Emergency Care of The Sick and Injured - 10/E Sample Chapter

AAOS Tenth Edition
Emergency
Care and Transportation of the Sick and Injured
Sample Chapter
Meets
the New
National EMS
Education
Standards
Series Editor: Andrew N. Pollak, MD, FAAOS

The Future of EMS Education Has Arrived!
Dear Educator,
As you know, the new National EMS Education Standards were
approved in January by the National Highway Traffic Safety
Administration. These Standards are part of a larger effort, based
on the National EMS Education Agenda for the Future, published
in 2000 at the request of National Association of State EMS
Officials. The Agenda was a consensus vision of the future of
EMS. It intended to promote quality and consistency among
all EMS education programs and establish common entry-level
requirements for the licensure of various levels of EMS providers
throughout the country.
The National EMS Education Standards document is being used

by publishers to develop new instructional materials and should
guide EMS educators in designing their programs and in making
decisions about the materials to use in their classrooms.
You may have noticed that the Standards are less prescriptive
than the Department of Transportation’s (DOT) National
Standard Curricula that they replace. Instead of specific
cognitive, affective, and psychomotor objectives, the National
EMS Education Standards identify the depth and breadth of
content and provide minimal terminal objectives for each EMS
provider level. Ultimately, the new National EMS Education
Standards allow for:
Increased program flexibility—Educators can now choose

to make certain modules in the Standards a prerequisite to
their courses, and they may choose to teach the material in
whatever order and fashion they choose.
Greater creativity in program and material design—

Educators have the freedom to be more creative about
how they cover content—for example, allowing students
to follow a course of independent study for the Medical
Terminology module, rather than having the instructor
lecture directly out of the training materials.
Better alternative delivery methods—Alternative delivery

methods will allow many options—from independent study
to online learning resources.
Increased ability to respond to changes in medical

knowledge—Educators will have a greater ability to adapt
their presentations to the latest medical information.
Bleeding control and the emphasis on compressions
instead of ventilations during CPR are excellent examples
of where the National Standard Curricula was less nimble
than the new National EMS Education Standards. As new
breakthroughs in medicine occur, this knowledge can easily
be incorporated into the classroom.
Many educators are trying to sort out what’s really new in the
National EMS Education Standards. First, the official names of the
provider levels have changed:
Emergency Medical Responder or EMR—

formerly First Responder
Emergency Medical Technician or EMT—

no longer referred to as “Basic”
Advanced Emergency Medical Technician or AEMT—

replaces EMT-Intermediate. The requirements are closer
to the 1985 National Standard Curriculum than the
1999 version.
Paramedic
New patient assessment terminology is being introduced,

although many educators will recognize the terms primary
and secondary assessment. Some skills have been added or
changed, and there is expanded cognitive material at every
level, such as public health, life span development,
pathophysiology, communication, medical terminology,
and patients with special challenges.
Tenth Edition Table of Contents
Correlated to the National EMS Education Standards
Tenth Edition National EMS Education Standards

Section 1. Preparatory
1. EMS Systems EMS Systems

Research
Public Health
2. Workforce Safety and Wellness Workforce Safety and Wellness
3. Medical, Legal, and Ethical Issues Medical/Legal and Ethics
4. Communication and Documentation Documentation

EMS System Communication
Therapeutic Communication
5. The Human Body Anatomy and Physiology

Pathophysiology
6. Life Span Development Life Span Development
Section 2. Pharmacology
7. Principles of Pharmacology Principles of Pharmacology

Medication Administration
Emergency Medications
Section 3: Patient Assessment
8. Patient Assessment Scene Size-Up

Primary Assessment
History-Taking
Secondary Assessment
Monitoring Devices
Reassessment
Section 4. Airway
9. Airway Management Airway Management

Respiration
Artificial Ventilation
Section 5. Shock and Resuscitation
10. Shock Shock and Resuscitation
11. BLS Resuscitation Shock and Resuscitation
Section 6. Medical
12. Medical Overview Medical Overview

Infectious Diseases
13. Respiratory Emergencies Respiratory
14. Cardiovascular Emergencies Cardiovascular
15. Neurologic Emergencies Neurology
16. Gastrointestinal and Urologic Emergencies Abdominal and Gastrointestinal Disorders

Genitourinary/Renal
17. Endocrine and Hematologic Emergencies Endocrine Disorders

Hematology
18. Immunologic Emergencies Immunology
19. Toxicology Toxicology
20. Psychiatric Emergencies Psychiatric
21. Gynecologic Emergencies Gynecology
Section 7. Trauma
22. Trauma Overview Trauma Overview

Multi-System Trauma
23. Bleeding Bleeding

Diseases of the Eyes, Ears, Nose, and Throat
24. Soft-Tissue Injuries Soft Tissue Trauma
25. Face and Neck Injuries Head, Facial, Neck, and Spine Trauma
26. Head and Spine Injuries Head, Facial, Neck, and Spine Trauma
Nervous System Trauma
27. Chest Injuries Chest Trauma
28. Abdominal and Genitourinary Injuries Abdominal and Genitourinary Trauma
Non-Traumatic Musculoskeletal Disorders

29. Orthopaedic Injuries Orthopedic Trauma
30. Environmental Emergencies Environmental Emergencies
Section 8. Special Patient Populations
31. Obstetrics and Neonatal Care Obstetrics

Neonatal Care
Special Considerations in Trauma
32. Pediatric Emergencies Pediatrics

33. Geriatric Emergencies Geriatrics

34. Patients With Special Challenges Patients With Special Challenges

Section 9. EMS Operations
35. Lifting and Moving Patients Workforce Safety and Wellness
36. Transport Operations Principles of Safely Operating a Ground Ambulance

Air Medical
37. Vehicle Extrication and Special Rescue Vehicle Extrication
38. Incident Management Incident Management

Multiple-Casualty Incidents
Hazardous Materials Awareness
39. Terrorism and Disaster Management Mass-Casualty Incidents due to

Terrorism and Disaster
Section 10: ALS Techniques
40. ALS Assist
Appendix: Medical Terminology Medical Terminology

What Steps are the AAOS and J&B Taking to Implement
the National EMS Education Standards?
Because the Standards are less prescriptive than the DOT For the last several years, we have been publishing technology-
objectives, we have gathered a team of outstanding educators based products and innovative supplementary materials that
from across the country to help develop new materials for the allow student-directed learning and hybrid courses. Now we
classroom. This consensus approach to content development are taking these tools to the next level for the instructors.
ensures that we publish only the best practices and nationally
accepted training materials. The Tenth Edition of Emergency Care and Transportation
of the Sick and Injured offers instructors and students
In addition to developing gold standard student textbooks, comprehensive coverage of every competency statement
18 Section 1 Preparatory
we are building a wide range of teaching and learning tools in the National EMS Education Standards in an engaging and
that will enable instructors to achieve one of the goals of the accessible format.
new Standards: greater individual creativity in course design.
Table 2-4 Warning Signs of Stress
Table 2-5 Strategies to Manage Stress
Irritability toward coworkers, family, and friends
� � Minimize or eliminate stressors
Inability to concentrate
� � Change partners to avoid a negative or hostile
� Difficulty sleeping, increased sleeping, or nightmares 18 Sectionpersonality
1 Preparatory
� Feelings of sadness, anxiety, or guilt � Change work hours

Table� 2-4Change Warning Signs of Stress
the work environment Table 2-5 Strategies to Manage Stress
� Indecisiveness
Inability toCut back on overtime
Irritability toward coworkers, family, and friends Minimize or eliminate stressors
Loss of appetite (gastrointestinal disturbances)
� �
� �
� concentrate � Change partners to avoid a negative or hostile
Students Will Enjoy

Difficulty sleeping, increased sleeping, or nightmares personality
Feelings ofChange
sadness, anxiety, your attitude aboutChange theworkstressor
�
� Loss of interest in sexual activities �

� or guilt � hours

� Indecisiveness � Change the work environment
� Isolation � Talk
Loss�of appetite about disturbances)
(gastrointestinal your feelings with �
people
Cut back on overtime you trust
� Loss of interest in sexual activities � Change your attitude about the stressor
� Loss of interest in work � �

Isolation Seek professional counseling �
if needed
Talk about your feelings with people you trust
Seek professional counseling if needed
� Loss of interest in work �
� Increased use of alcohol � Increased

� Doof alcohol
use not obsess over frustrating �
relapsing situations
alcoholics and nursingsuch as Focus
Do not obsess over frustrating situations such as
 A Relaxed, Readable Textbook—When writing EMS � Recreational drug use home transfers.
� Recreational drug use

�
backache)
relapsing
Physical symptoms alcoholics
such as chronic pain (headache, and nursing home transfers. Focus
�
on delivering high-quality care
Try to adopt a more relaxed, philosophical outlook
textbooks, authors often forget who their audience really � Feelings ofon delivering high-quality care
hopelessness
� Expand your social support system apart from your
� Physical symptoms such as chronic pain (headache, coworkers
is. Some publishers may use “experts” who have little

backache)
� Try to adopt a more relaxed,
�
�
Sustain friends and interests outside emergency services
philosophical
Minimize outlook
the physical response to stress by employing
Your job is to remain professional at all times. Try various techniques, including:
connection�toFeelings
the field.of The Tenth Edition creates a learning
hopelessness and stay� calm. Expand
Allow patients your
to expresssocial
including anger, without becoming angry yourself.
support– system
their feelings, A deep breath toapart
– Periodic stretching
from
settle an anger your
response
There arecoworkers
environment in which students are comfortable with the many methods of handling stress. Some are
positive and healthy; others are harmful and destructive.
– Slow, deep breathing
– Regular physical exercise
Sustain friends and per interests outside muscle emergency services
material presented. That comfort level translates into better Americans� consume more than 20 tons of aspirin day, – Progressive relaxation
and doctors prescribe muscle relaxants, tranquilizers, and – Meditation
� more Minimize theperphysical
year to patientsresponse toofstress
– Limit intake byandemploying
caffeine, alcohol, tobacco use
understanding and retention, and ultimately leads to better sedatives than 90 million times
various techniques,
in the United States. Although these medications have
including:
Your job is to remain professional at all times. Try legitimate uses, they do nothing to combat stress that
pass rates.and
Thisstay talks toAllow
text calm. your patients
students,tonot at them.
express their feelings,
may cause the medical problems described previously.
The term–“stress Amanagement”
deep breath refers to theto settle
tactics
cananquicklyanger
be drained response
of its reserves. This can leave it
depleted of key nutrients, weakened, and more suscep-
that have been shown to alleviate or eliminate stress reac-
including anger, without becoming angry yourself. – Periodic stretching
tions. These strategies may involve changing a few habits,
tible to illness.
changing your attitude, and perseverance .
A clue to– the Slow, deep breathing Nutrition
There are many methods of handling stress. Some are management of stress comes from
the fact that it is not the event itself but the individual’s Your body’s three sources of fuel—carbohydrates, fat, and
reaction to it–that Regular
determines howphysical exercise
protein—are consumed in increased quantities during
positive and healthy; others are harmful and destructive. much it will strain
the body’s resources. Remember that stress is defined stress, particularly if physical activity is involved. The
Americans consume more than 20 tons of aspirin per day, as anything you Progressive
– perceive as a threat to your muscle equilib- relaxation
quickest source of energy is glucose, taken from stored
glycogen in the liver. However, this supply will last less
rium. Stress is an undeniable and unavoidable part of
and doctors prescribe muscle relaxants, tranquilizers, and our everyday–life. By Meditation
understanding how it affects you than a day. Protein, drawn primarily from muscle, is a
long-term source of fuel. Tissues can use fat for energy.
physiologically, physically, and psychologically, you can
manage it more Limit intake of caffeine,
– successfully. alcohol, and tobacco use
The body also conserves water during periods of stress. To
sedatives more than 90 million times per year to patients The following sections provide some suggestions for do so, it retains sodium by exchanging and losing potas-
sium from the kidneys. Other nutrients that are suscepti-
how to prevent the effects of stress from affecting you.
in the United States. Although these medications have Some of them may be useful in helping you prevent
problems from developing. Others may help you solve
ble to depletion are the vitamins and minerals that are not
stored by the body in substantial quantities. These include
legitimate uses, they do nothing to combat stress that problems should they develop. water-soluble B and C vitamins and most minerals.
As an EMT, you have little control of what stressors
you will face on any given day. Consequently, stress in one
may cause the medical problems described previously. Wellness and Stress Management
can quickly be drained of its reserves. This can leave it
Anyone can respond to sudden physical stress for a short
form or another is an unavoidable part of your life. As you
would study for a test, dress properly for a day of snow
The term “stress management” refers to the tactics time. However, if stress is prolonged, and especially if skiing, or train for a sporting event, you should physi-
depleted of key nutrients, weakened, and more suscep-
physical action is not a permitted response, the body cally prepare your body for stress. Physical conditioning
that have been shown to alleviate or eliminate stress reac-
tible to illness.
tions. These strategies may involve changing a few habits,
changing your attitude, and perseverance . 78286_CH02_002_049.indd 18 10/9/09 10:26:12 PM
Nutrition
A clue to the management of stress comes from
the fact that it is not the event itself but the individual’s Your body’s three sources of fuel—carbohydrates, fat, and
reaction to it that determines how much it will strain protein—are consumed in increased quantities during
the body’s resources. Remember that stress is defined stress, particularly if physical activity is involved. The
as anything you perceive as a threat to your equilib- quickest source of energy is glucose, taken from stored
rium. Stress is an undeniable and unavoidable part of glycogen in the liver. However, this supply will last less
our everyday life. By understanding how it affects you than a day. Protein, drawn primarily from muscle, is a
physiologically, physically, and psychologically, you can long-term source of fuel. Tissues can use fat for energy.
manage it more successfully. The body also conserves water during periods of stress. To
The following sections provide some suggestions for do so, it retains sodium by exchanging and losing potas-
how to prevent the effects of stress from affecting you. sium from the kidneys. Other nutrients that are suscepti-
Some of them may be useful in helping you prevent ble to depletion are the vitamins and minerals that are not
problems from developing. Others may help you solve stored by the body in substantial quantities. These include
water-soluble B and C vitamins and most minerals.
appropriate hospital. Signs such as tachycardia, tachyp-
nea, weak pulse, and cool, moist, and pale skin are signs looking, listening, and feeling for signs of airway prob-
of hypoperfusion and imply the need for rapid transport. lems. Look at the patient and ask yourself the following
You should be alert to these signs and reassess your prior- questions:
ity and transport decision if they develop. 1. Is the patient in a tripod position?
2. Is the patient gasping for air?
4History Taking 3. What is the skin’s color and condition?

