INTRODUCTION TO EMS SYSTEM

The goal of most emergency medical services is to either provide treatment to those in need of urgent
medical care, with the goal of satisfactorily treating the presenting conditions, or arranging for timely
removal of the patient to the next point of definitive care. This is most likely an emergency department at a
hospital. The term emergency medical service evolved to reflect a change from a simple system of
ambulances providing only transportation, to a system in which actual medical care is given on scene and
during transport. In some developing regions, the term is not used, or may be used inaccurately, since the
service in question does not provide treatment to the patients, but only the provision of transport to the
point of care.

Levels of Training

• First Responder (Emergency Medical Responder; Emergency First Responder; Medical First
Responder):
 First Responders in an emergency.
 Trained to manage immediate care of an emergency.
 Skills include…
 Airway management,
 Bleeding control,
 CPR and AED (automated external defibrillation),
 And scene control.
• EMT (Emergency Medical Technician):
 Used to be called EMT-Basic.
 In addition to the skills of a first responder, the EMT provides transportation and
more advanced medical care using the facilities in an ambulance.
 The role of the EMT is to stabilize the patient's conditions until arrival at the
hospital, where treatment will be provided.
• AEMT (Advanced EMT):
 Used to be called EMT-Intermediate.
 In addition to the skills of an EMT, the AEMT can administer much more
medications.
 These include both oral and intravenous medications.
• Paramedic:
 The paramedic provides the highest level of pre-hospital care.
 These include advanced interventions, administering a wide variety of
medications, and advanced life support

EFR Responsibilities

• BSI (Body Substance Isolation) Scene Safe:

 Before entering any scene, always make sure that you are not placing yourself or
your crew in danger.
• Patient Assessment and Emergency Care:
  Assess and evaluate the patient, recognize the problem at hand, and provide
interventions to stabilize the condition.
• Safe Lifting and Moving:
 Transportation of the patient from the scene of accident to the ambulance.
• Transport and Transfer of Care:
 Involves ongoing assessment and intervention while driving the ambulance to the
nearest hospital, where care will be transferred.
• Documentation:
 Complete the PCR (pre-hospital care report) carefully for incident.
 This will ensure that you have the proper documentation for legal issues.
• Patient Advocacy:
 Be supportive of the patient at all times and protect the patient's confidentiality.
Patient confidentiality is an important legal issue that will be discussed in a later
section.
• QI (Quality Improvement):
 To ensure a high quality of service, the EFR is to document carefully, participate in
review and feedback programs, maintain the functionality of equipment’s, and
participate in education programs.
• Medical oversight:
 Lastly, keep in mind that EFR are the extended arms of a doctor called the
medical director, who is in charge of and legally responsible for clinical aspects of
the EMS system under his or her authority.
 As long as an EFR follows medical direction, he or she is not legally held
responsible for medical consequences.

THE EMERGENCY MEDICAL SERVICES SYSTEM

The six branches of the star are symbols of the six main tasks executed by rescuers

• Detection:
 The first rescuers on the scene, usually
untrained civilians or those involved in
the incident, observe the scene,
understand the problem, identify the
dangers to themselves and the others,
and take appropriate measures to
ensure their safety on the scene
(environmental, electricity, chemicals,
radiation, etc.).
• Reporting:
 The call for professional help is made
and dispatch is connected with the
victims, providing emergency medical dispatch.
• Response:
 The first rescuers provide first aid and immediate care to the extent of their
capabilities.
 • On scene care:
 The EMS personnel arrive and provide immediate care to the extent of their
capabilities on-scene.

• Care in Transit:
 The EMS personnel proceed to transfer the patient to a hospital via an ambulance
or helicopter for specialized care. They provide medical care during the
transportation.
• Transfer to Definitive care:
 Appropriate specialized care is provided at the hospital.

WELL BEING OF AN EMERGENCY MEDICAL RESPONDER

Emotional Well Being

Cases with High Emotional Stress

• MCIs (Multiple-casualty incidents). • Incident involving a friend, relative, or

• Child abuse and neglect. coworker.
• Abuse of the elderly. • Traumatic injuries.
• Dealing with patients and family
members involved in death and dying.

Coping with Death and Dying

• For patients:
Treat dying patients with dignity and respect. Communicate to the patient what you are
planning to do and let the patient know that you are doing everything you can to help. This
will bring assurance to the patient and establish trust. Even if the patient may look
unconscious, he or she may still be able to hear and understand what you say.
• For family members:
Be compassionate to the patient's friends and relatives who may be around. An important
skill is to be able to listen empathetically to the grieving of family members. Assure that
you are doing everything you can for the patient, but at the same time do not give false
assurances. Be honest with the relatives about the patient's status, but also be tactful.
• For yourself:
Prepare yourself emotionally to encounter death and dying situations and be able to cope
with it. One aspect is to recognize and understand the five stages of denial, anger,
bargaining, depression, and acceptance. Learning to recognize and accept these
emotional stages in your patients can help you come to terms with death and dying.

Recognizing and Managing Stress

 • There are three stress reactions with symptoms that include anxiety, irritability, nausea, guilt,
isolation, and loss of concentration, appetite, and interest in life. Learn to recognize them in
yourself and in others and manage them accordingly.
• Acute Stress Reaction: occurs immediately after an emotionally traumatic incident.
• Delayed Stress Reaction: occurs after a delayed period after an incident. One example is the
Posttraumatic stress disorder.
• Cumulative Stress Reaction: occurs as a result of many stressful reactions over time.
• Stress management involves both physical and mental adaptations.
• Exercise: Activity provides an outlet for emotions, releases positive hormones, and improves
physical condition.
• Diet: Take up a healthy diet and avoid dependence on caffeine or alcohol.
• Relax: Slow and deep breathing, yoga, and vacations all help relieve stress.
• CISM (Critical Incident Stress Management): System to manage the stress of EMS workers.
Involves stress education, peer support and CISD (Critical Incident Stress Debriefing).

Physical Well Being

Body Substance Isolation

• Body substance isolation involves using proper equipment to prevent the transmition of infectious
diseases.
• The equipment used in BSI is called PPE (Personal protective equipment). These include gloves,
eyewear, gowns and masks.
• Hand washing: The single most effective way to prevent the spread of infectious diseases is by
washing your hands thoroughly after each incident, even if gloves were worn. The guidelines for
hand washing is 10-15 seconds of vigorous scrubbing with soap and rinsing with the hottest water
that you can bear.

Scene Safety

• Hazmat: Look out for hazardous materials by identifying signs and placards listed in the
Emergency Response Guidebook available inside every ambulance.
• Violence: Do not enter scenes with potential violence. These include scenes of fights, aggression,
and weapon use. When in doubt, call law enforcement to check for scene safety.
• Do not try to handle hazardous scenes without the proper training and protective gear.

Medical, Legal and Ethical Issues

Medical Issues

• Organ Donation: Only consider the patient for organ donation if there is signed, legal
documentation. Communicate the possibility of organ donation with medical direction.
• Medical Identification Tag: Look for these during patient assessment as they provide information on
any medical conditions the patient may have, including allergies, asthma, diabetes, or epilepsy.
• Death: When in doubt, always assume the patient is alive and begin resuscitation efforts. Signs of
death include
  Absence of breathing and pulse.
 Completely unresponsive to any stimuli.
 Rigor mortis.
 Dependent lividity (skin discoloration due to the effect of gravity on blood causing the
underside to be dark red to purple).
 Obvious signs such as decapitation, decomposition, and suicide.

Legal Protection

Terms to Understand and Rules to Abide By

• Duty to Act:
o While on-duty, EMR are required by law to care for a patient who requires and consents to
it.
• Scope of Practice:
o Defines what an EMR with the appropriate licensure can and cannot do by law.
• Standard of Care:
o Defined as the level of care at which the average, prudent provider in a given community
would practice.
• Medical Direction:
o EFR must follow medical direction at all times. This includes off-line directions such as
protocols approved by medical direction and on-line directions directly communicated by
the doctor. When in doubt, always ask for medical direction.
• Patient Consent:
o The conscious, mentally competent adult has the right to accept or refuse emergency
medical care. Thus, always make sure that the patient consents before beginning
emergency care. There are three types of consents: expressed, implied, and that which
deals with a minor.
• Patient Refusal or Withdrawal of Treatment:
o Always ask the patient to fill out sign a refusal form, including documentation of what was
told to the patient and his or her response. However, before this, the EFR should have
persuaded the patient to receive care and then made certain that the patient is indeed
mentally competent and capable of making rational decisions.
• Advanced Directives:
o These are instructions given in advance such as a DNR (Do Not Resuscitate) order. These
directions should be honored if clear, unambiguous documentation exists.
• Crime Scenes:
o When treating patients in a crime scene, always take steps to preserve evidence. These
include communicating with police officers, document unusual discoveries, avoid cutting
through evidence such as knife or bullet holes in clothing, and ask the patient to avoid
washing or going to the bathroom if the crime is rape.
• Reporting:
o If patient assessment suggests child abuse or crime, report to the appropriate authorities.
Offenses

• Negligence: Occurs when all four of the following conditions are met

1. The EMR had a duty to act.

2. The EMR breached that duty.
3. Harm or damages were caused to the patient.
4. The harm or damages were caused by the breach of duty.

• Abandonment: When an EMR begins treating a patient, but stops without transferring the care to
someone with appropriate expertise.

• Assault: can occur as an act or a threat to inflict harm on a patient.

• Battery: the act of touching a patient without consent.

• False Imprisonment: keeping and transporting the patient without consent.

• Defamation: Release of damaging information about a patient to the public. Verbal defamation is
called slander, and the written form is called libel.

Ethical Responsibilities

• Treat all patients with dignity and respect without respect to factors such as race, gender or creed.
• Treat all coworkers and health care workers with dignity and respect.
• Maintain knowledge and skill competencies as an EMR.
• Exercise honesty and integrity when documenting.
• Advocate for the patient's best interest at all times, even off-duty.

SURFACE ANATOMY

Directional Terms

Anterior Posterior Superior Inferior

 Medial Lateral Proximal Distal

Body Planes
Positional Terms

In addition to directional terms, there are specific positional terms with which you should be familiar with.

Body Cavities

There are 4 major body cavities – Cranial cavity, Thoracic Cavity, Abdominal Cavity and Pelvic Cavity.
Housed in these cavities are the major organs.

Cranial Cavity Houses the brain and its specialized membranes. The spinal cord runs out of the
cranium and down through the center of the vertebrae of the spine. The bones of
the spine protect the spinal cord and its specialized membrane.

Thoracic Cavity Also known as the chest cavity, is enclosed by the rib cage. It holds and protects
the lungs, heart, great blood vessels, part of the windpipe (Trachea), and part of
the esophagus, which is the tube leading from throat to the mouth. The lower
border of the chest cavity is the diaphragm, a dome-shaped muscle used in
breathing and separates the chest cavity from the abdominal cavity.

Abdominal Cavity Lies between the chest cavity and the pelvic cavity. The stomach, liver,
gallbladder, pancreas, spleen, small intestine, and most of the large intestine can
be found in the abdominal cavity.

Pelvic Cavity The pelvic cavity is protected by the bones of the pelvic girdle. This cavity houses
the urinary bladder, portions of the large intestine, and the internal reproductive
organs.
Abdominal Quadrants
The Body Systems

The human body is made up of several organ systems that work together as one unit. Ten major organ
systems of the body are listed below, along with several organs that are associated with each system.

Organ Systems

1. Circulatory System: The main function of this system is to transport nutrients and gasses to cells
and tissues throughout body. This is accomplished by the circulation of blood.

a. Cardiovascular: This system is comprised of the heart, blood, and blood vessels. The
beating of the heart drives the cardiac cycle which pumps blood throughout body.

b. Cardiovascular organs: heart, blood vessels, blood

c. Lymphatic: This system is a vascular network of tubules and ducts that collect, filter, and
return lymph to blood circulation. As a component of the immune system, the lymphatic
system produces and circulates immune cells called lymphocytes.

d. Lymphatic organs: lymph vessels, lymph nodes, thymus, spleen, tonsils

2. Digestive System: This system breaks down food polymers into smaller molecules to provide
energy for the body. Digestive juices and enzymes are secreted to break down the carbohydrates,
fat, and protein in food.

a. Primary organs: mouth, stomach, intestines, rectum

b. Accessory organs: teeth, tongue, liver, pancreas

3. Endocrine System: This system regulates vital processes in the body including growth,
homeostasis, metabolism, and sexual development. Endocrine organs secrete hormones to
regulate body processes.

a. Endocrine structures: pituitary gland, pineal gland, thymus, ovaries, testes, thyroid gland

4. Integumentary System: This system protects the internal structures of the body from damage,
prevents dehydration, stores fat and produces vitamins and hormones.

a. Integumentary structures: skin, nails, hair, sweat glands

 5. Muscular System: This system enables movement through the contraction of muscles.

a. Structures: muscles

6. Nervous System: This system monitors and coordinates internal organ function and responds to
changes in the external environment.

a. Structures: brain, spinal cord, nerves

7. Reproductive System: This system enables the production of offspring through sexual
reproduction. It is comprised of male and female reproductive organs and structures which produce
sex cells and ensure the growth and development of offspring.

a. Male organs: testes, scrotum, penis, vas deferens, prostate

b. Female organs: ovaries, uterus, vagina, mammary glands

8. Respiratory System: This system provides the body with oxygen via gas exchange between air
from the outside environment and gases in the blood.

a. Respiratory organs: lungs, nose, trachea, bronchi

9. Skeletal System: This system supports and protects the body while giving it shape and form.

a. Structures: bones, joints, ligaments, tendons, cartilage

10. Urinary/Excretory Systems: This system removes wastes and maintains water balance in the body.

a. Structures: kidneys, urinary bladder, urethra, ureters

It is important to keep in mind that these organ systems don't just exist as individual units. The final product
of these cooperating systems is one unit called the body. Each system depends on the others, either
directly or indirectly, to keep the body functioning normally.

