, and smoking.",
        "hpi": "* Due date\n* Time, amount of any vaginal bleeding\n* Sensation of fetal activity\n* Past medical and delivery history\n* Medications\n* Recent vaginal exam, sexual intercourse",
        "signs and symptoms": "* Painless but profuse bright red vaginal hemorrhage\n* Hypotension\n* Tachycardia\n* Soft and non-tender uterus\n* Lack of abdominal pain\n* Detectable fetal movement and heart sounds",
        "considerations": "* Abruptio placenta\n* Ectopic pregnancy\n* Preterm labor\n* Vasa-previa\n* Shock, (hemorrhagic or hypovolemic)\n* Spontaneous abortion",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%\n4. Place patient in a position of comfort.\n5. Establish an IV of Normal Saline\n6. If the patient is exhibiting symptoms of shock, refer to the Medical \u2013 Hypotension/Shock protocol .\n7. Transport promptly and reassess as indicated.",
        "pearls": "1. Providers must NOT perform a pelvic exam on a patient with placenta previa. Due to the placenta precariously placed over the cervical opening, minimal maneuvers to the cervix or uterus may induce heavy vaginal bleeding.\n2. Avoid palpating the fundus, which may cause fetal movement and possible placental tearing.\n3. Women older than 30 years are 3 times more likely to have placenta previa than women younger than 20 years."
    },
    {
        "document title": "Obstetrical/Gynecological Emergencies",
        "protocol title": "Physiological Changes with Pregnancy",
        "overview": "Many changes occur in the pregnant woman's body, starting from the time of conception and throughout the pregnancy. The most obvious body system to undergo change is the reproductive system, but all of the others will change as well. Brief summaries of the physiologic changes that occur during pregnancy have been listed by system. Most of these physiologic changes will resolve during the postpartum period.",
        "respiratory system": "As the uterus enlarges during pregnancy, it causes the diaphragm to rise, decreasing the resting lung volume, and decreasing the Functional Residual Capacity (FRC). The tidal volume (volume of air inspired and expired during each breath) increases throughout pregnancy by 40%, which in turn causes the minute ventilation (volume of air inspired or expired in one minute) to also increase by 40%. Because of this hyperventilation (which is caused by the increasing presence of progesterone), there is an increase in the arterial PO2 to 106 - 108 mmHg, and a decrease in the arterial PCO2 to 27 - 32 mmHg. These changes are reflected in the appearance of a respiratory alkalosis on an ABG. Another change occurring during pregnancy is the increase in total body oxygen consumption by about 15 \u2013 20%. This is secondary to the increased requirements of the cardiac and renal systems, with additional requirements from the extra work of respiratory muscles and breasts (in preparation for lactation). Lastly, the upper respiratory passages are engorged secondary to increased vascularity, predisposing the pregnant patient to nasopharyngeal bleeding, transient blockage of the Eustachian tubes, and nasal stuffiness.",
        "cardiovascular": "Total blood volume increases by 50% during pregnancy. The bone marrow will increase the production of RBC\u2019s, but the plasma component of the blood volume increases more rapidly, causing an \u201canemia of pregnancy\u201d. Normal hemoglobin is 12 g, and normal hematocrit is 31 - 34%. The WBC count also increases slightly to 9,000 to 12,000 / \uf06dL. Because of this increased blood volume, the cardiac output is increased by 1 \u2013 1.5 L / minute. \nDue to the increasing size of the uterus, the mother\u2019s heart is elevated and rotated forward to the left. The patient\u2019s heart rate rises gradually throughout pregnancy, to an increase by 12 - 18 beats / minute. Palpitations early in the pregnancy are caused by disturbances in the sympathetic nervous system, while palpitations toward the end of gestation are the result of increasing intra-abdominal pressure of the enlarged uterus.\n Baseline arterial blood pressures decrease during pregnancy, and are at their lowest values at 20 - 24 weeks gestation. This is due to the increased cardiac output, and reduced peripheral vascular resistance. They will gradually rise to pre-pregnancy values at term, when vasoconstrictor tone increases. Systolic BP decreases by 4 - 6 mmHg, diastolic BP decreases by 8 - 15 mmHg, and the mean BP decreases by 6 - 10 mmHg\nHypertension in pregnancy is usually indicative of an obstetrical complication, such as preeclampsia.\nBlood pressure is further affected by position. As the pregnancy progresses, the enlarging uterus displaces and compresses the iliac veins, inferior vena cava, and the aorta. When the pregnant woman is in the supine position, this causes increasing venous compression, decreasing venous return, and cardiac output. This may cause a significant hypotension, which in turn may cause nausea, dizziness, or syncope. These symptoms can be relieved by turning the patient on her side, either right or left lateral recumbent.\nVenous compression can also cause complications such as varicose veins, hemorrhoids, and edema in the lower extremities.",
        "gastrointestinal": "Hormonal changes (progesterone) cause the gastro-esophageal sphincter to relax, as well as all of the muscular tone around the stomach and esophagus. This can cause prolonged gastric emptying time, constipation, heartburn, and gastro-esophageal reflux.\nThe enlarging uterus displaces the stomach and intestines upward, which can also contribute to GE reflux. The gradual stretching of the abdominal wall alters the normal response to peritoneal membrane irritation. The pregnant patient may not be able to note tenderness. The appendix may also be displaced laterally and upward.\nLiver function tests (LFT\u2019s) may be altered and alkaline phosphatase isoenzymes that are produced by the placenta cause the total alkaline phosphatase levels to nearly double. Serum cholinesterase levels are also decreased while serum leucine aminopeptidase activity is markedly elevated.\nThe pregnant patient is also more prone to gallstones because of prolonged emptying time from decreased tone and incomplete evacuation of the gallbladder secondary to distension.",
        "urinary and renal": "The pregnant patient may experience urinary frequency during the first months of pregnancy because of hormonal effects, and because of pressure on the bladder caused by the enlarging uterus. UTI\u2019s and / or cystitis are common secondary to urinary stasis, and ineffective emptying of the bladder.\n There usually is an increase in the amount of urine, and the specific gravity is lower. The spilling of glucose in the uterine is not uncommon, as there is a decreased renal threshold for glucose. This should be monitored closely, however, as it may be indicative of pregnancy induced diabetes mellitus. Renal function tests may indicate decreases in the following values: plasma creatinine (< 0.7 mg / dL), urea concentrations (< 10 mg / dL), and urine concentration. Renal plasma flow and the glomerular filtration rate (GFR) increase to 40% greater than pre-pregnancy levels. Plasma levels of renin, renin substrate, and angiotensin I and II will increase.The ureters, especially the right, become markedly dilated. This is secondary to endocrine influences, causing a softening of the ureteral walls and also from pressure on the ureters from the uterus as they arise out of the pelvic ring.",
        "integumentary": "Striae Gravidarum (\u201cstretch marks\u201d) appear over the abdomen and breasts of a pregnant woman. These elongated streaks, of pink and red, are the results of the rapid stretching of skin and the underlying connective tissues during the rapid weight gain associated with pregnancy. Chloasma is the \u201cmask of pregnancy\u201d, an increase in facial pigmentation occurring over the nose and cheeks. Increased pigmentation can also occur as a dark line extending from the mons pubis to the umbilicus. This is referred to as linea negra. Due to an increase in circulating estrogens, spider hemangiomas may appear on the skin. These are red blemishes with spider-like legs that branch off from a central body, and tend to be more pronounced on fair-skinned women. Hormonal increases also can cause an increase of the activity of the sebaceous glands, sweat glands, and hair follicles.",
        "musculoskeletal": "Increased progesterone levels cause a relaxation of the ligaments supporting the joints. The sacroiliac joint relaxes and widens, as well as the symphysis pubis (by 4 to 8 mm), causing instability of the pelvis. This, in turn, causes additional strain on the thigh and back muscles, and amounts for the swayback, waddling gait of the pregnant patient. The torso also tilts backwards to assist with maintaining equilibrium, as the full term, pregnant uterus can weigh up to 12 pounds. As the uterus enlarges, it creates tension on the abdominal muscle wall. This tension occasionally becomes so great, that the abdominal recti muscles separate in the median line. This separation is known as diastasis recti.",
        "endocrine": "During pregnancy, the placenta acts as the major endocrine gland. It secretes four hormones that are necessary to maintain the pregnancy: human chorionic gonadotropin or HCG, human chorionic somatomammotropin (also known as human placental lactotgen or hPL), estrogen, and progesterone. HCG prolongs the life of the corpus luteum (a structure within the ovary), which in turn produces estrogen and progesterone, which maintains the endometrium (the lining of the uterus). The presence of HCG in the urine is the diagnostic indication of pregnancy. HPL influences the somatic cell growth of the fetus, and prepares the breasts for lactation. Both progesterone and estrogen affect the growth of the uterus and the development of the breasts. The pituitary gland has two lobes, the anterior and the posterior. During pregnancy, the posterior lobe secretes the hormone Oxytocin, which stimulates contractions during abor, stimulates the uterus to continue to contract after delivery, and stimulates lactation. The anterior lobe continues to function as usual, except it no longer releases gonadotropins (FSH and LH), and it increases its production of prolactin, the protein necessary for milk production. The thyroid gland enlarges during pregnancy. This, however, does not cause an increase in thyroid activity. Serum iodine and thyroxine levels increase, but this is due to an elevation in the level of thyroid-binding protein in the blood (probably from an increase in circulating estrogen). The adrenal glands secrete an increased amount of aldosterone, as early as the 15th week of pregnancy. The hormone aldosterone is responsible for sodium retention by the kidneys. This explains the common problem of fluid retention in pregnancy, and possible edema. Increased levels of glucocorticoids, estrogens, and progesterone affect glucose metabolism. This change in metabolism, along with the stress of pregnancy, increases the pregnant patient\u2019s need for insulin. This may actually induce gestational diabetes mellitus.",
        "reproductive": "The uterus will soften, becomes more globular, and increases in size throughout pregnancy to accommodate the growing fetus, placenta, and amniotic fluid. By the 12th to 14th week of gestation, the uterus has risen out of the pelvis, and is palpable just above the symphysis pubis. By the 16th week, it is at a height between the symphysis pubis and the umbilicus. The uterus can be palpated at the level of the umbilicus by 20 weeks, and is at its highest point, almost at the xiphoid process, by the 36th week. Two to four weeks before labor begins, the fetal head descends back down into the pelvic cavity. Estrogen stimulates hypertrophy of the uterine muscle fibers, which enables the uterus to contract during labor. The cervix will soften, and the cervical mucus glands will form a mucus plug, that seals the uterus during pregnancy, protecting it from vaginal bacteria. This plug is expelled, along with a small amount of blood, at the end of the pregnancy, before labor begins. This event has been termed as the \u201cbloody show\u201d. The mammary glands further develop in pregnancy by stimulation from placental estrogen and progesterone. The ductile system within the breasts will grow from the effects of estrogen, while progesterone enables alveolar glands to develop at the ends of these ducts. The glandular tissue replaces pre-pregnancy adipose tissue in the breasts, causing them to almost double in size. Actual milk production does not occur during pregnancy, as it is inhibited by the presence of progesterone. However, the watery precursor to milk, colostrum, may be present."
    },
    {
        "document title": "Toxicological Emergencies",
        "protocol title": "Exposure \u2013 Organophosphate",
        "overview": "Organophosphates irreversibly bind to cholinesterase, causing the phosphorylation and deactivation of acetylcholinesterase. The accumulation of acetylcholine at the neural synapse causes an initial overstimulation, followed by exhaustion and disruption of postsynaptic neural transmission in the central nervous system (CNS) and peripheral nervous systems (PNS). If the organophosphate / cholinesterase bond is not broken by pharmacologic intervention within 24 hours, large amounts of cholinesterase are destroyed, causing long-term morbidity or death. Carbamate poisoning exhibits a similar clinical picture to organophosphate toxicity. However, unlike organophosphates, carbamate compounds temporarily bind cholinesterase for approximately 6 hours with no permanent damage. Carbamates have poor CNS penetration and cause minimal CNS symptoms.",
        "hpi": "The most important historical factors to obtain include: what poison was involved, how long the exposure lasted, and how and when they were exposed.\n* Exposure or suspected exposure of a potentially toxic substance\n* Substance exposure, route, and quantity\n* Time of exposure\n* Reason (suicidal, accidental, criminal)\n* Available medications in home\n* Past medical history",
        "signs and symptoms": "S.L.U.D.G.E.\n* Salivation (excessive production of saliva)\n* Lacrimation (excessive tearing)\n* Urination (uncontrolled urine production)\n* Defecation (uncontrolled bowel movement)\n* Gastrointestinal distress (cramping)\n* Emesis (excessive vomiting)\n\nD.U.M.B.E.L.S. (Muscarinic)\n* Diarrhea\n* Urination\n* Miosis\n* Bradycardia / Bronchospasm / Bronchorrhea\n* Emesis\n* Lacrimation\n* Salivation / Secretion / Sweating\n\nB.A.M.\n* Breathing difficulty (wheezing)\n* Arrhythmias (bradycardia, ventricular arrhythmias, AV blocks)\n* Miosis (pinpoint pupils)\n\nDays of the week (Nicotinic)\n* Mydriasis\n* Tachycardia\n* Weakness\n* Hypertension / Hyperglycemia\n* Fasciculation\u2019s\n\nThree C\u2019s of CNS effect\n* Confusion\n* Convulsions\n* Coma",
        "considerations": "Poison Control may be contacted at any time for information on poisoning (1-800-222-1222) but only Medical Control may give patient treatment orders.\n***Decontamination MUST be completed prior to transport***\n1. Decontamination should be initiated and completed by qualified personnel.\n2. Decontamination takes precedence over ALS interventions.\n3. Consider calling for additional drug kits for additional atropine.\n4. Separate patient from causative agent. Most exposures are to liquid solutions.\n5. Clothes should be removed on scene, bagged and sealed by personnel wearing appropriate PPE, and left for appropriate disposal. DO NOT transport clothes in ambulance or to hospital where they may spread contamination.\n6. DO NOT use personal antidote kit, if issued, to provide patient care.",
        "procedure": "1. Scene Safety and consider HAZ MAT activation.\n2. Ensure patient has been thoroughly decontaminated.\n3. Obtain general assessment of the patient.\n4. Administer Oxygen to maintain SPO2 94 - 99%\n5. Suction oropharynx as necessary.\n6. Establish IV of Normal Saline. Titrate to maintain a systolic BP > 90 mmHg.\n7. Place the patient on a cardiac monitor and obtain / interpret 12 lead ECG.\n8. If the patient has respiratory distress due to secretions, administer ATROPINE SULFATE 1 - 2 mg IVP every 5 minutes until signs of pulmonary secretions decrease improve or medication supply is exhausted. There is no maximum dose in this situation.\n9. If available, administer 2PAM 1 - 2 Gram IV one dose \u2013OR - 0.6 Gram IM x 3 doses in rapid succession.\n10. If patient is seizing, refer to the Medical Care Seizure protocol.\n11. For bronchospasm, administer ALBUTEROL and ATROVENT per Medial Care: Respiratory Distress protocol.\n12. Transport promptly in position of comfort. Reassess vital signs as indicated."
