Paramedic Refresher Download 2010

EEI Paramedic Refresher 201 0
EMERGENCY EDUCATIONAL INSTITUTE INTERNATIONAL EMT and PARAMEDIC REFRESHER Copyright 2010
Florida DOE Licensed School #3252 Florida Bureau of EMS Site #115
NO REPRODUCTION OF ANY KIND MAY BE DONE WITHOUT PERMISSION FROM EEI.
Emergency Educational Institute 9381 W Sample Rd #200 Coral Springs, Fl. 33065
954-753-6869 Fax 954-755-9050 [email protected] www.eeii.org Todd Soard, NREMT-P, Ph,D. Sindiana Echeverri, IEMSR-P, EMT-P, MPS
PARAMEDIC REFRESHER
Instructions for the Refresher Program
YOU WILL NEED TO READ, SIGN, AND SEND BACK THIS PAGE WITH YOUR COMPLETED PACKET!
The module packet is for your reference. Other source material may be used to complete the worksheets.
Complete the worksheets in-depth. NO short answers will be accepted. EMTs must have the skill evaluation sheet signed and returned with the completed worksheets. The HIV portion needs to be completed as well and the worksheet returned. A copy of a current CPR card must be with your returned worksheets. A copy of an ACLS card is required for Paramedic as well. Please copy your worksheet answers and keep them until your certificate of completion is received back from us. EEI is not responsible if they are lost in the mail or in delivery to our office in any format. Remember to keep all records for 3 years. DO NOT throw away any certificates or cards used to renew. If audited, the State wishes to see what you used to renew with during this renewal period. Again, DO NOT throw your CPR, ACLS, or certificates away when you renew them later on. Remember that in an audit YOU are the one the State must hear back from. If your agency renewed for you that is good, however YOU must answer the State. (F.S. 401) It is YOUR responsibility to send in your fee and application to the State. Usually, the State sends out your application in August or September. The State must have your current address on file. That is the law! (F.S. 401 and Rule 64E-2) If you do not receive an application YOU must call them to receive one. ALL WORKSHEETS MUST BE MAILED. FYI: Check these sites out: www.eeii.org, www.fapep.org, www.naemt.org , www.iemsr.org
I have read the above information and attest that all answerers were completed by me. ___________________________ Signature _________Date Licenses FL #: _________________________ Print Name National #____________
PMD_______________
Refresher for Retest Purposes Only? _____________ Other State: ______________

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Module 1 EEI, INC PREPARATORY
Scene Safety Body Substance Isolation (BSI) is one of the most important parts of your patient care. We need to remember that hand washing is needed even if we wear gloves. Eye protection is required in the prevention of splashes to the eyes. If prescription eyeglasses are worn than removable side shields can be applied. Gloves are required when coming into contact with a patient for any reason. We must change our gloves when dealing with multiple patients such as in a multi-trauma call. When cleaning equipment or our unit we need to have gloves on as well. Gowns are good when you may come into contact with large amount of body fluids that could splash. It is an OSHA standard that we carry an extra uniform so that we can change when our uniform becomes contaminated. Masks are a part of our BSI. They should be worn when the possibility of blood splashes may be present. A HEPA mask is required when coming into contact with a TB patient. The TB patient should wear airborne disease mask as well. If an exposure should occur you need to refer to your Policy and Procedures Manual for reporting and documentation PERSONAL PROTECTION
Hazardous materials play a large part in our everyday world. When responding to a HazMat scene we need to observe the scene and protect those around the scene and ourselves. View the scene with binoculars and look for placards. The HazMat team should be advised of your findings and the HazMat team controls the scene. We need to keep contamination low and obtain special training for these cases. In any rescue attempt we must identify certain threats. These may include electrical wires, fire, explosions, and hazardous materials. In violent situations the scene must be controlled by law enforcement. If law enforcement is not present then you should take any necessary precautions. Do not become a patient yourself. Quality Improvement
In Florida EMTs and Paramedics can only operate under the direction of a Medical Director. The physician must be a M.D. or D.O. and licensed in Florida. The goal of the Medical Director is to establish and maintain Quality Assurance (Q.A.), proper education, training and certifications of EMTs, and have oversight of medical treatment protocols. These protocols can be on-line or off-line direction. The Office of the Medical Director must do review of paperwork. Most States do have a percentage of the run reports that must be observed. Health and Safety
Lifting Lifting is the most common cause of back injuries. We all need to use our LEGS when lifting and keep the weight of the person or object close to us as much as possible. If needed, ask for assistance 3

and know your limitations. Do not twist when lifting and have your feet properly positioned. Talk the lifting procedure over with your partner before you actually do the maneuver. Consider using a power-lift. This technique is good for those with weak knees or thighs. The feet are apart in a comfortable position. The back is tight and the abdominal muscles lock the back in a slight inward curve. Straddle the object and keep the feet flat. Place your weight to the balls of the feet or just behind them. Stand by making sure the back is locked in and the upper body comes up before the hips. The power-grip makes use of all your hand power. The palm and fingers come into full contact with the object and all are bent in the same direction. Your hands should be about 10 inches apart. Always keep your back in a locked position. Always avoid bending at the waist.
Carrying/Pushing/Reaching When carrying a patient or object always think before you lift. Know your limitations and that of your partner as well. Try pushing an object rather than pulling when ever possible and avoid overhead pushing or pulling. Keep your arms close to your body and elbows bent. Stressful Situations We need to understand that the field we are in has stress. We may experience this by seeing a Mass Casualty Incident, a traumatic injury to a child, abuse, or death. On top of these situations we have the stress of family, bills, and the issues of our employment. Once we recognize what produces stress then we need to address it. Stress Management We need to recognize the warning signs of stress. Look for irritability reactions to others, inability to concentrate difficulty sleeping, anxiety, indecisiveness, guilt, and loss of appetite, loss of interest in sexual activities, isolation and loss of interest in work. We need to see what the problem is and make changes for the better. Understanding that things may not make us better overnight but we are moving ahead on the situation. This will prevent burnout. Burnout only comes from you! You make your job what it is. If it is that bad consider changes because no job is worth you health and life. We all need to watch our diet. We should practice what we preach when it comes to eating out and avoid a high intake of fats, sugar, caffeine, alcohol and smoking should be reduced or just avoided. We also need a balance between work, family and friends. Dont make EMS your main resident address. You know what I mean! There is a life outside the lights and sirens. Be aware of family and friends when you are out with them. Naturally, we speak of work and what has happened but is it the topic of conversation the whole time? You need a break from work and this causes burnout for you and those around you if this is all you talk about. I know we need to talk to each other about what goes on in our field when we are around each other. This could be for various reasons, but mainly it is found that our significant other is not part of the medical field. We do not feel like giving EMT 101 in order to explain what happened at the call. It looses its spice when we have to do this. What happens is that we hold it in until we see others in our field. But look at your significant other and/or friends. Do they always want to hear whats happening all the time? This is where balance is needed on both sides. Divorce among uniformed personnel is high and mostly due to lack of communication. Vacations are recommended but I say, DO IT! Money is always a factor so do what you can but get away. I mean, GET AWAY! Dont hang around the house or the county you live in. This is not stress relief. CISD 4

Critical Incident Stress Debriefing is offered to all on the scene of a call that can affect mental stability. Dont hold things in since this is a cause of burnout. Teams are brought in to assist and to help and anything that is said is confidential. The supervisory staff is debriefed separately from the field crew so that employees are more comfortable in speaking out. Usually debriefings are done within 24 to 72 hours of the major incident. The whole CISD procedure is to accelerate the healing process of the EMS worker.
Medical Legal
EXPRESSED CONSENT This type of consent deals with patient of legal age and sound in mind. The patient must be informed of the procedures being conducted. This form of consent must be obtained from the patient before giving treatment. IMPLIED CONSENT Implied consent is active when a patient is unconscious or becomes unconscious even if he or she denied treatment while conscious. This implied consent is based on the assumption that the person would consent to life saving interventions. Children and Mentally Incompetent Adults A parent or legal guardian must provide consent. In some cases you may run into an Emancipated minor. They have been judged by the court to be an adult and they usually have papers from the court on their person showing proof of this ruling. In most states a minor is considered to be anyone under the age of 18. When a life-threatening situation occurs and the parents or guardians cannot be contacted, this situation falls under implied consent. Confidentiality We in the EMS field need to cautious in our view of confidentiality. We cannot give out, except to those at the hospital, what we have found out from our patient in the interview process, findings, and treatment rendered. The releasing of this information requires a signed form from the patient. Releases are not required when other healthcare workers have a need to know. Most State laws require the reporting of rapes, abuse or gunshot wounds. Third party billing forms are okay as well as legal subpoena. Refusal of Care The patient does have a right to refuse care and may withdraw treatment at anytime. Refusals must be made by mentally competent adults following the rules of expressed consent. The patient must be informed of the risk of their actions and sign a release of liability form. When in doubt err in favor of providing care. Document all factors of the call including what you advised the patient upon refusal. If assistance from law enforcement is needed than ask for it. Make sure that the patient is of sound mind, in your findings, and not under the influence. Try to persuade the patient to going. A call was related to me that come into mind. A women called 911. On arrival her only complaint was that her daughter would not talk to her. No one was in the house but it was discovered that she thought the lamp was her daughter. The crew turned the light on but the patient still insisted her daughter was not talking to her. To get her to go to the hospital, because she was refusing to go, the crew placed the lamp on the stretcher and strapped it in. They advised the patient that she needed to accompany her daughter to the hospital to find out why she would not talk to her. She willingly got up and left with the crew. At the hospital, you could imagine their faces, assisted the patient, the real 5

one, to a private room. This was inventive of the crew and proved beneficial since the caller was refusing to leave. Do Not Resuscitate Orders (DNRO) The patient does have the right to refuse treatment. In general, this requires a written order from a physician. You need to follow your written protocol concerning this issue. When in doubt or a DNR order is not present, treat the patient. EEI, INC Abuse and Neglect of a Child or the Elderly The definition of abuse is the improper or excessive action so as to injure or cause harm. The definition of neglect is giving insufficient attention or respect to someone whom has a claim to that attention. We all need to recognize these situations. Signs and symptoms of abuse are: Multiple bruises in various stages of healing Injury inconsistent with mechanism described Repeated calls to the same address Fresh burns Parent or guardian seem inappropriately unconcerned Conflicting stories Fear on the part of the patient to discuss how the injury occurred Signs and symptoms of neglect are: Lack of adult supervision Malnourished appearance Unsafe living environment Untreated illness i.e. no medication present or given CNS injuries are most lethal and are seen in shaken baby syndrome (SBS). In any case we do not want to accuse anyone while on the scene. Your findings need to be relayed to the facility to prevent delay of treatment to your patient. It is your obligation to report what you see and hear; not what you think is happening. Follow your protocol concerning proper chain of reporting since the Medical Director will need to be advised as well.
Module II EEI, INC Airway
Opening the Airway The head-tilt lift is the preferred method of opening an airway when NO injury to the C-spine is suspected. This is accomplished by pushing back the forehead and lifting the chin. If trauma is suspected than the jaw thrust maneuver is to be performed. This is done by grasping the back of the jaw at the angle and pushing forward, being careful not to lift or rotate the neck. In all airway maneuvers we need to have suctioning available. Techniques of Suctioning Our suctioning equipment should be inspected frequently. A properly functioning unit with a gauge should have about 300mmHg. If we have a battery-operated unit it should be charged and ready for operation. We should use a rigid catheter for suctioning the mouth of infants and children. Nasal passages should be done with a bulb suction or French catheter with low suctioning. When suctioning we move the catheter from side to side and suction while pulling our catheter out. Suctioning should only last for 15 seconds at a time. If further suctioning is required then ventilate the patient for at least 2 minutes and re-suction. Having sterile water nearby will help if the catheter or tubing becomes blocked with large objects that need to be dissolved. Techniques of Artificial Ventilation We always need to use proper equipment when ventilating our patients. Mouth-to-mask, bag-valvemask, and oxygen-powered devices are our tools of the trade. We always need to keep in mind the use of our body substance isolation when dealing with any patient. Beware of T.B. and have a proper HEPA mask for yourself and your partner. Bag-valve-mask The bag volume is 1600 milliliters of air and we need to deliver at least 800 milliliters. We must practice using the BVM since the mask must be made to complete a seal. This can be difficult since we must push down and pull the head back to ventilate. Use of an oral or nasal airway can be beneficial in ventilating. If trauma is suspected be careful not to move the neck too much but an open airway is vital. Make sure the chest rises and you have good lung sounds. To immobilize the head while ventilating you may use your knees.

Airway Adjuncts Oropharyngeal Airway Oropharyngeal airways may be used to assist in maintaining an open airway on unresponsive patients without a gag reflex. Measure the OP from the corner of the patients lips to the bottom of the earlobe or angle of the jaw. Open the patients mouth and look for obstructions. Remove any of course. Insert the OP upside down with the tip towards the roof of the mouth. Make sure you do not push the tongue back. It will block the airway. Advance the OP gently until resistance is felt and turn 180 degrees. Rest the flange on the patients teeth. Another way of doing this procedure is to insert right side up, using a tongue depressor to press the tongue own. This method is preferred in infants and children.
Nasopharyngeal Nasopharyngeal airways are less likely to stimulate vomiting and can be used on patients that are responsive. You do need to lubricate the tube but remember that the insertion can still be painful. In selecting the proper size you need to measure from the tip of the nose to the tip of the patients ear. The diameter should be the nare. Insert the tube posteriorly with the bevel toward the base of the nare or toward the septum. Never force the tube. If resistance is met, use the other nostril. OXYGEN Non-Rebreather masks are used for patients that need high flow O2. Remember to inflate the bag portion of the mask and adjust the liter flow as to where the bag does not collapse. We treat the patients needs, not machines that may show an acceptable O2 Sat. or if the patient has a history of COPD or is a child. NO evidence has been shown to prove that high flow O2 will hurt these patients. Liter flow is to be 10-15 liters. Nasal Cannulas are used on patients that need only a low liter flow or will not tolerate a nonrebreather mask. NC is used with 2-6 liters of O2.
MODULE III EEI, INC PATIENT ASSESSMENT
SCENE SIZE-UP/ASSESSMENT Scene size up means that you are gathering information about your surroundings. We must do this on every call since in order to give proper care to every patient on the scene and for our safety and our partners safety. Always have proper BSI (Body Substance Isolation) available and wear it with every patient. Think of scene safety. Is it safe to approach the patient? Be aware of hazards in a crash situation. Look for toxic substances. Be aware of crime scenes and make sure the one or ones that committed the crime are restrained or Police are on scene. Look for unsafe surfaces such as wet areas, ice, slopes, overhangs, awnings, etc. Protection of the patient needs to be considered as well. Bystanders need to be asked to move from the area to avoid becoming potential patients and from getting in the way. This needs to be done politely since we are in the public eye. We need to determine the true nature of the call. Is it a medical or trauma? We need to be ready to obtain the information needed so that proper care can be given. INITIAL ASSESSMENT

Look at the general appearance of the patient. Determine the problem and assess for any life threatening injuries or situations. If this is the case then treat the patient as necessary to prevent further harm. Assess patients mental status. Speak to the patient and obtain their name, age, medical history, and medications at the least. Assess the patients mental status by speaking to them. Maintain spinal immobilization and obtain an AVPU level. Alert, Responds to Verbal stimuli Responds to Painful stimuli Unresponsive-no gag or cough. Assess the patients airway. Check the ABCs and include lung sounds. If the patient is not breathing perform the appropriate method for opening the airway such as Chin-lift head-tilt or Jaw-thrust maneuver. Listen and look for possible obstructions and clear them if any are found. All patients breathing adequately and are responsive should receive oxygen. All responsive patients breathing >24 or <8 should receive high flow O2. Your standards locally may be different so consult your protocols. If the patient is not breathing, ventilator adjuncts are required. Assess the pulse for circulation. If the patient has no radial pulse then feel for the carotid. If no carotid pulse is present and the patient is > or = 8 years old, start CPR and apply the AED. If <8 or <90lbs start CPR only. In trauma patients start CPR or follow your local protocol. In any case treat your patient as per protocol until advanced care arrives. Assess the skin color, temperature, and evaluate to see if they are clammy or sweating heavily. Note these items in your report. Identify priority patients and triage them if you have multiple patients. If the patient is experiencing an altered mental status, difficulty in breathing, shock, complicated childbirth, chest pain, uncontrolled bleeding or sever pain you need to expedite transport and have ALS treatment conducted as soon as possible. Focused History and Physical Examination Trauma We must perform a rapid assessment with our patients. Determine the cause of the injury while helping your patient. Spinal stabilization is required and ALS treatment is no doubt a need. Use the following assessment: DECAP-BTLS D formities C ontusions A brasions P unctures/penetrations and for breathing paradoxical movement B urns T tenderness L acerations S welling Any findings that present a life and death crisis stop and treat it or delegate the task to someone else and continue on with your assessment. Assess the neck area before you place a C-collar on. Evaluate the neck for JVD and stair stepping of the back of the neck. Assess the chest for paradoxical motion or crepitation. Listen for breath sounds. Palpate the abdomen. Is it soft, hard, rigid, or distended? Assess the pelvis. Note any abnormalities. Assess the extremities and check for distal pulses. Obtain a SAMPLE: 10