4. Are there any signs of increased respiratory efforts
such as retractions, nasal flaring, pursed lip
Investigate Chief Complaint
breathing, or use of accessory muscles?
After the life threats have been managed during the  Patient Assessment—The Tenth Edition also applies this
primary assessment, investigate the chief complaint Next, listen for air movement at the patient’s mouth
unique approach of concept reinforcement to patient
or history of present illness. The EMT should obtain a and nose. Then listen to breath sounds with a stetho-
assessment. This critical topic is presented in a single,
medical history and be alert for injury-specific signs and scope. Breath sounds should be clear and equal bilater-
comprehensive chapter, ensuring that students understand
symptoms as well as any pertinent negatives such as no ally, anteriorly, and posteriorly. Determine the patient’s
patient assessment as a single, integrated process. This also
pain or loss of sensation. rate and quality of respiration. Finally assess asymmetric
chest wallallows instructors to teach patient assessment the way that
movement.
Make every attempt to obtain a SAMPLE history
from your patient. Using OPQRST may provide some You must bewill
students actually
able practice
to quickly it inpulse
assess the field.
rateRecognizing
and
the importance of assessment-based care,
quality; determine the skin condition, color, and temper- each medical
background on isolated extremity injuries. You have the
ature; andandcheck
traumathechapter reflrefi
capillary ects the patient assessment process,
ll time.
opportunity to interview the patient well in advance of
using the same language and
Assess the neurologic system to gather visual cues to strengthen
baseline data
the emergency physician. Any information you receive
students’ command of this process.
on your patient. This examination should include:
will be very valuable if the patient loses consciousness.
If the patient is not responsive, attempt to obtain the his- level of consciousness—use AVPU
12 Section 7 Trauma
tory from other sources, such as friends or family members. pupil size and reactivity
consider rapid transport to the hospital for treatment Medical identification jewelry and cards in wallets may also
or request ALS support. Whereas treatment performed provide information about the patient’s medical history.
following 12 the primary
Section 7 Trauma assessment is directed at quickly Typical signs of an open injury include bleeding,
addressing
78286_CH23_002_049.indd 12 consider life
rapidthreats,
transport to theyou hospitalshould
or request ALS support. Whereas treatment performed
for treatment not delay
Medical transport
identification jewelry and cards in of break(s)
wallets may also
provide information about the patient’s medical history.
in the skin, shock, hemorrhage, and 10/24/09
disfigure-
10:05:01 PM
a traumafollowing patient, particularly

the primary assessment is directed at quickly
addressing life threats, you should not delay transport of
if the patient has a closed
Typical signs of an open injury include bleeding,
break(s) in the skin, shock, hemorrhage, and disfigure-
ment or loss of a body part. Typically symptoms include
soft-tissue injuryinjury thatthatmay be amay sign of a be
a trauma patient, particularly if the patient has a closed
soft-tissue a signment
more serious painof a burning
more at the serious
or loss of a body part. Typically symptoms include
and/or injury site. Conditions such pain and/or burning at the injury site. Conditions such
deeper injury. Patients with a significant MOI may require as anemia (low quantity of hemoglobin in the blood) and
deeper injury. Patients
a secondary assessment with
to identify a significant
these injuries. MOI
hemophilia may
(a disorder require
in which blood has a diminished as anemia (low quantity of hemoglobin in the blood) and
Although most patients do not require immediate ability to clot) can complicate open soft-tissue injuries.
a secondary load and assessment
go transportation, there to identify
are certain conditions these injuries.
Medications such as aspirin and other blood-thinning hemophilia (a disorder in which blood has a diminished
for which treatment is limited in the field and therefore medications frequently taken by older patients may inter-
Although most
immediate transport is thepatients
better choice. The do not
following
list will help to guide you in recognition of the types of
require
fere with clotting and immediate
make bleeding control difficult. ability
the injury was self-inflicted, the patient may also have a
If to clot) can complicate open soft-tissue injuries.
load and go patients transportation,
that need immediate
Poor initial general impression

transportation. there are certain
behavioral problem. conditions Medications such as aspirin and other blood-thinning
for which treatment is limited in the4
Altered level of consciousness

Dyspnea

fieldSecondaryand Assessment
therefore medications frequently taken by older patients may inter-
The secondary assessment is a more detailed, compre-
immediate Irregular transport
Shock

vital signs
is the better choice. The offollowing
hensive examination the patient that is used to uncover fere with clotting and make bleeding control difficult. If
injuries that may have been missed during the primary
list will help to
Severe pain

guide you in recognition
It is easy for you to become distracted when a patient
assessment.of the
In some types
instances such as aof the injury was self-inflicted, the patient may also have a
critically injured
patient or a short transport time, the EMT may not have
patients has that need immediate transportation.
significant soft-tissue injuries, there is a large amount of
blood, and the patient is most likely frightened and may be
time to conduct a secondary assessment. behavioral problem.
screaming. However, at this point you need to focus on the Physical Examinations
Poor initial
problems at hand and general
follow the protocolsimpression
you have learned. If signifi cant trauma has likely affected multiple systems,
4
start with a rapid full-body scan to be sure that you have
The ABCs are simple enough to remember and treat.
Altered Patientslevel
who have of visibleconsciousness
significant bleeding or signs
of significant internal bleeding may quickly become unsta-
found all of the problems and injuries. Begin with the
head and neck while manually holding the head in place.
Dyspnea
ble. Treatment must be directed at quickly addressing life When you are done, apply a cervical spine immobiliza-
threats and providing rapid transportation to the closest tion device if you have not done so already.
Assessment of the respiratory system should involve The secondary assessment is a more detailed, compre-
Irregular vital signs
appropriate hospital. Signs such as tachycardia, tachyp-
looking, listening, and feeling for signs of airway prob-
nea, weak pulse, and cool, moist, and pale skin are signs
of hypoperfusion and imply the need for rapid transport. lems. Look at the patient and ask yourself the following hensive examination of the patient that is used to uncover
Shock
ity and transport decision if they develop. 1. Is the patient in a tripod position? injuries that may have been missed during the primary
Severe pain 2. Is the patient gasping for air?
4 History Taking 3. What is the skin’s color and condition? assessment. In some instances such as a critically injured
It is Investigate
easy forChief you to become distracted
Complaint suchwhen a patient
as retractions, nasal flaring, pursed lip patient or a short transport time, the EMT may not have
has signifi cant soft-tissue injuries, there isNext,
After the life threats have been managed during the
primary assessment, investigate the chief complaint
a listen
large for airamount
movement at the ofpatient’s mouthtime to conduct a secondary assessment.
and nose. Then listen to breath sounds with a stetho-
blood, and the patient isinjury-specifi
most clikely
or history of present illness. The EMT should obtain a
medical history and be alert for signs and frightened
scope. Breath sounds and shouldmaybe clearbe and equal bilater-
screaming. pain orHowever,

loss of sensation. at this point you rate
symptoms as well as any pertinent negatives such as no ally, anteriorly, and posteriorly. Determine the patient’s
need to offocus
and quality respiration.on Finally the
assess asymmetric
Physical Examinations
problemsfromatyour
Make every attempt to obtain a SAMPLE history
hand patient.and follow
Using OPQRST maythe
provide protocols
some
chest wall movement.
Youyou must behave
able to learned.
quickly assess pulse rate and If significant trauma has likely affected multiple systems,
quality; determine the skin condition, color, and temper-
The ABCs
background on isolated extremity injuries. You have the
are simple
opportunity to interview the enough toadvance
patient well in remember
of ature; andand treat.
check the capillary refi ll time. start with a rapid full-body scan to be sure that you have
Assess the neurologic system to gather baseline data
the emergency physician. Any information you receive
Patients
will be who have visible significantlevel
very valuable if the patient loses consciousness. bleeding or signs
on your patient. This examination should include: found all of the problems and injuries. Begin with the
If the patient is not responsive, attempt to obtain the his- of consciousness—use AVPU
head and neck while manually holding the head in place.

of significant internal bleeding may quickly become unsta-

tory from other sources, such as friends or family members.
pupil size and reactivity
ble. Treatment must be directed at quickly addressing life When you are done, apply a cervical spine immobiliza-
threats and providing rapid transportation to the closest
78286_CH23_002_049.indd 12 10/24/09 10:05:01 PM
tion device if you have not done so already.
appropriate hospital. Signs such as tachycardia, tachyp- Assessment of the respiratory system should involve
nea, weak pulse, and cool, moist, and pale skin are signs looking, listening, and feeling for signs of airway prob-
of hypoperfusion and imply the need for rapid transport. lems. Look at the patient and ask yourself the following
ity and transport decision if they develop. 1. Is the patient in a tripod position?
2. Is the patient gasping for air?
4 History Taking 3. What is the skin’s color and condition?

such as retractions, nasal flaring, pursed lip
Investigate Chief Complaint
After the life threats have been managed during the
primary assessment, investigate the chief complaint Next, listen for air movement at the patient’s mouth
or history of present illness. The EMT should obtain a and nose. Then listen to breath sounds with a stetho-
scope. Breath sounds should be clear and equal bilater-
patients with serious facial injuries . Because nary circulation. Studies for this treatment have shown
the blood supply to the face is so rich, injuries to the face positive results in patients with obstructive pulmonary
can result in severe tissue swelling and bleeding into the diseases and those with acute pulmonary edema. The
airway. Control bleeding with direct pressure and suction therapy is typically delivered through a face mask that is
as necessary. held to the head with a strapping system. A good seal with
minimal leakage State-of-the-Art
 Current, between the faceMedical and mask is essential.
Content—Medicine is
Many CPAP systems use oxygen
constantly changing and prehospital medicine as the driving force
varies across
Continuous Positive Airway to deliver the and
positive ventilatory pressure to the patient.
states regions. The content of the Tenth Edition reflects
Pressure Frequently check
the guidance the oxygen
and regulator
recommendations when administer-
of an extremely
6 Introduction ing CPAP; depending
experienced,
invades the flbody,
on the
geographically ow and thethe
diverse
body goess on
patient’
groupthe ofrespi-
alert and initiates a
authors.
6
Continuous positive airway pressure (CPAP) is a ratory rate, some CPAPseries of responses
units of will to
empty inactivate
a D cylinder invader.
groupinof authors
E
Supporting the efforts this outstanding
noninvasive means of providing ventilatory support for
very year, at least 1,000 Americans isdie as little as 5 to 10 minutes.
a team of Medical Editors from the American Academy of
patients experiencing respiratory distress. Many people The face mask is fiPathophysiology
tted with a pressure-relief valve
from allergic reactions. When managing Orthopaedic Surgeons (AAOS). Educators in search of the
who have been diagnosed with obstructive sleep apnea
wear a CPAP unit at night to allergy-related emergencies,
maintain their airways while you patient be standard
(such
6
that determines the amount of pressure delivered to the
mustgold in EMS education need look no further than
cm H2O). to
as 5Contrary Thewhatresult manyis similar to hang-
the Tenth Edition. people think, an allergic
they sleep aware. Overof the thepossibility
past severalofyears,acutetheairwayingobstruc- your head outreaction the window , an while driving on
exaggerated the high-response to any
immune
use of CPAP in the tionprehospital environment collapse
and cardiovascular has proven and beway. This9 results
prepared
Chapter Airwayin a high inspiratory
Management
substance, is not caused 51flowdirectly
and thebyneed an outside stimulus,
to be an excellent adjunct in the treatment of respiratory to push a pressuresuch valveasopen
a bite with
or exhalation.
sting. Rather, While
it is a this
reaction by the body’s
to treat these life-threatening complications. You
roviding bag-mask device or mouth-to-mask ven- distress associatedmay withappear to require
obstructive a great
pulmonary
immune deal
system, of effortreleases
disease
which on the chemicals
part of to combat the
on is usually much easier whenmust denturesalsocanbebeableleft to and distinguish
acute pulmonary betweenedema. the Typically, many of these
stimulus. Among these chemicals are histamines and
ace. Leaving the dentures in body’ place sprovides
usual response
more to a sting
patients wouldor bite be andmanaged an with advanced . An
leukotrienes airway
allergic reaction may be mild and local,
cture” to the face and will generally allergic assist
reaction,
you in which devices,
may require such as epinephrine.
endotracheal intubation. Research
involving hives, itching, has or tenderness, or it may be severe
able to provide a good face-to-mask seal, thus shown
Your ability to recognize and manage the many that there is a signifi cant increase in morbidity and
and systemic, resulting in shock and respiratory failure.
ering adequate tidal volume. However, loose den- mortality when these patients receive intubation Anaphylaxis for their
is an extreme allergic reaction that is
signs and symptoms ofcondition
make it difficult to perform artificial ventilation by
allergic reactions may be
in the field. CPAP offers life an alternative
threateningmeans and involves multiple organ systems. In
method and can easily obstruct thetheonly thing
airway. standingforbetween
There- providing aventilatory
patient’sassistance
life to patients,
cases,and helps
dentures and dental appliances and
should be removed. Dentures and appliances may
imminent
that do not stay death.
in to decrease the overall morbidity and
patients. Because of the simplicity aofhigh-pitched,
severe
FPO
mortality
of the most common
the device and
anaphylaxis
for
can rapidly result in death. One
these signs of anaphylaxis is wheezing,
its
This chapter describes immunology, the study of the whistling breath sound that is typically
me loose or be completely out of place following an great benefit to the patient, CPAPheard is becoming
on widely usually resulting from bronchos-
expiration,
body’s immune system, and the five categories of stimuli
ent or as you are providing care. Periodically reas- used at the EMT level. pasm/bronchoconstriction and increased mucous pro-
that may provoke allergic reactions. You will learn what to
he patient’s airway to make sure these devices are duction. Also present is widespread urticaria, or hives.
look for in assessing patients who may be having an aller-
y in place. Mechanism
gic reaction and how to care for them, including adminis- Urticaria consists of small areas of generalized itching or
tration of epinephrine. TheCPAP chapter then describes
increases pressureinsectin the lungs, burning opens thatcollapsed
appear as multiple, small, raised areas on
Facial Bleeding bites and stings and their management.
alveoli, pushes more oxygen across the alveolar mem- the skin . You may also note hypotension as
ay problems can be especially challenging in brane, and forces interstitial fluid back into the pulmo- shock due to increased capillary
a result of hypovolemic
nary circulation. Studies for this treatment permeability. have shown
nts with serious facial injuries . Because
Anatomy
ood supply to the face is so rich, injuries to the face and Physiology
positive results in patients with obstructive Given pulmonary
the right person and the right circumstances,
6
esult in severe tissue swelling and bleeding into the diseases and those with acute pulmonary edema. almost any substance
The can trigger the body’s immune
The immune
y. Control bleeding with direct pressure and suction system therapy is typically delivered through a face mask that isan allergic reaction: animal bites,
protects the human body from system and cause
substances and organisms that to
held aretheforeign
head withto the body. system.
a strapping food, Alatex
goodgloves,
seal with and many other substances can be
cessary.
78286_CH09_002_063.indd 51 10/7/09 2:14:16 PM
Without the immune system for protection, life as you allergens
minimal leakage between the face and mask is essential. common allergens, however, fall
. The most
know it would not exist. You would Many CPAP be undersystemsconstant
use oxygen into
as the
the following
driving force five general categories:
Continuous Positive Airway
attack from any type of invader, to deliversuch as a bacterium
the positive ventilatory pressure � Insect
to thebites patient.and stings. When an insect bites
Pressure or virus that wanted to make your body
Frequently checka thehome. For-regulator when
oxygen you administer-
and injects the bite with its venom, the act
tunately, most people have ingimmune systems that areflow the
invades theispatient’
andbody, called
the body s envenomation
goes on alert and or, more commonly,
initiates a a
Introduction CPAP; depending on the respi-
6
inuous positive airway pressure well equipped
(CPAP)to isdetect a unauthorized
ratory rate, some visits CPAP
or invadingserieswill
units emptysting.
of responses The sting
a Dtocylinder
inactivate in theof ainvader.
honeybee, wasp, ant, yellow
E
nvasive means of providing ventilatory attacks bysupport
foreign forsubstances. Once
as little as 5a toforeign substance
10 minutes. jacket, or hornet may cause a severe reaction
very year, at least 1,000
nts experiencing respiratory distress. Many people
Americans die
The face mask is fitted with a pressure-relief valve
have been diagnosed with obstructive from allergic sleep reactions.
apnea When managing Pathophysiology
a CPAP unit at night to maintain allergy-related
their airways whileemergencies,
that
patient
determines
you must
(such as 5becm H2O).
6
the amount of pressure delivered to the
The result is similar to hang-
Contrary to what many people think, an allergic
 Constant Reinforcement of Concepts—Health care
PART 1
sleep . Over
aware theofpasttheseveral years, of
possibility theacuteing airway
your head obstruc-
out the window while driving on the high-
f CPAP in theeducation
prehospital
tion
canenvironment
and
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be complicated,
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he P
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has and for manyway.
proven
collapse
students,
and This
be
the in a highreaction
results
prepared
, an exaggerated immune response to any
inspiratory flow and the need
substance, is not caused directly by an outside stimulus,
an excellent EMT
adjunct class
in is
thetheir first exposure
treatment to anatomy,to
of respiratory physiology,
push a pressure valve open with exhalation. While this
medicaltoterminology,
treat theseand life-threatening
medical care. The complications.
Tenthappear such as
You a great deal of effort
Editiontois require a bite or sting. Rather, it is a reaction by the body’s
may on the part of
immune system, which releases chemicals to combat the
built onmust also be
the premise thatable
studentsto need
distinguish between the
a solid foundation
stimulus. Among these chemicals are histamines and
in the basics
body’and
that content.
allergic
then appropriate
s usual
Forreaction,
response to
example, whichChaptermay
reinforcement
a sting or ofbite and an
5, The Humanepinephrine.
require Body, FPO
leukotrienes. An allergic reaction may be mild and local,
involving hives, itching, or tenderness, or it may be severe
provides students with a comprehensive understanding of
Your ability to recognize and
the entire anatomy, physiology, and pathophysiology of the
manage the many and systemic, resulting in shock and respiratory failure.
Anaphylaxis is an extreme allergic reaction that is
human signsbody. At and thesymptoms
beginning ofofChapter
allergic18,reactions
Immunologic may be
life threatening and involves multiple organ systems. In
the only
Emergencies, the text thing
brieflstanding
y revisits the between
relevant aanatomy,
patient’s life
physiology, and pathophysiology
and imminent death. of the immune
thus solidifying this knowledge in the students’ minds and
system, FPO
severe cases, anaphylaxis can rapidly result in death. One
of the most common signs Chapter of anaphylaxis
17 Immunologic is wheezing
Emergencies, 3
This chapter describes immunology , the study of the a high-pitched, whistling breath sound that is typically
offering them context when studying specific emergencies. heard on expiration, usually resulting from bronchos-
body’s immune system, and the five categories of stimuli
that may provoke allergic reactions. You will learn what to pasm/bronchoconstriction and increased mucous pro-
look for in assessing
78286_CH17_002_021.indd 3 patients who may be having an aller- duction. Also present is widespread urticaria, or hives. 10/6/09 6:09:43 PM
8 Section 5 Shock and Resuscitation
8 Section 5 Shock and Resuscitation
division of the autonomic nervous system that controls infection. In all cases,division
however, the damage
of the autonomic nervous systemoccurs because
that controls
involuntary functions by sending signals to the cardiac,
infection. In all cases, however, the damage occurs because
of insufficient perfusion of organs and tissues. As soon as
involuntary functions by sending signals to the cardiac, of insufficient perfusionsmooth, of and organs and
glandular muscles. tissues.
This responseAs
autonomic nervous system causes the release of hor-
soon
by the as stops or becomes impaired, tissues start to die,
perfusion
affecting all local body processes. If the conditions causing
smooth, and glandular muscles. This response by the perfusion stops or becomes
mones such as impaired, tissues start
epinephrine and norepinephrine. Theseto die,
shock are not promptly arrested and reversed, death soon
hormones cause changes in certain body functions such follows.
autonomic nervous system causes the release of hor- affecting all local body as anprocesses. If the conditions
in the strength causing
 Clear Application of Material to Real-World EMS increase in the heart rate and
cardiac contractions and vasoconstriction in nonessen-
of
mones such as epinephrine and norepinephrine. These shock are not promptly arrested
primarily in and
the skinreversed, death
tract soon
Words
W ords ooff W
Wisdom
isdom
Situations —Students
hormones cause changes in who wantbody
certain to become
functions EMTs
such arefollows.
tial areas, and gastrointestinal
(peripheral vasoconstriction). Together, these actions are Shock is a complex physiologic process that gives subtle
designed to maintain pressure in the system and, as a signs to its presence before it becomes severe. These
focused on learning
as an increase to help
in the heart ratepeople. They
and in the need of
strength to know result, sustain perfusion of all vital organs.
Eventually, there is also a shifting of body fluids to
early signs relate very closely to the events that lead to
more severe shock, so it is even more important than
why information
contractionsis and
important to learn.in“How will this W
usual for you to know the underlying processes thor-
cardiac vasoconstriction nonessen- help maintain pressure within the system. However,
tial areas,
Words
or d s o
of
f W
Wisdom
i s d o
the m
response of the autonomic nervous system and hor-
oughly. If you understand what causes shock, you will be
able to recognize it in many patients before it gets out
help me inprimarily in theThrough