    },
    {
        "document title": "Toxicological Emergencies",
        "protocol title": "Medical \u2013 Overdose/Poisoning \u2013 Opioid",
        "overview": "The goal in treating an opiate overdose patient is generally not to wake the patient, but to maintain breathing and the airway. While difficult, this is especially important as opiates are often mixed with stimulants and other drugs at the street level, and the opiate may be masking or suppressing other toxic effects. Unfortunately, the history of poisoning / overdose is notoriously unreliable whether it is obtained from the patient, friends and family members or emergency services personnel, and especially what else was taken. Poison Control may be contacted at any time for information on poisoning (1-800-222-1222) but only Medical Control may give patient care direction. Despite the possible inaccuracies, the most important historical factors include what poison was involved, how much was taken, how it was taken, when it was taken, why it was taken, and treatment orders.",
        "hpi": "* Use or suspected use of a potentially toxic substance\n* Substance ingested, route, and quantity used\n* Time of use\n* Reason (suicidal, accidental, criminal)\n* Available medications in home\n* Past medical history",
        "signs and symptoms": "* Mental status changes\n* Hypotension / hypertension\n* Hypothermia / hyperthermia\n* Decreased respiratory rate\n* Tachycardia, other dysrhythmias\n* Seizures",
        "considerations": "* Tricyclic anti-depressants (TCAs)\n* Acetaminophen (Tylenol)\n* Depressants\n* Stimulants\n* Anticholinergic\n* Cardiac medications\n* Solvents, alcohols, Cleaning agents\n* Insecticides",
        "procedure": "1. Obtain general patient assessment. \n2. Administer Oxygen to maintain SPO2 94 - 99% \n3. Suction oropharynx as necessary. \n4. Obtain blood glucose sample. If glucose is < 60 mg / dL or > 300 mg / dL, refer to the Hypoglycemia or Hyperglycemia Protocol. \n5. If necessary, refer to Patient Restraint protocol. \n6. Place patient on cardiac monitor. \n7. Establish IV of Normal Saline. Titrate rate to maintain systolic BP > 90 mmHg. \n8. If respiratory effort remains diminished and opiate administration is suspected, give NARCAN INTRANASAL 2mg (one vial) to maintain an adequate respiratory effort. *Dose may be repeated as necessary. \n    **a.** If respiratory effort remains diminished and opiate administration is suspected, give NARCAN 0.4 - 2.0 mg slow IVP/IM (ALS levels only) to maintain an adequate respiratory effort. Dose may be repeated as necessary. \n9. Transport promptly in position of comfort. Reassess VS as indicated.",
        "opiate toxidrome": "* Altered Mental Status\n* Miosis\n* Unresponsiveness\n* Shallow Respirations\n\n* Slow Respiratory Rate\n* Decreased Bowel Sounds\n* Hypothermia\n* Hypotension",
        "pearls": "1. If patient is a suspected opiate addict, the administration of Naloxone should be titrated to increase respirations to normal levels without fully awakening patient to prevent hostile and confrontational episodes and withdrawal symptoms.\n2. Any patient receiving Naloxone should be transported for continued monitoring. Many opiates have a longer bioavailability than Naloxone, therefore re-sedation may occur.\n3. The administration of Naloxone should be titrated to increase respirations to normal levels without fully awakening patient to prevent hostile and confrontational episodes and withdrawal symptoms.\n4. Any patient receiving Naloxone should be transported for continued monitoring. Some opiates may have a longer bioavailability than Naloxone, therefore re-sedation may occur.\n5. Some opiates may require significant Naloxone dosing.\n6. Do not rely completely on patient history of ingestion (route, dose, substance), especially in suicide attempts.\n7. Providers who may encounter fentanyl or fentanyl analogs should be trained to recognize the symptoms and objective signs of opioid intoxication, have naloxone readily available, and trained to administer naloxone.\n8. For opioid toxicity to occur the drug must enter the blood and brain from the environment. Toxicity cannot occur from simply being in proximity to the drug.\n9. Toxicity may occur in canines utilized to detect drug. The risks are not equivalent to those in humans given the distinct contact that dogs, and not humans, have with the local environment.\n10. Nitrile gloves provide sufficient protection against dermal absorption. In situations where an enclosed space is heavily contaminated with a potential highly potent opioid, water resistant coveralls should be worn.\n11. Incidental dermal exposures should immediately be washed with copious amounts of water.\n12. Alcohol based hand sanitizers should not be used for decontamination as they do not wash opioids off the skin and may increase dermal drug absorption.\n13. In the unusual circumstance of significant airborne suspension of powdered opioids, a properly fitted N95 respirator is likely to provide reasonable respiratory protection.\n14. OSHA-approved protection for eyes and face should be used during tasks where there exists a possibility of splash to the face."
    },
    {
        "document title": "Toxicological Emergencies",
        "protocol title": "Medical \u2013 Overdose/Poisoning \u2013 Stimulant",
        "overview": "Hyperdynamic \u201cstimulant\u201d drugs, also known as sympathomimetics, include cocaine, methamphetamine, amphetamine, and MDMA (ecstasy). Patient care should be focused on preventing/mitigating hyperthermia, agitated delirium, positional asphyxia, hypoxia, and physical self-harm. With a stimulant overdose (tachycardia, agitation, hyperthermia, and/or hypertension), treatment with benzodiazepines is indicated in addition to rhythm-specific therapy or anti-hypertensive meds (with the exception of beta-blockers).\n\nUnfortunately, the history of poisoning/overdose is notoriously unreliable whether it is obtained from the patient, friends and family members, or emergency services personnel. Despite the possible inaccuracies, the most important historical factors include what poison was involved, how much was taken, how it was taken, when it was taken, why it was taken, and especially what else was taken. Poison Control may be contacted at any time for information on poisoning (1-800-222-1222) but only Medical Control may give patient treatment orders.",
        "hpi": "* Use or suspected use of a potentially toxic substance\n* Substance ingested, route, and quantity used\n* Time of use\n* Reason (suicidal, accidental, criminal)\n* Available medications in home\n* Past medical history",
        "signs and symptoms": "* Mental status changes\n* Hypertension\n* Hyperthermia\n* Tachypnea\n* Tachycardia, other dysrhythmias\n* Seizures",
        "procedure": "1. Obtain general assessment of the patient.\n2. Administer Oxygen to maintain SPO2 94-99%\n3. Suction oropharynx as necessary.\n4. Obtain blood glucose sample. If glucose is < 60 mg/dL or > 300 mg/dL, refer to Hypoglycemia or Hyperglycemia protocol.\n5. Establish IV of Normal Saline. Titrate to maintain a systolic BP > 90 mmHg.\n6. Place the patient on a cardiac monitor and obtain/interpret 12 lead ECG.\n7. For chest pain due to suspected cocaine use, WITHOUT ST elevation, administer MIDAZOLAM 5 mg IV. If Midazolam is not available, administer DIAZEPAM 2.5-5 mg IV. Refer to Medical \u2013 Chest Pain \u2013 Cardiac Suspected as needed.\n8. If patient is seizing, refer to the Medical Care Seizure protocol.\n9. Transport promptly in position of comfort. Reassess vital signs as indicated.",
        "pearls": "1. Do not rely on patient history of ingestion, especially in suicide attempts.\n2. Bring bottles and contents to ER with patient.\n3. Ecstasy (MDMA), and the more toxic drug para-Methoxyamphetamine (PMA), have both amphetamine and hallucinatory-like effects. The stimulant effects of MDMA/PMA, which enable users to perform physical exertion (like dancing) for extended periods, may also lead to dehydration, tachycardia, and hypertension. MAOIs may potentiate toxic effects. While any of the hyperdynamics can be dangerous, MDMA and PMA especially have been known to cause a marked increase in body temperature (malignant hyperthermia) leading to rapid onset of muscle breakdown, DIC, seizures, renal failure, and cardiovascular system failure.",
        "toxidrome": "* Restlessness\n* Excessive speech and motor activity\n* Tremors\n\n* Insomnia\n* Tachycardia\n* Hypertension\n\n* Hyperthermia\n* Hallucinations\n* Seizures"
    },
    {
        "document title": "Toxicological Emergencies",
        "protocol title": "Medical \u2013 Overdose/Poisoning \u2013 Beta Blocker",
        "overview": "Beta blockers are a type of drug generally used to treat hypertension. Although the specific ingredients vary among manufacturers, the main ingredient among them all is a beta-adrenergic blocking substance. This substance blocks the effects of epinephrine on the body. Medical complications of beta-blocker overdose include hypotension, bradycardia, heart failure, impaired atrio-ventricular conduction, bronchospasm, and occasionally, seizures. Unfortunately, the history of poisoning/overdose is notoriously unreliable whether it is obtained from the patient, friends and family members, or emergency services personnel. Despite the possible inaccuracies, the most important historical factors include what poison was involved, how much was taken, how it was taken, when it was taken, why it was taken, and especially what else was taken. Poison Control may be contacted at any time for information on poisoning (1-800-222-1222) but only Medical Control may give patient treatment orders.",
        "hpi": "* Use or suspected use of a potentially toxic substance\n* Substance ingested, route, and quantity used\n* Time of use\n* Reason (suicidal, accidental, criminal)\n* Available medications in home\n* Past medical history",
        "signs and symptoms": "*Mental status changes\n*Hypotension\n*Bradycardia",
        "considerations": "*Co-ingestions\n*Cardiac medications\n*Anti-hypertensive medications",
        "procedure": "1. Obtain general assessment of the patient.  \n2. Administer Oxygen to maintain SPO2 94 - 99%\n3. Suction oropharynx as necessary.  \n4. Establish IV of Normal Saline. Titrate to maintain a systolic BP > 90 mmHg.  \n5. Place the patient on a cardiac monitor and obtain / interpret 12 lead ECG.  \n6. If symptomatic bradycardia is present, administer ATROPINE 0.5 - 1 mg IVP / IO. If no response to initial dose, administer one (1) repeat dose of Atropine 0.5 - 1 mg IV P / IO.  \n7. If no response noted to Atropine, administer GLUCAGON 1 mg IVP / IO. If no response in five (5) minutes, administer one (1) repeat dose of Glucagon 1 mg IVP / IO.  \n8. Transport promptly in position of comfort. Reassess vital signs as indicated.",
        "common beta blocker medications": "* Acebutolol (Sectral)\n* Atenolol (Apo-atenolol)\n* Bisoprolol (Zebeta)\n* Labetalol (Normodyne)\n* Metoprolol (Toprol, Lopressor)\n* Nadolol (Corgard)\n* Sotalol (Betapace)\n* Penbutolol (Levatol)\n* Pindolol (Novo-pindol)\n* Propranolol (Inderal)\n* Bystolic (nebivolol)",
        "pearls": "1. Bradycardia with associated hypotension and shock (systolic BP < 80 mm Hg, HR < 60 BPM) defines severe beta-blocker toxicity. Bradycardia by itself is not necessarily helpful as a warning sign because slowing of the heart rate and dampening of tachycardia in response to stress is observed with therapeutic levels.\n2. Glucagon increases heart rate and myocardial contractility, and improves atrio-ventricular conduction. These effects are unchanged by the presence of beta-receptor blocking drugs. This suggests that glucagon's mechanism of action may bypass the beta-adrenergic receptor site. Because it may bypass the beta-receptor site, glucagon can be considered as an alternative therapy for profound beta-blocker intoxications.\n3. Be prepared to manage the airway after Glucagon administration due to possible emesis.\n4. While case reports have documented hypotension in the absence of bradycardia, blood pressure usually does not fall before the onset of bradycardia. Bradycardia may be isolated or accompanied by mild conduction disturbances affecting the entire cardiac conduction system from the sinus node to the intraventricular Purkinje system.\n5. Cardiac pacing may be effective in increasing the rate of myocardial contraction. Electrical capture is not always successful and, if capture does occur, blood pressure is not always restored. Reserve cardiac pacing for patients unresponsive to pharmacological therapy. Multiple case reports describe complete neurological recovery, even with profound hypotension, if a cardiac rhythm can be sustained.\n6. Agents with combined alpha- and beta-selective properties (Dopamine and Epinephrine) may be necessary to maintain blood pressure. A beta-agonist may competitively antagonize the effect of the beta-blocker. The amount of beta-agonist required might be several orders of magnitude above those recommended in standard ACLS protocols.\n7. Do not rely on patient history of ingestion, especially in suicide attempts.\n8. Bring bottles and contents to ER with patient."
