HISTORY AND DEVELOPMENT PHILOSOPHY

As part of the revision project for the EMT-Intermediate and EMT-Paramedic: National Standard Curricula (NSC), the contractor was directed to develop the EMT-Paramedic and EMT-Intermediate Continuing Education, National Guidelines. The guidelines document, developed as a substitute for traditional refresher courses, gives the reader an overview of competency assurance mechanisms to promote the delivery of medically appropriate patient care. The guidelines document defined refresher programs as follows:

Although the guidelines document is widely used by the EMS community, the definition for refresher programs caused the EMS community to ask that refresher courses be developed. A contract to develop the refresher courses went to the National Association of EMS Educators (NAEMSE) and they convened a task force of EMS stakeholders inclusive of regulators, physicians, association representatives, providers, and educators.

Some challenges undertaken by the task force were:

1. The development of a refresher program based on scientific data.
2. A program that could be delivered in different formats.
3. A program flexible enough to meet the specific needs of different systems while maintaining the intent of a refresher program.
4. The need to incorporate relevant contemporary material.

The task force used EMS provider practice data, an EMS literature review, expert opinion, and a final EMS community review to develop the refresher programs. Previous versions of EMS refresher programs have been based on a perceived need and not on scientific evidence. With this in mind, the Refresher Development Task Force relied heavily on the findings of the 1999 NREMT Practice Analysis and the following documents:

1. The EMS Agenda for the Future
2. The EMS Education Agenda for the Future, A Systems Approach
3. The National EMS Education and Practice Blueprint
4. EMT-Paramedic and EMT-Intermediate Continuing Education, National Guidelines
5. 1999 EMT-Intermediate National Standard Curriculum

Each of the above documents was created as individual projects, but they are designed to work as a systems approach to EMS and integrate with one another. Contact the NHTSA EMS Division to obtain copies of these documents.

In 1994, the National Registry of Emergency Medical Technicians (NREMT) performed the first nationally conducted practice analysis of EMS. The information obtained in the first analysis was used in the development of the 1998 EMT-Paramedic and 1999 EMT-Intermediate: NSC. In 1999, the NREMT conducted its second practice analysis.

The 1999 NREMT Practice Analysis is a scientific, randomized national sampling of practicing EMT-Paramedic and EMT-Intermediates. The EMT�s participating in the practice analysis provided data on 123 various patient assessments focusing on patient care and operational tasks that make up the day-to-day functions of the providers. Each provider indicated the frequency they performed each task and the potential for harm they experienced accomplishing each task. A Practice Analysis Committee reviewed the data, validated the responses, and published the data in a peer reviewed medical journal. The NREMT Practice Analysis Committee used this data to develop a plan that grouped the identified tasks into the following six content areas:

• Airway and Breathing
• Cardiology
• Medical
• Trauma
• Pediatrics/Obstetrics
• Operations

The specific tasks from the practice analysis are listed in appendix A. The NREMT supplied the data from their practice analysis to the EMT-Intermediate refresher development task force. This information was used to help determine specific content for the refresher course.

The refresher task force used the NREMT data to identify tasks that are infrequent and may cause potential harm to the patient if delayed, performed improperly, or omitted when providing care. The panel decided to "refresh" these tasks since patient outcome is jeopardized if the task is not correctly performed. An example of this would be "Provide care to an infant or child with cardiac arrest." The practice analysis categorizes this task as number 113 of 123 for frequency, but lists it as the number one task for potential for harm. The panel agreed and decided to include this task as a mandatory part of the refresher program.

Likewise, a task such as "Provide care to a patient with a painful, swollen, deformed extremity" is listed as task number 98 in frequency and number 100 as potential for harm. This task is not included as a mandatory part of the refresher program. Other tasks that are performed frequently and lack potential for harm are not included as a mandatory part of this refresher program. Again, the refresher course only targets infrequently performed tasks with a high potential for harm.

Upon further review of the practice analysis, the task force identified a few frequently performed tasks that have a very high potential for harm. The task force decided to also include all tasks with a high potential for harm, regardless of their frequency of performance.

Another tool used in the development of this refresher program was an EMS literature review. The literature review found issues not identified by the data from the NREMT Practice Analysis. The task force also sought expert opinion and feedback from the EMS community to identify additional course content.

Traditional refresher programs refresh material already known by the students. The intent of these programs is to maintain a student�s competence in knowledge and skill performance. This refresher program embraces the same concept, but it also encourages the inclusion of new and expanded information. New and expanded information may be added to the course but not at the expense of content that is core material for the program. This course is not designed to be continuing education for the participants. If a system wishes to incorporate additional information or a new intervention that requires a substantial amount of time to teach, the information must be offered in addition to the content of the refresher program. Moreover, this course is not a transition or bridge course for EMT-Intermediates to become certified at the revised 1999 EMT-Intermediate level.