S igns and symptoms of present illness or injury A llergies M edications P ertinent past history L ast oral intake: solid or liquid E vents leading to the injury or illness If the patient has only minor injury your focus needs to be on the specific injury. Responsive Medical Patients Assess the history of the present illness. Look at the OPQRST O nset P rovocation Q uality R adiation S everity T ime Obtain a SAMPLE and perform a rapid assessment. Obtain a baseline of vital signs.
Unresponsive Medical Patients Perform a rapid assessment and obtain SAMPLE information, if possible, from bystanders, family, or friends. Do a head to toe survey to get the big picture.
Detailed Physical Exam This is also formally known as the artist Prince. Just kidding! This is formally known as the secondary survey. This is our more detailed exam so that we can pick up on special conditions and problems that are not life threatening but need to be noted. As you inspect the patient have the DCAP-BTLS in mind. D eformities C ontusions A brasions P unctures/penetrations (in lung sounds look for Paradoxical movement) B urns T enderness L acerations S welling Assess the head, face, ears, eyes, nose, and mouth. Look for bleeding or fluids. Be aware of possible obstructions. Palpate to note deformities and assess for pulses. Ongoing Assessment
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Repeat the assessment you have done every 15 minutes for a stable patient and every 5 minutes for an unstable patient. Assure that no other problems have surfaced that is critical. Verbal Communication After you arrive at the hospital a verbal report needs to be given. Introduce the patient by name if known. They are not The Patient. The patient is a person as you are and we need to keep their dignity in mind. Summarize what was provided over the radio report. Relates the chief complaint, history, treatment en route, vital signs, and additional information that have occurred. Interpersonal Communication As in our everyday life we need to follow proper communication skills. This makes you a more respected person and makes our profession professional. Keep eye contact with our patient. If you dont they will feel that your not sure of yourself or something is wrong. When practical, position yourself lower than your patient. Use language the patient will understand. This is of consideration when dealing with children. Sometimes the use of slang that the area uses may help in obtaining information properly and quickly. Just make sure it is appropriate and you know what youre using. Be aware of body language so that you not acting defensively. Speak clearly, slowly and distinctly but no to belittle the patient. Use the patients proper name, first or last, depending on proper use. Ask how they wish to be addressed. If your patient has difficulty hearing, speak clearly with lips visible. Dont raise your voice volume. If they cant hear dont make your partner deaf from your volume. Same with a patient who is old, has had a possible stroke, or is mute. They can probably still hear. If they speak another language, speaking louder will not make the translation go through any better. Allow the patient to respond before asking the next question. Act and speak in a calm manner. This will maintain control of your scene. Pre-hospital Care Report Your run report is an extension of you. It represents you as a person and who you are. Document properly and watch your spelling. Never use abbreviations that are not authorized. This will get you into trouble and can make it hard on your partner if youre not around and they have to testify on what you wrote. The billing information section is PART OF YOUR JOB. No matter whom you work for your check comes from the payment of the care provided. Without proper billing information administration cannot collect and this can effect pay raises, etc. You may use a computer pad for documentation and this is good. Make sure that you do the check off section correctly and your handwriting is satisfactory. The information in your run report must be in relation to the call. Keep it to that. Personal opinions are not part of the report. Record what you see on the call such as in the case of an assault, rape, etc. This may prove beneficial later on. Never falsify a report because it will come back to bite you later and also makes you look bad. On top of that you can loose you job and possibly have you certification revoked. If you forgot to provide a form of treatment then state it and how it was corrected.
MODULE 4 EEI, INC MEDICAL / BEHAVIORAL Throughout this and proceeding sections we will address the actions of the EMT-B and the Paramedic. Even though the EMT-B does not do the Paramedic skill I feel it is good for you to have the knowledge. The trademark of EE5, Inc is Giving Life Through Education and by this education everyone benefits. The worksheets for the Paramedic are in addition to the EMT-B worksheets.
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GENERAL PHARMACOLOGY Medications carried on the EMS unit for the EMT-B consists of Activated Charcoal, Oral Charcoal, Oral Glucose, and Oxygen. Medications that the patient may have and you are approved by the Medical Director to assist with consist of Prescribed Inhaler and Nitroglycerin. The EMT-B may use the Epinephrine auto-injector under the approval of your protocol. This is used in the event of an anaphylactic reaction. The device is spring loaded and come in an adult and child dose. It can be administrated in the thigh or upper arm. You pop off the top cap and push the other end of the barrel against the patients skin. Hold it for 30 to 60 seconds. Terminologys for medications are as follows: Generic = The name listed in the U.S. Pharmacopoeia and is the name assigned to the drug before it becomes officially listed. The name is based on the chemical name. Trade = Brand name the manufacturer uses in marketing the drug. Indications = Use of the drug for its intended purpose(s). Contraindications = Situations in which the drug should not used due to knowledge of how it may or will harm your patient. Medications come in different forms. Examples are given beside each one listed. Compressed powders or tablets - nitroglycerin, aspirin, Tylenol. Liquids for injection epinephrine, atropine, lidocaine, etc. Gels glucose Suspensions activated charcoal Fine powder for inhalation prescribed inhaler Gases oxygen Sublingual spray nitroglycerin spray. Read the canister. DO NOT SHAKE! The medication stays at the bottom. Liquid/vaporized fixed dose nebulizers - Atrovent, Albuterol All medications are in a specific form to allow proper controlled concentrations of the drug to enter the body and target the system desired. Dose = The amount found to be needed to obtain the desired effect. Actions = Desired effects of the medication. Side Effects = Actions of the medication(s) that is not desired. During administration of any medication(s) vitals and assessments need to be done with our patient on a continuos basis. Document the actions that the medications performed.
BREATHING DIFFICULTY Signs and symptoms are shortness of breath, restlessness, and increased pulse rate, increased breathing rate, decreased breathing rate. Skin color changes such as cyanotic (blue), pale or flushed (red). Noisy breathing such as crowing, audible wheezing, gurgling, snoring, or stridor, which is a harsh sound, heard during breathing or an upper airway obstruction. Be aware of how the patient is speaking, use of accessory muscles, sitting upright, pursing the lips, barrel chest, coughing. 13

The patient needs treatment in any situation of difficulty breathing. Oxygen and an inhaler, if prescribed for the patient can be given as per your protocol. The ALS care is to give a breathing treatment via a nebulizer as per protocol. If you are assisting the patient with their inhaler make sure it is theirs. If protocol dictates you can assist, then hold it for them as they normally would and have the patient push down on the inhaler when they are ready. The effects will be a beta action. This dilates the bronchioles. Watch for increased pulse rate, this comes from the Epi., tremors, and nervousness. Always reevaluate your patient. In infants and children remember that cyanosis is a late finding. Frequent coughing may be present rather than wheezing in some children. Handheld inhalers are commonly used with children. CARDIAC EMERGENCIES If the patient is experiencing chest pain they may use Nitro if they have it. The paramedic would follow the protocol for chest pain, which usually includes the use of Nitro spray. Remember to check the patients B.P. before and after the administration of Nitro since it dilates and the B.P. will drop. The systolic should be greater than 100. The use of Nitro will not be needed if the B.P. is that below 100 systolic, pain is relieved, or you have give 3 doses of Nitro. Typically you give 1 dose every 3 to 5 minutes and no more than 3 doses in 10 minutes. If CPR is required we need to remember our skills and perform them adequately. They are as followed: Always remember your ABCs and check for unresponsiveness. Obtain help right away and get early defibrillation present. Remember to use barrier devices when doing ventilations and wear gloves. Adult CPR 1 man CPR compression to ventilation is 30 to 2. 2 man CPR compression to ventilation is 30 to 2.. Pulse check is done at the carotid artery. Our depth of compression is 1/3 of the chest size. (i.e., 1 to 2 inches.) We use the heels of the hand locked together keeping our fingers off the chest. Rescue breathing is 1 breath every 5 seconds. Child CPR 1 man CPR is at a compression to ventilation rate of 30 to 2. In 2 man CPR it is 15 to 2. Pulse check done at the carotid artery. Our depth of compression is 1/3 of the chest size. (i.e., 1 to 1 inches.) We use both hands overlapped or the heal of one hand. Infants CPR Compression to ventilation is 30 to 2. The position is one finger width below the nipple line using 2 fingers or use your thumbs in the same position overlapping each other. The depth is to 1 inch.
AUTOMATIC EXTERNAL DEFIBRILLATION As we know, the use of early defibrillation saves lives. The chain of survival consist of: 1) Early access 2) Early CPR 3) Early defibrillation 4) Early ACLS
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Studies have proven, as in Manchester, Wisconsin, that AEDs save lives due to the early access by the police and those having an AED. Many groups and organizations are using the AED. You no doubt have seen it on the news reports of the airlines purchasing them mostly in response to the proven need. Many police departments are placing them in patrol cars and BLS units are doing the same. Shopping mall and residential security companies are making use of the AED as well. The AED comes in 2 different functions. Fully automated and Semi-automated. In the fully automated all you assess the patient for need attach the patches and turn the unit on. In the Semi automated, the most used unit, the computer voice prompts you throughout the rescue. The AED is programmed to only shock in V-Fib, Pulseless VTach, and a rate of 180 or more. Naturally, these rhythms are pulseless. During the evaluation period of the AED CPR must be stopped if it has already begun. If the rescue unit is moving you will need to stop for proper evaluation of the patient. You must follow your protocol for the use of the AED. In Florida the AED is covered under the Good Samaritan Act for Laypersons. The proper use of the AED is simple. At the time, my 7-year-old daughter viewed the training unit and can tell you how it works. She is now 15 and can operate it. Im not saying we let a child use the unit, but that is how simple it is. The unit is applied on an unconscious, pulseless patient that weighs more than 90lbs and is over the age of 8. Place the patches on the patient and make sure the unit is turned on. Then let the AED advise you as to what to do next. The unit will shock, if needed, 3 times at 200j, 300j, and 360j. Some units use only 150j and others begin at 140j and max out at 320j. Reason? More is not always better. The unit detects the needed amount of energy required to resuscitate. If the unit is Biphasic it may choose a lower setting on its own. The AED evaluates the rhythm after each shock. If needed, after the 3rd shock the unit advises to check pulse and do CPR if no pulse. Every 60 seconds the unit will advise to stand clear so that is can evaluate the patient to see if there is a shockable rhythm. Some AEDs have the rhythm screen on top so that the actual EKG can be determined and others now have a visual command screen for the hearing impaired. EKG units can be switched over with a key or key card from the Paramedic and make the unit into a regular ALS monitor/defibrillator. In any case regular checks and maintenance is required. Follow the manufacture recommendations on these procedures. The unit also records the event for viewing by the medical director and is downloaded into your computer for this purpose after each rescue. Written reports are also needed. At this time, July 2006, AEDs are being reprogrammed to meet the new 2005 Guidelines. How these manufactures conduct this will be the responsibility of each. MEDICATIONS Nitroglycerin is used with patients experiencing chest pain. For the EMT and Paramedic you need to follow your protocol on its administration. Always remember that if the BP is below 100 systolic or the max dose of 3 times in 10 minutes has been accomplished, no further administration is needed. Always ask the patient if they have taken any Nito before your arrival. Be aware of Nito patches on the patient and ask as to when it may have been changed. After administration of Nito check the BP within 2 minutes. Nitro dilates blood vessels so the patient may experience hypotension, headache, and pulse rate changes. Nitro should not be given if the patient is on any sildenafil citrate. (i.e., Viagra, Cealis - Lavitra tm) Nitro may come in different forms, spray, tablet, or patch. Remember the spray type does NOT need to be shaken before administration. Oral Glucose is given to patients with an altered mental status with a known history of diabetes. Under ALS treatment, D50 via IV will be administered if called for under the protocol for any altered mental status with a low glucose level. Most protocols for D50 are to administer 25mg at first and a follow-up of 25mg if needed. If the EMT gives Oral Glucose, you must make sure the 15

patient can swallow and has a good airway. Place the gel between the check and gum. This should absorb into the patients system. Epinephrine (Adrenaline) is used on patients that are experiencing an allergic reaction. The EMT, as per protocol, may administer the medication via an Epinephrine auto-injector pen. The procedure for administration for the auto-injector is as follows: Obtain orders or follow your protocol. Remove the safety cap from the auto-injector. Place the tip of the auto-injector against the patients thigh. Push the injector until the medication is delivered, usually about 30 to 60 seconds. Record the time and any reactions. In the ALS setting the Paramedic will administer Epi 1:1000 with a 1cc syringe. .3 to .5 cc will be given SubQ. Protocol will be followed in any case. The Epi comes in a vial and will be drawn up in the syringe. In some cases the Epi 1:1000 will be in a pre-filled syringe and ready for use. Actions will be dilation of the bronchioles with constriction of blood vessels. The side effects can be increased heart rate, pallor, dizziness, chest pain, headache, nausea, vomiting, excitability and anxiousness. The patient will need to be assessed constantly and proper treatment required for any situation that may prevail. EMERGENCY MEDICAL CARE of POISONING / OVERDOSE There are different means of poisoning. We will cover each of these. Ingestion may cause nausea, vomiting, diarrhea, altered mental status, abdominal pain, and chemical burns around the mouth, breath odor. Care includes removing any substance from the mouth that may be present. Activated charcoal may be called for and the patient needs transport to the hospital. Stabilize the patient by monitoring ABCs. ALS procedures would include IV, monitor, and following proper protocol. Watch for arrhythmias and treat appropriately. In any case try to bring the bottle or container that the substance was derived from. Inhalation poisoning will show difficulty breathing, chest pain, cough, hoarseness, dizziness, headache, confusion, seizures, or an altered mental status. Care would be to remove the patient from the contaminated environment and start O2 therapy right away. In the ALS setting watch for arrhythmias, start an IV and transport. Always follow your protocol and obtain what the patient was exposed too, for how long and how much. In a toxic situation the patient may experience weakness, dizziness, chills, fever, nausea and vomiting. Airway is of concern and proper treatment by protocol. Obtain what the substance the patient was exposed too and be aware that a HazMat team may need to come in to retrieve the patient. In absorption situation the patient may experience burns, itching, irritation, and redness. Remove any clothing and protect yourself from being contaminated. If a powder is the problem brush it off. If it is a liquid then about 20 minutes of irrigation is required. The same goes for any contact with the eye. Irrigate for at least 20 minutes and in any case transport ASAP. Maintain you ABCs In the ALS setting monitor the patient, IV and O2. EEI, INC BEHAVIORAL EMERGENCIES
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Many of our EMS calls relate to some form of mental instability. Always be aware of suicide attempts or the want to do so. Watch for depression, sadness, tearing, and the speaking of death. Some of the risk factors include but not limited too: Males over 40, single widowed or divorced, alcoholic, depression. Defines action of causing death. Purchasing of a gun or a large amount of medications prescribed or not. Prior incidents of suicide attempts. Recent diagnosis of serious illness. Recent loss of a loved one. Loss of a job, arrest, imprisonment.
Be watchful of your surroundings and make sure the patient is never left alone. I was on a call that the gentleman explained that he had to go to the bathroom and wanted to be left alone. When he was told he would not be left alone he became very upset. Behind the bathroom door was a loaded shotgun. What do you think he wanted to be alone for? When dealing with behavioral patients never be alone. This will assist in keeping the patient from possibly doing more harm and assists in limiting possible allegations. Document what was said and done.
Altered Mental Status

An altered mental status comes about from various reasons such as Stroke, Seizures, Hypoglycemia, Drugs and Alcohol. We need to do a complete assessment on these patients and treat them appropriately.
Heat Exhaustion
Heat Exhaustion occurs when the body overheats and is dehydrated. Our body can be fooled if the environment has high humidity. The body senses moisture so it does not sweat enough. After a period of time the body over heats and now the problem begins. In other cases the body sweats and the person does not take in enough fluids. This causes dehydration and an electrolyte imbalance. The person will experience profuse sweating, cold and clammy skin, thirst, nausea, vomiting, headache, tachycardia, low BP, and a slight fever. Treatment includes getting the person out of the heat, and provide fluids. If they can not keep fluids down, they will need an I.V. right away.
MODULE V EEI, INC TRAUMA
Shock (hypoperfusion syndrome) is defined as inadequate tissue perfusion. Signs and symptoms are: Restlessness, anxiety, altered mental status. Delayed capillary refill >2 seconds. Temperature infant and child patients only. Weak, thready or no peripheral pulses. Pale, cool, clammy skin. A late sign would be BP. 17

Increased pulse rate, which is an early sign. Increased shallow or labored breathing. Dilated pupils. Thirst Nausea and vomiting. Pallor with cyanosis to the lips.
The types of shock include: Anaphylactic- An allergic reaction Cardiogenic Inadequate heart function Hypovolemic- Loss of Blood or fluids Metabolic- Excessive fluid and elecrolyte loss due to vomiting, urination, and diarrhea Neurogenic- Damaged cervical cord causing vessel dialation Psychogenic- Fainting from the site of something or pain. Septic- Severe bacterial infection Keep in mind that infants and children can sustain an adequate BP down to the point of loosing more than half their volume. They have low reserves. Care for our patient entails use of BSI, airways stabilization, bleeding control, raise the extremities and attempt to keep the patient from moving around. Our Primary Survey encompasses ABCs. The term ABC is expanded. Assess the airway for proper opening based on the patients needs. Observe for obstructions. Maintain C spine, listen for lung sounds and apply oxygen. In an ALS setting the patient may require needle decompression on one or both sides due to a pneumothorax. If you have an open chest wound apply and occlusive bandage. This is a BLS or ALS treatment. Use of Vaseline gauze or an electrode with the sponge removed can assist in this matter. Make sure pressure does not build up. If it does, pull the bandage up to release the pressure. Assess pulses, radial and carotid, and look for extreme bleeding. If the patient is bleeding cover the area right away. Making sure our patient is unclothed will help in our assessment. While looking over the body observe for bruising, swelling, etc. Just remember that we need to stop and treat any life-threatening situation. If you have not taken a BTLS or PHTLS course please do so. You will learn a lot.
In a Secondary survey you are going over the patient in a more detailed head to toe. Look over the whole body systematically with a DCAPBLS in mind. D eformity C repitus A brasions P unctures and Penetrations B urns L aceration S welling
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When examining any area always look for these specifics in any area of the body. Also be aware of body fluids that may come from the ears, nose or mouth. When possible, have a crewmember on the scene go to the unit to have the IVs, EKG, and suctioning ready for the patient. This will save time while enroute to the hospital. Be prepared to treat any complications that may arise. EEI, INC Remember safety. Observe the scene for dangers of any kind. While in a house be aware of other people and their actions. Just because 911 is called not all want you present. Make sure the area is secure by observing if hazards are present such as chemical, fluid spillage, wires, fire, and any thing that can cause injury or death. Get the big picture. Look at the mechanism of injury. How sever is the damage to the vehicle or structure? Forces radiate throughout the object to the body and then, throughout the body. Be aware of injuries from blunt trauma. The apparent effected area may not be the only injured area. Penetrating trauma may have underlining damage. Try to identify the width and depth of the object. The organs underneath may have been touched. Rapid extrication may be needed so while observing the scene relate if you need more help. You can do certain treatments while they are trapped. O2 therapy, even intubation, C-collar, I.V.s, etc.
Types of Trauma
In any case of trauma, bleeding control is the main function. Applying pressure, elevation, and raising the extremity can provide this. In nose bleeds keep the persons head forward and apply pressure. In penetrating trauma the object must be stabilized to prevent further injury. Only remove the object if the airway is compromised or CPR is required.
MODULE VI EEI, INC OBSTETRICS, INFANTS, AND CHILDREN
NORMAL DELIVERY It is best to transport the mother as soon as possible unless delivery is immanent. Obtain information from your patient such as: Are you pregnant? How long have you been pregnant? Are there and contractions or pain? 19

