RESPIRATORY EMERGENCIES

CASE

ASSESSMENT

PATHOPHYSIOLOGY

STATUS ASTHMATICUS

Onset
Provocation
Quality
Radiation
Severity

Acute asthmatic attack

involves airway obstruction
due to :
1. Bronchospasm
2. Swelling of mucous
membranes
3. Mucus secretions

SAMPLE Hx

PULMONARY EDEMA

CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE
(COPD)

Chronic
Bronchitis

Provocation:
1. Resp Infection
2. Emotional Stress
3. Allergic Reaction
Excess FLUID BUILD UP in the
lungs often caused by MI or
related heart disease and
occasionally by inhalation of
smoke and or toxic fumes.
Alveoli collapse due to
adhesive property of H2O.

Repeated infections
thicken and destroy the
lining of the bronchi and
bronchioles causing
narrowing and
becoming obstructive
by too much MUCUS
and EXCESSIVE
CONTRACTIONS of the
muscle in their walls.

Alveoli of the lungs

become inflated or over
distended with trapped
air (may burst and
merge to make fewer
but larger alveoli

Pulmonary
Emphysema

SIGNS AND SYMPTOMS

1.
2.
3.
4.
5.
6.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Anxiety
Patient breathes through pursed
lips
Wheezing
Chest overinflated
Tachycardia
Tripod post

RAPID HEART RATE

Cyanosis
Distended Neck Veins
Wheezing
Frothy or flecked sputum
Water filled spongy lung
Dyspnea
Frothy fluid in bronchi
Cool, Clammy skin
Edema

MANAGEMENT
VENTILATION
OXYGEN
POSITION

1.
2.

1.

High Flow O2
Consider
PEEP/CPAP

Ventilate with
100% O2.

TRANSPORT
CONSIDERATION
IMMEDIATE while
monitoring vital
signs.

IMMEDIATE

causing reduction in the

lungs surface area)
Less oxygen through
walls of the alveoli and
into the bloodstream.
Asthma

Same as Status
Asthmaticus

Hyperventilation
Syndrome

Deep Venous
Thrombosis and
PULMONARY EMBOLISM

DANGER SIGNS!!!
1. Loss of Wheezing
2. Change in Sensorium (Confusion,
Irritability, Lethargy)
3. Hypoxia

Onset
Provocation
Quality
Radiation
Severity
SAMPLE Hx

Abnormal increase in
respiration rate and
tidal volume.

Anxiety of an
emergency often
leads to
hyperventilation.

Could cause acidosis.

Formation of blood clot in a
deep vein due to VIRCHOWS
TRIAD:

Stasis

Hypercoagulation

Blood vessel
endothelial damage
3% chance Pulmonary
Embolism will kill your
patient.
Blood clot in deep veins goes
to the lungs and interrupt
blood flow to the lungs.

Affected extremity:

Painful

Swollen

Red

Warm

Superficial Veins Engorged

Prevent Lethal
Hypoxia

Depending on the
level of hypoxia.

Reassurance and
instruct the patient
to slow down
breathing.

Depending on the
severity.

IMMEDIATE

Pulmonary Embolism
1. LOC restless, anxiety
C
1. Rapid heart rate
2. Cold clammy skin
3. Falling blood pressure
4. Distended Neck Veins
5. Cyanosis
A&B
1.
2.
3.

Respiratory Infections
Croup

Onset
Provocation

Viral
Upper Airway

Sharp and stabbing chest pain

Sudden unexplained dyspnea
Cough +/- blood

Agitated and Barking

VENTILATE with
100% O2

Epiglotitis

Pneumonia

Bacterial
Quality
Radiation
Severity

1.

SAMPLE Hx

Virus, Bacteria, Fungi

Develops in days
Young children and elderly
are at high risk
Alveoli infected decrease in
O2 that leads to dyspnea.

CASE

ASSESSMENT

PATHOPHYSIOLOGY

Angina Pectoris

OPQRSTA

Sudden pain when portion of

the myocardium is not
receiving enough oxygenated
blood

Swelling cause airway

obstruction
2. DROOLING SALIVA
Dyspnea

CARDIOVASCULAR EMERGENCIES
SIGNS AND SYMPTOMS
1.
2.
3.
4.
5.

Indigestion
Chest pain that comes after
exertion
Chest pain that lasts only for a
few minutes
Relieved after admin of
nitroglycerins
SOB, Nausea, increased pulse
rate

MANAGEMENT
1.
2.

3.

4.
ACUTE MYOCARDIAL
INFARCTION
(Silent MI patient
doesnt feel any pain)

Heart Attack
Portion of the myocardium
dies due to deprived
coronary blood flow.

1.

2.
3.

Chest Pain rel to stress and

exertion or even at rest.
Originates from sternum but
radiate to arm, neck, and jaw
and described as sharp,
squeezing or throbbing pain
Pain lasts 30 minutes to several
hours.
Accompanied dyspnea, nausea,
diaphoresis, dizziness, and
FEELING OF IMPENDING DOOM.

High flow O2
asap.
Assist in
nitroglycerin
admin if systo
BP is greater
than 90 (know
if
administered
already and
know how
many times)
Place in restful
and
comfortable
position.
Reassure.

Conscious:
1. High conc. O2
2. Keep patient
calm and still.
3. Take the Hx and
VS.
4. Help patient
with prescribed
medications
5. Transport
immediately in

TRANSPORT
CONSIDERATION
LIGHTS ONLY

Transport
immediately in
semi sitting
position. Quiet
transport (little
or no use of siren)

4.

Signs of shock

6.

semi sitting
position. Quiet
transport (little
or no use of
siren)
Monitor VS
throughout care
and transport

Unconscious:
1. Establish and
maintain Airway.
2. Provide
CPR/Defib if
needed. PPV if
needed through
BVM.
3. High conc. O2.
4. Transport
immediately in
semi sitting
position. Quiet
transport (little
or no use of
siren)
5. Monitor VS
throughout care
and transpo.
Aortic Aneurysm

OPQRSTA

Dilatation or
outpouching of a blood
vessel particularly the
aorta.

1.

2.

3.

Sudden chest pain (ripping,

tearing, and sharp that starts
between the shoulder blades)
BP discrepancy between arm or
decrease in femoral or carotid
pulse.
Signs of Shock.

1.

2.

3.

Calm and
reassure the
patient.
Administer
100% O2 by
NRM
Place in a

Transport without
delay

4.
HYPERTENSIVE
EMERGENCIES
Hypertension

Cardiac Tamponade

Pericarditis

CHF (Congestive Heart

Failure)

Major contributing
cause in many cases of
MI, CHF, and CVA.
Present when BP at rest
is consistently greater
than 140/90 mmHg
Common complication
is renal damage, heart
failure and brain attack.
Accumulation of blood
in the pericardial sac
Most common result in
penetrating injury.

1.
2.
3.
4.
5.
6.
7.

Severe headache
Nausea and vomiting
Altered Mental Status
Aphasia, sudden blindness
Muscle twitching
Seizures
Hemiparesis

1.

1.
2.
3.
4.
5.

Muffled heart sounds

Falling blood pressure
Distended neck veins
Tachycardia
Pale, cool, sweaty skin.

1.
2.
3.

Inflammation of the
pericardium (inner wall of
the heart )

Idiopathic infection

Metabolic factors

Trauma

1.
2.

Excessive fluid build up in

the lungs and or other organs
and in the body because of
inadequate pumping

1.
2.

3.

3.
4.
5.
6.
7.
8.

Dyspnea
Chest Pain that aggravates while
2.1. Breathing
2.2. Lying on left side
2.3. Turning on Bed
Fever, Chills, Fatigue (sign of
infection)
Anxiety or Confusion
Engorged, pulsating neck vein
(LATE SIGN)
Cyanosis
Normal/ Elevated BP
Tachycardia
Pedal Edema
Dyspnea
Pulmonary Edema with rales,
sometimes coughing of Frothy
white or pink sputum

2.
3.

4.
5.

1.

2.

3.
1.

2.

3.

comfortable
position.
Transport
without delay.

Secure airway ,
administer O2.
Transport
without delay
Seizure
precaution

Transport without
delay

Semi-fowlers
O2
Immediate
transport
Monitor
Surgeons will
immediately do
a
pericardiocent
esis

IMMEDIATE

Priority of care
CAB, Administer
O2.
Immediate
transport in
sitting position
Monitor
Place patient in
a comfortable
position (Semi
fowler or sitting)
Give high
concentration
O2 through NRM
Monitor

Immediate
transport in sitting
position

Lights only?

9.