The participant make-up in a refresher program may challenge the instructional staff. Participants who attend a refresher program may do so for a variety of reasons. Some students may not have practiced for a period of time and are attending to gain back their level of competence prior to practicing again. Others may attend to remediate or gain refresher or continuing education hours. Knowledge of the participant make-up will help the instructors meet the participant�s needs. A thorough knowledge of the re-credentialing requirements and approval process is a must for any organization sponsoring a refresher program.

NREMT PRACTICE ANALYSIS TASK ITEMS

The NREMT Practice Analysis task items are listed at the beginning of each module. These tasks are included based upon their performance frequency and potential for harm.

The objectives and declarative material are extracted from the 1999 EMT-Intermediate: NSC and they support the identified practice analysis tasks. The objectives and declarative material are renumbered for formatting purposes; however, the original objective number from the NSC is found at the end of each objective. The declarative material provides guidance for programs to use to establish their own individual lesson plans.

The objectives in modules 1-5 are mandatory objectives and must be included in every refresher program. The objectives for the operational section should be considered recommended content for the refresher course. Any other objectives and declarative information has not been included and should be developed by the sponsoring agency.

The length of this refresher program will vary according to a number of factors. Some of these factors are as follows:

• The student�s basic academic skills competence
• The student�s EMS knowledge and skills
• The faculty to student ratio
• The student�s motivation
• The student�s prior emergency/health care experience
• The student�s prior academic achievements
• The clinical and academic resources available
• The quantity of patient contacts

The recommended time to instruct the mandatory objectives for the refresher program is 40 to 80 hours. Training institutes will need to adjust these times based on their individual needs. The agencies responsible for program oversight are cautioned against using these hours as a measure of program quality. Competence of the participants, not adherence to arbitrary time frames, is the true measurement of program quality.

The first step for the needs assessment is the performance of a comprehensive analysis of the factors that influence the local pre-hospital emergency care delivery system. Some factors included in this analysis are:

• Recertification requirements (local, state, national, professional).
• System structure.
• Call characteristics (i.e., volume, type).
• Community demographics.
• Community hazard assessment.

The second step of the needs assessment is an analysis of the education needs of the course participants. This assessment may include the following:

• Pre-testing
• Surveys
• Observations
• Expert Judgments
• Data Analysis

The information collected during the assessment process may be used as a guide to select specific material for the classroom. The assessment results can determine the course format, course schedule, and course methods. The selected material may be subjected to national, State, and local standards.

The following steps will assist with the design and implementation of the course design.

Determine regulatory requirements for course conduct:
The refresher course will be approved or accredited by the appropriate local or state agency. A part of this approval process will be the length of the course, the course content, and the faculty requirements or restrictions.

Develop schedule:
The course is designed to allow programs to present the material in a variety of formats. The program may be delivered in class sessions that might include 8 hour consecutive days or may be taught in a shorter sessions extended over a period of months.

Determine class size:
The course emphasizes the evaluation of participant skills. Class size should be manageable and allow students an opportunity to ask questions and receive answers or assistance from the instructor.

Since the instructor must observe and evaluate student performance, it is essential that the group�s size not be too large when evaluating practical skills. Consider segmenting the class into smaller groups, such as 6:1 (students to instructor) when doing the practical skills session.

Instructing a refresher program for practicing EMT-Intermediates is a challenge. We often hear that refresher programs lack challenge, cover material already well known, and are not deemed as useful for the participants. Faculty members must possess expertise in both the content area they instruct and in multiple delivery styles. Instructors must be proficient in performing the skills that they are instructing. Knowing your student�s abilities and the local EMS system�s expectations is essential for a successful program.

Instructional staff must be appropriately credentialed according to local or state requirements. The course medical director must be available throughout the program and be aware of the course design and evaluation instruments being used. The course medical director may be utilized for medical expertise.

Given the repetitive nature of refresher education, it is easy for participants to become bored and lack enthusiasm about the program. The overuse of lecturing is ineffective as the sole method of learning. To improve the quality of the educational experience for instructors and participants, creative and innovative instructional activities are strongly recommended. Consider using some of the following:

Case Presentation
Case presentation and discussion helps participants apply and understand the content by relating to their field experiences. The instructional staff can generate cases by using actual calls. Instructors should develop case studies to highlight key points of their presentations and the area of content being delivered. The most successful case presentations are those placing the participant(s) in a decision-making role allowing them to see the consequences of their decisions. Case presentations can be used in any format, such as, large classes, small groups, and individual instruction. Several examples and templates for case construction are in Appendix B.

Simulations
Simulations are case presentations incorporating role-playing situations. The role players may be other participants, programmed (standardized) patients, or manikins. Simulations work best when they are realistic and present situations the participant(s) may encounter, highlighting key points of the content area. Instructors and participants may critique simulations if the classroom environment is adequate.

Technology
We live in a time when technology is expanding in development and practical use. Though it is hard to say what will be the state of the art delivery system for education resources in the future, participation by the student will likely enhance the learning process.

