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. AIRWAY ANATOMY PHYSIOLOGY.
● Upper Airway Anatomy ○ Nasopharynx, oral cavity, mouth, uvula, laryngopharynx, down to larynx ○ Cricoid cartilage: firm ridge forming lower part of the larynx below thyroid cartilage (only complete ring around trachea) ○ Epiglois closes over trachea while swallowing and is at base of oropharynx ○ Pharynx is the throat and is composed of the nasopharynx, oropharynx, and laryngopharynx. ● Upper Airway Physiology ○ Warms, filter, and humidifies air as it enters mouth and nose ● Lower Airway Anatomy ○ Trachea - divides left and right into bronchi at carina which branch into the left and right lungs ○ Lungs - divided into lobes which are made of millions of Alveoli (tiny air sacs) ● Lower Airway Physiology ○ Deliver O 2 to alveoli
. SPECIAL POPULATIONS.
● Childrens airways are smaller and more flexible than adults, so obstruction is easier
● The tongue is proportionately larger and takes up more space
● The cricoid cartilage is the most narrow part of the pediatric airway
. PATHOPHYSIOLOGY.
● Ventilation - Breathing in and out, diaphragm and intercostal muscles contract to inhale and relax to
exhale
● Respiration - Gas exchange that happens in the lungs when O 2 is inhaled and CO 2 is exhaled. Diusion
allows this to happen.
● Oxygenation - Delivery of O 2 into the hemoglobin in blood cells
○ Nervous system chemoreceptors monitor pH in spinal fluid, O 2 , and CO 2 in the body then send
signals to respiratory center in the brain to change breathing rate and depth
○ Medulla Oblongata (brainstem), is the center of respiratory control and uses chemoreceptor
input to adjust breathing
○ When breathing is based on low O 2 levels, it's called hypoxic drive
. KEY TERMS/IDEAS.
● Minute Ventilation MV = tidal volume x respiratory rate
● Tidal Volume - air that moves in and out of lungs with each respiratory cycle
● Negative Pressure - caused by diaphragm dropping and expanding chest wall, causes inhalation
● Positive Pressure - relaxing both, causes exhalation
. BREATHING SIGNS.
ADEQUATE
● 12 20 breaths/min - adult ● regular paern, rise, and fall ● adequate depth ● clear and equal lung sounds
INADEQUATE
● under 12 or over 20 with dyspnea ● irregular rhythm, unequal rise and fall ● diminished, absent, noisy lung sounds ● cyanotic or moist skin
. PATIENT ASSESSMENT.
- Determine adequacy of breathing a. Respiratory rate b. ‘Work of breathing’ c. Depth d. Level of consciousness LOC
- Check SpO 2 (pulse ox) →note that SpO2 can be inaccurate w/ nail polish and cold hands
- Evaluate skin color/temperature/moisture
. AIRWAY MANAGEMENT.
● Supine pt is ideal
● Head Tilt-Chin Lift - heel of one hand on patient’s forehead, firm pressure applied to tilt the patient’s head back,fingertips of alternate hand placed under lower jaw and chin lifted upward ○ can be used on trauma patient IF jaw thrust fails to open airway ○ avoid if spinal injury is suspected unless there is no alternative way to open airway ● Jaw Thrust - use if cervical/spinal trauma suspected (even if no obvious signs) - fingers behind angle of lower jaw, jaw moved upward with index and middle fingers and the thumbs help position the lower jaw ● Suction: suction mouth + nose to remove all secretions ○ Mouth - Yankauer (rigid tip) ○ Nose - French (soft top flexible) ○ Measure tip of ear to corner of mouth - 15 sections adult, 10 kids, 5 infants ● Adjuncts - used to keep airway open ○ Oropharyngeal - only use on unresponsive pts without gag reflex, inserted in pt mouth upside down and rotated 180 degrees until the flange rests on the patient's lips and/or teeth. If
● Pneumonia
○ What - infection that inflames the air sacs in one or both lungs ○ S/S - fever, tachycardia, hypotension, dyspnea, wheezing/crackles/rhonchi, dehydration, chest pain, weight loss, AMS ○ Treatment - O 2
● Pulmonary Edema
○ What - a condition caused by excess fluid in the lungs. ○ Risk Factors - history of MI/CHF ○ S/S - sudden crackles or wheezes, JVD, pedal edema ○ Treatment - O 2 + CPAP
