Final Rubric Exam Answers .docx

Final Rubric Exam Answers 1. Understand scope of practice vs. standard of care. Know who gives authority to practice (Medical Director, we operate under their license.) 2. Know proper lifting techniques. Understand the definition between decontamination and sterilization. Know gloves is a universal...

Final Rubric Exam Answers 1. Understand scope of practice vs. standard of care. Know who gives authority to practice (Medical Director, we operate under their license.) 2. Know proper lifting techniques. Understand the definition between decontamination and sterilization. Know gloves is a universal precaution. 3. Negligence is provable by 4 components. Duty to Act, Breach of Duty, Willful Intent, and Damages. Medical Liability = medical malpractice: Can you prove that another person would’ve acted differently? 4. Types of consent: Implied, Informed, Expressed. DNR must be signed by 3 people, doesn’t expire, and can be on any color of paper. Confidentiality is key, and you can be sued for breaking it. Documentation: if you didn’t write it, it didn’t happen. 5. Assault: The threat of harm. Battery: The act of touching a person without consent. Slander: written. Libel: verbal. False imprisonment: Taking a patient against their will. 6. Sodium: Responsible for muscle contraction and water retention. Potassium: Responsible for muscle relaxation. Calcium: Responsible for muscle excitability. Magnesium: Regulates muscle function, and can help with energy production and glucose function. Bicarb: responsible for the alkalinity of your blood. Normal PH is 7.35-7.45/Bicarb 22-26/CO2 35-45. Your blood is isotonic for the most part. Hypotonic solutions will pull H2O into the cell, and can cause it to burst. Hypertonic solutions will cause fluid to LEAVE the cell, and it can shrivel. 7. Diffusion: high to low. Osmosis: low to high. Hydrostatic pressure: the pressure inside your vessels, high can cause leaky vessels. Oncotic pressure: the pressure outside your vessels, low can cause leaky vessels. 8. ADH (Anti-diuretic hormone) is produced by your hypothalamus and excreted by your posterior pituitary. ADH is excreted when your BP is low, so you retain more water and thus increase your BP. When ADH is inhibited, you lose water more readily. I.E. Alcohol inhibits ADH, and that’s why you pee so much when you’re drinking. RAAS cycle. Renin is released by your kidneys when your BP is low. Renin activates Angiotensin 1 which needs a ACE (Angiotensin Converting Enzyme) that is found in your lungs and kidneys to activate Angiotensin II. Angiotensin II then activates your adrenal gland to release aldosterone, which causes your body to retain salt. Since water follows salt, you retain more fluid in the container and increase your BP. Catecholamines: Epinephrine, Norepinephrine, and Dopamine. Epi: alpha, beta 1 & 2. Norepi: alpha primarily. Dopamine: depends on amount. Renal/mesentery effects, then beta, then alpha. 9. Ineffective production of energy. Shock is defined as a situation in which there is a problem with the fluid, the pipes, or the pump that causes a decrease in aerobic metabolism and normal function of the body. 10. Hypovolemia: problem with the fluid. Often caused by hemorrhage, but can also happen from dehydration. Causes problems with energy production as you lose the ability to transport nutrients and O2, along with it taking longer to remove waste. Look for hemorrhage causes. Treat with fluids, pressors, and eventually blood transfusions. 11. Cardiogenic: problem with the pump. Often caused by an MI, tamponade, or PE. Often seen in chest trauma or pt’s with an MI. Very rare, causes the body to not receive proper blood flow due to a severely reduced CO due to the damaged heart. Treated with pressors. 12. Neurogenic Shock: Problem with the pipes. Caused by a spinal cord injury. All the vessels below the injury suddenly have no neuro stimulation, so they dilate. This causes the heart to work harder to try and pump blood through those dilated vessels, and the body again doesn’t receive the O2 and energy it needs to function. Classically seen by warm and dry skin below the injury, with pale and cool skin above the injury. Treated with atropine and pressors. 12B. Anaphylaxis: problem with the pipes. Due to a massive IgE response from an allergen, massive amounts of histamine into your body, causing massive vasodilation and then bronchoconstriction. Treatment is with epi, which will cause vasoconstriction and bronchodilation. 13. Fight or flight system. Causes vasoconstriction, pupil dilation, bronchodilation, increase HR and BP. Epi and Norepi found here. Called the adrenergic system. 14. Digest and rest. Causes vasodilation, pupil constriction, bronchoconstriction, increase blood flow to kidneys and GI, lowers HR and BP. Called the cholinergic system. 15. Know the 5 rights (route, date, patient, drug, dose). Understand that some drugs come from plants (aspirin) and some come from animals (heparin). Understand the medical packaging required by the FDA states it must give the drug name and concentration on the packaging. Know that drugs have different actions, such as anticholinergics, antiplatelet, diuretics, Na+ channel blockers etc. Know sharps are required to be disposed of immediately. FDA has drug schedules based on addictability. Versed is a schedule 4 drug. Fentanyl is a schedule 2 drug. 16. Know lb to kg = divide by 2.2 | kg to lb = multiply by 2.2 | to find mL to pull up: desired dose x total mL divided by total dose. 17. IV access used for medications administration and fluid resuscitation. AC is most common site. Take care to clean well to avoid infections. 18. Watch for accidental needle sticks, blood contact, and verify vein is large enough for the catheter choice. Complications: infection, blown vein, air embolism, infiltration. To verify patency, push a 10mL flush or open line and ensure it flows smoothly and is not creating a raised bump. Monitor for infiltration (fluid) and extravasation (drug). 19. Know how to give medications in all routes and the required equipment. 20. Understand therapeutic techniques, such as reflection, confrontation, and redirecting. Make eye contact, don’t overcrowd personal space. Understand patients with special needs require more patience. Get on their level and use words people will understand. 21. Intubation: Indicated in patient’s in respiratory arrest, or impending respiratory arrest, also for aspiration risk pts and those unable to maintain their airway. Contraindicated in spontaneously breathing pt’s with no respiratory compromise, and in pt’s with multi-facial trauma. Select tube size and blade per patient (My go to is a Mac 4 and a 7.0 tube). Pt needs to be preoxygenated for 3 min prior to intubation, and O2 sat needs to remain above 90 during the entire attempt. Pt needs to be in a sniffing position if possible. 22. You want to be looking for the vocal cords, with the adenoid cartilage (white triangles) at the base of the vocal cords. If possible, may be able to see cricoid rings as well. Visualize the epiglottis, and lift it up to expose vocal cords. Miller blade directly lifts the epiglottis, Mac blade goes into the valecula and indirectly lifts the epiglottis. Must sweep tongue to the left, while holding blade in your left hand. Visualize the cords, and then glide the tube in, after having inserted a stylet and tested the cuff. Once the cuff is past the vocal cords, stop and inflate the cuff, and then immediately remove the syringe. Use tube size x 3 to get the average depth: 7.0 x 3 = 21cm. Inline requires a more bent stylet, and for the patient’s head to be in your crotch. Nasal Intubation: indicated in semi-conscious patients. Done with an ETT at least one size smaller than you’d use for oral. Slide tube in the R nostril, and first resistance is the hard palate. 