Any bleeding or discharge? Is crowning occurring with contractions? Youll need to observe this. What is the frequency and duration of contractions? Does the patient feel a bowel movement r urge to urinate? Does the patient have a need to push? Do you have a rock hard abdomen?
Always use your BSI and prepare for delivery if that is the choice you are making. Do not let the mother go to the bathroom and do not hold the mothers or allow her to place her legs together. Do realize your limitations and you may deliver while enroute to the hospital. During delivery, attempt to have a sterile area with the use of your OB kit. Remember that we assist in delivery and Mother Nature does the rest. Once the head is delivered use the bulb suction and suction the mouth first, then the nose. Infants take their first breath by mouth so that is why we suction the mouth first. As the baby is coming out of the birth canal gently push on the head but not hard. You are preventing an explosive presentation that could rip the vaginal area. Assist the shoulders and rotate as needed. After delivery of the baby be aware of possible multiple births. The placenta will deliver usually within 20 minutes. The placenta must be given to the hospital so that it may be evaluated for wholeness. The mother will have blood loss so I.V. therapy needs to be considered but 500cc is the usual loss and can be tolerated. Evaluate your infant and keep them warm. Uses of blankets are good. In a disaster situation you can make an incubator by using a box with shredded paper as the base and blankets around the child. Evaluate an APGAR score at birth and 5 minutes later. Resuscitation may be required. Certain perimeters have been established but always follow your protocol. Shallow or absences of breathing will call for your intervention. First, attempt to stimulate the patients breathing flicking the soles of the feet or rub the infants back. If breathing less than 60/min assist ventilations and reassess in 30 seconds. If no improvement, continue. Heart rate less than 100 assist in ventilations as well and reassess in 30 seconds. If the heart rate is less than 80 start chest compressions. If the rate is less than 60 start compressions and ventilation together. If poor coloring presents itself and the patient is breathing adequately, administer O2 10 15 L using O2 tubing as a blow by.
ABNORMAL DELIVERIES Prolapsed cords do happen. This is where the cord presents itself before delivery of the baby and is a serious emergency. Treat you mother appropriately and apply O2 on mom, 10 15 L NRB mask. Keep her buttocks raised and her head down which lessens the gravity and pressure on the birth canal. Insert a sterile gloved hand into the vagina pushing the presenting part of the fetus away from the pulsating cord. Rapid transport is required. Breech birth is when the buttocks or lower extremities present before the fetus is delivered. Immediate transport is needed and your assistance. If delivery is not completed within a few minutes you will need to insert a gloved hand, find the nose, and making a V with your fingers, raise the face off the birth canal. Youre doing this since the baby may desire to start breathing on its own and suffocate. 20

Limb presentations pose an extreme emergency. You must transport rapidly and take care of the mother. The mother will no doubt need a C section. Advise the mother not to push, even though she may feel that she has too. Meconium, amniotic fluid that is greenish or brownish-yellow is an indication of possible fetal distress during labor. Do not stimulate the infant until suctioning is complete. Maintain a good airway and transport. Premature births have a risk of hypothermia and respiratory problems. Treat by your protocol. MEDICAL PROBLEMS in CHILDREN In most cases respiratory problems are the main problems. Once corrected the child recovers. Airway obstructions are corrected by back blows and chest thrust for infants and abdominal thrust for children. Croup shows itself with a barking cough and epiglottis produces drooling. Croup needs to be evaluated on the first occurrence by a physician and the parents are directed as to how to handle it if the problem should arise again. Breathing treatments may be needed on an ALS level. A nebulizer may be used even as a blow by. Usually moist air will relieve the problem. Epiglottis needs medical attention. Assess the breathing effort and treat appropriately. If cardiac arrest occurs treat as per the American Heart Association guidelines and your protocol. Remember ABCs. In the ALS setting the use of a Browslow tape will assist in proper care as well as your protocol. Diarrhea, dehydration, vomiting, blood loss, infection and abdominal injuries may cause shock. The patient may show signs of mental status changes, rapid respiratory rate, pale, cool, clammy skin, weak or absent peripheral pulses, delayed capillary refill, decreased urine output. Measure output by how many diapers have been used. Care should be to keep them warm, O2, and on an ALS side I.V. therapy is recommended. When evaluating the child, start at the feet and have the patient with the parent or guardian if possible. This will make your life easier and fulfill a proper exam without crying and distractions. TRAUMA in CHILDREN This is always hard for all of us but remember that we need to treat the child. Never forget that the parents need to be kept informed and involved if at all possible. Always evaluate the child as you would an adult for life threatening emergencies. Maintain ABCs and comfort the child as much as possible. Prevention is always the key. Community education is always the best prevention. Educate parents on proper home safety, CPR, First Aid, car seats and seatbelts.
Bio-Terrorism and Acts of Terrorism

Bio-Terrorism has now come to the forefront. After the events of September 11,2001 the U.S. became members of something that we have always feared but hoped would never come to our land, anthrax. Agents such as anthrax have been present for many years and have been developed and studied. Its now use threatens our very society and way of life, as it has in lands overseas. 21

As Healthcare workers we are on the front line of possible exposure, so much that we all need to be diligent in our keeping alert to our surroundings. Unexplained illnesses and/or multiple reported exposures can be a signs of a Biological attack, as we have seen in Florida, Washington DC, New Jersey and New York plus in the New England area. Provided from our other course EEC offers, Biological Warfare and Terrorism, is a history of Bio-Terrorism from that student manual.
HISTORY OF BIOLOGICAL WARFARE AND CURRENT THREAT

The use of biological weapons and efforts to make them more useful as a means of waging war have been recorded numerous times in history. Two of the earliest reported uses occurred in the 6th century BC, with the Assyrians poisoning enemy wells with rye ergot, and Solons use of the purgative herb hellebore during the siege of Krissa. In 1346, plague broke out in the Tartar army during its siege of Kaffa (at present day Feodosia in Crimea). The attackers hurled the corpses of those who died over the city walls; the plague epidemic that followed forced the defenders to surrender, and some infected people who left Kaffa may have started the Black Death pandemic, which spread throughout Europe. Russian troops may have used the same plague-infected corpse tactic against Sweden in 1710. On several occasions, smallpox was used as a biological weapon. Pizarro is said to have presented South American natives with variola-contaminated clothing in the 15th century, and the English did the same when Sir Jeffery Amherst provided Indians loyal to the French with smallpoxladen blankets during the French and Indian War of 1754 to 1767. Native Americans defending Fort Carillon sustained epidemic casualties, which directly contributed to the loss of the fort to the English. In this century, there is evidence that during World War I, German agents inoculated horses and cattle with glanders in the U.S. before the animals were shipped to France. In 1937, Japan started an ambitious biological warfare program, located 40 miles south of Harbin, Manchuria, in a laboratory complex code named Unit 731. Studies directed by Japanese General Ishii continued there until 1945, when the complex was leveled by burning it. A post World War II investigation revealed that numerous organisms had received Japanese research attention, and that experiments had been conducted on prisoners of war. Slightly less than 1,000 human autopsies apparently were carried out at Unit 731, most on victims exposed to aerosolized anthrax. Many more prisoners and Chinese nationals may have died in this facility -some have estimated up to 3,000 human deaths. In 1940, a plague epidemic in China and Manchuria followed reported over flights by Japanese planes dropping plague-infected fleas. By 1945, the Japanese program had stockpiled 400 kilograms of anthrax to be used in a specially designed fragmentation bomb.
In 1943, the United States began research into the offensive use of biological agents. This work was started, interestingly enough, in response to a perceived German biological warfare (BW) threat as opposed to a Japanese one. The United States conducted this research at Camp Detrick (now Fort Detrick), which was a small National Guard airfield prior to that time, and produced agents at other sites until 1969, when President Nixon stopped all offensive biological and toxin weapon research and production by executive order. Between May 1971 and May 1972, all stockpiles of biological agents and munitions from the now defunct U.S. program were destroyed in the presence of monitors representing the United States Department of Agriculture, the 22

Department of Health, Education, and Welfare, and the states of Arkansas, Colorado, and Maryland. Included among the destroyed agents were Bacillus anthracis, botuli n urn toxin, Francisella tularensis, Coxiella burnetll, Venezuelan equine encephalitis virus, Brucella suis, and Staphylococcal enterotoxin B. The United States also had a medical defensive program, begun in 1953, that continues today at USAMRI ID. In 1972, the United States and many other countries signed the Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and on Their Destruction, commonly called the Biological Weapons Convention. This treaty prohibits the stockpiling of biological agents for offensive military purposes, and also forbids research into such offensive employment of biological agents. The former Soviet Union and the government of Iraq were both signatories to this accord. However, despite this historic agreement among nations, biological warfare research continued to flourish in many countries hostile to the United States. There were also several cases of suspected or actual use of biological weapons. Among the most notorious of these were the yellow rain incidents in Southeast Asia, the accidental release of anthrax at Sverdlovsk, and the use of ricin as an assassination weapon in London in 1978. Testimony from the late 1970s indicated that planes and helicopters delivering aerosols of several colors attacked the countries of Laos and Kampuchea. After being exposed, people and animals became disoriented and ill, and a small percentage of those stricken died. Some of these clouds were thought to be comprised of trichothecene toxins (in particular, T2 mycotoxin). These attacks are lumped under the label Yellow Rain. There has been a great deal of controversy about whether these clouds were truly biological warfare agents: some have argued that the clouds were nothing more than bee feces produced by swarms of bees. In late April of 1979, an incident occurred in Sverdlovsk (now Yekaterinburg) in the former Soviet Union, which appeared to be an accidental release of anthrax in aerosol form from the Soviet Military Compound 19, a microbiology facility. Residents living downwind from this compound developed high fever and difficulty breathing, and a large number died. The final death toll was estimated at the time to be between 200 and 1,000. The Soviet Ministry of Health blamed the deaths on the consumption of contaminated meat, and for years controversy raged in the press over the actual cause of the outbreak. All evidence available to the United States government indicated a massive release of aerosolized anthrax. In the summer of 1992, U.S. intelligence officials were proven correct when new Russian President Boris Yeltsin acknowledged that the Sverdlovsk incident was in fact a large-scale accident involving the escape of an aerosol of anthrax spores from the military research facility. In 1994, Meselson and colleagues published an in-depth analysis of the Sverdfovsk incident (Science 266:1202-1208). EEI, INC They documented that all of the 1979 cases occurred within a narrow zone extending downwind in a southerly direction from Compound 19. Meselsons team, including 66 fatalities and 11 survivors, identified a total of 77 patients. Before the Sverdlovsk incident, in 1978, a Bulgarian exile named Georgi Markov was attacked in London with a device disguised as an umbrella, which injected a tiny pellet filled with ricin toxin into the subcutaneous tissue of his leg while he was waiting for a bus. He died several days later. On autopsy, the tiny pellet was found and determined to contain the toxin. The communist 23

Bulgarian government, it was later revealed, carried out this assassination, and the technology to commit the crime was supplied to the Bulgarians by the former Soviet Union. In August of 1991, the first United Nations inspection of Iraqs biological warfare capabilities was carried out in the aftermath of the Gulf War. On August 2, 1991, representatives of the Iraqi government announced to leaders of United Nations Special Commission Team 7 that they had conducted research into the offensive use of Bacillus anthracis, botulinum toxins, and Clostridium perfringens (presumably one of its toxins). This was the first open admission of biological weapons research by any country in recent memory, and it verified many of the concerns of the U.S. intelligence community publicly. Iraq had extensive and redundant research facilities at Salman Pak and other sites, many of which were destroyed during the war. In 1995, further information on Iraqs offensive program was made available to United Nations inspectors. Iraq conducted research and development work on anthrax, botulinum toxins, Clostridium perfringens, aflatoxins, wheat cover smut, and ricin. Field trials were conducted with Bacillus subtilis (a simulant for anthrax), botulinum toxin, and aflatoxin. Biological agents were tested in various delivery systems, including rockets, aerial bombs, and spray tanks. In December 1990, the Iraqis filled 100 P400 bombs with botulinum toxin, 50 with anthrax, and 16 with aflatoxin. In addition, 13 Al Hussein (SCUD) warheads were filled with botulinum toxin, 10 with anthrax, and 2 with aflatoxin. These weapons were deployed in January 1991 to four locations. All in all, Iraq produced 19,000 liters of concentrated botulinum toxin (nearly 10,000 liters filled into munitions), 8,500 liters of concentrated anthrax (6,500 liters filled into munitions) and 2,200 liters of aflatoxin (1,580 liters filled into munitions). The threat of biological warfare has increased in the last two decades, with a number of countries working on offensive use of these agents. The extensive program of the former Soviet Union is now controlled largely by Russia. Russian president Boris Yeltsin has stated that he will put an end to further offensive biological research; however, the degree to which the program has been scaled back, if any, is not known. Recent revelations from a senior BW program manager who defected from the FSU in 1992 outlined a remarkably robust biological warfare program including active research into genetic engineering, binary biologicals and chimeras. There is also growing concern that the smallpox virus, eliminated from the face of the earth in the late 1970s and now stored in only two laboratories at the CDC in Atlanta and the Institute for Viral Precautions in Moscow, Russia, may have been bargained away by desperate Russian scientists seeking money. There is intense concern in the West about the possibility of proliferation or enhancement of offensive programs in countries hostile to the western democracies, due to the potential hiring of expatriate Russian scientists. It was reported in January 1998 that Iraq had sent about a dozen scientists involved in BW research to Libya to help that country develop a biological warfare complex disguised as a medical facility in the Tripoli area. In a report issued in November 1997, Secretary of Defense William Cohen singled out Libya, Iraq, Iran, and Syria as countries aggressively seeking nuclear, biological, and chemical weapons. There is also an increasing amount of concern over the possibility of terrorist use of biological agents to threaten either military or civilian populations. There have been cases of persons loyal to extremist groups trying to obtain microorganisms, which could be used as biological weapons. The Department of Defense is leading a federal effort to train the first responders in 120 American cities to be 24

prepared to act in case of a domestic terrorist incident involving WMD. Certainly the threat of biological weapons being used against U.S. military forces is broader and more likely in various geographic scenarios than at any point in our history. Therefore, awareness of this potential threat and education of our leaders and medical care providers on how to combat it are crucial.
Followed is an explanation of the most common Bio threats:

Anthrax. A nonspecific prodrome (i.e., fever, dyspnea, cough, and chest discomfort) follows inhalation of infectious spores. Approximately 2--4 days after initial symptoms, sometimes after a brief period of improvement, respiratory failure and hemodynamic collapse ensue. Inhalational anthrax also might include thoracic edema and a widened mediastinum on chest radiograph. Gram-positive bacilli can grow on blood culture, usually 2--3 days after onset of illness. Cutaneous anthrax follows deposition of the organism onto the skin, occurring particularly on exposed areas of the hands, arms, or face. An area of local edema becomes a pruritic macule or papule, which enlarges and ulcerates after 1--2 days. Small, 1--3 mm vesicles may surround the ulcer. A painless, depressed, black eschar usually with surrounding local edema subsequently develops. The syndrome also may include lymphangitis and painful lymphadenopathy. Plague. Clinical features of pneumonic plague include fever, cough with muco-purulent sputum (gram-negative rods may be seen on gram stain), hemoptysis, and chest pain. A chest radiograph will show evidence of bronchopneumonia. Botulism. Clinical features include symmetric cranial neuropathies (i.e., drooping eyelids, weakened jaw clench, and difficulty swallowing or speaking), blurred vision or diplopia, symmetric descending weakness in a proximal to distal pattern, and respiratory dysfunction from respiratory muscle paralysis or upper airway obstruction without sensory deficits. Inhalational botulism would have a similar clinical presentation as foodborne botulism; however, the gastrointestinal symptoms that accompany foodborne botulism may be absent.
Smallpox (variola). The acute clinical symptoms of smallpox resemble other acute viral illnesses, such as influenza, beginning with a 2--4 day nonspecific prodrome of fever and myalgias before rash onset. Several clinical features can help clinicians differentiate varicella (chickenpox) from smallpox. The rash of varicella is most prominent on the trunk and develops in successive groups of lesions over several days, resulting in lesions in various stages of development and resolution. In comparison, the vesicular/pustular rash of smallpox is typically most prominent on the face and extremities, and lesions develop at the same time. 25