BLEEDING (Heart,
Blood Vessels,
Blood)
External Bleeding

Severity:

1000 cc for adults

500 cc for child

100 200 cc for infant

Enlarged liver, spleen with

abdominal distention (LATE)

Arterial bright red, spurting

Venous dark red, steady flow
Capillary dark red, slowly
oozing, often clots
spontaneously

1.
2.

Safety BSI
Control bleeding
2.1. Direct
pressure
2.2. Elevation
above level
of heart (if
swollen or
deformed DO
NOT)
2.3. Pressure
points
2.4. Splints
2.5. Pressure
splints
2.6. Torniquet
(last resort)
2.6.1. Torniquet
must be at
least 4
inches
2.6.2. Put the
tourniquet
around
twice
2.6.3. Knot and
put a stick
2.6.4. Twist and
secure the
stick or
rod until
bleeding
stops
2.6.5. Document
2.6.6. NEVER use
a wire
2.6.7. NEVER
remove
once

Depends on the
amount of
bleeding.

Internal Bleeding

Most common cause :

Injured or damaged
internal organs

Fractured extremities
esp. Femur and Pelvis

1.
2.
3.
4.
5.

Pain, tenderness, swelling,

discoloration of site
Bleeding from mouth, rectum,
vagina, other orifice
Vomiting bright red blood or
blood (coffee ground)
Dark, tarry stools with bright red
color.
Tender, rigid, distended
abdomen.

LATE SIGNS:
1. Altered LOC, Anxiety,
restlessness, combativeness.
2. Weakness, faintness, dizziness
3. THIRST
4. Signs of shock

SHOCK

Scene Size
up
Monitor for
s/sx of
shock
through
focused Hx
and PE
Establish
VS
Mental
Status
Peripheral
perfusion

Mental Status:
1. Restlessness
2. Anxiety
3. Altered LOC
Peripheral Perfusion and skin
perfusion
1. Pale, cool, clammy skin
2. Weak, thread, or absent
peripheral pulses
3. Delayed capillary refill in ambient
air temp.
VS
1. Increased Pulse rate
2. Increased RR deep, shallow,
labored, irregular
3. Decreased BP(LATE)

secured
2.6.8. Leave in
OPEN
VIEW
2.6.9. NEVER
APPLY TO
JOINT
Goals:

Recognize
presence of
internal
bleeding

Maintain body
perfusion

Provide rapid
transport
1. Safety BSI
2. Open airway
and provide O2
and ventilation
per SpO2 and
ETCO2
3. Transport
Immediately
4. Shock
treatment
1. Safety BSI
2. Maintain open
airway
3. Control any
external
bleeding
4. Elevate lower
extremities
approx. 8 to 12
inches
5. Splint suspected
injuries
6. Use blanket to
warm patient
7. IMMEDIATE
TRANSPORT
ADVANCED CARE
1. Fluid

IMMEDIATE

IMMEDIATE

Class I
(Compensated)
15% 750 ml

Compensates

for Blood loss

Constricts
blood vessels
in effort to
maintain BP
and deliver
oxygen to ALL
organs

MI
TheACUTE
Four Stages
of Shock
Class II
Class III
(Decompensate (Decompensated)
Other:
d)
1.30%
Dilated
1,500pupils
ml (sluggish)
40% 2000 ml
2. Marked
thirst
Body
Response
3. Nausea and vomiting
Continued
Compensatory
4. Pallor and cyanosis to the lips
vasoconstrictio
mechanism
n
to
maintain
become
R heart failure Pulmonary
edema
but Pedal edema
overtaxed.
L perfusion
heart failure
with some
Vasoconstrictio
difficulty
n cannot

N LOC
N VS
750 ml
enough to
occupy a limb
or a body
cavity which
could cause
little
discomfort,
pain,
swelling.

pressure rise
and fall. May
stay the same
on healthy
patients

Decreased
pulse
pressure

Class IV
(Irreversible)
replacement
LR/NSS
warmml
>40%
>2000
1.1. Large bore IV
G16, G14
min.
Compensatory
ideal
vasoconstrictio
1.2. Use blood
n become a
tubings
complicating
1.3. Apply
factor further
pressure
to
impairing
bag
to speed
tissue
Blood is
up
infusion
maintain BP
perfusion
BT is and
shunted to
begins to fall. 2. Unless
cell
available,
titrate
vital organs
Decreased CO
oxygenation.
fluid
infusion to
Decreased flow
and perfusion
the BP using
to intestines,
Patient can still
radial pulse as
kidneys, and
recover with
guide. 250
skin.
prompt
initial until
treatment.
radial pulse is
Effect on Patient
present then
Restlessness
Confused,
TKOLethargy,
3. Head
injury
and confusion
restless,
drowsy,
min
systolic
anxious
stuporous90
Pale, cool, dry
mmHg
Classic signs
Sign of shock
skin due to
shunting
of shock
become more
appears
pronounced
Diastolic

Cool clammy

Pulse Pressure
continues to
narrow

Symphatetic
response also
causes rapid
HR

Stages of Shock

Increased RR
Delayed
capillary refill.

ANGINA
Pain after exertion or stress
Relieved by Rest
Usually relieved by nitro (post
3 doses in 15 min assume MI)
BP not affected
Short term

extremities

Pain often related to stress or

exertion
Not relieved
Nitro may relieve pain
Reduced BP. Diaphoresis
Pain may last 30 min to hour

Continued BP
fall

Organ failure
and death due
to insufficient
blood flow.

Compensatory Shock maintain perfusion

Progressive Stage normal compensatory will work only for so long
Irreversible Stage cannot be reversed.

7 Stages of Cell Death

1. Normal Cell
2. Hypoxia > Ischemia > Anaerobic metabolism >lactic acid build up > met. Acidosis >sodium pump fails
3. Ion Shift sodium rushes into the cell bringing water with it.
4. Cellular edema
5. Mitochondrial edema cessation of ATP production.
6. Intracellular disruption releases lysosomes (cell digesting enzymes) > cell membrane breakdowns.
7. Cell destruction lead to cell death.

Cardiogenic Shock
Hypovolemic Shock
Obstructive Shock

Distributive Shock

CLASSIFICATION OF SHOCK
Heart in origin
Severe Blood loss

Hemorrhagic Shock
Problem in the vascular system

Cardiac tamponade

Tension Pneumo

Pulmonary embolism
Fluid or blood in the wrong place

Spinal/ Vasogenic shock

Septic Shock

Anaphylactic Shock

NEUROLOGICAL EMERGENCIES
CASE
Transient Ischemic
Attack (TIA)

ASSESSMENT

PATHOPHYSIOLOGY

RECURRENT
neurological deficits
of any type that
correspond to the
disorientation of a
particular cerebral
artery and vertebrabasilar artery and
last anywhere from a
FEW SECOND to 12
HOURS.

SIGNS AND SYMPTOMS

1.

Carotid System Blockage

1.1. Hemiparesis / Hemiplegia
1.2. Unilateral Numbness
1.3. Aphasia
1.4. Confusion, coma
1.5. Convulsion
1.6. Incontinence, sometimes
1.7. Numbness of face
1.8. Slurred speech
1.9. Dysphagia
1.10. Posterior headache
1.11. Dizziness or Vertigo

MANAGEMENT

TRANSPORT
CONSIDERATION

SEIZURE DISORDERS
Tonic Clonic (Grand
Mal)

Neurologic
examination
between attacks
maybe ENTIRELY
NORMAL
Some patients
onset of attack is
clearly related to
standing up after
lying or sitting or it
occurs on relation to
exertion, emotional
stress or bout of
coughing.

Tonic phase the body

becomes rigid
stiffening for no more
than 30 sec. Breathing
may stop. Patient may
bite his tongue.
Incontinence may
result.
Clonic phase body jerks
about violently, usually
for more than 1 2
minutes. Patient may
foam at the mouth and
drools. Face and lips
may become cyanotic
Postictal phase regains
consciousness
immediately and enter
a stage of drowsiness
and confusion or he
may remain
unconscious.

Types of Seizures:
1. Simple partial seizure (focal
motor, focal sensory or
Jacksonian) tingling, stiffening
or jerking in just one part of the
body. Aura may present (bright
lights, crust of colors, or a rising
sensation in the stomach)
2. Complex partial seizure
(psychomotor) abnormal
behavior that varies. May
involve confusion, glassy stare,
lip smacking or chewing, aimless
moving about or fidgeting with
clothing.

1.

2.
3.

4.

5.

Protect the
patient from
injury
Guard airway but
NPO
DO NOT restrain
patient. Remove
objects and gently
guide away from
danger.
Loosen
obstructive
clothing.
Take vital signs
and monitor
respirations
closely.

