NREMT Paramedic NCCP Review.pdf

NREMT NCCP Paramedic Review NREMT Paramedic National Core Competencies Program Paramedic Review Airway and Ventilation • Continuous Positive Airway Pressure (CPAP) a. CPAP is used to provide better oxygenation to patients who are hypoxic i. Not designed to ventilate patients b. Reduces the effort...

NREMT NCCP Paramedic Review NREMT Paramedic National Core Competencies Program Paramedic Review Airway and Ventilation • Continuous Positive Airway Pressure (CPAP) a. CPAP is used to provide better oxygenation to patients who are hypoxic i. Not designed to ventilate patients b. Reduces the effort for the patient to breathe, improves oxygenation and reduces hypercarbia c. Can prevent the exacerbation of respiratory distress or respiratory failure d. Applies positive airway pressures above atmospheric pressure during inhalation and provides positive end expiratory pressure (PEEP) during exhalation e. Indications i. Patient needing ventilatory support who is in moderate to severe respiratory distress or early respiratory failure ii. Patient must be awake, able to obey commands, and have intact airway reflexes f. Contraindications i. Inability to maintain an open airway ii. Severe hypotension (systolic BP < 90) iii. A respiratory rate of less than 8 breaths/min g. The EMS provider needs to deliver assisted artificial ventilations to patients who exhibit deterioration in mental status because of hypoxia and hypercarbia • Supraglottic i. Examples 1. Laryngeal mask airway (e.g., LMA™) 2. Esophageal-tracheal tube (e.g., Combitube™) 3. Laryngeal tube (e.g., King LT ™) 4. I-Gel ii. Advantages 1. Does not require visualization of the glottis (blind insertion) 2. Initial training and maintenance of skills are easier 3. Chest compressions do not need to be interrupted to insert 4. Minimal equipment required for insertion iii. Disadvantages pg. 1 NREMT NCCP Paramedic Review 1. Contraindicated in patients with a gag reflex 2. Some devices contraindicated in patients at risk for regurgitation which can lead to aspiration (e.g., LMA™) 3. Unrecognized improper placement can occur 4. Additional contraindications common per local protocol • Endotracheal Tube (ETT) i. Advantages 1. Keeps the airway patent 2. May protect the airway from aspiration 3. Allows suctioning of deep airway secretions 4. Potential route for drug administration ii. Disadvantages 1. Difficult initial training 2. Insufficient skill maintenance without frequent practice 3. Frequently causes trauma to the oropharynx 4. Hypoxemia possible with prolonged intubation attempts 5. Adverse outcomes common when providers fail to recognize tube displacement or misplacement 6. High incidence of complications a. when performed by inexperienced providers b. with inadequate monitoring of tube placement • Newborn care – suctioning the airway a. Suctioning the airway in the newborn may cause bradycardia b. Suctioning immediately following birth (including the use of a bulb syringe) should only be done in newborns who have an obvious obstruction to spontaneous breathing or who require positive pressure ventilation c. Presence of meconium does not necessarily require suctioning i. Review AHA Guidelines 1. Do not suction if newborn exhibits vigorous crying/respirations 2. Suction if newborn exhibits respiratory compromise/distress • End tidal CO2 a. Utilized to measure ventilation pg. 2 NREMT NCCP Paramedic Review b. ETCO₂ measures partial pressure (mmHg) or volume (% vol) of exhaled CO₂ exiting the airway at the end of exhalation i. Carbon dioxide generated from metabolism c. Reflects change in ventilation within 10 seconds d. Breath-to-breath measurement provides information within seconds e. Not affected by i. Motion artifact ii. Poor perfusion iii. Dysrhythmias f. SpO₂ measures percentage of O₂ in red blood cells i. Reflects change in oxygenation within 5 minutes II. Physiology a. Carbon dioxide can be measured b. Arterial blood gas is PaCO₂ i. Normal range: 35-45 mmHg c. Mixed venous blood gas is PvCO₂ i. Normal range: 46-48 mmHg d. Exhaled carbon dioxide is ETCO₂ i. Normal range: 35-45 mmHg (5% vol) III. ETCO2 reflects and monitors changes in a. Ventilation - movement of air in and out of the lungs i. e.g., asthma, COPD, airway edema, foreign body, stroke b. Diffusion - exchange of gases between the air-filled alveoli and the pulmonary circulation i. e.g., pulmonary edema, alveolar damage, CO poisoning, smoke inhalation c. Perfusion - circulation of blood i. e.g., shock, pulmonary embolus, cardiac arrest, severe dysrhythmias • Why Measure Ventilation— Intubated patients a. Provide examples of and discuss the ETCO2 findings for the following scenarios: i. Verify (and document) ET tube placement pg. 3 NREMT NCCP Paramedic Review ii. Incorrectly placed or dislodged ETT (may result in death) iii. Immediately detect changes in ET tube position iv. Assess effectiveness of chest compressions v. Earliest indication of ROSC vi. Indicator of probability of successful resuscitation vii. Optimally adjust manual ventilations in patients sensitive to changes in CO₂ • Why Measure Ventilation— Non-Intubated Patients a. Provide examples of and discuss the ETCO2 findings for the following scenarios: b. Objectively assess acute respiratory disorders i. Asthma ii. COPD c. Possibly gauge response to treatment d. Gauge severity of hypoventilation states e. Congestive heart failure f. Sedation and analgesia g. Stroke h. Head injury i. Assess