3.2.1 Survey and Assess:

Members of an Emergency Response Team - In-Field

• Paramedic: They carry out the duty of a physician and can examine, evaluate, and treat patients with equipment and medications and are

  • also utilized as emergency care practitioners on ambulances or first response emergency vehicles.

• Emergency Medicine Technician: Conducts assessments for medical, trauma, CPR, airway devices, or basic life-saving

  • First to arrive on the scene

• Disaster Response Technician: Helps clear and clean the scene of toxins or debris

  • Cleans up toxic chemicals, lifts heavy objects, and is usually at the sites of oil spills or trucking accidents

• Emergency Medicine Physician: ER Doctor who specializes in emergent care

  • assists patients, takes care of medical planning/history, and requests testing and or diagnostics

  • Many don’t work in the field

Members of an Emergency Response Team - In-Facility

• Emergency Services Coordinator: In charge of assisting and leading the response before or after emergencies

  • Provides technical expertise

• Triage Nurse: Sorts patients based on emergent cases

  • They also release, transport, and give treatment to patients

• Emergency Medicine Nurse-Practitioner: Evaluate, treat, and diagnose patients without supervision from a physician

  • Provides critical care and psychological support

  • Many work in the field

• Emergency Communications Specialist: Operates and receives/relays calls on emergencies

  • Operatees on public safety law and consoles for a regional 911 communication center

Assessing the Scene

• Control the situation

  • Stay calm and act quickly to ensure everyone’s safety.

•  Look for potential hazards

  • Assess whether there is anything that could harm your team, the patient, or a bystander (a person who is present but uninjured).

•  Assess the situation

  • Quickly gather any available information about the situation using your own senses and also asking questions of the patient or any bystanders.

•  Protect and prioritize

  • Use personal protective equipment to protect yourself, keep bystanders out of harm’s way, and prioritize individuals who appear to be in the most need of help.

• Listen for unusual sounds and use your sense of smell to detect any unusual odors.

Assessing your Patient

Steps of Primary Assessment

1.  Form a general impression of the patient

   • What appears to have happened? How serious is the patient’s condition?

2.  Determine the Mechanism of Injury (MOI)

   • What caused the trauma, or physical damage, to the patient’s body?

3.  Determine the patient’s responsiveness

   • Is the patient alert, able to speak, in too much pain to respond, or unconscious? 

4.  Consider stabilizing the patient’s spine

   • Is a spinal injury suspected based on their position and MOI? If so, the patient’s back and neck must be held in place to prevent further injury.

5. Check the patient’s ABCs (Airway, Breathing, and Circulation)

   A - Airway	Is the patient’s airway partially or completely blocked? Can you feel air moving from their mouth or nose? Is their breathing noisy or high-pitched?
   B - Breathing	Is the patient breathing properly? What is their respiration rate? Are their breaths sporadic?
   C - Circulation	Does the patient have an adequate pulse? Is there any bleeding?

• In a trauma case where injury to the back, head, or neck has occurred, the spine must be immobilized with a spinal board or other device. Failure to immobilize an injured spine could lead to permanent paralysis or death.

  

  • Cervical Fracture: A cervical fracture is a traumatic injury that results from excessive force on the spine of the neck, they can put increased pressure on the spinal cord at the level of the fracture and can cause a spinal cord injury resulting in loss of sensation, paralysis, or even instant death

    

• To assess the airway for a patient who has not suffered a spinal, neck, or head injury, you can use the following head-tilt/chin-lift maneuver:

  1. Kneel beside the patient’s head and neck.

  2. Place one hand on the patient’s forehead.

  3. Place the fingertips of your other hand under the bony part of the patient’s lower jaw near the chin.

  4. Use firm backward pressure from the palm of your hand to tilt the head back while lifting the jaw up with the fingertips to extend the chin forward.

  5. Keep pressure on the patient’s forehead to help maintain the airway in an open position.

     

  Note: If the patient is a child, tilt the head so the airway is only slightly past neutral. For an infant, tilt the head so the airway is in a neutral position.

• Stridor, or noisy, wheezing breaths are due to a constricted airway.  A bag-valve-mask resuscitator is a mask with a handheld pump that is used for manual ventilation, or the providing of air, of a patient suffering a respiratory emergency.

  

  Note: In the field, an emergency responder would typically assess a patient’s airway and pulse at the same time.

Steps of Secondary Assessment

1.  Perform a rapid physical assessment

   • Check the patient head to toe for injuries or signs of illness, including the head, neck, chest, abdomen, and extremities.