Causes of seizure:
1. Febrile
2. Idiopathic
3. Brain tumor
4. Congenital brain
deficits
5. Metabolic
6. Infection
7. Toxic

Absence (Petit mal)

Stroke
(Cerebrovascular
Accident/ CVA)

Ischemic Stroke

Hemorrhagic Stroke

Seizure is brief usualy

only 1 10 sec. There is
no dramatic motor
activity. Person does not
slump on face. Goes
unnoticed by everyone
except by the person
and knowledgeable
members of the family.
Sudden onset of focal
neurological deficit
caused by a nontraumatic brain injury
resulting in occlusion or
rupture of the cerebral
blood vessel.

Blockage in arteries
supplying oxygenated
blood will result in
damage to affected parts
of the brain.
An aneurysm or other
weakened are of an artery
ruptures.
Often associated with
arteriosclerosis and
hypertension
Two effects:
1. An area of the brain
is deprived of
oxygenated blood
2. Pooling blood push

8. Trauma
Same as grand mal

Classification:
1. Transient Ischemic Attack
2. Reversible Ischemic Neurologic
Deficit
3. Stroke in Evolution/Completed
Stroke

Pathological Process (applicable

on ischemic and hemorrhagic):
1. Intrinsic blood vessel pathology
(atherosclerosis, lipohyalinosis,
inflammation, amyloid
deposition, arterial dissection,
developmental malformation,
aneurismal dilation and /or
venous thrombosis.)
2. Lodging of embolus in
intracranial vessel from a
remote part such as heart or
extracranial circulation
3. Decreased perfusion pressure or
increased blood viscosity with
inadequate cerebral blood flow.

3 Types of Cerebral
Edema
1. Cytotoxic
2. Vasogenic
3. Interstitial
If Brain Edema
suspected:
1. Modest Fluid
restriction
2. Elevation of head
of bed (20 30
degree)
3. O2 and Ventilation
support
4. Control of
agitation and
pain.
Conscious:
1. Ensure an open
airway
2. Keep patient calm
3. Maintain eye
contact and speak
SLOW and
CLEARLY.
4. High O2
5. Monitor VS
6. Semi reclined post
7. NPO
8. Keep warm
9. Sit in front of
patient.
Unconscious:

LOAD AND GO
Window period 3
hours but the
faster the
better.

increased ICP on the

brain, displacing
tissue and interfering
with function.

Altered Mental Status

Causes:
A Alcohol and other
drugs
E pilepsy,
Endocrine/Exocrine
I insulin, hypo/hyper
O oxygen, overdose and
opiates
U Uremia
T trauma and temp
I infection (Sepsis or
Meningitis)
P poisons and
psychiatric
S shock, stroke or space
occupying lesion.

4.

Vessel rupture in subarachnoid

space or intracerebral tissue.

S/Sx:
1. Confusion
2. Hemiparesis
3. Hemiplegia
4. Impaired speech
5. Facial flaccidness and loss
expression
6. Headache
7. Unequal pupil size
8. Impaired vision
9. Cushings Triad
9.1. Hypertension
9.2. Irregular RR
9.3. Slow pulse
10. Convulsions
11. Coma
12. Incontinence
13. Inappropriate behavior
14. Stiffed neck
15. Staggering gate

1.
2.
3.
4.
5.
6.

1.

2.
3.

4.
5.

6.

Maintain open
airway
High O2
Ventilation if
needed
Monitor VS
Lateral recumbent
post.
Protective
padding

Secure airway and

control respiration
1.1. O2 guided
by SpO2
1.2. Ventilation
guided by
ETCO2
Protective reflexes
(+/-)
Immobilize spine
unless absolutely
certain injury not
suspected
Monitor Neuro VS
q 5min
Protect patient
eyes on long
transpo
Treat and reassure
accordingly

Visual
Memory

Comprehensi
on
Proprioceptio
n
Verbal
Memory
Carelessness
and
Impulsivenes
s
Emotion and
Affect

Right Hemisphere Lesion

Impaired Visuomotor
perception
X: Loss of visual memory
Lack of insight and judgment
BUT NOT OBVIOUS because
of intact verbal fluency
OK: No deficit understand
and express
X: Inability to assess position
in space and safely interact
with the environment
OK: Intact. Perceptual
memory impaired
YES: Careless. Obvious
mistakes. Impulsive with
decreased ability to
anticipate consequence of
behavior.
X: Inappropriate emotion and
affect

Left Hemisphere Lesion

Unable to communicate
properly
OK: Positive visuomotor
retention and memory
Positive visuomotor
retention and memory
X: Aphasia
OK: Unimpaired

X: Impaired ability to retain

verbal information; remote
memory impaired
NO?: Usually impaired.

OK: Appropriate

7 Ds of Stroke Management:
1.
2.
3.
4.
5.
6.
7.

Detection recognition of the s/sx of stroke or TIA and activate

EMS.
Dispatch EMS dispatcher must prioritize the call same as an AMI.
Delivery transport to stroke center.
Door hospital that can provide fibrinolytic therapy within 1 hour
after arrival.
Data hospital obtaining CT scan.
Decision identifying eligible patient for fybrinolytic therapy.
Drug treating with fibrinolytic therapy.

DIABETIC EMERGENCIES normal glucose 60 to 120 mg/dL

CASE

ASSESSMENT

Hyperglycemia

Hypoglycemia

Have you
taken your
meals?
Have you
taken your
insulin?
Have you
vomited
your
meals?
Have you
done
strenuous
activities?

CAUSES

SIGNS AND SYMPTOMS

Condition has not been

diagnosed or treated
Has not taken insulin
Over eaten flooding
the body with excess
carbs
Diabetic suffers an
infection that disrupts
his glucose/insulin
balance

1.
2.
3.
4.

Gradual onset in days

Dry mouth, intense thirst
Abd. Pain and vomiting common
Gradually increasing restlessness,
confusion followed by stupor and
coma
5. Weak, rapid pulse
6. Air hunger deep sighing
respirations (Kaussmals
breathing)
7. Acetone breath (child)
8. Warm, red, dry skin
9. Normal or slightly elevated BP
10. Sunken eyes
11. No hostile or aggressive behavior

Taken too much insulin

Not eaten enough to
provide N sugar intake
Over exercised/ exerted
Vomited

1.
2.
3.
4.

Rapid onset in minutes.

Copious saliva, drooling
Patient intensely hungry.
Dizziness and headache, sudden
fainting, seizures and occasionally
coma
5. Full rapid pulse
6. Normal respiration , no odor
7. Cold, clammy, pale skin.
8. N BP
9. N eyes
10. Hostile/aggressive behavior.

MANAGEMENT
1.
2.

O2 via NRM
Transport to
medical
facility
3. Arrange for
ALS intercept.
However, all
management to
DM
emeregencies
towards
hypoglycemia.

1.

Granular
Sugar under
tongue.
1.1. Conscious:
any sweet
solid or
liquid
1.2. Unconsciou
s:
1.2.1. Avoid
giving
liquid
1.2.2. Turn head
to side or
place in
lateral
recumbent
.

CAUSE OF
DEATH
1. Dehydration
and poor
nutrition
2. Hypokalemia
3. Hypoinsuline
mia
4. DKA (Diabetic
Ketoacidosis)
ketones in
urine >
acidosis
>compensate
s by
Kaussmals
breathing to
decrease
acidosis >
Diabetic
COMA
Hyperinsulinemia
- Insulin Shock.

2.
3.

4.

Provide High
O2
Transport to
medical
facility
Arrange ALS
intercept.

ACUTE ABDOMINAL EMERGENCIES

CASE
All adults with
abdominal pain
always consider
MI.
o
Heart problem
irritates the
vagus nerve>
affects gastric
mucosa >
producing
excess HCl
and
abdominal
pain.
Causes:
o
Ulcer
o
Intestinal
Obstruction
o
Cholecystitis
o
Hernia
(emergency
due to
possibility of
circulation
obstruction)
o
Abdominal
Aortic
Aneurysm
o
Pancreatitis
o
Appendicitis

ASSESSMENT

Supine
Knee chest
flexed
Examine
last most
painful
part
N abd.
Assess:
No pain,
soft, non
rigid,
warm to
touch, not
distended

PATHOPHYSIOLOGY

SIGNS AND SYMPTOMS

1.
2.
3.
4.
5.
6.
7.
8.

Pain/ tenderness
Anxiety / fear
Guarded position
Rapid shallow breathing
Rapid pulse
Nausea vomiting or diarrhea
Rigid or tense abdomen
Internal bleeding

MANAGEMENT
1.
2.
3.

4.

5.
6.
7.
8.