    },
    {
        "document title": "Toxicological Emergencies",
        "protocol title": "Medical \u2013 Overdose/Poisoning \u2013 Tricyclic Anti-depressant",
        "overview": "Aggressive care at onset of signs and symptoms of a TCA overdose is essential, as the patient can decompensate quickly. Early signs and symptoms include: widening of the QRS, tachycardia, hypotension and altered LOC. Unfortunately, the history of poisoning/overdose is notoriously unreliable whether it is obtained from the patient, friends and family members or emergency services personnel. Despite the possible inaccuracies, the most important historical factors include what poison was involved, how much was taken, how it was taken, when it was taken, why it was taken, and especially what else was taken. Poison Control may be contacted at any time for information on poisoning (1-800-222-1222) but only Medical Control may give patient treatment orders.",
        "hpi": "- Use or suspected use of a potentially toxic substance\n- Substance ingested, route, and quantity used\n- Time of use\n- Reason (suicidal, accidental, criminal)\n- Available medications in home\n- Past medical history",
        "signs and symptoms": "- Mental status changes\n- Hypotension / hypertension\n- Hypothermia / hyperthermia\n- Decreased respiratory rate\n- Tachycardia, other dysrhythmias\n- Seizures",
        "considerations": "Co-ingestions such as:\n- Acetaminophen (Tylenol)\n- Depressants\n- Stimulants\n- Anticholinergic\n- Cardiac medications\n- Solvents, alcohols, Cleaning agents\n- Insecticides",
        "procedure": "1. Obtain general assessment of the patient. \n2. Administer Oxygen to maintain SPO2 94 - 99% \n3. Suction oropharynx as necessary. \n4. Obtain blood glucose sample. If glucose is < 60 mg / dL or > 300 mg / dL, refer to Hypoglycemia or Hyperglycemia protocol. \n5. Establish IV of Normal Saline. Titrate to maintain a systolic BP > 90 mmHg.  \n6. Place the patient on a cardiac monitor and obtain / interpret 12 lead ECG. \n7. If TCA overdose is suspected and any progressive widening of QRS, > 0.12 ms, seizure activity, hypotension, tachycardia or heart block is noted, administer SODIUM BICARBONATE 50 mEq IVP. \n8. Transport promptly in position of comfort. Reassess vital signs as indicated.",
        "pearls": "1. Amiodarone is contraindicated, as are other drugs that widen the QRS.\n2. Common TCA\u2019s include but are not limited to: Elavil, Triavil, Etrafon, and Amitriptyline.\n3. Flexeril (cyclobenzaprine) can mimic TCA overdose.\n4. Do not rely on patient history of ingestion, especially in suicide attempts.\n5. Bring bottles and contents to ER with patient."
    },
    {
        "document title": "Toxicological Emergencies",
        "protocol title": "Medical - Overdose/Poisoning - Calcium Channel Blocker",
        "overview": "Overdose by immediate-release agents is characterized by rapid progression to hypotension, brady-arrhythmias, and cardiac arrest. Overdose by extended-release formulations can result in delayed onset of arrhythmias, shock, delayed cardiac collapse, and bowel ischemia. Unfortunately, the history of poisoning / overdose is notoriously unreliable whether it is obtained from the patient, friends and family members or emergency services personnel. Despite the possible inaccuracies, the most important historical factors include what poison was involved, how much was taken, how it was taken, when it was taken, why it was taken, and especially what else was taken. Poison Control may be contacted at any time for information on poisoning (1-800-222-1222) but only Medical Control may give patient treatment orders.",
        "hpi": "* Use or suspected use of a potentially toxic substance\n* Substance ingested, route, and quantity used\n* Time of use\n* Reason (suicidal, accidental, criminal)\n* Available medications in home\n* Past medical history",
        "signs and symptoms": "* Mental status changes\n* Hypotension\n* Brady cardia, other dysrhythmias",
        "considerations": "* Co-ingestions\n* Cardiac medications\n* Anti-hypertensive medications",
        "procedure": "1. Obtain general assessment of the patient.\n2. Administer Oxygen to maintain SPO2 94 - 99%\n3. Suction oropharynx as necessary.\n4. Obtain blood glucose sample. If glucose is < 60 mg/dL or > 300 mg/dL, refer to Hypoglycemia or Hyperglycemia protocol.\n5. Establish IV of Normal Saline. Titrate to maintain a systolic BP > 90 mmHg.\n6. Administer Normal Saline 250 ml Bolus as needed to maintain systolic BP > 90 mmHg. Bolus amount should not exceed 20 cc/kg. Caution should be used with patients with history of renal failure and HF. Re -assess after 250 ml for signs of fluid overload.\n7. Place the patient on a cardiac monitor and obtain / interpret 12 lead ECG. Refer to appropriate Cardiac Care protocol.\n8. Administer CALCIUM CHLORIDE 2.0 - 4.0 mg/kg IVP / IO every 10 minutes until signs and symptoms improve.\n9. If no response noted to Calcium Chloride, administer GLUCAGON 1 mg IVP / IO. If no response in five (5) minutes, administer one (1) repeat dose of Glucagon 1 mg IVP / IO.\n10. Administer LEVOPHED Infusion 0.1 - 0.5 mcg/kg/minute for hypotension that remains after fluid bolus administration.\n11. Transport promptly in position of comfort. Reassess vital signs as indicated.",
        "pearls": "1. Aggressive cardiovascular support is necessary for management of massive calcium channel blocker overdose. While calcium may overcome some adverse effects of calcium channel blockers, it rarely restores normal cardiovascular status.\n2. Consider using calcium only if a witness confirms a CCB overdose; calcium may induce fatal arrhythmias in digoxin overdose, which can present with similar findings.\n3. Empiric use of glucagon (adults: 5 - 15 mg IV) may be warranted for patients with an unknown overdose presenting with bradycardia or hypotension.\n4. Atropine may be tried if hemodynamically significant bradycardia occurs; however, heart block is usually resistant to atropine in CCB toxicity. Mid-dose dopamine (5 - 10 mcg/kg/min) may improve heart rate and contractility.1\n5. According to many case reports, glucagon has been used with good results. However, vasopressors are frequently necessary for adequate resuscitation and should be administered early if hypotension occurs.\n6. Be prepared to manage the airway after Glucagon administration due to possible emesis.\n7. Do not rely on patient history of ingestion, especially in suicide attempts.\n8. Bring bottles and contents to ER with patient.\n1 MedScape: Emergent Management of Calcium Channel Blocker Toxicity; Author B. Zane Horowitz, MD, FACMT",
        "common calcium channel blocker medications": "* Amlodipine (Norvasc)\n* Bepridil (Vascor)\n* Diltiazem (Cardizem)\n* Felodipine (Plendil\n* Isradipine (Dynacirc)\n* Nicardipine (Cardene)\n* Nifedipine (Adalat, Procardia)\n* Nimodipine (Nimotop)\n* Nisoldipine (Sular)\n* Verapamil (Calan, Isoptin)"
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Overdose/Poisoning/Toxic Ingestion",
        "overview": "Ingestion and overdose are among the most common pediatric \u201caccidents.\u201d The substance usually is a medication prescribed for family members or for the child. Other commonly ingested poisons include cleaning chemicals, plants, and anything that fits in a child\u2019s mouth. Primary manifestations may be a depressed mental status and/or respiratory and cardiovascular compromise. Contact Medical Control for patient care orders. Contact Poison Control (804-828-1222 or 800-222-1222) for advice. Do not confuse Poison Control with Medical Control.",
        "hpi": "- Use or suspected use of\n  - a potentially toxic\n    substance\n- Substance ingested,\n  - route, and quantity used\n- Time of use\n- Reason (suicidal,\n  - accidental, criminal)\n- Available medications in\n  - home",
        "signs and symptoms": "- Mental status changes\n- Hypotension /\n  - hypertension\n- Hypothermia /\n  - hyperthermia\n- Decreased respiratory\n  - rate\n- Tachycardia, other\n  - dysrhythmias\n- Seizures",
        "considerations": "- Acetaminophen\n  - (Tylenol)\n- Depressants\n- Stimulants\n- Anticholinergic\n- Cardiac medications\n- Solvents, alcohols\n- Cleaning agents\n- Insecticides",
        "procedure": "1. Perform general patient management. *****\n2. Support life-threatening problems associated with airway, breathing, and circulation. *****\n3. Administer oxygen to maintain SpO2 94 - 99%. *****\n4. Establish an IV of normal saline per patient assessment. **\n5. If child is over 20kg and respiratory effort remains diminished and opiate administration is suspected, give NARCAN INTRANASAL 2mg (one vial). May repeat one time. ***\n6. a. If respiratory effort remains diminished and opiate administration is suspected, give NARCAN 0.1mg/kg slow IVP/IM max 2mg (ALS only). ***\n7. Place patient on cardiac monitor and monitor pulse oximetry. **\n8. Transport and perform ongoing assessment as indicated. *****",
        "narcan dosage guide": "Age Pre-Term Term 3 mos. 6 mos. 1 year 3 years 6 years 8 years\n\nWeight (lb / kg) 3.3 lb\n1.5 kg 6.6 lb\n3 kg 13.2 lb\n6 kg 17.6 lb\n8 kg 22 lb\n10 kg 30.8 lb\n14 kg 44 lb\n20 kg 55 lb 25 kg\n\nNarcan IV 0.1 mg / kg 0.15 mg 0.3 mg 0.6 mg 0.8 mg 1.0 mg 1.4 mg 2.0 mg 2.0 mg"
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Diabetic \u2013 Hypoglycemia",
        "overview": "Symptomatic hypoglycemia is defined as a blood glucose level < 60 mg / dL with signs of altered mental status and / or unconsciousness. The many signs and symptoms that are associated with hypoglycemia can be divided into two broad categories: adrenergic and neurologic. The adrenergic stimulation is due to the increased epinephrine levels and the neurologic due to central nervous system dysfunction from the decreased glucose levels.",
        "hpi": "* History of diabetes\n* Onset of symptoms\n* Medications\n* Fever or recent infection\n* Alcohol consumption\n* Last meal",
        "signs and symptoms": "* Anxiety, agitation, and / or confusion\n* Cool, clammy skin\n* Diaphoresis\n* Seizure\n* Decreased visual acuity, blindness\n* Abnormal/ hostile behavior\n* Tachycardia\n* Hypertension\n* Dizziness, headache, weakness",
        "considerations": "* Hypoxia\n* Seizure\n* Stroke\n* Brain trauma\n* Alcohol intoxication\n* Toxin/ substance abuse\n* Medication effect / overdose",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Assess for signs of trauma. Provide spinal immobilization as necessary.\n4. Administer oxygen to maintain SPO2 94 - 99%.\n5. For altered mental status, perform rapid glucose determination.\n6. If glucose < 60 mg / dL or clinical signs and symptoms indicate hypoglycemia:\n    a. If the patient can protect airway, give Oral Glucose 15 grams. Repeat in 15 minutes if necessary.\n7. If glucose < 60 mg / dL or clinical signs and symptoms indicate hypoglycemia and oral glucose is contraindicated: Establish an IV of normal saline at KVO.\n    a. If > 30 days, administer DEXTROSE 10% (5 mL / kg, max dose 100mL ) via IV or IO.\n    b. If < 30 days, administer DEXTROSE 10% (2 mL / kg) via IV or IO.\n    c. If DEXTROSE 10% bag unavailable:\n        * If patient is < 30 days old, administer Dextrose 10% (2cc/kg) IV or IO, mixed as below.\n        * If patient is > 30 days old but < 8 years old, administer Dextrose 25% (2cc/kg) IV or IO, mixed as below.\n        * If patient is > 8 years old, administer Dextrose 50% (0.5mg/kg, max 25gm) IV or IO.\n    d. If unable to establish an IV, alternatively administer GLUCAGON:\n        * Under 20 kg: 0.5 mg IM/IN (ALS only)\n        * >20 kg: 1.0 mg IM/IN (EMT and above) (over 20kg only)\n8. For signs and symptoms of hypovolemic shock or dehydration, follow the Pediatric Shock protocol.\n9. Place on cardiac monitor per patient assessment.\n10. Transport and perform ongoing assessment as indicated.",
        "procedure for making dextrose 25 and 10 percent": "Dextrose 25%: In 50 ml syringe, mix 25 ml of Dextrose 50% with 25 ml Normal Saline. Mixture will yield 50 ml of Dextrose 25%.\nDextrose 10%: In 50 ml syringe, mix 10 ml of Dextrose 50% with 40 ml Normal Saline. Mixture will yield 50 ml of Dextrose 10%.",
        "dosage guide by age and weight": "For preterm infants (weight not specified), glucagon is not indicated; dextrose 10% (bag or diluted at 2 mL/kg) is given as 4.0 mL, while dextrose 10% at 5 mL/kg and dextrose 25% at 2 mL/kg are not applicable. For term infants (6.6 lb/3 kg), give glucagon 0.5 mg, dextrose 10% (bag or diluted at 2 mL/kg) as 6.0 mL, and no dose of dextrose 10% at 5 mL/kg or dextrose 25% at 2 mL/kg. At 3 months (13.2 lb/6 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 30.0 mL; dextrose 25% at 2 mL/kg is 12.0 mL (3 g). At 6 months (17.6 lb/8 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 40.0 mL; dextrose 25% at 2 mL/kg is 16.0 mL (4 g). At 1 year (22 lb/10 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 50.0 mL; dextrose 25% at 2 mL/kg is 20.0 mL (5 g). At 3 years (30.8 lb/14 kg), administer glucagon 0.5 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 70.0 mL; dextrose 25% at 2 mL/kg is 28.0 mL (7 g). At 6 years (44 lb/20 kg), administer glucagon 1.0 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 100 mL; dextrose 25% at 2 mL/kg is 40.0 mL (10 g). Finally, at 8 years (55 lb/25 kg), administer glucagon 1.0 mg; dextrose 10% (bag or diluted at 2 mL/kg) is not used; dextrose 10% at 5 mL/kg is 100 mL; dextrose 25% at 2 mL/kg is 50.0 mL (12.5 g).",
        "pearls": "1. Hypoglycemia is the most common metabolic problem in neonates.\n2. Use aseptic techniques to draw blood from finger. Allow alcohol to dry completely prior to puncturing finger for blood glucose level. Alcohol may cause inaccurate readings. Do not blow on or fan site to dry faster.\n3. Blood glucose levels should be taken from extremity opposite IV and medication administration for most accurate reading.\n4. After puncturing finger, use only moderate pressure to obtain blood. Excessive pressure may cause rupture of cells causing inaccurate results.\n5. Know your specific agency\u2019s glucometer parameters for a \u201cHI\u201d and \u201cLO\u201d reading.\n6. When administering IV fluids, a minimum amount should be delivered as large amounts may lower blood glucose level and impede original goal of administering Dextrose.\n7. Patients who are consuming aspirin, acetaminophen, anti-psychotic drugs, beta-blockers, oral diabetic medications, or antibiotics such as sulfa-based, tetracycline, and amoxicillin that experience a hypoglycemic episode are at a greater risk for relapse. These patients should be strongly encouraged to accept transport.\n8. An inadequate amount of glucose for heat production, combined with profound diaphoresis, may place a hypoglycemic patient at greater risk for hypothermia. Keep patient warm as needed.\n9. Glucagon causes a breakdown of stored glycogen to glucose. Glucagon may not work if glycogen stores are previously depleted due to liver dysfunction, alcoholism, or malnutrition. Effects of Glucagon may take up to 30 minutes.\n10. Any patient that has had a hypoglycemic episode without a clear reason should be transported for further evaluation."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Hypotension/Shock (Non-trauma)",