the field?” skin and evolving
gastrointestinal
patienttractcase mones comes within seconds. It is this response that
causes all the signs and symptoms of shock in a patient.
of control.
(peripheral vasoconstriction). Together, these actions are

studies in each chapter, the Tenth Edition gives students Shock
designed to maintain pressure in the system and, as a
is a complex physiologic process that gives subtle Understanding the basic physiologic causes of shock
signs to its presence Causes before of it Shock
becomes severe. Thesewill better prepare you to treat it . There are
aresult,
genuine context for the application
sustain perfusion of all vital organs. of the knowledge 6
early signs relate very
Shock canclosely tomany
result from theconditions,
eventsincluding lead tocardiovascular
that respi- and noncardiovascular causes of shock.
Cardiovascular causes of shock include heart attack,
presented in the
Eventually, chapter.
there is also aThis approach
shifting of bodymakes it clear more
fluids to severe shock, sofailure,
ratory it isacute
even
allergicmore
usual for you to know the underlying processes thor-
reactions,important
and overwhelming thandisease, and injury. Noncardiovascular causes include
how
help all of this pressure
maintain new information
within thewill be used
system. to help theiroughly. If you understand what causes shock, you will be
However,
the response of the autonomic nervous system and hor- able to recognize itY Youo
inumany are
are tthe he P
patientsProvider:
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ider: P PART RT 2
itAgets out
patients in the field. of control.
mones comes within seconds. It is this response that You arrive at the clinic and are escorted to the patient by a clinic technician.
technician You fi find
nd the patient lying supine
on an examination table. She is conscious, but restless, and her skin is notably pale and diaphoretic. She has a
causes all the signs and symptoms of shock in a patient. blanket covering her, her legs are elevated, and she is receiving oxygen via a nasal cannula at 4 L/min. Several
attempts at establishing intravenous (IV) access were unsuccessful. Your assessment of the patient reveals the
following:
Understanding the basic physiologic causes of shock
Causes of Shock will better prepare you to treat it . There are
6 cardiovascular and noncardiovascular causes of shock.
Shock can result from many conditions, including respi- Cardiovascular causes of shock include heart attack,
ratory failure, acute allergic reactions, and overwhelming disease, and injury. Noncardiovascular causes include
The clinic physician tells you that the patient presented approximately 15 minu
minutes ago complaining of abdominal
ART 2
pain and rectal bleeding, which apparently started about 24 hours ago. There is no history of trauma, she ha
has
You
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are
re tthe
he P
Provider:
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PART a history of irritable bowel syndrome, she takes lubiprostone (Amitiza) and di
and she is allergic to codeine.
dicyclomine hydrochloride (Bentyl),
3. On the basis of your assessment, does this patient require any changes
chang in the treatment she is currently
receiving?
You arrive at the clinic and are escorted to the patient by a clinic technician.
technician You4.fi
find
nddothe
How patient
the patient’s lying
signs and supine
symptoms correlate with the body’s res
response to inadequate perfusion?
on an examination table. She is conscious, but restless, and her skin is notably pale and diaphoretic. She has a
blanket covering her, her legs are elevated, and she is receiving oxygen via a nasal cannula at 4 L/min. Several
attempts at establishing intravenous (IV) access were unsuccessful. Your assessment of the patient reveals the
78286_CH10_002_033.indd 8 10/24/09 4:53:32 PM
following:
The clinic physician tells you that the patient presented approximately 15 minutes ago complaining of abdominal
pain and rectal bleeding, which apparently started about 24 hours ago. There is no history of trauma, she has
a history of irritable bowel syndrome, she takes lubiprostone (Amitiza) and dicyclomine hydrochloride (Bentyl),
and she is allergic to codeine.
3. On the basis of your assessment, does this patient require any changes in the treatment she is currently
receiving?
4. How do the patient’s signs and symptoms correlate with the body’s response to inadequate perfusion?
78286_CH10_002_033.indd 8 10/24/09 4:53:32 PM
 Emergency Care and Transportation of the Sick and Injured,

Tenth Edition sets the standard for quality, clarity, and
flexibility in the delivery of EMT education. To learn more,
visit www.jbpub.com.
Educators Will Enjoy

 A Textbook That Reflects the Expertise of its Author
Team—The Tenth Edition authors are seasoned EMS
providers with decades of experience in both the care
of prehospital patients and the education of future EMS
providers. This textbook is clearly written by one of us, for
all of us.
Clear Application of Material to Real-World EMS


Situations —Instructors will find countless opportunities
to place their students “in the field” with progressive
case studies that include full patient care reports, video
products that show providers in action, and case-based
critical thinking examination tools. Opportunities to apply
30 Section 7 Trauma knowledge ultimately make students better-equipped
providers. And isn’t that our goal: to teach students how to
You
You a
are
re tthe
he P
Provider:
rovider: S
SUMMARY,
UMMARY, continued
c be great EMS providers?
ontinued
a lacerated liver or stop bleeding in the brain; thus, their focus on trauma care should be no different from
the EMT—to recognize injuries, stabilize the patient, and provide rapid transport.
In many cases, the EMT will be called on to assist the paramedic in performing advanced level skills. Depend-
ing on local protocols, EMTs may even be able to perform additional skills as deemed necessary by the EMS
system medical director.
EMS Patient Care Report (PCR)

Date: 9-1-09 Incident No.: 012109 Nature of Call: Motor vehicle crash Location: 2100 Block Hwy 46
Dispatched: 1520 En Route: 1520 At Scene: 1528 Transport: 1538 At Landing Zone: In Service:
1540 1552
Patient Information
Age: 20 Allergies: Unknown
Sex: M Medications: Unknown
Weight (in kg [lb]): estimated at 68 (150 lb) Past Medical History: Unknown
Chief Complaint: Multiple traumatic injuries
Vital Signs
Time: 1533 BP: 84/64 Pulse: 120 Respirations: 28 SaO2: 97%
EMS Treatment
(circle all that apply)
Oxygen @ 15 L/min via (circle one): Assisted Ventilation Airway Adjunct CPR
NC NRM
Defibrillation Bleeding Control Bandaging Splinting Other: Thermal
management,
suction, full spi-
nal precautions
Narrative
Dispatched for a motor vehicle versus tree head-on collision. Engine 3 and law enforcement was dispatched as well.
Arrived at the scene and noted that a small passenger vehicle made frontal impact with a large tree. Damage to the
front of the vehicle was significant. The driver, a 20-year-old male, was still in the vehicle; however, he was unrestrained.
Driver and passenger side airbags both deployed, and patient was not entrapped. Partner accessed patient through
backseat and manually stabilized his head. Primary assessment revealed that the patient was responsive only to pain.
He had blood in his oropharynx, a large hematoma and laceration with active bleeding to his forehead, and facial bleed-
ing. His respirations were rapid and labored. Suctioned the patient’s oropharynx, controlled the bleeding on his forehead,
applied cervical collar, and rapidly extricated him from the vehicle. Due to the MOI and patient’s clinical status, requested
air transport. Applied oxygen @ 15 L/min via nonrebreathing mask and performed secondary assessment, which revealed
diffuse bruising and crepitus to the chest. Breath sounds were diminished over the left side of the chest. Pelvis and
upper and lower extremities were unremarkable for gross injury. Pupils were dilated and sluggish to react. Engine 3 fire-
fighter reported interior damage to the steering wheel and a starburst fracture to the windshield with evidence of human
hair. Applied full spinal precautions and a blanket for warmth, and loaded patient into the ambulance. Reassessment
revealed that his respiratory rate had increased, his breathing effort was more labored, and his oxygen saturation had
decreased. Began assisting his ventilations with a bag-mask device and high-flow oxygen. Engine 3 EMT drove ambulance
to landing zone to meet with air transport helicopter. Continued to reassess patient every 3 to 5 minutes and noted
no change in his clinical status. Contacted air medical helicopter via radio and provided patient status update. Con-
tinued to assist patient’s ventilations and suctioned his oropharynx as needed to maintain airway patency. Vital signs
were also reassessed, as noted above. After a brief wait at the LZ, air transport helicopter arrived. Gave verbal report
to flight paramedic, and transferred patient care to the flight crew. Helicopter departed the LZ at 1550, and EMS 3
 Constant Reinforcement of Concepts—EMS educators are
concerned about the National EMS Education Standards and
its impact on their classrooms. The Tenth Edition eases any
transition to the new National EMS Education Standards.
The Tenth Edition is the cornerstone of a complete teaching
and learning system consisting of ample resources for
both student and faculty. With online resources,
students and faculty are able to take practice tests,
work on module assignments, and use JBTest Prep Technology Supplements: Interactive Course
to ensure competency. Educators will enjoy the eBook/eWorkbook
updated presentations, test banks, and JB Navigate. CourseSmart
This system provides an outstanding platform for a JB Navigate (formerly known as JBCourse Manager)
JBTest Prep
dynamic learning environment for Audio Book
all students. Website
Instructor Supplements: Instructor’s ToolKit CD-ROM

Test Bank CD-ROM
Scenario DVD
Student Supplements: Student Workbook

EMT Field Guide
Chapter 22 Bleeding 17
Applying a Commercial Tourniquet
Step 1 Hold pressure over the bleeding Step 2 Click the buckle into place, pull the
site and place the tourniquet just strap tight, and turn the tightening
above the injury. dial clockwise until pulses are no
longer palpable distal to the tour-
niquet or until bleeding has been
controlled.
6. To release the tourniquet at the hospital, or if “time applied.” Securely fasten the tape to the
otherwise instructed by medical control, push the patient’s forehead. Notify hospital personnel on
release button and pull the strap back. Be aware your arrival that your patient has a tourniquet in
that bleeding may rapidly return upon tourniquet place. Record this same information on the ambu-
release and that you should be prepared to reapply lance run report form.
 Current, State-of-the-Art Medical Content—EMS has
it immediately if necessary. 7. As an alternative, you can use a blood pressure
long struggled to prove that the care delivered in the tourniquet is not available, follow
If a commercial cuff as an effective tourniquet. Position the cuff
field has real impact on patients’ lives. The
these Tenth
steps Edition
to apply a tourniquet using a triangular ban-
incorporates evidence-based medicaldage and a stick or rod:
concepts to ensure
1. Fold a triangular bandage until it is 4" wide and
that students are taught assessment and treatment
six to eight layers thick.
modalities that will help patients today—not
2. Wrapsimply
the bandage around the extremity twice.
Choose an area only slightly proximal to the bleed-
recycle what has been taught year after year. ing to reduce the amount of tissue damage to the
extremity.
3. Tie one knot in the bandage. Then place a stick
or rod on top of the knot, and tie the ends of the
CHAPTER
CHAPTER
22
Bleeding
National EMS Education