2.  Take the patient’s vitals

   • Using medical devices to obtain more accurate readings, record the patient’s pulse, blood pressure, and respiration rate.

3.  Get a patient history

   • If the patient is not responsive, get a history from any family members or bystanders if possible.

4.  Provide appropriate emergency care

   • Ensure adequate airflow, provide oxygen if necessary, stop bleeding, and provide any medicines deemed appropriate.

• Pupillary response is the involuntary changing of size of the pupil and can serve as a useful tool to determine the health of the patient’s nervous system, whether they’ve suffered any nerve or brain damage, or are under the influence of certain drugs

  • Constriction, or narrowing, of the pupil, followed by the dilation, or widening, of the pupil

  • A response in the opposite eye from the one in which they’re shining a light is called a consensual pupillary reflex

  • Neurological problems may be present if the pupil stays dilated when exposed to light, stays constricted even in the dark, or if the consensual reflex is not observed

• Endotracheal tube are sometimes put down a patient’s trachea so air can then be delivered to the patient through the endotracheal tube

3.2.2 Drug Delivery

Live-Saving Medication

• Skin turgor is a measure of the elasticity of the skin and is used as an indicator of dehydration. To test skin turgor, you gently pinch, pull up, and release the skin on the back of the hand. Skin that remains raised after being pulled up and released

• Anaphylaxis: Severe allergic reaction

• Antigen: Anything that stimulates an immune response

• Antibody: A protein produced by B cells in the blood; that works to impair pathogens. Also called an immunoglobulin

• When an individual encounters a substance they are allergic to, the immune system recognizes it as an antigen and goes into attack mode, producing antibodies

  • The result can be mild symptoms, such as itchy, watery eyes or runny nose, or it can be severe, as in the case of your patient who is in anaphylaxis

• An allergic reaction is a condition in which the body's immune system overreacts to a foreign substance

  • Common triggers of an allergic reaction include nuts or fruits, certain medications, latex, metal or fabric dye, and insect stings. In patients with a stinging insect allergy, the venom from the sting elicits a broad, systemic allergic reaction

• Anaphylaxis is a severe systemic allergic reaction affecting multiple organ systems, often including the respiratory system and integumentary system (skin)

  • Patients undergoing a systemic allergic reaction may experience swelling of the face, tongue, throat, or airways. Other symptoms of anaphylaxis include hives, flushed skin, nausea, and dizziness.

• When a person with an allergy comes in contact with their allergen trigger, white blood cells release chemicals to attack the allergen

  • One of the chemicals released during anaphylaxis is histamine. Histamine causes the dilation (widening) of blood vessels and increases heart rate and gland secretion

  • Other chemicals released during the immune response cause constriction of the airways and increase the permeability of blood vessels

• Hives (urticaria) is a common dermatological condition characterized by raised, itchy welts on the skin

  • Welts associated with hives have well-defined edges, may vary in size, and are often grouped together spanning a large area

  • The appearance of hives is initiated by the release of inflammatory molecules from skin cells, commonly due to allergic reactions.

• Swelling of the lips, eyes, and face is a common characteristic of anaphylaxis.

• Swelling and constriction of the throat and airways can lead to wheezing and difficulty breathing.

• During anaphylaxis, some individuals may stop breathing, and/or their heart stops beating

  • If this happens, the first step is to administer cardiopulmonary resuscitation (CPR)

Routes of Entry

• Enteral Drugs: Medications that enter the body through the digestive tract, like oral medications such as pills or liquids

• Parenteral Drugs: Enter the body in a manner other than through the digestive tract

Determining Dose

• Kilograms to Pounds: lb = kg x 2.2046

Healthy Hydration

• IV refers to intravenous (IV) therapy, the delivery of medication and/or fluids over a period of time through a vein

  • A needle is used to place a tube called a catheter in a vein on either the back of the hand or the inside bend of the elbow. Medications and fluids can then be administered to the vein through the catheter.

• IV Therapist: A licensed practical nurse (LPN) or registered nurse (RN) who obtains additional certification for IV therapy

  • IV therapists place IVs in patients, administer IV medications and fluids, and document and monitor patients’ progress.

• The fluids in our bodies are not pure water; they’re solutions

  • Solutions are mixtures of a solvent, the substance doing the dissolving, and a solute, the substance being dissolved

    • In our bodies, the solvent is typically water. The outer membrane of our cells is semipermeable, meaning smaller molecules are able to pass through, but large molecules are not

    • Water molecules are able to diffuse or move in and out of the cell through special pores or channels called aquaporins. This movement is of water is called osmosis

• Homeostasis: the body’s maintenance of a stable internal environment, the inside of cells and the blood that surrounds them contain the same relative concentration of solutes, and water remains balanced

  • If the balance of dissolved substances shifts, water will move and cells will either swell or shrink.

