EMS Chapter 1: Pre-Hospital Care System

Professional Responders and Pre-Hospital Care System

• Definition: Network of community resources and medical personnel providing emergency care to patients with injuries or illnesses requiring highly trained professional care.
• Components of Pre-Hospital Care System:
  • Communication
  • Transportation
  • Facilities
  • Medical Control
  • Trauma Systems
  • Public Information and Education
  • Human Resources
  • Resource Management

Types of Emergency Responders

• Emergency Medical Responder (EMR):
  • Recognized emergency care and transportation training program
  • Often associated with volunteer emergency services in rural and remote communities
• Primary Care Paramedic (PCP):
  • Completed recognized education programs in paramedicine at the PCP level
  • May be volunteers or career paramedics
  • Capabilities include:
    • IV cannulation
    • Administration of some medications
• Advanced Care Paramedic (ACP):
  • Completed recognized education programs in paramedicine at the ACP level
  • Provide enhanced levels of assessment
  • Utilize advanced techniques to manage life-threatening problems affecting airway, breathing, and circulation
  • May implement invasive or pharmacological measures
• Critical Care Paramedic (CCP):
  • Highest level of paramedics in Canada
  • Responsibilities depend on organization's operational, administrative, or training requirements

Medical Oversight and Professional Conduct

• Medical Oversight:
  • Medical Director: Physician responsible for hospital emergency medical care
  • Provides oversight for all emergency care
  • Medical director delegates acts and care given in a pre-hospital cycle
• Professional Conduct:
  • Not responsible for delivering distressing news to patients or their families
  • Effective communication and mutual respect within the team
  • Self-care is crucial: manage fears and anxieties, maintain a safe and healthy lifestyle

Primary Responsibilities of First Responders

• Safety:
  • Ensure your safety and avoid putting yourself in danger
  • Ensure the safety of bystanders, distance people from hazards
• Access and Assessment:
  • Gain access to the patient unless the scene is too dangerous
  • Determine life-threatening injuries using primary assessment (Airway, Breathing, Circulation)
  • Request advanced medical care if needed
• Provide Necessary Care:
  • Stay within your scope of practice
  • Direct bystanders if needed, maintain confidentiality, and reassure family or friends without disclosing sensitive information

Interpersonal Communication and Legal Principles

• Interpersonal Communication:
  • Be conscious of non-verbal communication (body language, eye level, eye contact)
  • Listen to the patient and those around them for valuable information
  • Be respectful of cultural or religious considerations
• Legal Principles:
  • Duty of Care:
    • Athletic therapists, physiotherapists, and medical first responders have a duty to provide care
    • Failure to provide care could result in legal action
  • Consent:
    • Obtain consent from individuals before providing care
    • Identify yourself, state your level of training, explain the situation, and ask for consent to help
    • Use implied consent for unresponsive, confused, or seriously ill individuals

Responding to the Call

• Preparing for an Emergency Response:
  • Considerations:
    • Equipment
    • Plan of Action
    • Communications
    • Training
    • Psychological Preparation
• Equipment:
  • Ensure all equipment is stocked, maintained, and inspected
  • Common Equipment:
    • Trauma Response Kit
    • AED
    • Portable Oxygen
  • Plan of Action:
    • Develop specific plans for different situations or locations
    • Familiarize yourself with surroundings and resources (equipment, human resources)
    • Review EAP (Emergency Action Plan) with opponents' medical staff
    • Rehearse as a team to ensure everyone knows their roles

Scene Safety

• Assess the Scene:
  • Request additional personnel if needed
  • Wear appropriate personal protective equipment (PPE)
  • Perform only skills within your training and scope of practice
• Manage Hazards:
  • Be aware of obvious and hidden hazards
  • Ensure your safety and the safety of others, including the patient
  • Avoid putting yourself in dangerous positions

Infection Prevention and Control

• Pathogens:
  • Bacteria
  • Viruses
  • Fungi
  • Protozoa
  • Rickettsia
  • Parasitic Worms
• Modes of Transmission:
  • Direct Contact
  • Indirect Contact
  • Airborne Transmission
  • Vector-Borne
• Infection Factors:
  • Pathogen presence
  • Sufficient quantity of pathogen to cause disease
  • Susceptibility of the person to the pathogen
  • Route of entry into the body
• Preventing Disease Transmission:
  • Personal Protective Equipment (PPE)
  • Personal Hygiene
  • Cleaning and Disinfecting Equipment
  • Following Workplace Procedures