2nd will be the epiglottis, and your patient should gag when you hit it. Wait for a breath and then pass the tube. Selleck maneuver is used when you can’t visualize the cords. Use the BURP (Back, Up, Right Pressure) on the cricoid membrane. 23. Positube: If you pull the plunger back and you don’t meet resistance, YOU ARE IN THE TRACHEA. (Cricoid rings don’t collapse, so you’ll be able to pull the plunger out.) Bulb Detector: If you compress the bulb and it refills, YOU ARE IN THE TRACHEA. (Refills due to the air in the trachea and the rigid rings of the trachea.) EtCo2: 35-45 is goal, a waveform means you’re in the trachea. Complications: DOPE pneumonic. Securing the tube: Use a tube tamer or do a chevron tape method to hold it in place. 24. Needle Cric: done on pediatrics. Surgical cric: done on adults. Both are done when you need an airway and you either are unable to ventilate/intubate due to trauma, swelling, FBAO, or a locked jaw. Contraindicated in patients you can effectively ventilate without a surgical cric. Advantage is you can get an effective airway, and is almost impossible to miss the trachea. Disadvantage is that you can cause serious airway trauma, can get very bloody, and you can nick vital vessels. 25. SAMPLE ALL DAY. 26. ABCs 1st. You can then do a rapid trauma assessment, a focused exam, or a detailed exam depending on the time frame and severity of your patient. 27. Airway: Is it open and is it patent? Breathing: Are they breathing? What’s the rate, rhythm, quality and depth? Accessory muscle use or retractions? Lung sounds? Circulation: Any major bleeding? Skin parameters? Pulse, rate and quality? Know your vital signs, which include SpO2 and a dexi. 28. Cranial nerves; Visual acuity (CN II): how many fingers am I holding up? Pupil reactivity (CN III): Use a pen light. Facial sensation (CN V): Can you feel me touching your cheek? Facial movement (CN VII): Can you smile big for me? 29. Adventitious lung sounds; wheezing (musical sound), rales/crackles (small pops), rhonci (wet sounds), stridor (upper airway obstruction), seal-like bark (croup). 30. Know your basic safety and scene rules, and remember if you’re not safe you can’t help anyone! 31. General impression: chief complaint and initial assessment findings. Initial assessment: ABCDE and transport priority. 32. Extra Value Meals cost $4.56. (eyes, verbal, movement, numeric value of 4, 5, and 6.) 33. Focused History and Physical Exam: regarding the chief complaint and/or injured body system. Detailed PE: Head to toe, thorough and don’t miss a system. Transport decision is based off your general impression of the patient’s status. 34. The FRA is the FCC, who monitor radio traffic. Online medical control is speaking directly with an ECRN or physician, offline is using your protocols. It is required you contact the receiving facility and give them a report. There are one way (simplex), two way (duplex), and multi (multiplex.) Radios require a base station, a repeater, and a receiver. UFH: ultrahigh-little interference but short bandwidth. VHF: very high, more interference, but longer bandwidth. 35. Understand kinematics. Know Newton’s First Law: at body at rest will stay at rest and body in motion will stay in motion until acted upon by an outside force. 2nd law: energy is not created or destroyed, but simply changes form. Know types of impact: Frontal (up and over will give you head, spine and internal organ sheer injuries – down and under will give you leg and ankle trauma.) Rear impact (will give you femur and pelvic injuries, as well as cervical injuries from whiplash.) Lateral impact (clavicle, chest, head, abdomen, and pelvis injuries.) Rollover (free for all, especially in the driver was unrestrained. Understand temporary and permanent cavitation. 36. HR, BP, Skin Color, Mental Status, Respiratory Status. Class 1-4. Class 1 and 2 are compensated shock, and using only result in increased heart rate, respiratory rate and agitation. Class 3 is decompensated shock, includes a decreased BP and an altered mental status. Skin color becomes worse, and classic signs of shock show here. Class 4 is irreversible shock, and most patients do not fare well here. Everything drops, and they become unconscious. 37. Controlled bleed: monitor for changes, and initial fluid bolus to maintain a BP of 90-100. Uncontrolled bleed: dressings, tourniquets, and for internal bleeds close eye on distention. Minimum of 2 L of fluid, and 2 large bore IVs. This patient requires aggressive management. 38. Closed: bruises, contusions, hematomas, and tenderness are all closed soft tissue injuries. Open: lacerations, abrasions, avulsions, and penetrating trauma. Sprain is ligament (bone to bone) and a strain is tendon (muscle to bone). A sprain is worse. Most common tendon injuries involve hyperextension or overuse, and create a small tear in the tendon. Seen in knees, elbows and wrists most commonly. Apply pressure to stop the bleeding, cover with sterile gauze, and clean the wounds as best as possible. 39. Crush injuries: occur when a limb has been compressed for over 4 hours. Causes toxin to build up in the compressed part as the body can’t get blood flow to the affected limb. Once released, you can expect a severe drop in BP as the body now must pump the same amount of fluid into a bigger container. Also expect to see peaked T waves and a widening QRS due to the potassium influx. Sodium Bicarb and fluid boluses are key treatment. Compartment syndrome: Pressure builds up into a small space, and causes a decreased blood and oxygen flow distal to the injury site, and can cause nerve damage and loss of the limb if left untreated. Pressure often caused by bleeding into a small space, like a leg or elbow. Surgery is treatment. 40. The rule of nines (Torso is 18 per side, Legs are 9 per side, arms are 4.5 per side, head is 4.5 per side and genitals is 1% for adults). Rule of palms is that the PATIENT’S palms are 1% of their body, usually used in 1 degree burns or burns that are less than 10%. 41. Electrical, thermal, chemical, radiation, inhalation. Partial thickness will be red to pale skin, BLISTERS are key here and extremely painful. Full thickness is white waxy skin, with eschar as well Usually no feeling as it is all the way past the dermis. 42. Under 10% and occurred within 15 minutes? Cool with tepid water. Over 10%? Cover with dry, sterile burn gauze and consider fluid management. NEVER ICE. And ensure the patient is warm, and burns damage the skin’s ability to thermoregulate. 43. Inhalation: High flow O2, inspect for signs of airway compromise, consider intubation if burns to airway look significant (think swelling), if unable to intubate, surgically cric. If wheezing, give albuterol. Chemical burns: Hazmat! Brush off powders and remove clothes. Find out what is it and if it’s water reactive. Irrigate with copious amounts of water. 