perfusion status j. Noninvasive monitoring of patients in DKA • Interpreting ETCO₂ and the capnography waveform a. Normal waveform of one respiratory cycle (Similar to ECG) i. Height shows amount of CO₂ ii. Length depicts time iii. Waveforms on screen and printout may differ in duration iv. On-screen capnography waveform is condensed to provide adequate information the in 4-second view v. Printouts are in real-time vi. Capnograph detects only CO₂ from ventilation vii. No CO₂ present during inspiration viii. Baseline is normally zero b. Capnogram Phase I - Dead space ventilation pg. 4 NREMT NCCP Paramedic Review i. Beginning of exhalation ii. No CO₂ present iii. Air from trachea, posterior pharynx, mouth and nose 1. No gas exchange occurs there 2. Called “dead space” c. Capnogram Phase II - Ascending Phase i. CO₂ from the alveoli begins to reach the upper airway and mix with the dead space air ii. Causes a rapid rise in the amount of CO₂ iii. CO₂ now present and detected in exhaled air d. Capnogram Phase III - Alveolar Plateau i. CO₂ rich alveolar gas now constitutes the majority of the exhaled air ii. Uniform concentration of CO₂ from alveoli to nose/mouth iii. CO₂ exhalation wave plateaus e. Capnogram Phase III - End-Tidal i. End of exhalation contains the highest concentration of CO₂ ii. The “end-tidal CO₂” iii. The number seen on your monitor iv. Normal ETCO₂ is 35-45mmHg v. End of the wave of exhalation f. Capnogram Phase IV - Descending Phase i. Inhalation begins ii. Oxygen fills airway iii. CO₂ level quickly drops to zero iv. Inspiratory down-stroke returns to baseline • AHA Guidelines now recommend that patients with suspected acute coronary syndrome (ACS) or stroke not receive oxygen unless a. SpO2 less than 94% (on room air) i. If pulse oximeter is unreliable or not available, oxygen should be administered b. Presenting with dyspnea c. Has signs and symptoms of shock or heart failure pg. 5 NREMT NCCP Paramedic Review II. Oxygenation of chest pain and stroke patients a. 2 L/min via nasal cannula for patients who i. Complain of dyspnea ii. Experience signs and symptoms of shock iii. Experience heart failure iv. Have an SpO₂ of less than 94% (on room air) b. Titrate oxygen to maintain an SpO₂ of at least 94% III. Tissue damage may increase a. When high concentrations of oxygen are given to ACS and stroke patient i. Oxygen releases “free radicals;” therefore, it is no longer recommended ii. Free radicals 1. Byproducts of metabolism 2. Toxic to neighboring cells a. Destroys their membranes b. Causes increased local tissue damage iii. Reintroducing high concentrations of oxygen to cells that have been functioning anaerobically increases the production of free radicals causing cell membrane damage and tissue death b. Delivering high concentrations of oxygen to ACS and Stroke patients may be more harmful than keeping the patient on room air Cardiovascular • Recognition of Return of Spontaneous Circulation (ROSC) a. CPR must be continued until signs of life are observed i. Sudden increase of ETCO2 level ii. Presence a pulse after an organized rhythm is observed iii. Patient breathing iv. Patient movement • Optimizing ventilation and oxygenation in the post cardiac arrest patient a. Maintain an SpO2 of greater than or equal to 94% pg. 6 NREMT NCCP Paramedic Review i. Once your patient’s SpO2 is 94%, more oxygen is not necessarily better b. Avoid excessive ventilation (over-bagging) i. Reduces cardiac output ii. Decreases cerebral blood flow c. ETCO2 between 35-40mm/Hg • Hemodynamic instability in the post-cardiac arrest patient a. Monitor vital signs b. Ensure vascular access c. Monitor and manage cardiac hemodynamics i. Hypotension – Systolic BP less than 90mm/Hg 1.Fluid bolus 2.Vasopressors (drips) titrated to systolic BP of at least 90mm/Hg or Mean Arterial Pressure (MAP) of 65 a. Norepinephrine b. Dopamine c. Dobutamine d. Epinephrine ii. Arrhythmias 1.Treat cardiac arrhythmias as required 2.Do not administer antiarrhythmics prophylactically • Identifying the potential cause of cardiac arrest a. Obtain and interpret a 12-lead EKG i. Evidence of AMI may require transport to a specialized facility for further treatment b. Consider and manage reversible causes • ALS Management of Cardiac Arrest a. Airway management i. BVM 1. Avoid hyperventilation as it decreases preload 2. Best technique is the 2-Rescuer technique with one rescuer holding mask seal and the other squeezing the bag with both rescuers watching for chest rise 3. 2 breaths for every 30 compressions without an advanced airway pg. 7 NREMT NCCP Paramedic Review 4. One breath every 6-8 seconds after placement of advanced airway 5. May need to adjust ventilator rate based on capnography ii. Endotracheal Tube (ETT) 1. Compressions should not be interrupted in the placement of an ETT iii. Supraglottic airways 1. Considered an advanced airway 2. Alternative to ETT placement 3. Acceptable during CPR 4. Capnography should be attached to these airways b. Continuous waveform capnography i. Typically 35-45mm/Hg in a normally perfusing patient 1. Greater than 45 mm/Hg a. Ensure adequate ventilatory rate and volume 2. 