Anatomy and Physiology

• Anatomical Terminology and Position:
  • Basic terms for body regions and their parts
  • Anatomical position
• Major Body Cavities:
  • Cranial Cavity
  • Spinal Cavity
  • Thoracic (Chest) Cavity
  • Abdominal Cavity
  • Pelvic Cavity
• Body Systems:
  • Respiratory System
  • Circulatory System
  • Nervous System
  • Musculoskeletal System
  • Integumentary System
  • Digestive System

Assessment

• Scene Assessment:
  • Gather Information Before Approaching the Patient
  • Formulate a hypothesis on the mechanism of injury and chief complaint
  • Determine the number of patients and if additional resources are needed
• Primary Assessment:
  • Airway, Breathing, and Circulation (ABCs)
  • Skin
  • Pulse Oximetry
  • Rapid Body Survey (RBS)
  • Transport Decision and Patient Positioning
• Secondary Survey:
  • Interview and Acronym SAMPLE
  • Vital Signs
  • Head-to-Toe Physical Examination
  • Appropriate Treatments or Interventions

Reaching, Lifting, and Extracting Patients

• Gaining Entry into Buildings:
  • Locked Doors
  • Legal Implications
  • Contact Dispatch
  • Forcible Entry
  • Safety First
• Motor Vehicle Accidents:
  • Inaccessible Patients
  • Unstable Vehicles
  • Fire and Downed Power Lines
  • Patient Entrapment
  • Scene Assessment
  • Stabilizing Vehicles
  • Moving Patients### Providing Proper Treatment
• Scene assessment for dangerous conditions
• Considerations: size of the patient, physical ability, availability of assistance, and patient's condition
• Lifting techniques: use legs, not the back; keep weight close to the body; maintain body alignment; avoid lifting and reaching more than 20 cm in front; reduce lift height in stages; use as many people as possible; never twist while lifting; keep the back straight

Patient Extrication Techniques

• Walking assist: suitable for moving a responsive patient with one or two responders
• Support the patient on the injured or weaker side
• Two-Person Seat Carry: for responsive patients unable to walk
• Place one arm under the patient's thighs and the other across the back
• Interlock arms with the other responder and lift
• Clothes Drag: for patients with suspected head or spinal injury
• Cradle the patient's head and pull to safety
• Blanket Drag: similar to clothes drag, but uses a blanket
• Roll the patient onto the blanket and drag
• Extremity Lift: for lifting patients from the floor to a chair or stretcher
• Not suitable for patients with suspected head, spinal, pelvic, or limb injuries

Stretcher and Lifting Devices

• Scoop Stretcher: rigid stretcher that separates into two pieces
• Suitable for lifting a patient without rolling
• Backboard: long, rigid board used for extrication
• Becoming less common due to the potential for injury during prolonged use
• Basket Stretcher: metal or plastic frame with wire mesh liner and raised sides
• Suitable for transporting a patient or another stretcher
• Multi-Level Stretcher: adjustable height, equipped with wheels and safety rails
• Commonly used in ambulances
• Stair Chair: used to transport patients in a seated position through tight spaces
• Useful in small elevators or staircases
• Army-Type Stretcher: simple stretcher with wooden poles and canvas
• Commonly used in soccer in Europe

Pharmacology

• Pharmacology: study of drugs and how they interact with the body
• Administration vs. Assisting:
  • Administration: making the decision to give a medication to a patient and then introducing the drug into their body
  • Assisting: following a patient's specific direction to help with medication, which can include locating the drug, helping the patient prepare it, guiding the patient in taking it, reading the packaging to the patient, etc.
• Examples of assisting: opening a pill bottle, opening an epinephrine auto-injector, unwrapping a transdermal patch, reading a medication label out loud, pushing pills out of a blister pack
• Examples of administering: injecting the medication, placing the medication in a patient's mouth, placing a transdermal patch on the patient's skin, spraying medication into the patient's nose
• The Six Rights of Medication:
  • Right Person: ensure the patient receiving the medication is the one whose name is on the label of the medicine container
  • Right Medication: read the label and confirm the name of the medication
  • Right Dosage: accurately measure the indicated quantity of medication
  • Right Time: give the medication at the correct time
  • Right Route: read the directions carefully and administer the medication via the correct method
  • Right Documentation: completely document your actions and findings, including time, dosage, route, and effect