n Standard importance
4. Understand the import tance of identifying the mechanism of
injury, nature of illness,
illnesss, and signs and symptoms for a patient with
Competencies suspected internal bleeding.
bleeding. (pp 9–10)
5. Describe how to assess a patient with external bleeding. (pp 10–14)
Trauma 6. Describe how to assess a patient with suspected internal bleeding.
Applies fundamental knowledge to provide basic emergency care and (pp 10–14)
transportation based on assessment findings for an acutely injured
patient. 7. Describe the emergency medical care for a patient with external
bleeding. (pp 14–20)
8. Describe the emergency medical care for a patient with suspected
Bleeding internal bleeding. (pp 20–21)
Recognition and management of
Bleeding (pp 33–47)
Skills Objectives
Pathophysiology, assessment, and management of 1. Demonstrate how to control external bleeding. (pp 14–20, Skill Drill 22-1)
Bleeding (pp 29–47) 2. Demonstrate the application of a tourniquet. (pp 16–17, Skill Drill 22-2)
3. Demonstrate the control of epistaxis. (pp 19–20, Skill Drill 22-3)
Knowledge Objectives 4. Demonstrate how to control internal bleeding. (pp 20–21, Skill Drill 22-4)
1. Understand the basic anatomy and physiology of the cardiovascular
system, including blood, blood vessels, and the heart. (pp 3–6)
2. Understand the role of perfusion. (pp 6–7)
3. Know how to determine the significance and characteristics of The National EMS Education
external bleeding. (pp 7–8)
Standards Competencies
along with the chapter’s
Knowledge Objectives and
Skill Objectives are listed
at the beginning of each
chapter with corresponding
page references.
2
Introduction
6 Head, arm, and upper trunk
A
Venule Arteriole
fter managing the airway, recognizing
bleeding and understanding how it
affects the body are perhaps the most
important skills you will learn as an EMT. Bleed-
Vein Artery
ing can be external and obvious or internal and
hidden. Either way, it is potentially dangerous,
first causing weakness and, if left uncontrolled, Aorta Lung
eventually shock and death. The most common
cause of shock following trauma is bleeding.
Generally the shock from trauma is caused at
least in part from bleeding.
This chapter will help you understand how the Heart
cardiovascular system reacts to blood loss. The chapter
begins with a brief review of the anatomy and function
Reinforcement of the
of the cardiovascular system. It then describes the signs,
anatomy and physiology
symptoms, and emergency medical care presented
of both external
in Chapter 5,
and internal bleeding. The chapter concludes with a dis-occurs
The Human Body,
cussion on the relationship between bleeding and hypo-
throughout the text. Abdominal
volemic shock. organs
Lower
Anatomy and Physiology of the body
Cardiovascular System and legs
6
The cardiovascular system circulates blood to all of
the body’s cells and tissues, delivering oxygen and
nutrients and carrying away metabolic waste prod-
ucts . Cells in the brain, spinal cord, and
heart cannot tolerate a lack of blood for more than a
few minutes. Cells in other organs, such as the lungs of inadequate perfusion. After that, their cells begin to
and kidneys, can survive for almost an hour while skel- die. This can lead to a permanent loss of function or, if
etal muscle cells may survive for two hours in a state enough cells die, death.
Progressive case studies

capture the student’s
attention and offer an
ou a
You
Y are
re tthe
he Provider:
Provider: PART 1
PART authentic context for
students to apply their
At 4:20
4 20 PM, you are di
dispatched
t h d to
t a woodworking
d ki shop
h att 517 East
E t Graham
G h for 32 knowledge.
for a 32-year-old
ld man withith severe
bleeding from the arm. The exact mechanism of injury is unknown. You and your partner respond to the scene
with a response time of approximately 6 minutes.
1. What are the functions of arteries? What major arteries are located in the upper extremity?
2. Why is arterial bleeding more severe than venous bleeding?
4 Section 7 Trauma
The cardiovascular system, the main system responsible

for supplying and maintaining adequate blood flow, consists Superior vena cava Left pulmonary
(oxygen-poor blood from artery (blood
of three parts: head and upper body) to left lung)
The pump (the heart)
A container (the blood vessels that reach every cell
in the body) Right pulmonary
The fluid (blood and body fluids) artery (blood to
right lung)
The Heart Right atrium
The heart is a hollow muscular organ about the size of a

Inferior vena cava
clenched fist. It is an involuntary muscle that is under the (oxygen-poor blood
from lower body)
control of the autonomic nervous system, but it has its
own regulatory system. Thus, it can function even if the
Right ventricle
nervous system shuts down.
The heart is always working; all other organs depend
on it to provide a rich blood supply. For this reason,
it has a number of special features that other muscles Right pulmonary Oxygen-rich blood to head
veins (oxygen-rich and upper body
do not. First, because the heart cannot tolerate a disrup- blood from
tion of its blood supply for more than a few seconds, the right lung)
heart muscle needs a rich and well-distributed blood

supply. Second, the heart works as two paired pumps Left pulmonary veins
(oxygen-rich blood
. Each side of the heart has an upper chamber from left lung)
(atrium) and a lower chamber (ventricle), both of which
pump blood. Blood leaves each chamber of a normal
heart through a one-way valve, which keeps the blood Left atrium
moving in the proper direction by preventing backflow.
The right side of the heart receives oxygen-poor (deox-
Left ventricle
ygenated) blood from the veins of the body. Blood enters
the right atrium from the vena cava, then fills the right
ventricle. After the right ventricle contracts, blood flows
into the pulmonary artery and the pulmonary circulation.
The now oxygen-rich (oxygenated) blood returns to the Oxygen-rich blood
to lower body
left side of the heart from the lungs through the pulmo-
nary veins. Blood enters the left atrium, then passes into
the left ventricle. This side of the heart is more muscular
than the other because it must pump blood into the aorta
and on to the arteries throughout the body. It is important
to remember that the left ventricle is responsible for pro-
viding 100% of the body with oxygen-rich blood.
Blood Vessels and Blood arterioles. Capillaries are small tubes, with the diameter
of a single red blood cell, that pass among all the cells in
There are five types of blood vessels:
the body, linking the arterioles and the venules. Blood
Arteries leaving the distal side of the capillaries flows into the
Arterioles venules. These small, thin-walled vessels empty into the
Capillaries veins, and the veins then empty into the vena cava. This
Venules is the process that returns blood in the venous side of
Veins the circulatory system to the heart. Oxygen and nutrients
As blood flows out of the heart, it passes into the easily pass from the capillaries into the cells, and waste
aorta, the largest artery in the body. The arteries become and carbon dioxide diffuse from the cells and into the
smaller as they move away from the heart. The smaller capillaries . This transportation system allows
vessels that connect the arteries and capillaries are called the body to rid itself of waste products.
each cell of the surrounding tissue; when the muscles are

closed (constricted), there is no capillary blood flow. The
Capillary to
tissue cells
muscles dilate and constrict in response to conditions
such as fright, heat, cold, a specific need for oxygen, and
O2 and nutrients the need to dispose of metabolic waste. In a healthy indi-
vidual, all the vessels are never fully dilated or fully con-
stricted at the same time.
The last part of the cardiovascular system is the con-
CO2 and waste tents of the container, or the blood. Blood contains red
cells, white cells, platelets, and a liquid called plasma
Pulmonary arteriole . As discussed in Chapter 5, The Human Body,
red blood cells are responsible for the transportation of
oxygen to the cells and for transporting carbon dioxide
(a waste product of cellular metabolism) away from the
cells to the lungs, where it is exhaled and removed from
the body. Platelets are responsible for forming blood
clots. In the body, a blood clot forms depending on one
CO2 of the following principles: blood stasis, changes in the
O2
vessel wall (such as a wound), or the blood’s ability to clot
(due to a disease process or medication). When injury
occurs to tissues in the body, platelets will begin to collect
at the site of injury; this causes red blood cells to become
Lung alveoli
capillaries sticky and clump together. As the red blood cells begin
to clump, another substance in the body called fibrino-
gen reinforces the red blood cells. This is the final step in
formation of a blood clot. Blood clots are an important
response from the body to control blood loss. Certain
Highly descriptive
medicalandconditions that interfere with the normal clotting
process will be discussed later in this chapter.
detailed illustrations
enable the studentTheto autonomic nervous system monitors the body’s
Pulmonary venule needs from moment to moment and adjusts the blood
clearly visualize
flow by adjusting vascular tone as required. During
human anatomy.
emergencies, the autonomic nervous system automati-
cally redirects blood away from other organs to the heart,
brain, lungs, and kidneys. Thus, the cardiovascular
CO2 system is dynamic and constantly adapting to changing
O2
Lung alveolus
White blood cells
Red blood cells
Platelets
At the arterial ends of the capillaries and in the

arteries themselves are circular muscular walls, which
constrict and dilate automatically under the control of the
autonomic nervous system. When these muscles open
(dilate), blood passes into the capillaries in proximity to
6 Section 7 Trauma
conditions in the body to maintain homeostasis and

perfusion. At times, the system fails to provide sufficient
circulation for every body part to perform its function.
This condition is called hypoperfusion, or shock. Artery
Pathophysiology and Perfusion

6 Arterioles
Blunt force trauma may cause injury and significant
bleeding that is unseen inside a body cavity or region, An in-depth and topic-
such as when injury occurs to the liver or the spleen. specific exploration of Capillaries
These injuries cause the patient to lose significant the pathophysiology Organ or tissue
amounts of blood, causing hypoperfusion without visible presented in Chapter 5,
bleeding. In penetrating trauma, the patient may have The Human Body, occurs
only a small amount of bleeding that is visible; however,throughout the medical
the patient may have sustained injury to internal organs and trauma sections.
that will produce significant bleeding that is unseen by
you and may cause death quickly. Both of these situations
are examples of serious internal bleeding, in which blood
volume and supply have been interrupted to the cells of
the body; this interruption is the cause of hypoperfusion
(or shock) in the trauma patient. Capillaries
Perfusion is the circulation of blood within an organ Venules
or tissue in adequate amounts to meet the cells’ current
needs for oxygen, nutrients, and waste removal. Blood
enters an organ or tissue first through the arteries, then
the arterioles, and finally the capillary beds . Vein
While passing through the capillaries, the blood delivers
nutrients and oxygen to the surrounding cells and picks
up the wastes they have generated. Then the blood leaves
the capillary beds through the venules and finally reaches
the veins, which take the blood back to the heart. Oxygen
and carbon dioxide exchange takes place in the lungs.
Blood must pass through the cardiovascular system can quickly lead to death of the organism, the human.
at a speed that is fast enough to maintain adequate cir- Emergency medical care is designed to support adequate
culation throughout the body and slow enough to allow perfusion to these organs and their systems, listed in
each cell time to exchange oxygen and nutrients for car- , until the patient arrives at the hospital.
bon dioxide and other waste products. Although some
tissues, such as the lungs and kidneys, never rest and
require a constant blood supply, most require circulating
blood only intermittently, especially when active. Mus-
Table 22-1 Organs and Corresponding
Organ Systems
cles are a good example. When you sleep, they are at rest
Organ Organ System
and require a minimal blood supply. However, during
exercise, they need a very large blood supply. The gastro- Heart Cardiovascular system
intestinal tract requires a high flow of blood after a meal. Brain Central nervous system
After digestion is completed, it can do quite well with a Lungs Respiratory system
small fraction of that flow.
All organs and organ systems of the human body are Kidneys Renal system
dependent on adequate perfusion to function properly.
Some of these organs receive a very rich supply of blood
and do not tolerate interruption of blood supply for very The heart requires constant perfusion to function
long. If perfusion is interrupted to these organs and dam- properly. The brain and spinal cord can be injured after
age occurs to the organ tissue, dysfunction and failure of 4 to 6 minutes without perfusion. It is important to
that organ system will occur. Death of an organ system remember that cells of the central nervous system do not
have the capacity to regenerate. Kidneys can be damaged

after 45 minutes of inadequate perfusion. Skeletal Safet y
Safety
muscle demonstrates evidence of injury after 2 hours Remember that a bleeding patient may expose you to
of inadequate perfusion. The gastrointestinal tract can potentially infectious body fluids; therefore, you must
tolerate slightly longer periods of inadequate perfusion. always follow standard precautions when treating
These times are based on a normal body temperature patients with external bleeding. Wear gloves and eye
protection in all situations, and wear a gown and mask
(98.6°F [37.0°C]). An organ or tissue that is consider- if there is a risk of blood splatter . Avoid
ably colder may be better able to resist damage from direct contact with body fluids if possible. Take special
hypoperfusion. care if you have an open sore, cut, scratch, or ulcer.
Also remember that frequent, thorough handwash-
ing between patients and after every run is a simple
yet important protective measure. You will be called to
External Bleeding respond to emergencies involving more than one patient
6 who needs emergency care. As you complete the assess-
ment and care for each patient, remember to place clean
Hemorrhage means bleeding. External bleeding is visible gloves on your hands. Always keep spare gloves with
hemorrhage. Examples include nosebleeds and bleeding you when responding to these incidents. This approach
from open wounds. As an EMT,, you must understand to patient care will greatly minimize the chance that
how to control external bleeding. you could cause cross-contamination of body fluids and
Reinforces safety for
blood between both you may be caring for.
patients
the EMT and the patient.
The Significance of External
Bleeding
When patients have serious external blood loss, it is often
difficult to determine the amount of blood that is present.
This is a difficult task because blood will look different on
different surfaces, such as when it is absorbed in clothing
or when it has been diluted when mixed in water. Always
attempt to determine the amount of external blood loss,
but the presentation and assessment of the patient will
direct the care and treatment the patient will receive from
you as an EMT.
Words
Words ooff W
Wisdom
isdom
Signs and Symptoms of Hypovolemic Shock
Rapid, weak pulse
Low blood pressure (late sign)
Changes in mental status
Cool, clammy skin
Cyanosis (lips, oral membranes, nail beds)
The body will not tolerate an acute blood loss of put this in perspective, a soft drink can holds roughly
greater than 20% of blood volume. The typical adult 355 mL of liquid.
has approximately 70 mL of blood per kilogram of body How well people compensate for blood loss is related
weight, or 6 L (10 to 12 pints) in a body weighing 80 kg to how rapidly they bleed. A healthy adult can comfort-
(175 lb). If the typical adult loses more than 1 L of blood ably donate 1 unit (500 mL) of blood during a period
(about 2 pints), significant changes in vital signs will of 15 to 20 minutes and adapts well to this decrease in
occur, including increasing heart and respiratory rates blood volume. However, if a similar blood loss occurs in
and decreasing blood pressure. Because infants and a much shorter period, the person may rapidly develop
children have less blood volume to begin with, the same hypovolemic shock, a condition in which low blood
effect is seen with smaller amounts of blood loss. For volume results in inadequate perfusion and even death.
example, a 1-year-old infant has a total blood volume The body simply cannot compensate for such a rapid
of about 800 mL. Significant symptoms of blood loss blood loss. The age and preexisting health of the patient
will occur after only 100 to 200 mL of blood loss. To should also be considered.
8 Section 7 Trauma
You should consider bleeding to be serious if the blood (bleeding from damaged capillary vessels) is dark
following conditions are present: red and oozes from a wound steadily but slowly. Venous
It is associated with a significant mechanism of and capillary blood is more likely to clot spontaneously
injury (MOI). than arterial blood .
The patient has a poor general appearance and is On its own, bleeding tends to stop rather quickly,
calm. within about 10 minutes, in response to internal mecha-
Assessment reveals signs and symptoms of shock nisms and exposure to air. When a person is cut, blood
(hypoperfusion). flows rapidly from the open vessel. Soon afterward, the
Key
cutterms
endsare of easily
the vessel begin to narrow ((vasoconstriction),
You note a significant amount of blood loss. identifi ed andthedefined within of bleeding. Then a clot forms,
The blood loss is rapid. reducing amount
the text. A vocabulary
plugging the hole and list sealing the injur
injured portions of the
You cannot control the bleeding.
concludes each chapter,
vessel. This process is called coagulation. Bleeding will
In any situation, blood loss is an extremely serious and a comprehensive
never injured ves-
stop if a clot does not form, unless the injur
problem. It demands your immediate attention as soon sel is completely
glossary appears at the cut off
of from
from the main blood supply.
as you have cleared the airway and managed the patient’s end of Despite the efficiency of this system, it may fail in
the textbook.
breathing. certain situations. Movement, medications, removal of
bandages, and the external environment or body tem-
Characteristics of External perature commonly affect the blood’s clotting factors.
For example, a number of medications, including aspi-
Bleeding rin, interfere with normal clotting. With a severe injury,
Injuries and some illnesses can disrupt blood vessels and the damage to the vessel may be so large that a clot can-
cause bleeding. Typically, bleeding from an open artery not completely block the hole. Sometimes only part of
(arterial bleeding) is brighter red (high in oxygen) and the vessel wall is cut, preventing it from constricting. In
spurts in time with the pulse. The pressure that causes these cases, bleeding will continue unless it is stopped
the blood to spurt also makes this type of bleeding dif- by external means. Occasionally, blood loss occurs very
ficult to control. As the amount of blood circulating in rapidly. In these cases, the patient might die before the
the body drops, so does the patient’s blood pressure and, body’s defenses, such as clotting, could help.
eventually, the arterial spurting. A very small portion of the population lacks one or
Blood from an open vein (venous bleeding) is darker more of the blood’s clotting factors. This condition is called
(low in oxygen) and flows slowly or severely, depending hemophilia. There are several forms of hemophilia, most of
on the size of the vein. Because it is under less pressure, which are hereditary and some of which are severe. Some-
most venous blood does not spurt and is easier to manage; times bleeding may occur spontaneously in hemophilia.
however, it can be profuse and life threatening. Capillary Because the patient’s blood does not clot, all injuries, no
Punctures/Penetrations, Burns, Tenderness, Lacerations,