15-35 mm/Hg a. Common in cardiac arrest patients with CPR in progress 3. Less than 10-15 mm/Hg a. Focus efforts on improving chest compressions b. Make sure the victim is not receiving excessive ventilations ii. A sudden increase in ETCO₂ could indicate a return of spontaneous circulation (ROSC) iii. Use caution with interpretation of ETCO₂ values within 1-2 minutes after administration of epinephrine due to decreased pulmonary blood flow. • Pedi Cardiac Arrest c. Consider possible underlying causes i. “Hs and Ts” 1. Hypoventilation, Hypoxia, Hydrogen ion (acidosis), Hyper/hypo-kalemia, hypothermia, hypo/hyper-gylcemia 2. Toxins, Tamponade (cardiac), Tension pneumothorax, Thrombosis (coronary and/or pulmonary), Trauma ii. Other considerable underlying causes 1. Drug overdose –toxic levels of drugs can occur, even if small amounts are ingested pg. 8 NREMT NCCP Paramedic Review 2. Hypertrophic Cardiomyopathy (HOCM) – Heart muscle becomes thick. Many patients have no symptoms. Often, the first symptom of HOCM in young patients is sudden collapse and possible sudden cardiac arrest. Almost half of sudden cardiac arrests due to HOCM occur immediately after physical activity 3. Commotio Cordis – Cardiac arrest secondary to blunt trauma to the chest (R on T). Most common in young, healthy patients 4. Long QT - AHA channelopathy – Previously undiagnosed conduction abnormalities leading to sudden cardiac arrest • Pathophysiology of CHF a. May refer to right or left sided heart failure b. No valves between left atria and lungs i. May allow fluid backup II. Common causes of CHF a. Increased peripheral vascular resistance (PVR) i. Chronic hypertension 1. Increased left ventricular workload 2. Hypertrophy/cardiomegaly 3. P mitrale (seen with left atrial enlargement) ii. Chronic COPD iii. Pulmonary emboli iv. Non-compliance with medications b. Ventricular failure i. Myocardial Infarction 1. AMI 2. Previous MI with ventricular involvement 3. Non-compliance with medications c. Fluid overload i. Non-compliance with medications ii. Renal failure III. Presentation/Signs/Symptoms of CHF a. Distended neck veins b. Peripheral edema pg. 9 NREMT NCCP Paramedic Review i. Can be pitting (late sign) c. Difficulty breathing i. Crackles and wheezes in dependent portions of the lungs • Treatment of CHF a. Continuous Positive Airway Pressure (CPAP) i. Positive end expiratory pressure ii. Forces alveoli open and helps keep them open 1. Forces fluid out of alveoli 2. Increases oxygenation iii. Contraindications 1. Inability for the patient to maintain their own airway 2. Hypotension (systolic BP of 90mm/Hg or less) may be a contraindication. Follow local protocol or guidelines. 3. Recent esophageal surgery b. Nitroglycerin i. Peripheral venodilator ii. Reduces oxygen demand in the heart iii. Dilates coronary arteries iv. If unable to tolerate sublingually, use nitroglycerin paste v. Contraindications 1. Hypotension (systolic BP of 90mm/Hg or less) 2. Use of phosphodiesterase inhibitors in the past 24-48 hours (e.g., Cialis®, Viagra®) c. Check local protocol for use of furosemide (e.g., Lasix®) • Acute Coronary Syndrome I. Recognize injury patterns on a 12-lead EKG a. Review the anatomical view of the heart with each lead b. Provide 12-lead examples that demonstrate STEMI’s from each area of the heart c. 12-lead crash course – review abnormal examples II. Differentiate STEMI from STEMI imposters pg. 10 NREMT NCCP Paramedic Review a. Common STEMI imposters (provide examples of 12-lead EKGs that show imposters) i. Left ventricular hypertrophy ii. Bundle branch blocks 1. It is difficult to determine an acute from a chronic left bundle branch block without access to a previous 12- lead EKG 2. A left bundle branch block, without other signs or symptoms of MI is not a STEMI b. Implanted pacemakers c. Pericarditis Trauma • CDC Field Triage Decision Scheme a. Reference: i. 4Guidelines for Field Triage of Injured Patients, 2011 b. Four specific steps to consider during triage i. Step 1—Assess vital signs and level of consciousness; they are good predictors of patient’s potential outcomes 1. Glasgow Coma Scale (GCS) 2. Systolic blood pressure 3. Respiratory rate ii. Step 2—Assess anatomy of injury 1. Consider priority transport to a trauma facility if patient is found with: a. Penetrating injuries above the knee b. Unstable chest wall c. Proximal long bone fractures (two or more) d. Extremity that is crushed, degloved, mangled, or pulseless e. Amputation proximal to wrist or ankle f. Pelvic fractures g. Skull fractures (open or depressed) h. paralysis pg. 11 NREMT NCCP Paramedic Review iii. Step 3—Assess mechanism of injury and evidence of high energy impact 1. Consider priority transport to a trauma facility if the mechanism of injury (MOI) meets any of the following criteria, despite patient assessment findings in steps 1 and 2 a. Falls i. Adults >20 feet ii. Children >10 feet or >2x child’s height b. Auto crash i. Intrusion >12 inches where occupied or >18 inches on any side ii. Partial or complete ejection from automobile iii. Death in same automobile iv. Vehicle telemetry data that indicates a high risk of injuries c. Pedestrian/bicyclist vs. automobile i. Thrown ii. Run over iii. Impact at speeds >20 mph d. Motorcycle crash >20 mph iv. Step 4—Assess special patient or system considerations 1. Consider priority transport to a trauma facility if patient meets these special considerations: a. Older adults i. 55 years and older have increased chances of injury/death ii. 65 years and older my present with shock if SBP is <110 iii. Mechanism is low impact (ground height falls) b. Children i. Consider transporting all children to pediatric trauma centers c. Anticoagulants and bleeding disorders i. Head injuries may present with rapid deterioration d. Burns