44. C-SPINE. Monitor for EKG changes (very common), cover wounds with dry dressings, no need to cool. 45. S&S of ICP – Cushing’s Triad (Increased Systolic BP, decreased HR, and irregular respirations). Herniation includes sudden decrease in mental status, irregular respirations, and usually a blown pupil of the affected side. Skull fracture: severe MOI, obvious deformity, CSF leaking out the ears, nose, and down the throat. Concussion: amnesia of the event, positive LOC, projectile vomit, and dilated pupils. 46. Monitor BP, it’s important to maintain a systolic BP of 90-100. Ensure adequate O2/BGL levels. Prepare for seizures. Keep the pt flat, and continually reassess and trend vitals. 47. Dental: loose teeth can cause airway obstruction and be aspirated. Significant force to knock out teeth, bleeding can be excessive due to vasculatures of the mouth. LaForte Fxs: Type 1: maxilla detaches from jaw, the mustache fracture. Type 2: runs from the bridge of your nose, and creates a triangle down to your maxilla, the SCBA mask fracture. Type 3: Separation of your facial bones from the skull, which includes maxilla, zygomatic, and nasal bones, the glasses line fracture. Mandibular fracture: significant force and MOI to fracture a lower jab, creates a massive airway management problem. Not a candidate for intubation. Orbital fxs: can cause paralysis of upward gaze, and often lead to some sort of vision disturbance for life. 48. All can get tetracaine as the treatment except ruptured globe and penetrating trauma. Patch both eyes. Glaucoma involves intraocular pressure. Macular degeneration is a disease process, involves the retina. 49. Spinal Injuries: understand what MOIs can cause them. C-SPINE until you decide they’re good. Pain, tenderness, abnormal sensations, and altered mental status are all signs to c-collar. Ensure you assess PMS on all extremities, and do a thorough head to toe. 50. Rapid extrication is done on c-spine injured patients who are hemodynamically unstable and require immediate transport. That would include a c-collar, and then a backboard and secured to the board after the extrication. A KED is used on back pain patients, who are hemodynamically stable. Use the backboard as a full body splint when multiple injuries are present. 51. Tension Pneumo: results when there is an injury to the chest that either creates a whole in the chest wall into the lung cavity or when a lung pops a hole and leaks air into the lung space. This then creates tension against the lung expanding as the air has nowhere to go. S&S: diminished lung sounds, low O2 sat, harder to bag, JVD and tracheal deviation. Treated with either burping the occlusive dressing in a sucking chest wound or by decompressing the chest with a needle. 52. Flail chest: occurs when 2 or more ribs are broken in 2 or more places, creating a floating segment of the chest wall. Inhibits the patient’s ability to breathe, as it is incredibly painful. S&S: shallow respirations, low O2 sats, chest wall instability, a section moves in during inhalation and out during exhalation. Treated with O2, bulky dressings, and in severe cases intubation, as the positive pressure will internally splint the patient. 53. Open pneumo: Sucking chest wound. Cover with 3-sided occlusive dressing and monitor for a tension pneumo. 54. Tamponade will have Beck’s Triad; muffled heart tones, JVD, and a narrowing pulse pressure. Happens when trauma causes the pericardial sack to swell, and fluid to accumulate in the sac, causing compression to the heart. Treated with fluids to increase the preload, and then ultimately treated with pericardialcentesis. Blunt cardiac injury: When blunt trauma to the chest wall bruises the cardiac muscle, tends to make it more irritable. No real medical treatment, just time for the muscle to heal. Thoracic aortic disruption; happens when the heart swings forward, often in a car accident, and is sheared off at the aortic arch by the ligamentum arteriosum. This injury is often fatal before even first responders are on scene, and the only fix is surgery. 55. Abdominal Trauma: Know if your patient is in shock but you have no obvious bleeding, it’s abdominal trauma. Hollow organs produce colicky, constant and diffuse pain, so tenderness without distention. Solid organs produce point tenderness, rebound tenderness, and will also cause abd. Distention due to the amount of blood that can hemorrhage from solid organs. Kidneys are main retro organs, keep in mind of a kidney laceration with Cullen’s and Grey Turner’s sign. Major vessels in the abdominal aorta, keep in mind! 56. Pelvic Trauma: pelvis can hold up to 2 L of blood in a fracture. Understand pelvic fractures are extremely hard to do, and suspect a high MOI when found. Any instability or pain felt during palpation, leave along once elicited. If plausible, fully immobilize the patient. IV fluids and surgery are the treatment plans. A sheet splint may also be useful, tie around pelvis and tie together very tight! 57. Fractures: Open vs closed. Open includes broken skin, and obvious fracture. DO NOT ATTEMPT TRACTION, splint in place, give pain meds, and cover in wet gauze. Control hemorrhage as best as possible. Closed: deformity, and point tenderness is a sign of a closed fracture. Attempt to realign if no pulse present, if does not return after one attempt, splint in place and transport. Dislocations are extremely painful, and if not fixed quickly can cause permanent nerve damage. Do not attempt to place back in socket. Elevate, ice, and transport. Sprain = ligament (longer to heal; bone to bone). Strain = tendon (quicker to heal; muscle to bone.) 58. Pain control: long bone injuries with muscle rigidity = versed. Pain 4-10 = Fentanyl. Pain <4: Nitrous. Ice, elevate. Splint in normal anatomic function when possible, however if too painful or unable to do so, splint in position. Traction splint is femur fractures, attempt x1. Only indicated in femur fractures with no distal or proximal fractures. PMS is vital in these types of injuries. 59. Asthma: A reactive lower airway disease in which your body produces a severe reaction to an irritant causing bronchoconstriction, excessive mucus production, and airway inflammation. Most commonly noted as wheezing and SOB. Seen especially in kids, as is common childhood disease. 60. Asthma: give supplemental O2 if patient is in respiratory distress, along with an albuterol treatment. Albuterol has beta 2 effects, causing bronchodilation and allowing pts to begin coughing up mucus and better exchange o2/co2. Monitor for improvement in work of breathing, wheezing, and O2 sats. If pt’s begins to worsen despite albuterol treatment, give 0.3mg Epi 1:1 IM. Not improving or respiratory arrest, intubate and give INLINE neb tx along with Epi. 61. Emphysema/Chronic Bronchitis. Emphysema is a chronic airway disease in which your alveoli lose their elasticity, and do not collapse as well. Stiff chest wall is common. Pts are called “pink puffers”: pink skin (CO2 level) with a barrel chest due to increased work of breathing and the inability for the chest to completely exhale. THIS IS AN AIRTRAPPING DISEASE. Chronic Bronchitis: defined as a patient who has bronchitis more than 3 times a year that last 3 months or longer in duration. Excessive inflammation and mucus production limit the patient’s ability to exchange O2 effectively. Commonly called the “blue bloaters”, these patients are often heavy set due to a sedentary lifestyle and are blue/pale in color due to a constant state of hypoxia. Both will have a hypoxic drive running their body, meaning they function normally on a higher EtCO2 level: 45-55 could be their norm, with low O2 sats (92% is goal). 