Inhalational tularemia. Inhalation of F. tularensis causes an abrupt onset of an acute, nonspecific febrile illness beginning 3--5 days after exposure, with pleuropneumonitis developing in a substantial proportion of cases during subsequent days (7). Hemorrhagic fever (such as would be caused by Ebola or Marburg viruses). After an incubation period of usually 5--10 days (range: 2--19 days), illness is characterized by abrupt onset of fever, myalgia, and headache. Other signs and symptoms include nausea and vomiting, abdominal pain, diarrhea, chest pain, cough, and pharyngitis. A maculopapular rash, prominent on the trunk, develops in most patients approximately 5 days after onset of illness. Bleeding manifestations, such as petechiae, ecchymoses, and hemorrhages, occur as the disease progresses.
Our furtherance of our training and education in Bio-Terrorism will make us more aware of the cases that can, and will no doubt at some point, rise from the depth of some mad man or organization. All for a cause or score to settle! All at the cost of humanity!
Physical Acts of Terrorism

Terrorist activity has occurred in this nation from New York to Oklahoma. From Georgia to Colorado. We all need to be prepared for the possibility that It can happen here. When we respond to a call, especially that of mass casualty, be aware of secondary situations. If one bomb has gone off then another is no doubt in the works after you have arrived and are setting up a triage area or just treating patients. What a better time to have secondary devices to go off when Police, Rescue, Fire, News teams, and bystanders are present. It can come from nearby cars, trash bins or trees. In drug houses that we may be called into, be aware of trip wires, sensors, and the like that may be set by the criminal force. These are aimed at the Police but the device does not determine as to whom is present in the room. The threat we now face is from International organizations that will die for there cause. We need to be prepared and always alert. Never let your guard down and if something looks suspicious, then report it. It is better to be safe than sorry theory goes into play in the times we are in. Our schools are threatened so take threats serious even if it from a child. You may save many from a shooting tomorrow. Prevention is the key so more community involvement is needed. We must get our young ones, our future EMS providers, interested in helping instead of hurting others. Educating our parents to just communicate will assist as well. By having both child and parent involved in community involvement projects, such as EMS, may just stimulate that
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communication. We are Healthcare Professionals and can guide the future of our community. All it takes is stepping forward to start the cause.
Domestic Violence
It is a shame, but domestic violence is on the rise. We see more so today than in years past. This has been attributed to the seeing of violence in the home and passing it on to children. Our children our exposed to more violence on TV than ever before. Not just the Hollywood scene, but also the local news. The neighborhood environment can add to violent tendencies. Stress, in one form or another, can lead to an outburst of anger if left in for a period of time. Family issues and a death of a loved one can cause someone to loose reality, even if for a moment. 27

The fact is that Domestic Violence is not okay and we as EMS personnel must deal with it in the community we work in and, in some cases, within ourselves. Domestic Violence affects mostly women, but men are sometimes abused as well. We need to understand that just leaving the home, the situation, is easier said then done. The one being abused may still care for the one inflicting harm. Children may be involved and taking them out of the home environment may not be possible. Financially, the one being abused may not be able to sustain there self if they leave. Fear is the biggest obstacle. Fear that the one inflicting harm will find them and cause even more harm or possibly kill them. Counseling may help some, but NOT ALL. If the act of violence was an isolated case, counseling is usually productive. Accepting words of apology, candy, or roses cannot treat persistent acts of violence. Long term counseling may help, if the abuser will allow it to change them and jail time or probation is part of the course. Chronic abusers are, in most cases, beyond help from the one being abused, family, or friends. Extreme measures in counseling; court intervention and jail time is in order. Outcome for these types of abusers is very poor. In extreme cases the one being abused needs to find a way to escape to safety. These steps will assist in that decision and are in no certain order since each case is different. Another act of violence may alter your time line or decisions. Have a small bag always packed and ready to go if you need to leave in a hurry. Make sure any prior abuses are documented with the Police and you may wish to have copies of these reports secure in that small bag. File charges against the abuser and make them stick. Do not let the abuser talk you out of dropping the charge. Get a restraining order. This is so that the Police can legally remove the abuser from your presence if they violate the order. Have the order on your person at all times. Usually this is for months.
Obtain a Post Office box at the US Post office or a Mail Box provider franchise. Physical locations cannot be given out to anyone requesting it, as was the case in years past. Only by court order can that physical address or change of address be obtained. Obtain a checking account in your name only. You will need this for financial stability and you may wish to build a nest egg in it.
Get a credit card in your name and make sure the address you provide is that of a family member, friend, or that of a Mail Box, etc location. Use the # sign for MBE box since this fulfills the law requirement. The credit card company usually wants a physical address listed and the abuser can sometimes; trace that if they know how to do it. 28

Once you have your own home, get to know your neighbors and confide in those around you. This will assist you if the abuser finds you and the neighbors can call for help. Have your phone unlisted and unpublished. A caller I.D. device is always good to have so that you can possibly identify those calling. Have younger children to never answer the phone. If the abuser somehow would get your number the child may be convinced or feel impelled to tell the abuser your address. Have a security system put in. Many security companies offer free installation with a small monitoring fee contract. Get a cellular phone. This could save your life. Be careful on email accounts not to have a profile on yourself stored and never answer the abuser back if they would email you. If they are eager enough, they could track you down by impersonating you on the phone to the online service provider and obtain your personal information. Remember, you may have been together for a while so the abuser may know or have record of your Social Security Number, dates of birth, usual passwords you liked, etc. Yes, your life will need to change somewhat. Let your employer know of the situation so that they may not give out private information on your whereabouts to anyone, and I mean anyone! Always be alert to your surrounding at all times and have friends around you when you are out.
Safety is the key in this extreme situation. So plan ahead, dont act hastily. Mistakes will be made that way.
Herbal Supplements
Peoples viewpoint on healthcare and treatments have changed dramatically over the last few years. 29

Homeopathic and Eastern Medicine have taken over many peoples way of treating ailments. Each type of medicine, Eastern, Western, and Homeopathic, has its place. All in the right time and for the situation at hand. Some though need to understand that our medicines are derived from many herbs, plants and roots. This may cause an overdose if they are taking the supplements along with prescribed medications. We have put together a variety of Herbal Supplements that you may encounter in the field. In our assessment, we need to ask, on top of everything else, are you taking any herbal supplements? As for Eastern Medicine, many herbs are put together to formulate a treatment that helps that person. Many of these carry Chinese names so we may not be able to find out what they are for until the Doctor they see is contacted and explained the situation. We have provided several herbal supplements for your reference. This is a general look and in no way is intended to make you an expert in herbal therapy or recommend treatment. This is intended to expand your knowledge of what our patients are doing and what we need to be made aware of. Many references we derived from www.botanical.com and Quick study guide.
Angelica Medicinal Action and Uses---The root stalks, leaves and fruit possess carminative, stimulant, diaphoretic, stomache, tonic and expectorant properties, which are strongest in the fruit, though the whole plant has the same virtues. Angelica is a good remedy for colds, coughs, pleurisy, wind, colic, rheumatism and diseases of the urinary organs, though it should not be given to patients who have a tendency towards diabetes, as it causes an increase of sugar in the urine. It is generally used as a stimulating expectorant, combined with other expectorants the action of which is facilitated, and to a large extent diffused, through the whole of the pulmonary region. It is a useful agent for feverish conditions, acting as a diaphoretic.
Black Cohosh ---Medicinal Action and Uses---Astringent, emmenagogue, diuretic, alterative, expectorant. The root of this plant is much used in America in many disorders, and is supposed to be an antidote against poison and the bite of the rattlesnake. The fresh root, dug in October, is used to make a tincture. In small doses, it is useful in children's diarrhoea. In the paroxyms of consumption, it gives relief by allaying the cough, reducing the rapidity of the pulse and inducing perspiration. In whoopingcough, it proves very effective. The infusion and decoction have been given with success in rheumatism.
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In infantile disorders, it is given in the form of syrup. It is said to be a specific in St. Vitus' Dance of children. Overdoses produce nausea and vomiting. May affect diabetes B/P meds, and estrogen therapy.
Echinacea ---Medicinal Action and Uses---Echinacea increases bodily resistance to infection and is used for boils, erysipelas, septicaemia, cancer, syphilis and other impurities of the blood, its action being antiseptic. It has also useful properties as a strong alterative and aphrodisiac. As an injection, the extract has been used for haemorrhoids and a tincture of the fresh root has been found beneficial in diphtheria and putrid fevers. Should not be used by those with AIDS, TB, MS, leucosis, collagenoses or severe allergies.
Feverfew ---Medicinal Action and Uses---Aperient, carminative, bitter. As a stimulant it is usefulas an emmenagogue. Is also employed in hysterical complaints, nervousness and lowness of spirits, and is a general tonic. The cold infusion is made from 1 OZ. of the herb to a pint of boiling water, allowed to cool, and taken frequently in doses of half a teacupful. A decoction with sugar or honey is said to be good for coughs, wheezing and difficult breathing. The herb, bruised and heated, or fried with a little wine and oil, has been employed as a warm external application for wind and colic. A tincture made from Feverfew and applied locally immediately relieves the pain and swelling caused by bites of insects and vermin. It is said that if two teaspoonfuls of tincture are mixed with 1/2 pint of cold water, and all parts of the body likely to be exposed to the bites of insects are freely sponged with it, they will remain unassailable. A tincture of the leaves of the true Chamomile and of the German Chamomile will have the same effect. Planted round dwellings, it is said to purify the atmosphere and ward off disease. An infusion of the flowers, made with boiling water and allowed to become cold, will allay any distressing sensitiveness to pain in a highly nervous subject, and will afford relief to the face-ache or earache of a dyspeptic or rheumatic person. May interact with thrombotic meds, Asprin and warfarin.
Foxglove
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---Medicinal Action and Uses---Digitalis has been used from early times in heart cases. It increases the activity of all forms of muscle tissue, but more especially that of the heart and arterioles, the all-important property of the drug being its action on the circulation. The first consequence of its absorption is a contraction of the heart and arteries, causing a very high rise in the blood pressure. After the taking of a moderate dose, the pulse is markedly slowed. Digitalis also causes an irregular pulse to become regular. Added to the greater force of cardiac contraction is a permanent tonic contraction of the organ, so that its internal capacity is reduced, which is a beneficial effect in cases of cardiac dilatation, and it improves the nutrition of the heart by increasing the amount of blood. In ordinary conditions it takes about twelve hours or more before its effects on the heart muscle is appreciated, and it must thus always be combined with other remedies to tide the patient over this period and never prescribed in large doses at first, as some patients are unable to take it, the drug being apt to cause considerable digestive disturbances, varying in different cases. This action is probably due to the Digitonin, an undesirable constituent. The action of the drug on the kidneys is of importance only second to its action on the circulation. In small or moderate doses, it is a powerful diuretic and a valuable remedy in dropsy, especially when this is connected with affections of the heart. It has also been employed in the treatment of internal haemorrhage, in inflammatory diseases, in delirium tremens, in epilepsy, in acute mania and various other diseases, with real or supposed benefits. The action of Digitalis in all the forms in which it is administered should be carefully watched, and when given over a prolonged period it should be employed with caution, as it is liable to accumulate in the system and to manifest its presence all at once by its poisonous action, indicated by the pulse becoming irregular, the blood-pressure low and gastro-intestinal irritation setting in. The constant use of Digitalis, also, by increasing the activity of the heart, leads to hypertrophy of that organ. Digitalis is an excellent antidote in Aconite poisoning, given as a hypodermic injection. When Digitalis fails to act on the heart as desired, Lily-of-the-Valley may be substituted and will often be found of service. In large doses, the action of Digitalis on the circulation will cause various cerebral symptoms, such as seeing all objects blue, and various other disturbances of the special senses. In cases of poisoning by Digitalis, with a very slow and irregular pulse, the administration of Atropine is generally all that is necessary. In the more severe cases, with the very rapid heart-beat,
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the stomach pump must be used, and drugs may be used which depress and diminish the irritability of the heart, such as chloral and chloroform. Ginger ---Medicinal Action and Uses---Stimulant, carminative, diuretic, diaphoretic. Used in chronic chest complaints, dropsy with albuminaria, painful spasms of bowels and stomach. Anti-inflammatory. Should not be used in morning sickness due to its cholagogic, promoting flow of bile, and in patients with gallstones. May alter cardiac, antidiabetic and anticoagulant drugs. May cause heartburn if used in excess.
Aloe Vera Wound healing, sunburns, minor skin irritations. Oral consumption assist with constipation, peptic ulcers, diabetes, and asthma. Should not be used in patients with intestinal obstruction, acute inflamed intestinal disease, appendicitis, and children under 12. Long oral intake may cause electrolyte depletion. Rare dermatitis has been noticed in patients.
Bilberry ---Medicinal Action and Uses---The leaves can be used in the same way as those of UvaUrsi. The fruits are astringent, and are especially valuable in diarrhoea and dysentery, in the form of syrup. The ancients used them largely, and Dioscorides spoke highly of them. They are also used for discharges, and as antigalactagogues. A decoction of the leaves or bark of the root may be used as a local application to ulcers, and in ulceration of the mouth and throat. The fruit is helpful in scurvy and urinary complaints, and when bruised with the roots and steeped in gin has diuretic properties valuable in dropsy and gravel. A tea made of the leaves is also a remedy for diabetes if taken for a prolonged period. Avoid exposure to UV light. Chamomile Antispasmodic, diuretic, anti-inflammatory, calmative
Ephedra Sinica (Ma-huang)