Safety and
BSI
CAB
Keep airway
patient be
alert for
vomiting
Place pt. to
position of
comfort
NPO
Calm and
reassure pt.
Be alert for
shock
Transport
efficiently

TRANSPORT
CONSIDERATION
Efficient Transport

Urinary Colic

Nephrolitiasis formation
of stone in the kidney (or
anywhere in the urinary tract
but calculi begin to form in
kidney). Stone size may vary
in size.
Renal calculi classification

Calcium Phosphate
65%

Calcium Oxalate

Magnesium
Ammonium

Phosphate (stravite)
15%

Uric Acid 10%

Cystine Stone 10%

Factors promoting to Stone

Formation:

Supersaturation of
Urine stone formation
due to crystalloid

Presence of Nidus a
must. Nidus or nuclei
which layer can be
deposited

Stasis further
promotion of stone
formation

pH or solution

Pain intensity depends upon the

size of the calculi.
Renal colic a group of symptoms
associated with movement of a
calculus through the narrow
anatomical points in the ureter
causing obstruction of urine.
o
Severe costovertebral angle
pain radiates throughout the
flank area and groin due to
the muscle spasm injured by
the stretching and
obstruction of the ureter by
the calculus

1.

2.

3.

4.

If alert, advise
to increase
fluid intake to
over 4000
ml/24 hour.
Administer
analgesic/anti
spasmodic
according to
local protocol
Keep on bed
rest (with
Entonox)
Transport to
hosp for
further
management.

Transport
efficiently

OBSTETRICS - GYNECOLOGICAL EMERGENCIES

CASE
Common
Gynecological
Emergencies
Ectopic Pregnancy

Rupture of Ovarian
Cyst

Pelvic Inflammatory
Disease (PID)

ASSESSMENT

PATHOPHYSIOLOGY

Development of a fetus
outside the womb
Causes:

Past ectopic
pregnancy

Past salpingitis

Surgery of the
fallopian tube
Formation of mass in the
ovary with idiopathic cause.

Infection from the vagina

making the pelvis inflamed.
Causes:

Sexually transmitted
disease

SIGNS AND SYMPTOMS

1.
2.
3.
4.
5.
6.

Ammenorhea
Pain in the L/R iliac region
Abnormal vaginal bleeding
Low back pain
Breast tenderness
Nausea

1.

Sharp, piercing pain in the

lower abdominal quadrant.
Fever
Nausea
Vomiting
Weakness, dizziness or fainting
Signs of internal bleeding
Fever
Profuse discharge from the
vagina
Malaise
Lower abd pain
Difficulty passing urine

2.
3.
4.
5.
6.
1.
2.
3.
4.
5.

MANAGEMENT

1.
2.
3.
4.

5.
6.

Ensure open
airway
O2 as
required
NPO
Vomiting
precaution
(positioning)
Monitor VS
Shock
precaution

TRANSPORT
CONSIDERATION

ALL LOAD AND

GO

Dysfunctional Uterine
Bleeding (DUB)

Bleeding from the uterus that

is not due to menstrual
period
Cause:

Estrogen imbalance

Menopause syndrome

Female of advanced
age

6.
1.

2.
3.
4.
5.
6.
7.
8.

Other : Rape

OBSTETRICS
o

o
o
o
o

3 weeks
zygote/ fertilized
ovum
3-8 weeks
embryo
9-38 weeks
fetus
Birth to 28 days
neonate
29 days to 1 yo
infant

Irregular vaginal bleeding

Increase PR >20 bpm when
pt. sits from supine
position. > blood loss of
more than 1 unit.
Abnormal vaginal bleeding
Abnormal spotting
Metrorrhagia bleeding in b/t
period
Menorrhagia excessive
bleeding
Bleeding after menopause
Bleeding unrelated to periods
Bleeding in young girls

Maximum
tact and
sensitivity

Female
EMT
should be
present

EMT must
take care
of urgent
med.
Problems

Preserve
evidence

Protect
patients
privacy

Document
Important
elements of
Assessment:
1. Age of
patient
2. LMP
3. AOG
4. Gravida
5. Parity
Criterias:
1. Due date
2. Contraction

1.
2.
3.
4.

5.
6.

Mech. Of Delivery:
Engagement > Descent >
Flexion > Internal Rotation >
Extension > Expulsion
Equipments:
1. Gloves
2. Drawsheet
3. Suction Bulb
4. Towels
5. Gauze
6. Scalpel
7. Umbilical clamp

Sx of
1.
2.
3.

imminent delivery:
Urgeto push
Presence of crowning
Increase pressure in the vagina

Labor and Delivery

1. Safety BSI
2. Lie knee flexed drawn up wide
separated, semi-fowlers
3. Create sterile field around vag.
Opening with sterile towels
4. Crowning place gentle pressure
on perineum

Ensure open
airway
O2 as
required
NPO
Vomiting
precaution
(positioning)
Monitor VS
Shock
precaution

Imminent delivery:
1. Do not allow
to use toilet
2. Consult MD
concerning
decision to
deliver baby
at the scene.
3. Do not
clamp/cut
cord if the
baby is not
breathing on

General Steps in
NSD
1. Prepare
mother for
delivery
2. Assist
3. Initial care of
the newborn

o
o

1 yo to 12 yo
child
UTZ most
reliable dx tool

3.

4.
5.
6.

COMPLICATION
ONFIRST TRIMESTER
Abortion

? Frequency
and
Duration?
Increase
Spressure
in vagina?
Urge to
push?
Crowning?
Broken bag
of water?

8.

Cotton with alcohol

Premature (<38 weeks/

<2500 kg) TRANSPORT to
ER for incubator
500 ml normal bleeding
during delivery
Cord Cutting 10 incles away
from umbilicus

Termination of pregnancy
before 28 weeks
1.
2.

Threatened
Closed cervix
a. Mild pain (back pain,
lower abd.)
b. Mild vaginal spotting
3. Inevitable cannot
preserve pregnancy
a. With placental/fetal
fragments came out
b. Severe back pain
c. Moderate, obvious
bleeding
d. Shock
4. Incomplete
placental/fetal
fragments expelled
5. Complete
abortus/fetus expelled

5.

Once delivered, support the head

as it rotates and wipe neonates
mouth and nose > suction mouth
and nose
6. Guide head down to deliver 1st
shoulder, then up to deliver the
2nd shoulder > support the baby
7. Grasp the feet firmly with one
hand
8. Clean out the babys mouth with
gauze. Suction. The baby should
start to cry. If not, ABC of
resuscitation.
Intervention for non breathing
baby
1. Rub the back
2. Snap fingers at soles of the
feet
3. ABC
4. If with spontaneous breathing,
let neonate breath room air
5. If APGAR is low (4-7) give O2
via blowby

its own.
If within 5
minutes woman
will deliver the
baby, do not load
and go. If inside
the ambu,stop
and deliver the
baby.

Pre Eclampsia

Eclampsia
Supine Hypotension
H-mole

out with bleeding

6. Criminal
7. Therapeutic
Hypertension. BP of more
than 130/80.
Comlications:

Eclampsia

Abrutio Placenta

Cerebral retinal
damage

Pulmonary edema

1.
2.
3.
4.
5.
6.

Neurological
Compression of the Vena
Cava due to pregnancy.
No fetus but with signs of
pregnancy

1.
2.
3.
Excessive vomiting during
pregnancy

1.
2.

3.
4.
3RD TRI/ANTENATAL
COMPLICATIONS
Abruptio Placenta

Placenta Previa

Premature separation of the

placenta before labor and
delivery

Implantation of the placenta

over the cervical opening

LIGHTS ONLY

Left Lateral
Position

Incompetent Cervix

Hyperemesis Gravidum

Transport
FHT
monitoring
CAB
Prevent
stimulus
O2 per SpO2
Therapeutic
Environment

1.

Mild to moderate vaginal

bleeding
2. Sx of shock
3. Continous knife like pain in the
abdomen
4. Rigid tender uterus
Painless bright red vaginal bleeding.

Complete bed
rest
Constant OB
supervision
Cervical
Cerclage
Crackers on
bed side
Small
frequent
feeding
Ensure
nutrition
Maintain
hydration

Transport for
Emergency CS

1.
2.

Transport
immediately
Shock
precaution

IMMEDIATE

Uterine Rupture

Common to G3 above
Due to Blunt Trauma.
Repeated stretching of
the uterine wall
Old CS
Prolonged labor against
o
Obstruction
o
Weakened uterine
wall

COMPLICATIONS OF
LABOR and
DELIVERY
Prolapsed Cord

For emergency CS
Cord compressed
between the neonates
head and birth canal

1.
2.
3.
4.

Tearing abdominal pain

Severe hypovolemic shock
Firm rigid abd.
Vaginal bleeding

No pulsation of the umbilical cord

3.
1.
2.

Do not IE
CAB
Transport

1.

Position
mother to
knee chest
position
Push the
neonates
head to
relieve
compression
to cord
Wrap cord
with moist
sterile gauze
to prevent
damage
Upon delivery
of head look
for the cord if
looped around
the neck
Gently slip if
possible
If not, clamp
the cord and
cut (protocol)

2.