i. No other trauma—triage to burn facility ii. Other trauma findings—triage to trauma center pg. 12 NREMT NCCP Paramedic Review e. Pregnancy >20 weeks f. Use provider judgement II. Transport according to local protocol a. When in doubt transport to a trauma center V. Tranexamic acid (TXA) a. A medication that interferes with the process of breaking down of a blood clot to help maintain and stabilize the newly formed clot b. Has been used for years in other areas of medicine to help with bleeding c. Research surrounding the use of TXA in the out-of-hospital setting i. A randomized clinical trial showed a reduced risk of death by bleeding with TXA treatment if given within three hours of injury ii. In the same trial, the administration of TXA after three hours of the initial injury increased the risk of death by bleeding • Fluid Resuscitation I. Fluid Therapy a. Permissive hypotension - allowing specific patients to experience some degree of hypotension in certain settings. i. The goal of fluid resuscitation is to maintain vital organ perfusion ii. Level of consciousness is an indicator of vital organ perfusion iii. Assessment of the level of consciousness may guide the need for fluid administration iv. Normalization of blood pressure through fluid administration may be harmful and is discouraged II. Dangers of excessive crystalloid administration a. Dilution of clotting factors and platelets b. Physical disruption of a clot c. Expanding the area of vascular defect as blood pressure increases d. Enhances red blood cell loss, thus reducing the total oxygen carrying capacity of the blood e. Research i. 11National Institute of Health: Aggressive Early Crystalloid Resuscitation adversely affects outcomes in adult blunt trauma patients III. Understand Mean Arterial Pressure (MAP) as a tool to better evaluate perfusion pg. 13 NREMT NCCP Paramedic Review a. Mean Arterial Pressure (MAP) is a better assessment tool to determine perfusion to vital organs compared to systolic blood pressure. b. Calculated using the following formula: i. MAP=Diastolic Pressure +1/3 Pulse Pressure c. Example: If your patient has a BP of 120/80 then to calculate their MAP: MAP=80+[(120-80)/3] MAP=80+40/3 MAP=80+13.3 MAP=93.3 or about 93 d. Aim for a MAP of 60-65mmHG during fluid therapy IV. Discuss and understand local fluid resuscitation protocol Medical • Abnormal Presentations In Childbirth a. Breech i. Buttocks or both feet present first ii. Management 1.Prompt transport (field delivery is not ideal) 2.When delivery is unavoidable: a. Support buttock and legs b. Do not pull c. If head does not deliver within 3 minutes i.Arrange for immediate transport ii.Insert gloved hand into the vagina and use your fingersto form a “V” on either side of the infants nose iii.Push the vaginal wall away from the infant’s face b. Limb presentation i. One leg or arm protruding from vagina ii. Management pg. 14 NREMT NCCP Paramedic Review 1.Do not touch the limb 2.Do not attempt field delivery 3.Provide supportive care and transport in the knee-chest position c. Multiple Births i. More than one fetus ii. Management 1.Manage as normal delivery, recognizing the need for additional equipment and personnel d. Prolapsed Cord i. Umbilical cord presents from the vagina prior to fetus ii. Management 1.Immediate transport in Trendelenburg or knee-chest position 2.Insert two fingers of a gloved hand into the vagina to remove pressure off the cord 3.Keep the cord moist with sterile dressing 4.Do not attempt to pull the cord or push the cord back into the vagina e. Shoulder dystocia i. Shoulders unable to pass beyond pubic symphysis ii. “Turtle sign”- head delivers but retracts back into the perineum because the shoulders are trapped. iii. Management 1.McRoberts maneuver- (buttocks off the end of the bed with thighs flexed upward) and apply firm pressure with your hand above the pubic symphysis 2.Transport immediately (even if delivery attempt is unsuccessful) f. Nuchal cord i. Cephalic presentation but the umbilical cord is around the neck ii. Common finding during delivery and rarely associated with adverse outcomes iii. Management 1.Attempt to slip the cord over the infant’s head. 2.If unable to slip the cord up and over the head, clamp and carefully cut the cord • III. Magnesium Sulfate for Eclampsia/Pre-Eclampsia. pg. 15 NREMT NCCP Paramedic Review a. Reference: 12ACOG—Hypertension in Pregnancy, 2013 b. Recommended treatment for hypertension (eclampsia) c. Not recommended for pre-eclampsia d. Magnesium Sulfate can cause toxicity and result in cardiac arrest e. Discontinue magnesium sulfate if a pregnant patient in cardiac arrest has been receiving it as a treatment • Medication Delivery I. Benefits of intramuscular (IM) drug administration over the subcutaneous (SQ) route a. With certain drugs (e.g. epinephrine) IM drug administration is more consistent than SQ in the prehospital setting i. Obese patients ii. Pediatrics iii. Movement of the ambulance b. Prehospital medications previously given via the SQ route are transitioning to the IM route i. More predictable absorption in critical patients 1. Peripheral vasoconstriction or poor perfusion (e.g. shock) c. Larger volumes of medication can be given via the IM route compared to the SQ route II. Intranasal delivery of medications a. Combines a method of measuring a unit dose of medication i. Delivered with a syringe or unit dose pump with a spray tip ii. Medication is aerosolized into fine