Routes of Drug Administration

• Oral: drugs swallowed and absorbed through the digestive system
• Sublingual: drug delivered under the tongue and rapidly absorbed into the blood
• Buccal: drug placed between the cheek and gum, absorbed through mucous membranes
• Rectal: suppositories that dissolve with body heat
• Intravenous (IV): directly into a vein
• Endotracheal: restricted to advanced life support practitioners
• Subcutaneous: drug administered into a layer of fat between muscle and skin
• Intradermal: drug administered into the dermis
• Intramuscular (IM): drug administered into a large muscle
• Inhalation: drug reaches lower airways and passes into general circulation
• Intranasal: drug administered into the nostril in mist form

Assisting with Medication

• Ensure that you are following the Six Rights of Medication:
  • Right Person: verify it is the correct patient
  • Right Medication: confirm the name and type of medication
  • Right Dosage: ensure the correct amount is administered
  • Right Time: administer at the correct time
  • Right Route: use the correct method of administration
  • Right Documentation: accurately record all relevant details, including time, dosage, route, and the effect of the medication

Airway Management and Respiratory Emergencies

• Respiration requires an open airway for the lungs to receive sufficient oxygen and to inflate and deflate rhythmically
• Respiratory emergencies can arise from various causes, including trauma, inhaled toxins, low oxygen environments, airway obstructions, and neurological injuries or conditions

Signs and Symptoms

• Dyspnea: labored breathing or struggling to breathe
• Abnormal Breathing Sounds: high-pitched noise
• Abnormal Respiratory Rate: either too fast or too slow
• Abnormal Skin: unusually moist or discolored
• Emotional Effects: restlessness or anxiety
• Neurological Effects: tingling
• Patient Position: unusual positions such as the tripod position

Airway Obstruction

• Types of Airway Obstruction:
  • Partial Obstruction: more effective to dislodge the item while seated and leaning forward
  • Complete Obstruction: the patient is unable to speak, breathe, or cough effectively
  • Anatomical Obstruction: blockage by an anatomical structure such as the tongue or swollen tissue
• Most common obstruction in an unconscious patient is the tongue
• Foreign-Body Airway Obstruction (FBAO):
  • Interventions:
    • Back Blows: stand behind the patient, ensure a stable stance, and deliver five firm back blows between the shoulder blades
    • Abdominal Thrusts: perform quick upward thrusts into the abdomen
    • Chest Thrusts: recommended for pregnant women, performing thrusts directly back towards you

Anaphylaxis

• Definition: a life-threatening allergic reaction causing air passages to constrict
• Causes: extreme allergy to substances such as food, medication, or insect venom
• Signs and Symptoms:
  • Swelling of the face
  • Dizziness
  • Confusion
  • Distress
  • Fainting
  • Coughing/wheezing
  • Tightness in the chest
• Treatment: assist with an epinephrine auto-injector to slow the harmful reaction by constricting blood vessels and increasing heart rate

Chronic Obstructive Pulmonary Disease (COPD)

• Definition: a condition characterized by a loss of lung function
• Components:
  • Emphysema: alveoli lose elasticity and become distended with trapped air
  • Chronic Bronchitis: inflammation of the bronchial tubes with excessive mucus secretions
  • Bronchospasm: constriction of air passages

Asthma

• Definition: a condition that narrows air passages and makes breathing difficult
• Triggers: allergic reactions, emotional distress, cold weather, exercise
• Signs and Symptoms:
  • Wheezing during exhalations
  • Enlarged chest appearance due to trapped air
• Treatment: use of a metered-dose inhaler or nebulizer

Pneumonia

• Definition: lung infection with fluid or pus-filled alveoli
• Causes: bacteria, virus, smoke, vomit
• Signs and Symptoms:
  • Dyspnea
  • Tachypnea (rapid breathing)
  • Chest pain
  • Productive cough with pus or mucus
  • Fever and chills

Acute Pulmonary Edema

• Definition: fluid buildup in the alveoli due to heart or lung damage
• Causes: congestive heart failure, pneumonia, smoke inhalation, drug overdose, high altitude
• Treatment: encourage patient to sit up and dangle legs to pool fluid in legs