3.

Cord coil/ Cord loop

1.

2.
3.

Meconium Staining

Common in pre term

and post term
Lack of O2 > Spasm of
the large intestines >
meconium staining >

Sign of fetal distress

1. No FHR
2. FHR < 120
3. Mother do not feel baby
moving

IMMEDIATE

greenish discoloration
of the amniotic fluid

Complication:
o
Neonatal Sepsis
meconium
aspiration
o
Neonatal
respiratory distress
neonate may not
be able to clear
lungs.

Difficulty of fetus to
come out

Infection

Trauma

Complication to mother
o
Leak to pelvis
>Amniotic fluid
enter circulation >
Pulmonary Embolism

Amniotic Fluid Leak

NEONATAL CARE
Cardio respiratory
changes that occur in
birth:
o
To get rid of the
fluid filling the
lungs so that it
can expand
o
Closing of the
foramen ovale
and ductus
arteriosus

Routine care:
1. Warming
2. Airway
3. Position
4. Cord
cutting
5. Prevention
of
meconium
aspiration

Risk factor for shock and

hypotension
1. Low birth weight
2. Maternal sepsis
3. Prolapsed cord
4. Acute onset of
maternal vaginal
bleeding

N neonatal vital signs

RR 30 50 cpm
PR 120 160 bpm
BP >60 mmHg

HR

< 60 CPR

>100 breath on room air

60 100 ventilate (full 5 Lpm;

premature 3 Lpm)

APGAR
8 10 mild distress
4 7 moderate
1 3 severe
Medical

Unconscious or decreasing level of

consciousness

Dilated pupil
GCS <10
Pediatric trauma score <8
Persistent Fever
Increase effort in breathing

Trauma

Fall from a height of 20 ft

Involved in an accident with

fatalities

Ejected in a car accident

Struck by a car.
NEONATAL SEIZURES

Stage
1st
2nd
3rd

Causes:
1. Hypoxic Ischemic
Encephalopathy
2. Metabolic Disturbance
3. Meningitis or
Encephalitis
4. Developmental
abnormalities
5. Drug withdrawal
6. Maternal anesthesia
7. Stroke

Hallmark Signs
True labor to full cervical dilation
Full cervical dilatation to birth of neonate
Birth of neonate to placental delivery

Contractions
PainSIGN
radiation
Appearance
Bluish
Pain alleviation
Frequency,
Duration,
Intensity
Cervical Dilatation

Duration for Primi

12 to 16 hours
30 min
Within 20 min

False Labor
True Labor
Irregular
Regular
Abdomen
Lower back then
0
1
2
or pale
Pink trunk, blueabdomen
Pink
Alleviated by
Not alleviated
extremity
ambulation
No increase
Increasing

No dilatation

Types:
1. Subtle Head part ocular, facial,
oral or ligual movements and
respiratory manifestation such as
apnea or stutortorous breathing
2. Tonic pre-term infant: seizure
appear decerebrate or decorticate
posturing
3. Multifocal clonic term infants:
noted in one limb and migrate to
another part of the body.
4. Focal clonic term infants:
localize and are accompanied by
short activity of EEG.
5. Myoclonic premature and term
infants: single multiple jerk and
flexion of the upper and lower
extremities

With dilatation

APGAR SCORING

Duration for Multi

30 min
Matter of minutes
Within 20 min

Pulse
Grimace

Absent
No Response

Activity

Limp

Respiration

Absent

<100 bpm
Some motion,
grimace
Some flexion,
extremeties
Slow and
irregular

>100 bpm
Cry, cough,
sneeze
Active, good
motion
Normal, crying

Insert Neonatal Circulation and Neonatal Resuscitation

BURN EMERGENCIES
CASE
Type
1.
2.
3.
4.
5.
6.
7.

of burns
Chemical
Radiation
Electrical
Thermal
Scald
Contact
Flash

ASSESSMENT

PATHOPHYSIOLOGY

SIGNS AND SYMPTOMS

MANAGEMENT

Factors to consider in
evaluating burns
1. Agent of burn
2. Depth
3. Severity (BSA)
a. Rule of nines
b. Palm rule
4. Age under 5 and
over 55 (adults
reaction to burn
injury increases after
age 35)
a. Infants and children
are at higher risk
due to more body
surface area
i. Hypovolemic
shock
ii. Airway problem
iii. Hypothermia
5. Other illnesses and
injuries

Thermal Burn:
1. Emergent Phase
response to pain >
catecholamine release.
2. Fluid shift massive
shift from intracellular to
extracellular fluid
3. Hypermetabolic phase
increase demands for
nutrients
4. Resolution phase
scar tissue and
remodeling of tissue

Special Considerations:
Pedia:
1. Thin skin
2. Large surface volume
2.1. Rapid fluid loss
2.2. Increased heat loss
3. Dehydration vs. Overhydration
4. Immature Immunological response

Treatment of burn
wound
1. Low priority
after CAB and
IV
2. Do not
rupture
blisters.
3. Dry Sterile
Dressings
4. Cover with burn
sheet

Complications:
1. Hypovolemia leading to
shock - Leading
2. Infection
3. Renal/hepatic failure
4. Formation of eschar
5. Complication of
circumferential burn
(tourniquet effect)
6. Increase catecholamine
release,
vasoconstriction
7. Inability to maintain
body temperature
Eschar formation:

Geria:
1. Decreased Myocardial reserve
2. Fluid resuscitation difficult
3. Peripheral vascular disease
4. COPD
5. Decreased immune response
6. % mortality = age + % of BSA
affected

4 Phases of burn
management
1. Emergent
Phase time of
injury to
structural
2. Resuscitation
Phase admin
of IV fluids,
return of
capillary
membrane to N
level
2.1. Parkland
formula:
4 mL/kg *
total BSA

TRANSPORT
CONSIDERATION

1.
2.
3.
4.

Skin denaturing
Skin constricts over
wound
Respiratory compromise
Circulatory compromise

Jacksons Burn Theory

1. Zone of Coagulation
2. Zone of Stasis
3. Zone of Hyperemia
Thermal

Rapid PE
1. Check for other
injuries
2. Rapid estimate
burned wound
3. Remove restricting
band
Hx:
1.
2.
3.
4.
5.
6.
7.

How long ago?

What has been done?
What cause?
Close space?
LOC?
Allergies/meds?
Past med Hx?

2.2. 1st half in first

8 hrs
2.3. 2nd half in
next 16 hrs.
3. Acute Phase
hemodynamical
ly stable
4. Rehabilitation
Phase
1.

Remove patient
from the scene
2. Stop burning
process
3. Ensure open
airway, assess
breathing
4. Look for signs
of airway injury,
soot deposits,
burnt nasal
hair, facial
burns
5. Complete the
intial
assessment.
6. Treat for shock.
High O2 (per
SpO2). Treat
serious injuries.
7. Evaluate burns
by depth,
extent and
severity.
8. Do not clear
debris
9. Wrap with dry
sterile dressing.
10. Burns of hands
or feet
remove rings
and jewelry that
may constrict
with swelling.
Separate

IMMEDIATELY

fingers or
toes with
gauze pads.
11. Burns to eyes
do not open
eyelids if
burned.
11.1. Be certain
burn is
thermal, not
chemical.
11.2. Apply sterile
gauze pads
to both eyes
to
immobilize.
11.3. If burn is
chemical,
flush eyes
for a
minimum of
20 minutes.
12. Shock
precaution (if
theres other
injuries)
Others:
1. Analgesic
Morphine
Sulfate
1.1. 2-3 mg q
10 min
titrated to
adequate
ventilation
and BP
1.2. 0.1 mg/kg for
pedia
1.3. May require
large but
tolerable
doses.
2. Avoid topical

agent except
per protocol
(Silvadine)
3. Fluid Therapy
3.1. Objective:
3.2. HR < 110
bpm
3.3. Urine output:
30 50 cc per
hour or
0.5-1 cc/kg/h
r for pedia
Insert chemical
burn handout

Chemical

Inhalation

Electrical

Problems:
1. Hypoxia
2. CO toxicity
2.1. SpO2 could be
meaningless
3. Upper airway injury
3.1. May result to edema
of pharynx and larynx
4. Lower airway injury
4.1. Rare, involves lung
parenchyma,
Transport

Ohms law 1 = V/R

Anticipate respiratory problems

1. Head, Face, Neck or Chest burns
2. Nasal/ eyebrow hairs signed
3. Hoarsness, tachypnea
4. Coughing - Black sputum

Generally get
chemical
contaminated object
off the body and
flush with LR/NS
except if chemical
reacts with water.
Airway, O2,
Ventilation:
1. Bronchodilators
needed?
2. Diuretics are
not appropriate
Circulation:
1. Treat for Shock
(rare)
2. IV access
2.1. LR/NS large
bore multiple
IVs
2.2. Titrate fluids
to maintain
systolic BP

AC current:

Others:
Treat burns and
injuries
1. TRANSPORT

Low voltage 500 1000V

High voltage 1000V up
(Lightning)

1.

