Paramedic NREMT Study Guide PDF

Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 1 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide....

Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 1 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. About the Authors Adam Peddicord Co-Founder, Pass with PASS, LLC Adam has been a Paramedic since 1998 and started his fire service career in 1993. He is currently the EMS Coordinator and a Captain/Paramedic at Newport (KY) Fire/EMS Department where he also serves as the Medical Commander of the Newport Police Department SWAT Team. He holds multiples Associate’s Degrees along with a Bachelor’s and Master’s Degree in Nursing and is a board-certified Family Nurse Practitioner. As a Nurse Practitioner, Adam has experience in orthopedics and addiction medicine. Adam has over 20 years of experience in EMS education through the University of Cincinnati and Gateway Community and Technical College. Brandon Schoborg Co-Founder, Pass with PASS, LLC Brandon is currently the EMS Education Manager of a hospital and college based EMT/Paramedic Program in Kentucky. Previously, he was the EMS Education Manager for the Columbus (OH) Division of Fire, Director of EMS Education at Cleveland Clinic Akron General, Assistant Paramedic Program Coordinator at a community college in Kentucky and the Assistant EMS Coordinator, Engineer/Paramedic, and SWAT Paramedic with the Newport Fire/EMS Department in Kentucky for 8 years. He began his teaching career at the University of Cincinnati Clermont College. He completed his paramedic education at the University of Cincinnati in 2010. Brandon has an Associate’s Degree in EMSParamedic, Bachelor’s Degree in Health Science, and a MBA in Healthcare Management. Copyright 2021 - Pass with PASS, LLC 2 2 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Disclaimer All procedures listed in the study guide should only be performed by appropriately licensed/certified, authorized, and trained personnel as your local government, state, or country allow. Medication dosages may differ across the country, any medication dosages in the study guide are relatively standardized, however, we encourage you to check your local protocol and/or program’s preferred dosages. Copyright © 2021 by Pass with PASS, LLC. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Pass with PASS, LLC. Although we make every effort to ensure that the material contained within the study guide is current and accurate, we cannot guarantee accuracy. However, please know, that accurate and current study guides is extremely important to us and we continuously review our guides for quality assurance. Copyright 2021 - Pass with PASS, LLC 3 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Table of Contents 1. The NREMT Exam 5 2. Medical Terminology 7 3. Respiratory & Airway 19 4. Cardiology 47 5. Neurology 79 6. Toxicology and Pharmacology 93 7. Trauma 105 8. Medical 122 9. Special Populations 149 10. EMS Operations 153 Final Steps 163 Copyright 2021 - Pass with PASS, LLC 4 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 1 THE NREMT EXAM Copyright 2021 - Pass with PASS, LLC 5 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 1: The NREMT Exam The NREMT Exam The National Registry examinations are broken into two segments: the cognitive exam (“the written”) and the psychomotor exam (“hands-on”). The cognitive exam is computer based and is adaptive, meaning that the exam will tailor it’s questions based on your performance and the level of difficulty of each question. Once the exam is 95% confident that you have reached the level of competency or is 95% confident that you cannot reach competency, the exam will stop (as long as you have answered the minimum amount of questions, 80, or have not exceeded the total time allowed, 2 hours and 30 minutes). This study guide will primarily focus on the cognitive examination. • Pilot Questions: 20 questions that are not factored into the student’s performance. • Calculator: An onscreen calculator is available during testing. You are not permitted to bring your own calculator. • Pediatrics: 15% of the questions in each of the five categories are pediatric based questions. Psychomotor Exam Check out our 1-hour Psychomotor Exam Review Lecture on our website! Topic Area Percentage of Questions Airway, Respiration, & Ventilation 18 – 22% Cardiology & Resuscitation 22 – 26% Trauma 13 – 17% Medical/OB-GYN 25 – 29% EMS Operations 10 – 14% Copyright 2021 - Pass with PASS, LLC 6 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 2 Medical Terminology Copyright 2021 - Pass with PASS, LLC 7 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology Medical Terminology Do not underestimate the power of medical terminology! A good understanding and working knowledge of medical terminology will often be a lifeline on the NREMT exam. Most often, signs and symptoms will not be described using “common language”, rather it will be described using medical terminology. For example… “You are dispatched to a 13 year old male who is dyspneic. Upon your arrival, you find the patient in the tripod position, gasping for air. As your EMT partner applies oxygen via non-rebreather mask, you auscultate lung sounds and hear bilateral expiratory wheezes. As you expose the patient, you observe urticaria on the patient’s neck, chest, and back. What is your primary impression of this patient?” A. Asthma B. Croup C. Anaphylaxis D. Epiglottitis That was a pretty simple and straightforward question, but notice that medical terminology was used at almost every opportunity…”dyspneic, auscultate, bilateral, urticaria.” If you did not know that “dyspneic” = short of breath, “auscultate” = to listen, “bilateral” = both sides, and “urticaria” = hives, this question could have been a lot more difficult to understand and ultimately come up with the correct answer. By the way, it was “C – Anaphylaxis” We know that medical terminology isn’t the most invigorating thing to put your time and energy into, but believe us, studying medical terminology thoroughly will payoff on test day. Now, let’s get to it! Copyright 2021 - Pass with PASS, LLC 8 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology A Aerobic: the presence of air or oxygen. Agonist: to enhance