        "overview": "Shock is defined as a state of inadequate tissue perfusion. This may result in acidosis, derangements of cellular metabolism, potential end-organ damage, and death. Early in the shock process, patients are able to compensate for decreased perfusion by increased stimulation of the sympathetic nervous system, leading to tachycardia and tachypnea. Later, compensatory mechanisms fail, causing a decreased mental status, hypotension, and death. Early cellular injury may be reversible if definitive therapy is delivered promptly.",
        "hpi": "- Blood loss (vaginal or gastrointestinal)\n- Fluid loss (vomiting, diarrhea)\n- Fever\n- Infection\n- Medications\n- Allergic Reaction\n- Pregnancy, ectopic\n- Trauma\n- Coffee -ground emesis\n- Tarry stools",
        "signs and symptoms": "- Restlessness, confusion\n- Weakness, dizziness\n- Weak, rapid pulse\n- Pale, cool, clammy skin\n- Delayed capillary refill\n- Hypotension",
        "considerations": "- Hypovolemic\n- Cardiogenic\n- Septic\n- Neurogenic\n- Anaphylactic\n- Ectopic pregnancy\n- Dysrhythmia\n- Pulmonary embolus\n- Tension pneumothorax\n- Medication effect / overdose\n- Vaso -vagal\n- Trauma",
        "procedure": "1. Perform general patient management.\n2. Support life -threatening problems associated with airway, breathing, and circulation.\n3. Assess for signs of shock including, but not limited to: Restlessness, altered mental status, hypoperfusion (cool, pale, moist skin), tachypnea (rapid breathing), rapid, weak pulse, orthostatic hypotension (blood pressure suddenly drops on standing up), nausea and thirst.\n4. Administer oxygen to maintain SpO2 94 - 99%. Support respirations as necessary with a BVM.\n5. Transport as soon as possible.\n6. Control external bleeding with direct pressure, then tourniquet if direct pressure is inadequate.\n7. Establish a large bore IV or IO of Normal Saline. If time permits, establish second access. Do not delay transport to establish vascular access\n8. Maintain systolic BP appropriate for patient:\n    - Birth to 1 month - 60 mmHg\n    - 1 month to 1 year - > 70 mmHg\n    - Greater than 1 year - 70 + [2 x Age (years)]\n9. Give a 20 mL / kg bolus. If no improvement after first 20 mL / kg bolus, may repeat once. While administering a fluid bolus, frequently reassess perfusion for improvement. If perfusion improves, slow the IV to KVO and monitor closely. If patient develops fluid overload respiratory distress (dyspnea, crackles, rhonchi, decreasing SpO2), slow the IV to KVO.\n10. Place the patient on the cardiac monitor.\n11. Transport and perform ongoing assessment as indicated.",
        "classes of shock": "Hypovolemic: Caused by hemorrhage, burns, or dehydration.\nDistributive: Maldistribution of blood, caused by poor vasomotor tone in neurogenic shock, sepsis, anaphylaxis, severe hypoxia, or metabolic shock.\nCardiogenic: Caused by necrosis of the myocardial tissue, or by arrhythmias.\nObstructive: Caused by impairment of cardiac filling, found in pulmonary embolism, tension pneumothorax, or cardiac Tamponade.",
        "pearls": "1. GI bleeding may be a less obvious cause of hypovolemic shock if it has been gradual. Ask patient about possible melena, hematemesis, and hematochezia.\n2. Ectopic pregnancy may be a less obvious cause of hypovolemic shock. Consider this diagnosis in all female patients of child-bearing age if there is a complaint of abdominal or pelvic pain."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Altered Mental Status",
        "overview": "Although each of these presentations has unique considerations, prehospital treatment is similar. The unconscious patient is one of the most difficult patient-management problems in pre-hospital care. Causes range from benign problems to potentially life-threatening cardiopulmonary or central nervous system disorders. In the usual clinical approach to a patient, the provider first obtains a history, performs a physical examination, and then administers treatment. However, this sequence must be altered for patients that are unconscious or with an altered level of consciousness. Simple syncope may be the result of a wide variety of medical problems, although the major cause of syncope is a lack of oxygenated blood to the brain. In this situation, it is quickly remedied when the patient collapses, improving circulation to the brain. Altered LOC is such a major variance from normal neurological function that immediate supportive efforts may be required. Efforts should be made to obtain as much of an HPI as possible from family members or bystanders.",
        "hpi signs symptoms considerations": "Cardiac history, stroke, seizures Occult blood loss (GI, ectopic)\nFemales (LMP, vaginal bleeding) Fluid loss (nausea, vomiting, diarrhea)\nPast medical history Recent trauma\nComplaint prior to event Loss of consciousness with recovery\nLightheadedness, dizziness Palpitations, slow or rapid pulse\nPulse irregularity Decreased blood pressure\nVaso-vagal Orthostatic hypotension\nCardiac syncope / dysrhythmia Micturation\nPsychiatric Hypoglycemia\nSeizure Shock\nGI Bleed Ectopic Pregnancy\nToxicological (ETOH) Medication effect (hypertension)",
        "procedure": "1. Perform general patient management.\n2. Maintain patient in a supine position and assess for C -spine precautions.\n3. Administer oxygen to maintain SPO2 94 - 99% \uf0b7\n4. Assess blood glucose level.  Refer to Pediatric Hypoglycemia Protocol.\n5. If child is over 20kg and respiratory effort remains diminished and opiate administration is suspected, give NARCAN INTRANASAL 2mg (one vial). May repeat one time. \n6. Establish IV of Normal Saline. Keep at KVO rate unless hypotensive. If hypotensive, refer to Pediatric Shock protocol.  \n7. Transport and reassess as needed.",
        "narcan dosage guide": "Age Pre-Term Term 3 6 1 3 6 8\nWeight (lb / kg) 3.3 lb1.5 kg 6.6 lb3 kg 13.2 lb6 kg 17.6 lb8 kg 22 lb10 kg 30.8 lb14 kg 44 lb20 kg 55 lb25 kg\nNarcan IV 0.1 mg/kg 0.15 ml 0.3 ml 0.6 ml 0.8 ml 1.0 ml 1.4 ml 2.0 ml 2.0 ml",
        "pearls": "1. Assess for signs and symptoms of trauma if questionable or suspected fall with syncope.\n2. Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Seizure",
        "overview": "A seizure is a period of altered neurologic function caused by abnormal neuronal electrical discharges. Generalized seizures begin with an abrupt loss of consciousness. If motor activity is present, it symmetrically involves all four extremities. Episodes that develop over minutes to hours are less likely to be seizures; most seizures only last 1 - 2 minutes. Patients with seizure disorders tend to have stereotype, or similar, seizures with each episode and are less likely to have inconsistent or highly variable attacks. True seizures are usually not provoked by emotional stress. Most seizures are followed by a postictal state of lethargy and confusion.",
        "hpi signs symptoms": "Reported, witnessed seizure activity description\n Previous seizure history information\n Medic alert tag\n Seizure medications\n History of trauma\n History of diabetes mellitus\n History of pregnancy\n Decreased mental status\n Sleepiness\n Incontinence\n Observed seizure activity\n Evidence of trauma",
        "considerations": "CNS (head) trauma\n Tumor\n Metabolic, hepatic, renal failure\n Diabetic\n Hypoxia\n Electrolyte abnormality\n Drugs, medications, non-compliance\n Infection, fever, meningitis\n Alcohol withdrawal\n Hyperthermia",
        "procedure": "1.Perform general patient management.\n2.Support life-threatening problems associated with airway, breathing, and circulation.\n2a.Suction the oro - and nasopharynx as necessary.\n2b.Place a nasopharyngeal airway as necessary (avoid in head trauma).\n3.Administer oxygen to maintain SpO2 94 - 99%. Support respirations as necessary with a BVM.\n4.Do not restrain the patient. Let the seizure take its course but protect patient from injury.\n5.If the seizure persists give MIDAZOLAM 0.2 mg / kg INTRANASAL (max single dose 10 mg) \u2013OR- give MIDAZOLAM 0.1 mg / kg IV / IM (max single dose 10 mg)\n5a.Repeat dose in 5 minutes if seizure persists.\n5b.If Midazolam is unavailable, administer, DIAZEPAM 0.25 mg / kg up to 5 mg slow IV push, titrated to effect. Diazepam may also be administered Per Rectum (PR) in pediatric patients.\n 6.Perform rapid glucose determination. If glucose less than 60 mg / dL or clinical signs and symptoms indicate hypoglycemia, refer to the Hypoglycemia protocol\n 7.Establish an IV of normal saline at KVO.\n 8.Place patient on cardiac monitor (sometime life-threatening dysrhythmias can cause seizure-like activity).\n 9.Consider placing the patient in the recovery position during the postictal period.\n10. Transport and perform ongoing assessment as indicated.",
        "generalized seizure types": "Absence (Petit -Mal)\n Atonic (Drop Attack)\n Myoclonic (Brief bilateral jerking)\n Tonic-Clonic (Grand - Mal)",
        "simple partial seizure types": "Focal / Local: Localized twitching of hand, arm, leg, face, or eyes. Patient may be conscious or unconscious",
        "complex partial seizure types": "Temporal Lobe\n Psychomotor",
        "pediatric dosage information table": "Age Pre- Term Term 3 month 6 month 1 year 3 years 6 years 8 years\nWeight (lb / kg) 3.3 lb 1.5 kg 6.6 lb 3 kg 13.2 lb 6 kg 17.6 lb 8 kg 22 lb 10 kg 30.8 lb 14 kg 44 lb 20 kg 55 lb 25 kg\nMidazolam IV 0.15 mg 0.3mg 0.6mg 0.8 mg 0.1mg 1.4mg 2mg 2.5mg\nMidazolam IN *1/2 dose per nostril* 0.3 mg 0.6mg 1.2mg 1.6mg 2mg 2.8mg 4mg 5mg\nDiazepam IV (5.0 mg / ml) 0.3 mg/kg 0.1 ml 0.2 ml 0.4 ml 0.5 ml 0.6 ml 0.84 ml 1.2 ml 1.5 ml\nDiazepam PR (5.0 mg / ml) 0.5 mg / kg 0.15 ml 0.3 ml 0.6 ml 0.8 ml 1.0 ml 1.4 ml 2.0 ml 2.0 ml",
        "pearls": "1. Respirations during an active seizure should be considered ineffective and airway maintenance should occur per assessment.\n2. Status epilepticus is defined as two or more consecutive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway support, treatment, and transport.\n3. Grand Mal seizures are generalized in nature and associated with loss of consciousness, incontinence, and possibly tongue trauma.\n4. Focal seizures affect only a specific part of the body and are not usually associated with loss of consciousness.\n5. Jacksonian seizures are seizures, which start as focal in nature and become generalized.\n6. Petit Mal seizures may be localized to a single muscle group or may not involve visible seizure activity all. Always examine pupils for nystagmus, which would alert provider to continued seizure activity.\n7. Be prepared for airway problems and continued seizures.\n8. Investigate possibility of trauma and substance abuse.\n9. Be prepared to assist ventilations as dosages of benzodiazepines are increased."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Diabetic Hyperglycemia",
        "overview:": "- Diabetes mellitus is the most common endocrine disorder of childhood, affecting approximately 2/1,000 school-age children in the United States.\n- Symptomatic hyperglycemia is defined as a blood glucose level > 300 mg/dl with signs of severe dehydration, altered mental status, and/ or shock.\n- Hyperglycemia is usually the result of an inadequate supply of insulin to meet the body's needs.\n- Most pre -hospital care should be focused around the treatment of severe dehydration and support of vital functions.",
        "hpi": "- History of diabetes\n- Onset of symptoms\n- Medications",
        "signs and symptoms": "- Anxiety, agitation, and / or confusion\n- Dry, red, and / or warm skin\n- Fruity / acetone smell on breath\n- Kussmaul respirations\n- Dry mouth, intensive thirst\n- Abnormal/ hostile behavior\n- Tachycardia\n- Dizziness / headache",
        "considerations": "- Hypoxia\n- Brain trauma\n- Alcohol intoxication\n- Toxin / substance abuse\n- Medication effect / overdose",
        "procedure": "1. Perform general patient management.\n2. Support life -threatening problems associated with airway, breathing, and circulation.\n3. Assess for signs of trauma. Provide spinal immobilization as necessary.\n4. Administer oxygen to maintain SPO2 94 - 99%\n5. For altered mental status, perform rapid glucose determination.\n6. If glucose > 300 mg / dL, start an IV of normal saline.\n7. For signs and symptoms of hypovolemic shock or dehydration, follow the Pediatric Shock protocol.\n8. If glucose level is > 300 mg / dL, and no signs of shock are noted, administer maintenance Normal Saline infusion:\n    - 4.0 ml / kg for first 1 - 10 kg of weight.\n    - Add 2.0 ml / kg for next 11 - 20 kg of weight.\n    - Add 1.0 ml / kg, for every kg of weight, > 20 kg.\n    - Multiply total amount x 2= total hourly hyperglycemic maintenance amount.\n9. Place on cardiac monitor and obtain / interpret 12 lead ECG per assessment.\n10. Transport and perform ongoing assessment as indicated.",
        "pearls:": "1. Know your specific agency's glucometer parameters for a \"HI\" and \"LO\" reading.\n2. It is estimated that 2 - 8% of all hospital admissions are for the treatment of DKA, while mortality for DKA is between 2 - 10%. Published mortality rates for HHS vary, but the trend is that the older the patient and higher the osmolarity, the greater the risk of death."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Nausea/Vomiting",
        "overview": "The pre-hospital provider should be very careful to ensure that patients who present with vague complaints such as nausea and vomiting are thoroughly evaluated. The patient\u2019s symptoms and recent history must determine the most appropriate care. Frequently, treatment of an underlying cause and limiting movement may resolve or greatly reduce these complaints. However, persistent nausea and vomiting of unknown etiology may respond well to pharmaceutical therapy. All patients presenting with nausea and vomiting should be screened for potential life-threats initially. Anti-emetic treatment should occur only as a secondary priority.",
        "hpi": "Age\n Time of last meal\n Last bowel movement, emesis\n Improvement, worsening with food or activity\n Duration of signs and symptoms\n Other sick contacts\n Past medical, surgical history\n Medications\n Menstrual history (pregnancy)\n Travel history\n Recent trauma\n Pain\n Character of pain (constant, intermittent, sharp, dull, etc.)",