PRINCIPLES OF LIFTING AND TRANSFER

Body Mechanics

Proper body mechanics is the proper and efficient use of your body to facilitate lifting and moving. These
are important steps that Emergency Medical Responders must follow to lift efficiently and to prevent injury.

When you are ready to lift, follow the rules of proper body mechanics to minimize the chances of injury to
yourself, your co-workers, or the patient.

• Position your feet properly (they should be on a firm, level surface and positioned a comfortable
width apart. Take extra care of the surface is slippery or unstable. It may be necessary to postpone
the move until more help or equipment is on hand.
• Lift with your legs. (Keep your back straight as possible and bend at your knees.)
 • When lifting with one hand, avoid leaning into opposing side.
• Minimize twisting during a lift
• Keep the weight as close to your body as possible
• When carrying a patient on stairways, use a chair or a commercial stair chair.

When to move a patient

Emergency Medical Responders should only move a patient when absolutely necessary. Your primary role
is to assess the patient, provide basic emergency care, and continue to monitor patient’s condition until a
more advanced help arrives. Emergency situations in which it may be necessary to move a patient
include…

• The presence of dangerous environment where the patient is at risk for further injury.
• When you cannot adequately assess the patient’s ABC’s or bleeding.
• When you are unable to gain access to other patients who need lifesaving care.

Emergency Moves

An emergency move should be considered in the following situations:

• The patient or rescuer are in danger

• Lifesaving care cannot be given because of the patients’ location or position.
• You must move the patient to gain access to other patients who need life-saving care.
Standard Moves

A preferred move when the situation is not urgent, the patient is stable, and you have adequate time and
personnel for the move. Standard move should be carried out with the help of other trained personnel or
by-standers. Take care to prevent additional injury, as well as to avoid patient discomfort and pain.

Standard Transport Equipment’s

Wheeled Stretcher

Portable Stretcher

Scoop Stretcher

Basket Stretcher

Vacuum Stretcher
 SKEDCO

Stair Chair

Kendrick Extrication Device

Flexible Stretcher

COMMUNICATION AND DOCUMENTATION

The purpose of a communications system is to relay information from one location to another when it is
impossible to communicate face to face. The results of using a communication system will be only as
accurate as the information that is put into the system.

Good communication means that the person receiving the message understands exactly what the person
who sent the message meant.

• Effective communication requires feedback.

• The receiver needs to communicate to the sender that the message has been received and
understood.
Documentation

Documentation is a process for verifying your actions using written records or computer-based records.
Proper documentation includes:

• The age and sex of the patient

• The history of the incident
• The condition of the patient when found
• The patient’s description of the injury/illness
• The patient’s chief complaint
• The patient’s level of responsiveness
• The status of initial and subsequent vital signs
• The results of the physical examination
• Pertinent medical conditions using the SAMPLE format
• The treatment you gave the patient
• Any change in the patient’s condition
• The agency and personnel who took over treatment
• The following times:
o The time you were dispatched o Any reportable conditions present
o The time you arrived on the scene o Any infectious disease exposure
o The time other providers arrived on o Anything unusual about the case
the scene o Any other helpful facts
o The time you departed the scene
• Complete your patient care report as soon as possible after each call.

VITAL SIGNS AND SAMPLE HISTORY

Vital signs are measurements of the body's most basic functions. The four main vital signs routinely
monitored by medical professionals and health care providers include the following:

 Body temperature
 Pulse rate
 Respiration rate (rate of breathing)
 Blood pressure (Blood pressure is not considered a vital sign, but is often measured along with the
vital signs.)
 Pulse Oximetry (Oxygen saturation in the blood)

Vital signs are useful in detecting or monitoring medical problems. Vital signs can be measured in a
medical setting, at home, at the site of a medical emergency, or elsewhere.

Body Temperature

The normal body temperature of a person varies depending on gender, recent activity, food and fluid
consumption, time of day, and, in women, the stage of the menstrual cycle. Normal body temperature can
range from 97.8 degrees F (or Fahrenheit, equivalent to 36.5 degrees C, or Celsius) to 99 degrees F (37.2
degrees C) for a healthy adult. A person's body temperature can be taken in any of the following ways:
  Orally. Temperature can be taken by mouth using either the classic glass thermometer, or the
more modern digital thermometers that use an electronic probe to measure body temperature.

 Rectally. Temperatures taken rectally (using a glass or digital thermometer) tend to be 0.5 to 0.7
degrees F higher than when taken by mouth.

 Axillary. Temperatures can be taken under the arm using a glass or digital thermometer.
Temperatures taken by this route tend to be 0.3 to 0.4 degrees F lower than those temperatures
taken by mouth.

 By ear (tumpanic). A special thermometer can quickly measure the temperature of the ear drum,
which reflects the body's core temperature (the temperature of the internal organs).

 By skin. A special thermometer can quickly measure the temperature of the skin on the forehead.

Body temperature may be abnormal due to fever (high temperature) or hypothermia (low temperature). A
fever is indicated when body temperature rises about one degree or more over the normal temperature of
98.6 degrees Fahrenheit, according to the American Academy of Family Physicians. Hypothermia is
defined as a drop in body temperature below 95 degrees Fahrenheit.

Pulse Rate

The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute. As
the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood.

Taking a pulse not only measures the heart rate, but also can indicate the following:

 Heart rhythm
 Strength of the pulse

The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The pulse rate may fluctuate
and increase with exercise, illness, injury, and emotions. Females ages 12 and older, in general, tend to
have faster heart rates than do males. Athletes, such as runners, who do a lot of cardiovascular
conditioning, may have heart rates near 40 beats per minute and experience no problems.

Patient Slow (bradycardia) if Normal (at rest) Rapid (tachycardia) if

below above
Adult 60 60-80 100
Child 80 80-150 150
Infant 120 120-150 150
 Pulse characteristic Possible problems / diagnosis

Normal rate, regular rate, and strong (full) pulse Normal person at rest

Exertion, fright, fever, high blood pressure, initial

Rapid, regular and strong
response to injury and bleeding

Rapid, regular and weak (also called regular and

Indication of shock
thready)

Head injury, drug use (barbiturate or narcotic),

Slow
poisons, possible cardiac problem

No pulse Cardiac arrest

Pulsus paradoxus (decrease in pulse strength Severe cardiac or respiratory injury, illness or
during inhalation) blood loss

Respiration Rate

The respiration rate is the number of breaths a person takes per minute. The rate is usually measured
when a person is at rest and simply involves counting the number of breaths for one minute by counting
how many times the chest rises. Respiration rates may increase with fever, illness, and with other medical
conditions. When checking respiration, it is important to also note whether a person has any difficulty
breathing.

Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.
Average resting respiratory rates by age are:
Blood Pressure

Blood pressure, measured with a blood pressure cuff and stethoscope, is the force of the blood pushing
against the artery walls. Each time the heart beats, it pumps blood into the arteries, resulting in the highest
blood pressure as the heart contracts.

Two numbers are recorded when measuring blood pressure. The higher number, or systolic pressure,
refers to the pressure inside the artery when the heart contracts and pumps blood through the body. The
lower number, or diastolic pressure, refers to the pressure inside the artery when the heart is at rest and
is filling with blood. Both the systolic and diastolic pressures are recorded as "mm Hg" (millimeters of
mercury). This recording represents how high the mercury column in an old-fashioned manual blood
pressure device (called a mercury manometer) is raised by the pressure of the blood.

High blood pressure, or hypertension, directly increases the risk of coronary heart disease (heart attack)
and stroke (brain attack). With high blood pressure, the arteries may have an increased resistance against
the flow of blood, causing the heart to pump harder to circulate the blood.

According to the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, high
blood pressure for adults is defined as:

140 mm Hg or greater systolic pressure or 90 mm Hg or greater diastolic pressure

In an update of NHLBI guidelines for hypertension in 2003, a new blood pressure category was added
called prehypertension:

120 mm Hg – 139 mm Hg systolic pressure or 80 mm Hg – 89 mm Hg diastolic pressure

• Hypertension: high blood pressure in an adult is considered over 140 / 85.

• Pulse pressure: the difference between systolic and diastolic pressure. Normally falls between 25
% and 50 % of systolic pressure.
 • Narrow (low) pulse pressure: shock, cardiac tamponade (blood filling the pericardial sac,
compressing the heart), tension pneumothorax (injury to one lung, causing pressure on the heart
and the other lung).

• Measuring blood pressure: Using a sphygmomanometer (wrapped around the arm), applying
pressure (by pumping) over the brachial artery until a radial pulse can no longer be detected. Over
pump 30 mmHg, then slowly release the pressure. Detect for a return of pulse by either
auscultation or palpation.

• Auscultation: listening with a stethoscope for the return of the brachial pulse. The first sound
marks the systolic pressure and the last sound (either a disappearance or a notable drop in
volume) marks the diastolic pressure.

• Palpation: palpating for the radial pulse. When the radial pulse returns, this is the systolic
pressure. The palpation technique cannot measure diastolic pressure (a "P" is noted in place of the
diastolic pressure). The systolic pressure measured is approximately 7 mmHg lower than those
obtained by auscultation. Do not over pump more than what is needed- it can be very painful for
the patient.

Oxygen Saturation

Pulse Oximetry

Pulse oximetry is a way to measure how much oxygen your blood is carrying. By using a small device
called a pulse oximeter, your blood oxygen level can be checked without needing to be stuck with a needle.
The blood oxygen level measured with an oximeter is called your oxygen saturation level (abbreviated
O2sat or SaO2). This is a percentage of how much oxygen your blood is carrying compared to the
maximum it is capable of carrying. Normally, more than 89% of your red blood should be carrying oxygen.

Normal 96%–100%
Mild hypoxia 91%– 95%
Significant or moderate hypoxia 86%– 90%
Severe hypoxia 85% or less

• Measured over the tip of the index finger, can detect hypoxia, which can be treated by applying
oxygen via a Non re-breather mask.

• Limitations: Directly measures hemoglobin saturation, not oxygen level. Therefore, false readings
can occur during carbon monoxide poisoning.

Vital Sign Reassessment

• Stable patients: every 15 min

• Unstable patients: every 5 min
PATIENT ASSESSMENT MODEL

Four major components:

 Scene Size-up
o Is an overview of the scene to identify any obvious or potential hazards
 Primary Assessment
o The purpose of the initial assessment is to prioritize the patient and to determine the
existence of immediately life-threatening conditions.
o This is a quick assessment of the patient’s Airway, Breathing, Circulation, and bleeding
undertaken to detect and correct immediate life-threatening problems
 Secondary Assessment
o A more thorough assessment of the patient and has 2 sub components
 History (Includes all the information that you can gather regarding the patient’s
condition as well as any previous medical history).
 Reassessment
o Monitoring the patient to detect any changes in his condition, this components repeats the
primary assessment (done usually while en route to hospital), corrects any additional life-
threatening problems, repeats vital signs, and evaluates and adjusts as needed any
interventions performed, such as repositioning the patient or increasing supplemental
oxygen.

Scene Safety

The conditions at a safe scene will allow you the EMR to access and provide care to patients without
danger to yourself. An unsafe scene is one that contains hazards that are either immediate or potential.

• Never enter an unstable hot zone.

• Be mindful of Rescuers Safety, Patient Safety and By stander Safety
• Traffic safety and control.
o Limit exposure to traffic.
o Control traffic
o Wear reflective clothing.
o Turn the wheels of your parked vehicle to point away from the scene (if someone
crashes into it, you won't get run over by your own vehicle).
• Do not enter active crime scenes until it is under control by law enforcement. Take extra
precautions if you suspect crime, or simply call for law enforcement.
• Take precautions for unstable surfaces and slopes.
• Scene control: tell crowds to step back. Introduce yourself to patients and always ask for their
consent to any treatment. Be courteous, let patients know you are here to help.
• Maintain an escape route.
• If a scene turns hazardous at any point, leave.

Mechanism of Injury / Nature of Illness

Mechanism of Injury Is made up of the combined forces that caused the injury.
Nature of Illness Is directly related to the patients Chief Complaint (CC).