an expected response. Anaerobic: the absence of air or oxygen. Aniscoria: a condition characterized by unequal pupil size. Antagonist: to inhibit or counteract the effects of other drugs or undesired effects. Anion: an ion with a negative charge. Aphasia: inability or difficulty in speaking. Apnea: the cessation of spontaneous respirations. Ascites: abnormal accumulation of fluid in the abdomen. Ataxia: failure of muscle coordination. Atrophy: shrinkage of a cell or muscle. Aura: sensation (may be visual, smell, taste, etc.) that may precede a migraine or seizure. B Benign: nonmalignant, often not problematic. Bile: secreted by the liver, stored in gallbladder. Blebs: collection of air between the lung and visceral pleura that can result in spontaneous pneumothorax. Bruit: an abnormal sound or murmur due to a narrowing of the vessel. Bursa: a sac containing synovial fluid that helps ease friction between tendons and bone. Copyright 2021 - Pass with PASS, LLC 9 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology C Carcinogens: cancer-causing agents. Cartilage: smooth and firm connective tissue. Cation: an ion with a positive charge. Cell: basic unit of life. Cerumen: ear wax found in external ear canal. Chyme: mass of partially digested food passed from stomach to the duodenum. Cilia: small, hair-like structures. Coma: deep state of unconsciousness, unarousable. Confabulation: made up stories to fill in gaps of lost memory. Congenital: present at birth. Contrecoup: occurs at a site opposite of the side of impact. Crepitus: a grating sound or sensation often caused by bone on bone rubbing, or with inflammation in joints. D Dehydration: an excessive loss of water or fluids from the body. Demarcation: line or visible mark between living and necrotic tissues. Dendrites: found at the end of neurons, allows propagation of message towards cell body. Dentalgia: is a toothache. Dermatomes: specific area that is supplied by a single spinal nerve. Dysarthria: poor articulation of speech. Often due to affected muscles used in speaking. Dyskinesia: disorder related to involuntary muscle movements. Dysplasia: abnormal growth of a cell. Dysphagia: difficulty in swallowing. Dysuria: difficult or painful urination. Copyright 2021 - Pass with PASS, LLC 10 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology E Edema: excess fluid in the interstitial spaces. Epidemic: a widespread occurrence of an infectious disease in a community at a particular time. Erythrocytes: red blood cells. F Facilitated diffusion: a carrier-mediated process moving substances from areas of high concentration to low concentration. Fascia: connective tissue that surrounds or separates muscles. Fecalith: fecal impaction in the colon. Fibrinogen: blood protein used in clotting cascade. Frailty: characterized by exhaustion, slowed performance, weakness, weight loss, low physical activity, often seen in the elderly. G Gait: walking or moving on foot. Ganglia: a group of nerve cell bodies in the peripheral nervous system. Gestation: period from fertilization of ovum to birth of fetus. Globulins: simple proteins classified by their size, mobility, and solution. Glomerulus: mass of capillaries found at the beginning of each nephron. Copyright 2021 - Pass with PASS, LLC 11 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology H Hematuria: blood in the urine. Hemiparesis: one-sided weakness; often seen in those with CVA’s. Hemolysis: breakdown of red blood cells. Hemophilia: hereditary bleeding disorders due to missing factors for proper blood coagulation. Hemoptysis: coughing up blood. Host: an animal or human with exposure to an infectious agent. Hydrocele: a fluid-filled sac along the spermatic cord. Hymen: a mucous membrane covering the vaginal outlet. Hyperemia: increased blood flow to an organ. Hyperopia: distant vision is clear, but near vision is often blurry (farsightedness). Hyperplasia: excessive increase in the number of cells. I Idiopathic: unknown cause. Idiosyncrasy: an abnormal response to a drug. Incontinence: inability to control bowel or bladder function. Infarction: death of tissue from lack of oxygen. Inferior: down/bottom, toward the feet. Infiltration: how fluids pass into tissues. Copyright 2021 - Pass with PASS, LLC 12 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology J Jejunum: part of the small intestine. Joule: measurement of electrical energy. K Keloid: excessive scar tissue that goes beyond the original border. Kyphosis: abnormal curvature of the spine, increased convexity as viewed laterally. L Lactate: found in cells during metabolism, byproduct of lactic acid. Laryngitis: inflammation of the larynx. Lobules: small lobes. Luxation: a complete dislocation. M Malaise: general weakness. Malignant: cancerous, has ability to metastasize or spread. Mania: a mood disorder characterized by hyperactivity, agitation, excitement and occasional violent and selfdestructive behavior. Melena: black, tarry stools containing digested blood. Metastasis: movement or spreading of cancer cells from location to another. Myalgia: muscle pain. Copyright 2021 - Pass with PASS, LLC 13 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology N Necrosis: death of a cell or a group of cells as the result of disease, ischemia, or injury. Neoplasia: new and abnormal growth that may be malignant or benign. Nephron: the structural and functional unit of the kidney. Nocturia: excessive urination at night. Nucleus: controlling body of a cell. Nystagmus: involuntary jerking actions of the eyes. O Oliguria: diminished ability to create or pass urine. Orchitis: inflammation of the testicle that may be painful. Osmolality: osmotic pressure of a solution. Osmosis: the diffusion of solvent (water) through a membrane from a less concentrated solution to a more concentrated solution. Ostomy: a surgical opening that creates a hole from the inside of the body to the outside. Ovum: a female egg or egg cell. P Parenteral: any medication route other than the oral route. Paresthesia: sensation of numbness tingling or “pins and needles.” Pathogen: a cause of a disease. Phobia: anxiety disorder characterized by an obsessive, irrational, and intense fear of a specific object or activity. Photophobia: a sensitivity to light that is