        "signs and symptoms": "Distention\n Constipation\n Diarrhea\n Anorexia\n Radiation\n Associated symptoms (helpful to localize source)\n Fever, headache, blurred vision, weakness, malaise, myalgias, cough, dysuria, mental status changes, rash",
        "considerations": "CNS (increased pressure, headache, lesions, trauma, hemorrhage, vestibular)\n Drugs (NSAIDs, antibiotics, narcotics, chemotherapy)\n GI or renal disorders\n Gynecological disease (ovarian cyst, PID)\n Infections (pneumonia, influenza)\n Electrolyte abnormalities\n Food or toxin induced\n Medications, substance abuse\n Pregnancy\n Psychologic",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO\u2082 94 - 99%\n4. Allow the patient to lie in a comfortable position.\n5. Establish an IV of normal saline per patient assessment.\n6. Assess for signs of shock. If shock is suspected, follow the Pediatric Shock protocol.\n7. For severe nausea or vomiting, if available, give ONDANSETRON (ZOFRAN).\n*If only IV formulation is available, administer 0.1 mg / kg IV / IM up to 4 mg over 2 to 5 minutes.*\n8. In lieu of IV ONDANSETRON, may administer 4 mg PO ONDANSETRON OTD tablet for patients over 44 lbs (20 kg).\n9. May repeat Ondansetron PO or IV dosing after 10 minutes, if needed.\n10. Perform ongoing assessment as indicated and transport.",
        "ondansetron dosing table": "Ondansetron IV (0.1 mg/kg) is not specified for term infants (6.6 lb/3 kg) or 6-month-olds (17.6 lb/8 kg). For a 1-year-old (22 lb/10 kg), administer 1.0 mg; for a 3-year-old (30.8 lb/14 kg), 1.5 mg; for a 6-year-old (44 lb/20 kg), 2.0 mg; for an 8-year-old (55 lb/25 kg), 2.5 mg; for a 10-year-old (75 lb/34 kg), 3.5 mg; and for both 12-year-olds (88 lb/40 kg) and 14-year-olds (110 lb/50 kg), 4.0 mg.",
        "pearls": "1. Nausea and vomiting has many subtle, sometimes life-threatening causes. Do not minimize its importance as a symptom.\n2. Ondansetron may not be as effective for vertigo and labyrinthitis related nausea and vomiting.\n3. For nausea and vomiting associated with dehydration, fluid replenishment may be sufficient in improving patient comfort and reduce the need for medication administration.\n4. Ensuring that you have reasonably addressed possible causes, will help minimize the potential that you are overlooking a life-threat and/or concern that should receive priority over anti-emetic treatment.\n5. In cases of toxic ingestion, including alcohol, poisons, and drug overdoses, vomiting is an internal protective mechanism and should not be prevented with pharmacological therapy in the pre-hospital environment. Care should be given to prevent aspiration.\n6. Ondansetron is also safe and effective for nausea and vomiting in trauma patients and can be used in conjunction with pain management.\n7. Proper documentation should include the mental status and vital signs before and after medication administration."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "General \u2013 Fever",
        "overview": "Fever is a common chief complaint of children encountered in the pre-hospital environment. Patients with fever present in many different ways, depending on the age of the patient, the rate of rise of the temperature, the magnitude of the fever, the etiology of the fever, and the underlying health of the patient. The patient\u2019s skin will be warm to the touch and may be flushed on observation. The patient may also complain of being warm and perspiring. It is important to recognize that fever represents a symptom of an underlying illness, and the actual illness must be determined and treated. Flu-like symptoms may accompany fevers, but it should not be assumed that fevers with these symptoms are minor, as there may be a serious underlying medical condition. Febrile seizures usually are self-limiting and typically occur once from a rapid rise in temperature, usually above 101.8 \uf0b0F / 38.7\uf0b0C. If more than one seizure occurs, causes other than fever should be suspected. The first occurrence of a seizure warrants the most concern because the benign nature of the illness has not been established.",
        "hpi": "- Age\n- Duration of fever\n- Severity of fever\n- Any previous decrease or elevation of fever since onset\n- Past medical history\n- Medications\n- Immunocompromised (transplant, HIV, diabetes, cancer)\n- Recent illness or socialization with others with illness\n- Vaccinations\n- Poor PO intake\n- Urine production, decrease in diapers\n- Last acetaminophen dose",
        "signs and symptoms": "- Altered mental status\n- Unconsciousness\n- Hot, dry, or flushed skin\n- Tachycardia\n- Hypotension, shock\n- Seizures\n- Nausea, vomiting\n- Weakness, dizziness, syncope\n- Restlessness\n- Loss of appetite\n- Decreased urine output\n- Rapid, shallow respirations\n- Associated symptoms (helpful in localizing source): myalgias, cough, chest pain, headache, dysuria, abdominal pain, mental status changes, rash",
        "considerations": "- Infection, sepsis\n- Neoplasms, cancer, tumors, lymphomas\n- Medication or drug reaction\n- Connective tissue disease\n- Vasculitis\n- Thermoregulatory disorder\n- Hyperthyroid\n- Heat stroke\n- Drug fever",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%\n4. If the patient is having a seizure, refer to the Pediatric Seizure protocol.\n5. If temperature is greater than 106 \uf0b0 F / 41\uf0b0C, refer to Hyperthermia Patient Care Protocol.\n6. Begin passive cooling by removing excess and constrictive clothing. Avoid overexposure.\n7. Obtain blood glucose sample. If glucose is < 60 mg / dL or > 300 mg / dL, refer to Pediatric Hypoglycemia or Hyperglycemia Patient Care Protocol.\n8. Establish an IV of normal saline at KVO. Titrate to a systolic pressure appropriate for child:\n- Birth to 1 month - 60 mmHg\n- 1 month to 1 year - > 70 mmHg\n- Greater than 1 year - 70 + [2 x Age (years)]\n9. If hypoperfusion is suspected, refer to the Pediatric Shock protocol.\n10. Perform ongoing assessment as indicated and transport promptly.",
        "pearls": "1. Fevers with rashes are abnormal and should be considered very serious.\n2. Fevers in infants \u2264 3 months old should be considered very serious.\n3. Patient may seize if temperature change is rapid, be cautious and prepared to manage both seizure activity and airway at all times.\n4. If fever is present with hypotension, it may indicate the patient is in septic shock.\n5. Febrile seizures are more likely in children with a history of febrile seizures.\n6. It is important to know if an elevation in temperature signals the abrupt onset of a fever or represents the gradual worsening of a long-term fever.\n7. Cooling in the pre-hospital environment with water, alcohol, or ice is discouraged.\n8. Fevers in children of 104 \uf0b0F / 40\uf0b0C for greater than 24 hours should be considered serious.\n9. A common error in the treatment of fever is to wrap the patient in multiple layers of clothing and blankets. This only contributes to the rise in temperature."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "General \u2013 Universal Patient Care/Initial Patient Contact",
        "overview": "Few encounters cause greater anxiety for medical providers than a pediatric patient experiencing a life-threatening situation. Although pediatric calls only account for approximately 10% of all EMS calls, they can be among the most stressful. Pre-hospital providers need to be prepared to face these challenges, as prompt recognition and treatment of potentially life-threatening diseases in children in the field may have a significant impact on the outcome of the patient. Of the 10% of EMS calls that involve pediatric patients, fewer than 5% are for life- or limb-threatening situations. When EMS does respond to a pediatric call, treatment such as administering oxygen, starting an IV, or performing endotracheal intubation can be involved in more than 50% of the cases.",
        "primary assessment": "Approach to the pediatric patient varies with the patient's age and the nature of illness or injury. It is critical that EMS providers be cognizant of the emotional and physiological needs of a child throughout the assessment. It is equally important to identify the needs of the child's family members. In this stressful environment, family members will be trying to find the cause of injury or illness in their child and may be unruly when the answers they seek are not available or are contrary to what is expected. The key to pediatric assessment in EMS is to identify and manage immediate life threats. It is often easy to determine whether a child is sick just by looking at him. Sick kids look sick. If a child is active, appropriate and alert, he is not sick. The opposite is true as well. If a child is inactive and non-interactive, assume he is sick until proven otherwise. The most widely accepted approach to forming a general impression in a child is using the Pediatric Assessment Triangle. This tool is especially useful because the assessment criteria are determined during the general impression. This assessment can be performed from across the room, before contact with the patient is ever made.",
        "airway": "The patient\u2019s airway should be assessed to determine whether it is patent, maintainable, or not maintainable. For any patient who may have a traumatic injury, cervical spine precautions should be utilized while the airway is evaluated. Assessment of the patient\u2019s level of consciousness, in conjunction with assessment of the airway, provides an impression of the effectiveness of the patient\u2019s current airway status. If an airway problem is identified, the appropriate intervention should be initiated. The decision to use a particular intervention depends on the nature of the patient\u2019s problem and the potential for complications during transport. Specific equipment, such as a pulse oximetry or capnography, help provide continuous airway evaluation during transport. In addition, it is important to also be able to identify differences between adult and pediatric anatomy and physiology. The anatomical and physiologic variations between adults and children can cause confusion if the EMS provider does not fully understand these differences",
        "summary of primary airway assessment": "Airway: Patent, maintainable, un-maintainable\nLevel of consciousness\nSkin appearance: Ashen, pale, gray, cyanotic, or mottled\nPreferred posture to maintain airway\nAirway clearance\nSounds of obstruction",
        "differences in the pediatric airway": "Larger tongue in relation to free space in oropharynx.\nTrachea is more pliable and smaller in diameter with immature tracheal rings\nEpiglottis is large and is more u-shaped or oblong\nLarynx is at the level of the 1st or 2nd vertebrae\nMain stem bronchi has less angle",
        "breathing": "The assessment of ventilation begins with noting whether the patient is breathing. Patients presenting with apnea or severe respiratory distress, require immediate intervention. If the patient has any difficulty with ventilation, the problem must be identified and the appropriate intervention initiated. Emergent interventions may include manual ventilation of the patient via bag valve mask, endotracheal intubation, and / or needle thoracentesis.\nNormal respirations in an infant can be irregular and, as a result, respiratory rates should be assessed over a minimum of 30 seconds, but ideally 60 seconds. The variability of respiration in infants may not produce an accurate rate when only observed for 15 seconds. It is important to note that the variable rate of respiration in infants may include cessation in breathing for up to 20 seconds. Anything greater than 20 seconds should be considered abnormal and will require intervention.",
        "summary of primary breathing assessment": "Rate and depth of respirations\nCyanosis\nWork of breathing\nUse of accessory muscles\nFlaring of nostrils\nPresence of bilateral breath sounds\nPresence of adventitious breath sounds\nAsymmetric chest movements\nOxygen saturation measured with pulse oximetry",
        "circulation": "Palpation of both the peripheral and the central pulse provides information about the patient\u2019s circulatory status. The quality, location, and rate of the patient\u2019s pulses should be noted along with the temperature of the patient\u2019s skin being assessed while obtaining the pulses. Observation of the patient\u2019s level of consciousness may also help evaluate the patient\u2019s perfusion status initially.\nAlthough the pediatric and adult hearts share identical anatomy, several important distinctions need to be made between the adult and pediatric cardiovascular systems. First, the adult heart increases its stroke volume by increasing inotropy (strengthening contractions) and chronotropy (increasing heart rate). In contrast, the pediatric heart can only increase chronotropy in an attempt to increase stroke volume. The pediatric heart has low compliance as it relates to volume; therefore, it cannot compensate well by increasing stroke volume. Consequently, heart rate should be seen as a significant clinical marker when monitoring cardiac output in the fetus, neonate and pediatric patient. When the pediatric patient becomes bradycardic, it should be assumed that cardiac output has been drastically reduced. Bradycardia is most commonly caused by hypoxia. Bradycardia may be an early sign of hypoxia in the neonate; however, it is an ominous sign of severe hypoxia in the infant and child.\nCapillary refill time is typically quite accurate in children and considered to be reliable in most cases. Just as in the adult patient, environmental factors like cold ambient temperatures can influence capillary refill times and should be taken into consideration. For this reason, capillary refill time should be assessed closer to the core in areas like the kneecap or forearm. Normal capillary refill time is less than two to three seconds.",
        "summary of primary circulation assessment": "Pulse rate and quality\nSkin appearance: Color\nPeripheral pulses\nSkin temperature\nLevel of consciousness\nUrinary output\nBlood Pressure\nCardiac monitor\nInvasive monitor",
        "disability": "The basic, primary neurological assessment includes assessment of the level of consciousness, the size, shape, and response of the pupils, and motor sensory function. This simple method shows if AVPU should be used to evaluate the patient\u2019s overall level of consciousness. The Glasgow Coma Scale (GCS) provides assessment of the patient\u2019s level of consciousness and motor function and may serve as a predictor of morbidity and mortality after brain injury. If the patient has an altered mental status, it must be determined whether the patient has ingested any toxic substances, such as alcohol or other drugs, or may be hypoxic because of illness or injury. A patient with an altered mental status may pose a safety problem during transport. Use of chemical sedation or physical restraint may be necessary to ensure safe transport of the patient and EMS providers",