● Pulmonary Embolism
○ What - condition when one or more arteries in the lungs become blocked by a blood clot ○ Risk Factors - long flight/travel, recent surgery, birth control use, smoking ○ S/S - shortness of breath, chest pain, wheezing, hypoxia, tachycardia, clear lung sounds, tender calf ○ Treatment - O 2 at 15 lpm, rapid transport
● Pneumothorax
○ Spontaneous ■ Risk Factors: associated with emphysema, asthma, tall thin men ■ S/S: dyspnea, pleuritic chest pain (sharp, stabbing pain on one side that is worse with inspiration or expiration), absent decreased breath sounds on aected side ○ Tension ■ Causes: caused by blunt trauma, fractured rib that lacerates lung or bronchus ■ S/S: chest pain, respiratory distress, decreased lung sounds, tachycardia, signs of shock, tracheal deviation
● Croup
○ What - an upper airway infection ○ Risk Factors - young children ○ S/S - fever, stridor, raspy ‘barking’ cough ○ Treatment - O 2 (blow by)
● Epigloitis
○ What - tissue protecting the windpipe becomes inflamed ○ Risk Factors - children ○ S/S - high fever, drooling, red oropharynx, mued voice ○ Treatment - O 2 (blow by)
● Pertussis (Whooping Cough)
○ What - respiratory tract infection ○ Risk Factors - not vaccinated, children ○ S/S - whoop on inhale after cough aack, dark thick mucus, fever for 1 2 weeks ○ Treatment - O 2 (blow by)PPE
● Anaphylaxis
○ What - severe allergic reaction ○ Risk Factors - insects, bees, food, meds
○ S/S - stridor, wheezing, hives, nausea/vomiting (N/V) ○ Treatment - epinephrine 0.3mg adults, 0.15mg child)
. LUNG SOUNDS.
● Stridor - brassy high pitched sound on inhalation
● Wheezing - high pitched whistle sound on exhale ● Rhonchi - low pitched noisy exhale ● Rales - wet sounding crackles
. BREATHING PATTERNS.
Normal Cheyne-Stokes
Bradypnea Kussmaul
Tachypnea Ataxic
Apnea Biot
. BLEEDING.
INTERNAL
● Hard to detect ● Contusion = clue, watch out for broken bones (ie. femur = 1L blood loss) ● S/S: tachycardia, dizzy, cool/clammy skin, dyspnea, weak cap refill, hypotension, ALOC ● Watch for blood in: ○ Stool - dark/black stool ○ Urine - hematuria ○ Vomit - hemoptysis
EXTERNAL
● Hemorrhage - bleeding (same thing) ● Average amount of blood ○ Male 70 mL/kg body weight ○ Female 65 mL/kg body weight ● Body cannot tolerate >20% blood loss ● 3 types of bleeding
- Arterial - bright red, spurts w/ pulse
- Venous - darker color, fast or slow
- Capillary - dark red, oozing steady
● Epistaxis = nosebleed ● Hemophilia = condition aecting cloing factors ● Most bleeding stops in 10 minutes ● Treatment:
SOFT TISSUE INJURIES.
OPEN
● Protective layer of skin is broke ● Abrasion - caused by friction, superficial ● Laceration - “jagged” cut ● Incision - sharp, smooth cut ● Avulsion - separated layers of soft tissues, can be detached or a flap of skin ● Amputation - part of body severed, tourniquet needed ● Evisceration - organs protrude through open wounds → don’t touch organs, cover with damp sterile gauze, occlusive dressing, tape
CLOSED
● Soft tissue damage underneath, no break in skin (blunt trauma), pain, discoloration, swelling at site ● Contusion - bruise, bleeding underneath skin ● Ecchymosis - black + blue discoloration ● Hematoma - damaged blood vessel bleeds into surrounding tissue ● Crush Injuries - significant force on body, can cut o circulation in region ● Crush Syndrome - when pinned 4+ hours, arterial blood flow compromised, crushed
● Impaled Object - only remove if blocking airway, control bleeding, stabilize object ● Bites - dry, sterile dressing, splint if needed for pain management
TREATMENT
RICES (Rest, Ice, Compression, Elevation, Splint
beyond repair, harmful substances released once pt is freedCALL ALS ● Compartment Syndrome - result of edema/swelling, pressure goes up in soft tissue compartment, common in extremities, can result in tissue death
TREATMENT
Direct pressure + hemostatic agent/tourniquet
. BURNS.