abnormal. Plasma: the fluid part of blood. Copyright 2021 - Pass with PASS, LLC 14 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology P (cont.) Platelets: fragments of cells that are responsible for initiating the clotting process. Poikilothermia: inability to regulate the body temperature in comparison to the ambient temperature. Polycythemia: unusually large number of red blood cells in the blood as a result of their increased production by the bone marrow. Often caused by COPD and/or right ventricular failure/enlargement. Polyuria: excessive urination. Priapism: a painful and persistent erection. Pulsus paradoxus: abnormal decrease in systolic blood pressure (10-15mmHg) during inspiration. Q Quadriplegia: weakness or paralysis of all four extremities and the trunk. Often occurs after a high-level cervical spine fracture. R Referred pain: pain felt at a site away from its origin. Renin: enzyme secreted by the kidneys that is involved in the release of angiotensin; plays an important role in maintenance of blood pressure. Rhinitis: inflammation of the mucous membranes of the nose. Rhonchi: abnormal, course, rattling respiratory sounds, usually caused by secretions in the bronchial airways or muscular spasm/constriction. Copyright 2021 - Pass with PASS, LLC 15 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology S Sciatica: pain that radiates along the path of the sciatic nerve. Sclera: the white outer layer of the eyeball. Slander: false statements about a person. Solutes: the minor component in a solution that is dissolved in solution. Stridor: high-pitched musical sound caused by an obstruction in the trachea or larynx. Stroke volume: volume (amount in milliliters) of blood ejected from one ventricle in a single heartbeat. Normal range is 60 – 100 with average being 70mL. Subluxation: a partial dislocation. Surfactant: substance that reduces the surface tension of the pulmonary fluids. Synapse: junction between two nerve cells. Most often referred to with regards to sympathetic (norepinephrine) and parasympathetic nervous systems (acetylcholine). Synergism: the combined action of two agents is greater than the action of the agents independently. T Tendons: bands of connective tissue that connect muscle to bone. Tetany: involuntary contraction of skeletal muscles. Tetraplegia: weakness or paralysis of all four extremities and the trunk (another term for quadriplegia). Tidal volume: volume (or amount) of air inspired or expired in a single breath. Tort: personal harm or injury caused by civil versus criminal wrongs. Trismus: limited jaw range of motion commonly caused by muscle spasms of the jaw. Can be primary symptom in tetanus. Copyright 2021 - Pass with PASS, LLC 16 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology U Untoward effects: side effects that prove harmful to the patient. Urea: a nitrogen containing waste product. Uremia: excess of urea and other nitrogen based wastes in the blood. Urticaria: hives. V Ventilation: mechanical movement of air into and out of the lungs. Vesicants: an agent that causes blistering. Virulence: the harmfulness of a disease or poison. Viscosity: the degree of friction between liquid molecules. Volvulus: twisting of the intestines. W Wheals: small areas of swelling that result from an allergic reaction. Similar to hives (urticaria). X Xiphoid process: smallest of three parts of the sternum. Articulates caudally with the body of the sternum and laterally with the seventh rib. Can fracture with inappropriate hand placement during CPR. Copyright 2021 - Pass with PASS, LLC 17 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 2: Medical Terminology Z Zone of coagulation: central area of a burn wound that has sustained the most intense contact with the thermal source. Zone of hyperemia: area in which blood flow is increased as a result of the normal inflammatory response to injury in a burn. Zone of stasis: area of burn tissue that surrounds the critically injured area from a burn. Zygote: a fertilized ovum (egg). Copyright 2021 - Pass with PASS, LLC 18 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 3 Respiratory & Airway Copyright 2021 - Pass with PASS, LLC 19 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Key Terms Air In Ventilation: The process of air movement into and out of the lungs Perfusion: The circulation of blood through the lung tissues (alveoli) Air Out Blood transition through capillary membrane O2 In CO2 Out Diffusion: The process of gas exchange (carbon dioxide and oxygen) Copyright 2021 - Pass with PASS, LLC 20 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Respiratory Anatomy Nasopharynx Oropharynx Trachea Respiratory center is housed in the brainstem, more specifically the medulla oblongata Bronchi Lungs Epiglottis Vocal Cords Glottic Opening Copyright 2021 - Pass with PASS, LLC 21 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Lung Sounds Crackles (rales): fine, bubbling sound heard on auscultation of the lung. Produced by air entering the distal airways and alveoli that contain serous secretions. Rhonchi: abnormal, coarse, rattling respiratory sounds, usually caused by secretions in the bronchial airways. Stridor: abnormal, high-pitched, musical sound caused by an upper airway obstruction (subglottic). Wheezing: form of rhonchi, characterized by a high pitched, musical quality. Produced in the lower airways (bronchioles). Stridor Rhonchi (upper airway/subglottic inspiratory) (expiratory wheezing) Rales (inspiratory/expiratory) Wheezes (expiratory) Crackles (end-inspiratory) Copyright 2021 - Pass with PASS, LLC 22 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Respiratory Patterns Eupnea: normal respirations Tachypnea: increased (fast) respirations Bradypnea: decreased (slow) respirations Apnea: no respirations (not breathing) Cheyne Stokes: abnormal respirations with regular, periodic breathing with intervals of apnea and a crescendo-decrescendo pattern of respirations. Biot’s: abnormal respirations characterized by regular deep inspirations followed by regular or irregular periods of apnea. Apneustic: abnormal rapid respirations associated with deep, gasping inspirations – most often associated with stroke or trauma. Kussmaul’s: rapid and deep respirations – most often associated