Severity depends on
1. Tissue
2. With or extent of current
3. AC/DC
4. Duration of current
contact

2.
3.
4.
5.
6.

Radiation

Skin
Surface
s
Sensati
on
Healing

<15%
Mottled red, moist
<2%
and except
shiny for
face, genitalia,
hands and feet

Dry (-)
blisters

(+) blisters with

weeping

Painful

Painful

3-6 days

2 4 weeks
depending on
depth

CASE

ASSESSMENT

Poisons could be:

Odor

2.
3.
4.

Make sure
current is off
CAB
Rhabdomyolysi
s breakdown
of muscle fiber
that leads to
release of
myoglobin to
bloodstream
which is
harmful to the
kidneys.

Alpha large
Beta small
Gamma most
dangerous

Burn Depth Characteristics

1st Degree
2nd Degree Burn severity
3rd Degree
Depth
Minor
Moderate
Cause
Sun or
Hot liquids,
Chemicals,
Superficialminor flash <flashes
50% or flame
>15%
electricity,

Partial Thickness
Skin
Red
Full Thickness
Color

Tetanic Muscle Contraction

1.1. Muscle injury
1.2. Tendon rupture
1.3. Joint distraction
1.4. Fractures
Cardiac arrhythmias
Apnea
Seizure
Contact burn/Flash burn
Flame burn

flame, hot
metals
15 30%
Pearly
white
2 10%
and
or
charred
translucent
and
parchmentlik
e
Dry with
thrombosed
blood vessels
Anesthetic

Critical
All complicated by
injury of soft tissue
and bones
>30%
>10% Partial full
thickness on hands,
genitalia,
circumferential burn.

Insert Rule of Nines for Adult, Child and Pedia

Requires skin
grafting

POISONING EMERGENCIES
PATHOPHYSIOLOGY

Poison (toxin )

SIGNS AND SYMPTOMS

1.

Burns and strains around

MANAGEMENT
General approach:

TRANSPORT
CONSIDERATION

Ingested
Inhaled
Absorbed
Injected

Level of
Consciousness
Vital Signs
Hx
What?
When?
How much?
What else was
taken, if
anything?
Antidote?
Vomited, if so
how long after
the ingestion?
Why?
Odor
Level of
Consciousness
Vital Signs
Hx
What?
When?
How much?
What else was
taken, if
anything?
Antidote?
Vomited, if so
how long after
the ingestion?
Why?

substance which, if
taken into the body in
sufficient quantity can
cause temporary or
permanent damage
Self poisoning and
parasuicide
deliberate ingestion of
more than the
therapeutic dose of a
drug or substance not
intended for
consumption usually
by an adult in a
moment of distress
Accidental poisoning
non intentional

3 Leading causes of
Poisoning:
1. Alcoholic intoxication
2. Methamphetamine
3. Isoniazid toxicity
Organophosphate agent
most commonly associated
with mortality.

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

mouth
Unusual breath/body/
clothing/scene odor
AbN breathing
AbN pulse rate
Profuse sweating,
headache, dizziness
Excessive salivation or
foaming at the mouth
Pain in the mouth or throat
Abdominal pain
Abdominal tenderness
sometimes with distention
Nausea, vomiting
Seizures
Altered mental status
Signs of shock

Circulation
Airway
Breathing
Drug induced CNS
depression

Electrolytes and
metabolic
abnormalities

Oxygen
precautions
o
Watusi
o
Paraquat
o
Zinc phosphate
Activated Charcoal

Absorbs many
poisonous
compounds to its
surface, thereby
reducing their
absorption by the
body

Effective among:
o
Aspirin
o
Amphetamines
o
Strychnine
o
Dilantin
o
Theophylline
o
Phenobarbitals

Ineffective:
o
Methanol
o
Caustic acids
o
Alkalis
o
Iron tables and
lithium

1g/kg

Syrup of IPECAC
Induces vomiting
Contraindications
o
Stupor/Coma
o
Absent gag reflex
o
Seizures
o
Pregnancy

Acute MI
Children < 6 mo
Ingestion of
corrosives
o
Volatile
hydrocarbons
o
Strycnines or
iodides

Dosage
o
Children 3-5 tsp
followed by a
glass of water
o
Adults 1-2 tsp
followed by
water
1. Maintain open
airway
2. Transport
Immediately
3. Follow protocol
of your EMS
system
4. Keep patient on
NPO
5. Position the
conscious
patient in semi
recumbent
position
6. Monitor
vomiting
7. Save all vomits
and endorse to
the hospital
o
o
o

Ingested

Inhaled

1.

2.
3.

Remove patient
from inhaled
poison. Avoid
touching
contaminated
clothing.
Maintain open
airway
Provide needed
BLS measures

and administer
O2 (if not
contrainidicated
) NRM

Injected

1.
2.

3.

4.
5.
Absorbed

1.

2.

3.

Insert Table of S/Sx of common poisons.

Follow local
protocol
Monitor patient
and maintain
open airway
Remove jewelry
from affected
limbs
Keep the limb
immobilized
Transport
immediately
Move the patient
from the source
of the poison
while avoiding
contact with the
substance
Use water to
immediately
flood all the
areas of the
patients body
that has been
exposed to the
poison
Monitor patient
and transport
immediately

COLD EMERGENCIES
CASE

ASSESSMENT
Temp Conversion:
C = (F-32)*5/9
F = C*5/9 +32
Keeping warm:

Thermogenesis
o
Conversion of food
to energy in body
cells
o
Muscle activity,
voluntary or
involuntary

Heat absorption

During cold conditions

o
Constricting blood
vessels at body
surface to keep
warm blood at the
core
o
Reducing sweating
o
Erecting body hairs
to trap: the warm
air at the skin
Losing body heat

Heat maybe lost to

o
Cool surrounding air
o
Cool objects in
contact with skin

PATHOPHYSIOLOGY
Core Temp
Internal temp of
normothermic humans
Does not vary >1-2 from
normal temp
Esophageal and tymphanic
temp almost the same
with pulmonary artery
May cause permanent
disability or death
Hypothalamus temp
regulator center
Mechanism of Heat Loss
1. Convection heat loss
to surrounding air
2. Conduction heat loss
to nearby objects
through physical
contact
3. Radiation Body heat
is lost to nearby
objects without direct
contact
4. Evaporation Body
heat loss through
perspiration
5. Respiration

SIGNS AND SYMPTOMS

MANAGEMENT

TRANSPORT
CONSIDERATION

Local Cold Injury

1st degree frostbite
(Frostnip)

2nd degree
(Superficial Frost)

3rd Degree to 4th

Degree (Deep
Frostbite)

In hot conditions, the

body reacts to lose
heat
o
Blood vessels in or
near the skin dilate
tin order to lose
blood heat
o
Sweat glands
become active.
Sweat evaporates in
cooler air. Hairs are
flat
o
The rate and depth
of breathing will
increase

General S/Sx
1. Shivering
2. Numbness
3. Stiff, rigid posture
4. Drowsiness or inability
to do even simplest
activity
5. Rapid breathing and
rapid pulse in early
stages, Late stage:
Slow pulse and
breathing.
6. Decrease LOC
7. Cool skin temp
8. Loss of motor
coordination
9. Joint, muscle stiffness
and rigidity.

Victim unaware unless

he sees himself in the
mirror and notices
unusual pallor and the
return of the warmth to
frotnipped area
Skin is stiff but
underlying tissue is soft

Redness and tingling

sensation

1.
2.

3.
1.
2.
3.

Waxy and white

Numbness
As thawing occurs
3.1. Area turned
mottled blue
3.2. Stinging
sensation
3.3. Edema and
blister within a
few hours
1. White , mottled blue or
white hard cold
2. Tissue feels like block
of wood
3. When thawed
3.1. Soothing pain
3.2. Burning
3.3. Throbbing
3.4. Aching
3.5. Possible joint pains
3.6. Gangrene within a

4.
5.

6.

1.
2.

3.
4.

Remove patient
from site
Remove all of the
patients clothing
that is wet
During transport,
rewarm the patient
Shock treatment
Give warm fluid for
conscious and
alert patient
Keep patient at
rest.