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Cardiac stimulant. Has been known to cause death, anxiety, high BP, plus many other difficulties.
Garlic ---Medicinal Action and Uses---Diaphoretic, diuretic, expectorant, stimulant. Many marvellous effects and healing powers have been ascribed to Garlic. It possesses stimulant and stomachic properties in addition to its other virtues. As an antiseptic, its use has long been recognized. In the late war it was widely employed in the control of suppuration in wounds. The raw juice is expressed, diluted with water, and put on swabs of sterilized Sphagnum moss, which are applied to the wound. Where this treatment has been given, it has been proved that there have been no septic results, and the lives of thousands of men have been saved by its use. It is sometimes externally applied in ointments and lotions, and as an antiseptic, to disperse hard swellings, also pounded and employed as a poultice for scrofulous sores. It is said to prevent anthrax in cattle, being largely used for the purpose. In olden days, Garlic was employed as a specific for leprosy. It was also believed that it had most beneficial results in cases of smallpox, if cut small and applied to the soles of the feet in a linen cloth, renewed daily. It formed the principal ingredient in the 'Four Thieves' Vinegar,' which was adapted so successfully at Marseilles for protection against the plague when it prevailed there in 1722. This originated, it is said, with four thieves who confessed, that whilst protected by the liberal use of aromatic vinegar during the plague, they plundered the dead bodies of its victims with complete security. It is stated that during an outbreak of infectious fever in certain poor quarters of London, early last century, the French priests who constantly used Garlic in all their dishes, visited the worst cases with impunity, whilst the English clergy caught the infection, and in many instances fell victims to the disease. Syrup of Garlic is an invaluable medicine for asthma, hoarseness, coughs, difficulty of breathing, and most other disorders of the lungs, being of particular virtue in chronic bronchitis, on account of its powers of promoting expectoration. It is made by pouring a quart of water, boiled hot, upon a pound of the fresh root, cut into slices, and allowed to stand in a closed vessel for twelve hours, sugar then being added to make it of the consistency of syrup. Vinegar and honey greatly improve this syrup as a medicine. A little caraway and sweet fennel seed bruised and boiled for a short time in the vinegar before it is added to the Garlic, will cover the pungent smell of the latter.
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A remedy for asthma, that was formerly most popular, is a syrup of Garlic, made by boiling the bulbs till soft and adding an equal quantity of vinegar to the water in which they have been boiled, and then sugared and boiled down to a syrup. The syrup is then poured over the boiled bulbs, which have been allowed to dry meanwhile, and kept in a jar. Each morning a bulb or two is to be taken, with a spoonful of the syrup. Syrup made by melting 1 1/2 OZ. of lump sugar in 1 OZ. of the raw expressed juice may be given to children in cases of coughs without inflammation. The successful treatment of tubercular consumption by Garlic has been recorded, the freshly expressed juice, diluted with equal quantities of water, or dilute spirit of wine, being inhaled antiseptically. Bruised and mixed with lard, it has been proved to relieve whooping-cough if rubbed on the chest and between the shoulder-blades. An infusion of the bruised bulbs, given before and after every meal, has been considered of good effect in epilepsy. A clove or two of Garlic, pounded with honey and taken two or three nights successively, is good in rheumatism. Garlic has also been employed with advantage in dropsy, removing the water which may already have collected and preventing its future accumulation. It is stated that some dropsies have been cured by it alone. If sniffed into the nostrils, it will revive a hysterical sufferer. Amongst physiological results, it is reported that Garlic makes the eye retina more sensitive and less able to bear strong light. The juice of Garlic, and milk of Garlic made by boiling the bruised bulbs in milk is used as a vermifuge.
Ginkgo Biloba Used for Organic Brain Syndrome, leg weakness and vertigo. Some have had mild GI complaints.
Golden Seal Antibiotic, anti-inflammatory and astringent properties when applied topically. Promotes glandular function and helps prevent colds and flu. High doses can lead to vomiting, shortness of breath, bradycardia, and possible paralysis. Not be used for long periods or when pregnant. Extended use can lead to hallucinations, constipation, excitatory states, and digestive disorders. Grapeseed Extract
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Assist in circulatory dysfunction. No known problems.
Hawthorne Increases coronary blood flow, used in mild cardiac insufficiency, senile heart and chronic corpulmonale. Not to be used while breast feeding, during pregnancy or patients that are taking HTN or CHF medications. Licorice Used for upper respiratory tract infections; gastric and duodenal ulcers. Not to be used in chronic hepatitis, cirrhosis, renal problems, hypertonia, hypokalemia, pregnancy and nursing mothers. High doses can lead to excess sodium in the blood, edema, HTN, and cardiac problems.
Panax ginseng Protects against physical and mental stress. Large overdosing can bring on sleeplessness, edema and hypertonia.
Saw Palmetto Helps with Urination problems in benign prostate hyperplasia. Rare cases of stomach problems have been reported.
Uva Ursi Treats disorders of the urinary tract. Should not be taken by pregnant or nursing mothers or children under 12. Nausea or vomiting may occur in those with a sensitive stomach.
Gotu Kola Anti-inflammatory, diuretic, CNS depressant, laxative. Has helped children to increase mental capacity with known mental disabilities. Do not take in known cases of Epilepsy, pregnancy, breast-feeding. May interact with heparin.
Green Tea
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Stomach disorders, vomiting, diarrhea, atherosclerosis, hypertension, hypercholesterolemia. Reduces platelet aggregation. May prevent stomach cancer. Excessive use may cause nervousness, anxiety, insomnia, and irritability.
Kava-Kava Anti-anxiety, sedative, antispasmodic, anti-convulsant. Should not be taken in cases of depression since Kava-Kava may increase the chance of suicide. May manifest a yellowing of the skin, enlarged pupils, or GI disturbances.
Milk Thistle Taken for toxic liver damage and supports in liver disease. No complications known.
St. John Wart Taken for anxiety, depression, nervousness, post therapy of acute and contused injuries. Also, for dyspeptic complaints. Not to be taken with other anti-depressants.
Siberian Ginseng Taken for fatigue and failing concentration. Not to be used if HTN is present. Not to be used for long periods. Valerian
Used in restlessness, sleep disorders, mental strain, lack of concentration, nervousness, cardiomyopathy, nervous stomach and headache. Has caused rare GI complaints and with long term use, causes the situations it is designed to help with.
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Refresher Evaluation Form 2006 You may include this in your returned packet or mail it separately to: EEI 1750 N University Dr #227 Coral Springs, FL 33071. Your return address on the envelope may be omitted
Did the course content meet your expectations?
Was the course beneficial to you? Please explain.
What, if anything, would you like to see added and/or improved?
Additional Comments:
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EMT-B and Paramedic Refresher Worksheets
2010 NAME________________________________ EMT _______ Cert #______________ PARAMEDIC ______ Cert #__________ NATIONAL _______ Cert #___________
FULL ADDRESS____________________________________________________________________________ PHONE_________________________________ Email Address_______________________________ Be detailed and specific in your responses. Quick answers will be returned. Please type your answers or print them so that it can be read. Thank you. 1) What is BSI?
2) What articles are included in your BSI?
3) What is involved in Quality Improvement?
4) Define proper lifting techniques that should be used.
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5) What precautions are needed when carrying a patient?
6) Define some stressful situations that may produce stress on me.
7) List some warning signs of stress.
8) What can we do to promote less stress and health?
9) What is CISD?
40
10) Define expressed and implied consent and what situations would this occur?
11) Define confidentiality and how we assist in this manner.
12) Under what conditions can a patient refuse care?
41
13) Define a DNR and what must you do to assure is proper application?
14) What are some signs of abuse and neglect?
15) How do we go about reporting the abuse or neglect?
16) Define proper suctioning techniques.
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17) Define artificial ventilation techniques.
18) Describe the use and proper application of an Oropharyngeal airway.
19) Describe the use and proper application for a Nasopharyngeal airway.
20) What methods do we have to deliver O2 and define its proper application method(s)
21) What is involved in a Scene Size-up? 43
22) What is obtained in an initial assessment?
23) What does AVPU mean?
24) In assessing breathing, what are you looking for?
25) In assessing circulation what are you observing? 44
26) In assessing the skin what are you looking for?
27) List and define priority patients?
28) Define DCAP BLS and what application is it being used in? 45
29) Define SAMPLE.
30) Define OPQRST.
31) What is involved in a Detailed (secondary) Exam? Be specific from head-to-toe! 46
32) What is involved in the verbal report?
33) What interpersonal communication skills can be applied?
34) Write a full SOAP or Narrative report on a call you may have recently run. If you have made no run recently, make a scenario up. Then justify your treatment and actions as if I was the Medical Director.
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35) What can happen in the falsification of a report?
36) Explain how the Epi-injector pen used and for what purpose?
37) Name all forms that medications come in.
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38) Define the terms: dose, administration, actions, and side effects.
39) What signs and symptoms are there for breathing difficulties?
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40) Define how an inhaler is to be used and for what purpose?
41) What is an AED?
42) In what patients can an AED not be used?
43) What questions should be asked of a cardiac patient feeling pain or discomfort?
44) What types of AEDs are available?
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45) What rhythms will the AED defibrillate in?
46) Do you have to stop CPR or the Unit to use the AED? Explain your answer.
47) What is Nitroglycerin and how is it used?
48) Give and describe causes of an Altered Mental Status.
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49) How do we care for a diabetic patient? Be specific.
50) What is an allergic reaction and what sign and symptoms will a patient have?
51) How may we treat the patient in question 50?
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52) List and define the different areas of poisoning? Be specific.
53) What are the risk factors for suicide?
54) How can we effectively calm and assess a mentally disturbed patient?
55) Define Shock and list its signs and symptoms.
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56) How do we care for an: Open Chest Wound?
57) Open Abdominal Wound
58) Amputation(s)
59) Bones and joints
60) Head and spine 54
61) What is rapid extrication?
62) Define what a normal delivery is.
63) How much bleeding may be acceptable during a normal delivery?
64) Define the APGAR score.
65) What care does a newborn require?
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66) How would you care for a Prolapsed Cord situation? Be specific.
67) What is a Breech Birth and how can we care for it?
68) How do we care for a limb presentation?
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69) What is Meconium and what precautions must we take?
70) What is Croup and how do we care for it?
71) What is Epiglottis and how do we care for it?
72) What may cause seizures in children? How do we care for them?
73) What items may cause shock in a child?
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74) What types of trauma may a child experience?
75) What area is usually affected on a child experiencing trauma?
76) How can injuries be prevented?
Please define these areas of research

77) Define the Rules of 9 in burn patients? Adult, Child, and Infant.
78) Give the proper procedures of CPR for Adult, Child, and Infant. 58
79) What areas do most ambulance accidents occur in and how can we prevent them?
80) How can we educate the public?
81) What is professionalism and how can we enhance it?
82) For Florida certified personnel, please tell me what Rule 64J-1 is and what does it do for EMS. You may do research on this from the Florida Bureau of EMS site at www.fl-ems.com.
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83) For Florida Paramedics: What does FL. Statue 401 do for EMS? Hint: Look at FS 401.
84) For NON-Florida certified personnel, please tell me what laws govern your state. Please name the statue number.
85) Provide a brief history of Bio-Terrorism.
86) Please name the Bio agents that present a problem and what symptoms they show.
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87) How can we assist in the prevention of Domestic Terrorism?
88) What may be some factors that cause Domestic Violence?
89) What factors may make it difficult for the one being abused to leave?
90) In what case of DV may counseling show most productive and why?
91) Which cases in DV have poor outcomes?
92) Briefly, what should the one being abused do if they consider leaving the abuser?
93) What drug comes from Foxglove?
94) What herbal supplements affect cardiac function? 61
95) If a patient is on an anti-depressant, what herb should NOT be taken?
96) What herb can be taken orally and applied to the skin that promotes healing?
97) What herb acts as an antibiotic?
98) What herbs help in brain function?
99) Describe how medication errors occur:
100)
What is t he purpose of FAPEP? Go to www.fapep.org
101)
What is the purpose of NAEMT? www.naemt.org
102)
What programs does the NAEMT offer?
103)
What does ITLS do? www.itrauma.org 62
Multiple Choice Questions: Circle your best answer. If you are doing this on your computer, please place an X by the answer of your choice.
Paramedic Refresher 2010 Name: Date: 1. In the context of cardiac compromise, syncope occurs due to: A) an increase in vagal tone. B) a drop in cerebral perfusion. C) a sudden cardiac dysrhythmia. D) an acute increase in heart rate. 2. An accelerated idioventricular rhythm is characterized by all of the following, EXCEPT: A) QRS complexes greater than 0.12 seconds in duration. B) irregular R-R intervals and a rate less than 40 beats/min. C) wide QRS complexes with P waves buried in the T waves. D) regular R-R intervals and a rate between 40 and 100 beats/min.
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3. Levine sign is MOST accurately defined as: A) pushing on the sternum with the fingertips. B) rubbing the arm to which pain is radiating. C) a subconsciously clenched fist over the chest. D) a state of denial in patients with an acute MI. 4. With regard to stroke volume, the healthy heart: A) has a relatively fixed stroke volume. B) has an average stroke volume of 40 mL. C) can double stroke volume if demand is high. D) can easily increase stroke volume by 50%. 5. You respond to the residence of a known heroin abuser. The patient, a 30-year-old man, is unconscious and unresponsive. His is hypoventilating, bradycardic, and hypotensive. Administration of up to 10 mg of naloxone has had no effect, and your transport time to the hospital is approximately 30 minutes. You should: A) check his blood glucose level as your partner prepares to intubate. B) transport at once and administer additional naloxone while en route. C) administer 25 g of 50% dextrose and reassess his level of consciousness. D) hyperventilate him with high-flow oxygen to minimize tissue hypoxia.
6. A neoplasm is MOST accurately defined as a: A) normal cell. B) new growth. C) damaged cell. D) cancerous tumor.
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7. Unlike exocrine glands, endocrine glands: A) do not affect the rate of cellular metabolism. B) release chemicals directly into the bloodstream. C) have ducts that carry their secretions into a body cavity. D) produce chemicals that work faster than the nervous system. 8. Unlike hypothyroidism, hyperthyroidism: A) results in a decreased cardiac output. B) causes a decrease in the metabolic rate. C) causes an increase in oxygen demand. D) often results in acute myxedema coma. 9. The primary treatment for hypotension secondary to anaphylaxis is: A) epinephrine. B) diphenhydramine. C) isotonic crystalloid. D) a dopamine infusion. 10. Early clinical manifestations of an allergic reaction include all of the following, A ) pruritis. B ) stridor. C ) urticaria. D ) coughing. 11. A patient with a positive tilt test: A) often requires atropine. B) is severely hypotensive. C) may faint upon standing. D) has intra-abdominal bleeding. 12. The conversion of glycogen to glucose occurs in the: A ) bl ood . B) liver. C ) spl een. D) Pancreas EXCEPT:
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13. It is MOST important for the paramedic to consult with medical control prior to administering analgesia to a patient with severe flank pain and suspected acute renal failure because:
A) B) C) D)
patients with renal failure often require high doses of analgesia. renal failure may cause analgesics to accumulate to toxic levels. most patients who are given analgesia will experience hypotension. analgesia will mask the patient's pain and skew further examination.
14. A 70-year-old female dialysis patient presents with a headache. She is conscious and alert, has a blood pressure of 190/100 mm Hg, a pulse rate of 90 beats/min and regular, and respirations of 14 breaths/min and regular. In addition to administering supplemental oxygen, you should: A) recognize that she probably received an overaggressive dialysis treatment. B) start an IV line with normal saline and infuse 200 mL of normal saline per hour. C) transport at once, start an IV line en route, and give nitroglycerin to lower her blood pressure. D) monitor her cardiac rhythm, transport, and start an IV line en route to the hospital.
15. Severe salicylate toxicity produces: A) bradypnea. B) metabolic acidosis. C) increased pH levels. D) respiratory acidosis. 16. Fluid-refractory hypotension following a barbiturate overdose is treated MOST effectively with: A) dopamine. B) naloxone. C) atropine. D) calcium.
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17. In which of the following situations would a transfusion reaction MOST likely occur? A) A person with type AB blood receives type 0 blood. B) A person with type 0 blood receives type AB blood. C) A person with type A-negative blood receives type 0 blood. D) A person with type B-positive blood receives type B-positive blood
18. Anemia would result from all of the following conditions, EXCEPT: A) acute blood loss. B) an increase in iron. C) chronic hemorrhage. D) erythrocyte hemolysis. 19. The MOST common symptom of frostbite is: A) localized edema. B) white, waxy skin. C) an altered sensation. D) cyanosis of the skin. 20. If a small amount of water is aspirated into the trachea during a submersion event: A) the victim asphyxiates, becomes profoundly acidotic, and dies. B) laryngospasm occurs and temporarily protects the lower airway. C) permanent laryngeal spasm occurs and requires cricothyrotomy. D) resulting hypoxemia causes the body to shift to aerobic metabolism.
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21. Following defibrillation of a 28-pound child with ventricular fibrillation, you should:
22. A child's vocal cords can be difficult to visualize during intubation because:
A) B) C) D)
the epiglottis is floppy and U-shaped. the cords themselves are more posterior. a sniffing position is difficult to achieve. the area of the cricoid cartilage is narrow.
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23. To ensure that an infant's head is in a neutral position during spinal immobilization, you should: A) provide slight extension of his or her head. B) place padding under the infant's shoulders. C) place a towel roll behind the infant's neck. D) use towel rolls for lateral head stabilization. 24. When assessing and caring for a 17-year-old gang member, it is MOST important to remember that he or she: A) must be separated from other gang members. B) generally desires the presence of a caregiver. C) typically boasts about the use of illicit drugs. D) may have a weapon and a reputation to earn. 25. Aging is a linear process, which means that: A) the older we get, the faster our bodies decline in function. B) the rate at which we lose functions does not increase with age. C) older people exhibit the cumulative results of a longer aging process. D) older adults experience decreased functions faster than younger adults.
26. Adverse drug reactions in elderly people are the result of: A) partial digestion secondary to delayed gastric emptying. B) changes in body composition and an increase in body water. C) changes in drug metabolism due to diminished hepatic function. D) increased drug elimination due to decreased antidiuretic hormone.
27. People who abuse their partner or spouse: A) were not victims of abuse as children. B) often become less violent with each ensuing attack. C) may use intimidation and threats to maintain control. D) demonstrate a lack of remorse following the attack.
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A) When suspected abuse is detected you should report it to the authorities 28. A) True B) False
29. When making initial contact with a mentally impaired patient, you should: A) immediately introduce yourself, your partner, and any other EMS personnel at the scene. B) have your team members remain at a distance until you can establish a rapport with the patient. C) recall that the patient will probably not be able to communicate his or her chief complaint effectively. D) approach the patient with at least two team members to immediately allay the patient's fear or anxiety. 30. Hypernasality would MOST likely be caused by conditions such as: A) cleft palate and enlarged adenoids. B) chronic laryngitis and cleft palate. C) laryngeal polyps and acute pharyngitis. D) enlarged polyps and laryngeal cancer.
31. Which of the following is LEAST suggestive of hearing impairment? A) An inability to speak B) Presence of hearing aids C) Poor word pronunciation D) Failure to respond to questions
32. Which of the following is an example of a speech production disorder?