Pulmonary Embolism

• Definition: blockage of a pulmonary artery by a clot or other material
• Symptoms:
  • Shortness of breath
  • Coughing
  • Pain
  • Anxiety
  • Fainting
  • Low blood pressure
  • Shock
  • Fever
  • Distended neck veins### Cardiopulmonary Resuscitation (CPR)
• Definition: Combines assisted ventilations and chest compressions to artificially replicate the functions of the lungs and heart.
• Purpose: Increases survival chances by keeping the body supplied with oxygen until advanced medical care is available.
• Components: Consists of cycles of compressions and ventilations.
• Basic Ratio: 30 compressions to 2 ventilations (may vary based on age and number of responders).
• CPR Execution:
  • Uninterrupted process: Once CPR starts, it should only be interrupted for critical interventions or changes in the patient's condition.
  • Chest Compressions:
    • Purpose: Move blood through the circulatory system by creating pressure within the chest cavity.
    • Compression fraction: The percentage of total CPR time the patient receives compressions.
    • Hand position: Center of the chest, lower half of the sternum.
    • Interlock hands and maintain right angles with pressure going straight downwards.
    • Responder position: Kneeling beside and facing the patient.
    • Arms straight, shoulders above elbows, elbows above hands.
    • Use upper body weight to create the necessary force.
    • Chest recoil: Ensure complete chest recoil after each compression.
    • Compression depth:
      • Adults: 5-6 cm (2-2.4 inches).
      • Children/Infants: At least one-third the diameter of the chest.
    • Compression rate: 100-120 compressions per minute.
• Age-Specific Guidelines:
  • Adults:
    • Hands position: Two hands on the sternum.
    • Compression depth: 5-6 cm.
    • Ratio: 30 compressions to 2 ventilations.
  • Children:
    • Hands position: One or two hands on the sternum (based on size).
    • Compression depth: One-third chest depth.
    • Ratio: 30:2 (one responder), 15:2 (two responders).
  • Infants:
    • Hands position: Two fingers on the sternum or thumbs using the encircling method.
    • Compression depth: One-third chest depth.
    • Ratio: 30:2 (one responder), 15:2 (two responders).
• High-Performance CPR (Team Approach):
  • Feedback: Responder B provides feedback on the effectiveness of Responder A's compressions.
  • Role distribution:
    • Responder A: Starts CPR, performs chest compressions, and ventilates using BVM until Responder B returns.
    • Responder B: Retrieves defibrillator (AED), assists with airway management, and ensures proper BVM seal.
  • Position switching: Every 2 minutes or 5 cycles, switch roles to maintain effectiveness and reduce fatigue.

Automated External Defibrillators (AEDs)

• Deployment: Apply AED as soon as cardiac arrest is confirmed, aiming for deployment within 90-120 seconds.
• Placement:
  • Adults: Standard placement.
  • Children/Infants: Use adult pads on the front and back if pediatric pads are unavailable.
• Preparation:
  • Ensure patient is dry.
  • Remove excessive hair for good contact.
• Operation:
  • Attach pads, plug in, turn on AED.
  • Follow AED instructions, pausing CPR only during analysis.
  • Resume CPR immediately after shock delivery.

Shock

• Definition: A life-threatening condition where vital organs do not receive adequate oxygen-rich blood, leading to compromised functionality.
• Causes of Shock:
  • Cardiogenic Shock: Heart is not functioning effectively, causing inadequate blood circulation.
  • Hypovolemic Shock: There is too little blood volume circulating.
  • Distributive Shock: Blood vessels fail to constrict properly, causing a drop in blood pressure even though blood volume remains unchanged.
• Types of Shock:
  • Septic Shock: A form of distributive shock due to severe infection.
  • Hypovolemic Shock: Caused by significant blood loss.
  • Obstructive Shock: Physical blockage prevents the heart from filling or emptying effectively.
  • Neurogenic Shock: A form of distributive shock from loss of nervous system control over blood vessel constriction.
  • Anaphylactic Shock: A severe allergic reaction causing hypovolemic shock.
• Stages of Shock:
  • Compensated Shock: The body attempts to restore normal circulation by constricting blood vessels.
  • Decompensated Shock: The body's compensation fails, leading to hypoxia in tissues.
  • Irreversible Shock: The vascular system fails to maintain internal pressure, blood pools in the extremities, and survival is not possible despite intervention.
• Care for Shock:
  • ABCs: Ensure the airway is clear, breathing is adequate, and circulation is supported.
  • Positioning: Help the patient into a recovery or supine position to improve blood flow to vital organs.
  • Elevation: Elevate the patient's feet about 8-12 inches unless a head injury is suspected.
  • Temperature Maintenance: Keep the patient warm to maintain normal body temperature.
  • Avoid Eating or Drinking: Do not give anything to eat or drink, especially if the patient's level of responsiveness is affected.