with diabetic ketoacidosis (DKA) as a compensatory mechanism in an attempt to correct the body’s metabolic acidosis Copyright 2021 - Pass with PASS, LLC 23 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Airway Adjuncts & Devices OROPHARYNGEAL AIRWAY Used on patients without gag reflex, moves tongue forward as it curves back to pharynx Measured from center of mouth to angle of jaw Insert device along roof of mouth, rotate 180 degrees to sit anatomically (can insert in “normal” position in pediatrics) NASOPHARYNGEAL AIRWAY Used in patients with intact gag reflex, moves tongue and soft tissue forward to provide channel for air. Measured from patient’s nostril to the tip of the earlobe or to the angle of the jaw Bevel always goes towards the nasal septum NASAL CANNULA Liters/Minute: 1 – 6 Oxygen Concentration: 24 – 44% NEBULIZER Nebulized albuterol, ipratropium, and epinephrine Liters/Minute: 4 – 6 (hand-held); 6 – 8 (mask) NON-REBREATHER MASK Liters/Minute: 12 – 15 Oxygen Concentration: 80 – 100% Copyright 2021 - Pass with PASS, LLC 24 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Airway Adjuncts & Devices BAG VALVE MASK Liters/Minute: at least 15 Use two rescuers when possible to deliver ventilations Deliver breath over 1 second of time, allow for adequate exhalation Squeeze bag until you see chest rise, release bag Average tidal volume in adult patient is 500mL Average dead space in adult patient is 150mL 12 breaths per minute in adults 20 breaths per minute in pediatrics CPAP (CONTINUOUS POSITIVE AIRWAY PRESSURE) Tight fitting mask, not a leak tolerant system Centimeters of water pressure (cmH2O): 4 – 20 Most protocols do not exceed 10cmH2O Indications for CPAP: F: Flail Chest N: Near Drowning C: COPD “Go get the F’n CPAP!” P: Pulmonary Edema, Pulmonary Embolism A: Asthma, ARDS P: Pneumonia Typically not used in pediatrics (< 12 years of age), however, pediatric CPAP is gaining traction in prehospital setting. In pediatric CPAP, all settings are the same, it’s simply a smaller mask. Copyright 2021 - Pass with PASS, LLC 25 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Supraglottic Airways LARYNGEAL MASK AIRWAY Sizes 1 – 5 Inserted through mouth into pharynx Advanced until resistance is felt as end of tube “seats” in the hypopharynx Black line marked on LMA should rest midline against patient’s upper lip Confirm placement through traditional methods i-GEL Non-inflatable cuff Designed to rest over the larynx Insertion is same as LMA, but without inflation Takes less than 5 seconds to insert, faster than LMA KING LT-D AIRWAY Similar to i-gel and LMA Single tube with two cuffs, that is placed into the esophagus, large balloon is inflated in the esophagus Holes between the two cuffs allow for ventilations to be delivered near the glottis Copyright 2021 - Pass with PASS, LLC 26 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Intubation MILLER BLADE Straight blade, sizes 1 – 4 Tip of blade is applied directly to the epiglottis to expose vocal cords Typically recommends for infant intubation → provides greater displacement of the tongue May be better for anterior airways MACINTOSH BLADE Curved blade, sizes 1 – 4 Tip of blade is inserted into the vallecula → displaces tongue to the left to lift the epiglottis without touching it My reduce chance of dental trauma STYLET May be inserted through ET tube before intubation, adds rigidity and shape to tube Must be recessed 1 - 2” into the tube, should not pass the “Murphy’s Eye” BOUGIE 60 – 70cm in length Can be used in place of stylet, performs very well in difficult and anterior airways Patient can be “intubated” with the bougie, then ET tube is slid over bougie into the airway (remove bougie after tube is in place) Copyright 2021 - Pass with PASS, LLC 27 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Intubation ENDOTRACHEAL TUBE Sizes: 0.5 – 10 Average Adult Male: 7.5 Average Adult Female: 7 Direct placement through glottis opening into trachea Confirm placement with traditional methods – capnography is the gold standard! ENDOTROL Same sizes as endotracheal tubes, performs same way as endotracheal tube Often used for nasotracheal intubation due to ring at top of tube that allows for distal manipulation/movement of the tube BAAM DEVICE Placed on end of endotracheal tube (or Endotrol) to help identify proximity of glottis opening and when patient is inhaling/exhaling during nasotracheal intubation. Device will produce loud whistling noise. Glottis is largest during inspiration, which is when tube should be advanced into glottic opening. Things to Remember Nasotracheal intubation can only occur in the patient with respirations “DOPE” (diagnosing tube problems) Displacement or dislodgement Obstruction Pediatric Tube Size Formula: (16 + age*) / 4 *age in years Copyright 2021 - Pass with PASS, LLC Pneumothorax Equipment failure 28 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Arterial Blood Gases One of the most fierce enemies of the paramedic student, arterial blood gases. ABGs are the often argued, “Why does this apply to me as a paramedic student…I’m not drawing blood gases in the prehospital setting!?” You’re right, most paramedics are not drawing blood gases in the prehospital setting, but ABGs aren’t going anywhere soon…so as the phrase goes, “If you can’t beat em’, join em’!” When approaching ABG interpretation, try to keep things in their simplest form (I know, simple and ABGs seem like oxymoron's). But seriously, when making an ABG interpretation, you are looking at three values (pH, CO2, HCO3) to determine what is happening with the pH - is it low (acidic), normal, or high (alkalotic) and then determine if the CO2 or the HCO3 correlates with the pH. The most critical step in ABG interpretation is knowing what values are considered normal. pH: 7. 