If still frozen,
leave it frozen
Pad the injured
extremity to
protect from
further trauma
Do not massage
Notify the
receiving facility
so that they can
start preparing

few days requiring

amputation of
injured part

Hypothermia

Prolonged exposure to
cold outdoor especially
in wet and windy
conditions
Death from cold water
immersion may be
caused by hypothermia
rather than drowning

and re-warming
both.
5. If the extremity is
partially thawed,
rewarm the
injured area at 38
42 C
6. Once rewarming
is comlete
6.1. Dry extremity
very gently and
apply it gently to
thawed part
6.2. Take care not to
rupture blisters.
6.3. Use soft sterile
gauze or cotton
to separate
frostbiten
fingers and toes
7. Transport the
patient in supine
position and
elevate the
injured extremity
on soft pillow, well
covered and
protect from cold.
1. Remove patient
from cold
environment
2. Remove any wet
clothing and
cover the patient
with blanket
3. Handle the
patient with
extreme care.
Avoid rough
handling at all
cost
4. Admin high flow
O2 (warmed and
humidified)

5.

6.
7.

Do not allow the

patient to eat or
drink stimulants
Do not massage
extremities
Check for a pulse
for an extended
period of 30 to 45
sec before
initiating BLS

Too hot
Too cold
Blood
Vasodilation
Vasoconstriction
vessels
Perspiratio
Increase
Decrease
n
Cardiac
Increase
Decrease
output
Respiratory Increase
Decrease
Rate
Heat
Decrease
Decrease
production
Stages of Hypothermia (ILCOR 2005)
Progression of Hypothermia
C
F
Body Temperature
Symptoms
Mild
36 34 C
96.8 93.2 F
37 35.5 C
Shivering
Moderat
34 30 C
86 F
35.5 32.7 C
1. Decreased shivering replaced
e
by strong muscular rigidity
Severe
< 30 C
<86 F
CASE

ASSESSMENT

Heat Cramps
29.4 27.7 C

2. Less
clear thinking
HEAT
EMERGENCIES
PATHOPHYSIOLOGY
SIGNS ANDisSYMPTOMS
3. General comprehension
dull
Severe muscle cramps
Exhaustion
4. Possible total1.
amnesia
2. Dizziness
(usually in the legs and
1. Irrational 3. Periods of faintess
abdomen)
2. Loses contact with envi and
drifts into stuporous state
3.
4.

26.6 20.5 C

Slow pulse and respiration

MANAGEMENT
1.
2.

3.

Possible cardiac
dysrhythmias
Unconscious without reflexes

4.

Move patient to a
nearby cool place
Give the conscious
patient fluids and
electrolytes
Massage the cramped
muscle to help ease the
patients discomfort.
Massaging with
pressure will be more
effective than light
rubbing
Apply moist towels to

TRANSPORT
CONSIDERATION

5.

Heat Exhaustion

Volume and electrolytes lost

through perspiration and is
not replaced > dehydration
> hypovolemia > decrease
brain perfusion

1.
2.
3.
4.
5.
6.
7.

Rapid, shallow RR
Weak pulse
Cold, clammy skin
Heavy perspiration
Total body weakness
Dizziness
Possible
unconsciousness

1.
2.
3.

4.
5.

6.

7.

8.
9.

Heat Stroke

1.
2.
3.
4.
5.
6.

Deep breaths and

shallow breathing
Rapid, strong pulse,
then rapid weak pulse.
Dry hot skin
Dilated pupils
Loss of consciousness
(possible coma)
Seizures or muscular
twitching may be seen

1.

2.

3.

the patients forehead

and over cramped
muscles
If cramps persists, or if
more serious symptoms
and signs develop,
ready the patient and
transport
Move to cool place
Keep @ rest
Remove enough
clothing to cool the
patient without chilling
him (watch for
shivering)
Fan the patients skin
Give the conscious
patient fluids with
electrolytes.
Do not try to administer
fluids to an unconscious
patient
Treat for shock but do
not cover to the point
of overheating patient
Provide high conc. O2
If unconscious, fails to
recover rapidly, has
other injuries, or has a
hx of medical problems,
transport as soon as
possible
Cool the patient in
any manner rapidly.
Remove from heat
source.
Remove patients
clothing and wrap him
in wet towels and
sheets. Pour cool water
over these wrappings.
Body heat must be
lowered rapidly or
brain cells will die.
Treat for shock and

administer high conc.

O2.
4. If cold packs or ice bags
are available,wrap and
place one under each
4.1. Armpit
4.2. Knee
4.3. Groin
4.4. Wrist and ankle
4.5. Each side on
patients neck
5. Immediate transport
6. Delayed transport: Find
a tub or container.
Immerse patient up to
the face in cooled
water. Constantly
monitor to prevent
drowning
7. Monitor vital signs
throughout process

Condition

Heat Cramps
Heat
Exhaustion
Heat Stroke

Muscle
Cramps

Weakne
ss

Breathing

Pulse

Skin

Perspirati
on

Varies

Varies

Heavy

Rapid shallow

Weak

Heavy

Sometimes

Deep, then
shallow

Full Rapid

Moistwarm
Cold
clammy
Dry-hot

Loss of
Consciousn
ess
Seldom

Little or
none

Often

INSECT BITES & STINGS EMERGENCIES

CASE

ASSESSMENT

Typical sources of
infected poisons or
toxins (insect, spider
& scorpion)

PATHOPHYSIOLOGY

SIGNS AND SYMPTOMS

1.

Gather
information
from the
patient,
bystanders,
at the
scene.

2.
3.
4.
5.
6.
7.

Find out
whatever
you can
about the
insect or
other
possible
source of
the
poisoning

8.
9.
10.
11.
12.
13.
14.
15.

Snake bites

1.
2.

3.
4.
5.
6.
7.
8.

MANAGEMENT

Noticeable bites and stings on

the skin
Blotchy skin
Localized pain or itching
Numbness
Muscle cramps, chest
tightening & joing pains
Burning sensation
Difficulty of brerathing and
abnormal pulse rate
Excessive saliva formation,
profuse sweating
Weakness/ collapse
Headaches/Dizziness
Chills and fever
Nausea and vomiting
Redness
Swelling or blistering
Anaphylaxis

1.

Bite on the skin

Discoloration, pain, swelling, at
area. Slow to develop from 30
min to hours
Rapid pulse and labored
breathing
Progressive general weakness
Blurring of vision
Nausea and vomiting
Seizures
Drowsiness of unconsciousness

1.

2.

3.
4.

5.

2.

3.

4.

5.

Pit Viper

Has pit in
maxillary bone

Eliptical pupil

Tissue Necrosis

Minimal

None

Swelling

Pain

1.
2.
3.

TRANSPORT
CONSIDERATION

CAB treat for

shock
Follow insect bites
and sting protocol
in your local EMS
Remove jewelry
from affected limb
Immobilized the
affected part, if
allowed by your
protocol, apply
cold compress
Transport in semisitting position for
conscious patient
and recovery
position for
unconscious
patient
Locate the fang
marks and clean
the site with soap
and water
Remove any
jewelry from the
bitten extremity
Keep the bitten
extremity
immobilized
Apply light
contracting band
above the bitten
part if allowed by
local protocol
Transport and
monitor the
patient
Safety BSI
Supine
Open and maintain
airway

IMMEDIATE

Triangular head

4.

Immobilize injured
limb and maintain
it.

1.
2.
3.

Calm Victim
O2
Proximal
constricting band
(+/-)
Clean bandage
wound
Immobilize bitten
area
Watch constricting
bands

Moderate

Progressive swelling

Coral Snake

Red on yellow
kill a fellow; Red
on black venom
lack

Thin

Small rounded

4.
5.
6.

Dog bites

Very common street

emergency especially in rural
areas
Areas of the body most
commonly bitten:

Head

Neck

Upper Extremities
Percentage
Face 11%
Trunk 7%
Upper extremity 28%
Lower extremity 31%

Children <12 yo are

usually bitten on the
face.
Most dog bites occur in
hot weather when a
person provokes a dog

7.
1.

2.

3.

4.

5.

Immediately and
thoroughly wash
the wound with
soap and water
Flush the wound
with water and
apply dressing
Transport the
patient to the
hospital for
medical care
especially if the
wound needs
stitching or
occurred in the
face or neck
Do not kill the dog
unless it is
absolutely
necessary to
prevent a full
scale crippling
attack.
If you kill the dog,
call for an animal

Bee Sting (insert bee

scientific name)

Spiders
Black Widow
(Larodectus
mactans)

Brown recluse
(Loxosceles reclusa)

Fiddle-back
spiders

6 eyes

Violin markings

officer and
request that the
corpse be
examined for
rabies.
6. Immobilize injured
part
7. Patient is usually
frightened calm
him/her down.
1. Remove stinger by
scraping with a
plastic card or
blunt edge of a
knife
2. Manage airway
3. O2 / Ventilation
4. Shock position
5. Epinephrine
5.1. Dilate airway
5.2. Constrict Blood
vessels
5.3. Ask for
medical
direction
5.4. Dosage
5.4.1. Adult 0.3 mg
yellow
5.4.2. Child 0.15
mg

Local reaction
Bronchospasm
Hypotension
Anaphylaxis

Neurotoxic

Hemolytic Anemia >

Necrosis

1.