Words
Words ooff W
Wisdom
isdom and Swelling) over the chest or abdomen, including contu-
If a bandage has already been applied to control bleed- sions, abrasions, lacerations, and other signs of injury or
ing before you arrive on the scene, obtain a descrip- deformity. You should always suspect internal bleeding in a
tion of the wound and the amount of bleeding from the patient who has penetrating injury or blunt trauma.
patient or bystanders.
Provides real-world Nature of Illness for Internal

advice from experienced Bleeding
matter how trivial, are potentiallyfield
serious. A patient with
providers.
hemophilia should be transported immediately. Internal bleeding is not always caused by trauma. Many
illnesses can cause internal bleeding. Some of the more
common causes of nontraumatic internal bleeding
Internal Bleeding include bleeding ulcers, bleeding from the colon, rup-
6 tured ectopic pregnancy, and aneurysms.
Abdominal tenderness, guarding, rigidity, pain, and
Internal bleeding is any bleeding in a cavity or space
inside the body. It can be very serious, especially because distention are frequent in these situations but are not
you might not be aware that it is happening. Injury or always present. In older patients, dizziness, faintness, or
damage to internal organs commonly results in extensive weakness may be the first sign of nontraumatic internal
internal bleeding, which can cause hypovolemic shock bleeding. Ulcers or other gastrointestinal problems may
before you realize the extent of blood loss. A person with cause vomiting of blood or bloody diarrhea or urine.
a bleeding stomach ulcer may lose a large amount of It is not as important for you to know the specific
blood very quickly. Similarly, a person who has a lacer- organ involved as it is to recognize that the patient is in
ated liver or a ruptured spleen may lose a considerable shock and respond appropriately.
amount of blood within the abdomen. Yet the patient has
no outward signs of bleeding. Signs and Symptoms of Internal
Broken bones, especially broken ribs, also may cause Bleeding
serious internal blood loss. Sometimes this bleeding
extends into the chest cavity and the soft tissues of the The most common symptom of internal bleeding is pain.
chest wall. A broken femur can easily result in the loss Significant internal bleeding will generally cause swell-
of 1 L or more of blood into the soft tissues of the thigh. ing in the area of bleeding. Intra-abdominal bleeding will
Often the only signs of such bleeding are local swelling often cause pain and distention. Bruising is a sign of inter-
and bruising due to the accumulation of blood around nal bleeding. It is most common in head, extremity, and
the ends of the broken bone. Severe pelvic fractures may pelvic injuries and can be a sign of significant abdomi-
result in life-threatening hemorrhage. nal trauma. Bleeding into the chest may cause dyspnea in
You must always be alert to the possibility of inter- addition to tachycardia and hypotension. A bruise is also
nal bleeding and assess the patient for related signs and called a contusion, or ecchymosis. A hematoma, a mass
symptoms, particularly if the MOI is severe. If you sus- of blood in the soft tissues beneath the skin, indicates
pect that a patient is bleeding internally, you should bleeding into soft tissues and may be the result of a minor
promptly transport him or her to the hospital. or a severe injury. Bruising or ecchymosis may not be pres-
ent initially, and the only sign of severe pelvic or abdomi-
nal trauma may be redness, skin abrasions, or pain.
Mechanism of Injury for Internal Bleeding, however slight, from any body opening is
Bleeding serious. It usually indicates internal bleeding that is not
A high-energy MOI should increase your index of suspi- easy to see or control. Bright red bleeding from the mouth
cion for the possibility of serious unseen injuries such as or rectum or blood in the urine (hematuria) may suggest
internal bleeding in the abdominal cavity. Internal bleed- serious internal injury or disease. Nonmenstrual vaginal
ing is possible whenever the MOI suggests that severe bleeding is always significant.
forces affected the body. These forces include blunt and Other signs and symptoms of internal bleeding in
penetrating trauma. Internal bleeding commonly occurs both trauma and medical patients include the following:
as a result of falls, blast injuries, and automobile or Hematemesis. This is vomited blood. It may be bright
motorcycle crashes. Remember that internal bleeding can red or dark red, or, if the blood has been partially
result from penetrating trauma as well. digested, it may look like coffee-grounds vomitus.
As you assess a patient, look for signs of injury Melena. This is a black, foul-smelling, tarry stool
using DCAP-BTLS (Deformities, Contusions, Abrasions, that contains digested blood.
10 Section 7 Trauma
Hemoptysis. This is bright red blood that is that energized electrical lines are not close to where
coughed up by the patient. you will be working. In incidents involving violence,
Pain, tenderness, bruising, guarding, or swelling. These such as assaults or gunshot wounds, make sure that
signs and symptoms may mean that a closed frac- police are on scene. At times you may need to stage
ture is bleeding. several blocks away until law enforcement personnel
Broken ribs, bruises over the lower part of the chest, have secured the area.
or a rigid, distended abdomen. These signs and Follow standard precautions. Place several pairs of
symptoms may indicate a lacerated spleen or gloves in your pocket for easy access in case your gloves
liver. Patients with an injury to either organ may tear or there are multiple patients with bleeding. If you
have referred pain in the right shoulder (liver) or are entering a residence, be alert for anxious bystanders
left shoulder (spleen). You should suspect inter- and family members because they may become hostile.
nal abdominal bleeding in a patient with referred Ensure that you are only going to have to provide care for
pain. one patient. Consider early on what you may need, and
The first sign of hypovolemic shock (hypoperfusion) verify as you begin your assessment.
is a change in mental status, such as anxiety, restless- Mechanism of Injury/Nature of Illness
ness, or combativeness. In nontrauma patients, weak- Determine the nature of the illness (NOI) (such as bloody
ness, faintness, or dizziness on standing is another early emesis or bloody stool), or the MOI (such as a turned-
sign. Changes in skin color or pallor (pale skin) are seen over step stool). Consider the need for manual spinal sta-
often in both trauma and medical patients. Later signs of bilization and the need for additional resources, such as
hypoperfusion suggesting internal bleeding include the an advanced life support unit. Be sure to also consider
following: environmental factors in your decision making. For
Discusses the specific
Tachycardia example, caring for a sick or injured victim of a car crash
Weakness, fainting, or dizziness at rest needs and emergency
on a clear, sunny day is a bit different than treating the
Thirst same victim during a snowstorm. Extreme hotpatients,
care of pediatric or cold
Nausea and vomiting geriatric
weather can worsen a patient’s overall patients, and
condition.
Cold, moist (clammy) skin special needs patients.
Shallow, rapid breathing
Dull eyes SSpecial
pecial PPopulations
opulations
Slightly dilated pupils that are slow to respond
In older patients, dizziness, syncope, or weakness may
to light
be the first sign of nontraumatic internal hemorrhage.
Capillary refill of more than 2 seconds in infants
and children
Weak, rapid (thready) pulse

Decreasing blood pressure
Altered level of consciousness
4Primary Assessment
In patients with suspected significant blood loss from a
Patients with these signs and symptoms are at risk.
visible wound or from unseen internal bleeding, you must
Some may be in danger. Even if their bleeding stops, it
not be distracted from identifying life threats. The EMT
could begin again at any moment. Therefore, prompt
should treat the patient according to the ABCs and pro-
transport is necessary.
vide treatment needed to preserve life. The management
of life-threatening concerns during the primary assess-
ment is determined by asking yourself, “What is going
Patient Assessment for External to kill my patient first?” For example, in some situations,
significant bleeding may need management before apply-
and Internal Bleeding
6 ing oxygen for a person with adequate breathing. The
Reinforcement of the
decision on what to treat first will come with experience.
patient assessment process
4Scene Size-up Treating according to the ABCs is always a good choice.
taught in Chapter 8, Patient
Form General
Assessment, as it relatesImpression
Scene Safety specifically to externalaand
As you approach trauma patient, you must note impor-
As you approach the patient, be alert to potential tant indicators
internal bleeding. that may alert you to the seriousness of
hazards to yourself and the crew, bystanders, and the the patient’s condition. For example, patients with exter-
patient(s). At vehicle crashes, ensure that there is no nal bleeding may have blood stains on their clothing.
leaking fuel in the area where you will be working and Be aware of obvious signs of injury and distress (such
as facial grimace), along with determining gender and can be bandaged later in your assessment as necessary.
age. Assess skin color. Pale or gray, cool, moist skin sug- Significant bleeding, internal or external, is an immedi-
gests a perfusion problem. Determine the patient’s level ate life threat. Treat the patient for shock if needed by
of consciousness using the AVPU scale (Awake and alert; applying oxygen, improving circulation, and maintaining
responsive to Verbal stimuli or Pain; Unresponsive). Is a normal body temperature.
the patient able to speak? This will indicate whether or
not the airway is patent. What is the mental status of Transport Decision
the patient? These indicators will help you determine The results of your initial general impression and assess-
whether the patient is sick or not so sick; this assists you ment of the ABCs will help you develop a sense of urgency
in developing an index of suspicion for serious illness or for the patient and guide you in your transport decision
injuries related to internal bleeding. to manage the patient on scene or manage the patient on
the way to the hospital. For example, if the patient has
Airway and Breathing
signs and symptoms of internal bleeding or airway or
Consider the need for spinal stabilization. At the same
breathing problems, you must transport quickly to the
time, ensure a patent airway, look for adequate breathing,
appropriate hospital for treatment by a physician. The
and check for breath sounds. If necessary, provide the
condition of patients who may have significant bleeding
patient with high-flow oxygen or assist ventilation with a
will quickly become unstable. Signs such as tachycardia,
bag-mask device or nonrebreathing mask, depending on
tachypnea, low blood pressure, weak pulse, and clammy
the patient’s level of consciousness and rate and quality of
skin are signs of impending circulatory collapse and
breathing. If the patient is unconscious, the airway may
imply the need for rapid transport.
be obstructed.
Circulation
You must be able to quickly assess pulse rate and qual-
ity; determine the skin condition, color, and tempera-
4History Taking
ture; and check the capillary refill time to help establish Investigate Chief Complaint
the potential for internal bleeding and shock. When life- After the primary assessment is complete, investigate the
threatening external bleeding is seen, you must begin chief complaint and be alert for signs or symptoms of
the steps necessary to control the external bleeding and other injuries due to the MOI and/or NOI. Internal bleed-
treatment of shock should begin as quickly as possible. ing can be found in both medical and trauma patients.
Non–life-threatening bleeding, such as with abrasions, If the bleeding is severe, you may have identified it in
ou a
You
Y are
re tthe
he Provider:
Provider: PART 2
PART
Y arrive
You i att th
the scene andd findd the
th patient
ti t standing
t di outside
t id iin ffrontt off th
the shop.
h He h
H has a ttowell wrapped
d
around his left wrist; however, it is soaked in blood and you can see a large amount of blood on the ground. He is
conscious and alert, but anxious, and tells you that he cut his wrist on a table saw when his arm slipped and ran
into the blade.
3. Is the patient effectively controlling the bleeding from his injury?

4. What should be your initial treatment priority?
12 Section 7 Trauma
the primary assessment and begun treatment and rapid Look for signs and symptoms of shock (hypoperfusion)
transport to the hospital. If the signs and symptoms of and determine how much blood has been lost.
internal bleeding are not as obvious as described previ-
ously, you will need to look more carefully in this step of
the patient assessment process . In a responsive
4Secondary Assessment
As described earlier, the secondary assessment is a
trauma patient who has an isolated injury with a limited detailed, comprehensive examination of the patient to
MOI, consider a focused assessment before assessing vital uncover injuries that may have been missed during the
signs and obtaining a history. primary assessment. The EMT should record vital signs,
When you encounter a patient who is bleeding, it is complete a focused assessment of pain, and attach appro-
important to avoid focusing only on the bleeding. With priate monitoring devices. In some instances, such as a
significant trauma, you should assess the entire patient, critically injured patient or a short transport time, there
looking for fractures and other problems. Determine if may not be time to conduct a secondary assessment.
there are any preexisting illnesses.
Physical Examinations
SAMPLE History When performing a secondary assessment, the examina-
Obtain a SAMPLE history from your patient. Be sure to tion should include a systematic full body scan. Assess the
ask the patient if he or she takes blood-thinning med- respiratory system. Specifically assess the airway for pat-
ications. If so, be aware that bleeding will generally be ency and determine the rate and quality of respirations.
more profuse and more difficult to control. If the patient In the neck, look for distended neck veins and a deviated
is unresponsive, obtain history information from medical trachea. In the chest, check for paradoxical movement of
alert tags or ask bystanders if they have any information. the chest wall and bilateral breath sounds.
Table 22-2 The Mechanism of Injury: Indicators of Internal Bleeding