1. 1st - similar to sunburn, superficial, epidermis only
- 2nd - most painful, partial thickness, deep but nerves still intact (epidermis + partial dermis)
- 3rd - most damage, deepest, full thickness, nerve damage (bones, muscles, tendons)
● Types of burns ○ Thermal - Most common burn, high temp + contact time = severity ○ Chemical - Acid/Alkali, will change skin, watch areas like eyes ○ Electrical - Lightning, current ○ Radiation - Ionizing, vs nonionizing
RULE OF NINES Adult Child Infant RULE OF PALMS 1% of pts body = their palm Head 9 18 18
Torso 18 18 18
Back 18 18 18
Arms 9 9 9
Legs 18 14 14
MINOR
● Adult = <15% ● Child = <10%
MODERATE
● 2nd degree ● Adult 15 25% ● Child 10 20%
SEVERE
● Chemical burn ● Inhalation burn ● High voltage burn
As well as: headache, nausea, vomiting, ALOC (altered level of consciousness), sluggish pupils, posturing, widening pulse pressure
Posturing = later sign
Abnormal flexion - decorticate posturing (arms to core), goes with Cheyne-Stokes
Abnormal extension - deceberate posturing (down and hands locked laterally), with ataxic
● Layers of brain + Hematoma
○ Outermost to innermost: Cranium, dura mater, arachnoid space, subarachnoid, pia mater, brain gray maer ○ Epidural hematoma - blood between cranium and dura mater, often lose consciousness immediately with a brief lucid interval then unconscious again. ICP increases, pupils become fixed + dilated ○ Subdural hematoma - below dura mater above arachnoid space after falls with strong deceleration forces, ICP develops more gradually, fluctuating LOC/slurred speech ○ Subarachnoid hematoma - beneath arachnoid space, bloody CSF, meningeal irritation (neck rigidity + headache), increased ICP, decreased LOC, changes in pupils/pulse, seizures
● Concussion
○ May lose memory/be confused (amnesia) ○ Retrograde amnesia - remembering everything up to event but forgeing everything after ○ Anterograde amnesia/post traumatic amnesia - forgeing everything after event ○ S/S confusion, nausea/vomiting, dizziness, drowsiness, photophobia (light sensitivity), balance problems ○ Grades:
- Confusion, NO LOC (loss of consciousness), symptoms clear within 15 min
- Confusion, NO LOC, symptoms 15 min+
- ANY LOC, no maer how long
● Contusion
○ Often more serious than a concussion because physical injury to the brain tissue, bleeding/swelling, increased ICP
. FACE + NECK INJURIES.
● Soft Tissue Injury
○ Blunt injury causing a break in blood vessel, blood collects under skin (hematoma) ○ Skin flap can be peeled back from underlying muscle/fascia ● Dental Injuries ○ Lower jaw (mandible), injuries are very common, signs are misaligned teeth, numb chin, can’t open mouth, swelling, bruising, loose/missing teethREMOVE ANY TEETH/TOOTH FRAGMENTS IN MOUTH!
● Eye Injuries ○ Stabilize impalement with roller gauze donut ○ Chemical burns immediate irrigation with saline and/or water, dry dressing after ● Neck Trauma ○ Subcutaneous emphysema - air under skin, bulges a lile, crackling sensation, common with blunt trauma
. HEART TRAUMA.
● Cardiac Tamponadeaka Pericardial Tamponade
○ The result of penetrating trauma (ie. GSW, stabbing to chest), causes tears in heart chamber walls ○ Pericardial sac fills with ‘fluid’ (blood), that causes ❤ to not pump fully + eectively
. ABDOMINAL TRAUMA.
● Evisceration - organs protrude through open wounds →
don’t touch organs, cover with damp sterile gauze, occlusive dressing, tape ● Acute Hemorrhagic Pancreatitis ○ Cullen's Sign - Hemorrhagic patches of skin around pt naval ○ Grey Turner's Sign - Bruising of skin around flanks ● Hematuria - Blood in urine ● Peritonitis - Inflammation of lining of abdominal wall, hollow organ leaks contents ● Kehr’s Sign - pt struck left upper quadrant, think spleen, left shoulder pain causes a hemoperitoneum (blood in peritoneal cavity)
. ORTHOPEDIC TRAUMAS.