        "summary of primary disability (neurological) assessment": "A - Alert, V - Responds to verbal stimuli, P - Responds to painful stimuli, U - Unresponsive",
        "glasgow coma scale (gcs)": "For infants under one year, the Glasgow Coma Scale scores are as follows: Eye Opening\u2014Spontaneous (4), To voice (3), To pain (2), No response (1); Verbal Response\u2014Coos, babbles (5), Irritable cry, consolable (4), Cries persistently to pain (3), Moans to pain (2), No response (1); Motor Response\u2014Spontaneous (6), Withdraws to touch (5), Withdraws to pain (4), Decorticate flexion (3), Decerebrate extension (2), No response (1). For children aged 1\u20134 years, the scores are: Eye Opening\u2014Spontaneous (4), To voice (3), To pain (2), No response (1); Verbal Response\u2014Speaks and interacts socially (5), Confused speech but consolable (4), Inappropriate and inconsolable (3), Incomprehensible and agitated (2), No response (1); Motor Response\u2014Spontaneous (6), Localizes pain (5), Withdraws to pain (4), Decorticate flexion (3), Decerebrate extension (2), No response (1).",
        "exposure": "As much of the patient\u2019s body as possible should exposed for examination, depending on complaint, with the effects of the environment on the patient kept in mind. Discovery of hidden problems before the patient is loaded for transport may allow time to intervene and avoid disastrous complications. Although exposure for examination is emphasized most frequently in care of the trauma patient, it is equally important in the primary assessment of the patient with a medical illness.\nThe pre-hospital provider should always look under dressings or clothing, which may hide complications or potential problems. Clothing may hide bleeding that occurs as a result of thrombolytic therapy or rashes that may indicate potentially contagious conditions. In inter-facility transport, intravenous access can be wrongly assumed underneath a bulky cover. Once patient assessment has been completed, keep in mind that the patient must be kept warm. Hypothermia can cause cardiac arrhythmias, increased stress response, and hypoxia.",
        "summary of primary exposure assessment": "Identification of injury, active bleeding, or indication of a serious illness.\nAppropriate tube placement: o Endotracheal tubes, o Chest tubes, feeding tubes, o Naso-gastric or oro-gastric tubes, and urinary catheters.\nIntravenous access: o Peripheral o Central o Intraosseous",
        "secondary focused assessment": "The secondary assessment is performed after the primary assessment is completed and involves evaluation of the patient from head to toe. Illness specific information is collected by means of inspection, palpation, and auscultation during the secondary assessment. Whether the patient has had an injury or is critically ill, the pre-hospital provider should observe, and listen to the patient. The secondary assessment begins with an evaluation of the patient\u2019s general appearance. The pre-hospital provider should observe the surrounding environment and evaluate its effects on the patient. Is the patient aware of the environment? Is there appropriate interaction between the patient and the environment? Determination of the amount of pain the patient has as a result of illness or injury is also an important component of the patient assessment. Baseline information should be obtained about the pain the patient has so that the effectiveness of interventions can be assessed during transport. Pain relief is one of the most important interventions for prehospital patient care providers."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Respiratory Distress/Asthma/COPD/Croup/Reactive Airway RESPIRATORY DISTRESS/ASTHMA",
        "overview": "Respiratory distress is characterized by a clinically recognizable increase in work of breathing while respiratory failure is characterized by ineffective respirations with a decreased level of consciousness. Acute respiratory emergencies in the pediatric patient are common. When not properly treated, respiratory distress can result in significant morbidity and mortality. One of the common causes of respiratory distress is asthma. The treatment of patients in severe asthmaticus must be prompt and efficient. Decisive intervention is mandatory to insure the best outcome. Appearance of the child reflects the adequacy of oxygenation and ventilation. An increased effort to breathe may indicate an airway obstruction or lack of oxygenation. Decreased breathing effort may indicate impending respiratory failure.",
        "hpi": "* Time of onset\n* Possibility of foreign body\n* Medical history\n* Medications\n* Fever or respiratory infection\n* Other sick siblings\n* History of trauma",
        "signs and symptoms": "* Wheezing or stridor\n* Respiratory retractions\n* See-saw respirations\n* Diaphoresis\n* Tripod position\n* Increased heart rate\n* Altered LOC\n* Anxious appearance",
        "considerations": "* Asthma\n* Aspiration\n* Foreign body\n* Infection\n* Pneumonia, croup, epiglottitis\n* Congenital heart disease\n* Medication or toxin\n* Trauma",
        "procedure": "1. Perform general patient management.\n2. Support life -threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%. Support respirations as necessary with a BVM.\n4. Place patient in a position of comfort, typically sitting upright.\n5. If stridor present and croup is suspected, refer to Croup & Epiglottitis Protocol 9-11\n6. Monitor Capnography , if available.\n7. Assist patient with prescribed METERED DOSE INHALER (MDI). If no dosing schedule is prescribed, repeat in 5 to 10 minutes as needed.\n8. If in critical respiratory distress, provide BVM ventilation with patient\u2019s spontaneous efforts. If patient becomes unresponsive, perform BVM ventilation with an airway adjunct. If BVM ventilation is inadequate, secure airway with a n alternative airway or endotracheal tube [P only].\n  For patients in respiratory distress:\n9. Give ALBUTEROL via nebulizer :\n   Pt. <10kg : use 2.5 mg\n   Pt > 10kg: use 5.0 mg and IPRATROPIUM 0.5 mg via small volume nebulizer.\n   a. Greater than or equal to 4 years of age \u2013 nebulizer with mouthpiece or facemask.\n   b. Repeat ALBUTEROL every 10 minutes up to 4 treatments if respiratory distress persists and no contraindications develop. Note: IPRATROPIUM bromide is only administered with the 1st treatment.\n10. Start an IV of normal saline.\n11. If greater than 2 years of age and wheezing present, administer DEXAMETHASONE 0.6mg/kg IV/IM/PO to max of 10 mg.\n12. Administer CPAP with 5 - 10 cm H20 PEEP for moderate to severe dyspnea.\n13. In the asthmatic patient, for severe respiratory distress that is non -responsive to standard medications, consider administration of MAGNESIUM SULFATE 40 mg / kg IV over 20 minutes (max dose of 2 grams).\n14. In the asthmatic patient, for severe respiratory distress that is non -responsive to standard medications, consult Medical Control to consider administration of EPINEPHRINE 1:1,000 0.01 mg / kg up to 0.3 mg IM.\n15. Place on cardiac monitor and obtain 12 lead ECG per assessment.\n16. Transport and perform ongoing assessment as indicated.",
        "pearls": "1. The most important component of respiratory distress is airway control.\n2. Any pediatric patient presenting with substernal and intercostal retractions is in immediate need of treatment and transport. Do not delay on scene with treatments that can be completed enroute.\n3. Intramuscular epinephrine administration assists with bronchodilation throughout lung tissue. In children < 8 years of age, it should be administered in the lateral thigh for optimal drug delivery. In children > 8 years of age, the deltoid can be used.\n4. With repeated nebulized treatments, patients will become tachycardic. Benefits of further treatments should be weighed against the risks of tachycardia. Don\u2019t hesitate to call medical control for concerns or questions.\n5. Dexamethasone can be diluted with a small amount of juice (3-5mL) when administered orally."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Airway \u2013 Obstruction/Foreign Body",
        "overview": "Airway obstruction is one of the most readily treatable yet immediately life-threatening emergencies faced by pre-hospital providers. Approximately 3000 deaths occur each year in the United States from choking. Most of these deaths are in children younger than four years of age. In children, you should consider the possibility of foreign body aspiration in any patient who presents with ongoing respiratory distress or resolved respiratory distress. The child may have a history of a sudden onset of respiratory distress with choking and cough, by an absence of symptoms and then followed by delayed stridor or wheezing. This cycle occurs when the foreign body is not cleared from the airway but passes distally into the smaller airways. In children, a foreign body may also lodge in the esophagus, causing stridor. Patients may present with any degree of obstruction from simple hoarseness cleared with a cough to complete obstruction requiring a surgical airway, such as a cricothyrotomy. Significant airway obstruction can occur at any time. Early recognition and treatment is essential to a successful outcome. Because of this, it is important to distinguish this problem from more serious conditions that cause sudden respiratory failure, but are treated differently.",
        "hpi": "* Age\n* What was happening at onset? (Missing Toys?)\n* Past medical / surgical history\n* Medications",
        "signs and symptoms": "* Fever\n* Traumatic mechanism\n* Improvement or worsening with movement\n* Stridor, hoarseness, wheezing\n* Ineffective respirations\n* Universal sign of choking\n* Tachycardia\n* Tachypnea\n* Flushing, cyanosis, chills, diaphoresis\n* Presence of drooling, trismus, angio-neurotic edema",
        "considerations": "* Croup\n* Epiglottitis\n* Angio-neurotic edema\n* Traumatic obstruction\n* Chemical or thermal injury\n* Abscesses\n* Tumors and cysts",
        "fbao conscious patient gte 1 year of age": "1.For the suspected conscious choking victim, quickly\nask, \u201cAre you choking?\u201d If the victim indicates \u201cyes\u201d\nby nodding his head without speaking, this will verify\nthat the victim has severe airway obstruction.\n2.Apply abdominal thrusts (Heimlich maneuver) in rapid\nsequence until the obstruction is relieved. \na.Note: If the patient has a mild obstruction and\nis coughing forcefully ; do not interfere with the\npatient\u2019s spontaneous coughing / breathing\neffort. \n3.If the patient becomes unresponsive, carefully\nsupport the patient to the ground and follow the\nFBAO \u2013 UNCONSCIOUS PATIENT GREATER\nTHAN OR EQUAL TO 1 YEAR OF AGE protocol.\n4.Transport and perform ongoing assessment.",
        "fbao conscious patient lte 1 year of age": "1.Assess the patient to determine the extent of the\nobstruction. When the airway obstruction is mild, the\ninfant can cough and make some sounds. When the\nairway obstruction is severe, the infant cannot cough\nor make any sound.\n2.If FBAO is mild, do not interfere. Allow the victim to\nclear the airway by coughing while you observe for\nsigns of severe FBAO.\n3.If the FBAO is severe (i.e., the victim is unable to\nmake a sound), deliver 5 back blows (slaps) followed\nby 5 chest thrusts.\n4.If the patient becomes unresponsive, follow the\nFBAO \u2013 UNCONSCIOUS PATIENT LESS THAN 1\nYEAR OF AGE protocol.\n5.Transport and perform ongoing assessment.",
        "fbao unconscious patient gte 1 year of age": "1.If the patient was previously conscious with an airway\nobstruction, carefully support the patient to the\nground.\n2.Use head -tilt, chin lift or jaw thrust (suspected\ntrauma) to open airway. Look for an object in the\npatient\u2019s mouth. Use a finger sweep only when you\ncan see solid material obstructing the airway.\n3.Assess the patient\u2019s breathing.\n4.If respirations are absent, deliver 2 breaths. If chest\nrise is not detected, reposition the airway, make a\nbetter mask seal and try again.\n5.If unable to deliver rescue breaths, start CPR.\n6.Each time the airway is opened during CPR, look for\nan object and remove if found with a finger sweep. \n7.If the FBAO is not relieved by BLS maneuvers,\nattempt direct visualization of the airway via\nlaryngoscopy. If the obstruction is visualized, use\nforceps to remove the obstruction.\n8.If the FBAO is not relieved by BLS maneuvers or\nlaryngoscopy, perform a cricothyrotomy . For children\nyounger than 12, a needle cricothyrotomy with\npercutaneous transtracheal (jet) ventilation is the\nsurgical airway of choice.\n9.Transport and perform ongoing assessment.",
        "fbao unconscious patient lte 1 year of age": "1.If the patient was previously conscious with an airway\nobstruction, carefully position the patient for CPR.\n2.Use head -tilt, chin lift or jaw thrust (suspected\ntrauma) to open airway. Look for an object in the\npatient\u2019s mouth. Use a finger sweep only when you\ncan see solid material obstructing the airway.\n3.Assess the patient\u2019s breathing. \n4.If respirations are absent, deliver 2 breaths. If chest\nrise and fall is not detected, reposition the airway,\nmake a better mask seal and try again.\n5.If unable to deliver rescue breaths, start CPR. \n6.Each time the airway is opened during CPR, look for\nan object and remove if found with a finger sweep.\n7.If the FBAO is not relieved by BLS maneuvers,\nattempt direct visualization of the airway via\nlaryngoscopy If the obstruction is visualized, use\nforceps to remove the obstruction.\n8.Transport and perform ongoing assessment.",
        "fbao pearls": "1. Abnormal auscultative sounds are more inspiratory if the foreign body is in the extra-thoracic\ntrachea. If the object is in the intra-thoracic\ntrachea, noises will be symmetric but sound more\nprominent in the central airways. The sounds are a\ncoarse wheeze (sometimes referred to as an inspiratory\nstridor) heard with the same intensity over the entire chest.\n2. Once the foreign body passes the carina, the breath sounds are usually\nasymmetric. However, remember that the chest of\nyounger patients transmits sound well, and the\nstethoscope head is often bigger than the lobes being\nauscultated. A lack of asymmetry should not dissuade\nthe provider from considering the diagnosis."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Allergic Reaction/Anaphylaxis",
