1. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DOT National Standard EMT-Intermediate/85 Refresher DOT National Standard EMT-Intermediate/85 Refresher Welcome!

2. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Allergic reaction Possible overdose Near-drowning ALOC Diabetes Allergic reaction Possible overdose Near-drowning ALOC Diabetes

3. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES ■ Assess and provide care to a patient experiencing a seizure ■ Assess and provide care to a patient exposed to heat or cold ■ Assess and provide care to a patient experiencing a behavioral problem ■ Assess and provide care to a patient with suspected communicable disease ■ Assess and provide care to a patient experiencing a seizure ■ Assess and provide care to a patient exposed to heat or cold ■ Assess and provide care to a patient experiencing a behavioral problem ■ Assess and provide care to a patient with suspected communicable disease

4. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Airway, Breathing & Circulation ■ Provide ventilatory support for a patient ■ Attempt to resuscitate a patient in cardiac arrest ■ Provide care to a patient experiencing cardiovascular compromise ■ Provide post resuscitation care to a cardiac arrest patient ■ Provide ventilatory support for a patient ■ Attempt to resuscitate a patient in cardiac arrest ■ Provide care to a patient experiencing cardiovascular compromise ■ Provide post resuscitation care to a cardiac arrest patient

5. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES BEHAVIORAL EMERGENCIES Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx

6. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective You & your EMT partner respond with an engine company to a “rollover accident” 3 of the girls are ambulatory, you find that a small sedan carry 4 college-aged girls has rolled over.

7. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective 3 of the girls are ambulatory; the 4th is trapped, with her hips lying under the car. She is unresponsive to deep pain & is lying on her side. Her skin is pale & warm. Her respirations are shallow at 12/ min & her pulse is irregular & difficult to palpate at 88 beats/min. The engine company can safely remove her in 10 minutes 3 of the girls are ambulatory; the 4th is trapped, with her hips lying under the car. She is unresponsive to deep pain & is lying on her side. Her skin is pale & warm. Her respirations are shallow at 12/ min & her pulse is irregular & difficult to palpate at 88 beats/min. The engine company can safely remove her in 10 minutes

8. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective What is your general impression of this pt? What additional assessment will be important in the evaluation of this pt? Can you complete any assessments before extrication? What interventions should you initiate this time? What is your general impression of this pt? What additional assessment will be important in the evaluation of this pt? Can you complete any assessments before extrication? What interventions should you initiate this time?

9. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective

10. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology

11. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Pathophysiology Ventilatory support –Minute volume = tidal x respiratory rate –Tidal volume is the lung volume representing the normal volume of air displaced between normal inspiration and expiration when extra effort is not applied. Typical values are around 500ml or 7ml/kg bodyweight Ventilatory support –Minute volume = tidal x respiratory rate –Tidal volume is the lung volume representing the normal volume of air displaced between normal inspiration and expiration when extra effort is not applied. Typical values are around 500ml or 7ml/kg bodyweight

12. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Epidemiology Ventilatory support can be for a deficit of tidal volume or rate Tidal volume that is too low is problematic Rate that is too high or too low is problematic Ventilatory support can be for a deficit of tidal volume or rate Tidal volume that is too low is problematic Rate that is too high or too low is problematic

13. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Epidemiology Ventilatory support is usually achieved using –BVM with or without adjuncts (NPA or OPA) –Advanced airway insert: King or Combitube –CPAP –Transtracheal Jet Insufflation Always be ready to suction Ventilatory support is usually achieved using –BVM with or without adjuncts (NPA or OPA) –Advanced airway insert: King or Combitube –CPAP –Transtracheal Jet Insufflation Always be ready to suction

14. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training –BVM with or without adjuncts (NPA or OPA) Head & neck position are vital Head & neck must midline –Head-tilt –Jaw thrust –Jaw thrust & head tilt Be ready to suction –BVM with or without adjuncts (NPA or OPA) Head & neck position are vital Head & neck must midline –Head-tilt –Jaw thrust –Jaw thrust & head tilt Be ready to suction

15. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training NPA –Right nare larger –Bevel toward septum –Size it correctly –lubrication NPA –Right nare larger –Bevel toward septum –Size it correctly –lubrication

16. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training NPA –Indication -- can’t use an OPA –Contraindication severe head or facial injuries, or have evidence of a basilar skull fracture (Battle's sign, raccoon eyes, cerebrospinal fluid/blood from ears, etc.) due to the possibility of direct intrusion upon brain tissue. –An OPA may be used instead, but these devices frequently trigger a patient's gag reflex, while nasopharyngeal airways usually do not. NPA –Indication -- can’t use an OPA –Contraindication severe head or facial injuries, or have evidence of a basilar skull fracture (Battle's sign, raccoon eyes, cerebrospinal fluid/blood from ears, etc.) due to the possibility of direct intrusion upon brain tissue. –An OPA may be used instead, but these devices frequently trigger a patient's gag reflex, while nasopharyngeal airways usually do not.

17. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training –OPA Indications: unconscious & no gag reflex Sizing Insertion: rotation or tongue depressor –Does not definitively protect from aspiration –OPA Indications: unconscious & no gag reflex Sizing Insertion: rotation or tongue depressor –Does not definitively protect from aspiration

18. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training BVM Apneic or inadequate ventilation –Positive pressure ventilations (PPV) Mouth-to-mouth ventilation Mouth-to-nose ventilation Mouth-to-barrier device ventilation Mouth-to-mask ventilation –Rate AND Depth are important Apneic or inadequate ventilation –Positive pressure ventilations (PPV) Mouth-to-mouth ventilation Mouth-to-nose ventilation Mouth-to-barrier device ventilation Mouth-to-mask ventilation –Rate AND Depth are important

19. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training BVM Gastric distention Mask to face seal Sellick’s maneuver? Gastric distention Mask to face seal Sellick’s maneuver?

20. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Combitube Allows ventilation of lungs & reduces the risk of aspiration 37F- 4-5feet 41F- >5feet Page 17/260 procedure

21. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Combitube When teeth/gum line located between black lines

22. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training King Size 3 - 4-5 feet Size 4 - 5-6feet Size 5- >6feet –Page 33/260 procedure

23. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Transtracheal Jet Insufflation

24. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Transtracheal Jet Insufflation page 54/260

25. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training CPAP

26. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training

27. COPD Hypoxic drive to breathe

28. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Exhaled CO2

29. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Wheezing Rales Rhochi Stridor Wheezing Rales Rhochi Stridor

30. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training LS –Right & left fields –Upper & lower fields –Expiratory &/or inspiratory sounds LS –Right & left fields –Upper & lower fields –Expiratory &/or inspiratory sounds

31. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Questions? References –Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. –Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. –Wolfson, Allan B. ed., Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010. References –Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. –Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. –Wolfson, Allan B. ed., Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.