● Causes: direct blow, indirect blow, twisting forces, high energy/high MOI
● FractureIS THE SAME THING as break ● Closed fracture - no wound, all internal ● Open fracture - bone protruded
● Non-Displaced - one site fractured ● Displaced - deformity present ● Reduction - puing joint back in place ● Sprain - JOINT twisted beyond normal range ● Strain - MUSCLE stretch/tear
MINOR
● Minor strains/sprains ● Fractured fingers/toes
MODERATE
● Non-displaced long bone fracture
SEVERE
● Displaced pelvic/long bone fracture ● Open/multiple fractures ● Bi-lateral long bone
● Splints
○ Rigid - padded board (legs) ○ Formable - SAM splint (arms) ○ Sling + Swathe - (relieve pain + stabilize) ○ Pelvic Binder - (reduce possible hemorrhage, pain) ○ Traction - pulls back to natural alignment, stabilize, reduce pain
. SPINAL TRAUMA.
● Common in: MVA, falls, assault, sporting events
● Bones in back are called vertebrae ○ Cervical 7 - Nerve tracts, head, neck, diaphragm (C3-C5 , delts, biceps, wrist, traps, hand ○ Thoracic 12 - chest muscle, abdominal muscle ○ Lumbar 5 - leg muscles ○ Sacral 5 - b -owel, blader, sexual function ○ Coccygeal 4 - N/A ● Axial loading - direct force goes down spine (ie. diving + landing on head) “compression injury” ● Subluxation - PT hyperflexes/extends (ie. MVA CSpine can dislocate + hit spinal cord ● Ditraction - from hanging, cervical spine stops while body continues down ● Hyperflexion - c-spine pushed forward, dislocation can be caused ● Hyperextension - “whiplash”, MVA (rear end), roller coasters ● Babinski Sign - positive indicates spinal cord injury ○ Use pen, start at heel and go laterally to great toe ○ Positive - toes “fan out” ○ Negative - toes curl in ○ N/A in children under 2 years old ● Spinal Shock - period of paralysis/flaccid that lasts up to 24 hours, then returns ● Neurogenic Shock - results from damage to spinal cord which leads to loss of sympathetic nervous response, which will result in BP ↓, HR ↓, overall vasodilation
. ENVIRONMENTAL EMERGENCIES.
● Central thermoreceptors - hypothalamus, sends messages to skeletal muscle when needed in CNS
● Peripheral thermoreceptors - on skin/mucous membranes, both cool + warm receptors ● Hyperthermia - too hot of an environment or exercising in hot environment ○ Heat Cramps - aect tired muscles, alert with hot/sweaty skin, HR ↑, normal BP, muscle cramps ○ Heat Exhaustion - more severe, dizzy, nausea, headache, core temp to 103°F, near syncope, orthostatic hypotension BP ↓ when standing) ○ Heat Stroke - core temp 105°F +, damage to tissues, ‘total body collapse’ ■ Classic - eects very young and old ■ Exertional - eects athletes in hot conditions ○ S/S fainting, ALOC, seizures after fainting, HR ↑, BP ↓ ○ TREATMENT get to cool environment (ice packs neck, groin, under arms), replace sodium/water or IV dip, check blood glucose levels ● Hypothermia - Core body temp below 95°F ○ Mild - 93°-95°, goal is to get to warm environment, remove wet clothes, dry blankets, lethargic, tired, ‘dulled’ mentally, A+O ○ Moderate - 86°-93°, ALOC + confused, can’t shiverTRY NOT TO MOVE PT ○ Severe - <86°, found unconscious + unresponsive, move GENTLY, CPR + defib, may appear dead but aempt resuscitation,NEVER DEAD UNTIL WARM AND DEAD ● Drowning
. PATIENT ASSESSMENT PARTS.
- Scene size up → safety + considerations
- Primary assessment → impression/life threats/rapid exam/LOC/Transport
- History taking → OPQRST + Sample)
- Secondary assessment → detailed head to toe
- Vitals → BP, HR, RR, field impression, treat
- Reassessment → reassess, pt report
● Signs - objective findings, you can observe/measure (ie. JVD ● Symptoms - subjective, what the pt tells you (ie. cramp)
. PRIMARY ASSESSMENT. remember 123 ABC GO 1. General impression → What does my pt look like? 2. Level of consciousness → AVPU + person/place/time/event 3. Chief complaint/life threats A. Airway → Is the airway patent? ○ If pt can speak/cry, airway is patent ○ Some pt (unresponsive) need head tilt-chin lift (medical) or jaw thrust (trauma) ○ Suction/remove obstructions ○ Adjunct OPA or NPA ○ Ventilate/ O2 treatment as needed BVM ○ S/S: stridor, snoring, bubbling, obstruction, gurgling shallow/absent respirations ○ Remember, ‘OPEN, CLEAR, KEEP’ B. Breathing → Is it normal or not? ○ Respiratory rate RR / SPO 2 / Words per sentence / Labored? / Position / Chest rise fall ○ When to ventilate: slow/shallow respirations, signs of distress/failure C. Circulation → Bleeding and condition ○ Skin color? jaundice = yellow (liver) cyanotic = blue (hypoxic) ○ Skin temp? ○ Skin moisture? ○ Capillary refill (should be 2 seconds) ✴ GO (transport decision)
. HISTORY TAKING.