Additional resources

• Can your unit handle this? If not, call for additional resources.
• Additional EMS units.
• Law enforcement.
• Fire department.
• Hazmat team.

Initial/Primary Assessment

General impression

• Manage immediate life threats:

o Check for airway compromises such as airway obstruction. Open their airway.
o Look for breathing abnormalities such as paradoxical movement a segment of the chest.
Provide PPV and O2.
o Control circulation problems such as major bleeding and open wounds. Direct pressure on
open wounds.
• Trauma or medical.
• C-spine for trauma patients with a high index of suspicion.

Level Of Consciousness

A Alert (awake, oriented, and obeys commands)

Alert and Oriented to Person, Place, Time and Event (A&O x 4)
V Responds to Verbal stimuli (awake but confused, or unconscious but responds in some
way to verbal stimuli)
P Responds to Pain (unconscious but responds in some way to touch or painful stimuli)
U Unresponsive (no gag or cough reflex)

Airway

The highest priority in resuscitation is securing and maintaining the airway because loss of the airway is the
most rapidly lethal event. Evaluation of the airway begins by asking the patient a simple question, such as,
“What is your name?” A response in a normal voice suggests that the airway is not in immediate jeopardy.
A weak voice, breathlessness, hoarseness, or absent response, however, suggests compromise of the
airway. Agitation and combativeness may be signs of airway compromise resulting in hypoxia. Noisy
breathing, cyanosis, and use of the accessory muscles of respiration are all strongly suggestive of
obstruction of the airway.

 Alert and talking or crying patients have patent airway.

 Altered mental status or unresponsive patients cannot protect their airway. You need to open
their airway.
  Snoring patients: perform head-tilt chin-lift or jaw thrust, insert airway adjuncts.
 Gurgling patients: suction.
 Crowing and stridor: administer oxygen and artificial ventilation.

Breathing

High-flow delivery of oxygen provides the opportunity for optimal oxygen saturation of hemoglobin. The
oxygen saturation is most readily assessed by the use of a pulse oximeter, as the clinical determination of
adequate oxygenation is virtually impossible by any other noninvasive means. Two of the factors that affect
reliability of the pulse oximeter readings are anemia less than 5 g% and hypothermia less than 30°C (86°F)

 Is the patient breathing at all? If not, give two artificial ventilations then check for pulse.
 If breathing, is the breathing adequate (rate and volume)?
 Are there breath sounds and chest rise and fall?
 Look for signs of breathing difficulties such as retractions, use of accessory muscles, nasal
flaring, hypoxia and shock signs.
 Does the pulse Oximetry vital sign read above 95%?
 Treat inadequate breathing / hypoxia with oxygen administration and or artificial ventilation.

Circulation and Hemorrhage Control

Stop the bleeding! After the airway has been secured and the dynamics of breathing are being restored, the
status of the circulatory system is addressed next. Shock, defined as inadequate organ perfusion and
tissue oxygenation, must be diagnosed and treated. The most common type of shock in the trauma patient
is hemorrhagic shock. The most important management principle in treating hemorrhagic shock is to find
the source of blood loss and stop the bleeding. Hemorrhage from open wounds is treated by direct
pressure at the wound site or, if required, at proximal pressure points where arterial inflow can be
compressed (e.g., femoral artery at the groin or brachial artery at the elbow).

 Pulse: Is there a pulse at all? Check the carotid pulse if no radial pulse is felt.
 No breathing, no pulse = begin CPR: 5 cycles of 30/2 compressions/ventilations followed by
AED.
 If you just witnessed the cardiac arrest, apply AED immediately if available.
 Is the pulse rate normal? Is the quality strong and regular?
 Check for possible major bleeding: are there open wounds? Control any major bleeding
(spurting arterial or fast flowing venous blood).
 Assess perfusion: (Capillary refill test: <2 Seconds is Good; whereas >3 Seconds bad) is the
patient in shock? Shock = cool and clammy skin that appears pale, mottled or cyanotic.
 Check skin:
o Pale or mottled: onset of shock.
o Cyanotic: late sign of shock.
o Red: anaphylactic or vasogenic shock, poisoning, overdose or other medical condition.
o Yellow: jaundice, liver problems.
o Cool and clammy: shock.

Secondary Assessment
The main purpose of the secondary assessment is to discover the patient’s specific injuries or medical
problems. It is a very systematic approach to the patient assessment. Includes physical examination that
focuses on a specific injury or medical complaint, or it may be a rapid exam of the entire body. It includes
obtaining history and taking vital signs.

 Patient History
o Includes any information relating to the patient’s current complaint or condition, as well as
pat medical problems that could be related.
 Rapid Secondary Assessment
o A quick less detailed head-to-toe assessment of the critical patients
 Focused Secondary Assessment
o Is conducted on stable patients
o Focuses on specific injuries or chief complaint
 Vital Signs
o The first set of vital signs taken is referred to as baseline vital signs. All subsequent vital
signs should be compared to the baseline vital signs to identify developing trends
 Symptoms
o Reported by the patient, such as chest pain, dizziness, nausea, etc…
o Also called subjective findings
 Signs
o What you see, feel, hear, and smell as you examine the patient, such as cool, clammy
skin, or unequal pupil size, facial droop, slurred speech.
o Also called objective findings

The SAMPLE History

Medical history obtained from the patient, family and bystanders

• Signs and Symptoms

o Signs: what you can observe and measure about the patient, such as the vital signs.
o Symptoms: what the patient describes to you- pain, numbness...etc. You cannot observe
these, so you must ask OPQRST
 Onset: "what were you doing when it started?"
 Provocation or Palliation: "does anything make it worse? Anything makes it
better?"
 Quality of pain: "can you describe it to me? Is it sharp, dull, constant, intermittent?"
 Region and Radiation: "where exactly does it hurt? Does the pain extend
anywhere else?" (Myocardial infarction produces pain that radiates to the arms
and jaw)
 Severity: "on a scale of 1 to 10, how much does it hurt?"
 Time: "how long has this been going on? How has this progressed over time?"

• Allergies: "Do you have any allergies?" This includes medication, food, or other environmental
factors. Check for medical alert tags.
 • Medications: "Are you on any medications? Have you taken medications recently?" This includes
prescriptions, over-the-counter, birth control pills, illicit drugs or herbal medicine. Look for medical
tags.
• Pertinent past history: "Have you ever had any illnesses? Operations? Have you ever been
admitted to a hospital?" Find out medical problems and past surgical procedures.
• Last oral intake: "When did you last eat or drink something? What was it?" A diabetic patient who
hasn't consumed anything for 8 hours may be hypoglycemic.
• Events leading up to the injury or illness: "What happened? How did this happen?" The events
leading up to the injury provide clues for the underlying cause.

Reassessment / Ongoing Assessment

Ongoing assessment and management includes the critical procedures performed on scene and during
transport and communication with medical direction. The ITLS Ongoing Exam is an abbreviated exam to
assess for changes in the patient’s condition. Ongoing Exam may be performed multiple times during a
long transport. In critical cases with short transport times, there may not be time to perform a Secondary
Survey; the Ongoing Exam may take its place. It should be performed and recorded no less than every five
minutes for critical patients and every 15 minutes for stable patients. The Ongoing Exam also should be
performed as follows:

• Each time the patient is moved

• Each time an intervention is performed
• Any time the patient’s condition worsens

This exam is meant to find any changes in the patient’s condition, so concentrate on reassessing only
those things that may change. For example, if you have applied a traction splint, reassess the limb for
decreased pain and for the presence of distal pulses, motor function, and sensation (PMS). On the other
hand, if you decompress a chest, you must reassess almost everything in the initial assessment and rapid
trauma survey down through the abdominal exam.

The Trauma Patient

The trauma patient is one who received a physical injury of some type.

• Significant Mechanism of injury

o Ejection from the vehicle
o Death of one or more passengers in a vehicle
o Falls greater than 15 feet
o Rollover collision
o High-speed vehicle collision
o Vehicle-Pedestrian collision
o Motorcycle crash
o Unresponsive or AMS (Altered Mental Status) patient
o Penetrations of the head, neck, chest, or abdomen
o For Children Include:
 Falls of more than 10 feet
  Bicycle collision
 Medium-speed vehicle collision

Rapid Trauma Assessment

· DCAP-BTLS
HEAD · Blood & fluids from the head (CSF)
Inspect and palpate for · Pupillary Reaction (PERRLA)
signs of injury. · Raccoon Eyes
· Battle Sign

· DCAP-BTLS
· JVD (Jugular Vein Distention)
NECK · Crepitation
Inspect and palpate for · Tracheal Deviation
signs of injury. · Apply CSIC (Cervical Spinal
Immobilization Collar) - if not already
done

CHEST · DCAP-BTLS
Inspect and palpate for · Paradoxical movement
signs of injury. · Crepitation

· DCAP-BTLS
ABDOMEN · Pain
Inspect and palpate for · Firm
signs of injury. · Soft
· Distended

PELVIS · DCAP-BTLS
Inspect and palpate for If no pain is noted, gently compress
signs of injury. the pelvis to determine tenderness
or unstable movement
 EXTREMITIES · DCAP-BTLS
Inspect and palpate the · Crepitation
lower and upper · Distal pulses
extremities for signs of · Sensory function
injury. · Motor function

DCAP-BTLS – A mnemonic for EMT assessment in which each area of the body is evaluated for:

Deformities Burns

Contusions Tenderness
 Abrasions Laceration

Punctures
Swelling
Penetrations

The Medical Patient

For the medical patient, you are more concerned with the brief medical history of the patient. For the
responsive medical patient, gather patient history, observing sing’s and symptoms while asking about the
history of present illness. The patient’s chief complaint helps direct the questioning. For the unresponsive
medical patient perform a rapid secondary assessment to determine if there are obvious signs of illness.

Establish a good rapport

 Introduction
 Consent
 Patient's name
 Patient's age
 Chief complaint

TRAUMA OVERVIEW

Traumatic emergencies occur as result of physical forces applied to the body. Medical emergencies occur
from an illness or condition not caused by an outside force.

The index of suspicion is your awareness and concern for potentially serious underlying and unseen
injuries.

Traumatic injury occurs when the body’s tissues are exposed to energy levels beyond their tolerance. The
mechanism of injury (MOI) is the way traumatic injuries occur. Describes the forces acting on the body that
cause injury
The Trauma Patient

Different MOIs produce many types of injuries.

 No significant injuries
o Injury to an isolated body part
o A fall without the loss of consciousness
 Significant injuries:
o Injury to more than one body system (multisystem trauma)
o Falls from heights
o Motor vehicle and motorcycle crashes
o Car versus pedestrian
o Gunshot wounds
o Stabbings

Vehicular Collisions

 Motor vehicle crashes are classified as:

o Frontal o Rollovers
o Rear-end o Rotational
o Lateral
 The principal difference is the direction of the force of impact.

Car against another car, tree, or object

 Damage to the car has an indirect effect on patient care.

 By assessing the vehicle, you can often determine the MOI.
 Passenger against the interior of the car
 Common passenger injuries include lower extremity fractures, flail chest, and head trauma.
 Passenger’s internal organs against solid structures of the body
 Internal injuries may not be as obvious as external injuries, but are often the most life threatening.

Significant MOIs include the following findings:

 Death of an occupant in the vehicle

 Severe deformity of vehicle or intrusion into vehicle
 Altered mental status
 Ejection from the vehicle
 Evaluate supplemental restraint system
 Seatbelts and air bags are effective in preventing a second collision inside the motor vehicle.
 Air bags decrease the severity of deceleration injuries.
 Air bags decrease injury to the chest, face, and head.
 Despite air bags, suspect injuries to:
o Extremities (resulting from the second collision)
 o Internal organs (resulting from the third
collision)
 Children shorter than 4' 9" should ride in the rear
seat.
o In a pickup truck or single-seated vehicle,
the air bag should be turned off.
 Remember that if the air bag did not inflate during
the accident, it may deploy during extrication and
that supplemental restraint systems can cause
harm whether they are used properly or improperly.

Lateral Collisions

 Side impacts
 Commonly called T-bone collisions
 A vehicle struck from the side is usually struck above its center of gravity.
o Begins to rock away from the o Results in the passenger
side of impact sustaining a lateral whiplash
injury
 If substantial intrusion into the passenger compartment, suspect:
o Lateral chest and abdomen o Organ damage from the third
injuries on the side of the impact collision
o Possible fractures of the lower
extremities, pelvis, and ribs
Rollover Crashes

 Large trucks and sport utility vehicles are  Spins are conceptually similar to
prone. rollovers.
 Injuries depend on whether the  Opportunities for the vehicle to strike
passenger was restrained. objects
 Most common life-threatening event is o Such as utility poles
ejection or partial ejection of the
passenger from the vehicle.