35 – 7.45 Carbon Dioxide, CO2: 35 – 45 Bicarb, HCO3: 22 – 26 Copyright 2021 - Pass with PASS, LLC 29 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Arterial Blood Gases A mnemonic often discussed with ABGs is ROME: “Respiratory Opposite, Metabolic Equal” ROME refers to the directions that the pH and CO2 or HCO3 move in correlation with one another. Respiratory Opposite In respiratory-caused conditions, when the pH decreases (< 7.35, acidic) the CO2 increases (> 45, acidosis). Conversely, when the pH increases (> 7.45, alkalosis) the CO2 decreases (< 35, alkalosis) Metabolic Equal In metabolic-caused conditions, when the pH decreases (< 7.35, acidic) the HCO3 decreases (< 22, acidosis). Conversely, when the pH increases (> 7.45, alkalosis) the HCO3 increases (> 26, alkalosis) Copyright 2021 - Pass with PASS, LLC 30 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Arterial Blood Gases Respiratory Acidosis: Hypoventilation (retaining too much CO2) Treatment: increase ventilatory rate Respiratory Alkalosis: Hyperventilation (blowing off too much CO2) Treatment: decrease ventilatory rate Metabolic Acidosis: Build up of lactic acid – lactic acidosis, diabetic ketoacidosis, renal failure, sepsis, toxic ingestion Treatment: controlling respiratory rate, IV fluids, sodium bicarbonate Metabolic Alkalosis: Rare, loss of hydrogen ions (vomiting or gastric suction) – consumption of large amounts of baking soda or antacids Treatment: correct underlying condition EXAMPLE pH 7.28 CO2: 54 HCO3: 24 What is the pH doing? It’s below 7.35 therefore it’s acidic. Now, which of the other values are also acidic? CO2! A normal CO2 is 35 – 45, the given value is 54 which is higher than normal and is acidic. The HCO3 is within a normal range. Interpretation: Respiratory Acidosis Believe it or not, as paramedic students, we cover ABGs on a surface level – there is much more to ABG interpretation, but a basic understanding of interpretation and the most common causes of abnormalities is what we are most concerned with! Copyright 2021 - Pass with PASS, LLC 31 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Capnography Hear us when we say, “Capnography is the GOLD standard in endotracheal tube intubation and confirmation!” Capnography is an AHA Class I recommendation for cardiac arrest patients – essentially meaning that there is no patient risk and all benefits. We’ve already discussed normal values of carbon dioxide (CO2) so, let’s jump right into the actual capnography waveform (or “capnogram”). CO2 Phase 1: The respiratory baseline. It is flat when no CO2 is present and corresponds to the late phase of inspiration and the early part of expiration. Phase 2: The respiratory upstroke. This represents exhalation of a mixture of dead-space gases and alveolar gases from alveoli with the shortest transport time. Phase 3: The respiratory plateau. It reflects the airflow through uniformly ventilated alveoli with a nearly constant CO2 level. The highest level of the plateau is called the “ETCO2” and is recorded as such by the capnometer. Phase 4: The inspiratory phase. It is a sudden down stroke and ultimately returns to the baseline during inspiration. The respiratory pause restarts the cycle. Copyright 2021 - Pass with PASS, LLC 32 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Capnography Waveforms NORMAL Square box waveform ETCO2 = 35 – 45mmHg DISLODGED ENDOTRACHEAL TUBE (ETT) Loss of waveform Loss of ETCO2 reading Management: Replace ETT ESOPHAGEAL INTUBATION (OR APNEA) Absence of waveform Absence of ETCO2 reading Management: Ventilate or intubate Copyright 2021 - Pass with PASS, LLC 33 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Capnography Waveforms CPR Square box waveform ETCO2 = 10 – 15mmHg Management: Change rescuers if ETCO2 falls below 10mmHg OBSTRUCTIVE AIRWAY “Shark fin” waveform With or without prolonged expiratory phase Can be seen before actual “attack” or “exacerbation” Bronchospasm → asthma, COPD, anaphylaxis, FBAO Management: Bronchodilators & treat underlying cause (albuterol, atrovent, racemic epinephrine, epinephrine) ROSC During CPR, sudden increase of ETCO2 above 10 – 15mmHg Management: Check femoral or carotid pulse Copyright 2021 - Pass with PASS, LLC 34 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Capnography Waveforms RISING BASELINE Patient is rebreathing CO2 Management: Check equipment for adequate oxygen flow, allow more time for exhalation, ensure cuff has good seal HYPOVENTILATION Prolonged waveform ECTO2 > 45mmHg Management: Assist ventilations, increase respiratory/ventilatory rate HYPERVENTILATION Shortened waveform ECTO2 < 35mmHg Management: Slow respirations/ventilatory rate Consider other causes: DKA, sepsis, TCA overdose, methanol ingestion Copyright 2021 - Pass with PASS, LLC 35 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Capnography Waveforms BREATHING AROUND ETT Angled, sloping down stroke on waveform Ruptured cuff or ETT too small Management: Check cuff and tube size, possible re-intubation CURARE CLEFT Neuromuscular blockade is wearing off Patient takes small breath that causes the cleft Management: Consider re-administration of neuromuscular blockade medication Copyright 2021 - Pass with PASS, LLC 36 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Respiratory Emergencies COPD Asthma Pneumonia ARDS Pulmonary Embolism Hyperventilation Syndrome Pneumothorax Acute Mountain Sickness High Altitude Pulmonary Edema Copyright 2021 - Pass with PASS, LLC 37 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway COPD Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term that covers both chronic bronchitis and emphysema. You may have found that asthma is at times classified under the COPD umbrella, but many argue because it is fully reversible, it is not considered COPD. For us, we will just leave it at chronic bronchitis and emphysema. MANAGEMENT Oxygen and bronchodilators DuoNeb: Albuterol: 2.5mg in 3mL / Ipratropium: .5mg Consider steroids for inflammation Consider CPAP Copyright 2021 - Pass with PASS, LLC 38 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Asthma Asthma is two-pronged issue: bronchoconstriction and inflammation. Prehospital treatment is aimed at bronchodilation (albuterol) and reducing inflammation (steroids). In severe cases, epinephrine is considered for additional bronchodilatory effects along with nebulized magnesium sulfate to act as smooth muscle relaxer. MANAGEMENT Oxygen and bronchodilators DuoNeb: Albuterol: 2.5mg in 3mL / Ipratropium: .5mg Nebulized Magnesium Sulfate Consider steroids for inflammation IV fluids Epinephrine IM Consider CPAP Copyright 2021 - Pass with PASS, LLC 39 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Pneumonia & ARDS Copyright 2021 - Pass