1.

2.

Muscle Spasms within 15 min to

2 hours
Bite of 1mm apart fang mark

1.
2.
3.
4.

Necrosis
Hemoglobinuria
Hypotension
Possibility of death

Supportive care

2.
3.

Local cold
application
Symptomatic care
Immediate
transport

IMMEDIATE

Scorpion
( Centuroides
sculpturatus)

1.

Airway
management
2. Look out for
cardiac
dysrrhytmias
1. CAB
2. Flush with water
3. Immerse in warm
water
Vinegar and hot
water
1. Safety BSI
2. LOC
3. CAB
4. O2/ ventilation
5. Immerse wound
30-40 min as hot
as can be
tolerated, repeat
as necessary to
control pain
without scalding
6. Transport

Sting ray

Jellyfish
Scorpion/Lion/Stone
fish
Sea Urchins

Hypotension
Stonefish being the most
poisonous of them

WATER EMERGENCIES
CASE

ASSESSMENT

Drowning

Active
drowning:

Conscious

Thrashing

Vertical in
H2O

Unable to
call for
help

Body
maybe low
in H2O

Causes:
Rip Currents

PATHOPHYSIOLOGY

Step 1
Victim goes under,
water enters the
airway.
Coughing and
gasping victim
swallows water
Step 2
A small amount
enters the larynx
and causes
laryngospasm
Breathing ceases
and metabolic
acidosis occurs.
Dry drowning (10

SIGNS AND SYMPTOMS

MANAGEMENT

Stages of water rescue:

1. Yell
2. Reach and pull
3. Throw
4. Tow
5. Go

Stages of
management of
drowning
1. Do not enter
unless trained
in water
rescue
2. Ensure open
airway and
attempt
rescue
breathing
3. Continue
rescue
breathing and
remove from

Fresh water drowning not much

problem
Salt wather drowning water has
high osmolarity which attracts fluids
which results to pulmonary edema

TRANSPORT
CONSIDERATION

Diving Emergencies
Boyles law
o
As pressure
increase, volume
decreases
o
As pressure
decreases, volume
increases
Daltons law
o
P1= P(O2) + P(N2)
+ P(X)
o
Total pressure of gas

15% of gases)
Step 3
Laryngeal muscles
became severely
hypoxic and relax
allowing air and
water to enter the
lungs. (Wet
drowning)
Triggers peripheral
airway resistance
and constriction of
the pulmonary
vessels > Stiff
Lung lung ceases
to be compliant.
Step 4
Victems
hypercarbic/hypoxi
c drive further
stimulate inhalation
of water which
mixes with air and
chemical resident
in the lungs to form
a froth.
Brain damage and
death follows

4.

5.
6.

What to find out about a diving

emergency
1. Type of diving and the Type of
Equipment
2. Diving activity (photographing,
fishing)
3. Number of dives made the past 72
hours with each has
4. Depth
5. Bottom time
6. Surface Interval
7. Details of in-water decompression
8. In-water recompression? (a no-no!)

the water
Check pulse, if
no pulse, start
chest
compression
Transport
If given the
opportunity
positive
pressure
ventilation
using PEEP to
dry the lungs.

mix is sum of partial

pressure of its
components

9. Dive complications, if any.

10. Pre-dive and post-dive activity
11. Onset of symptoms (when and
what came first)

Henrys law
o
Pressure of a gas in
liquid is proportional
to its pressure in
the atmosphere
o
1 atm 34 ft water
Barotrauma
compression or expansion
of gas actually in adjacent
to body air spaces
Descent

Ear Squeeze

External

Middle

Sinus Squeeze

Lung Squeeze

Ascent
POPS (Pulmonary
Overpressure Syndrome)
Burst lung

Body air spaces attempts to

equilibrate on the outside
atmospheric pressure >
blockage> barotrauma
Lung Squeeze
Breath hold > 100 fsw >
compression of volume >
negative pressure of lungs >
pulling of interstitial fluid and
blood in shrunken air spaces
Could cause:

Pneumothorax/Tension
Pneumothorax

Pneumomediastinum

Subcutaneous
emphysema

Arterial Air Embolism

Lung squeeze is typically rare. For lung

squeeze to occur, a breath-hold diver
must descend to a depth which total
lung volume is significantly
compressed (100 feet)
Lung Squeeze

Dyspnea

Chest pain

Cough

Hemoptysis

Pulmonary edema

Pneumomediastinum/
Subcutaneous emphysema
o
Fullness of his throat
o
Dysphagia
o
Dyspnea
o
Substernal chest pain
o
Subcutaneous air palpable
above clavicles
o
Crunching noise synch with
heart beat

Dysbaric Air Embolism Symptoms occurs within seconds

or minutes after surfacing. Air
bubbles coalesce into larger and
larger bubbles as they travel
through the veins >

Lung Squeeze
1. No PPV or
PEEP
2. 100% O2 NRM
3. IV
4. Keep patient
sitting up
5. TRANSPORT to
hosp

Pneumomediastinu
m/
Subcutaneous
emphysema
o
Bed rest and
oxygen
therapy
POPS
o
100% O2
NRM
o
Dont give
PEEP to
POPS
o
keep patient
quiet
o
transport him
to hospital.

Cornoray arteries > MI

or
Cerebral artery > just like
Stroke
Pneumothorax/Tension
Pneumothorax
o
Tracheal deviation
o
Unequal breath sounds
o
Hyper resonance on the
affected side
o
o
o

Decompression
Sickness
Narcosis (Narcs/Rapture of
the deep)
Not dangerous but can
impair the divers
judgment.
Type I DS
DS of the skin
DS of the joints
(musculoskeletal)

Accumulation of nitrogen in
the tissues > increase
pressure > increase amount
of dissolved nitrogen in the
tissues > anesthetic effect >
martini effect
Most common but least
reported

If in doubt of
AIR
EMBOLISM >
go to
hyperbaric
chamber
facility

Ascend slowly to
alleviate martini
effect.

1.
2.
3.
1.
2.
3.
4.

Pruritis
SQ emphysema
Mottled rashes
Deep, dull aches in muscle/joints
Movement worsen pain
Fatige
Inflating cuff will relieve pain

1.

2.
3.

4.

5.

6.

Ensure
Adequate
Airway
Give 100%
oxygen
Start an IV
with LR and
give as
directed
Give steroids,
preferably
Methylpredni
silone 125
mg IV
Do not use
nitrous oxide
for analgesia
Advise hospital
that you will
require a use
of a hyperbaric
chamber

TYPE II DS
DS of the CNS
4-10 min rule

Brain involvement

CHOKES

1.
2.
3.
4.
1.
2.
3.
4.

Paresthesia
Seizure
Spinal cord involvement
Paralysis
Chest pain
Dry cough
Dyspnea
Pulmonary edema

1.

2.
3.

4.

5.

6.
Treatment of Suspected Air Embolism

1.

Ensure adequate airway, especially in the unconscious

patient if licensed to do so, INTUBATE

2.
3.

Admin. 100% O2

4.
5.

If licensed establish an IV lifeline with LR

6.

Have the following drugs ready for use Under Medical

Direction:

Transport in L Lateral recumbent with 10 degree head

down tilt
Monitor cardiac rhytm and be prepared to treat
dysrhythmias

6.1. Diazepam, 5mg for Seizures

6.2. Dopamine infusion 10mg/kg/min for treatment of
Hypotension

7.

Notify medical command/ hospital to make arrange for

reception at a hyperbaric chamber facility
Treatment of Decompression Sickness

1.
2.
3.
4.
5.
6.

Ensure Adequate Airway

Give 100% oxygen
Start an IV with LR and give as directed
Give steroids, preferably Methylprednisilone 125 mg IV
Do not use nitrous oxide for analgesia
Advise hospital that you will require a use of a hyperbaric
chamber

Ensure
Adequate
Airway
Give 100%
oxygen
Start an IV
with LR and
give as
directed
Give steroids,
preferably
Methylpredni
silone 125
mg IV
Do not use
nitrous oxide
for analgesia
Advise hospital
that you will
require a use
of a hyperbaric
chamber

WATER EMERGENCIES
CASE
Drowning

ASSESSMENT

PATHOPHYSIOLOGY

SIGNS AND SYMPTOMS

MANAGEMENT

TRANSPORT
CONSIDERATION