Car versus Pedestrian

 Injuries are often graphic and apparent. o Whether the patient was thrown
 Can also be serious unseen injuries through the air
 You should determine: o Whether the patient was struck
o Speed of the vehicle and pulled under the vehicle
 Evaluate the vehicle that struck the
patient for structural damage.
Car versus Bicycle

 Presume that the patient has sustained an injury to the spinal column, or spinal cord, until proven
otherwise at the hospital.
 Spinal stabilization must be initiated and maintained during the encounter.

Car versus Motorcycle

 Protection using:
o Helmet
o Leather or abrasion-resistant clothing
o Boots
 Collisions usually occur against larger vehicles or stationary objects.
 When you are assessing the scene, attention should be given to the:
o Deformity of the motorcycle
o Side of most damage
o Distance of skid in the road
o Extent and location of deformity in the helmet

Falls

 Injury potential depends on the height from which the patient fell.
o More than 15' or 3 times the patient’s height is considered significant.
 Internal injuries pose the greatest threat to life.
 Patients who fall and land on their feet may have less severe internal injuries.
o Their legs may have absorbed much of the energy of the fall.
 Take the following factors into account:
o The height of the fall
o The type of surface struck
o The part of the body that hit first, followed by the path of energy displacement

Penetrating Trauma

 Second leading cause of trauma death after blunt trauma

o May be caused accidentally by impalement
o May be caused intentionally by a knife, ice pick, or
other weapon
 With low-energy penetrations, injuries are caused by the
sharp edges of the object moving through the body.
 Knives may have been deliberately moved around internally,
causing more damage than the external wounds suggest.
 Path of the projectile may not be easy to predict.
o Bullet may ricochet within the body before exiting.
o Path the projectile takes is its trajectory.
o Fragmentation will increase damage.
 Cavitation can result in serious injury to internal organs.
 o Temporary cavitation is caused by the acceleration of the bullet.
o Permanent cavitation is caused by the bullet path.
 Relationship between distance and severity of injury varies depending on the type of weapon
involved.
o Drag slows the projectile.
o Energy available for a bullet to cause damage is more a function of its speed than its
mass.

Golden Principles of Prehospital Trauma Care

 Your main priority is to ensure:

o Your safety
o Safety of your crew
o Safety of the patient
 Determine the need for additional personnel or equipment.
 Evaluate the kinematics of the MOI.
 Identify and manage life threats.
 Then focus on patient care.
o ABCs
o Shock therapy
o Backboard
 Transport immediately to the appropriate facility.
 Definitive care requires surgical intervention.
o On-scene time should be limited to 10 minutes or less.
 Obtain a SAMPLE history and complete a secondary assessment.
 Consider ALS intercept and/or medical transportation.

Perfusion and Shock

Shock develops or occurs in a step-by-step progression. The

development of shock can be rapid or it can go about slowly.

 Perfusion

o Adequate supply of well-oxygenated blood and

nutrients to all vital organs

 Shock (hypoperfusion)

o Failure of body's circulatory system to provide enough

oxygenated blood and nutrients to all vital organs

 Normal Perfusion

o Oxygen and carbon dioxide exchanged

o Nutrients and waste products exchanged
 o Fluid and salt balance maintained between blood and tissues

 Shock develops or occurs in step-by-step progression; can be rapid or come about slowly.
 Shock can be life-threatening.
 Care for patients with shock should not be delayed.

The Four Categories of Shock

Heart is not pumping blood properly or efficiently.

Cardiogenic
Results when heart is unable to pump enough blood at
consistent pressure to all vital organs.

Vascular tone problem; blood is not allocated properly.

Neurogenic shock: caused when spinal cord is damaged

and unable to control tone of blood vessels by way of
sympathetic nervous system.

Anaphylactic shock: caused when body experiences

Distributive
severe allergic reaction.

Psychogenic shock: results in a sudden, temporary

dilation of blood vessels.

Septic shock: caused by widespread infection of the

blood.
Develops when an obstruction of a vessel causes less
blood to be pumped by the heart.
Hypovolemic
Hemorrhagic shock: occurs when body loses significant
amount of whole blood from circulatory the system.
Develops when an obstruction of a vessel causes less
blood to be pumped by the heart.

Respiratory/Metabolic: Disruption of oxygen transfer into

Obstructive
the cells or the cells are not able to utilize the available
oxygen.

Caused by cyanide, carbon monoxide, or iron poisoning.

Body’s Response to Shock

The patient will experience anxiety and

mental status changes. The brain begins to
feel the effect of decreased oxygen.

The patient will have cool, pale, sweaty skin

Condition in which body is using and an increased pulse and respirations.
specific mechanisms (increased Blood is shunted from the skin the vital areas.
Compensated Shock pulse rate; increased breathing Pulse and respirations increase to
rate) to compensate for lack of compensate for shock.
adequate perfusion.

In addition to sweating, the patient also may

experience nausea and vomiting as blood is
shunted from the abdomen to more vital
areas.
 Late signs of shock include a drop in blood
pressure.

 Early Signs and Symptoms of Shock

o Restlessness
o Altered mental status
o Increased heart rate
o Normal to slight low blood
pressure
o Mildly increased breathing
rate
o Skin that is pale, cool, and
moist
o Sluggish pupils
o Nausea and vomiting
 Later Signs and Symptoms of Shock
Condition in which body is no
o Unresponsiveness
Decompensated longer able to compensate for
o Decreasing heart rate
lack of adequate perfusion.
o Very low blood pressure
o Slow and shallow respirations
o Skin that is pale, cool, and
moist
o Dilated, sluggish pupils
o Respiratory and cardiac arrest
can develop
 Signs and symptoms of shock
worsen with time. Look for these
patterns:
o Increased pulse rate
o Increased breathing rate
o Restlessness or
 combativeness
o Pale, cool, moist skin
o Changes in mental status

MUSCULOSKELETAL INJURIES

Trauma, whether minor or major, can cause a variety of injuries to the muscles, bones, and other tissues
that make up the musculoskeletal system. Sometimes, injuries can be easily identified as fractures,
dislocations or both, simply due to the amount of deformity.

Four Major Functions of the Musculoskeletal System

 Support
Bones support the soft tissues of the body, acting as a framework to give the body form
and to provide rigid structure for the attachment of muscle and other body parts.
 Movement
Muscles, bones, and joints act together to allow for movement.
 Protection
Many of the bones in the body provide protection for vital organs.

Skull protects Brain

Spine protects Spinal Cord
Ribs protects Heart
Lungs
Liver
Stomach
Spleen
Pelvis protects Urinary Bladder
Internal Reproductive Organs
 Cell Production
Some bones have special function of producing cells

Two Major Division of the Skeletal System

 Axial Skeleton

All the bones that form the upright axis of the body,
including the skull, spinal column, sternum (breastbone),
and the Ribs

 Appendicular Skeleton

All the bones that form the upper and lower extremities,
including the collarbones, shoulder blades, arms, wrists,
hands, hips, legs, ankles and the feet.
Causes of Extremity Injuries

Direct force: applied to bone when person falls and strikes object or when person is struck by
object.
Indirect force: energy of a force transferred up or down extremity; results in injury farther along
extremity.
Twisting force: when someone gets hand or foot caught in wheel or gear.

Closed injury No break in skin.

Open injury Soft tissues adjacent to injury damaged and open.

Fracture: Any time bone is broken, chipped, cracked, or splintered.

Dislocation: One end of a bone that is part of a joint is pulled or pushed out of place.
Sprain: Excessive twisting forces cause ligaments and tendons to stretch or tear.
Strain: Caused by overexerting, overworking, overstretching, or tearing of a muscle.
Angulated (deformed) injuries
Extremity is bulging, bent, or angulated where it normally should be straight.
Signs-Symptoms of Extremity Injuries

 Pain  All injured extremities should be

 Swelling assessed for adequate circulation,
 Discoloration sensation, motor function (CSM) before
 Deformity and after immobilization.
 Inability to move a joint or limb  If injury site is swollen and discolored,
 Numbness or tingling sensation there is bleeding in tissues.
 Loss of distal pulse  If no distal pulse and extremity is pale
 Slow capillary refill and cool, circulation to extremity may be
 Grating compromised.
 Sound of breaking at time of injury  If extremity is blue, there is lack of
 Exposed bone circulation and lack of oxygen in limb.

Splinting

Immobilizing injury, using device (piece of wood, cardboard, folded blanket); any object that can be
used to restrict movement of injury. Application of splints allows reposition and transfer of patients
while minimizing movement of injury.

Manual stabilization

Using your hands to restrict movement of injured person or body part.

Complications resulting from splinting include:

 Pain  Restricted blood flow

 Damage to soft-tissues  Closed injuries become open injuries
 Bleeding

General Rules for Splinting

 Assess and reassure patient. an angulated limb in anatomical position

 Expose injury site. before splinting.
 Control all major bleeding.  Immobilize suspected fracture site and
 Dress open wounds. joints above and below injury site.
 Check distal circulation, sensation, and  Secure splints with cravats or roller
motor function before and after splinting. gauze.
 Splint injuries before moving patient.  Elevate extremity.
 Have materials ready before splinting.  Minimize effects of shock by maintaining
 If distal circulation is absent and local body temperature and providing oxygen
protocols allow, gently attempt to realign per local protocols.
Types of Splints

Soft splints: pillows, blankets, towels, cravats, dressings, triangle bandage, sling, swathe.

Rigid splints: plastic, metal, wood, or compressed cardboard; very little give or flexibility.

Pneumatic antishock garment (PASG): special device for splinting suspected pelvic and femur fractures.
Check local protocol.

Inflatable splints (air splints): used for patients with injuries to arm or lower leg bones.

Lower Extremity Injuries

 Pelvic injuries are serious; they can damage major blood vessels and internal organs.
 Pelvic girdle injuries may be managed with long spine boards, scoop stretchers, and blankets.
 Pneumatic antishock garment (PASG) may be considered for immobilization.
 Anterior hip dislocation:
Leg from hip to foot rotated outward (laterally) farther than uninjured side.
 Posterior hip dislocation
Leg rotated inward (medially); knee is usually bent.
 Injuries to upper leg or thigh bone (femur) can be life-threatening even when injury is closed;
bleeding inside tissues can be severe.
 Traction splints
Mechanical devices that allow for application of constant traction of injured extremity.
  You will not be able to tell if knee is fractured, dislocated, or both.
 Do not attempt to reposition or straighten injured knee.

Caring for Head, Neck and Spine Injuries

Anatomy

 Cranium (skull)
Cranium sits at top of spinal column; able to twist and move in many directions.
 Cranial vault
Area inside skull where brain is located.
 Face bones
Part of eye sockets, cheeks, upper part of nose, upper and lower jaw.
 Central Nervous System
Responsible for many of body's involuntary functions (heartbeat, respirations, temperature
regulation).
 Peripheral Nervous System
Nerves that extend from spinal cord throughout body.
 Brain
o Brain surrounded by three protective layers called meninges.
o Brain and spinal cord surrounded by clear fluid called cerebrospinal fluid.
o Spinal column begins at base of skull and extends down into pelvis; comprises 33 bones
called vertebrae.

Mechanism Of Injury

 Falls  Significant blunt trauma

 Forces that caused excessive flexion  Penetrating trauma (e.g., gunshots or
(bending) or extension (stretching) of stabbings)
neck or spine  Blows by assault-and-battery or abuse
 Pulling or hanging forces that caused incidents
spinal stretching  Any trauma situation where patient is
 Motor-vehicle crashes unresponsive
 Contact sports (e.g., football, boxing)

Injuries to the Neck and Spine

Injuries to the spine can cause paralysis, breathing impairment, and even cause death. Injuries along the
rest of the spinal column also can cause paralysis and reduce normal body movement and function. Spine
injuries are caused by forces to the head, neck, back, chest, pelvis, or legs.
The spine can be injured by a variety of different mechanisms.

Compression
Flexion Injury
Injury

Hyperextension
Distraction Injury
Injury

Flexion-rotation Penetration
Injury Injury

Neck and Spine Injuries

 Injuries to cervical spine can cause paralysis, impair breathing, even death.
 Caused by forces to head, neck, back, chest, pelvis, or legs.
 If patient has numbness, loss of feeling, or paralysis in legs with no problems in arms, injury to
spine is probably below neck.
 If numbness, loss of feeling, or paralysis involves arms and legs, injury is probably in neck.

Assessing Patient Spine Injury

 Do arms or legs feel numb?  Can patient feel you touch his/her hands
and feet?
  Can he/she squeeze your hand?  See if patient can move arms and legs.
 Look and feel gently for injuries and
deformities.

Signs and Symptoms of Spine Injury

 Pain over spine  Paralysis

 Deformity over spine  Incontinence (bladder or bowel)
 Numbness, weakness, tingling in  Priapism (involuntary erection of penis)
extremities
 Loss of sensation

Abnormal posturing is a sign of significant head and/or spine injury. (A) Abnormal extension (decerebrate
posture).

Abnormal posturing is a sign of significant head and/or spine injury. (B) Abnormal flexion (decorticate
posture).

Rules for Care of Spine Injury

 Make certain airway is open.