with PASS, LLC 40 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Pulmonary Embolism Rapid onset of difficulty breathing and chest pain – especially high suspicion in the patient without a significant cardiac or respiratory history. COMMON PATIENTS Bedridden (chronically or after surgery) Long flights History of deep vein thrombosis (DVT) Female patient (teens – 40’s) on birth control (birth control produces increased levels of estrogen and progesterone which have been proven to increase blood clots) History of smoking SIGNS & SYMPTOMS Rapid onset of dyspnea Cough Pain Anxiety Hypertension Tachypnea Tachycardia Crackles, wheezes, rhonchi TREATMENT Identification and Rapid Transport! Additional EKG Findings (higher level – not necessarily entry-level) Right Axis Deviation S1 Q3 T3 S-wave in lead I, Q-wave in lead III, inverted T-wave in lead III Obstructive Shock PE will develop into Obstructive Shock Once patient has entered shock state, administer 20mL/kg fluid boluses, repeating as needed to support BP Copyright 2021 - Pass with PASS, LLC 41 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Hyperventilation Syndrome CALM DOWN! But seriously…try to coach your patient to calm down. Hyperventilation syndrome is often produced by an anxiety or panic attack. Try to move them to a quiet, calm, and controlled environment and coach them to slow down their breathing (apply oxygen if needed). Remember, hyperventilation will cause too much CO2 to be eliminated, so put the patient on capnography and monitor their CO2. OTHER POTENTIAL CAUSES Hypoxia Cardiac or pulmonary disease Infection/fever Pain Pregnancy Drug use SIGNS AND SYMPTOMS Dyspnea Tachypnea Chest pain Carpopedal spasms Copyright 2021 - Pass with PASS, LLC 42 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Pneumothorax Copyright 2021 - Pass with PASS, LLC 43 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway High Altitude Emergencies Copyright 2021 - Pass with PASS, LLC 44 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 3: Respiratory & Airway Review Questions 1. In the adult patient, the average tidal volume is: _________mL. 2. Most commonly, the maximum cmH2O we should administer through CPAP is: ______cmH2O. 3. When using the Miller blade, the tip of the blade is applied directly to the ________ to expose the cords. 4. When using the Macintosh blade, the tip of the blade is inserted into the: 5. True or False: When nasotracheally intubating a patient, he or she must be breathing. 6. Which mnemonic should be used to assist in diagnosing endotracheal tube problems? 7. A normal ETCO2 level is: ____ to ____. 8. When the pH falls below 7.35, it is considered to be: 9. The normal HCO3 (or bicarbonate) range is: ____ to ____. 10. What is considered to be the “gold standard” in confirming endotracheal tube placement? 11. This type of patient, is commonly referred to as a “pink puffer” due to polycythemia. He or she can also experience clubbing of the fingers, a non-productive cough, and a barrel-chest appearance. 12. This type of patient is chronically hypoxic and therefore experience chronic cyanosis. Additionally, he or she has a productive cough and is typically overweight. 13. In the pneumonia patient, you would typically expect to find a fever and unilateral / bilateral (circle one) diminished breath sounds. 14. If left untreated, a pulmonary embolism will develop into _______________ shock. 15. Which characteristic type of capnography waveform is seen during an asthma attack or COPD exacerbation? 16. How much anatomical dead space is typically found in the adult patient? 17. The oxygen concentration from a nasal cannula is: ____ to ____%. 18. What is the medical term for cramping of the fingers (as seen in hyperventilation syndrome)? Copyright 2021 - Pass with PASS, LLC 45 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Want more Respiratory & Airway review? Check out our Paramedic Respiratory & Airway Study Guide or our Respiratory & Airway Review Lecture for more in-depth information! www.passwithpass.com Copyright 2021 - Pass with PASS, LLC 46 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. 4 Cardiology Copyright 2021 - Pass with PASS, LLC 47 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Cardiac Anatomy VALVE ANATOMY Chordae Tendineae Papillary Muscle Right Atrium Left Atrium Pulmonic Valve Mitral Valve Tricuspid Valve Aortic Valve Right Ventricle Left Ventricle VALVE ORDER THREE LAYERS OF HEART MUSCLE “Toilet Paper My A..” Endocardium: Innermost layer Myocardium: Middle layer Pericardium or Epicardium: Outer layer “Peri”/”epi” mean “around” or “on top of” Copyright 2021 - Pass with PASS, LLC 48 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Cardiac Conduction INTRINSIC RATES Sinoatrial (SA) Node: 60 – 100 Atrioventricular (AV) Node: 40 – 60 Purkinjes: 15 – 40 Copyright 2021 - Pass with PASS, LLC 49 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Cardiac Emergencies Stable Angina Unstable Angina Variant Angina Left Sided Heart Failure Right Sided Heart Failure Cardiac Tamponade Myocardial Infarction Copyright 2021 - Pass with PASS, LLC 50 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Angina Angina is the term for “pain in the chest”. It occurs when the heart’s demand for oxygen exceeds the blood’s oxygen supply. It’s commonly caused by atherosclerosis and coronary artery disease (CAD). It may also results from a spasm of the coronary arteries (Variant Angina). There are three types of angina and they are primarily categorized by their cause and duration: MANAGEMENT Relieve anxiety/pain Place patient in a position of comfort Administer oxygen Establish IV access Obtain a 12 lead EKG Consider medication administration (MONA) Oxygen Aspirin Nitroglycerin Morphine (or Fentanyl) Copyright 2021 - Pass with PASS, LLC 51 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Heart Failure Primarily, we are concerned with two types of heart failure: left-sided and right-sided. Knowing the differences between the causes, signs and symptoms, and treatments are critical to your success on the NREMT! CAUSES OF RIGHT & LEFT HEART FAILURE Right Heart Failure Left Heart Failure Left Heart Failure (#1 cause) Cor Pulmonale (right ventricular hypertrophy) Right Ventricular Infarct Tricuspid