Chest, Abdominal, and Pelvic Injuries

• Chest Injuries:
  • Causes: Blunt or penetrating trauma.
  • Signs and Symptoms:
    • Respiratory distress or arrest.
    • Pain at the injury site, worsening with deep breaths or movement.
    • Obvious deformity.
    • Unequal or paradoxical chest movement.
    • Signs of shock.
  • Types of Chest Injuries:
    • Rib Fractures:
      • Causes: External blunt force.
      • Signs: Painful, shallow, and labored respiration.
      • Care: Position for comfort, support with soft or bulky objects, provide respiratory distress interventions.
    • Flail Chest:
      • Causes: Multiple rib fractures.
      • Care: Stabilize the flail segment with a bulky dressing, secure with tape.
    • Hemothorax:
      • Causes: Blood accumulates in the pleural space.
      • Signs: Respiratory distress, shock, decreased breath sounds on the affected side.
      • Care: Provide respiratory distress interventions and assisted ventilations if necessary.
    • Pneumothorax:
      • Causes: Air enters the pleural space.
      • Signs: Chest pain, dyspnea, decreased breath sounds, subcutaneous emphysema.
      • Care: Same as for hemothorax, monitor for tension pneumothorax.
    • Tension Pneumothorax:
      • Causes: Continuous air leak into the pleural space.
      • Signs: Tachycardia, hypotension, hypoxia, jugular vein distension.
      • Care: Provide necessary respiratory interventions.
    • Penetrating Chest Wound:
      • Causes: Creates a hole in the chest.
      • Care: Use a non-occlusive dressing taped on three sides to allow air to escape, replace saturated dressings.
• Abdominal Injuries:
  • Causes: Blunt or penetrating trauma.
  • Signs and Symptoms:
    • Pain, bruising, external bleeding, signs of internal bleeding.
    • Nausea, vomiting, signs of shock.
    • Thirst, distension, rigidity, tenderness.
  • Care for Abdominal Injuries:
    • Position patient supine; bend knees if not painful.
    • Control external bleeding.
    • Prepare for rapid transport.
    • Evisceration:
      • Causes: Severe injury with protruding organs.
      • Care: Remove clothing around the wound, apply a moist sterile dressing, cover with a towel, avoid touching or re-inserting organs.
• Pelvic Injuries:
  • Causes: Significant force.
  • Signs and Symptoms:
    • Pain, pelvic instability, crepitus.
    • Numbness in legs, decreased range of motion, paralysis.
    • Rectal, urethral, or vaginal bleeding, hematoma.
  • Care for Pelvic Injuries:
    • Keep patient supine, avoid movement.
    • Immobilize pelvis if trained.
    • Prepare for rapid transport.
    • Pelvic Binding Technique:
      1. Remove outer clothing, bring legs together.
      2. Place an 8-12 inch sheet across the stretcher.
      3. Place padding between knees and ankles.
      4. Insert sheet from under the knees, slide towards the pelvis.
      5. Ensure top of sheet is level with iliac crest.
      6. Cross ends of sheet anteriorly, twist to desired tension.
      7. Secure binding to maintain tension.
      8. Tuck loose ends.
      9. Reassess circulation and sensation.
      10. Periodically reassess binding.

Head and Spinal Injuries

• Head Injuries:
  • Mechanism of Injury (MOI):
    • Unresponsive patients with unknown causes.
    • Falls > 1 meter.
    • Motor vehicle accidents.
    • Damaged/broken helmets.
    • Severe blunt force.
    • Penetrating injuries.

Test your knowledge on the components of the Pre-Hospital Care System, including communication, transportation, and more.