 Attempt to control serious bleeding.
 Always conclude unresponsive trauma patient has spine injuries.
 Do not attempt to splint long-bone injuries if indications of spine injuries, unless you have
appropriate help.
 Never move patient with suspected spine injuries unless you must provide CPR.
 Continuously monitor patients with possible spine injury.
A collar that is too big will extend well beyond the chin, allowing
for excessive movement. Consider readjusting or selecting a
smaller size collar.

Helmet Removal

Helmets are designed to absorb energy forces and prevent injury to the head. However, well-fitting
helmets-even the most modern ones-cannot prevent the brain from striking the interior of the skull in
extreme or high-speed crash forces.

 Remove immediately if issues with the ABCs.

 For unresponsive patient wearing helmet, always suspect spine injury.
 Monitor ABCs; properly immobilize spine.
 For football players wearing shoulder pads, helmet left in place keeps cervical spine in midline
position.
 If helmet has face guard or shield, remove it to gain access to airway.
 Provide care to any unresponsive patient as if there is spine injury.
 When you find helmeted patient facedown or on one side, log roll him onto his back (supine).
 Well-fitting helmet can stay in place as long as patient is breathing.
 Remove if does not fit snugly; patient's head moves inside helmet.
 Remove if cardiac or respiratory arrest.

CHEST AND ABDOMINAL INJURIES

Chest cavity or also known as Thoracic Cavity, makes up approximately half of the torso. The major organs
contained within the chest are the heart and lungs. There are also major vessels such as the aorta and the
vena cava that either originate or terminate in the chest. Deep within the mediastinum houses the trachea,
esophagus, heart, vena cava, and aorta. The sides of the chest are occupied by the lungs. Each lung is
surrounded by a thin saclike structure called the pleura.
Chest Injuries

Most closed chest injuries are the result of blunt force trauma. Falls, contact sports, vehicle collisions, and
blasts are common causes of closed chest injuries. Open chest injuries are often the result of a penetrating
injury such as bullet, knife, or similar projectile.

 Blunt trauma Blow to chest can fracture ribs, sternum, and rib cartilages.
 Penetrating objects Bullets, knives, pieces of metal or glass, steel rods, pipes can penetrate
chest wall, damaging internal organs and impairing respiration.
 Compression Results from severe blunt trauma in which chest is rapidly compressed
(driver in motor-vehicle collision strikes chest on steering column).

Closed Chest Injuries

Often caused by blunt force trauma to chest or back and are not associated with open wound.

 Damage to ribs
 Pneumothorax
Chest cavity filling with air from ruptured lung.
 Hemothorax
Blood from damaged soft-tissues and vessels enter chest cavity.
 Flail chest
Results when two or more ribs are broken in two or more places; can be life-threatening.
More often a result of blunt trauma. It There will be significant pain upon palpation.
 Crepitus
Grating sound when bones rub together.

Closed Chest Injuries: Signs-Symptoms

 Pain on breathing  Uneven chest wall movement during

 Ecchymosis breathing
 Increased difficulty breathing  Signs and symptoms of shock
 Accessory muscle use

Chest Injury Assessment

 Perform primary assessment; ensure ABCs are intact.

 Provide positive pressure ventilations, if breathing is inadequate.
 Remove clothing over area where there is complaint of pain.
 Observe and palpate for signs of deformity.
 Administer oxygen; follow local protocols.
 Splint chest using bulky dressings or towels.
 Place patient in a position of comfort, if no suspected spine injury.
 Care for shock.
 Transport patient.
Open Chest Wounds

 Immediately seal with something that prevents air from

entering wound, like gloved hand.
 Take appropriate Standard Precautions.
 Occlusive dressing (sterile gauze saturated with
petroleum jelly).
 Place occlusive dressing directly over wound and hold it
in place.
 Provide high-flow oxygen; care for shock.

(Left) Penetrating chest injuries can allow air and blood to enter the chest cavity. (Right) A collapsed lung
(spontaneous pneumothorax) can occur without outside trauma.
Impaled Chest Wounds

 Impaled objects must be stabilized and left in place.

 Take appropriate Standard Precautions.
 Perform primary assessment; ensure ABCs are intact.
 Assist ventilations as appropriate.
 Provide high-flow oxygen per local protocol.
 Provide care for shock.
 Initiate immediate transport.

Abdominal Emergencies

A sudden or gradual onset of pain in the abdomen or pelvis can be a symptom of a serious problem. Due to
the fact that the abdomen and pelvis contain so many organs, it is often difficult to determine the exact
cause the pain. Abdominal pain without a history of injury as well as trauma to the abdomen, are still
considered serious medical emergencies.

Retroperitoneal cavity: Area behind abdominal cavity that contains kidneys and ureters.

Generalized Abdominal Pain

 Bleeding  Infection
  Ulcers  Diabetic emergencies
 Indigestion  Kidney stones
 Constipation  Gallstones
 Food poisoning  Appendicitis
 Menstrual cramps  Ectopic pregnancy

Acute Abdominal Pain: Signs-Symptoms

 Pain that is either sharp or dull  Nausea/vomiting

 Pain on palpation  Cramping
 Rigid or tight abdomen  Pain that radiates to other areas
 Bloating (distention)  Guarding (protecting abdomen)

Acute Abdominal Pain: Assessment

 Rule out history of trauma.  Signs and symptoms can be delayed for
 Injuries to abdomen can cause bleeding hours, sometimes days.
that is very slow.  Thorough medical history.

Abdominal injuries can produce life-threatening emergencies.

Signs and Symptoms

 Deep cut or puncture wound to abdomen, pelvis, or lower back

 Blunt trauma to abdomen or pelvis
 Pain or cramps in abdominal or pelvic region

Caring for Closed Abdominal Injury

 Perform thorough assessment of abdomen; palpate all quadrants.

 Expose abdomen to observe for signs of injury.
 Allow patient to maintain position of comfort.

Abdominal Evisceration

Open wound of abdomen characterized by protrusion of intestines through abdominal wall. Never attempt
to place spilled abdominal contents back into open wound.

UNDERSTANDING CHILDBIRTH

Anatomy of Pregnancy

Fetus Unborn baby

Ovum Unfertilized egg produced by the mother
Uterus Muscular structure that holds baby during pregnancy
 Full term Pregnancy achieved complete gestation of between 38 and 40 weeks
Trimester Three months of pregnancy
Labor Process body goes through to deliver fetus
Cervix Opening of uterus
Bloody show Normal discharge of bloody mucus prior to delivery
Vagina Birth canal
Crowning Showing of baby's head at opening of vagina.
Imminent delivery
Delivery that is likely to occur within a few minutes.
Amniotic sac Fluid-filled sac that surrounds developing fetus.
Rupture of membranes
Sac breaks during labor; the fluid flows out of vagina.
Placenta Organ of pregnancy that serves as filter between mother and developing fetus.
Umbilical cord Structure that connects baby to placenta.
Contraction time
Span of time from beginning of contraction until it relaxes.
Interval time Span of time from start of one contraction to beginning of next contraction.
Braxton Hicks contractions (false labor)
Not as regular and rhythmic as true labor contractions.

Stages of Labor

 First stage: begins with onset of regular contractions; ends when cervix is fully dilated allowing baby to
enter birth canal.
 Second stage: begins when baby enters birth canal; ends when born.
 Third stage: begins when baby is born; ends when placenta (afterbirth) delivered.

It is rather normal to have vaginal discharges throughout labor. Contractions of uterus cause labor pains.

CARING FOR ENVIRONMENTAL EMERGENCIES

Temperature and the Body

 Temperature regulation Process of maintaining proper body temperature.

  Hypothermia When body loses heat faster than it can produce heat.
 Hyperthermia When heat gain occurs faster than body can shed heat.
 Radiation Body heat is emitted into environment. Heat energy transfers from
higher temperature to lower temperatures.
 Conduction Loss of body heat through direct contact with object or ground. Or
the transfer of heat from warmer to cooler environments through
direct physical contact.
 Convection Loss of body heat when air close to skin moves away, taking body
heat with it.
 Evaporation Loss of body heat through evaporation of moisture in form of
sweat on skin.
 Respiration Heat leaves body with each breath.

Heat Emergencies

 Core temperature: temperature in core of body 98.6°F (37°C).

 Heat generated through digestion, metabolism, and movement.
 Heat lost through breathing and sweating.
 Hypothalamus: body's thermostat.
 Effects of heat loss through evaporation greatly reduced when humidity is high.
 Perform history and physical exam.
 Very young, very old, those with chronic illnesses susceptible to effects of heat and cold.

Heat Cramps

Heat cramps are intermittent cramps, ranging from mild to severe, in large muscle groups. Heat cramps are
secondary to underlying salt deficiency in a dehydrated patient.

 Painful muscle spasms following strenuous activity in hot environment.

 Usually caused by electrolyte imbalance.
 Patient fully alert and sweaty with normal to warm skin temperature.
 Move to cool environment; replenish fluids.

Heat Exhaustion

Heat exhaustion occurs when the heat dissipating mechanism of the body become fatigued because of
dehydration in the setting of heat stress. Heat exhaustion is usually the result of exercise or work in an
environment with a high ambient temperature.

 Exposure to excessive heat for prolonged period of time.

 Body barely able to shed as much heat as it is generating.

Signs and Symptoms

 Mild to moderate perspiration  Warm or cool skin temperature

  Skin color may be normal to pale  Rapid, weak pulse
 Weakness, exhaustion, dizziness  Rapid, shallow breathing
 Nausea and vomiting  Altered mental status (extreme cases)
 Muscle cramps (usually in legs)

Emergency Care for Heat Exhaustion

 Take appropriate BSI precautions.  Cool patient by fanning.

 Primary assessment; ensure breathing is  Be careful not to overcool patient.
adequate.  Place patient in recovery position.
 Move patient to cool area.  Provide oxygen per local protocol.
 Loosen or remove excess clothing.

Heat Stroke

Heatstroke is a true medical emergency. Heatstroke occurs when the heat-dissipating mechanisms are
completely overwhelmed. The body’s core temperature rises above 104°F, leading to a cascade that that
affects multiple organ systems. Early heat stroke can be difficult to distinguish from severe heat exhaustion.
However, with heat exhaustion, the patient is diaphoretic, and with heatstroke, patients usually present with
anhidrosis. The most important factor distinguishing the two disorders is the presence of central nervous
system symptoms. These symptoms include altered mental status, seizure and even coma.

 Temperature-regulating mechanism fails; unable to rid excess heat.

 Core temperature allowed to rise uncontrolled, causing body to overheat.
 It is life-threatening emergency.
 Temperature may increase to 105°F (40.5°C) or higher.

There are 2 types of heatstroke

 Classic Heatstroke
o Is seen in individuals typically predisposed to heat illness. This group includes the elderly,
those with psychiatric illness, those who live in the inner city populations without circulating
air and those with medical conditions that increase the risk for heat-related illness.
 Exertional Heatstroke
o Is seen in younger persons, athletes, military personnel, or persons performing strenuous
exercise or work under heat stress conditions.

Signs and Symptoms

 Altered mental status  Rapid pulse

 Skin hot to touch  Weakness, exhaustion, dizziness
 Skin slightly moist to dry  Nausea and vomiting
 Rapid, shallow breathing  Convulsions
Emergency Care for Heat Stroke

 Take appropriate Standard Precautions.

 Primary assessment; ensure breathing is adequate.
 Move patient to cool area; remove excess clothing.
 Cool patient by dowsing or immersing in cool water.
 Do not overcool patient to the point of him/her shivering.
 Wrap cold packs or ice bags; place under armpits, the area just below the groin, and each side of
neck.
 Place patient in recovery position.
 Provide oxygen per local protocol.
 Monitor vital signs.

Cold Emergencies

Hypothermia

Is defined as a core body temperature less than 35°C. It can be thought of as a syndrome in which heat
loss exceeds heat production. Hypothermia has effects on many different organ systems and, in contrast to
frostbite, is a systemic, not focal, cold injury. Hypothermia does not require freezing temperatures.

 Body loses heat faster than it can be generated (generalized cold emergency).
 Young children and elderly more susceptible.

Three Categories of Hypothermia

 Primary (accidental) Hypothermia

o Caused solely by exposure to cold temperatures. Heat loss occurs through conduction,
radiation, convection and evaporation with radiation and conduction contributing majority of
the heat loss. In contrast, heat production is much more limited and occurs through basic
metabolic activities like shivering, release of epinephrine, norepinephrine, thyroxine and by
initiating behavioral changes including seeking warmth, shelter and clothing.
 Secondary Hypothermia
o Refers to hypothermia resulting from an underlying disorder that predisposes patients to a
cold state by increasing heat loss, decreasing heat production, or altering the body’s ability
to thermo regulate.