Valve Damage Pulmonic Valve Damage Pulmonary Embolism Pulmonary Edema Hypertension Left Ventricle Infarct Mitral Valve Damage Aortic Valve Damage Cardiomyopathy Myocardial Infarction (#1 cause) SIGNS & SYMPTOMS OF RIGHT & LEFT HEART FAILURE Right Heart Failure Left Heart Failure JVD Peripheral Edema Ascites (abdominal swelling) Sacral/Scrotal Edema Orthopnea Hepato-Jugular Reflex Anxiety Tachycardia Hypertension Pale, Sweaty Skin Paroxysmal Nocturnal Dyspnea Orthopnea Rales/Crackles Pink Frothy Sputum (late sign) Pulsus Paradoxus Pulsus Alternans Copyright 2021 - Pass with PASS, LLC 52 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Heart Failure Primarily, we are concerned with two types of heart failure: left-sided and right-sided. Knowing the differences between the causes, signs and symptoms, and treatments are critical to your success on the NREMT! TREATMENT OF RIGHT & LEFT HEART FAILURE Right Heart Failure Left Heart Failure Position of Comfort Oxygen 12 Lead EKG Fluid administration (Starling’s Law) **Always monitor lung sounds and abdomen with fluid administration“** Position of Comfort Oxygen 12 Lead EKG Nitroglycerin CPAP Furosemide Copyright 2021 - Pass with PASS, LLC 53 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Cardiac Tamponade A cardiac tamponade often occurs due to blunt trauma (think steering wheel to the chest). Tamponade carries a heavy mortality rate but before we jump into mortality, let’s review what happens in tamponade… The heart is surrounded by a sac, called the pericardial sac. This sac has three layers (or linings). The innermost lining is the visceral pericardium (visceral to the vasculature!), then the parietal pericardium, then the fibrous pericardium. In between the visceral pericardium and parietal pericardium is 25mL of pericardial fluid. Beck’s Triad When a tamponade occurs, there is an excess accumulation of fluid that builds up in the pericardial sac. Because the sac is tough (think leather) it does not expand well with this excess fluid – this excess fluid and lack of expansion puts more pressure on the heart which prevents it from filling and pumping like it needs to. This causes cardiogenic or obstructive shock (EMS Standards Key Signs & Symptoms recognize Tamponade as both forms of shock). Tamponade can be caused by trauma, an MI, pericarditis, or neoplasms. Hypotension MANAGEMENT OTHER SIGNS & SYMPTOMS ABCs Oxygen IV Access Fluid Bolus (20mL/kg) Vasopressor Chest Pain, Dyspnea, Orthopnea, Narrowing Pulse Pressure, Electrical Alternans, Pulsus Paradoxus, Altered LOC Copyright 2021 - Pass with PASS, LLC 54 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Cardiogenic Shock CAUSES Impaired myocardial contractility (MI) Impaired ventricular emptying (left-sided heart failure) Tension pneumothorax Cardiac tamponade Trauma (cardiac contusion) SIGNS AND SYMPTOMS Systolic BP < 80mmHg Respiratory distress Chest pain Weakness Altered mental status Hypotension Tachycardia MANAGEMENT Rapid transport Position of comfort Oxygen Identify and treat underlying problems IV access/fluid administration* Consider medications: positive inotropes/vasopressors FLUID ADMINISTRATION Listen to lung sounds first! If dry: give fluids, 100 – 200mL boluses, (Starling’s Law) If wet: do not give fluids Copyright 2021 - Pass with PASS, LLC 55 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Dissecting Aortic Aneurysms Most common aortic catastrophe: affects three times as many people as “AAA” SIGNS AND SYMPTOMS Syncope Absent or reduced pulses Unequal blood pressure readings (right side vs. left side) Unequal pulse strength (right side vs. left side) Heart failure “Tearing” sensation in chest or back (this is a big one!) Flank pain Scapular pain Pain radiating into legs MANAGEMENT Rapid transport to hospital with emergency surgery capabilities Copyright 2021 - Pass with PASS, LLC 56 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology 12 Lead EKG Interpretation To be successful on the NREMT, you must not only know how to interpret a 12 lead EKG you must also know which vessels are likely occlude to cause the STEMI that you are interpreting. Be prepared to not only identify the 12 lead EKG (“Anterior Wall MI”) but also to identify which vessel would be occluded to cause this (“Left Anterior Descending Artery”). Lateral Leads: I, aVL, V5, V6 Inferior Leads: II, III, aVF Septal Leads: V1, V2 Anterior Leads: V3, V4 (Left Circumflex) (Posterior Descending Artery – Right Coronary Artery) (Left Anterior Descending) (Left Anterior Descending Copyright 2021 - Pass with PASS, LLC 57 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Myocardial Infarction The 12 lead EKG is a great tool in determining if the patient is having an MI, however, please remember that 50% of myocardial infarctions are STEMIs and 50% of MI’s are NSTEMIs. So, remember to use your assessment and the patient’s clinical presentation to best guide the treatment when the 12 lead EKG is unremarkable. TYPES OF MI Subendocardial: The MI extends partially through the thickness of the myocardium. May or may not produce a pathological Q-wave on future 12 lead EKGs. Transmural: The MI extends completely through the thickness of the myocardium. Will leave pathological Q-waves (Q-waves > .04s) on future 12 lead EKGs. STEMI: WHAT TO LOOK FOR 1mm (or more) of ST segment elevation in two or more anatomically contiguous or numerically consecutive leads. ANATOMICALLY CONTIGUOUS NUMERICALLY CONSECUTIVE I, aVL, V5, V6 II, III, aVF V1, V2 V3, V4 V1 – V2 V2 – V3 V3 – V4 V4 – V5 V5 – V6 NAMES OF MYOCARDIAL INFARCTIONS NAMES OF MYOCARDIAL INFARCTIONS: ST Segment Elevation (1mm or more) in: I, aVL, V5, V6 = Lateral Wall MI II, III, aVF = Inferior Wall MI V1, V2 = Septal Wall MI V3, V4 = Anterior Wall MI ST Segment Elevation (1mm or more) in: V2, V3 = Anteroseptal MI V4, V5 = Anterolateral MI V2, V3, V4, V5 = Extensive Anterior Wall MI Copyright 2021 - Pass with PASS, LLC 58 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Right Sided 12 Lead EKG When an Inferior Wall MI is identified (ST segment elevation in II, III, aVF) complete a rightsided 12 lead EKG. To do this, move V4 to the right side (same anatomical position as normal 12 lead, just on the right side of the sternum) and obtain another 12 lead. When