62. Manage with O2 when appropriate. If wheezing, administer albuterol. Monitor pt’s status closely. 63. PE: when a blood clot, often from the leg, travels up into the lungs and gets stuck inside a vein, blocking off blood flow and creating a portion of the lungs unable to exchange O2. Most pt’s with PE’s will complain of sharp, sudden onset chest pain. Pts will state they feel short of breath, and their O2 sats will be dramatically low. EtCo2 expected to be low as well. Seen in patients with A-fib, DVTs, and those who’ve recently flown; however, can happen to anyone. Managed with high flow O2, early recognition, and either TPA or surgery in the ED. 64. Pneumonia: an either viral or bacterial infection that inflames the alveoli. Alveoli may fill with fluid or pus, causing cough with phlegm, fever, chills, and difficulty breathing. Untreated, it can cause the lungs to consolidate and thus unable to exchange O2/CO2, and unable to ventilate due to excessive mucus in the lungs. Assessment will usually reveal diminished lung sounds unilaterally, and can be found in the apex and not the base. Pt’s will have a fever, and complain of cold symptoms for the past few days. Treat with high flow O2, fluids if hypoperfused, and transport to the ED. 65. Hyperventilation syndrome: often called a “panic attack”. Occurs when a pt is unable to slow breathing down, and subsequently blows off too much CO2 causing a respiratory alkalosis. Common complaints are tingling hands and fingers, carpopedal spasms, and light headedness. Treatment includes coaching a patient’s breathing to slow their respiratory rate. 66. Spontaneous Pneumo: Often seen in pt’s who are tall, lanky, and have a broad chest. Caused by blebs on the lungs which can burst off the lung, causing a hole in the lung. Common symptoms include severe and sudden shortness of breath, with decreasing lung sounds, but no known trauma. Simple pneumo management include high flow o2 and close monitoring in case it becomes a tension pneumo. Non-cardiogenic pulmonary edema: can be caused by inhalation injuries, and can also have no known cause (flash pulmonary edema). Treated the same, with nitro and CPAP. Monitor closely and anticipate intubation. 67. Rhythm ID: VT vs IVR. VT is fast and has no asystole lines. IVR will be slower, possibility of T waves. 68. Lethal rhythms: asystole, v-fib, and vtach. 69. Afib vs A-Flutter vs. SVT. Afib will have no visible p waves, wavy baseline, usually slower, and irregularly irregular. A-flutter will have flutter waves, also known as sawtooth waves, usually regular and usually slower. SVT: no p waves, over 150 in adults, and regular. 70. Blocks: 2nd degree type 1 (Mobitz 1): lengthening PR intervals until you miss a QRS complex, also called Wenchebach. 2nd degree type 2 (Mobitz 2): multiple p waves, yet those that conduct a QRS complex have the same PR interval. 3rd degree heart block: AV disassociation block. No correlation with P waves and R waves. However, P waves are consistent in distance, along with the R waves. 71. Stable Angina: occurs when a portion of the heart muscle is temporarily deprived of blood, usually from a temporary clot from atherosclerosis/arteriosclerosis or strenuous activity, but can pass the clot and reperfuse the area without much intervention. Most patients can relieve the pain simply by relaxing from the strenuous task or by taking a nitro. Unstable Angina: chest pain that occurs while at rest, or does not reside with nitro administration. Treated with nitro if the pressure is okay, and the 12 lead doesn’t show an inferior wall MI. ASA administration and pain management are also key. 72. AMI findings: a ST elevated or depressed 12 lead. Must show either depression or elevation in 2 or more contiguous leads (I, II, III | V1, V2, V3, V4 | V5, V6, AVL | II, III, AVF). Patients will usually complain of chest pain, that is crushing in nature. Cool, pale, and diaphoretic. May complain of nausea/vomiting. Remember that diabetics, elderly, and woman are the most likely to have “silent” MIs. Treat with nitro if applicable, ASA, consider placing Defib pads on, and alert hospital to a STEMI if applicable. 73. Right Heart Failure: usually caused by L heart failure. Causes fluid to back up into the extremities, most common sign is pedal edema. Left Heart Failure: usually caused by an MI or previous cardiac injury. Left ventricle is unable to pump effectively, which causes fluid to back into the lungs, causing pulmonary edema. Also lowers the preload, which can also lower your blood pressure. 74. Pulmonary Edema management: Nitro every 5 min if BP is maintained, dangle patient’s feet in possible, and CPAP if patient can tolerate it. If pt becomes altered, hypoperfused or unconscious, discontinue use and anticipate intubation. 75. Nitro: smooth muscle relaxant. Causes vasodilation, which in MIs can increase the blood flow to the affected part of the heart. Indicated in chest pain with a possible cardiac cause. Contraindicated in inferior wall MIs and in patient’s taking ED or pulmonary hypertension medications. Dose is 0.4mg. SE: Dizziness, lightheaded, hypotension 76. ASA: antiplatelet. Indicated in any chest pain pt who is not allergic or taking Brilinta (contact medical control). Contraindicated in pt’s who take Brilinta, have GI bleeds, and cautioned in asthmatics. Dose is 324mg. SE: anaphylaxis, angioedema, bronchospasms, GI bleeds, N/V. 77. Fentanyl: opioid analgesic with rapid onset, 30-60 seconds, binds to opiate receptors creating analgesia and sedation. Indicated in patients who have pain 4-10. Contraindicated in pt’s with a known sensitivity and those whose systolic blood pressure is under 100mmHg. Dose is 1mcg/kg or 0.5mcg/kg. SE: Bradypnea, hypotension, drowsiness, AMS, if pushed too fast = chest wall rigidity. 78. Vasopressin: artificial ADH, used in codes in place of your first or second round of epi. Used solely for its fluid retention purpose. SE: None. 78B. Epi 1;10. Used in cardiac arrests and severe anaphylaxis. In codes, given every 2-3 minutes and used as a vasoconstrictor. No contraindications in cardiac arrest. Given in 1mg in 10mL (usually a preload). SE: tachycardia, hypertension, palpitations, headache. 79. Amiodarone: increases the cardiac refractory period without influencing the resting potential of the cardiac muscle. Relaxes smooth muscle and reduces peripheral vascular resistance. Given in VTACH with a pulse, or VTACH/VFIB pulseless arrests. Contraindicated in hypokalemia, cardiogenic shock, sinus brady, 2nd or 3rd degree heart blocks. SE: hypotension, bradycardia, AV blocks, ataxia, dizziness, N/V, may cause prolonged QT. 80. Atropine: anticholinergic. Indication in symptomatic 1st degree heart blocks, bradycardia secondary to vasalvagal episode, and spinal cord shock. Contraindicated in 2nd or 3rd degree blocks, MI, closed angle glaucoma, GI obstruction and IVR. Dose is 0.5mg q 3 min; max of 3mg. 81. Dopamine: sympathomimetic. Increases the chronotropic, dromotropic, and inotropic effects of the heart, along with increasing systemic vascular resistance. Given in 5mcg/kg/min dose, but you can titrate up to 20mcgs/kg/min. Indicated in cardiogenic shock, septic shock, and neurogenic shock hypotension. Hypotension due to hypovolemia and tachydysrhythmias. SE: hypertension, n/v, headache, tachydysrhythmias, and tissue necrosis if infiltrated. 