Diseases and Conditions leading to hypothermia

Metabolic Hypoglycemia, hypothyroidism, hypopituitarism, hypoadrenalism, DKA

(Diabetic Keto Acidosis)
CNS Head Trauma, CVA (Cerebro Vascular Accident), spinal cord tumor/injury,
sarcoid, tumors, Alzheimer’s disease, Parkison’s disease.
Drugs Alcohol, narcotics, tricyclic antidepressants, benzodiazepines
Miscellaneous Sepsis, dermatological diseases, burns, trauma, malnutrition, anorexia
nervosa, pancreatitis, extremes of age, mental illness.
Signs and Symptoms

 Cool or cold skin temperature  Lack of coordination

 Shivering (may stop later)  Muscle rigidity
 Altered mental status  Impaired judgment
 Abnormal pulse (rapid, then slow)  Complaints of joint/muscle stiffness

Emergency Care for Hypothermia

 Take appropriate BSI precautions.

 Primary assessment; ensure adequate breathing.
 Remove patient from cold environment.
 Do not allow patient to walk or exert himself/herself in any way.
 Protect patient from further heat loss.
 Remove wet clothing and place blanket over and under patient.
 Handle patient gently.
 Administer oxygen per local protocols.
 Monitor vital signs.
 Do not give patient anything to eat or drink, including hot coffee, tea, alcohol.

Severe Hypothermia

 Patient unresponsive with skin cold to the touch; no vital signs.

 Do not assume patient is dead.
 Assess pulse for 30-45 seconds. If no pulse, begin CPR.
 Not be pronounced dead until core temperature to within normal range.

Localized Cold Injury

 Cold injury or frostbite: freezing or near  Skin remains soft

freezing of body part.  If thawed, tingling and pain present
 Caused by significant exposure to cold  White, waxy skin
temperature (below 0°F or 17°C).  Firm to frozen feeling upon palpation
 Occurs in extremities (fingers, toes, ears,  Swelling
face, nose).  Blisters
 Signs and Symptoms (Early Signs)  If thawed, flushed with areas of purple
 Numbness, tingling exposed area and blanching
 Slow or absent capillary refill

Emergency Care for Cold Injury

 Take appropriate BSI precautions.

 Primary assessment; ensure adequate breathing.
 Remove patient from cold environment; protect from cold exposure.
 Remove wet or constrictive clothing.
  Early injury:
o Manually stabilize extremity, o Do not rub or massage it.
affected part. o Do not re-expose part to cold.
o Cover affected part.
 Late injury:
o Remove jewelry from injured o Do not rub or massage injured
part. part.
o Cover injured part with dry, o Do not apply heat.
sterile dressings. Place dressing o Do not rewarm.
between fingers and toes prior to o If legs, do not allow patient to
covering. walk.
o Do not break blisters.

CARING FOR CARDIAC EMERGENCIES

Normal Heart Function

 The heart beats 100,000 times per day.

 It circulates 6,000 to 7,500 liters of blood each day.
 Blood flows through the right atrium into the right ventricle and then into the lungs.
 From the lungs, blood enters the left atrium and flows into the left ventricle.
 The heart muscle receives its blood supply from tiny vessels called coronary arteries.
 Many problems of the heart are the result of the coronary arteries becoming narrowed or blocked.
 The heart has an electrical system that keeps it beating and, at the core, is the conduction
pathway.
 Damage to the conduction pathway can lead to an abnormal heart rhythm and is a common cause
of poor circulation and perfusion.

Cardiac Compromise Symptoms

 Chest discomfort  Anxiety/irritability

 Diaphoresis  Feeling of impending doom
 Dyspnea  Abnormal pulse
 Nausea/vomiting  Abnormal blood pressure

Myocardial infarction

 Myocardial infarction (MI) is known as a heart attack.

 The heart receives its blood supply through coronary arteries.
 When these arteries become narrow or blocked and can no longer supply the heart with enough
oxygenated blood, the tissue of the heart begins to die.
 Heart attack (MI)/cardiac arrest differences.
 Patients in cardiac arrest are not breathing; are unresponsive; have no pulse.
Signs and symptoms of a heart attack:

 Chest/upper abdominal sensations of pain, pressure, tightness, or heaviness.

 Pain or discomfort behind the sternum.
 “Flu-like” signs and symptoms (nausea and vomiting)
 Indigestion
 Feeling of general weakness

Angina Pectoris

 Angina pectoris (angina) is pain in the chest.

 It occurs when one or more of the coronary arteries are unable to provide an adequate supply of
oxygenated blood to the heart muscle.
 With angina, there is no actual damage to the heart muscle.
 Chest pain caused by a heart attack and angina is often triggered by exertion.
 Signs and symptoms of angina are nearly identical to a heart attack.
 It is important to care for cardiac-related pain as though the patient is having a heart attack.

Congestive Heart Failure

 Congestive heart failure (CHF) is a condition that develops when the heart is unable to pump blood
efficiently.
 The heart muscle is weakened; it is unable to manage the normal blood volume; fluid backs up
within the circulatory system.
 Patients can have chest pain, difficulty breathing, or both.

Assessment for Cardiac Compromise

 Assessment—OPQRST
 Onset  Region and radiate
 Provocation  Severity
 Quality  Time

 Take appropriate Standard Precautions.

 Perform a primary assessment and support the ABCs as necessary.
 Obtain a medical history.
 If allowed, provide oxygen per local protocols.
 Keep the patient at rest. Provide emotional support and reassure the patient.
 Allow the patient to maintain a position of comfort (usually sitting up).
 Obtain vital signs.
 Continue to monitor vital signs.

CARING FOR RESPIRATORY EMERGENCIES

Respiratory Function
  Pathways where air enters body (nose and mouth); areas at back of throat (nasopharynx and
oropharynx).
 Oropharynx leads down throat into top of trachea (larynx), where vocal chords are positioned.
 Control center for respiratory is within the brain.

Upper airway All spaces and structures above vocal chords.

Lower airway All structures and spaces below vocal chords.
Carina Where trachea splits into right and left main stem bronchi.
Bronchioles Smaller airways.
Alveoli Where exchange of oxygen and carbon dioxide takes place.

Respiratory Compromise

 Inability of person to breath adequately.

 Hypoxia: when the body's cells do not receive adequate supply of oxygen.
 Signs: altered mental status, pale skin, cyanosis of nail beds/mucous membranes.
 Hypercarbia: condition of having too much carbon dioxide in blood.

Respiratory Distress (Dyspnea)

 Result of not getting adequate supply of oxygen; increased in levels of carbon dioxide in blood
 Increased work of breathing
 Increased respiratory rate
 Use of accessory muscles

Respiratory Failure

 When body's normal compensatory mechanisms fail.

 Breathing rate begins to slow.
 Tidal volume begins to get shallower.

Common causes:

 Hyperventilation  Emphysema
 Asthma  Exposure to poison
 Chronic bronchitis  Allergic reaction

Qualities of Normal Breathing

 Sufficient to support life.

 Easy and effortless (adequate).
 Do not work hard to breathe.
 Able to speak full sentences without having to catch breath.
 Normal respiratory rate, depth, and very little effort or work of breathing.
Characteristics of Normal Breathing

 Normal rate (number breaths per minute): 12 to 24 for adult; 16 to 32 for child; 24 to 48 for infant.
 Normal depth (size of each breath): tidal volume; normal breaths not too shallow and not too deep.
 Work of breathing: effort it takes for patient to move each breath in and out.
 Respiratory rhythm regular.

Abnormal Breathing

 Inadequate; not sufficient to support life.

 Left untreated, will result in death.
 Common signs:
 Increased work of breathing
 Increased respiratory rate
 Common signs:
o Decreased respiratory rate
o Respirations that are too deep or too shallow
o Irregular breathing rhythm
o Audible breath sounds (gurgling, snoring or wheezing)
 Tripod position: seated or standing with hands on knees, shoulders arched upward, head forward.
 Accessory muscles: muscles of neck, chest, abdomen that assist during respiratory difficulty.

Signs and Symptoms of Respiratory Compromise

 Labored or difficulty breathing; a feeling  Changes in skin color, particularly of lips

of suffocation. and nail beds.
 Audible breathing sounds.  Tripod position.
 Rapid or slow rate of breathing.  Altered mental status.
 Abnormal pulse rate (too fast or too
slow).

Chronic Obstructive Pulmonary Disease

Conditions: asthma, chronic bronchitis, emphysema

Signs and symptoms:

 History of heavy cigarette smoking  Maintaining tripod position

 Persistent cough  Fatigue
 Chronic shortness of breath  Tightness in chest
 Pursed-lip breathing  Wheezing

Asthma

 Condition affecting lungs, characterized by narrowing of air passages and wheezing.

  Caused by sensitivity to irritants (pollen, pollutants, exercise).
 Narrowing air passages cause wheezing.

Signs and symptoms:

 Moderate to severe shortness of breath

 Wheezing
 Anxiety
 Nonproductive cough

Bronchitis

 Causes swelling and thickening of walls of bronchi and bronchioles.

 Causes overproduction of mucus in air passages.
 Chronic bronchitis: productive cough for three consecutive months and occurs at least two
consecutive years.

Signs and symptoms:

 Overweight  Productive cough

 Mild to moderate shortness of breath  Wheezes
 Pale complexion

Hyperventilation Syndrome

 Occurs when person breathes out and eliminates excess amount of carbon dioxide.
 Most cases caused by anxiety and do not represent medical emergency.
 Can be a sign of something serious.
 Be alert for cyanosis.
 Monitor for changes in vital signs.
 Reduce anxiety by reassuring and comforting patient.

Signs and symptoms:

 Moderate to severe shortness of breath  Dizziness

 Anxiety  Spasm of fingers and/or toes
 Numbness or tingling of fingers, lips,  Chest discomfort
and/or toes

Emergency Care for Respiratory Compromise

 Observe body language.  Reassure patient.

 Determine characteristics of breathing.  Gather a history.
 Pay attention to level of distress and  Ability to speak clearly and in full
facial expression. sentences.
  Listen for sounds as patient breathes.  Arrange for ALS response if available.
 Take appropriate BSI precautions.  Assist with prescribed medication per
 Perform primary assessment; support local protocols and medical direction.
ABCs.  Obtain vital signs.
 Ensure patent airway; administer oxygen  Continue to monitor patient and provide
per local protocols. reassurance.
 Allow patient to maintain position of
comfort.

OXYGEN THERAPY

 Oxygen is a drug.
 The air we breathe contains 21 percent oxygen.
 Supplemental oxygen is 100 percent oxygen.
 Oxygen concentration: amount of oxygen being delivered to patient.

Patient may need oxygen for:

 Respiratory or cardiac compromise  Injury to lungs or chest

 Cardiac arrest  Airway obstruction
 Shock  Stroke
 Major blood loss

Common Indicators

 Abnormal signs and symptoms  Increased level of distress

 Significant mechanism of injury

Hazards of Oxygen

 Oxygen may be under 2,000 pounds per square inch (psi) of pressure (full tank).
 If tank is punctured or valve breaks off, supply tank and valve can become deadly projectiles.
 Oxygen itself is nonflammable, but it greatly increases rate and intensity of combustion.
 Oxygen and oil do not mix.

Oxygen-delivery System:

 Oxygen source
 Regulator
o Regulators have three functions:
o Reduce tank pressure
o Display tank pressure
o Control delivery of oxygen
 Delivery device
o Nasal cannula
 Used to deliver low concentrations of supplemental oxygen to breathing patient.
o Nonrebreather mask
Used to deliver high concentrations of supplemental oxygen.
 Oxygen Cylinders
o Various sizes, identified by letters.
o D cylinder (425 liters oxygen)
o Jumbo D cylinder (640 liters oxygen)
o E cylinder (680 liters oxygen)
o Pressure gauge determines pressure remaining in tank.
o Never allow to go completely empty.
o Never allow pressure in oxygen cylinder to fall below 200 psi.
 Aluminum cylinders filled with pressurized oxygen.

Oxygen System Safety

 Oxygen System Safety  Keep portable cylinders lying flat.

 Never allow smoking.  Use pressure gauges and regulators.
 Never use around open flames or  Ensure O ring is in good condition.
sparks.  Valves/connections hand-tight only.
 Never use grease or oil.  Open and close all valves slowly.
 Never put tape on cylinder.  Store in cool, ventilated room.
 Never store near high heat or in a closed  Have hydrostatically tested.
vehicle parked in the sun.

Portable Oxygen Tank Operations

Remove the plastic wrapper or cap protecting the

cylinder outlet.
 Keep the plastic washer that is used in some
setups.

“Crack” the main valve for one second.

Place cylinder valve gasket on regulator oxygen

port.

Tighten T-screw hand-tight. Do not over tighten

because this can crush or crack the washer, thus
causing a leak.

Attach tubing and delivery device.

 Explain the need for oxygen therapy

Open the main valve.

Attach delivery device and adjust flow meter

General Guidelines for Oxygen Therapy

 Explain you would like to provide oxygen; it will help the patient feel better.
 Show device; explain how it works; and how it will fit on face.
 Gently place device on face and confirm patient is comfortable; adjust as necessary.
 Remind patient to breathe as normally as possible.
 If patient is anxious and reluctant to accept device, provide extra reassurance.
 Monitor patient closely.