Mechanism of Injury Potential Internal Bleeding Sources
Fall from a ladder striking the head Head injury or hematoma
Fall from a ladder striking the Possible fractures; consider chest injury
extremities
Child struck by a car Head trauma, chest and abdominal injuries, leg fractures
Fall on an outstretched arm Possible broken bone or joint injury
Child thrown or falls from a height Children usually have a head-first impact, causing head injury
Unrestrained driver in head-on Head and neck, chest, abdomen injuries Organizes information
collision Knees, femur, hip, and pelvis injuries so students can quickly
Unrestrained front-seat passenger, locate
Humerus broken exposing the chest wall (possible flail chest); andand
pelvis retain critical
acetabulum
side impact collision with intrusion injuries information.
into vehicle
Unrestrained driver crushed against Chest and abdomen injuries, ruptured spleen, neck trauma
steering column
Road bike or mountain bike (over the Fractured clavicle, road rash, head trauma if no helmet
handlebars)
Abrupt motorcycle stop, causing rider Fractured femurs, head and neck injuries
to catapult over the handlebars
Diving into the shallow end of a Head and neck injuries
swimming pool
Assault or fight Punching or kicking injury to chest, abdomen, and the face
Blast or explosion Injury from direct strike with debris; indirect and pressure wave in enclosed space.
External injuries are dependent upon the anatomic area of the body injured. Internally,
air-containing organs such as the middle of the ears and lungs are the most susceptible
to injury.
Assess the cardiovascular system, specifically the rate nature. Children especially will compensate well for
and quality of pulses. blood loss and then “crash” quickly. The reassessment
Assess the neurologic system to formulate baseline is your best opportunity to determine whether your
data to guide further decisions. This examination should patient’s condition is improving or getting worse. Assess
include level of consciousness, pupil size and reactivity, the effectiveness of any interventions and treatments
motor response, and sensory response. provided to the patient.
Assess the musculoskeletal system. Perform a Vital signs show how well your patient is doing inter-
detailed full body examination. Look for DCAP-BTLS to nally. In all cases of severe bleeding, obtain the patient’s
be sure that you have found all of the problems and inju- vital signs every 5 minutes. Is the patient’s airway still
ries quickly. patent and breathing still adequate? Is the oxygen help-
Assess all anatomic regions. When you are exam- ing the patient to breathe easier? Is your treatment for
ining the head, be alert for raccoon eyes, Battle’s sign, shock resulting in better perfusion of the vital organs?
and/or drainage of blood or fluid from the ears or nose. Is the bandage controlling the bleeding?
In the abdomen, feel all four quadrants for tenderness
or rigidity. In the extremities, record pulse, motor, and Interventions
sensory function. Whenever you suspect significant bleeding, either exter-
nal or internal, provide high-flow oxygen. If significant
Vital Signs bleeding is visible, begin the steps to control external
You must assess baseline vital signs to observe the bleeding, as shown in Skill Drill 22-1. Using multiple
changes that may occur during treatment. A systolic methods to control external bleeding usually works best.
blood pressure of less than 100 mm Hg with a weak, If the patient has signs of hypoperfusion, provide aggres-
rapid pulse should suggest to you the presence of hypo- sive treatment for shock and rapid transport to the appro-
perfusion in a patient who may have significant bleed- priate hospital. If internal bleeding is suspected, apply
ing. Cool, moist skin that is pale or gray is an important high-flow oxygen via a nonrebreathing mask and provide
sign that the patient is experiencing a perfusion problem. rapid transport to the hospital. See Skill Drill 22-4 for
Because infants and children have less blood volume to additional steps to take.
begin with, the same effect is seen with smaller amounts You should not delay transport of a patient to com-
of blood loss. plete an assessment, particularly when significant bleed-
In geriatric patients, the pulse rate may not increase ing is present, even if the bleeding is controlled. The
with early shock; therefore, if possible, try to determine assessment can be started during transport.
the patient’s normal baseline blood pressure and circula-
tory status. Communication and Documentation
In patients with severe external bleeding, it is important
Monitoring Devices to recognize, estimate, and report the amount of blood
In addition to hands-on assessment, the EMT should loss that has occurred and how rapidly or over what
use monitoring devices to quantify oxygenation and cir- period of time it occurred. This can be a challenge to esti-
culatory status. The EMT may use a noninvasive tech- mate, especially if the surface the patient is on is wet or
nique to monitor blood pressure and a pulse oximeter absorbs fluids or if the environment is dark. For example,
to evaluate the effectiveness of oxygenation. It is recom- you may report that approximately one quart of blood
mended that the EMT always assess the patient’s blood was lost or that the bleeding soaked through three trauma
pressure with a sphygmomanometer and stethoscope dressings. Report this information to hospital personnel
(manually) before using a noninvasive blood pressure during transport to allow the hospital to evaluate needed
monitor to establish a baseline blood pressure and to resources, such as the availability of surgical suites, sur-
determine the accuracy of the noninvasive blood pres- geons, and other specialty providers. Your transfer report
sure machine. at the hospital should update hospital personnel on how
your patient has responded to your care. Be sure your
4Reassessment paperwork reflects all of the patient’s injuries and the care
you have provided.
The reassessment is an important tool to see how your With internal bleeding, describe the MOI/NOI and
patient is doing over time. Reassess the patient, especially the signs and symptoms that make you think internal
in the areas that showed abnormal findings during the bleeding is occurring. Report this information to the
primary assessment. The signs and symptoms of internal emergency department personnel to allow them to pre-
bleeding are often slow to present because of their covert pare to treat the patient on arrival. Communicate with
14
14 Section77 Trauma
Section Trauma
the
thehospital
hospitalon onyour
yourfifindings
ndingsandandthe
theinterventions
interventionsused
used
to
toimprove
improvethe thepatient’
patient’sscondition.
condition.Be Besure
sureto
todocument
document
all
all of
of the
the patient’
patient’ss injuries,
injuries, the
the care
care provided,
provided, and
and the
the
patient’
patient’ss response
response to to the
the care.
care. Give
Give the
the information
information to
to
emergency
emergencydepartment
departmentpersonnel.
personnel. 1.
1.Follow
Followstandard
standardprecautions.
precautions.
2.
2.Maintain
Maintain the
the airway
airway with
with cervical
cervical spine
spine immobi-
immobi-
lization
lization ifif the the mechanism
mechanism of of injury
injury suggests
suggests the the
Emergency
Emergency Medical
Medical Care
Care for
for possibility
possibilityof ofspinal
spinalinjury.
injury.
External
External Bleeding
Bleeding 3.
3.Administer
Administerhigh-fl high-flow owoxygen
oxygenas asnecessary.
necessary.
6
6 4.
4.Almost
Almost all all cases
cases of of external
external bleeding
bleeding can can bebe con-
con-
As
As you
you begin
begin to
to care
care for
for aa patient
patient with
with obvious
obvious external
external trolled
trolled simply
simply by by applying
applying direct
direct
Provides local
local pressure
written pressure to
step- to
bleeding,
bleeding,rememberrememberto tofollow
followstandard
standardprecautions.
precautions.ThisThis the
the bleeding
bleeding site. site. This
This method
method is
is by
by far
far
by-step explanations of the
the most
most
includes,
includes, atat aa minimum,
minimum, glovesgloves and
and eyeeye protection
protection andand effective
effective way way to to control
controlimportant
external
externalpsychomotor
bleeding.
bleeding. Pres- Pres-
often
often aa mask mask andand possibly
possibly aa gown.
gown. As As with
with all
all patient
patient sure
sure stops
stops the the flflow
ow of of blood
blood and
and permits
permits normal
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skills and procedures.
care,
care, makemake suresure that
that the
the patient
patient has
has anan open
open airway
airway andand coagulation
coagulation to to occur.
occur. You You may may apply
apply pressure
pressure
isis breathing
breathing adequately.
adequately. Provide
Provide high-fl
high-flowow oxygen
oxygen to to the
the withyour
with yourglovedglovedfifingertip
ngertipor orhand
handoveroverthe thetop topof
of
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then concentrate
concentrate on on controlling
controlling the the aa sterile
sterile dressing
dressing ifif one one isis immediately
immediately available.
available.
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bleeding. In In some
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life-threatening bleed-
bleed- IfIf there
there isis anan object
object protruding
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diate
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andcontrolled
controlledas asquickly
quicklyas aspossible.
possible. place,
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pressure as as best
best you
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can. Never
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Several
Several methods
methods are are available
available to to control
control external
external remove
remove an an impaled
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wound. Hold Hold
bleeding.
bleeding. Start Start with
with the
the most
most commonly
commonly used; used; these
these uninterrupted
uninterruptedpressure pressurefor foratatleast
least55minutes.
minutes.
include
includethe thefollowing:
following: 5.
5.Elevate
Elevate aa bleeding
bleeding extremity
extremity by by as
as little as 66"".. This
little as This
Direct,
Direct,evenevenpressure
pressureand andelevation
elevation often
often stops
stops venous
venous bleeding.
bleeding. Whenever
Whenever possible,
possible,
Pressure
Pressuredressings
dressings use
usebothbothtechniques:
techniques:direct directpressure
pressureand andelevation.
elevation.
Pressure
Pressurepoints
points(for
(forupper
upperandandlower
lowerextremities)
extremities) In
In most
most cases,
cases, thisthis will
will stop
stop the the bleeding.
bleeding. How- How-
Tourniquets
Tourniquets ever,
ever, ifif itit does
does not,
not, you
you still
still have
have several
several options.
options.
Splints
Splints Remember
Rememberto tonever
neverelevate
elevatean anopen
openfracture
fractureto tocon-
con-
ItIt will
will often
often bebe useful
useful toto combine
combine thesethese meth-
meth- trol
trolbleeding.
bleeding.Fractures
Fracturescan canbe beelevated
elevatedafteraftersplint-
splint-
ods.
ods. illustrates
illustrates thethe basic
basic techniques
techniques to to ing,
ing,andandsplinting
splintinghelpshelpscontrol
controlbleeding
bleeding Step Step11 ..
control
control external
external bleeding
bleeding thatthat do
do not
not require
require special
special 6.
6.Once
Onceyou youhave haveapplied
appliedaadressing
dressingto tocontrol
controlbleed-
bleed-
equipment.
equipment. ing,
ing, create
create aa pressure
pressure dressing
dressing to to maintain
maintain the the
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RTT3
Bleeding
Bleedingfrom
fromthe
thepatient’s
patient
patient’s
patientssinjury
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hasbeen
beencontrolled
controlled.
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controlled.While
Whileyou
youfurther
furtherassess
assessthe
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patient
patient,
patient your
yourpartner
partnerapplies
applies
high-fl
high-flow
owoxygen,
oxygen,obtains
obtainsthe
thepatient’s
patient’svital
vitalsigns,
signs,and
andinquires
inquiresabout
abouthis
hispast
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medicalhistory.
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anymedications.
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on oxygen
5.
5.What
Whatare
arethe
thecomponents
componentsof
ofthe
thecardiovascular
cardiovascularsystem?
system?How
Howdo
dothey
theyfunction
functionto
toperfuse
perfusethe
thebody’s
body’s
tissues
tissuesand
andcells?
cells?
6.
6.What
Whatfactors
factorsdetermine
determinethe
theseverity
severityof
ofexternal
externalbleeding?
bleeding?
pressure by firmly wrapping a sterile, self-adhering manual pressure through the dressing. Then add
roller bandage around the entire wound. Use 4" × more gauze pads over the first dressing, and secure
4" sterile gauze pads for small wounds and sterile them both with a second, tighter roller bandage.
universal dressings for larger wounds. Bleeding will almost always stop when the
Cover the entire dressing above and below the pressure of the dressing exceeds arterial pressure.
wound. Stretch the bandage tight enough to control This will assist in controlling bleeding and helping
bleeding. If you were able to palpate a distal pulse blood to clot Step 2 .
before applying the dressing, you should still be 7. If a wound continues to bleed despite use of direct
able to palpate a distal pulse on the injured extrem- pressure, elevate the extremity and move to the
ity after applying the pressure dressing. If bleed- use of a tourniquet Step 3 .
ing continues, the dressing is probably not tight Much of the bleeding associated with broken bones
enough. Do not remove a dressing until a physician occurs because the sharp ends of the bones cut muscles
has evaluated the p pp y additional
patient. Instead, apply and otherProvides
tissues.aAs longsummary
visual as a fracture remains unstable,
the bone ofends will move
important and continue to in
psychomotor injure partially
skills and procedures.
Controlling External Bleeding
Step 1 Apply direct pressure over the Step 2 Apply a pressure dressing.
wound. Elevate the injury above
the level of the heart if no fracture
is suspected.
Step 3 If the wound continues to bleed,

elevate the extremity and move to
the use of a tourniquet.
16 Section 7 Trauma
clotted vessels. Therefore, stabilizing a fracture and

decreasing movement is a high priority in the prompt
control of bleeding. Often, simple splints will quickly
control bleeding associated with a fracture . If
not, you may need to use another splinting device, such
as an air splint or a tourniquet, discussed next.
Recent studies have brought into question the effec-
tiveness of using pressure points in severe external
hemorrhage. It is preferable, if allowed by local proto-
col and policy, to move to the use of a tourniquet with-
out attempting pressure point control. If a tourniquet is
deemed necessary, it should be applied quickly and not
released until a physician is present.
Tourniquets
The tourniquet is especially useful if a patient has sub-
stantial bleeding from an extremity injury below the
axilla or groin. Follow the steps in to apply
a commercial tourniquet.
Words
Words ooff W
Wisdom
isdom
Superficial temporal
Historically, if direct pressure and elevation proved inef-
fective, EMS providers were advised to apply pressure to
a proximal arterial pressure point. A pressure point is External maxillary
a spot where a blood vessel lies near a bone. This tech-
nique should be considered interesting from a historic
Carotid
perspective only. Because a wound usually draws blood
from more than one major artery, proximal compression
of a major artery rarely stops bleeding completely. In rare Brachial
cases, it may help to slow the loss of blood. You would
need to be thoroughly familiar with the location of the
pressure points for this to work . Even if you
are familiar, there is no real evidence that this is an effec-
tive or safe method to control potentially fatal hemor-
rhage. If the patient has an open fracture of an extremity,
bleeding can be substantial. Consider a tourniquet early
if bleeding is not easily controlled with direct pressure or Ulnar
if pressure results in excessive pain. The method used to Femoral
control severe external bleeding may be governed by local Radial
protocol; regardless of the method, it must be quick and
Current,
effective. Remember that uncontrolled state-of-the-
bleeding results in
shock and then death. Patients can artand
medical content
do bleed is
to death
from extremity injuries. It is imperative that you use effec-
presented in an engaging
tive techniques to stop bleeding when you encounter it.
and comprehensive
writing style.
Words
Words ooff W
Wisdom
isdom
Hemostatic agents such as Celox, HemCon, and Quik- Posterior
tibial
Clot, are primarily utilized in the military to promote
hemostasis or, in other words, to stop profuse bleed-
ing. The agent may be granules poured into a wound or
contained in a dressing. The agent absorbs the water Dorsalis pedis
component of blood thereby concentrating the clotting
factors, activating platelets, and enhancing the coagula-
tion cascade. Some of these agents have an exothermic
affect that can damage the surrounding tissue.
1. Follow standard precautions.

2. Hold direct pressure over the bleeding site.
3. Place the tourniquet around the extremity just
above the bleeding site Step 1 .
4. Click the buckle into place and pull the strap
tight.
5. Turn the tightening dial clockwise until pulses are
no longer palpable distal to the tourniquet or until
bleeding has been controlled Step 2 .
6. To release the tourniquet at the hospital, or if
otherwise instructed by medical control, push the
release button and pull the strap back. Be aware
that bleeding may rapidly return upon tourniquet
release and that you should be prepared to reapply bleeding to reduce the amount of tissue damage to
it immediately if necessary. the extremity.
If a commercial tourniquet is not available, follow 3. Tie one knot in the bandage. Then place a stick
these steps to apply a tourniquet using a triangular ban- or rod on top of the knot, and tie the ends of the
dage and a stick or rod: bandage over the stick in a square knot.
1. Fold a triangular bandage until it is 4" wide and 4. Use the stick or rod as a handle, and twist it to
six to eight layers thick. tighten the tourniquet until the bleeding has
2. Wrap the bandage around the extremity twice. stopped; then stop twisting .
Choose an area only slightly proximal to the 5. Secure the stick in place, and make the wrapping
neat and smooth.
6. Write “TK” (for “tourniquet”) and the exact time
(hour and minute) that you applied the tourniquet
Step 1 Hold pressure over the bleeding Step 2 Click the buckle into place, pull the
site and place the tourniquet just strap tight, and turn the tightening
above the injury. dial clockwise until pulses are no
longer palpable distal to the tour-
niquet or until bleeding has been
controlled.
18 Section 7 Trauma
on a piece of adhesive tape. Use the phrase “time Splints

applied.” Securely fasten the tape to the patient’s Air splints can control internal or external bleeding
forehead. Notify hospital personnel on your associated with severe soft-tissue injuries, such as mas-
arrival that your patient has a tourniquet in place. sive or complex lacerations, or fractures .
Record this same information on the ambulance They also stabilize the fracture itself. An air splint acts
run report form. like a pressure dressing applied to an entire extremity
7. As an alternative, you can use a blood pressure rather than to a small, local area. Air splints are also
cuff as an effective tourniquet. Position the cuff commonly referred to as soft splints or pressure splints.
proximal to the bleeding point, and inflate it just Once you have applied an air splint, be sure to monitor
enough to stop the bleeding. Leave the cuff inflated. circulation in the distal extremity. Use only approved,
If you use a blood pressure cuff, monitor the gauge clean, or disposable valve stems when orally inflating
continuously to make sure that the pressure is not air splints.
gradually dropping. You may have to clamp the Rigid splints can help stabilize fractures as well as
tube with a hemostat leading from the cuff to the reduce pain and prevent further damage to soft-tissue
inflating bulb to prevent loss of pressure. injuries. Once you have applied a rigid splint, be sure to
Whenever you apply a tourniquet, make sure you monitor circulation in the distal extremity.
observe the following precautions: Traction splints are designed to stabilize femur frac-
Do not apply a tourniquet directly over any joint. tures. When the EMT pulls traction to the ankle, counter-
Keep it as close to the injury as possible. traction is applied to the ischium and groin. This reduces
Make sure the tourniquet is tightened securely. the thigh muscle spasms and prevents one end of the
Never use wire, rope, a belt, or any other narrow
material. It could cut into the skin.
Words
Words ooff W
Wisdom
isdom
Use wide padding under the tourniquet if possible.
This will protect the tissues and help with arterial Research indicates that a pelvic compression device is
compression. an effective method to reduce the width of pelvic ring
Never cover a tourniquet with a bandage. Leave it fractures. Overcompression has not been identified as
an issue to date. The decrease in the width of the frac-
open and in full view. ture will assist in the control of internal bleeding result-
Do not loosen the tourniquet after you have applied ing from the fracture, specifically an open book fracture
it. Hospital personnel will loosen it once they are of the pelvis.
prepared to manage the bleeding.
ou a
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Provider: PART 4
PART
The patient is placed onto the stretcher and loaded into the ambulance.
ambulance He remains conscious and alert,
alert but is
still anxious. You place him in a supine position, elevate his legs, and cover him with a blanket. Shortly before
departing the scene, you reassess him and obtain another set of vital signs.
Progressive case studies
introduce patients and
follow their progress from
dispatch to delivery at the
emergency department.
The cases become
progressively more detailed
on oxygen as new medical information
is presented.
7. How might a patient’s outcome be affected if bleeding is internal rather than external?
8. What are the signs and symptoms of internal bleeding?