82. Lasix: loop diuretic. Indicated in flash pulmonary edema pts and those in CHF exacerbation. Contraindicated in hypotensive pts? SE: hypotension, dizziness. 83. Adenosine: slows the electrical conduction of the heart at the AV node. Indicated in stable SVT pts. SE: sense of impending doom, flushing, chest pressure, throat tightness, numbness. Can worsen asthma. 84. Calcium Channel Blockers (verampil and Cardizem): prevent calcium from entering cells of the heart and blood vessel walls, resulting in lower blood pressure. Also relax and widen blood vessels by affecting the muscle cells in the arterial walls. Indicated in people with HTN. SE: lightheadedness, hypotension, bradycardia. 85. Cardiac Arrest: a pt who is not breathing and has no pulse is considered in cardiac arrest. Elderly pt’s and those with comorbidities are at the highest risk of cardiac arrest. Priorities in cardiac arrest are high quality CPR, early defibrillation, airway maintenance, and early recognition of impending arrest. In our system, may terminate arrest after initial rounds of drugs, patent airway and IV, compressions have all yielded a pt in asystole. Refer to triple zero policy. 86. Pacing: indicated in unstable bradycardia with hypoperfusion. Must have a monitor and pacing pads attached to work effectively. Place pads, and set initial rate at 70. Increase milliamps until you achieve both mechanical (pulse) and electrical (QRS after pacer spike on monitor). Can cause the patient pain, consider versed if time applicable. 87. Cardioversion: done in unstable SVT or VTach with a pulse. Start at 100j and work your way up. Defib: done on vtach without a pulse and vfib. 88. Phases of the cardiac cycle: phase 0: depolarization of the cardiac cell, when sodium influxes into the cell, causes the heart muscle to contract. Phase 1 and 2: slow repolarization of the cell. Sodium begins to leave, calcium channels open, and potassium starts rushing back into cell changing the action potential. Phase 3: rapid repolarization of the cell, the last of the sodium is pushed out and the cell begins to reach its height of repolarization. Phase 4: The cardiac muscle is fully repolarized and waiting for the next impulse. Resting time for the heart muscle. Preload: the force inside the ventricle while in diastole (or at rest and filling), afterload: the amount of force the ventricle must contract against to effectively pump blood (systole). Starlings law: the rubber band phenomenon. The farther you stretch the faster and harder it will contract. ANS on heart rate, rhythm and contractility: decreases all of them. 89. Electrophysiology: SA -> AV node -> AV Junction -> Bundle of His -> Purkinje Fibers -> R and L Bundle Branch. Major pacing sites intrinsic rate: SA (60-100), AV (60-80), AV Junction (40-60) and Purkinje Fibers are (20-40). Sodium in the extracellular cation and potassium is the intracellular cation. Magnesium goes with potassium, calcium with sodium. Refractory period is phase 2 and 3 of the cardiac cycle. 90. Phase 0 is the spike of the QRS. Phases 1-2 are the downswing of the QRS into the J point. T wave is phase 3, and then baseline is phase 4. EKG graphing paper = 1 small box is 0.04, 5 small boxes is 0.2, and 5 big boxes (which consist of 5 small boxes each) makes 1 sec. Two big boxes up is 1mv. Rate is calculated by how many QRS complexes are in one 6sec strip. There are precordial leads (V1, V2, V3, V4, V5, V6,), bipolar limb leads (I, II, III) and unipolar limb leads (aVR, aVF, and aVL). 91. AAA: tearing/ripping back pain, possibly mottled legs, groin pain, pulsating abdominal mass, hx of HTN, hypertensive pt (think 200/100). Manage with fluids, pain meds and high flow O2. 92. Neuro assessment – think GCS and AVPU. 93. Seizure: occurs when neurons in the brain over fire, causing a frenzy of reactions in the brain that the brain can’t tolerate. Can be caused by numerous outside factors not limited to: overdose, withdrawal, high fever in kids, hypoglycemia, brain injuries, poisonings, and genetic factors. Types include grand mal with your classic tonic (rigidity) and clonic (convulsions) movements. Petit mals (absence seizures) in which a person looks dazed and is unable to follow commands or speak. Focal seizures involve only one part of the body, which can include your eyes, your legs, your arms etc. The person is still aware throughout the focal seizures. Most people have an aura, alerting them they’re about to have a seizure. Then in tonic/clonic seizures, the tonic phase is first in which they are rigid. Clonic then involves rhythmic movements. Postical is after the clonic phase, and most people are either unconscious or dazed, with irregular respirations etc. Assessment: look for cause of the seizure, and ask the length of the seizure. Did they fall? Management: postical = anticipate another seizure, anticipate vomiting, and reassure pt. Actively seizing: 2mg q 2min IV / 10mg IN / <70kg = 5mg IM >70kg = 10mg IM. 94. Stroke: Hemorrhagic vs Ischemic. Ischemic is a clot, is slower, and can be treated with tPA. Hemorrhagic is quicker, a bleed, and needs to be treated with surgery. CSS: Facial droop, Arm drift (with palms up), and slurred speech. The side affected physically is the OPPOSITE side of the brain affected. Managed: anticipate loss of airway, seizures, vomiting. IV attempts limited to 2. Take to a primary stroke center, and be sure to obtain LAST KNOWN WELL. 95. Headaches: migraines (bad headache, usually lasts a few hours to days. Often recurrent, and most people know. Sensitive to light.) Cluster (usually on one side of the head, and often come in bouts. May have 3 in a week, and then none for months.) Subarachnoid (often a popping sensation, followed by “the worst headache of my life”, and a headache that moves down the head.) Syncope: a brief moment in loss of consciousness. No side effects afterwards usually. Can be caused by a variety of things, including standing up to fast, hyperventilating, fear, hypoglycemia, etc. Parkinson’s: a disease caused by low levels of dopamine. Causes muscle tremors and eventually loss of memory. MS: an autoimmune disease in which your body attacks the myelin sheath of your neurons. Causes muscle tremors, loss of movement, and eventually loss of memory function as well. Guillain-Barre Syndrome: an autoimmune disorder in which your body attacks your nerves. Starts in the feet and slowly moves upward, causing paralysis. Spina bifida: a neural tube defect when a portion of your spinal cord doesn’t form properly. the disease causes severe physical limitations, along with possible mental disabilities as well. 96. Type 1 (Juvenile): usually diagnosed in younger people, called insulin dependent diabetics. They’re pancreas either creates too little or no insulin. Type 2 (bad lifestyle): often seen in the elderly. They don’t process insulin correctly, thus creating high glucose levels because they don’t break down sugar right. Usually treated with pills. Insulin helps breakdown carbs into glucose so it can be used by the body. Normal glucose levels: 60-100. Hypo = <60, with signs and symptoms (sweating, cool, pale, AMS, seizures). Hyper = >180 with signs and symptoms (dry, hot, thirsty, fruity tones on breath, AMS). Oral hypoglycemic agents increase insulin sensitivity and decrease glucose production. Complications include kidney problems, HTN, easily injured and infection prone. 