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A) B) C) D) Dysarthria Hoarseness Stuttering Aphasia
33. When obtaining the peak flow reading of a patient following treatment for bronchospasm, you should: A) only document the third peak flow reading. B) obtain no more than 2 readings in a 30-minute period. C) ask the patient to take a deep breath through the nose. D) have the patient blow into the device for about 1 second. 34. Common side effects of chemotherapy include all of the following, EXCEPT: A) alopecia. B) leukopenia. C) polycythemia. D) thrombocytopenia. 35. In MOST ambulance collisions: A) the ambulance attempted to pass a vehicle on the left side but the vehicle suddenly swerved. B) the ambulance was not traveling in the proper lane or the operator was driving with excessive speed. C) the ambulance operator was under 21 years of age and the ambulance had a mechanical malfunction. D) studies found that less than 5% of ambulance operators were offered an emergency vehicle operator's course.
36. When landing a helicopter at night, you should: A) leave your headlights on to signify your location. B) avoid shining a spotlight up at the descending aircraft. C) place a single strobe light in the center of the landing zone. D) refrain from parking the ambulance under overhead wires.
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37. According to the JumpSTART triage system for pediatric patients, infants or children not developed enough to walk or follow commands should be: A) quickly moved to a designated area of the triage section and monitored closely. B) taken to the treatment sector as soon as possible for immediate secondary triage. C) labeled with a red tag and transported immediately to a pediatric trauma center. D) assigned the same triage category as the walking wounded and evaluated later.
38. The _______________ has the authority and responsibility to stop an emergency operation if he or she believes a rescuer is in danger. A) logistics chief B) rescue officer C) triage officer D) safety officer 39. Infection with the Ebola virus is characterized by: A) a progressive onset of high fever. B) internal and external hemorrhage. C) the formation of cutaneous blisters. D) paralysis of the respiratory muscles. 40. Which of the following statements regarding ricin is MOST correct? A) Ricin is five times more lethal than botulinum. B) Ricin is highly communicable only if it is inhaled. C) Calcium chloride is the preferred antidote for ricin. D) Ricin is extremely toxic by many routes of exposure. 41. A patient would MOST likely become trapped between the driver's seat and
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steering wheel following a: A) frontal crash. B) rollover crash. C) lateral collision. D) T-bone collision. 42. With regard to rescue, it is MOST important for the paramedic to be able to: A) have an advanced working knowledge of a wide variety of rescue equipment, such as the Jaws of Life. B) be trained well enough to be able to coordinate a rescue effort and function as the incident commander. C) understand and identify potential hazards and determine whether it is safe to gain access to the patient. D) quickly recognize a rapidly deteriorating situation so that the paramedic can relocate bystanders to a place of safety.
43. Prior to accepting a patient who has been decontaminated by the hazardous materials team, the paramedic must: A) make contact with the receiving medical facility. B) be informed about the degree of decontamination. C) receive a verbal report about the material involved. D) don the appropriate personal protective equipment. 44. Triage and emergency medical treatment should be performed: A) in the hot zone. B) in the cold zone. C) in the warm zone. D) at least 100 feet from the incident.
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45. You receive a call to a residence in a rural area of your jurisdiction for a patient with an acute COPD exacerbation. Upon arriving at the scene, you knock on the door and identify yourself. The patient, an elderly-sounding man, tells you that you took too long to get to him, and that he has a shotgun. You should: A) look inside a nearby window to see if he really does have a gun. B) immediately retreat to the ambulance and notify law enforcement. C) advise the patient that you got to the scene as quickly as possible. D) stay at a safe distance from the door and ask the man to walk outside.
46. If you are under fire from a sniper who is on the roof a building, and you are using a vehicle as cover, the MOST effective way of protecting yourself is to: A) break out one of the side windows, crawl into the vehicle, and lay prone across the front seat. B) position yourself next to the front wheel so that the engine block and tire can both protect you. C) crawl under the vehicle, in between the tires, but avoid the area of the vehicle near the gas tank. D) crouch down in between the wheels of the vehicle in order to make yourself as small a target as possible.
47. Which of the following statements regarding cold water submersion is NOT correct? A) Water that is colder than 70F will cause a marked increase in oxygen demand. B) The cold protective response secondary to hypothermia can protect vital organs.
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C) Patients submerged in cold water are often dehydrated secondary to cold diuresis. D) Bradycardia occurs after falling in cold water and lowers the basal metabolic rate.
48. The single MOST important process to ensure ongoing rescuer safety at a technical rescue incident is: A) the accountability system. B) assignment of a safety officer. C) mandated use of reflective vests. D) the presence of law enforcement. 49. The recommended IV dose and concentration of epinephrine for the newborn is: A) 0.01 mg/kg; 1:1,000. B) 0.3 to 1 mL/kg: 1:10,000. C) 0.01 to 0.03 mg/kg; 1:1,000. D) 0.1 to 0.3 mL/kg; 1:10,000. 50. During your assessment of a 30-year-old woman in active labor, she admits to being a chronic heroin abuser and states that she last "shot up" about 6 hours ago. After the baby delivers, you will MOST likely need to: A) give positive-pressure ventilations. B) administer 0.1 mg/kg of naloxone. C) suction meconium from its airway. D) administer free-flow oxygen by mask. 51. The MOST common risk factor for the development of type 2 diabetes in people over 65 years of age is: A) poor dietary habits and a sedentary lifestyle. B) frequent infections that do not heal properly. C) hypertension of longer than 5 years duration. D) the presence of more than one chronic disease.
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52. The relatively high use of nonsteroidal anti-inflammatory drugs by older patients predisposes them to: A) constipation. B) cholelithiasis. C) mesenteric ischemia. D) peptic ulcer disease. 53. The goal of doing the greatest good for the greatest number of people mandates that: A) life-threatening injuries should be treated during the triage phase. B) there should be one triage officer for every 10 victims of a disaster. C) triage assessment is brief and patient condition categories are basic. D) every victim should receive a detailed physical exam during triage.
54. During an incident involving an explosion, you determine that two critically injured patients should be transported to a trauma center by air. After stabilizing the patients' conditions to the best of your ability, you should: A) call the receiving trauma center and update them on the patients' conditions. B) contact the incident commander and request permission to utilize air transport. C) request air transport immediately and determine where you will land the helicopter. D) notify the transportation officer and request that he or she establish a landing zone. 55. Pain receptors are found in all of the following locations, EXCEPT the: A) j oi nt s. B) brain. C) musculature. D) visceral organs.
56. When a patient is receiving treatment with continuous positive airway pressure (CPAP), he or she: A) must be placed in a supine position. B) should experience a decreased tidal volume. C) should be encouraged to ambulate if possible.
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D) typically finds it difficult to exhale completely.
57. A third-service EMS system is one in which: A) a public agency not affiliated with the fire department provides EMS service. B) an EMS ambulance is housed in a fire department and is staffed by EMTBs. C) first responders from a fire department assist the ambulance on every EMS call. D) a privately owned ambulance service works in tandem with a public EMS system. 58. The MOST important factor to consider when determining if transport of a trauma patient via helicopter is appropriate is: A) the patient's hemodynamic status. B) delays in ground transport due to traffic. C) the injury mechanism that was involved. D) the need for definitive airway management. 59. When attempting resuscitation of a child with pulseless electrical activity (PEA), you should: A) administer epinephrine via the ET tube if possible. B) attempt to identify an underlying cause of the arrest. C) perform synchronized cardioversion if the rate is fast. D) give atropine if the heart rate is less than 60 beats/min.
60. The general area of a child's body that sustains initial trauma after being struck by an automobile depends MAINLY on: A) the child's height and the height of the bumper upon impact. B) the speed at which the vehicle was traveling and the child's weight. C) whether the child turns away from or toward the vehicle.
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61. You arrive at a convenience store to find a middle-aged male in cardiac arrest. Your protocols provide for standing orders in this type of scenario. This means that you should: A) contact medical control before providing advanced level care. B) perform certain interventions prior to contacting medical control. C) begin CPR and then contact medical control for further direction. D) pronounce the patient dead if there is no response after 10 minutes.
62. The LEAST preferable and reliable method of selecting people to participate in a research study is: A) random sampling. B) systematic sampling. C) convenience sampling. D) alternative time sampling. 63. Negative or injurious stress is also called: A) distress. B) eustress. C) projected stress. D) redirected stress. 64. Which of the following is NOT an example of a passive injury prevention intervention? A) The manufacture of child-resistant bottles B) Providing public education on the use of AEDs C) The use of softer materials for playground surfaces D) Installing sprinkler systems in commercial buildings
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65. The BEST way for a paramedic to evaluate a patient's decision-making capacity is for the paramedic to: A) determine if the patient knows what care is appropriate for the situation. B) talk to the patient to determine if he or she understands what is happening. C) confirm that the patient is at least 18 years of age or otherwise emancipated. D) ensure that pulse oximetry and blood glucose readings are within normal limits
66. Health care powers of attorney are also called "durable" powers of attorney because they: A) must be in the patient's possession at all times. B) can only be revoked by the patient's personal physician. C) remain in effect once a patient loses decision-making capacity. D) do not require anyone to make decisions on the patient's behalf. 67. Groups of cells form: A) tissues. B) organs. C) an organism. D) organ systems. 68. In order to relieve the bronchospasm associated with an acute asthma attack, the paramedic would give a/an: A) alpha-1 agonist. B) beta-2 agonist. C) beta-1 agonist. D) alpha-2 agonist. 69. An unconscious 4-year-old child with a blood glucose reading of 30 mg/dL requires 2 mL/kg of 50% dextrose (Dso). The child's estimated weight is 35 pounds. You have a prefilled syringe of Dso at a concentration of 25 g/50 mL How many grams of dextrose will you administer to the child? A) 12,400
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B) C) D) 13,800 14,000 16,000
70. In general, normal psychosocial factors that affect the life of a 35-year-old person include all of the following, EXCEPT: A) wo r k . B) st r e ss. C) family. D) anxiety. 71. Which of the following is NOT an example of an open-ended question? A) "How did you feel when you awoke today?" B) "Is there anything you would like to discuss?" C) "Can you describe the pain you are feeling?" D) "Does the pain radiate to your arm or jaw?"
72. In which of the following conditions would you be LEAST likely to encounter pulsus paradoxus? A) Moderate asthma attack. B) Pericardial tamponade C) Tension pneumothorax D) Decompensating COPD 73. You will MOST likely make your field diagnosis of a patient based on the: A) medications the patient is taking. B) chief complaint and patient history. C) results of your detailed physical exam. D) patient's perception of his or her problem. 74. Asymmetry of the pupils: A) is a normal finding in up to 40% of the population. B) indicates a significant ocular or neurologic pathology. C) is normal when a light is shined into one of the pupils. D) must be assessed in the context of the patient's overall presentation. 75. When the blood vessels supplying the skin are fully dilated, the skin becomes: A) cool and pale. B) cold and moist. C) warm and pink.
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D) blue or mottled. 76. Comments such as "I can't believe you called EMS for this!": A) show a lack of compassion and interest in providing the best possible care. B) demonstrate an illegal act for which the paramedic will be held accountable. C) are commonly made by paramedics with less than 5 years of field experience. D) are typically ignored by the patient because he or she is frightened at the time. 77. When documenting a statement made by the patient or others at the scene, you should: A) document the exact time that the statement was made. B) include the statement in an addendum to your run report. C) translate the statement into appropriate medical terminology. D) place the exact statement in quotation marks in the narrative.
78. After addressing any life threats in the order in which you find them, you should next:
A) consider the worst case scenario that could be causing the patient's symptoms and either rule it out or rule it in. B) determine the most common and statistically probable cause for the patient's current signs and symptoms. C) formulate a working field diagnosis on the basis of what you discovered in the initial assessment of the patient. D) provide symptomatic care and promptly transport the patient to an appropriate medical treatment facility.
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79. Which of the following situations is MOST challenging with regard to your critical thinking and decision-making skills? A) A rigid abdomen and signs of shock B) An elderly patient with prolonged asystole C) A driver who passed out and then struck a tree D) Isolated tibia/fibula fracture from minor trauma 80. The patient care report (PCR): A) provides for a continuum of patient care upon arrival at the hospital. B) is a legal document and should provide a brief description of the patient. C) should include the paramedic's subjective findings or personal thoughts. D) is only held for a period of 24 months, after which it legally can be destroyed. 81. The law of conservation of energy states that: A) kinetic energy can only be converted to thermal or chemical energy. B) the force that an object can exert is the product of its mass multiplied by its acceleration. C) energy can neither be created nor destroyed, it can only change form. D) a body at rest will remain at rest unless acted upon by an outside force. 82. Unlike blunt trauma, penetrating trauma: A) is especially common during the primary blast injury following an explosion. B) often causes damage to a large body surface area, even from a single projectile. C) involves a disruption of the skin and underlying tissues in a small, focused area. D) is usually more fatal because of the severe external bleeding that accompanies it.
83. The MOST common cause of exogenous hypovolemic shock is: A) dehydration. B) external bleeding. C) diabetic ketoacidosis. D) plasma loss from burns. 84. A motorcycle rider struck a parked car and was catapulted over the handlebars of
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his bike. Your assessment reveals that he is tachypneic, diaphoretic, and tachycardic. There is no gross external bleeding present. What is the MOST likely cause of this patient's clinical presentation? A) Closed head injury B) Bilateral femur fractures C) Proximal upper extremity fractures D) Sympathetic nervous system failure 85. During the neovascularization phase of the wound healing process: A) new blood vessels form as the body attempts to bring oxygen and nutrients to the injured tissue. B) histamine makes the capillaries more permeable, resulting in swelling in and around the injury site. C) collagen provides stability to the damaged tissue and joins wound borders, thereby closing the open tissue. D) microscopic vasculature damaged by the injury is digested by macrophages through a process called phagocytosis.
86. During the secondary phase of a blast injury: A) the patient is thrown against a solid object. B) the pressure wave damages air-filled cavities. C) full-thickness flash burns occur to the body. D) flying shrapnel may cause penetrating injuries.
87. A 33-year-old man was burned when the hot water heater he was working on exploded. The patient has superficial and partial-thickness burns to his face, neck, and arms. Your initial assessment reveals that he is restless and tachypneic. His BP is 80/54 mm Hg and his heart rate is 120 beats/min and weak. You should: A) conclude that he is experiencing burn shock, start two large-bore IV lines of normal saline, and administer fluids based on the Parkland formula. B) assist his ventilations with a bag-mask device, cover him with a blanket, and start a large-bore IV of normal saline set at a keep vein open rate. C) apply oxygen via nonrebreathing mask, cover his burns with cold moist dressings, start an IV with normal saline and give up to 4 mg of morphine for pain. D) administer high-flow oxygen, keep him warm, start at least one large-bore IV of normal saline, and administer fluid boluses to maintain adequate perfusion.
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88. The application of ice to partial-thickness burns: A) often negates the need to administer a narcotic. B) is not necessary because such burns are painless. C) offers excellent pain relief and minimizes swelling. D) can exacerbate tissue injury and should be avoided. 89. Which of the following statements regarding a closed head injury is MOST correct? A) In a closed head injury, the dura mater remains intact. B) Diffuse brain injury occurs with all open head injuries. C) Closed head injuries are less common than open head injuries. D) Intracranial pressure is usually minimal in a closed head injury. 90. What part of the eye is MOST commonly injured following a thermal burn? A) Gl o b e B) Retina C) Cor nea D) Eye l i ds
91. The MOST significant complication associated with prolonged immobilization of a patient on a long backboard is: A) pressure lesion development. B) compression of the vena cava. C) increased intracranial pressure. D) patient discomfort and frustration. 92. Upon arriving at the scene of a motor vehicle crash, you find the driver of the car still seated in her two-door vehicle. The passenger side of the vehicle has sustained severe damage and is inaccessible. The driver is conscious and alert and complains only of lower back pain. The back seat passenger, a young child who was unrestrained, is bleeding from the head and appears to be unconscious. You should: A) ask the driver to step out of the vehicle so you can access the back seat passenger. B) rapidly extricate the driver so you can gain quick access to the child in the back seat. C) carefully assess the driver for occult injuries before removing her
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from the vehicle D) apply a vest-type extrication device to the driver and quickly remove her from the car.
93. As air accumulates in the pleural space, the FIRST thing to occur is: A) decreased pulmonary function. B) contralateral tracheal deviation. C) compression of the great vessels. D) marked decrease in venous return.
94. A convenience store clerk was stabbed during a robbery attempt. He is semiconscious with shallow breathing and weak radial pulses. During the rapid trauma assessment, you find a single stab wound to his left anterior chest. His jugular veins are distended and his breath sounds are bilaterally diminished but equal. The MOST appropriate treatment for this patient involves: A) performing bilateral needle thoracenteses, intubating the patient and ventilating at 10 to 12 breaths/min, and transporting him to a trauma center. B) administering oxygen via nonrebreathing mask, transporting at once, and placing an occlusive dressing over the stab wound if his oxygen saturation is low. C) assisting his ventilations, initiating transport, starting a large-bore IV line en route, and administering fluids to maintain a systolic BP of 100 mm Hg. D) covering the stab wound with an occlusive dressing, assisting ventilations, transporting at once, and establishing large-bore IV lines en route.
95. What membranous tissue functions as the point of attachment for the various abdominal organs? A) P l e u r a B) Mesentery C) Peritoneum D) Ligamentum arteriosum
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96. During the third collision in a motor vehicle crash: A) hollow abdominal organs rupture upon impact. B) the person's abdomen collides with the steering wheel. C) rapid deceleration propels an unrestrained person forward. D) abdominal organs shear from their points of attachment. 97. The joints that connect the ribs to the sternum are examples of: A) fused joints. B) fibrous joints. C) synovial joints. D) cartilaginous joints.
98. The appendicular skeleton is composed of the: A) bones of the spinal column, scapulae, and clavicles. B) bones of the upper extremities and the structures of the torso. C) pectoral girdle, pelvic girdle, and the bones of the extremities. D) thoracic ribs, cervical vertebrae, and the bones of the cranium.
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99. Which of the following general statements regarding trauma is MOST correct? A) Bullet impact is less if the energy in the bullet is applied to a small area. B) The position of the patient at the time of the event is considered to be an internal factor. C) Blunt trauma is difficult to diagnose by paramedics in the field and is often more lethal than penetrating trauma. D) Rapidly applied amounts of energy are better tolerated than a similar amount of energy applied over a longer period. 100. Following a head-on collision of a motorcycle and a truck, the motorcyclist would MOST likely experience initial injury to the: A) cervical spine. B) chest and abdomen. C) wrists and forearms.
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Identify the following EKG rhythms and give rate.
Ventricular Paced rhythm with an elevated ST segment Rate = 80 bpm
Ventricular Fibrillation (Fine) / Asystole
Rate = None
Atrial Flutter
Rate = 115
Sinus rhythm with multifocal PVCs
Rate = 80 bpm
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Sinus rhythm Rate = 80 bpm
Sinus rhythm with a 1st degree AV block.
Rate = 60 bpm
Atrial Fibrillation
Rate = 90 bpm (Irregular)
Sinus rhythm with a PAC
Rate = 80 bpm
Accelerated Junctional rhythm
Rate = 80 bpm
Sinus rhythm with PVCs
Rate = 80 bpm
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HIV / AIDS UPDATE
Emergency Educational Institute 9381 W Sample Rd Coral Springs, Fl. 33065 Todd Soard, NREMT-P, PH.D Director Joe Nelson, M.D. Medical Director
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HIV / AIDS
HIV is short for Human Immuno-deficiency Virus. Once infected with HIV, a person is referred to as HIV positive. However, this does not necessarily mean that (s)he has symptoms or feels sick. An HIV positive person can feel and look healthy for a long time after first becoming infected.
AIDS, or Acquired Immune Deficiency Syndrome, can take many years to develop. Eventually, the virus kills or impairs more and more cells in the immune system and the body loses the ability to fight off common infections, such as diarrhea or colds. People with AIDS can die from diseases that are usually not dangerous for people with healthy immune systems.
TRANSMISSION
In our time the first case of AIDS came about in 1981. Cases have grown throughout the years and much research has been done and is in progress. The spread of AIDS is channeled through unprotected sex, the sharing of needles for drug use and direct contact with body fluids of an infected person. The fluid must enter through an opening of your skin to have the potential on becoming infected. Needle sticks are of much concern to EMS personnel. The risk of getting HIV / AIDS is present but getting Hepatitis B is greater. Urine, tears, saliva and perspiration may have small amounts of the virus have not been found to transmit the disease. Blood transfusions and organ transplants are at risk of being a transmitter. Intercourse either vaginally or anal places the participants at a high risk of getting the HIV virus. Oral sex is less of a risk but if you have an open mouth sore or cut the risk increases. Hemophiliacs are at risk due to the amount of blood by products they use and transfusions. The blood source donated is screened to reduce the chances of infected blood getting. Nursing mothers who are infected pose a risk of passing the virus on to the infant.
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How HIV is NOT Transmitted

Through air or by coughing and sneezing Through food or water Through sweat and tears By sharing cups, plates, and utensils with an infected person By touching, hugging and kissing an infected person By sharing clothes or shaking hands with an infected person By sharing toilets and bathrooms with an infected person By living with an infected person By mosquitoes, fleas, or other insects
Who is more at risk?