particles as it is being sprayed into the nose iii. Results in a broader distribution of the medication across the nasal mucosa and an increased bioavailability b. Not all medications can be delivered intranasally i. Must have the correct pharmacokinetics c. Medications that can be delivered via intranasal route include but are not limited to i. Fentanyl ii. Midazolam iii. Naloxone iv. Ketamine pg. 16 NREMT NCCP Paramedic Review v. Glucagon d. Split dosage between nares e. Max volume in each nare is 1.0ml IV. Pharmacological interventions for pain management a. Most commonly used agents i. Narcotics (morphine, fentanyl, hydromorphone, etc.) ii. Ketamine iii. Nitrous oxide iv. Nalbuphine (Nubain®) v. NSAIDS 1. Ketorolac (Toradol®) V. Monitoring and Documentation before and after analgesic administration a. Documentation of the patient’s clinical status before and after analgesic administration is required b. Vital signs i. Level of consciousness ii. HR, BP, pulse, pulse oximetry, etc. 1. Baseline 2. Following each intervention c. Document i. Any significant change in clinical status ii. Any corrective action taken d. Follow all local controlled substances policies for documentation, wastage, storage, etc. VI. Quality improvement and medical oversight a. Systems with established QI programs have better compliance to pain management protocols i. Establish benchmarks ii. Tracking plan iii. Feedback and discussion with ED staff, medical director, patients VII. Acute vs. chronic pain management pg. 17 NREMT NCCP Paramedic Review a. Dependence, abuse, and addiction of prescribed medications is well documented b. Perform a thorough pain assessment prior to providing treatment c. Pain management should depend on objective clinical decision making d. Pain is individualized with each patient. i. When patients report where their level of pain, it should not be influenced by the provider’s bias VIII. Sedation Monitoring a. Reference: 16ACEP—Out-of-hospital Use of Analgesia and Sedation i. Analgesia 1. Use of NSAIDs and acetaminophen with opioids 2. Fentanyl as an “ideal narcotic agent” 3. Misplaced fear of clouding ultimate diagnoses when using analgesia 4. Ketamine as a safe out-of-hospital analgesia ii. Sedation/Chemical Restraint 1. Midazolam as an “optimal agent…of anxiety and…agitation” 2. Monitor patient closely when administering benzodiazepines 3. Butyrophenone use for violent patients 4. Ketamine use for violent patients IX. Pediatric pain management a. Reference: 17ACEP—Reducing Pediatric Pain and Anxiety i. Optimizing the environment 1. Combat anxiety and reduce pain by improving the physical environment ii. Assessing pain 1. Self-reporting pain scale examples: a. Wong-Baker FACES® b. FACES and FACES revised c. OUCHER® 2. Non-self-reporting pain scale example a. FLACC Scale pg. 18 NREMT NCCP Paramedic Review i. Faces, Legs, Activity, Cry, Console ii. Utilizes presenting history and physical exam b. Non-invasive pain management i. Multidisciplinary/complimentary methods ii. Distraction iii. Alternative procedures 1. e.g., Steri-Strips ™ vs sutures c. Local and Regional Anesthesia i. Techniques 1. Skin stimulation 2. 25-gauge needles 3. Slow infiltration of medication 4. Room temperature medication d. Systemic Analgesia and Anxiolysis i. Oral/liquid medications are usually sufficient 1. NSAIDs and some opiate formulations ii. Intranasal 1. Less intrusive 2. Efficient 3. Easy and quick 4. Effective route for analgesia and anxiolysis X. Neo-natal pain management a. Reference: 17ACEP—Reducing Pediatric Pain and Anxiety b. Physiologic awareness of medication us in children less than six months (neonates) i. Most analgesics conjugate in the liver ii. Enzymes for drug metabolism develop for up to six months iii. Higher percentage of water/less fat 1. Water soluble drugs distribute greater volumes in neonates c. Topical anesthesia i. Requires appropriate dosing to prevent systemic toxicity pg. 19 NREMT NCCP Paramedic Review ii. No prolonged exposure XI. Research a. Consider conducting research for evaluating pain management in local area i. Intranasal vs. intravenous ii. Intranasal drugs 1. Fentanyl 2. Ketamine 3. Toradol • Chemical Restraint i. Indications ii. Patient poses a threat to himself or others iii. Patients requiring physical restraint who struggle or fight should immediately be chemically restrained iv. Requires continuous monitoring, assessment, and management v. Medication types 1. Ketamine 2. Benzodiazepines (e.g. midazolam, lorazepam etc.) 3. Antipsychotics (haloperidol, risperidone etc.) vi. Dosage 1. Titrate dosage to level of agitation 2. Combination therapy may be necessary 3. Consult with local medical direction when establishing protocols/designing education vii. Medication routes 1. IM 2. IV/IO 3. Nasal 4. P.O./buccal III. Synthetic Stimulants a. Effects of synthetic stimulants i. Psychological pg. 20 NREMT NCCP Paramedic Review 1. Agitation, insomnia, irritability, dizziness, depression, paranoia, delusions, suicidal thoughts, seizures, and panic attacks ii. Somatic (effects on the body) 1. Hyperthermia (significant with MDMA) 2. Rapid heart rate - can lead to heart attacks and strokes 3. Chest pains, nosebleeds, sweating, nausea, and vomiting b. Bath Salts c. Methamphetamine d. MDMA (methylenedioxymethamphetamine) i. Ecstasy, E, X, XTC, Smarties, Scooby-Snacks, Skittles IV. Tetrahydrocannabinol (THC) a. Natural i. Weed b. Synthetic c. Effects of THC i. Impaired short term memory