97. Hypo = <60, with signs and symptoms (sweating, cool, pale, AMS, seizures). Hyper = >180 with signs and symptoms (dry, hot, thirsty, fruity tones on breath, AMS). DKA is sugar above 400, HHNK is usually above 800. DKA has ketones, HHNK has none. 98. Treated with oral glucose if able to follow directions. D50% (25g in 50mL) pushed in pt’s unable to follow directions. Glucagon if unable to get a line, 1mg IM. 99. 200mL fluid boluses as long as lungs are clear. 100. an over exaggerated immune response to an antigen. Pt’s with an exaggerated immune system response to something normal, such as peanuts can cause a life-threatening reaction including laryngeal swelling, hives, and body wide vasodilation. Caused by IgE. Pt’s can present with local signs, such as swelling and redness to the site, itching and tingling. System wide includes hives, wheezing, or severe respiratory distress. Managed with Benadryl in local reaction. Epi 1:1 0.3mg IM used in systemic WITHOUT hypoperfusion. 101. Systemic WITH hypoperfusion. Anticipate intubation; inline neb if needed for wheezing. 1:10 0.5mg IV. If pressure still low, titrate to response. 102. Abdominal assessment: history is key, and ask if they can pinpoint the pain and then start palpating furthest from that point. Acute abdominal pain comes on quickly, and can usually be localized. Widespread visceral (or colicky/achy pain) is a common sign of peritonitis. 103. Upper GI bleed = black tarry stool, aka melena. Lower GI bleed = bright red blood, hematochezia. Peptic Ulcers = heartburn, nausea, vomiting, dull stomach ache, and gas. Caused by H. pylori or NSAID use. Esophageal varices: caused by chronic alcohol use. Pt’s will be vomiting bright red blood, and show s/s of shock. Can be deadly, and hard to treat in the field. Diverticulitis: inflammation/infection of a pocket in the small intestine. S/S bloating, cramps, diarrhea, gas, and n/v. Colitis: inflammation of the colon. Can be caused by Crohn’s disease (autoimmune disease). Causing bowel pain, gas, constipation, along with hematochezia. 104. Appendicitis: Lower R abdominal pain, that radiates to the umbilicus. McBurney’s point, between the navel and the LRQ, has rebound tenderness is a positive sign of acute appendicitis. When ruptured, can cause sepsis if left untreated. Your appendix is right at the point your cecum and ileum meet. Diverticulitis: an infection of diverticulum, which are small sacks that form on your large intestine. Can cause abdominal pain, along with diarrhea and gas when infected. Gastroenteritis: An intestinal infection marked by diarrhea, severe abdominal cramps, nausea, vomiting, and fever. Often caused by norovirus and rotavirus, and called the stomach flu. Colitis: Inflammation of the colon, often caused by an autoimmune disease. Causes bowel pain, gas, constipation, and bloody stool. Bowel obstruction: can be caused surgery, Crohn's disease, diverticulitis, hernias, certain medications, a twisted bowel, and colon cancer. Can cause severe abd. pain, nausea, vomiting feces, constipation and gas. Treated with pain medications, antiemetics, and fluids if hypoperfused. 105. Cholecystitis: acute inflammation your gallbladder, most commonly caused by gallstones. Presents with upper R quadrant pain, often after eating a fatty meal. Murphy’s sign, when pt breathe in, hands are under ribcage near liver, and produces pain due to inflamed liver. Referred shoulder pain is a common sign, as well as fatty, smelly stools. Cirrhosis: disease of the liver, often caused by alcoholism and hepatitis. Causes itching skin, clay colored stool, jaundice, icterus (eye jaundice), abd. pain, and GI bleeding. Pancreatitis: caused by gallstones and alcoholism. Can create long term problems if not treated quickly. Sharp back pain and epigastric pain are common, along with muscle spasms. Chronic pancreatitis can also rapid weight loss and malnutrition. Can also produce Cullen’s or Grey Turner’s sign if internal hemorrhage present. Manage with fluids and pain meds as needed. 106. Acute renal failure (reversible): caused by pre, intra, or post problems. Pre: hypoperfusion to the kidneys; most commonly caused by hypovolemia in shock, trauma, sepsis and heart failure. Intra: damage to the kidney structures; most commonly caused by Type 1 diabetes, kidney infections, and drug and alcohol abuse. Post: obstruction of urine flow; most commonly caused by kidney stones and an enlarged prostate. Chronic Renal Failure (irreversible): decreased kidney function; most commonly caused by unmanaged DM and HTN. Will ultimately turn into End Stage Renal Disease (ESRD) and require dialysis. Venous access in dialysis pts: CANNOT be done on the same side as the shunt, same goes for obtaining a BP. Complications of dialysis: hypotension/shock, potassium imbalance, disequilibrium syndrome, N/V, infections, and shunt hemorrhage. Missing dialysis causes: weakness, cramping, pulmonary edema, and uremic frost. Disequilibrium syndrome: after a dialysis treatment which rapidly lowers the concentration of urea in the blood, it remains in the CSF. Seen after treatment, as water shifts into the CSF to dilute it, causing a slight increase in ICP. S&S: nausea, vomiting, headache, and confusion. After a few hours, fluids balance out and symptoms improve. Electrolyte disorders: most commonly is a potassium disorder due to inability to properly excrete ingested K+, which causes many cardiac issues. HYPERkalemia (caused by missing dialysis or incomplete treatments): peaked T waves, and as worsens creates a widened QRS, and may create a 3rd degree heart block or asystole. HYPOkalemia (caused by overaggressive dialysis): can cause a flattened T wave, hypotension and bradycardia. Treat widened QRS of hyperkalemia with bicarb, and treat bradycardia of hypokalemia with atropine. 107. Kidney stones (renal calculi): extremely common and originate in the renal pelvis. The form when an excess of insoluble salt and uric acid crystalize in the urine. Most common stone is made up on calcium, and occurs more frequently in men. Causes extreme pain, 11/10 scale. Starts in the flank, and migrates down towards the groin as the stone moves. Can become lodged in the ureter, produces signs of a UTI such as painful urination and hematuria. Treat with fluids, to help pass the stone and pain medications. 108. Organophosphates: major component in pesticides. S&S: SLUDGEBAM; Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis, Bronchospasm, Arrhythmias, Miosis. Treated with 2mg of atropine repeated continuously. Cyanide: Seen in fumigation, and ingestion of silver polish and seeds of cherries, pears, apples, and apricots. Smells like almonds and silver polish. S&S: AMS, headache, palpitations, dyspnea, vomiting, mydriasis, and seizures. Cells suffocate due to the inability of O2 to be utilized at the cellular level. Treated with fluid boluses for hypotension, and administer Cyanokit (hydroxocobalamin) if applicable. 109. Narcotics/Opiates: Depressants toxidrome: heroin, opium, morphine, Diluadid, oxycotin, ambien, fentanyl. Causes the Narcan triad: miosis, respiratory distress, and AMS. Withdrawal symptoms are minimal, but a highly addictive drug. Treated with Narcan, 1mg, repeat 0.5mg q 2min for max of 2mg for transient response. Alcohol: has both an emotional and physical dependence. Withdrawal symptoms include: agitation, delirium tremors (after 48 hours), increased BP, vomiting, hallucinations and seizures. Management is supportive, airway is key. Fluids if hyoperfused and O2 if needed. 