Adolescents and young people Girls and young women Mobile populations People who use drugs Sex workers and their clients Social, sexual, ethnic, and religious minorities Street children and children who work
Numbers Infected Vital Statistics (Until.com, 2009) Worldwide:

Over 22 million people have died from AIDS. Over 42 million people are living with HIV/AIDS, and 74 percent of these infected people live in sub-Saharan Africa. Over 19 million women are living with HIV/AIDS. By the year 2010, five countries (Ethiopia, Nigeria, China, India, and Russia) with 40 percent of the world's population will add 50 to 75 million infected people to the worldwide pool of HIV disease.
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There are 14,000 new infections every day (95 percent in developing countries). HIV/AIDS is a "disease of young people" with half of the 5 million new infections each year occurring among people ages 15 to 24. The UN estimates that, currently, there are 14 million AIDS orphans and that by 2010 there will be 25 million.
United States:

An estimated one million people are currently living with HIV in the United States, with approximately 40,000 new infections occurring each year. 70 percent of these new infections occur in men and 30 percent occur in women. By race, 54 percent of the new infections in the United States occur among African Americans, and 64 percent of the new infections in women occur in African American women. 75 percent of the new infections in women are heterosexually transmitted. Half of all new infections in the United States occur in people 25 years of age or younger.
TESTING The process of looking for the antibodies that the body produces when a person becomes infected does testing. Usually a person who has become infected will show signs in the testing procedure 2 to 3 weeks after exposure. A higher number of people test positive after an exposure within 6 months. It is rare but must be noted that some people that have been exposed have not tested positive until two years later. Testing goes in an order of less expensive kits first. Then if an exposure is detected a more expensive test is done on the sample.
PREVENTION The best prevention is to abstain from sex. Protected sex should be used at all times. This goes even for those in the medical field. We do not have a special protection due to the fact we are a health care provider. Having one partner that we trust to be monogamous is of consideration. Drug use should not be a part of our lives and if we drink alcohol, do so in moderation. If our thinking is hindered so is our guard. Don't let your guard down and put yourself at risk of becoming infected. Be careful when handling patient and the use of needles. Use precautions to prevent needle sticks at any cost. Employees should consider Hep. A & B vaccines to prevent these diseases. 93

Another type of prevention is INFECTION CONTROL. Never forget to follow your universal precautions (BSI) and assume that any person you come in contact with may be infected. Following the guidelines set forth by your department or facility should be read and implicated on a daily basis. Cleaning with proper agents should be done all the time. Hand washing needs to be done even if gloves were worn. Eye protection and gowns should be worn if the situation calls for it.
CARE for those INFECTED
Ones who are infected are entitled to counseling. Counseling starts at the initial testing all the way through follow up care. Education is the key to handling the disease and many people do not know how to care for themselves in this case or how to extend their life by medications and a life style of eating properly. Early detection is always good. People though may not know they have the disease for some time so education is the key. Some key signs a patient who is infected may present the following: 1) Night sweats that are excessive. 2) Persistent infections. 3) Cancer of different types. 4) Fungal infections of the body in different areas. 5) Weight loss. These are just a few of the signs and symptoms a patient may encounter but are the most prominent.
THE LAW The Omnibus AIDS ACT was put in place here in Florida back in 1988. It covers how HIV affects the health care worker and what education requirements health care health care providers must meet. Testing is done by a testing site that falls in line with the 381.609 F.S. Testing is done at these sites as well as education and follow - up. The testing is confidential to the fullest. If a health care provider has had a confirmed exposure to a patient with HIV they have a right to see the infected patients files ONLY after the employer has legally obtained them. You must have a clear " need to know" to examine these files.
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Blood testing can be done on a patient that you have come in contact with and have had an exposure in two ways only. The blood from the patient was given voluntarily or the blood drawn was for some other reason during the emergency treatment. Non-medical persons, who may have rendered care, may have the same blood tested if they had an exposure but only from the blood drawn for the reasons stated already. In any case if an exposure and you are infected you have the right to counseling and follow up. You also may decline this counseling. It will be noted on your personnel chart not the patient chart. Under some circumstances, a physician may release the finding to a sexual partner. This is done only when the patient gives the names.
The Federal Rehabilitation Act states that AIDS is a handicap and persons with AIDS cannot be discriminated against in the workplace. For more information on Floridas view you may download a booklet at: http://www.doh.state.fl.us/Disease_ctrl/aids/legal/hartog.pdf
PATIENT CARE
We in the health care field always want to treat everyone with the most respect. HIV infected and AIDS patients are no exception. Special attention needs to given to them and we should not be judgmental. The person may of only acquired the disease from another partner they trusted or by a blood transfusion. ALL cases of 'NO FAULT" on their part. Confidentiality is a must. What ever the patient discloses to you should only be passed on to other medical personnel on a 'need to know" basis. Do not bring up names or locations of patients you have come in contact with. While notifying other of the patients condition, watch whom we are near and how loud we are speaking.
COUNSELING Counseling by law is to be confidential as well as all records. Mandatory testing of convicted prostitutes, convicted sexual offenders, federal prisoners, military personnel, those seeking immigration status, and donors of blood, sperm, bone, organs, and tissue is to be done. We in the health care field should encourage those at risk of HIV / AIDS to get tested and go for counseling and receive education on the disease. This plays a part of prevention to the public in which we all serve.
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Worksheet for HIV Course EEI, Inc

1. How is the HIV virus transmitted?
Unprotected sex, sharing of drug needles, other exposure to bodily fluids which make their way into the body.
2.
How is HIV NOT transmitted? What protection is needed on our part in the prevention of HIV/AIDS?
Through air or by coughing and sneezing Through food or water Through sweat and tears By sharing cups, plates, and utensils with an infected person By touching, hugging and kissing an infected person By sharing clothes or shaking hands with an infected person By sharing toilets and bathrooms with an infected person By living with an infected person By mosquitoes, fleas, or other insects
Practice safe sex, use caution when handling needles, practice universal precautions such as BSI, hand washing, eye protection, and gowns if necessary.
3.
What rights do the patients of HIV have? 96

Patients with HIV have the right to be respected, not discriminated against, and have their records remain confidential with certain limitations.
4.
What rights do medical personnel have?
Medical personnel have the right to access a patients records following an exposure, to have any blood taken from that patient tested, and to seek counseling if infected.
5.
What are the signs and symptoms of HIV?
1) Night sweats that are excessive. 2) Persistent infections. 3) Cancer of different types. 4) Fungal infections of the body in different areas. 5) Weight loss. 6. How can Healthcare workers become infected?
Exposure to bodily fluids, needle sticks, failure to utilize proper BSI precautions. 7. Healthcare workers are offered counseling if exposed. What privacy is extended to the employee?
Counseling and all records are to be held confidential by law. 8. To prevent other diseases, what vaccines should an employee have?
Hepatitus A and B Vaccines 9. What is the purpose of the CDC?
To monitor and control disease outbreaks, perform research, prevention, and public education in order to limit or prevent the spread of disease. 10. Please conduct research and quote current rates of the spread of HIV.
According to the CDCs website, more than 309 million people live in the U.S. and more than one million of those people are living with HIV (an estimated 1,106,400 adults and adolescents). The HIV transmission rate - the estimated annual number of new HIV infections per 100 persons living with HIV- has decreased over the past two decades.
97

o
Since the mid-1980s, the transmission rate declined approximately 89% (from 44 transmissions per 100 people with HIV in 1984 to 5 transmissions per 100 people in 2006).
HIV incidence the annual number of new HIV infections has decreased from an estimated high of about 130,000 new infections a year in 1985 to about 56,300 in 2006, despite there being more people every year living with HIV. Perinatal HIV infections those transmitted from mother to child have decreased from 1,000-2,000 per year in the early 1990s to an estimated 138 per year in 2004. HIV infections among injection drug users declined by approximately 80% between 1988 and 2006. The proportion of persons who know they are infected with HIV increased from 75% in 2003 to 79% in 2006. In October 2007, CDC launched the Expanded Testing Initiative. In two years,
o o
CDC grantees conducted nearly 1.4 million tests. 17,000 persons tested positive for HIV.
Of these, 10,500 individuals had no previous diagnosis of HIV. Nearly 6,500 of the 17,000 who tested positive had a previous diagnosis of HIV recorded in surveillance records. Yet many of these individuals were unaware of their diagnosis.
Of the more than 10,000 persons newly diagnosed with HIV, 86% received their positive HIV test result, 75% were successfully linked to medical care, and 78% were referred to partner services, so that their partners could be advised of their potential exposure to HIV and counseled to receive HIV testing.
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PARAMEDIC DRUG ADDENDUM

REFRESHER 2010 EEI,INC For the following drugs please list what action they have, the dose and route it may be administered and any contraindications they may have. Give your answer by ANY new guidelines you that are presently being used. The drugs listed are those we encounter in resuscitation of the patient and everyday use. ADENOSINE
CLASS: Antiarrhythmic ACTIONS: slows AV conduction INDICATIONS: symptomatic PSVT CONTRAINDICATIONS: second- or third-degree heart block, sick-sinus syndrome, known hypersensitivity to the drug. PRECAUTIONS: Arrhythmias, including blocks, are common at the time of cardioversion. Use with caution in patients with asthma. SIDE EFFECTS: Facial flushing, headache, shortness of breath, dizziness, and nausea. DOSAGE: 6 mg given as a rapid IV bolus over a 1-2 second period; if, after 1-2 minutes, cardioversion does not occur, administer a 12-mg dose over 1-2 seconds. ROUTES: IV; should be administered directly into a vein or into the medication administration port closest to the patient and followed by flushing of the line with IV fluid. PEDIATRIC DOSAGE: Safety in children has not been established.
ALBUTEROL 99

CLASS: Sympathomimetic (2 selective) ACTIONS: Bronchodilation INDICATIONS: Asthma reversible bronchospasm associated with COPD CONTRAINDICATIONS: Known hypersensitivity to the drug, symptomatic tachycardia PRECAUTIONS: Blood pressure, pulse, and EKG should be monitored use caution in patients with known heart disease SIDE EFFECTS: Palpitations, anxiety, headache, dizziness, and sweating DOSAGE: Metered Dose Inhaler: 1-2 sprays (90 micrograms per spray) Small-Volume Nebulizer: 0.5 ml (2.5 mg) in 2.5 ml normal saline over 5-15 minutes Rotohaler: one 200-microgram rotocap should be placed in the inhaler and breathed by the patient ROUTES: Inhalation PEDIATRIC DOSAGE: 0.15 mg (0.03 ml)/kg in 2.5 ml normal saline by small volume nebulizer
AMIODARONE
CLASS: Aniarrhythmic (Group III) ACTIONS: Prolongs action potential and refractory period Slows the sinus rate; Increases PR and QT intervals Decreases Peripheral vascular resistance INDICATIONS: Life-threatening cardiac arrhythmias such as ventricular tachycardia and ventricular fibrillation. CONTRAINDICATIONS: Severe sinus node dysfunction Sinus Bradycardia Second and Third Degree Block Hemodynamically significant bradycardia PRECAUTIONS: Heart Failure SIDE EFFECTS: Hypotension, Nausea, Anorexia, Malaise Fatigue, Tremors, Pulmonary toxicity, Ventricular escape beats DOSAGE: Adults V-Fib / V-Tach without pulses: 300 mg IV Adults Ventricular arrhythmias with a pulse: 150 mg over 10 minutess Maintenance Infusion: As with any Aniarrhythmic a maintenance infusion is required. However it is seldom used in the prehospital setting ROUTES: IV, Oral PEDIATRIC DOSAGE: Not recommended
ATROPINE 100

CLASS: Parasympatholytic (anticholinergic). ACTIONS: Blocks acetylcholine receptors, increases heart rate, decreases gastrointestinal secretions. INDICATIONS: Hemodynamically-significant bradycardia, hypotension secondary to bradycardia, asystole, organophosphate poisoning. CONTRAINDICATIONS: None when used in emergency situations. PRECAUTIONS: Dose of 0.04 mg/kg should not be exceeded except in cases of organophosphate poisonings, tachycardia, hypertension. SIDE EFFECTS: Palpitations and tachycardia, headache, dizziness, and anxiety, dry mouth, pupillary dilation, and blurred vision, urinary retention (especially older males). DOSAGE: Bradycardia: 0.5 mg every 5 minutes to maximum of 0.04 mg/kg. Asystole: 1 mg. Organophosphate poisoning: 2-5 mg. ROUTES: IV, ET (ET dose is 2 - 2.5 times IV dose). PEDIATRIC DOSAGE: Bradycardia: 0.02 mg/kg Maximum single dose (child 0.5 mg) (adolescent 1.0 mg) Maximum total dose (child 1.0 mg) (adolescent 2.0 mg)
BENICAR (Olmesartan)
CLASS: Angiotensin II receptor antagonists ACTIONS: Block the effects of angiotensin II by antagonizing the angiotensin II type 1 receptor INDICATIONS: Hypertension CONTRAINDICATIONS: Hypersensitivity, pregnancy, breastfeeding, Netherton's syndrome DOSAGE: 20mg per day ROUTES: Oral PEDIATRIC DOSAGE: Not indicated.
CALCIUM CHLORIDE
CLASS: Electrolyte. ACTIONS: Increases cardiac contractility. INDICATIONS: Acute hyperkalemia (elevated potassium), acute hypocalcemia (decreased calcium), calcium channel blocker (Nifedipine, Verapamil, etc.), overdose, abdominal muscle spasm associated with spider bite and portuguese man-o-war stings, antidote for magnesium sulfate. CONTRAINDICATIONS: Patients receiving digitalis. PRECAUTIONS: IV line should be flushed between calcium chloride and sodium bicarbonate administration. Extravasation may cause tissue necrosis. SIDE EFFECTS: Arrhythmias (bradycardia and asystole), hypotension. DOSAGE: 2-4 mg/kg of a 10% solution; may be repeated at 10-minute
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intervals. ROUTES: IV. PEDIATRIC DOSAGE: 5-7 mg/kg of a 10% solution.
CARDIZEM
CLASS: Calcium channel blocker. ACTIONS: Slows conduction through the AV node, causes vasodilation, decreases rate of ventricular response, decreases myocardial oxygen demand. INDICATIONS: To control rapid ventricular response associated with atrial fibrillation and flutter. CONTRAINDICATIONS: Hypotension, wide complex tachycardia, conduction system disturbances. PRECAUTIONS: Should not be used in patients receiving intravenous blockers. Hypotension. Must be kept refrigerated or discarded one month after removal from refrigeration. SIDE EFFECTS: Nausea, vomiting, hypotension, and dizziness. DOSAGE: 0.25 mg/kg bolus (typically 20 mg) IV over 2 minutes. This should be followed by a maintenance infusion of 5-15 mg/hour. ROUTES: IV, IV drip. PEDIATRIC DOSAGE: Rarely used.
DEXTROSE 50%
CLASS: Carbohydrate. ACTIONS: Elevates blood glucose level rapidly. INDICATIONS: Hypoglycemia. CONTRAINDICATIONS: None in the emergency setting. PRECAUTIONS: A blood sample should be drawn before administering 50% dextrose. SIDE EFFECTS: Local venous irritation. DOSAGE: 25 grams (50 ml). ROUTES: IV. PEDIATRIC DOSAGE: 0.5 g/kg slow IV; should be diluted 1:1 with sterile water to form a 25% solution.
DIAZEPAM ( VALIUM )
CLASS: Tranquilizer (Benzodiazepine). ACTIONS: Anticonvulsant, skeletal muscle relaxant, sedative. INDICATIONS: Generalized seizures, status epilepticus, premedication before cardioversion, skeletal muscle relaxant, acute anxiety states. CONTRAINDICATIONS: Patients with a history of hypersensitivity to the drug. PRECAUTIONS: Can cause local venous irritation. Has short duration of effect. Do not mix with other drugs because of possible precipitation problems. SIDE EFFECTS: Drowsiness, hypotension, respiratory depression, apnea.
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DOSAGE: Status epilepticus: 5-10 mg IV. Acute anxiety: 2-5 mg IM or IV. Premedication before cardioversion: 5-15 mg IV. ROUTES: IV (care must be taken not to administer faster than 1 ml/min) IM rectal. PEDIATRIC DOSAGE: Status epilepticus: 0.1 - 0.2 mg/kg.
DIPHENHYDRAMINE ( BENADRYL )
CLASS: Antihistamine. ACTIONS: Blocks histamine receptors, has some sedative effects. INDICATIONS: Anaphylaxis, allergic reactions, dystonic reactions due to henothiazines. CONTRAINDICATIONS: Asthma, nursing mothers. PRECAUTIONS: Hypotension. SIDE EFFECTS: Sedation, dries bronchial secretions, blurred vision, headache, alpitations. DOSAGE: 25-50 mg. ROUTES: Slow IV push deep IM. PEDIATRIC DOSAGE: 2-5 mg/kg.
DOPAMINE
CLASS: Sympathomimetic. ACTIONS: Increases cardiac contractility, causes peripheral vasoconstriction. INDICATIONS: Hemodynamically significant hypotension (systolic BP of 70100 mmhg) not resulting from hypovolemia, cardiogenic shock. CONTRAINDICATIONS: Hypovolemic shock where complete fluid resuscitation has not occurred. PRECAUTIONS: Should not be administered in the presence of severe tachyarrhythmias. Should not be administered in the presence of ventricular fibrillation, ventricular irritability. Beneficial effects lost when dose exceeds 20 g/kg/min. SIDE EFFECTS: Ventricular tachyarrhythmias, hypertension, palpitations. DOSAGE: 2-20 g/kg/minute. Start low and increase as needed. Method: 400 mg should be placed in 250 ml of D5W giving a concentration of 1600 g/ml. ROUTES: IV drip only. PEDIATRIC DOSAGE: 2-20 g/kg/minute.
EPINEPHRINE 1:1000 103