the new 12 lead prints, look specifically in lead V4 for any ST segment elevation of greater than 1mm. If there is elevation, this is indicative of a Right Ventricular Infarction (RVI). So, why do we do this? Well, it’s because of the coronary artery anatomy…let’s take a look! Look at this picture, the Right Coronary Artery ultimately supplies the Posterior Descending Artery and the Right Marginal Artery. The Posterior Descending Artery supplies the inferior wall. The Right Marginal Artery supplies the right ventricle. When an Inferior Wall MI is identified, a right-sided 12 lead occurs in an attempt to identify if the occlusion is happening in the posterior descending artery alone (point A) or if it is happening in the proximal RCA (point B) – which would cause infarctions of both the inferior wall and the right ventricle. When the right ventricle is involved, we are concerned with preload and nitroglycerin administration. B A When a RVI is found, use caution with nitroglycerin. Instead, consider a fluid bolus to support preload (Starling’s Law), aspirin, and oxygen. Copyright 2021 - Pass with PASS, LLC 59 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Bundle Branch Blocks There are two main bundle branches in the heart: the right bundle branch and the left bundle branch. The left bundle branch further divides into the left anterior fascicle and the lest posterior fascicle. But, we won’t dive too far into the different fascicles of the left bundle branch. Bundle branch blocks can be identified on the 12 lead EKG and are important to rule in/rule out as they can mimic or hide certain 12 lead findings. There are a few ways to identify a bundle branch block, but we are going to stick with the turn signal method. Step 1: In Lead V1 (this is important to remember), look to see if the QRS is wider than .12 (3 small boxes). If it is not, then you can stop. If it is, then proceed to step 2. Step 2: With a wide QRS in V1, you now need to determine if the QRS complex is deflected up or down. Step 3: Picture yourself holding a steering wheel. You are going to make a right turn so you hit the turn signal lever “up”. A QRS that is wide and deflected up is a Right Bundle Branch Block. Now, you are going to make a left turn, so you hit the turn signal lever “down.” A QRS that is wide and deflected down is a Left Bundle Branch Block. LBBB = 12 lead interpretation is a LBBB and then treat your patient’s clinical presentation RBBB = 12 lead interpretation is whatever you find “with a RBBB”. Treat your patient’s clinical presentation and 12 lead findings. Copyright 2021 - Pass with PASS, LLC 60 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Advanced Cardiac Life Support (ACLS) From our experience, there are few medication dosages that you will be required to know on the NREMT exam (that doesn’t mean you shouldn’t know them…). But, you can bet your money that you will be expected to know ACLS and PALS medication dosages. The medications and their dosages are AHA guidelines and are therefore nationally recognized, accepted, and practiced. Most other medications are somewhat protocol driven, so their dosages are not often tested. But, you are still required to know what the medications are, the indications, contraindications, etc. When we teach ACLS, we find it easiest to breakdown most all cardiac rhythms into a category: “slow, normal, fast, or dead”. This approach really makes the lightbulb go off with our paramedic students. Hopefully it has that same effect on you! Let’s get to it! Copyright 2021 - Pass with PASS, LLC 61 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Slow (HR < 60 bpm) **Patient must be symptomatic** Sinus Bradycardia Junctional Escape Second Degree Type 1 Second Degree Type 2 Third Degree Idioventricular Now, let’s divide these rhythms into two different categories based on the treatment that would be most beneficial (or that they are most likely to respond to). Sinus Bradycardia Junctional Escape Second Degree Type 1 1. 2. 3. Atropine: 1 mg, up to a max of 3mg Transcutaneous Pacing: 60bpm (AHA recommendation, increase as needed), 50+ mA until mechanical (pulse) and electrical (captured pacer spike) is achieved. Vasopressor infusion Dopamine: 5 – 20mcg/kg/minute Epinephrine: 2 – 10mcg/minute Second Degree Type 2 Third Degree Idioventricular 1. 2. Transcutaneous Pacing: 60bpm (AHA recommendation, increase as needed), 50+ mA until mechanical (pulse) and electrical (captured pacer spike) is achieved. Vasopressor infusion Dopamine: 5 – 20mcg/kg/minute Epinephrine: 2 – 10mcg/minute Copyright 2021 - Pass with PASS, LLC 62 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Normal (HR 60 – 150 bpm) Before we dive into the “Normal” category, we need you to be flexible here. Some of the rhythms below and the heart rate range above are not necessarily “normal” but if we have a patient in the back of the medic unit in some of these rhythms at a rate in the range above, we are not going to do anything for the rhythm specifically (per ACLS). We will treat their underlying problems, but we aren’t going to speed them up, slow them down, etc. Normal Sinus Rhythm Sinus Tachycardia Atrial Fibrillation Atrial Flutter Accelerated Junctional Junctional Tachycardia Copyright 2021 - Pass with PASS, LLC 63 Prepared exclusively for Robert Hug Transaction: PWP4834 No one other than the individual above should access or use this study guide. Contents are copyrighted. Chapter 4: Cardiology Fast (HR > 150 bpm) We further divide “fast” rhythms into “stable” or “unstable” Supraventricular Tachycardia (SVT) Ventricular Tachycardia (w/pulse) Remember, when treating “fast” rhythms, we have to determine if the patient is “stable” or “unstable”. STABLE: alert and oriented, no significant complaints, hemodynamically stable, “I feel weak”, lightheadedness UNSTABLE: disoriented, hemodynamically unstable, chest pain, difficulty breathing 1. 2. 3. STABLE SVT STABLE VT Vagal maneuvers (“bear down”) Adenosine, 6mg rapid IVP Adenosine, 12mg rapid IVP Amiodarone: 150mg over 10 minutes or Procainamide: 25 – 50mg/minute or Sotalol: 100mg (1.5mg/kg) over 5 min. Unstable SVT Unstable VT Synchronized cardioversion (50 – 100J, 200J, 300J, 360J…) Synchronized cardioversion (50 – 100J, 200J, 300J, 360J…) **may consider sed