110. Cocaine: stimulant toxidrome, also includes meth and bath salts. S&S include restlessness, agitation, incessant talking, dilated pupils, tachycardia, paranoia, seizures, HTN, hypotension due to decreased preload from tachycardia, and cardiac arrest. Treat with fluids, high flow O2, 12 lead and anticipate seizures and agitation. Tricyclics: antidepressant. Usually end in “line” or “mine”. Pamelor, Tofranil, Norpramin, and Aventyl most common. S&S: AMS, slurred speech, blurred vision, VT, QT prolongation, and hypotension. Treat with fluid boluses and treat widened QRS complex with bicarb. Hallucinogen: LSD, PCP, Ketamine, Peyote and Mushrooms. Causes a distortion of reality. LSD causes sensory disturbances. PCP causes nystagmus, grinding teeth, aggression, super human strength, and no pain threshold or self-perseveration. Ketamine: Dissociative anesthetic, causes dream state and increased sociability. Peyote and mushrooms cause sensory disturbances. Supportive care, and treat life threats appropriately. Anticipate aggression, and do not play into delusions. Recreational drugs: marijuana. Causes a feeling of distorted sense of time and space. S&S bronchodilation, blood shot eyes, tachycardia, euphoria and drowsiness. 111. Carbon Monoxide (CO): causes more deaths than any other substance. Has affinity 250 times greater than O2. S&S: headache, N/V, AMS, dilated pupils, cherry red skin (late) and usually a 100% SpO2 reading. Treated with high flow O2 and IV fluids. 112. Coagulation disorders: acquired vitamin K deficiency and heparin regimens. Hemophilia: von Willebrand disease. Also, type A&B / usually involves factor VIII (8) and IX (9). Factor 9 is also known as Christmas disease. DIC: occurs when a multisystem trauma occurs usually. 2 phases: initial is massive body wide clotting, second is systemic hemorrhage from sudden decrease in all clotting factors. Usually fatal. Thrombocytopenia: deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury. Anemia: has to do with RBC deficiency. Iron deficiency is the most common cause, though sickle cell and thalassemia (inherited low platelets) also cause it. Sickle Cell Disease: hereditary, causes elongated donut shaped RBCs, who also have a shorter life span. 3 types of sickle cell crises: vasooclusive, organ or body part swells due to decreased blood flow from RBCs blocking a vessel. Acute chest syndrome: vasooclusive crisis associated with pneumonia. Causes chest pain, fever and cough. Splenic sequestrian crisis: sickle cells block blood from leaving the spleen, causes a painful enlargement of the spleen and a hard, bloated abdomen. 113. Bites from spiders: black widow causes neurotoxic reactions such as muscle spasms, local pain, and eventually paralysis. Brown recluse causes a small usually painless bite site, with minor swelling and brownish colored lesion. Rare, but some develop loxocelism, a potentially fatal condition that includes an inflamed vesicle, severe pain, and gangrenous sloughing of skin. Snakes: Elapids: coral snakes, Crotalids: vipers. Bite venom is usually a neurotoxin. DO NOT ICE, TOURNIQUET, OR ELEVATE. Transport immediately, and attempt to identify the snake. Tick bites: occur in wooded areas. Carry Lyme disease and Rocky Mountain Spotted Fever. 114. Heat cramps: muscle spasms usually in abdomen or legs, caused by sodium loss due to profuse sweating. Cool and moist skin. Often afflict people in good physical condition, and treated with fluids, both oral and IV if patient able to. DO NOT MASSAGE. Heat exhaustion: syndrome caused by volume depletion and heat stress. Mild confusion, and pale, moist skin. Treated with fluids and lower body temp by cooling with tepid water. 115. Heat stroke: a severe heat emergency characterized by a core temp over 104 and AMS. Pt will be hot and dry. Seen in the really young and really old, middle aged only seen after extreme exertion. Anticipate seizures and vomiting. Aggressive fluid management, monitor for rhabdomyolysis, and cool with ice packs. 116. Frost bite: caused by exposure to cold temps, usually seen in hands, feet, nose and ears. Can be superficial or deep, depending on the tissue lost. DO NOT REWARM IN THE FIELD. Do not massage. Causes water to crystalize in tissue, causing numbness, tingling, and severe pain. Cover blisters and treat like a burn. Hypothermia: a decrease in a body core temp of 95 and under. Mild: 93.2-95; treat with warm fluids, moving around and feeding the patient. Pt will still shiver. Moderate: 86 – 93.2; use warm IV fluids and blankets, watch for Osbourne or J wave (extra wave at the J point). Afterdrop phenomenon seen here, where cold blood is pushed back to the heart from the extremities, along with peripheral vasodilation from rewarming, mimics signs of shock. Severe: less than 86; internal rewarming need. No drugs pushed if in cardiac arrest and handle carefully. 117. Drownings: mammalian diving reflex seen here if drowning occurred in water below 70 degrees, increases chance of survival. Anticipate respiratory problems, due to fluid in lungs as well as the possibility of a surfactant washout. All pt’s should be transported in any drowning, even if recovers at scene. We work drownings a lot longer than normal cardiac arrests, remember that. 118. Hep A: fecal-oral route. Hep B: needle sticks and blood. Hep C: blood and mucus membranes. Causes liver damage, and S&S: jaundice, low grade fever, N/V, lack of appetite and malaise. Vaccines available. Gloves and masks when appropriate, proper sharp disposal. TB: lung disease. NOT highly transmittable. Spread through airborne particles. Presents with cough, night sweats, fever, chest pain, and hemoptysis. N95 mask used here. 119. HIV: blood or body fluids, often contracted via sex or blood transfusion. HIV attacks the immune system and makes them susceptible to frequent infections. Can develop into AIDS. Use gloves and proper sharp disposal. Herpes: Type 1 is spread through oral contact (cold sores) and type 2 is spread through sexual contact (genital warts). No cure, and goes through active and dormant phases. Gloves and good handwashing. 120. Meningitis: inflammation of the meninges in the brain (which cover your brain and spinal cord). 2 types, bacterial and viral. Bacterial is the communicable type, and the deadliest. Droplet transmitted, not airborne. S&S: sudden onset of fever, severe headache, stiff neck, photosensitivity, rash, projectile vomiting, and change in mental status. Kernig's sign: pt can’t extend leg at the knee when thigh is flexed. Brudzinski sign: when a pt is supine, flexion of neck causes flexion of legs. Manage life threats as normal. Ask pt to wear a mask, wear gloves and a mask as well. 121. Restraints: minimum of 4 people needed to safely restrain someone. Always restrain in supine position, and ensure patency of airway. Reassess PMS after restraints. Ensure adequate documentation, and police help if necessary. Pt’s who are a threat to themselves or others and uncooperative with crew after several attempts to redirect are candidates for restraint. Ensure Medical Control is aware of pt being restrained. 