2. Help the patient to sit, leaning forward, with the
head tilted forward. This position stops the blood
from trickling down the throat or being aspirated
into the lungs.
3. Apply direct pressure for at least 15 minutes by
pinching the fleshy part of the nostrils together.
This is the preferred method. This technique may
also be self-administered by the patient Step 1 .
4. Placing a rolled 4" × 4" gauze bandage between
the upper lip and the gum is another option.
Have the patient apply pressure by stretching the
upper lip tightly against the rolled bandage and
pushing it up into and against the nose. If the
patient is unable to do this effectively, use your
gloved fingers to press the gauze against the gum
Step 2 .
fracture from impacting or overriding the other. Be sure
to pad these areas well to prevent applying excessive 5. Keep the patient calm and quiet, especially if he or
pressure to the soft tissue of the pelvis. Once you have she has high blood pressure or is anxious. Anxi-
applied a traction splint, be sure to monitor circulation in ety tends to increase blood pressure, which could
the distal extremity. worsen the nosebleed.
6. Apply ice over the nose.
Bleeding From the Nose, Ears, 7. Maintain the pressure until the bleeding is
completely controlled, usually no more than
and Mouth 15 minutes (assuming that this is the patient’s only
Several conditions can result in bleeding from the nose, problem). Most often, failure to stop a nosebleed is
ears, and/or mouth, including the following: the result of releasing the pressure too soon Step 3 .
Skull fracture 8. Provide prompt transport once the bleeding has
Facial injuries, including those caused by a direct stopped.
blow to the nose 9. If you cannot control the bleeding, if the patient
Sinusitis, infections, nose drop use and abuse, dried has a history of frequent nosebleeds, or if there is
or cracked nasal mucosa, or other abnormalities a significant amount of blood loss, transport the
High blood pressure patient immediately. Assess the patient for signs
Coagulation disorders and symptoms of shock. Treat appropriately for
Digital trauma (nose picking) shock, and administer oxygen via mask, if nec-
Epistaxis, or nosebleed, is a common emergency. essary.
Occasionally, it can cause enough of a blood loss to send Bleeding from the nose or ears following a head
a patient into shock. Keep in mind that the blood you injury may indicate a skull fracture. In these cases, you
see may be only a small part of the total blood loss. Much should not attempt to stop the blood flow. This bleeding
of the blood may pass down the throat into the stomach may be difficult to control. Applying excessive pressure
as the patient swallows. A person who swallows a large to the injury may force the blood leaking through the ear
amount of blood may become nauseated and start vom- or nose to collect within the head. This could increase
iting the blood, which is sometimes confused with inter- the pressure on the brain and possibly cause permanent
nal bleeding. Most nontraumatic nosebleeds occur from damage. If you suspect a skull fracture, loosely cover the
sites in the septum, the tissue dividing the nostrils. You bleeding site with a sterile gauze pad to collect the blood
can usually handle this type of bleeding effectively by and help keep contaminants away from the site. There
pinching the nostrils together. illustrates is always a risk of infection to the brain. Apply light
the basic techniques to control epistaxis. compression by wrapping the dressing loosely around
20 Section 7 Trauma
the head . If blood or drainage contains that must be done in the hospital. It is important for
cerebrospinal fluid, a characteristic staining of the dress- you to remain calm and reassure the patient. Keeping
ing, much like a target or halo, will occur . the patient as still and quiet as possible assists the body’s
clotting process. Next, if spinal injury is not suspected,
place the patient in the shock position. Provide high-
Emergency Medical Care for flow oxygen; also maintain body temperature. You can
Internal Bleeding usually control internal bleeding into the extremities
6 quite well in the field simply by splinting the extrem-
ity, usually most effectively with an air splint, and you
Controlling internal bleeding or bleeding from major
organs usually requires surgery or other procedures should never use a tourniquet to control the bleeding
from closed, internal, soft-tissue injuries. Follow the
steps in to care for patients with possible
internal bleeding.
Controlling Epistaxis
Step 1 Position the patient sitting, leaning Step 2 Alternative method: Use pres-
forward. Apply direct pressure, sure with a rolled gauze bandage
pinching the fleshy part of the between the upper lip and gum.
nostrils together. Calm the patient.
Step 3 Apply ice over the nose. Maintain

pressure until bleeding is con-
trolled. Provide prompt transport
after bleeding stops. Transport
immediately if indicated. Assess
and treat for shock, including oxy-
gen, as needed.
Photos of real emergencies

prepare students for
the field.
6. Monitor and record the vital signs at least every

5 minutes.
7. Give the patient nothing (not even small sips of
water) by mouth.
8. Elevate the legs 6" to 12" in nontrauma patients
2. Maintain the airway with cervical spine immobili- to help the blood return to the vital organs.
zation if a mechanism of injury suggests the pos- 9. Keep the patient warm.
sibility of spinal injury.
10. Provide immediate transport for all patients with
3. Administer high-flow oxygen and provide artifi-
signs and symptoms of shock (hypoperfusion).
cial ventilation as necessary.
Report any changes in the patient’s condition to
4. Control all obvious external bleeding. emergency department personnel.
5. Treat suspected internal bleeding in an extremity
by applying a splint.
ou a
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Provider: PART 5
PART
You continue to monitor the patient en route to the hospital and reassess his condition as appropriate.
appropriate After
reassessing the patient and his vital signs, you call your radio report into the receiving facility.
on oxygen
The patient is delivered to the hospital and you give your report to the attending physician. An intravenous line
is started, the patient is given normal saline to improve his perfusion status, and he is admitted for observation.
9. How does the body typically respond to blood loss?

22 Section 7 Trauma
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Provider: S
SUMMARY
UMMARY
1. What are the functions of arteries? What major arteries are located in the upper extremity?
Arteries are high-pressure blood vessels that distribute oxygenated blood throughout the body. The largest
artery in the body, the aorta, arises from the left ventricle and branches into smaller arteries and arterioles
that deliver oxygen to the body’s tissues and cells. In general, arteries carry highly oxygenated blood away
from the heart; an exception to this is the pulmonary artery, which carries deoxygenated blood from the
right ventricle to the lungs where it is reoxygenated.
Two major arteries are located in the upper extremity, the radial artery, which is located on the thumb-side
(lateral) aspect of the wrist, proximal to the hand, and the brachial artery, which is located on the inner
(medial) aspect of the arm, just proximal to the elbow.
2. Why is arterial bleeding more severe than venous bleeding? Progressive case studies are followed
by a summary of answers to the
Blood flow through the arteries is driven by contraction of the powerful left ventricle. Pressure in the arter-
pressurecritical-thinking
ies is much higher than pressure in the veins (high capacitance, low-pressure blood vessels questions,
that returnas well as:
deoxygenated blood to the heart). • Additional signs and symptoms
commonly associated with the
Because blood flow through the arteries is much higher, blood loss is generally more rapid and severe. Arte-
rial bleeding is also more difficult to control than venous bleeding. Oxygen loss patient’s
is more injury
severeor from
condition
arterial
bleeding than it is from venous bleeding; this is because arterial blood • Additional pathophysiologic
ood carries a higher concentration of
oxygen than do the veins. information regarding the
The color of blood and characteristic of the bleeding are often clues to the typepatient’s
of bloodinjury or condition
vessel that is
injured. Venous blood is dark red and flows from the injury site, whereas • Information
ereas arterial and justifi
blood is bright redcation
and
spurts from the wound each time the left ventricle contracts. for each treatment modality
3. Is the patient effectively controlling the bleeding from his injury?

As evidenced by the blood-soaked towel and large amount of blood on the ground, it is clear that the
patient is not effectively controlling the bleeding from his injury. Furthermore, you do not know how much
blood he has lost because he is standing outside—not in the area where the injury occurred. The fact that he
is anxious and has cool, pale skin suggests significant external blood loss.
4. What should be your initial treatment priority?

You must take immediate action to control the patient’s bleeding. His airway is patent, as evidenced by the
fact that he is conscious, alert, and talking. One EMT can attempt to control the patient’s bleeding as the
other applies high-flow oxygen.
In most cases, direct pressure will control both venous and arterial bleeding. However, if direct pressure
alone is ineffective, continued direct pressure and elevation of the extremity above the level of the heart
typically controls the bleeding. Historically, if direct pressure and elevation are ineffective, application
of pressure to a proximal arterial pressure point has been the next step in controlling severe external
bleeding.
Recent evidence exists that supports the application of a proximal tourniquet, instead of pressure point
control, if direct pressure and elevation are ineffective in controlling severe external bleeding. However, this
treatment is largely governed by local protocol. Regardless of the method used to control severe external
bleeding, it must be quick and effective.
5. What are the components of the cardiovascular system? How do they function to perfuse the body’s
tissues and cells?
The cardiovascular system—the system responsible for supplying and maintaining adequate blood flow to
the body’s tissues and cells—consists of three components: the heart (pump), the container (the blood
ou a
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Provider: S
SUMMARY,
UMMARY, ccontinued
ontinued
vessels), and the fluid (blood and body fluids). These components of the cardiovascular system are
interdependent—that is, they rely on each other mutually to perform a common function.
The heart must be able to contract forcefully and fast enough to move oxygenated blood through the blood
vessels to adequately perfuse the body’s tissues and cells. Failure of any one of these components will result
in inadequate perfusion of the body, a condition known as shock.
6. What factors determine the severity of external bleeding?

Several factors determine the severity of external bleeding. The single most influential factor is the type
and size of the blood vessel that is injured. A lacerated brachial artery, for example, will bleed more severely
than a small vein in the leg. As previously discussed, arteries are under high pressure, while veins are under
low pressure.
How the vessel is injured is also a determining factor in the severity of the bleeding and the diffi culty in
controlling it. A longitudinal laceration—one that extends in the direction of the length of the blood vessel—
usually bleeds more profusely and is more difficult to control than a transverse laceration—one that is
directly across the blood vessel.
The patient’s blood pressure and heart rate can also affect the severity of external bleeding. For example,
a patient with a blood pressure of 190/90 mm Hg and a heart rate of 120 beats/min would likely bleed
more profusely than a patient with a blood pressure of 70/40 mm Hg and a heart rate of 50 beats/min.
The greater the pressure on the arterial wall and the faster the heart rate, the more rapid the bleeding
tends to be.
Certain aspects of a patient’s medical history also can impact the severity of external bleeding. For example,
patients who take blood-thinning medications (ie, warfarin [Coumadin]) or those with a bleeding disor-
der (ie, hemophilia) tend to bleed faster because it takes longer for their blood to clot. For this and other
reasons, it is important to obtain an accurate medical history from the patient.
7. How might a patient’s outcome be affected if bleeding is internal rather than external?
Compared to external bleeding, which you can see and control, internal bleeding is hidden and cannot be
controlled in the prehospital setting. Many patients with internal bleeding do not present with signs or
symptoms of shock until a significant amount of blood has been lost.
Overall, patients with internal bleeding have a higher mortality rate than those with external bleed-
ing. Most of these deaths are the result of intrathoracic or intra-abdominal bleeding in which surgical
intervention is delayed. Internal bleeding can also be caused by multiple long bone fractures and pelvic
fractures.
You must always be alert to the possibility of internal bleeding and assess the patient for related signs and
symptoms, particularly if the mechanism of injury is significant. Remember this: if a trauma patient is in
shock but does not have any obvious external signs of injury, suspect internal bleeding!
8. What are the signs and symptoms of internal bleeding?

Since internal bleeding cannot be seen outright, you must rely on your assessment skills and careful evalu-
ation of the mechanism of injury. Signs and symptoms of internal bleeding are essentially those of shock:
restlessness or anxiety; cool, pale, clammy skin; tachycardia; rapid, shallow breathing; thirst; and as a late
sign, hypotension.
External indicators of internal bleeding in both medical and trauma patients include hematemesis (vomiting
blood), melena (dark, tarry stools), and hemoptysis (coughing up blood).
Other indicators of internal bleeding, which are more common in trauma patients, include redness or
bruising, swelling, or tenderness over the injured area.
24 Section 7 Trauma
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Provider: S
SUMMARY,
UMMARY, ccontinued
ontinued
9. How does the body typically respond to blood loss?

The body will not tolerate an acute blood loss of greater than 20% of blood volume. The typical adult has
approximately 70 mL of blood per kilogram of body weight; in a person who weighs 80 kg (175 lb), this
equals 6 L (10 to 12 pints).
If the typical adult loses more than 1 L of blood (about 2 pints), significant changes in vital signs will occur,
including increasing heart and respiratory rates, and as a later sign, a decreasing blood pressure.
A loss of circulating blood volume is sensed by receptors in the body, which send messages to the nervous
system. The nervous system, specifically, the sympathetic nervous system, releases epinephrine and nor-
epinephrine. Norepinephrine constricts the peripheral blood vessels (vasoconstriction), thus shunting blood
from areas of lesser need (ie, skin and muscles) to areas of greater need (ie, heart, brain, kidneys, liver).
Epinephrine causes increases in heart rate and cardiac contractility. The net effect is to maintain adequate
perfusion of the body’s vital organs. If blood loss continues, however, the body’s compensatory mechanisms
will eventually fail, the patient’s blood pressure will fall, and he or she will die.
EMS Patient Care Report (PCR)

Date: 6-30-09 Incident No.: 220109 Nature of Call: Laceration Location: 517 E. Graham
Dispatched: 1620 En Route: 1621 At Scene: 1627 Transport: 1642 At Hospital: 1655 In Service:
1704
Patient Information
Age: 32 Allergies: No known drug allergies
Sex: M Medications: None
Weight (in kg [lb]): 82 kg (180 lb) Past Medical History: None Progressive case studies
Chief Complaint: Laceration to left wrist
conclude with a complete
Vital Signs
Patient Care Report to
Time: 1637 BP: 104/60 Pulse: 120 Respirations: 24 O2: 95%
teach Sa
students how to
Time: 1642 BP: 112/70 Pulse: 116 Respirations: 24 properly : 98% patient
SaOdocument
2
Time: 1649 BP: 114/68 Pulse: 110 Respirations: 20 assessment