ii. Decreased concentration and attention iii. Impaired balance and coordination iv. Increased heart rate and blood pressure v. Increased appetite V. Opioids e. Common effects: i. Respiratory depression ii. Drowsiness iii. Constipation iv. Constricted pupils v. Dry mouth vi. Itching vii. Nausea and vomiting • Seizures I. Altered mental status definition and causes pg. 21 NREMT NCCP Paramedic Review a. Definition: change in a person’s level of awareness b. Causes (AEIOU-TIPPSS— acronym for assessment of AMS patient) i. Alcohol ii. Epilepsy (seizures) iii. Insulin (diabetic condition) iv. Oxygen (lack of) v. Uremia (kidney failure) vi. Trauma vii. Infection viii. Psychiatric ix. Poisoning (including drug overdose) x. Shock xi. Stroke II. Types of seizures a. Generalized i. Tonic-clonic ii. Absence b. Partial i. Simple ii. Complex c. Status epilepticus i. 24Epilepsy Currents-AESG—“Evidence Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society” 1. A continuous seizure lasting more than 30 minutes 2. Two or more seizures without regaining consciousness between any of them 3. Prolonged seizures last between 5 and 30 minutes a. Should be treated as status epilepticus ii. Complications 1. Aspiration pg. 22 NREMT NCCP Paramedic Review 2. Bone and spine fractures 3. Brain damage from lack of oxygen and/or depletion of glucose 4. Dehydration III. Causes a. Medication non-compliance b. Rapid increase in body temperature (febrile) c. Infection d. Hypoxia e. TBI f. Alcohol or drug withdrawal g. Stroke h. Hypoglycemia i. Eclampsia j. Seizure disorder k. Electrolyte disturbances l. Poisoning IV. Assessment findings a. Spasms/muscle contractions/shaking or tremors b. Sweating c. Cyanosis during seizure activity d. Increased secretions e. Incontinence f. Postictal state V. Management a. Protect from further injury; position on side to protect airway b. Ensure open airway, adequate ventilations, and oxygenation i. Consider using an NPA c. Provide emotional support; reduce stimulants that may trigger more seizures d. IV or IO e. Consider administering a benzodiazepine • Endocrine System pg. 23 NREMT NCCP Paramedic Review II. Diabetes a. Condition in which insulin is nonexistent, minimal, or nonfunctioning b. Without treatment it leads to high blood sugar c. Two types of diabetes i. Insulin dependent diabetes (IDDM, Type 1) 1.Early age of onset 2.Lack of insulin production ii. Non-insulin dependent diabetes (NIDDM, Type 2) 1.Later age of onset 2.Associated with obesity 3.Some cases are resolved with weight loss 4.Cells are less receptive to insulin a. Medication required to improve insulin sensitivity b. Common medications i. Metformin ii. Chlorpropamide iii. Glyburide c. Some may take insulin III. Hypoglycemia a. Rapid onset and changes in mental status b. Sweating c. Hunger d. Rapid pulse e. Rapid, shallow respirations f. Seizures, come (late) g. Bizarre behavior (sudden onset and abnormal for patient) IV. Hypoglycemia management a. Ensure an open airway, adequate breathing, circulation, and ability to swallow b. Determine blood glucose level c. Check for and deactivate insulin delivery device (insulin pump) i. Administer medication as appropriate pg. 24 NREMT NCCP Paramedic Review 1. Oral glucose 2. Glucagon 3. Dextrose IV d. Consider using a D10 solution and administering in 10g increments e. Supportive care V. Hyperglycemia a. Slow onset and changes in mental status b. Rapid breathing, sweet breath odor c. Dehydration, pale, warm, dry d. Weakness, nausea, vomiting e. Weak, rapid pulse f. Polyuria, polydipsia, polyphagia VI. Hyperglycemia management a. Ensure an open airway, adequate breathing and circulation b. Determine the blood glucose level (if available) c. Supportive care i. Blood sugar needs to be lowered slowly and monitored closely, usually in the ICU ii. Field management should focus on ABC’s and counteracting dehydration d. Transport VII. Insulin Pumps a. Pager or smart phone appearance b. Secrete short acting insulin over 24 hours c. Attached subcutaneously by catheter d. Suspend pump administration or disconnect when treating a patient with hypoglycemia e. Tracks/stores helpful information that may assist in determining when and why a hypoglycemic episode occurred VIII. Metabolic syndrome a. Named for a group of risk factors that increase the risk for coronary artery disease, stroke and type 2 diabetes i. Central obesity pg. 25 NREMT NCCP Paramedic Review 1. Extra weight around the middle and upper parts of the body 2. Often described as "apple-shaped" ii. Insulin resistance 1. Body uses insulin less effectively than normal 2. Insulin is needed to help control the amount of sugar in the body. a. Blood sugar and fat levels rise iii. Increased long-term risk for developing 1. Heart disease 2. Type 2 diabetes 3. Stroke 4. Kidney disease 5. Diminished blood supply to the legs. IX. Adrenal hypoplasia a. Addison’s Disease i. Adrenal glands fail to produce adequate amounts of steroid hormones 1. Cortisol 2. Aldosterone b. Congenital Adrenal Hyperplasia i. Can affect all adrenal hormones ii. Can cause hyperadrenalism and hypoadrenalism c. Waterhouse Friderichsen Syndrome i. Can present with life threatening hypoglycemia and hypotension during an adrenal crisis 1. Out-of-hospital treatments a. Fluid bolus for hypotension b. Dextrose administration c. Transport to the emergency department d. Patient may carry an emergency kit containing either hydrocortisone or dexamethasone. i. Check local