122. Risk factors: Caucasians, males under 55, alcohol or drug abuse, depression or sudden improvement in depression, chronic/debilitating illness, schizophrenia, previous attempts, family hx, financial setback, a plan. Clinical presentation: may present in many ways. Ask if they are planning to hurt themselves, or if they want to die. Most suicidal patients reach out before committing the act, be conscious of that. Management: do not leave them alone, acknowledge their feelings, and encourage voluntary transport. Understand people who you believe will truly hurt themselves or others DO NOT have a choice whether they go to the ED, may have to petition them. 123. Acute psychosis: a state of delusion in which the person is out of touch with reality. It is a profound thought disorder, with mood and perception disturbances. Bipolar: A patient that alternates between manic phase (easily distracted, thoughts of grandeur, extremely talkative, insomnia, like on a high) and depressive phase (listless, insomnia, feels guilty, loss of interest). Depression: listless, feels worthless and guilty, insomnia, decreased appetite and hunger, suicidal. Schizophrenia: Usually diagnosed in the early 20s. Experience delusions, hallucinations, apathy, mutism, a flat affect (key in diagnosing), erratic speech, and a disturbance in motor function. Maintain a calm demeanor when treating, and do not play into their delusions or hallucinations. 124. Miscarriage: occurs in 1 out of 5 pregnancies, usually in the first trimester (0-13 weeks). Also called a spontaneous abortion, and the exact cause is usually unknown. Can be from an acute illness, drugs, abnormalities in the fetus and placental attachment. Ectopic pregnancy: occurs when a fertilized ovum implants somewhere other than the uterus, majority implant in the fallopian tubes. Pt will exhibit all normal signs of early pregnancy. Most common is severe lower abdominal pain, localized to one side, and the pt is in hypovolemic shock from the tubal rupture. Treat with fluids, O2, and pain medication. 125. Supine Hypotensive Syndrome: occurs in the 3rd trimester, when the uterus is at its largest and the patient’s mobility is decreased. Occurs either lying flat or sitting down, and the uterus compresses the superior vena cava, which diminishes blood return to the heart. S&S include N/V, tachycardia, breathing difficulty, decreased BP, and syncope. Treated by placing pt on their L side. Usually that resolves the issue. Placenta Previa: painless bleeding, caused by an abnormal placenta attachment near or over the cervix, and the baby when head down compresses the placenta and causing bleeding. It is the leading cause of bleeding in 2nd and 3rd trimesters. Uterus will be soft and non-tender. Abruptio Placenta: a separation of the placenta from the uterine wall. Maternal HTN is the leading causes, followed by trauma and assault. Bright red bleeding, but incredibly painful. S&S include incredibly severe onset of abdominal pain, no longer feels the baby moving, signs of shock, abd will be tender and uterus rigid to palpation. Treat with fluids, O2, and monitor for life threats. 126. Preeclampsia: occurs after the 20th week of gestation, and usually in very young and very old mothers. Triad of symptoms: edema (usually face, hands and feet), gradual increase in blood pressure, and protein in the urine. Can be very dangerous to both mother and baby. Ecclampsia: when a pt has a seizure due to the increased BP. Pt’s with a systolic of 160-180 and a diastolic above 100 are impending signs of a seizure. Treat seizures as you normally would. Pregnancy Induced Hypertension: A blood pressure at or above 140/90 that develops after the 20th week of pregnancy, and usually resides after delivery. Occurs more commonly in obese and diabetic pts. May be an early sign of preeclampsia. 127. Delivery: 3 stages. 1st: onset of labor pains and contraction and ends with the amniotic sac rupturing. 2nd: baby’s head in the birth canal to delivery. 3rd: delivery of the placenta. Imminent delivery: contractions 2-3 minutes apart, and the baby is crowning. Head will deliver face down, and the baby will slowly turn to the side, then down and up to help deliver shoulders. After the shoulders, the baby will usually slide out very quickly, be prepared. Shoulder dystocia: occurs when the baby’s shoulders get stuck on the pubis bone, or the fetus is large. McRobert’s maneuever (knees to chest and wide legs) help the widen the pelvis and flatten the woman’s back. If occurs in the field, have the pt place knees to chest and then pant through every contraction. Major concern is brachial plexus nerve damage. 128. Meconium: the baby’s first stool. It is odorless, greenish black, and a tar-like consistency. It is sterile. Seen in instances of fetal distress, and the amniotic fluid will have a yellow tint if the meconium has been present for a while. Green-black flecks in the fluid indicates a recent passage of the meconium. Neonatal suctioning: the presence of meconium is not reason to suction. IF the baby is acting normally, do not suction. If the baby is depressed after stimulation, suction with an endotracheal tube and meconium aspirator. 129. Nuchal cord: the umbilical cord around the baby’s neck. Once the head delivers, check the neck for a cord. If present, use to fingers and attempt to slide it over the baby’s head. If unable to do so, place to clamps 2 inches apart and cut the cord AWAY from the infant. Prolapsed cord: anytime a woman is in labor, check the vagina for a protruding cord. If seen, immediately place two fingers in the vagina in a “V” shape, and push the baby’s head up and against the pubic bone to relieve pressure off the cord. DO NOT MOVE once you’ve inserted your fingers. Have the woman pant through every contraction and attempt to elevate her hips, and immediately contact the receiving hospital of the situation. Cover the cord will moistened gauze. Breech birth: if the presenting part is the baby’s bottom, then you DO NOT have time to get to the hospital. Deliver the baby’s body normally, and support the body, guiding it downwards. Once you see the hairline at the nape of the baby’s neck, gently guide the baby upward to the abdomen and the head should deliver. If it doesn’t deliver within 3 minutes, place you hand into the vagina in a “V” shape, and push the head upwards. Have the woman’s hips elevated and have her pant through every contraction. 130. Postpartum hemorrhage: anything over 500mL. Perform uterine massage and have the mother breastfeed. Also, two large bore IVs and fluid. Control external hemorrhage from tears with firm pressure. Uterine rupture: occurs in women with multiple children or previous C-section. Pt will show S&S of shock, feel weak and dizzy and be thirsty. Will most likely say she initially had very painful and strong contractions and now has none. Treat with fluids, O2, and rapid transport. Pulmonary Embolism: One of the most common causes of death in delivery. Often arises from a blood clot from pelvic circulation. S&S include sudden onset of SOB, tachycardia, a-fib, and hypotension. Pt may also say they have sharp and sudden chest or abdominal pain. Physical exam will reveal nothing unusual but tachycardia, tachypnea, and hypotension which may be misdiagnosed as shock. Treat with high flow O2, early recognition, and rapid transport. 131. Cord clamping: cut 6-8 inches from the baby, with the clamps 2 inches apart. Once cut, assess for bleeding. If the section attached to the baby continues to bleed, place a second clamp closer to the baby. Also inspect for one vein and two arteries. APGAR scoring: should be done at 1 min and 5 min. If the initial score is less than 7, reassess every 5 minutes until 20 minutes old. Max is 10, min is 0. Based on activity, pulse rate, grimace, appearance,