CARING FOR THE PATIENT WITH COMMON MEDICAL EMERGENCIES

Caused by infections, poisons, or failure of one or more of body's organ systems.

Signs and Symptoms:

 Altered mental status  Abnormal breathing rate and character

 Abnormal pulse rate and rhythm  Abnormal skin signs
  Abnormal pupil size or response  Fever or chills
 Unusual breath odors  Upset stomach and/or vomiting
 Tenderness or rigidity in abdomen  Dizziness or feeling faint
 Abnormal muscular activity (spasms or  Chest or abdominal pain
paralysis)  Unusual bowel or bladder activity
 Bleeding or discharges from body  Thirst, hunger, odd tastes in mouth
 Pain
 Shortness of breath

ssessment

 Take appropriate BSI precautions; complete a scene size-up.

 Perform primary assessment.
 Perform secondary assessment.
 Complete reassessments.
 Comfort and reassure patient while awaiting additional EMS resources.

Evaluating the Patients Mentation

 Normal mental status: complete and accurate awareness of one's surroundings.

 Altered mental status (AMS): decrease in patient's alertness and responsiveness to surroundings.

Common causes:

 Trauma to head  Diabetic emergencies

 Seizures  Poisonings and overdose
 Stroke (brain attack)  Hypoxia

Signs and Symptoms:

 Confusion  Combativeness
 Seizures  Syncope (collapse or fainting)
 Inappropriate behavior  Unresponsiveness
 Lack of awareness of surroundings

Assessing the Patient

 Focus on observation.
 Obtain complete medical history.
 Use AVPU scale:
o Alert
o Verbal
o Painful
o Unresponsive
Specific Conditions: Seizures

Irregular electrical activity in brain that can cause sudden change in mental status and behavior.
Can have many causes.

Causes of Seizures:

 Epilepsy (disorder of brain)  Infections, high fever (febrile)

 Ingestion of drugs, alcohol, poisons  Diabetic problems; stroke
 Alcohol withdrawal  Heat stroke; head injury
 Brain tumors

Types:

 Generalized: loss of consciousness and full body convulsions (uncontrolled muscular contractions).
 Partial: temporary loss of awareness with no dramatic body movements.

Generalized Seizure:

 Sudden loss of responsiveness

 Report of bright light, bright
colors, sensation of strong odor
prior to losing responsiveness
 Convulsions
 Loss of bladder and/or bowel
control
 Labored breathing (frothing at
mouth)
 Complaint of headache prior to or
following seizure
 Following seizure, patient's body
completely relaxes
 Postictal: the phase of seizure
following convulsions
Protect the patient from injury by removing objects that he may
strike and by placing something soft beneath his head.
Seizure Care

 Move objects away; place something soft under head.

 Do not attempt to restrain patient or force anything into mouth.
 Loosen restrictive clothing.
 After convulsions have stopped, place patient in recovery position.
Specific Conditions: Stroke

 Cerebrovascular accident (CVA) or brain attack.

 Blood flow to brain disrupted.
 Causes: obstruction or rupture of blood vessel.
 Portion of brain does not receive adequate supply of oxygenated blood.

Stroke Signs and Symptoms

 Headache  Numbness or paralysis (extremities or

 Syncope (fainting) face)
 Altered mental status  Difficulty with speech or vision
 Confusion, dizziness

Cincinnati Prehospital Stroke Scale (CPSS)

 Facial droop
 Arm drift
 Speech abnormalities/irregularities
 Time to take patient to hospital

Facial Arm Drift Slurred Speech Time to take patient to

Asymmetry/Droop hospital

Time is critical, patients with 1 of these 3 findings as a new event have a 72% probability of an ischemic
stroke. If all 3 findings are present the probability of an acute stroke is more than 85%. Take patient to
Emergency Department immediately
Ischemic stroke

Are caused by the interruption of blood flow to the brain due to a blood clot. The buildup of plaque (fatty
materials, calcium and scar tissue) contributes to most ischemic strokes by narrowing the arteries that
supply blood to the brain, interfering with or blocking the flow of blood. This narrowing is called
atherosclerosis.

Hemorrhagic Stroke

Are caused by uncontrolled bleeding in the brain. This bleeding interrupts the normal blood flow in the brain
and kills brain cells either by flooding at the leakage site or by shortage of blood supply beyond the
leakage.

Stroke Care

 Maintain open airway; be prepared to provide ventilations or CPR.

 Keep patient at rest; protect all paralyzed parts.
 Provide emotional support.
 Place patient in recovery position.
 Do not administer anything by mouth.

Specific Conditions: Diabetic Emergencies

 Diabetes: disease that prevents individuals from producing enough insulin or from using insulin
effectively.
 Insulin: hormone released by pancreas; allows glucose (blood sugar) to enter cells so glucose can
be used.

Hypoglycemia (low blood sugar):

 Diabetic who has taken too much insulin, eaten too little sugar, overexerted himself/herself, or
experienced excessive emotional stress may develop low blood sugar.
 Alert patient: provide oral glucose or suitable substitute, if allowed by protocol.
 Non-alert patient: do not provide anything orally if the patient is unable to swallow.

Hypoglycemia: Signs and Symptoms

 Altered mental status  Headache

 Pale, cool skin; often moist  Normal or shallow breathing
 Rapid, strong pulse  Very hungry
 Dizziness  Some patients develop seizures
Hyperglycemia: Signs and Symptoms

 Extreme thirst  Sweet or fruity odor (ketone) breath

 Abdominal pain  Dry mouth
 Dry, warm skin  Restlessness
 Rapid, weak pulse  Altered mental status, including coma

Care for Hyperglycemia

 If patient is alert and you are not certain if problem is too much sugar or too little sugar, give patient
sugar, candy, orange juice, or soft drink.

Overdose and Poisoning

Poison Any substance that can be harmful to the body.

Overdose When person takes in more medication than is normal.

Respiratory Emergencies

 Most common cause of cardiac arrest in infants and children is respiratory arrest.
 Review Chapter 8 for signs and symptoms and management of partial and complete airway
obstruction for pediatric patients.
 Difficulty breathing
 Simple cold
 Respiratory infection
 Apnea: interrupted breathing
 Sleep apnea: interrupted breathing while sleeping.
 Croup: acute respiratory condition common in infants and children; barking type of cough or stridor.
 Epiglottitis: swelling of epiglottis caused by bacterial infection; may cause airway obstruction.

Respiratory Distress: Signs-Symptoms

 Wheezing or high-pitched harsh noise, or  Drooling

grunting  Nasal flaring
 Exhaling with abnormal effort  Cyanosis (late sign)
 Breathing faster or slower than normal;  Capillary refill of more than two seconds
inadequate; requires assisted (late sign)
ventilations and oxygen  Slow heart rate (late sign)
 Use of accessory muscles to breathe  Altered mental status (late sign)
 Child holding a tripod position

Respiratory Emergencies

 Asthma can be life-threatening if left untreated.

 Use prescribed medication or inhaler.
  Signs and Symptoms
o Shortness of breath o Obvious respiratory distress
o Wheezing
 Asthma Signs and Symptoms
o Cough o Increased heart rate
o Faster than normal breathing o Sleepiness or slowed response
rate o Bluish (cyanotic) tint to skin
 Provide oxygen by pediatric-size Nonrebreather mask or using blow-by technique.
 Provide assisted ventilations with pediatric-size bag-mask and supplemental oxygen; call for
support.

INTRODUCTION TO EMS OPERATIONS AND HAZARDOUS RESPONSE

Safety

First consideration at any emergency scene is your own safety.

 Follow standard operating procedures (SOPs).

 Limit actions to your training level.
 Use proper equipment; required number of trained persons for
any task.
 Some risks you can avoid, some you can pass off to other
agencies, some you have to face.
 Prior to approaching patient, be certain it is safe to do so.
 Use protective gear appropriate for situation and for which you
are certified or qualified to wear.
 Legally and ethically, you are limited by your level of training.
 When you call dispatch, describe incident so that needed
personnel and equipment may respond as soon as possible.

THE EMERGENCY CALL

Six Phases of Emergency Call

 Preparation  Arrival at scene

 Dispatch  Transferring patients
 En route to scene  After emergency

Phase 1: Preparation

 Medical supplies  Equipment

 Nonmedical supplies  Personnel

Phase 2: Dispatch
  Be familiar with dispatch and communications system, and procedures.
 Note information dispatcher gives you about call.
 Dispatch centers staffed with personnel specially trained to dispatch appropriate units.

Phase 3: En Route to the Scene

 Operate emergency vehicle with “due regard” for safety of everyone on road.
 Emergency lights must be on for all emergency responses.
 Sirens used when traffic is issue.
 Have the essential information on call.

Phase 4: Arrival at the Scene

 Be alert and approach cautiously.

 Look for hazards.
 Position response unit where you have access to it but where it will not interfere with access to
scene.
 Keep eye on traffic.
 Notify dispatcher of your arrival.
 Provide additional information once you arrive on scene.
 Size-up scene to ensure it is safe.
 Put on PPE.
 Look for MOI in trauma scenes or determine if medical emergency.
 Stabilize vehicles.
 Determine if multiple-casualty incident; number of patients.
 Evaluate patients quickly to determine if high or low priority.

Phase 5: Transferring Patients

 EMRs help lift, carry, and load patients and assist in preparing for transport.
 Provide transporting personnel with accurate account of patient's status.
Phase 6: After the Emergency

 Prepare for next call.

 Clean and disinfect equipment, restock supplies, refuel emergency vehicle.
 Complete paperwork and file reports.
 Participate in debriefing.
 Notify dispatcher that you are back in service.
 You are dispatched to a pediatric arrest. The roads are icy and you are driving at what you
consider to be a safe speed for conditions. Dispatch requests that you “expedite” and your partner
yells at you to “step on it!”
 What do you do?

Hazards
Fire

 Firefighting requires special training, protective clothing, right equipment, and usually more than
one firefighter.
 Never approach vehicle in flames.
 Never attempt to enter building that is on fire or has smoke showing.
 Never enter a smoky room or building or go through an area of dense smoke.

Natural Gas

 Move patients away from area.

 Keep bystanders away from scene.
 Alert dispatch.
 Request gas in area be shut off or diverted.
 Evacuate building.

Electrical Wires and Aboveground Transformers

 Do not attempt a rescue.

 Position your vehicle at least a pole away from downed wires.
 Never assume power lines are dead; consider all downed lines as live.
 Request power be turned off.
 Tell victims in car to stay in vehicle and avoid touching any metal parts.
 Reassure victims that they will be helped as soon as the scene is safe.

Hazardous Materials

 Do not attempt rescue or perform patient care; no responders should enter hazardous materials
area unless trained to do so.
 Protect yourself/others around scene.
 Your responsibilities:
o Recognition and identification
o Notification and information sharing
o Isolation
o Protection
Decontamination

 Chemical or physical process used to remove and prevent spread of contaminants from
emergency scene to prevent harm to living beings and/or environment.
 All contaminated victims must remain in hot zone until hazmat team decontaminates them.

Hazardous Materials

 Stay clear of collisions involving radioactive materials.

 First duty is to protect yourself from exposure.
 Request appropriate resources.
 Look for radiation hazard labels.

MULTIPLE/MASS CASUALTY INCIDENTS

Multiple-Casualty Incident (MCI): any emergency that involves multiple victims and overwhelms first
responding units.

 Multiple vehicles  Large explosions

 Earthquakes  Building collapses
 Floods  Civil unrest

Low-Impact Incidents Manageable by local emergency personnel.

High-Impact Incidents Stresses local EMS, fire, and police resources.
Disaster, Terrorism IncidentsOverwhelms regional emergency response resources.
TRIAGE

 Method of sorting patients for care and transport based on severity of injuries or illnesses.
 Used in hospital emergency departments, battlefields, emergencies when there are multiple victims
and limited medical resources.
 EMRs first on scene; must be able to triage patients and initiate care rapidly.
 Patients with serious medical- or trauma-related problems (heart attack, shock, major injuries, heat
stroke) must be transported quickly.
 Patients with minor injuries or illnesses are transported later.

START Triage System

Patients classified into one of four categories; tagged with

denoted color-coded tag indicator.

 Immediate (red)
 Delayed (yellow)
 Minor (green)
 Deceased (black)

SALT Triage

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat
everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack
of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability
has the potential to inject confusion and miscommunication into the disaster incident, particularly when
multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were
developed to be a national guideline for mass casualty triage to ensure interoperability and standardization
when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general
considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The
criteria within each of these categories were developed by a workgroup of experts representing national
stakeholder organizations who used the best available science and, when necessary, consensus opinion.
This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

Step 1: Sort

SALT begins with a global sorting of patients, prioritizing them for individual assessment. Patients who can,
should be asked walk to a designated area and should be assigned last priority for individual assessment.
Those who remain should be asked to wave (i.e., follow a command) or be observed for purposeful
movement. Those who do not move (i.e., are still) and those with obvious life threat, such as obvious
uncontrolled hemorrhage, should be assessed first since they are the most likely to need lifesaving
interventions.
 Priority 1 Still/Obvious life threat
Priority 2 Wave/Purposeful movement
Priority 3 Walk

STEP 2: Assess

The first priority during the individual assessment is to provide lifesaving interventions. These include
controlling major hemorrhage; opening the patient’s airway; decompressing the chest of patients with a
tension pneumothorax; and providing antidotes for chemical exposures. These interventions were identified
because they can be performed quickly and can have a significant impact on patient survival. Life-saving
interventions are to be completed before assigning a triage category and should only be performed within
the responder’s scope of practice and if the equipment is readily available.