SaO2: 97%
and care.
EMS Treatment
(circle all that apply)
Oxygen @ 15 L/min via (circle one): Assisted Ventilation Airway Adjunct CPR
NC NRM
Defibrillation Bleeding Control Bandaging Splinting Other Shock
treatment
Narrative
Dispatched for a patient with severe bleeding from the arm. Arrived on scene to find the patient, a 32-year-old male,
standing in front of his place of employment, a woodworking shop. He was conscious and alert, but notably anxious.
His airway was patent and his breathing, although increased, was producing adequate tidal volume. Patient had blood-
soaked towel wrapped around his left wrist and an impressive amount of blood was on the ground where he was stand-
ing. Patient stated that his hand slipped while he was working with a table saw and his left wrist ran across the blade.
Immediately applied direct pressure to patient’s wrist with sterile dressing and elevated his left arm. This intervention
successfully controlled the bleeding; a pressure dressing was then applied to maintain bleeding control. Applied oxygen at
15 L/min via nonrebreathing mask and obtained vital signs, as noted above. Further assessment revealed that patient’s
skin was cool, pale, and dry. Patient denied significant past medical history and further denied taking any medications.
Placed patient onto stretcher, covered him with a blanket, elevated his lower extremities, and placed him into the ambu-
lance. Reassessed patient’s vital signs and began transport to the hospital. Continued to monitor patient’s condition
en route; he remained conscious and alert, although anxious, and his vital signs remained stable. Reassessed bandaged
wound and noted that the bleeding remained controlled. Called report to receiving facility to inform them of our arrival.
Delivered patient to hospital without incident. Verbal report given to charge nurse. **End of report**
External Bleeding Internal Bleeding
Scene Size-up
Scene Safety Ensure scene safety. If incident involved Ensure scene safety. Consider if additional
violence, ensure that police are on scene. resources are needed. Follow standard pre-
Consider if additional resources are needed. cautions.
Wear a minimum of gloves and eye protection
to protect from bleeding.
Mechanism of Determine the MOI/NOI. High-energy MOI should increase your index
Injury/Nature of of suspicion for possible internal bleeding.
Illness
Primary Assessment
Form General Check for responsiveness and look for blood Suspect internal bleeding after blunt or pene-
Impression stains or other obvious signs of external trating trauma. Determine level of conscious-
bleeding. Assess skin color. Manage signifi- ness using AVPU and check the patient’s
cant visible bleeding. mental status. Assess skin color. Consider the
need for manual spinal immobilization.
Airway and Ensure a patent airway, look for adequate Ensure a patent airway, look for adequate
Breathing breathing, and check for breath sounds. If breathing, and check for breath sounds. If
necessary, provide high-flow oxygen or assist necessary, provide high-flow oxygen or assist
ventilation. ventilation.
Circulation Assess pulse rate and quality, skin color and Assess pulse rate and quality, skin color and
temperature, and check capillary refill time. temperature, and check capillary refill time.
Control external bleeding with direct pressure, Treat the patient for shock if needed by
elevation, or use of a tourniquet. Treat for shock applying oxygen, improving circulation, and
if needed by applying oxygen, improving circu- maintaining normal temperature.
lation, and maintaining normal temperature.
Transport Transport quickly if breathing problem or If you suspect internal bleeding or signs of
Decision significant bleeding exists. shock are present, promptly transport to the
hospital.
History Taking
Investigate Ask the patient about the chief complaint, if Ask the patient what happened.
Chief Complaint responsive. Attempt to determine the amount
of blood loss.
Summarizes and reviews
the patient assessment
process and the specific
findings presented in
the chapter.
26 Section 7 Trauma
essment
Physical Perform a systematic full-body scan. Assess Perform a systematic full-body scan. Assess
Examinations respiratory, cardiovascular, neurologic, respiratory, cardiovascular, neurologic,
musculoskeletal (using DCAP-BTLS), and musculoskeletal (using DCAP-BTLS), and
anatomic regions. anatomic regions. Look for bruising, pain,
abdominal distention, and guarding.
Vital Signs Assess vital signs. Look for signs of shock: Assess vital signs. Look for signs of shock:
systolic blood pressure less than 100 mm Hg systolic blood pressure less than 100 mm Hg
with weak, rapid pulse. Pale or gray, cool, with weak, rapid pulse. Pale or gray, cool,
moist skin suggests a perfusion problem. moist skin suggests a perfusion problem.
Reassessment
Interventions Repeat the primary assessment and reassess Repeat the primary assessment and reassess
interventions performed. Reassess vital signs interventions performed. Internal bleeding
and the chief complaint. In cases of severe is often slow to present. Reassess vital signs
bleeding, obtain vital signs at least every and the chief complaint. Provide high-flow
5 minutes while providing high-flow oxygen. oxygen. Determine whether patient’s condi-
Control significant bleeding and if signs of tion is improving or deteriorating.
shock are present, treat aggressively. Deter-
mine whether patient’s condition is improving
or deteriorating.
Communica- Report approximate amount of blood lost, Describe the MOI/NOI and signs and symp-
tion and how rapidly, and over what period of time. toms that make you suspect internal bleed-
Documentation Communicate interventions performed, and ing is occurring. Communicate interventions
how patient has responded to care. performed, and how patient has responded
to care.
NOTE: Although the steps below are widely accepted, be sure to consult and follow your local protocol.
Emergency Care
re
Steps to Caring for Patient With External Steps to Caring for Patient With Internal
Bleeding Bleeding
1. Follow standard precautions—minimum of 1. Follow standard precautions.
gloves and eye protection. 2. Maintain the airway with cervical immo-
Summarizes and reviews 2. Maintain cervical stabilization if MOI bilization if MOI suggests possible spinal
the emergency care skills sugge
suggests possible spinal injury. injury.
3. Administer high-flow oxygen as necessary. 3. Administer high-flow oxygen and provide
for the illnesses and artificial ventilation as necessary.
4. Control external bleeding using one of the
injuries presented in following methods: 4. Control all obvious external bleeding.
the chapter. • Direct pressure and elevation 5. Apply a splint to an extremity where
• Pressure dressings internal bleeding is suspected.
• Tourniquets 6. Monitor and record vital signs at least
• Splints every 5 minutes.
Emergency Care
re
5. Apply direct local pressure to bleeding site. 7. Give the patient nothing by mouth.
6. Elevate the bleeding extremity. 8. Elevate the legs 6” to 12” in nontrauma
7. Create a pressure dressing. patients.
8. If the wound continues to bleed, consider 9. Keep the patient warm.
the use of a tourniquet. Follow local pro- 10. Provide immediate transport for patients
tocol for approved methods of bleeding with signs and symptoms of shock.
control. Report changes in condition to hospital
personnel.
2. Hold direct pressure over the bleeding site.
3. Place the tourniquet around the extremity
just above the bleeding site.
4. Click the buckle into place and pull the
strap tight.
5. Turn the tightening dial clockwise until
pulses are no longer palpable distal to the
tourniquet or until bleeding is controlled.
Treating Epistaxis
2. Help the patient to sit, leaning forward,
with the head tilted forward.
3. Apply direct pressure for at least 15 min-
utes by pinching nostrils together.
4. Keep the patient calm and quiet.
5. Apply ice over the nose.
6. Maintain the pressure until bleeding is
completely controlled.
7. Provide prompt transport.
8. If bleeding cannot be controlled, transport
patient immediately. Treat for shock and
administer oxygen via mask if necessary.
CHAPTER
Prep
22 KitHere and I need
Title Goes
6
the longest
Ready for Review title
6
Vital Vocabulary
Perfusion is the circulation of blood in adequate amounts aorta The main artery that receives blood from the left ventri-
to meet each cell’s current needs for oxygen, nutrients, cle and delivers it to all the other arteries that carry blood
and waste removal. to the tissues of the body.
Providesleading
arterioles The smallest branches of arteries a list oftokey
the vast
The three arms of the perfusion triad must be function- terms and definitions
network of capillaries.
ing to meet this demand: a working pump (heart), a set
of intact pipes (blood vessels), and fluid volume (enough artery A blood vessel, consisting offromthreethe chapter.
layers of tissue and
oxygen-carrying smooth muscle that carries blood away from the heart.
Summarizes chapter blood).
Hypoperfusion, or shock, occurs when one or more of capillaries The small blood vessels that connect arterioles and
content

in a comprehensive venules; various substances pass through capillary walls,
these three arms is not working properly and the cardio-
bulleted list. into and out of the interstitial fluid, and then on to the
vascular system fails to provide adequate perfusion. cells.
Both internal and external bleeding can cause shock. You coagulation The formation of clots to plug openings in injured
must know how to recognize and control both. blood vessels and stop blood flow.
The methods to control bleeding, in order, are: contusion A bruise, or ecchymosis.
– Direct local pressure
– Elevation ecchymosis Discoloration of the skin associated with a closed
wound; bruising.
– Pressure dressing
– Tourniquet epistaxis A nosebleed.
– Splinting device hematemesis Vomited blood.
Bleeding from the nose, ears, and/or mouth may result hematoma A mass of blood in the soft tissues beneath the skin.
from a skull fracture. Other causes include high blood hemophilia A congenital condition in which the patient lacks
pressure and sinus infection. Evaluate the MOI and con- one or more of the blood’s normal clotting factors.
sider the more serious problem of skull fracture.
hemoptysis Coughing up blood.
Bleeding around the face always presents a risk for air-
hemorrhage Bleeding.
way obstruction or aspiration. Maintain a clear airway by
positioning the patient appropriately and using suction hypoperfusion A condition that occurs when the level of tis-
when indicated. sue perfusion decreases below that needed to maintain
normal cellular functions; also called shock.
If bleeding is present at the nose and a skull fracture is
hypovolemic shock A condition in which low blood volume,
suspected, place a gauze pad loosely under the nose.
due to massive internal or external bleeding or extensive
If bleeding from the nose is present and a skull fracture loss of body water, results in inadequate perfusion.
is not suspected, pinch both nostrils together for 15 min- melena Black, foul-smelling, tarry stool containing digested blood.
utes. If the patient is awake and has a patent airway, place
a gauze pad inside the upper lip against the gum. perfusion Circulation of blood within an organ or tissue in
adequate amounts to meet the current needs of the cells.
Any patient you suspect of having internal bleeding
pressure point A point where a blood vessel lies near a bone.
or significant external bleeding should be transported
promptly. shock A condition in which the circulatory system fails to pro-
vide sufficient circulation so that every body part can per-
If the mechanism of injury is significant, be alert to signs form its function; also called hypoperfusion.
of unseen bleeding in the chest or abdomen—signs such
as serious bruising or symptoms such as complaints of tourniquet The bleeding control method used when a wound
continues to bleed despite the use of direct pressure and
difficulty breathing or abdominal pain.
elevation; useful if a patient is bleeding severely from a
Signs of serious internal bleeding include the following: partial or complete amputation.
– Vomiting blood (hematemesis) vasoconstriction Narrowing of a blood vessel, such as with
– Black tarry stools (melena) hypoperfusion or cold extremeties.
– Coughing up blood (hemoptysis)
veins The blood vessels that carry blood from the tissues to
– Distended abdomen
the heart.
– Broken ribs
venules Very small, thin-walled vessels.
Assessment
in Action
Y our unit is dispatched to a roadside construction site for a blast-related injury.
The fire department arrives before you and radios to tell you that the scene is safe.
On your arrival, you are informed that your patient is a 46-year-old man who had been
blasting rock and had set the fuse too short. As he was leaving the area to seek cover from
the explosion, he was blown forward onto a gravel area. He tells you that he remembers
everything and he did not lose consciousness. He also indicates that the entire front of his
body
A short case study withhurts and he can’t hear very well. He denies having any past medical history or allergies
both critical-thinking andnot take any medications.
and does
multiple-choice On examination, you find minor bleeding from his ears and some cuts and bruises to his
questions
arms. As
allows students to
you remove his clothing, you find that his chest and abdomen are bruised. He complains
of increasing pain and experiences severe trouble breathing. As you begin your transport, you notice that he is now
synthesize and apply
presenting with hematemesis, cool and clammy skin, tachycardia, and hypotension.
what they have learned
in the chapter.
1. Does the mechanism of injury create the suspicion of 7. Is your patient’s pain likely to be a result of internal
serious injury prior to your arrival? or external injuries? Explain your answer.
2. What is the first important factor to consider in this 8. What condition is likely when signs of hypotension,
scenario? tachycardia, and cool, clammy skin are found?
A. Scene safety A. Internal bleeding
B. Mechanism of injury B. Shock
C. Level of consciousness C. Central nervous system depression
D. Apparent injuries D. Intracranial bleeding
3. After considering this, what factor should you next 9. Effective primary treatment of this patient should
consider? consist of:
A. Scene safety A. tourniquet use.
B. Mechanism of injury B. direct pressure.
C. Level of consciousness C. rapid transport.
D. Apparent injuries D. Trendelenburg positioning.
4. Is your patient’s complaint of frontal body pain sig- 10. Trendelenburg positioning is effective because it:
nificant on your primary assessment? A. moves waste from the legs to the core.
B. moves blood from the legs to the core.
5. The minor bleeding from his ears is most likely an
C. allows a more comfortable transport position.
indication of:
D. creates a platform for fluid diffusion.
A. a skull fracture.
B. internal hemorrhaging.
www.emt.emszone.com
ww.emt.emszone.com
C. cardiac distress.
D. an ocular cavity.
6. You determine that your patient is experiencing
internal bleeding. What should you do first?
A. Apply pressure dressings
B. Immobilize the injury
C. Apply oxygen
D. Apply cold packs
w
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Source Code: EBSC09
AAOS Tenth Edition
Emergency Meets
the New
National EMS
Care and Transportation of the Sick and Injured
Education
Sample Chapter Standards
Forty years ago, the American Academy of Orthopaedic The Tenth Edition is the cornerstone in an advanced training
Surgeons (AAOS) ushered in the new era of cutting-edge program. Authored by a team of experienced and respected
prehospital care with the publication of Emergency Care leaders in the field, Emergency Care and Transportation of the
and Transportation of the Sick and Injured—the first edition Sick and Injured combines the new National EMS Education
of the “Orange Book.” This revolutionary training program Standards with a practical and concise patient assessment
set the standard for EMT-Basic education. Now, as the EMS process and current treatment modalities. The training
community is about to embark on a new chapter in its history program is supported with instructional, assessment, and
with the implementation of the new National EMS Education learning-performance management solutions for educators
Standards, the AAOS celebrates this industry milestone and and students. These student and instructor resources offer the
the 40th anniversary of their entrance into EMS education most up-to-date and cutting-edge digital platforms available.
with the publication of Emergency Care and Transportation of
the Sick and Injured, Tenth Edition. The AAOS has built a reputation as the most authoritative
national medical organization in EMS. There’s only one
training program that carries the AAOS name —
“Orange Book.”

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AAOS Tenth Edition

Series Editor: Andrew N. Pollak, MD, FAAOS

The National EMS Education Standards document is being used

Increased program flexibility—Educators can now choose

Greater creativity in program and material design—

Better alternative delivery methods—Alternative delivery

Increased ability to respond to changes in medical

Emergency Medical Responder or EMR—

Emergency Medical Technician or EMT—

Advanced Emergency Medical Technician or AEMT—

New patient assessment terminology is being introduced,

Tenth Edition National EMS Education Standards

1. EMS Systems EMS Systems

2. Workforce Safety and Wellness Workforce Safety and Wellness

3. Medical, Legal, and Ethical Issues Medical/Legal and Ethics

4. Communication and Documentation Documentation

5. The Human Body Anatomy and Physiology

6. Life Span Development Life Span Development

7. Principles of Pharmacology Principles of Pharmacology

Section 3: Patient Assessment

8. Patient Assessment Scene Size-Up

9. Airway Management Airway Management

Section 5. Shock and Resuscitation

10. Shock Shock and Resuscitation

11. BLS Resuscitation Shock and Resuscitation

12. Medical Overview Medical Overview

13. Respiratory Emergencies Respiratory

14. Cardiovascular Emergencies Cardiovascular

15. Neurologic Emergencies Neurology

16. Gastrointestinal and Urologic Emergencies Abdominal and Gastrointestinal Disorders

17. Endocrine and Hematologic Emergencies Endocrine Disorders

19. Toxicology Toxicology

20. Psychiatric Emergencies Psychiatric

21. Gynecologic Emergencies Gynecology

22. Trauma Overview Trauma Overview

23. Bleeding Bleeding

24. Soft-Tissue Injuries Soft Tissue Trauma

28. Abdominal and Genitourinary Injuries Abdominal and Genitourinary Trauma

Non-Traumatic Musculoskeletal Disorders

30. Environmental Emergencies Environmental Emergencies

Section 8. Special Patient Populations

31. Obstetrics and Neonatal Care Obstetrics

32. Pediatric Emergencies Pediatrics

33. Geriatric Emergencies Geriatrics

34. Patients With Special Challenges Patients With Special Challenges

Section 9. EMS Operations

35. Lifting and Moving Patients Workforce Safety and Wellness

36. Transport Operations Principles of Safely Operating a Ground Ambulance

37. Vehicle Extrication and Special Rescue Vehicle Extrication

38. Incident Management Incident Management

39. Terrorism and Disaster Management Mass-Casualty Incidents due to

Section 10: ALS Techniques

40. ALS Assist

Appendix: Medical Terminology Medical Terminology

� Feelings of sadness, anxiety, or guilt � Change work hours

Students Will Enjoy

� Loss of interest in sexual activities �

� Loss of interest in work � �

� Increased use of alcohol � Increased

� Recreational drug use

is. Some publishers may use “experts” who have little

4History Taking 3. What is the skin’s color and condition?

a traumafollowing patient, particularly