protocols to assist with or administer these medications pg. 26 NREMT NCCP Paramedic Review ii. Legislation requiring EMS to carry/administer hydrocortisone is being approached in many states • Allergic Reaction & Anaphylaxis I. Allergic reaction a. Hyperactive, localized immune response to an allergen b. Some histamine is released c. Localized: redness, swelling, hives, itching d. May cause nausea, vomiting, and/or diarrhea e. Usually requires minimal supportive therapies f. Repeat exposures may lead to anaphylaxis (e.g., insect stings, foods, etc.) II. Anaphylaxis a. Multiple body systems are affected, not just a localized reaction like allergies b. Life threatening reaction of the immune system to an allergen c. Large quantities of histamine are released throughout the body d. Vasodilation and increased capillary permeability e. May lead to shock f. Bronchoconstriction and mucous production g. May lead to respiratory distress i. Soft tissue swelling of the upper airway ii. Airway obstructions III. Treatment for Anaphylaxis a. Out-of-hospital treatment i. Ensure adequate airway, ventilation, and oxygenation ii. SpO2 <94% administer oxygen iii. Establish an IV or IO, administer fluids iv. Epinephrine 1. First line medication of choice a. Reverses many of the effects of the histamine i. Bronchodilation ii. Vasoconstriction b. Requires continuous reassessment pg. 27 NREMT NCCP Paramedic Review c. Consider additional dosing due to short half-life v. Diphenhydramine 1. Second line medication of choice a. Blocks histamine receptors i. Inhibits further histamine response vi. Consider Albuterol (via nebulizer) 1. Bronchodilator 2. Review local protocol Operations • FIELD TRIAGE—DIASTERS/MCIs I. MUCC (Model Uniform Core Criteria) a. Reference: i. 35National Implementation of the Model Uniform Core Criteria for Mass Casualty Incident Triage 2013 b. A science and consensus-based national guideline that recommends 24 core criteria for all mass casualty triage systems c. Used as the basis for CDC Field Triage Decision scheme and SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) II. SALT Triage a. Reference: Sort, Assess, Lifesaving interventions, Treatment/transport b. Steps to consider during triage i. Sort: Global sorting 1. Obvious life threat 2. Purposeful movement 3. Walk ii. Individual assessment 1. Perform lifesaving interventions as indicated 2. Perform ongoing reassessments iii. Treatment and/or transport pg. 28 NREMT NCCP Paramedic Review III. START (adult triage) a. Reference: Simple Triage and Rapid Treatment b. Steps to consider during triage i. Assess respirations ii. Assess perfusion iii. Assess mental status c. Immediate or delayed transport depends on the assessment findings IV. JumpSTART (pediatric triage) a. Reference: Pediatric MCI Triage Tool b. First, triage patients who do not walk independently (based on age) c. Steps to consider during triage i. Assess respirations ii. Assess perfusion iii. Assess mental status d. Determine immediate or delayed transport based on assessment findings • Terms • Scope of practice o is a description of what a licensed person legally can and cannot do o a legal description of the distinction between licensed health care personnel and the lay public as well as among the different levels of licensed health care professionals. It describes the authority vested by a State in people who are licensed in that State. o Defined parameters of various duties or services that may be provided by a person with specific credentials. Whether regulated by rule, statute, or court decision, it represents the limits of services a person may legally perform. o Education includes all the cognitive, psychomotor, and affective learning that people have undergone throughout their lives • Certification o is an external verification of the competencies that a person has achieved and typically involves an examination process o An external verification of the competencies that a person has achieved that typically involves an examination process. • Licensure o represents legal authority granted to a person by the State to perform certain restricted activities. Scope of practice represents the legal limits of the licensed person’s performance. States have mechanisms to define the margins of what a person is legally permitted to perform. pg. 29 NREMT NCCP Paramedic Review o • • The legal authority granted to a person by the State to perform certain restricted activities. A license is generally considered a privilege and not a right. Credentialing o is a clinical determination that is the responsibility of a physician medical director. o A clinical determination that is the responsibility of a physician medical director that authorizes a practitioner to perform a skill or role. For every person, these four domains are of slightly different relative sizes. However, one concept remains constant: a person may only perform a skill or role for which that person is: • educated (has been trained to perform the skill or role), AND • certified (has demonstrated competence in the skill or role), AND • licensed (has legal authority issued by the State to perform the skill or role), AND • credentialed (has been authorized by medical director to perform the skill or role). • Standard of Care Deals with the question, “Did you do the right thing and did you do it properly?” • Act of commission or omission not in conformance with the standard of care may lead to civil liability. I. Consent/Refusal