        "overview": "Acute respiratory emergencies in the pediatric patient are common. When not properly treated, respiratory distress can result in significant morbidity and mortality. Anaphylaxis in children commonly results from insect stings and, less frequently, from food or medications. Signs of shock as well as upper and lower airway obstruction are frequently present. If the reaction involves the respiratory system, signs similar to severe asthma may be present (cyanosis, wheezing, and respiratory arrest). Patients with allergic reactions frequently have local or generalized swelling while anaphylaxis can be characterized by wheezing, airway compromise, and/or hypotension.",
        "hpi": "* Onset and location\n* Insect sting or bite\n* Food allergy / exposure\n* New clothing, soap, detergent\n* Past history of reactions\n* Medication history",
        "signs and symptoms": "* Itching or hives\n* Coughing / wheezing or respiratory distress\n* Chest or throat constriction\n* Difficulty swallowing\n* Hypotension or shock\n* Edema",
        "considerations": "* Urticaria (rash only)\n* Anaphylaxis (systemic effect)\n* Shock (vascular effect)\n* Angioedema (drug induced)\n* Aspiration / airway obstruction\n* Vaso -vagal event\n* Asthma",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%\n4. Administer DIPHENHYDRAMINE 1 mg / kg up to 50 mg IM or IV. The IV route is preferred for the patient in severe shock. If an IV cannot be readily established, give diphenhydramine via the IM route.\n5. If the patient is experiencing respiratory distress with wheezing, refer to the Respiratory Distress protocol.\n6. Transport as soon as possible.\n7. For severe symptoms such as airway compromise, severe respiratory distress, or hypotension:\n   a. If available, administer epinephrine via an epinephrine autoinjector.\n   b. If epinephrine autoinjector is unavailable; give EPINEPHRINE 1:1,000 0.01 mg / kg up to 0.3 mg IM. Call Medical Control if no improvement.\n8. Establish an IV of normal saline at KVO. Titrate to a systolic pressure appropriate for child:\n   a. Birth to 1 month - 60 mmHg\n   b. 1 month to 1 year - > 70 mmHg\n   c. Greater than 1 year \u2013 70 + [2 x Age (years)]\n9. If hypoperfusion persists following the first dose of epinephrine, consider administration of 20mL/kg normal saline IV. While administering a fluid bolus, frequently reassess perfusion for improvement. If perfusion improves, slow the IV to KVO and monitor closely. If patient develops fluid overload respiratory distress (dyspnea, crackles, rhonchi, decreasing SpO2), slow the IV to KVO.\n10. Transport and perform ongoing assessment as indicated.",
        "epinephrine and diphenhydramine dosage": "Epinephrine is supplied as a 1:1,000 solution (1 mg/mL), dosed at 0.01 mg/kg, and diphenhydramine is dosed at 1 mg/kg. For a term infant weighing 6.6 lb (3 kg), the epinephrine dose is 0.03 mg and the diphenhydramine dose is 3.0 mg. At 6 months (17 lb/8 kg), the epinephrine dose is 0.08 mg and the diphenhydramine dose is 8.0 mg. At 1 year (22 lb/10 kg), the epinephrine dose is 0.1 mg and the diphenhydramine dose is 10.0 mg. At 3 years (30 lb/14 kg), the epinephrine dose is 0.14 mg and the diphenhydramine dose is 14.0 mg. At 6 years (44 lb/20 kg), the epinephrine dose is 0.2 mg and the diphenhydramine dose is 20.0 mg. At 8 years (55 lb/25 kg), the epinephrine dose is 0.25 mg and the diphenhydramine dose is 25.0 mg. At 10 years (75 lb/34 kg), the epinephrine dose is 0.3 mg and the diphenhydramine dose is 34.0 mg. At 12 years (88 lb/40 kg), the epinephrine dose remains 0.3 mg with diphenhydramine at 40.0 mg, and by 14 years (110 lb/50 kg), the epinephrine dose is still 0.3 mg while diphenhydramine is 50.0 mg.",
        "pearls": "1. The most important component of respiratory distress is airway control.\n2. Any pediatric patient presenting with substernal and intercostal retractions is in immediate need of treatment and transport. Do not delay transport with treatments that can be completed en route.\n3. Avoid intravenous initiation or medication administration into same extremity as bite or allergen site."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "Medical \u2013 Respiratory Distress/Asthma/COPD/Croup/Reactive Airway (Respiratory Distress \u2013 Croup/Epiglottitis)",
        "overview": "Croup (or laryngotracheobronchitis) is an acute viral infection of the upper airway, leading to swelling and the classical symptoms of a \"barking\" cough, stridor, and hoarseness. It may produce mild, moderate, or severe symptoms, which often worsen at night. It is often treated with a single dose of oral steroids; occasionally nebulized epinephrine is used in more severe cases. Epiglottitis is swelling of the epiglottis, which leads to breathing problems. Swelling of the epiglottis is usually caused by the bacteria Haemophilus influenza (H. influenza), although it may be caused by other bacteria or viruses. Upper respiratory infections can lead to epiglottitis. Medicines or diseases that weaken the immune system can make adults more prone to epiglottitis. Epiglottitis is most common in children between 2 and 6 years old. Respiratory Syncytial Virus (RSV) is a very common virus that leads to mild, cold-like symptoms in adults and older healthy children. It can be more serious in young babies, especially to those in certain high-risk groups. RSV is the most common germ that causes lung and airway infections in infants and young children. Most infants have had this infection by two years of age. Outbreaks of RSV infections typically begin in the fall and run into the spring.",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Administer oxygen to maintain SPO2 94 - 99%. Support respirations as necessary with a BVM.\n4. Place patient in a position of comfort, typically sitting upright.\n5. Obtain 12 lead ECG per assessment. a. Place on cardiac monitor and interpret\n6. If barking cough is present and croup is suspected, and age >1 year, administer Dexmethasone 0.6mg/kg IV/IM/PO to max of 10 mg.\n7. For resting stridor or respiratory distress in age >1 year, administration nebulized RACEMIC EPINEPHRINE (2.25%) 0.5mL AND 3mL of Normal Saline via nebulizer.\n8. Transport in position of comfort."
    },
    {
        "document title": "Pediatric General Medical Emergencies",
        "protocol title": "General \u2013 Pain Control",
        "overview": "The practice of pre- hospital emergency medicine requires expertise in a wide variety of pharmacological and non- pharmacological techniques to treat acute pain resulting from a myriad of injuries and illness. One of the most essential missions for all healthcar e pr oviders should be the relief and /or prevention of pain and suffering.  Approaches to pain relief must be designed to be safe and effective in the organized chaos o f the pre-hospital environment.  The degree of pain and the hemodynamic status of the patient will determine the rapidity of care.",
        "hpi assessment points": "- Age\n- Location\n- Duration\n- Severity (1 -10)\n- Past medical history\n- Medications\n- Drug allergies",
        "signs and symptoms assessment points": "- Severity (pain scale)\n- Quality (sharp, dull, etc)\n- Radiation\n- Relation to movement,respiration\n- Increased wit h pal pation of area",
        "pain source considerations": "- Musculoskeletal\n- Visceral (abdominal)\n- Cardiac\n- Pleural, respiratory\n- Neurogenic\n- Renal (colic)",
        "procedure": "1. Perform general patient management.\n2. Administer oxygen to maintain SPO 2 94 -99%.\n3. Determine and document patient\u2019s pai n score assessment.\n4. Place patient on cardiac monitor per patient assessment.\n5. Establish IV of normal saline per patient assessment.\n6. Determine if pain is acute or chronic (3 weeks or more). If chronic, attempt to identify cause (cancer/palliative care).\n7. If pain is mild, moderate, or chronic (cancer/palliative care excluded), consider use of non- opioid treatment. If age > 10 yrs, may alternatively consider one of the following, if available :\n    - Nitronox (via patient administered dosing system)\n    - Acetaminophen 10 -15 mg/kg PO\n    - Nonsteroidal such as ibuprofen 4-10 mg/kg PO (avoid in pts with open fractures or suspected hip/femur fractures)\n    ***OMD Option***\n    ***OMD Option***\n    ***OMD Option***\n    ***OMD Option***\n8. If NO nonsteroidal administered, for mild, moderate, or chronic pain (cancer/palliative care excluded), consider TORADOL 15 mg IV or 30 mg IM. Avoid use i f age less than 10 years or patients with history of renal disease.\n9. A. If significant pain, administer FENTANYL 2mcg/kg INTRANASAL (max first dose of 100 mcg) half dose in each nostril. May consider additional dose of up to 100mcg after 5 minutes if pain persists \u2013 OR-FENTANYL 1 mcg / kg IV, or IM (max single dose of 100 mcg).\n   B. FOR I/P LEVEL ONLY If significant pain, administer KETAMINE 0.1mg/kg IV/IM/IN up to max single dose of 15mg, with a maximum of 2 doses. If any additional doses are needed, contact medical control. Contact Medical Control for any patients under 2 years old or under 25kg.\n10. If Fentanyl or Ketamine are unavailable, administer MORPHINE SULFATE 0.1 mg / kg IV or IM (max single dose of 5.0 mg). Sickle cell patients may be given higher doses up to 10 mg IV or IM.\n11. Repeat the patient\u2019s pain score assessment.\n12. If indicated based on pain assessment, repeat pain medication administrati on after 10 minutes of the previous dose. Maximum total dose of Fentanyl is 200 mcg and Morphine Sulf ate is 20 mg for non-sickle cell patients. Sickle ce ll patients may have up to a total of 400 mcg of Fentanyl or 40mg of Morphi ne Sulfate. Maximum total dose of Ketamine is 30 mg.\n13. Transport in position of comfort and reassess as indicated.",
        "universal pain assessment tool details": "Verbal Descriptor Scale\n- No pain\n- Mild pain\n- Moderate pain\n- Severe pain\n- Very severe pain\n- Excruciating pain\n\nWong - Baker Scale\n- Alert\n- SmilingNo humor\n- Serious, flat\n- Furrowed brow\n- Pursed lips\n- Breath holding\n- Wrinkled nose\n- Raised upper lip\n- Rapid breathing\n- Slow blink\n- Open mouth\n- Eyes closed\n- Moaning\n- Crying\n\nActivity Tolerance Scale\n- No pain\n- Can be ignored\n- Interferes with tasks\n- Interferes with concentration\n- Interferes with basic needs\n- Bed rest required\n\nSpanish\n- Nada de dolor\n- Un poquito de dolor\n- Un dolor leve\n- Dolor fuerte\n- Dolor demasiado fuerte\n- Un dolor insoportable\n\nChart Courtesy of Richmond Ambulance Authority",
        "medication dosage guidelines chart": "Age  Term  Weight (lb / kg)  Fentanyl IM  Fentanyl IN  Morphine Sulfate  Toradol  Ketamine\n- 6 month 6.6 lb 3 kg 3mcg 6mcg N/A N/A N/A\n- 1 year 17.6 lb 8 kg 8mcg 16 mcg N/A N/A N/A\n- 3 years 22 lb 10 kg 10mcg 20 mcg 1.0 mg N/A N/A\n- 6 years 30.8 lb 14 kg 14mcg 28 mcg 1.4 mg N/A N/A\n- 8 years 44 lb 20 kg 20mcg 40 mcg 2.0 mg N/A N/A\n- 10 years 55 lb 25 kg 25mcg 50mcg 2.5 mg N/A N/A\n- 12 years 75 lb 34 kg 34mcg 50mcg 3.5 mg N/A 2.5 mg\n- 14 years 88 lb 40 kg 40mcg 50mcg 4.0 mg N/A 3.5 mg\n- 50 kg 50 mcg 50 mcg 5.0 mg 25 mg 4.0 mg",
        "clinical pearls and cautions": "1. Pain severity (0 - 10) is a vital sign that should be recorded before and after IV or IM medication administration and upon arrival at destination.\n2. Contraindications to opiate administration include hypotension, head injury, and respiratory depression.\n3. All patients should have drug allergies ascertained prior to administration of pain medication.\n4. Patients receiving narcotic analgesics should be administered oxygen.\n5. Narcotic analgesia was historically contraindicated in the pre -hospital setting for abdominal pain of unknown etiology. It was thought that analgesia would hinder the ER physician or surgeon\u2019s evaluation. Recent studies have demonstrated opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors.1\n6. Fentanyl is contraindicated for patients who have taken MAOIs within past 14 days, and used with caution in patients with head injuries, increased ICP, COPD, and liver or kidney dysfunction.\n7. Be aware that when administering ketamine, patients can experience lucid dreams and altered states of consciousness."
    },
    {
        "document title": "Environmental Emergencies",
        "protocol title": "Injury \u2013 Diving Emergencies Injury \u2013 Drowning/Near Drowning",
        "overview": "Drowning is a leading cause of accidental death. Drowning, like other causes of death, often strikes young or otherwise healthy people. Prevention of drowning and near drowning is the most effective way to reduce the number of deaths. The outcome of a patient following near drowning is dependent upon rapid recognition, rescue and resuscitation. Treatment of near drowning begins at the scene with rapid, cautious removal of the victim from the water. Spinal precautions should be observed if there is suspicion of a significant mechanism of injury, such as: high velocity impact, diving, or surfing. The concern of saltwater vs. freshwater aspiration is not of immediate importance in the pre-hospital environment. Factors that increase survivability include: younger age, cold water, and less time submerged.",
        "hpi": "* Submersion in water, regardless of depth\n* Possible history of trauma (i.e., diving board)\n* Duration of submersion\n* Temperature of the water\n* Type of water",
        "signs and symptoms": "* Unresponsive\n* Mental status changes\n* Decreased or absent vital signs\n* Vomiting\n* Coughing\n* Trauma",
        "considerations": "* Pre-existing medical problem\n* Pressure injury (diving)\n    * Barotraumas\n    * Decompression sickness",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation. Assess mechanism or injury and C-spine precautions.\n3. Administer oxygen to maintain SpO2 94-99%. Consider supporting respirations with a BVM.\n4. If the patient is in critical respiratory distress, consider placement of orotracheal intubation.\n5. Remove wet clothing and prevent heat loss. If suspected, refer to Hypothermia protocol.\n6. Monitor capnography.\n7. Place patient on cardiac monitor and obtain/interpret 12 lead ECG.\n8. Establish an IV of normal saline at KVO.\n9. Transport and perform ongoing assessment as indicated.",
        "pearls": "1. Near drowning patients are at high risk for experiencing secondary drowning several hours after the initial event. Secondary drowning occurs when delayed flash pulmonary edema occurs. All patients suspected of submersion should be transported for further evaluation.\n2. Adult Respiratory Distress Syndrome (ARDS) and pneumonia can both occur following the inhalation of water into lungs, causing damage to the alveoli. Make every effort to transport these patients to the hospital for further evaluation.\n3. For cold water submersion, attempt resuscitation on all patients unless the patient presents with injuries incompatible with life.\n4. Drowning is a leading cause of death among would-be rescuers."