CLASS: Sympathomimetic. ACTIONS: Bronchodilation. INDICATIONS: Bronchial asthma, exacerbation of COPD, allergic reactions. CONTRAINDICATIONS: Patients with underlying cardiovascular disease, hypertension, pregnancy, patients with tachyarrhythmias. PRECAUTIONS: Should be protected from light. Blood pressure, pulse, and EKG must be constantly monitored. SIDE EFFECTS: Palpitations and tachycardia, anxiousness, headache, tremor. DOSAGE: 0.3-0.5 mg. ROUTES: Subcutaneous (IV and ET for pediatric cardiac arrest). PEDIATRIC DOSAGE: 0.01 mg/kg up to 0.3 mg.
1:10,000
CLASS: Sympathomimetic. ACTIONS: Increases heart rate and automaticity. Increases cardiac contractile force. Increases myocardial electrical activity. Increases systemic vascular resistance. Increases blood pressure. Causes bronchodilation. INDICATIONS: Cardiac arrest, anaphylactic shock severe reactive airway disease. CONTRAINDICATIONS: Epinephrine 1:10,000 is for intravenous or endotracheal use; it should not be used in patients who do not require extensive resuscitative efforts. PRECAUTIONS: Should be protected from light. Can be deactivated by alkaline solutions. SIDE EFFECTS: Palpitations, anxiety, tremulousness, nausea and vomiting. DOSAGE: cardiac arrest: 0.5-1.0 mg repeated every 3-5 minutes. severe anaphylaxis: 0.3-0.5 mg (3-5 ml); occasionally and Epinephrine drip is required. ROUTES: IV, IV drip, ET. PEDIATRIC DOSAGE: 0.01 mg/kg initially. with subsequent doses, Epinephrine 1:1,000 should be used at a dose of 0.1 mg/kg.
FUROSEMIDE ( LASIX )
CLASS: Potent diuretic. ACTIONS: Inhibits reabsorption of sodium chloride, promotes prompt diuresis, vasodilation. INDICATIONS: Congestive heart failure, pulmonary edema. CONTRAINDICATIONS: Pregnancy, dehydration. PRECAUTIONS: Should be protected from light, dehydration. SIDE EFFECTS: Few in emergency usage.
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DOSAGE: Standard: 40-80 mg. ACLS: 1 mg/kg, max of 100 mg ROUTES: IV. PEDIATRIC DOSAGE: 1 mg/kg.
LIDOCAINE ( Both IVP and drip )
CLASS: Antiarrhythmic. ACTIONS: Suppresses ventricular ectopic activity, increases ventricular fibrillation threshold, reduces velocity of electrical impulse through conductive system. INDICATIONS: Malignant PVCs, ventricular tachycardia, ventricular fibrillation, prophylaxis of arrhythmias associated with acute myocardial infarction and thrombolytic therapy, premedication prior to rapid sequence induction. CONTRAINDICATIONS: High-degree heart blocks, PVCs in conjunction with bradycardia. PRECAUTIONS: Dosage should not exceed 300 mg/hr. Monitor for CNS toxicity. Dosage should be reduced by 50% in patients older than 70 years of age or who have liver disease in cardiac arrest, use only bolus therapy. SIDE EFFECTS: Anxiety, drowsiness, dizziness, and confusion, nausea and vomiting, convulsions, widening of QRS. DOSAGE: Bolus: Initial bolus of 1.5 mg/kg; additional boluses of 0.5 0.75 mg/kg can be repeated at 8-10-minute intervals until the arrhythmia has been suppressed or until 3 mg/kg of the drug has been administered; reduce dosage by 50% in patients older than 70 years of age. DRIP: After the arrhythmia has been suppressed a 2-4 mg/minute infusion may be started to maintain adequate blood levels. ROUTES: IV bolus, IV infusion. PEDIATRIC DOSAGE: 1 mg/kg.
MAGNESIUM SULFATE
CLASS: Anticonvulsant/Antiarrhythmic. ACTIONS: CNS depressant, anticonvulsant, antiarrhyhmic. INDICATIONS: Obstetrical eclampsia (toxemia of pregnancy), preeclampsia/ PIH, cardiovascular severe refractory ventricular fibrillation, pulseless ventricular tachycardia, post-MI as prophylaxis for arrhythmias, torsades de pointes (multi-axial ventricular tachycardia). CONTRAINDICATIONS: Shock, heart block. PRECAUTIONS: Caution should be used in patients receiving digitalis. Hypotension. Calcium Chloride should be readily available as an antidote if respiratory depression ensues. Use with caution in
105

patients in renal failure. SIDE EFFECTS: Respiratory depression, drowsiness. DOSAGE: 1-4 g. ROUTES: IV, IM. PEDIATRIC DOSAGE: Not indicated.
MANNITOL
CLASS: Osmotic diuretic ACTIONS: Decreases cellular edema Increases urinary output INDICATIONS: Acute cerebral edema Blood transfusion reactions CONTRAINDICATIONS: Pulmonary edema Patients who are dehydrated Hypersensitivity to the drug PRECAUTIONS: Rapid administration can cause circulatory overload Crystallization of the drug can occur at lower temperatures SIDE EFFECTS: Pulmonary congestion Sodium depletion Transient volume overload DOSAGE: 1.5 2.0 g/kg ROUTES: Slow IV bolus or infusion PEDIATRIC DOSAGE: 0.25 0.5 g/kg IV over 60 minutes
MORPHINE
CLASS: Narcotic. ACTIONS: CNS depressant, causes peripheral vasodilation, decreases sensitivity to pain. INDICATIONS: Severe pain, pulmonary edema. CONTRAINDICATIONS: Head injury, volume depletion undiagnosed abdominal pain, patients with history of hypersensitivity to the drug. PRECAUTIONS: Respiratory depression (narcan should be available), hypotension, nausea. SIDE EFFECTS: Dizziness, altered level of consciousness. DOSAGE: IV: 2-5 mg followed by 2 mg every few minutes until the pain is relieved or until respiratory depression ensues. IM: 5-15 mg based on patient weight. ROUTES: IV, IM. PEDIATRIC DOSAGE: 0.1-0.2 mg/kg IV.
NALOXONE ( NARCAN )
CLASS: Narcotic antagonist.

106

ACTIONS: Reverses effects of narcotics. INDICATIONS: Narcotic overdoses including the following: Codeine, Demerol, Dilaudid, Fentanyl, Heroin, Lortabs, Methadone, Morphine, Paregoric, Percodan, Tylox, Vicodin, synthetic analgesics, Overdoses including the following: Darvon, Nubain, Stadol, Talwin, alcoholic coma, To rule out narcotics in coma of unknown origin. CONTRAINDICATIONS: Patients with a history of hypersensitivity to the drug. PRECAUTIONS: Should be administered with caution to patients dependent on narcotics as it may cause withdrawal effects. Short-acting, should be augmented every 5 minutes. SIDE EFFECTS: none. DOSAGE: 1-2 mg. ROUTES: IV, IM ET (ET dose is 2.0-2.5 times IV dose). PEDIATRIC DOSAGE: < 5 years old: 0.1 mg/kg > 5 years old: 2.0 mg.
NITROGLYCERINE (Spray)
CLASS: Antianginal ACTIONS: Smooth-muscle relaxant, decreases cardiac work, dilates coronary arteries, dilates systemic arteries. INDICATIONS: Angina pectoris, chest pain associated with myocardial infarction. CONTRAINDICATIONS: Hypotension PRECAUTIONS: Constantly monitor vital signs. Syncope can occur. SIDE EFFECTS: Dizziness, hypotension, headache. DOSAGE: One spray administered under the tongue; may be repeated in 3 - 5 minutes; no more than three sprays in a 15-minute period; spray should not be inhaled. ROUTES: Sprayed under tongue on mucous membrane. PEDIATRIC DOSAGE: Not indicated.
NITROGLYCERINE (Paste)
CLASS: Antianginal. ACTIONS: Smooth-muscle relaxant, decreases cardiac work, dilates coronary arteries, dilates systemic arteries. INDICATIONS: Angina pectoris, chest pain associated with myocardial infarction. CONTRAINDICATIONS: Children younger than 12 years of age, hypotension. PRECAUTIONS: Constantly monitor blood pressure, syncope, drug must be protected from light, expires quickly once bottle is opened. SIDE EFFECTS: Dizziness, hypotension.
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DOSAGE: 1/2 to 1 inch ROUTES: Topical PEDIATRIC DOSAGE: Not indicated
OXYGEN
CLASS: Gas. ACTIONS: Necessary for cellular metabolism. INDICATIONS: Hypoxia. CONTRAINDICATIONS: None. PRECAUTIONS: Use cautiously in patients with COPD, humidify when providing high-flow rates. SIDE EFFECTS: Drying of mucous membranes. DOSAGE: Cardiac arrest: 100%. Other critical patients: 100%. COPD: 35%. ROUTES: Inhalation. PEDIATRIC DOSAGE: 24-100% as required.
OXYTOCIN
CLASS: Hormone (oxytocin) ACTIONS: Causes uterine contraction Causes lactation Slows postpartum vaginal bleeding INDICATIONS: Postpartum vaginal bleeding CONTRAINDICATIONS: Any condition other than postpartum vaginal bleeding. Cesarean section PRECAUTIONS: Essential to ensure that the placenta has delivered and that there is not another fetus before administration oxytocin. Overdose can cause uterine rupture Hypertension SIDE EFFECTS: Anaphylaxis Cardiac arrhythmias DOSAGE: Intravenous (IV): 10 20 units in 500 mL of D5W administered according to uterine response Intramuscular (IM): 3-10 units ROUTES: IV drip IM PEDIATRIC DOSAGE: Not indicated
PROCAINAMIDE
CLASS: Antiarrhythmic. ACTIONS: Slows conduction through myocardium, elevates ventricular fibrillation threshold, suppresses ventricular ectopic activity. INDICATIONS: Persistent cardiac arrest due to ventricular fibrillation and
108

refractory to Lidocaine, PVCs refractory to Lidocaine, ventricular tachycardia refractory to Lidocaine. CONTRAINDICATIONS: High-degree heart blocks, PVCs in conjunction with bradycardia. PRECAUTIONS: Dosage should not exceed 17 mg/kg. Monitor for central nervous system toxicity. SIDE EFFECTS: Anxiety, nausea, convulsions, widening of QRS. DOSAGE: Initial: 20 mg/minute until arrhythmia abolished, hypotension ensues, QRS widened by 50% of original width total of 17 mg/kg has been given. Maintenance: 1-4 mg/minute. ROUTES: Slow IV bolus, IV drip. PEDIATRIC DOSAGE: Rarely used.
SODIUM BICARB.
CLASS: Alkalinizing agent. ACTIONS: Combines with excessive acids to form a weak volatile acid, increases ph. INDICATIONS: Late in the management of cardiac arrest, if at all, tricyclic antidepressant overdose, severe acidosis refractory to hyperventilation. CONTRAINDICATION: Alkalotic states. PRECAUTIONS: Correct dosage is essential to avoid overcompensation of ph. Can deactivate catecholamines. Can precipitate with calcium preparations. Delivers large sodium load. SIDE EFFECTS: Alkalosis. DOSAGE: 1 mEq/kg initially followed by 0.5 mEq/kg every 10 minutes as indicated by blood gas studies. ROUTES: IV. PEDIATRIC DOSAGE: 1 mEq/kg initially followed by 0.5 mEq/kg every 10 minutes.
VASOPRESSIN
CLASS: Pituitary Hormone (Antidiuretic) ACTIONS: Promotes water reabsorption, vasoconstriction, increases smooth muscle activity. INDICATIONS: Diabetes insipidus, alternative to epinephrine in adult shock refractory ventricular fibrillation. CONTRAINDICATIONS: Vascular disease, angina pectoris, chronic nephritis PRECAUTIONS: Hyponatremia, water intoxication, asthma, epilepsy, migraine, CAD, CHF SIDE EFFECTS: N/V, intestinal activity, abdominal cramps, flatus, facial pallor, tremors, sweating, vertigo, skin blanching, bronchoconstriction, water intoxication, drowsiness, headache. DOSAGE: 5 10 units ROUTES: IM, SC PEDIATRIC DOSAGE: 2.5 10 units
109

VERAPAMIL
CLASS: Calcium channel blocker. ACTIONS: Slows conduction through the AV node, inhibits reentry during PSVT, decreases rate of ventricular response, decreases myocardial oxygen demand. INDICATIONS: PSVT. CONTRAINDICATIONS: Heart block, conduction system disturbances. PRECAUTIONS: Should not be used in patients receiving intravenous blockers, hypotension. SIDE EFFECTS: Nausea, vomiting, hypotension, and dizziness. DOSAGE: 2.5 - 5.0 mg. a repeat dose of 5 - 10 mg can be administered after 15-30 minutes if PSVT does not convert. maximum dose is 30 mg in 30 minutes. ROUTES: IV. PEDIATRIC DOSAGE: 0-1 year: 0.1-0.2 mg/kg (maximum of 2.0 mg) administered slowly. 1-15 years: 0.1-0.3 mg/kg (maximum of 5.0 mg) administered slowly.
Viagra
CLASS: Phosphodiesterase Inhibitors ACTIONS: Vasodilator Agents INDICATIONS: Erectile Dysfunction CONTRAINDICATIONS: Hypersensitivity, Nitrate usage PRECAUTIONS: Hypotension SIDE EFFECTS: Dependency, headaches, altered vision, nitrate potentiation DOSAGE: 25 50mg ROUTES: Oral
Wellbutrin
CLASS: Antidepressant ACTIONS: Inhibits reuptake of dopamine, norepinephrine, and serotonin INDICATIONS: Depression, S.A.D., and smoking cessation CONTRAINDICATIONS: Seizure disorders, Zyban treatments, bulimia, anorexia nervosa, benzodiazepine withdrawal, hypersensitivity, MAOI administration SIDE EFFECTS: seizure (convulsions);severe blistering, peeling, and red skin rash;fever, swollen
glands, rash or itching, joint pain, or general ill feeling;confusion, trouble concentrating; orhallucinations, unusual thoughts or behavior.
DOSAGE: 100 200mg ROUTES: Oral

Zocor
110

CLASS: HMG-CoA reductase inhibitors ACTIONS: Reduces LDL cholesterol INDICATIONS: CHD or high risk of CHD CONTRAINDICATIONS: Hypersensitivity, liver disease, pregnant or nursing SIDE EFFECTS: muscle pain, tenderness, weakness with fever or flu symptoms and dark colored urine DOSAGE: 5 80 mg ROUTES: Oral Lunesta CLASS: Cyclopyrrolone ACTIONS: Raises GABA levels to reduce brain activity INDICATIONS: Insomnia or other sleeping difficulty CONTRAINDICATIONS: Hypersensitivity SIDE EFFECTS: Drowsiness , Viral Infection, Dry Mouth, Dizziness, Hallucinations, Infection, Rash, Unpleasant Taste. DOSAGE: 1 3 mg ROUTES: Oral
EXUBERA
CLASS: Insulin ACTIONS: Regulation of glucose metabolism through stimulation of peripheral glucose uptake INDICATIONS: Diabetes CONTRAINDICATIONS: Hypersensitivity, lung disease, smoking SIDE EFFECTS: Hypoglycemia, chest pain, dry mouth DOSAGE: 1 3 mg ROUTES: MDI / INH
BOTOX
CLASS: Neurotoxin ACTIONS: Muscular paralytic INDICATIONS: Cervical dystonia, facial wrinkles CONTRAINDICATIONS: Hypersensitivity, infection at injection site SIDE EFFECTS: allergic reactions, rash, itching, headache, neck pain, difficulty swallowing, shortness of breath, nausea, and weakness DOSAGE: 1.25 5 units ROUTES: IM / SQ
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EEI Paramedic Refresher 201 0

NO REPRODUCTION OF ANY KIND MAY BE DONE WITHOUT PERMISSION FROM EEI.

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Instructions for the Refresher Program

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Module 1 EEI, INC PREPARATORY

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Module II EEI, INC Airway

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MODULE III EEI, INC PATIENT ASSESSMENT

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Altered Mental Status

MODULE V EEI, INC TRAUMA

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MODULE VI EEI, INC OBSTETRICS, INFANTS, AND CHILDREN

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Bio-Terrorism and Acts of Terrorism

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HISTORY OF BIOLOGICAL WARFARE AND CURRENT THREAT

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Followed is an explanation of the most common Bio threats:

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Physical Acts of Terrorism

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Ephedra Sinica (Ma-huang)

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