of Care A. Consent to Care 1. Nature of illness 2. Treatment recommendations 3. Risks and refusals 4. Alternatives pg. 30 NREMT NCCP Paramedic Review B. Types of Consent 1. Expressed consent – non-verbal 2. Informed consent -- research 3. Implied consent (emergency doctrine) and incapacitation a. Physical b. Mental 4. Involuntary consent a. Mental Health b. Incarceration 5. Minors a. Parental permission and In Loco Parentis emergency doctrines b. Emancipation i. Married ii. Armed Services iii. Independence – court decree 6. Medical Restraint and Use of Force Doctrine a. Reasonable prevention of harm i. Suicide ii. Homocide b. Nonpunitive 7. Legal complications related to consent a. Abandonment b. False imprisonment d. Battery C. Refusal of Care and/or Transportation 1. Patient must be alert and oriented to person, place, and time 2. Patient must be informed of the risks of refusing care (e.g., death) 3. Patient must be informed if problems return/persist they should call EMS or see a physician 4. Against medical advice a. Due diligence pg. 31 NREMT NCCP Paramedic Review i. Standard of care ii. Medical control b. Documentation II. Confidentiality A. Obligation to Protect Patient Information B. HIPAA C. Responsibility Arising From Physician – Patient Relationship 1. Assessment findings 2. Treatments rendered D. Privileged Communications 1. Need to know a. Healthcare providers 2. Education 3. Legally mandated a. Child abuse reported b. Subpoena 4. Third-party billing 5. Release of medical information E. Breach of Confidentiality 1. Libel 2. Slander III. Advanced Directives A. Patient Self-Determination Act 1. Do not resuscitate (DNR) 2. Living wills 3. Durable power of attorney IV. Tort and Criminal Actions A. Basic Legal Concepts 1. Judiciary system a. Origins of jurisprudence – common law b. Source of constitutional law pg. 32 NREMT NCCP Paramedic Review c. The legal process i. Role of courts a) Court of original jurisdiction – trial by judge or jury b) Appeals and precedents d. Elements of a Civil Lawsuit i. Actionable Cause ii. Complaint iii. Investigation – discovery a) Dispositions b) Interrogatives iv. Trial a) Decision b) Settlement v. Appeal e. Slander – defamation by spoken word f. Libel - defamation by written (literal) word B. Criminality 1. Breaches of conduct a. Assault b. Battery c. Kidnapping 2. Mandatory reporting requirements a. Abuse and assault i. Child abuse -- neglect ii. Elder abuse iii. Domestic Violence b. Criminality i. Sexual assault ii. Penetrating Trauma a) Gunshot b) Stab wounds pg. 33 NREMT NCCP Paramedic Review c. Communicable diseases i. Reportable ii. Animal Bites C. Civil Tort 1. Concept of negligence a. Res ispa loquitur b. Negligence per se 2. Elements of negligence a. Duty to act i. Contractual ii. Duty undertaken b. Breach of duty i. Standard of care ii. Commission a) Malfeasance b) Misfeasance iii. Omission-- nonfeasance iv. False imprisonment v. Wrongful death vi. Abandonment c. Proximate causation d. Damages to plaintiff i. Physical -- e.g. lost earnings ii. Psychological – e.g., pain and suffering iii. Punitive e. Defenses i. Good samaritan ii. Governmental immunity iii. Statute of limitations iv. Contributory negligence f. Protection from liability pg. 34 NREMT NCCP Paramedic Review i. Professionalism ii. Standard of care iii. Liability insurance VI. Mandatory Reporting A. Legally Compelled to Notify Authorities 1. Abuse 2. Neglect B. Arises From Special Relationship With Patient C. Legal Liability for Failure to Report VII. Health Care Regulation A. Scope of Practice B. Licensure 1. Occupational regulation 2. Practicing without a license C. Certification 1. Non-governmental D. Credentialing 1. Jurisdiction-specific 2. Medical control X. Ethical Principles/Moral Obligations A. Morals and Concepts of Right and Wrongs B. Ethics 1. Branch of philosophy 2. Study of morality 3. Industry standards C. Applied Ethics and Use of Ethical Values D. Ethical Conflicts 1. Futility of care: cardiac arrest in the wilderness 2. Allocation of limited resources (Medical Rationing) such as use of triage 3. Professional misconduct such as patient abuse 4. Economic triage such as patient-dumping pg. 35 NREMT NCCP Paramedic Review XI. Ethical Tests and Decision Making A. Do No Harm B. In Good Faith C. Patient’s Best Interest XII. Employment Law A. American With Disabilities Act B. Title VII – Civil Rights Act C. Amendments to Title VII D. Family Medical Leave Act E. Occupational Safety and Health Act F. Ryan White Act • Peripheral Nervous System 1. Cranial nerves and function a. Olfactory nerves b. Optic nerves c. Oculomotor nerves d. Trochlear nerves e. Trigeminal nerves f. Abducens nerves g. Facial nerves h. Vestibulocohlear nerves i. Glossopharyngeal nerves j. Vagus nerves k. Accessory nerves l. Hypoglossal nerves • Medications to know I. Specific Medications A. Activated Charcoal B. Adenosine C. Albuterol D. Amiodarone pg. 36 NREMT NCCP Paramedic Review E. Amyl Nitrite F. Aspirin G. Atropine H. Dextrose (50%, 25%, 10%) I. Diazepam J. Diltiazem K. Diphenhydramine HCl L. Dopamine M. Epinephrine N. Fentanyl O. Glucagon P. Glucose Q. Intravenous Fluids 1. Dextrose 5% in Water 2. Normal Saline 3. Lactated Ringer’s R. Ipratropium S. Lidocaine T. Lorazepam U. Magnesium V. Midazolam W. Morphine X. Naloxone Y. Nitroglycerin 1. Paste 2. Spray 3. Tablets Z. Nitrous Oxide AA. Oxygen BB. Oxytocin CC. Promethazine HCl pg. 37 NREMT NCCP Paramedic Review DD. Thiamine pg. 38