Once the lifesaving interventions are provided, patients are prioritized for treatment based on assignment to
one of five color-coded categories. Patients who have mild injuries those are self-limited if not treated and
can tolerate a delay in care without increasing their risk of mortality should be triaged as minimal and
should be designated with the color green. Patients who are not breathing even after life-saving
interventions are attempted should be triaged as dead and should be designated with the color black.
Patients who do not obey commands, or do not have a peripheral pulse, or are in respiratory distress, or
have uncontrolled major hemorrhage should be triaged as immediate and should be designated with the
color red. Providers should consider if these patients have injuries that are likely to be incompatible with life
given the currently available resources; if they are, then the provider should triage these patients as
expectant and should be designated with the color gray. The remaining patients should be triaged as
delayed and should be designated with the color yellow.

This prioritization process is dynamic and may be altered by changing patient conditions, resources, and
scene safety. Triage labeling systems should account for the dynamic nature of triage and be easily
modifiable for a single patient. After immediate patients have been cared for, patients designated as
expectant, delayed, or minimal should be re-assessed as soon as possible with the expectation that some
patients will have improved and others will have deteriorated.

INCIDENT COMMAND SYSTEM

What Is the Incident Command System?

The Incident Command System (ICS) is a standardized approach to incident management that:

 Enables a coordinated response among various jurisdictions and agencies.

 Establishes common processes for planning and managing resources.
 Allows for the integration of facilities, equipment, personnel, procedures, and communications
operating within a common organizational structure.

Incident Command System Origins

The Incident Command System was developed in the 1970s following a series of catastrophic fires in
California. Property damage ran into the millions, and many people died or were injured.
The personnel assigned to determine the causes of these disasters studied the case histories and
discovered that response problems could rarely be attributed to lack of resources or failure of tactics.

When Is ICS Used?

ICS can be used to manage any type of incident, including a planned event (e.g., the Olympics,
Presidential inauguration, etc.). The use of ICS is applicable to all hazards, including:

 Natural Hazards: Disasters, such as fires, tornadoes, floods, ice storms, earthquakes, food borne
illnesses, or epidemics.
 Technological Hazards: Dam breaks, radiological or hazmat releases, power failures, or medical
device defects.
 Human Caused Hazards: Criminal or terrorist acts , school violence, or other civil disturbances.

As a system, ICS is extremely useful. Not only does it provide an organizational structure for incident
management, but it also guides the process for planning, building, and adapting that structure.

Using ICS for every incident or planned event helps improve and maintain skills needed for the large scale
incidents.

ICS Features and Principles

As you learned in the previous lesson, ICS is based on proven management principles, which contribute to
the strength and efficiency of the overall system.

ICS incorporates a wide range of management features and principles, beginning with the use of common
terminology and clear text.

Common Terminology and Clear Text

The ability to communicate within the ICS is absolutely critical. During an incident:

 Communications should use common terms or clear text.

 Do not use radio codes, agency specific codes, acronyms, or jargon.

The goal is to promote understanding among all parties involved in managing an incident.

The next ICS principle is clarity of command or who is in charge. When you are using ICS to manage an
incident, an Incident Commander is assigned. The Incident Commander has the authority to establish
objectives, make assignments, and order resources. In doing so, the Incident Commander works closely
with staff and technical experts to analyze the situation and consider alternative strategies.

The Incident Commander should have the level of training, experience, and expertise to serve in this
capacity. Qualifications to serve as an Incident Commander are not based on rank, grade, or technical
expertise.
Chain of Command

 Chain of command is an orderly line of authority within the ranks of the incident management
organization.
 Allows an Incident Commander to direct and control the actions of all personnel under his or her
supervision.
 Chain of command does NOT prevent personnel from directly communicating with each other to
ask for or share information.

Unity of Command

Under unity of command, personnel:

Report to only one ICS supervisor.

Receive work assignments only from their ICS supervisors.

When you are assigned to an incident, you no longer report directly to your day to day supervisor.
Transfer of Command

The process of moving the responsibility for incident command from one Incident Commander to another is
called transfer of command. Transfer of command may take place when:

 A more qualified Incident Commander arrives and assumes command.

 A jurisdiction or agency is legally required to take command.
 The incident changes in complexity.

The transfer of command process always includes a transfer of command briefing, which may be oral,
written, or a combination of both.

Management by Objectives

Incident objectives are used to ensure that everyone within the ICS organization has a clear understanding
of what needs to be accomplished.

Incident objectives are established based on the following priorities:

1. Life Safety
2. Incident Stabilization
3. Property Preservation

Reliance on an Incident Action Plan

Every incident must have an Incident Action Plan (IAP) that:

 Specifies the incident objectives.

 States the activities to be completed.
  Covers a specified timeframe, called an operational period.
 May be oral or written—except for hazardous materials incidents, which require a written
IAP.

Incident Action Plans specify the incident activities, assign responsibilities, identify needed resources, and
specify communication protocols.

ICS Organization

The ICS organization is unique but easy to understand. There is no correlation between the ICS
organization and the administrative structure of any single agency or jurisdiction. This is deliberate,
because confusion over different position titles and organizational structures has been a significant
stumbling block to effective incident management in the past.

For example, someone who serves as a director every day may not hold that title when deployed under an
ICS structure.

Modular Organization

The ICS organizational structure:

 Develops in a top down, modular fashion that is based on the size and complexity of the incident.
 Is determined based on the incident objectives and resource requirements. Only those functions or
positions necessary for a particular incident are filled.
 Expands and contracts in a flexible manner. When needed, separate functional elements may be
established.
 Requires that each element have a person in charge.

Manageable Span of Control

Another basic ICS feature concerns the supervisory structure of the organization. Maintaining adequate
span of control throughout the ICS organization is very important.

Span of control pertains to the number of individuals or resources that one supervisor can manage
effectively during an incident.

Maintaining an effective span of control is important at incidents where safety and accountability are a top
priority.

Span of Control

The type of incident, nature of the task, hazards and safety factors, and distances between personnel and
resources all influence span of control considerations.

Effective span of control on incidents may vary from three to seven, and a ratio of one supervisor to five
subordinates is recommended.
Incident Commander and Command Staff Functions

Performance of Management Functions

Every incident requires that certain management functions be performed. The problem must be identified
and assessed, a plan to deal with it developed and implemented, and the necessary resources procured
and paid for.

Regardless of the size of the incident, these same management functions are still required.

Five Major Management Functions

There are five major management functions that are the foundation upon which an incident management
organization develops.

 Command  Logistics
 Operations  Finance & Administration
 Planning

These functions apply to incidents of all sizes and types, including planned events and emergencies that
occur without warning.

Management Function Descriptions

Incident Commander

The Incident Commander has overall responsibility for managing the incident by establishing objectives,
planning strategies, and implementing tactics. The Incident Commander is the only position that is always
staffed in ICS applications. On small incidents and events, one person—the Incident Commander —may
accomplish all management functions.

The Incident Commander is responsible for all ICS management functions until he or she delegates a
function.

Delegating Incident Management Functions

During a larger incident, the Incident Commander may create Sections and delegate the Operations,
Planning, Logistics, and Finance/Administration functions.
Incident Commander Responsibilities

In addition to having overall responsibility for managing the entire incident, the Incident Commander is
specifically responsible for:

 Ensuring overall incident safety.

 Providing information services to internal and external stakeholders, such as disaster survivors,
agency executives, and senior officials.
 Establishing and maintaining liaison with other agencies participating in the incident.

Selecting and Changing Incident Commanders

The Incident Commander is always a highly qualified individual trained to lead the incident response.
Therefore, as an incident becomes more or less complex, command may change to meet the needs of the
incident.

A Deputy Incident Commander may be designated to:

 Perform specific tasks as requested by the Incident Commander.

 Perform the incident command function in a relief capacity.
 Represent an assisting agency that shares jurisdiction.

Note that if a Deputy is assigned, he or she must be fully qualified to assume the Incident
Commander’s position.

Command Staff Overview

The Command Staff consists of the Public Information Officer, Safety Officer, and Liaison Officer, who all
report directly to the Incident Commander.

Let’s look at the roles of each member of the Command Staff. The Public Information Officer serves as the
conduit for information to internal and external stakeholders, including the media and the public.

Accurate information is essential. The Public Information Officer serves as the primary contact for
anyone who wants information about the incident and the response to it.
Another member of the Command Staff is the Safety Officer, who monitors conditions and develops
measures for assuring the safety of all personnel.

The Safety Officer is responsible for advising the Incident Commander on issues regarding incident safety,
conducting risk analyses, and implementing safety measures.

The final member of the Command Staff is the Liaison Officer, who serves as the primary contact for
supporting agencies assisting at an incident.

Additionally, the Liaison Officer responds to requests from incident personnel for contacts among the
assisting and cooperating agencies, and monitors incident operations in order to identify any current or
potential problems between response agencies.

A Command Staff may not be necessary at every incident, but every incident requires that certain
management functions be performed. An effective Command Staff frees the Incident Commander to
assume a leadership role.

ICS Organizational Components

Section: The organizational level with responsibility for a major functional area of incident management
(e.g., Operations, Planning, Logistics, Finance/Administration). The person in charge of each Section is
designated as a Chief.

Division: The organizational level having responsibility for operations within a defined geographic area.
The person in charge of each Division is designated as a Supervisor.

Group: An organizational subdivision established to divide the incident management structure into
functional areas of operation. The person in charge of each Group is designated as a Supervisor.

Branch: An organizational level used when the number of Divisions or Groups exceeds the span of control.
Can be either geographical or functional. The person in charge of each Branch is designated as a Director.

Task Force: A combination of mixed resources with common communications operating under the direct
supervision of a Task Force Leader.

Strike Team: A set number of resources of the same kind and type with common communications
operating under the direct supervision of a Strike Team Leader.

Single Resource: An individual, a piece of equipment and its personnel complement, or a crew or team of
individuals with an identified supervisor that can be used at an incident.

General Staff

As you previously learned, an Incident Commander is responsible for all incident management functions
including: operations, planning, logistics, and finance and administration. Depending on the incident needs,
the Incident Commander may delegate some or all of these functions by establishing Sections. If a Section
Chief is assigned to an incident, he or she will report directly to the Incident Commander.
Together, these Section Chiefs are referred to as the General Staff. Let’s take a look at the responsibilities
of each Section Chief.

The Operations Section Chief is responsible for developing and implementing strategy and tactics to
accomplish the incident objectives. This means that the Operations Section Chief organizes, assigns, and
supervises all the tactical or response resources assigned to the incident. Additionally, if a Staging Area is
established, the Operations Section Chief would manage it.

The Planning Section Chief oversees the collection, evaluation, and dissemination of operational
information related to the incident. It is the Planning Section’s responsibility to prepare and disseminate the
Incident Action Plan, as well as track the status of all incident resources. The Planning Section helps
ensure responders have accurate information and provides resources such as maps and floor plans.

The Logistics Section is responsible for providing facilities, services, and material support for the incident.
Logistics is critical on more complex incidents. The Logistics Section Chief assists the Incident Commander
and Operations Section Chief by providing the resources and services required to support incident
activities. During an incident, Logistics is responsible for ensuring the wellbeing of responders by providing
sufficient food, water, and medical services. Logistics is also responsible for arranging communication
equipment, computers, transportation, and anything else needed to support the incident.

Another critical function during complex incidents is Finance and Administration. The Finance and
Administration Section Chief is responsible for the entire financial and cost analysis aspects of an incident.
These include contract negotiation, recording personnel and equipment time, documenting and processing
claims for accidents and injuries occurring at the incident, and keeping a running tally of the costs
associated with the incident.

Sources:

2011 American Association of Orthopedic Surgeons Emergency Medical Responder Manual

9th Edition Emergency Medical Responder: First on Scene
Emergency Management Institute Incident Command System
Federal Emergency Management Agency

Although the author and publisher have made every effort to ensure that the information in this book was correct at press time,
the author and publisher do not assume and hereby disclaim any liability to any party for any loss, damage, or disruption caused
by errors or omissions, whether such errors or omissions result from negligence, accident, or any other cause.

The information in this book is meant to supplement, not replace, proper actual Emergency Medical Responder training. Like any
high risk training involving speed, equipment, balance and environmental factors, (this course) poses some inherent risk. The
authors and publisher advise readers to take full responsibility for their safety and know their limits. Before practicing the skills
described in this book, be sure that your equipment is well maintained, and do not take risks beyond your level of experience,
aptitude, training, and comfort level.