    • Cells that take in too much water will swell and can burst

    • Cells that lose water shrink and become shriveled

• During osmosis, water moves from a high concentration to an area of lower concentration in an attempt to balance the concentration of solutes

  • Three terms are used to describe solutions that affect the way water moves during osmosis: isotonic, hypotonic, and hypertonic

    • Isotonic: The concentration of solutes in the solution outside the cell is the same as that in the cell, there is no net movement of water

    • Hypotonic: The concentration of solutes outside the cell is less than that inside the cell, water moves into the cell and it swells

    • Hypertonic: The concentration of solutes outside the cell is greater than that inside the cell, water moves out of the cell and it shrinks

3.2.3 Control Bleeding

Under Pressure

• Bleeding occurs due to a damaged blood vessel that has broken open, and bleeding stops when the blood coming out of the injured blood vessel clots

  • Proteins cause platelets to become a sticky web of fibers, allowing them to stick together across an opening in the blood vessel and close the wound.

Steps to Stop Bleeding

• Another set of ABCs to remember when you encounter an injured person and need to get their bleeding under control: Alert, Bleeding, Compress

• Life-threatening Bleeding:

  • Blood will not stop coming out of the wound

  • Blood spurts out of the wound

  • Blood is pooling on the ground

  • Clothing is soaked with blood

  • Bandages continue to soak through with blood

  • Victim seems confused or is unconscious

  • Victim has lost all or part of an arm or leg

• A tourniquet is a device that applies extra pressure to the vessels within an arm or leg to slow the flow of blood to that limb

  • To apply a Tourniquet:

    1. Wrap the tourniquet around the limb about two to three inches above the wound

    2. Important: Do not place the tourniquet onto a joint. Go above the joint if necessary

    3. Pull the free end to make the tourniquet as tight as possible

    4. Secure the free end

    5. Tighten the tourniquet until the bleeding stops

  • Secure the tourniquet and note the time it was applied

    A tourniquet is not a long-term solution, because it cuts off blood supply from all vessels that travel down that arm and will cause permanent tissue death to a limb after about two hour

  • 

Under Control

• Ligate: tie-off an artery or vessel

• An arterial bleed is typically more dangerous than a venous bleed

  • Arteries are more muscular than veins and carry blood under higher pressure

  • An arterial bleed spurts out blood in large volumes, whereas a venous bleed, while still dangerous, flows steadily with less volume

• For life-threatening bleeding from the neck, shoulder or groin, or for bleeding from a limb when a tourniquet is not available, you need to pack, or stuff, the wound with gauze

  • This creates an even stronger barrier to prevent blood from flowing from the vessel

  • To pack a wound:

    1. Wipe away any pooled blood

    2. Stuff the wound with gauze or a clean cloth

    3. Apply steady pressure with both hands directly on the bleeding wound.

    4. Push down as hard as you can, and continue to hold pressure until help arrives

       

  • After the emergency medicine physician finishes providing medicine to the patient, you assist them in clamping and then ligating the injured vein.

• Hemostat: A tool used to clamp an open blood vessel, and be sure to practice using one before you attempt to stop the bleed

3.2.4 Crisis Communication

The Art of Triage

• Triage: The process of prioritizing patients based on who is most in need of immediate care. Within triage are levels of priority

  • Following triage, patients will have a physical examination including measurement of vital signs

  • Steps of Emergency Care Triage:

    1. Physical exam and diagnostic testing

    2. Medical treatment and reevaluation

    3. Admission to hospital or discharge to home

• Triage Nurse: Often trained and licensed as a registered nurse (RN)

• The Triage Categories:

  • Emergent: Highest priority; care needed immediately as the patient may not survive without treatment

  • Urgent: Care is needed quickly but can be delayed temporarily

  • Semi-urgent: Care is needed but can wait if other higher-priority patients exist

  • Non-urgent: Lowest priority; minor conditions which are not time-sensitive and care is not needed immediately

3.2.5 Medical Surge

The Aftermath

• Medical Surge: Occurs when the number of new patients challenges or exceeds a hospital’s ability to serve all of them

• Surge Capacity: Refers to the ability to care for an increased volume of patients that challenges or exceeds normal operations

  • This is a measure of how many patients a medical facility can triage, treat, and manage in addition to its normal average number of patients