HISTORY OF PRESENT ILLNESS
● Onset: what were you doing? Sudden or gradual? ● Provocation: anything makes beer/worse? ● Quality: what’s it feel like? ● Region/radiation: where is pain? Does it move ● Severity: scale 0 10 ● Timing: how long? Goen beer/worse?
PAST MEDICAL HISTORY
● Signs/Symptoms ● Allergies ● Medications ● Pertinent med history ● Last oral intake ● Events leading up to call
. VITALS .’
Adult 5 yo Infant
Blood sugar: 70 120 mg/dl Pulse ox: 95 100%
BP 120/80 100/60 90/
HR 60 100 80 120 80 160
RR 12 20 20 30 30 60
. ACRONYMS + VOCAB.
AVPU
● Alert: Patient is awake ● Verbal: Patient responds to verbal stimulus ● Pain: Patient responds to pain stimulus ● Unresponsive: Patient is unresponsive to stimulus
Alert/Oriented x ● Person: What’s your name? ● Place: Do you know where you are? ● Time: Who is the president? ● Event: What happened leading to this?
GCS
Eyes Spontaneous To speech To pain None
Mechanisms
● IV – intravenous * ● IO – intraosseous * ● IM – intramuscular ● PO – by mouth
● SA – subcutaneous ● TD – transcutaneous ● IN – intranasal * ● SL – sublingual *
● PR – per rectum * ● Inhalation *
9 Rights Of Drug Administration
- Right pt
- Right med/indication
- Right dose
- Right route
- Right time
- Right education
- Right to refuse
- Right response
- Right documentation
Shock aka hypoperfusion
● What is perfusion? ○ Heart (pump) ○ O2 (lungs) ○ Container (vessels)
Stage 1 Compensated
Stage 2 Decompensated
Stage 3 Irreversible
● Body reacts to events ● HR↑ ● Vasoconstriction ● RR↑ ● Awake ● Cool skin ● Altered mental status ● “Crisis mode”
● Low systolic BP (undergo) ● BP↓ ● HR↑ worsens ● RR↑ worsens ● Slowed cap refill ● Cyanosis ● Cold extremities ● “System-failure”
● BP↓ severe ● Lethal EKG changes ● HR↓ ● “Arrest-coma”
Cardiogenic Shock
● When the ♥ fails as a pump ● Causes: MI, myocardial contusion (trauma related), pulmonary embolism ● TREATMENT O2, aspirin for MI
Obstructive shock
● When normal blood flow is obstructed ● Causes: cardiac tamponade, pneumothorax, pulmonary embolism
● TREATMENT O2, 3-sided for tension pneumo
Distributive shock
3 subtypes:
- Anaphylactic shock – severe allergic reaction O2 and EpiPen
- Septic shock – pneumonia/UTI (bacteria in blood) O
- Neurogenic shock – damage to spinal cord O
Hypovolemia
● Causes: severe blood or fluid loss ● TREATMENT O2 + stop bleeding
TREATMENT O2, supine, keep warm, rapid go!
. INFECTIOUS DISEASES.
● Communicable disease – can spread from person to person ● Epidemic – new cases of disease in area that exceeds what is considered ‘normal’ ● Pandemic – outbreak on global scale ● Causes: bacteria (ie. salmonella), virus (ie. influenza), fungi (ie. mold), protozoa (ie. amoebas), helminths (ie. worms)
Influenza “the flu”
● Very young, very old, chronic conditions most aected ● Transmied by nasal secretions/droplets in air (cough/sneeze) ● S/S: fever, chills, cough, sore throat, nausea, vomiting (N/V) shortness of breath, resp/cardiac conditions
Covid-19 “Corona”
● Wide range of symptoms/outcomes ● Family of common cold viruses ● Very old/those w chronic illness (diabetes, resp. cardiac conditions) more at risk ● S/S: Fever, chills, cough, fatigue, muscle/body aches, sore throat, headache, loss of taste/smell, N/V short of breath, chest pain, confusion, cyanosis
Pertussis“whooping cough”
● Airborne disease ● Usually 6> years old from bacteria