    },
    {
        "document title": "Environmental Emergencies",
        "protocol title": "Injury \u2013 Bites and Envenomations \u2013 Land",
        "overview": "Insect stings and human, animal, snake, or spider bites from a variety of species can result in serious illness and injury. Animal bites from wild animals such as skunks, bats, raccoons, and foxes pose a special risk of rabies. Snakebites or stings from insects or spiders inject poisonous venom into their victims, generally affecting the cardiovascular or neurological system. Individual reactions to venom vary greatly depending on the person\u2019s sensitivity. Five percent of the general population is allergic to the stings of wasps, bees, hornets, yellow jackets, and ants. Insect stings cause twice as many deaths as snakebites each year. Anaphylactic shock can occur from any source, refer to the Allergic Reaction / Anaphylaxis Patient Care Protocol as needed. Do not apply ice or cold packs to snakebites as this can cause additional tissue damage. However, ice or cold packs can be applied to insect bites to reduce pain and swelling.",
        "hpi": "Type of bite / sting\nDescription of creature for identification\nTime, location, size of bite / sting\nPrevious reaction to bite / sting\nDomestic vs. wild\nTetanus or rabies risk\nImmuno-compromised patient",
        "signs and symptoms": "Rash, skin break, wound\nPain, soft tissue swelling, redness\nBlood oozing from the bite wound\nEvidence of infection\nShortness of breath, wheezing\nAllergic reaction, hives, itching\nHypotension or shock",
        "considerations": "Infection risk\nRabies risk\nTetanus Risk",
        "procedure": "1. Perform general patient management.\n2. Support life-threatening problems associated with airway, breathing, and circulation.\n3. Treat for shock and conserve body heat. Keep the patient calm.\n4. If applicable, locate the fang marks and clean the site with soap and water. Note: There may be only one fang mark.\n5. Remove any rings, bracelets, or other constricting items on the bitten / stung extremity.\n6. Keep any bitten / stung extremities immobilized \u2013 the application of a splint will help. Keep the injury at the level of the heart. When not possible, keep the injury below the level of the heart.\n7. DO NOT apply light constricting bands above and below the wound.\n8. If envenomation is suspected, every 15 minutes, use a pen to mark the border of the advancing edema and document the time.\n9. Consult Medical Control or Poison Control. For serious envenomation, the patient may need to be transported or evacuated to a hospital with the appropriate anti-venom.\n10. Start an IV of Normal Saline at KVO.\n11. For signs and symptoms of shock, follow the Medical \u2013 Hypotension/Shock protocol.\n12. Transport and perform ongoing assessment as indicated.",
        "special instructions": "Adequate identification of the snake is important. If the snake is live, contact local animal control and relay any available information regarding the identification of the snake to the receiving facility.\nDO NOT TRANSPORT A LIVE SNAKE IN THE AMBULANCE",
        "pearls": "1. Do not apply any type of constricting band or tourniquets as a treatment for any kind of bite or envenomation unless used to control severe hemorrhage.\n2. Human bites are worse than animal bites due to the normal mouth bacteria.\n3. Carnivore bites are more likely to become infected and all have risk of rabies exposure.\n4. Cat bites may progress to infection rapidly due to a specific bacterium.\n5. Poisonous snakes in this area are generally of the pit viper family: eastern diamondback rattlesnake, copperhead, and water moccasin.\n6. The amount of envenomation with snake bites is variable, but is generally worse with larger snakes and early spring.\n7. If no pain or swelling is noted, envenomation is unlikely.\n8. Black Widow spider bites tend to be minimally painful but, over a few hours, muscular pain and severe abdominal pain may develop.\n9. Brown Recluse spider bites are minimally painful to painless. Little reaction is noted initially, but tissue necrosis at the site of the bite normally develops over two to three days.\n10. Signs and symptoms of infection include swelling, redness, drainage, fever, and red streaks proximal to the wound.\n11. Immuno-compromised patients with diabetes, chemotherapy, organ transplants, HIV / AIDS, etc, are at an increased risk for infection."
    },
    {
        "document title": "Environmental Emergencies",
        "protocol title": "Environmental \u2013 Hypothermia",
        "overview": "Hypothermia is typically defined as a core temperature less than 35 \u00b0 Celsius / 95\u00b0 Fahrenheit. While most commonly seen in cold climates, it may develop without exposure to extreme environmental conditions. Hypothermia is not uncommon in temperate regions and may develop indoors even during summer. Hypothermia should be considered in any patient with an altered level of consciousness in a cool and /or wet environment. Individuals at the extremes of age and those of altered mental status are more susceptible to developing hypothermia. Vasoconstriction and bradycardia may cause extreme difficulty whi le attempting to palpate a pulse. Radiation accounts for the greatest form of heat loss. Conduc tion normally accounts for a much smaller amount, but increases significantly in wet clothes and astronomically in cold water. In patients that are hypothermic, pulse and respiratory rates may be slow or difficult to detect. If the hypothermic victim has no signs of life, begin CPR without delay.",
        "hpi": "* Past medical history\n* Medications\n* Exposure to environment even in <br> normal temperatures\n* Exposure to extreme cold\n* Extremes of age\n* Drug use: alcohol, <br> barbiturates\n* Infection, sepsis\n* Length of exposure, wetness",
        "signs and symptoms": "* Cold, clammy\n* Shivering\n* Mental status changes\n* Extremity pain, sensory abnormality\n* Bradycardia\n* Hypotension, shock",
        "considerations": "* Sepsis\n* Environmental <br> exposure\n* Hypoglycemia\n* CNS dysfunction\n    o Stroke\n    o Head injury\n    o Spinal cord injury",
        "procedure": "1. **Perform general patient management.**     \n2. **Support life -threatening problems associated with airway, breathing, and circulation.**     \n3. **Hypothermia WITH a perfusing rhythm (pulse):**\n    a. Prevent additional evaporative heat loss by removing wet garments and insulating the victim from further environmental exposures.     \n    b. Initiate passive rewarming with warmed blankets and a warm environment.     \n    c. Perform procedures gently. These patients are prone to develop ventricular fibrillation.     \n4. **Hypothermia WITHOUT a perfusing rhythm (pulse):**\n    a. Begin CPR immediately.     \n    b. Initiate rewarming procedures as noted in step #3 above.     \n    c. If not breathing, start rescue breathing immediately. If possible, administer warmed, humidified oxygen.     \n    d. If pulseless with no detectable signs of circulation, start chest compressions immediately. If there is any doubt about whether a pulse is present, begin compressions.     \n    e. Assess cardiac rhythm:\n        i. Attach AED / cardiac monitor. If the patient does not respond to one (1) defibrillation, further defibrillation attempts should be deferred.     \n    f. Secure airway with a definitive (Supraglottic / dual lumen) airway device or an endotracheal tube (levels I and P only).    \n    g. Establish an IV of Normal Saline.   \n    h. Give initial cardiovascular drugs based on presenting rhythm. If the patient fails to respond to the initial drug therapy, defer additional boluses of medication.  \n    i. Continue CPR and transport immediately.    \n5. **Transport and p erform ongoing assessment as indicated.**",
        "stages of hypothermia": "Normal Cold Response (35 \u00b0 C \u2013 37\u00b0 C / 95.1\u00b0F \u2013 98.6\u00b0F):\n* Feeling of cold\n* Shivering\n* Vasoconstriction\n\nMild Hypothermia (34 \u00b0C \u2013 35\u00b0C / 93\u00b0F \u2013 95\u00b0F):\n* Maximum shivering at 35 \u00b0C / 95\u00b0F\n* Cold, pale skin (vasoconstriction)\n* Pulse and BP are normal or elevated\n* Increasing rate of respirations\n* Mild confusion\n* Slurred speech\n* Unsteady gait\n* Amnesia\n\nModerate Hypothermia (30 \u00b0C \u2013 34\u00b0C / 86\u00b0F \u2013 93\u00b0F):\n* No longer shivering\n* Bradycardia\n* Decreased respirations\n* Increased risk of cardiac arrhythmia (A-Fib)\n* Intense vasoconstriction \u2013 surface pooling\n* Decreased LOC\n* Increased mortality in major trauma by 40 - 50%\n\nSevere Hypothermia (< 30\u00b0C / < 86\u00b0F):\n* Intense vasoconstriction \u2013 surface pooling\n* Lethal cardiac dysrhythmias (V-Fib)\n* Non-cardiac pulmonary edema\n* As core temp continues to decrease, risk of cardiac arrest increases dramatically\n\nIf the core temperature falls below 32\u00b0 C / 90\u00b0F, a characteristic J-wave (Osborn wave) may occur. The J-wave occurs at the junction of the QRS complex and the ST segment. T-wave inversion and prolongation of the PR, QRS, and QT interval may be noted.",
        "pearls": "1. Resuscitation efforts should not be ceased until rewarming efforts have been exhausted, unless the patient presents with injuries incompatible with life.\n2. Extremes of age, young and old, are more susceptible to effects of temperature.\n3. With temperature less than 31\u00b0C / 88\u00b0F, ventricular fibrillation is a common cause of death.\n4. Patients with extreme hypothermia MUST be handled gently.\n5. Cardiac arrest patients should be warmed before administering medications, as they may build in the system due to metabolism being ineffective.\n6. Defibrillation should be limited to one (1) shock prior to warming the core.\n7. If the temperature is unable to be measured, treat based on the suspected temperature.\n8. Hypothermia may cause severe bradycardia.\n9. Shivering typically ceases when the core temperature is below 32\u00b0 C / 90\u00b0F.\n10. Hot packs can be activated and placed in the armpit and groin areas, if available.\n11. If the patient is found with wet clothes, they should be exposed prior to the application of blankets.\n12. Hypothermic patients also exhibit cold diuresis. Peripheral vasoconstriction initially causes central hypervolemia, to which the kidneys respond by excreting large amounts of dilute urine, causing dehydration. Alcohol and water immersion increase this process."
    },
    {
        "document title": "Environmental Emergencies",
        "protocol title": "Environmental \u2013 Heat Exposure/Heat Exhaustion Environmental \u2013 Heat Stroke",
        "overview": "**OVERVIEW:**\n* Body temperature depends on heat production and heat loss balance.\n* Temperature regulation relies on conduction, convection, and evaporation.\n* Hyperthermia risks are higher for the elderly, poor, malnourished, and those with chronic illnesses or substance addiction.\n* Predisposing factors often develop over days rather than hours.\n* Hyperthermia can occur with various host factors, affecting thermoregulation and heat production.\n* Cognitive changes precede physical symptoms of heat stress.",
        "hpi": "**HPI**\n* Past medical history\n* Medications\n* Increased temperature/humidity exposure\n* Extreme age/exertion\n* Exposure time\n* Poor fluid intake",
        "signs and symptoms": "**Signs and Symptoms**\n* Fatigue/muscle cramping\n* Altered mental status/unconsciousness\n* Hot/dry/sweaty skin\n* Pale/clammy skin\n* Hypotension/shock\n* Seizures\n* Nausea\n* Weakness/dizziness/syncope\n* Rapid/shallow respirations\n* Fever",
        "considerations": "**Considerations**\n* Dehydration\n* Medications\n* Hyperthyroidism (storm)\n* Delirium tremens (DT's)\n* Heat cramps\n* Heat exhaustion\n* Heat stroke\n* CNS lesions/tumors",
        "procedure": "1. Perform general patient management.     \n2. Support life-threatening airway, breathing, and circulation problems.     \n3. Move the patient to a cool environment, but prevent shivering.     \n4. Administer oxygen to maintain SPO2 94-99%. Assist respirations with a BVM if necessary.     \n5. **Heat Cramps:** Signs include muscle twitching, spasms, nausea, vomiting, weakness, and diaphoresis.\n    a. Provide PO fluids if the airway is patent and the patient is not vomiting.     \n6. **Heat Exhaustion:** Signs include pallor, sweating, hypotension, headache, weakness, fatigue, and thirst.\n    a. Establish an IV of Normal Saline and infuse fluids as per Hypotension/Shock protocol. If fluid overload symptoms (respiratory distress) occur, slow the IV to KVO.   \n    b. Place on cardiac monitor.  \n7. **Heat Stroke:** Signs include altered mental status, high body temperature, minimal/no sweating, collapse, shortness of breath, shock, nausea, and vomiting.\n    a. Remove clothing.     \n    b. Do not give anything by mouth.     \n    c. Mist the patient with lukewarm water and fan.     \n    d. Wrap the patient in wet sheets if ambient airflow is good.     \n    e. Establish an IV/IO of Normal Saline and infuse fluids as per Hypotension/Shock protocol. If fluid overload symptoms occur, slow the IV to KVO.   \n    f. Place on cardiac monitor and obtain a 12-lead ECG.  \n8. Transport and perform ongoing assessment as needed.",
        "pearls": "1. Extremes of age are vulnerable to temperature changes.\n2. Certain drugs (cocaine, amphetamines, salicylates) can increase body temperature.\n3. Sweating usually stops when core temperature exceeds 104\u00b0 F.\n4. Shivering may occur during cooling."
    }
]