Distributed learning includes several alternative methods and media usage. Self-study programs, videotapes, audiotapes, and computer-based instruction are just a few examples of distributed learning. These alternative methods of instruction provide an opportunity to review and learn new cognitive knowledge, but they may not replace the need to practice or demonstrate a psychomotor skill. The use of a distributed learning process may best be applied in the remediation of cognitive knowledge identified in a needs assessment. Course directors and the credentialing agency should evaluate distributed learning products to assure that they meet the course goals and objectives.

In order for the refresher program sponsor to issue a certificate of program completion, an evaluation process must be employed. The evaluation process should measure both cognitive knowledge and psychomotor skills. Individuals who are unsuccessful may be counseled and a course of action for remediation developed.

Authoring a valid written evaluation is both a science and an art. While some instructors possess skills in writing test questions, some others may not. A variety of commercially available test question banks may be useful to the instructional staff during the refresher program. Regardless of the tool used, the purpose of the cognitive measurement tool must be known before a test can be validated. The instructional staff must use basic test construction principles to develop written evaluation instruments.

Written evaluation questions should be balanced to the program content. Items should be based upon what is taught and emphasized throughout the program and should have a difficulty measurement. A test written so each participant can obtain a score of 90% without taking the course lacks measurement ability and validation. Test items must be reviewed by faculty members, including the course medical director, to ensure content validation. Correct answers need to be the best choice or the only correct answer. Incorrect answers and distracters should be plausible to the item and have some attraction to the less than competent participant. Finally, a pass/fail score should be established based upon item analysis and judgment by faculty members responsible for issuing course completion certificates.

The following have been identified as essential items in the 2001 EMT-Intermediate Refresher Program:

Validation of psychomotor performance must be accomplished prior to issuing a certificate of course completion. Three opportunities are available to the instructional staff to validate a participant�s performance.

Pretest
The use of a psychomotor pretest is the best measurement of an individual�s performance. The pretest identifies skills that need to be emphasized during the course. Likewise, if all candidates possess competency in a skill prior to taking the program, it may not be necessary to cover that skill.

Skill Labs
When the sponsoring agency does not administer a pretest, the staff can use the skill labs to measure the competency of each participant. The skill labs ensure validation is sprinkled throughout the refresher program.

End of Program
At the end of the refresher program an evaluation process can be utilized if a pretest and skill labs were not used. If an end of program evaluation process is used, some skills may need to be re-evaluated if participants are unsuccessful.

Participants must have documentation of demonstrating competence for each skill identified during the program regardless of what process is used.

The refresher curriculum is the minimum acceptable content to be covered by education programs. With certifying agency approval, the student may meet some program objectives by satisfactorily completing a nationally recognized trauma life support program, cardiac care program, or pediatric care program. Although some certifying agencies allow providers to attend continuing education programs, it is recommended that providers participate in regularly scheduled group education sessions as well.

Participants who do not complete the program�s objectives or pass the evaluation process should have their performance reviewed by one of the instructional staff members. The participant�s strengths and weaknesses should be identified and a plan developed that helps the participant successfully complete the requirements. This plan may include additional classroom time, clinical time, field time, or repeating the entire program.

Refresher programs are often provided by the same instructional staff in a variety of settings to different groups of participants. The program staff should evaluate each program for its effectiveness when completed. The evaluation can include the participant�s point of view by administering post program evaluation surveys. Some questions to ask when evaluating program effectiveness include:

• Did the program conform to the course design?
• Were the resources adequate?
• Were the skills labs effective?
• Did the test provide valuable information?
• Were the instructors effective in delivering the material?
• Can other instructional methods be incorporated in future courses?
• What were the participant comments?
• Was the course cost effective?

The development of this document would not have been possible without the involvement and help of the following task force members and organizations. Gratitude and thanks are also extended to all the individuals who made comments during the development of this document.

Refresher Curriculum Development Task Force Members

• Provide ventilatory support for a patient.

COGNITIVE OBJECTIVES
At the completion of this unit, the EMT-Intermediate will be able to:

PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the EMT-Intermediate will be able to:

1. Ventilation
   1. Mouth-to-mouth
      1. Most basic form of ventilation
      2. Indications
         1. Apnea from any mechanism when other ventilation devices are not available
      3. Contraindications
         1. Awake patients
         2. Communicable disease risk limitations
      4. Advantages
         1. No special equipment required
         2. Delivers excellent tidal volume
         3. Delivers adequate oxygen
      5. Disadvantages
         1. Psychological barriers from
            1. Sanitary issues
            2. Communicable disease issues
               1. Direct blood/ body fluid contact
               2. Unknown communicable disease risks at time of event
      6. Complications
         1. Hyperinflation of patient's lungs
         2. Gastric distension
         3. Blood/ body fluid contact manifestation
         4. Hyperventilation of rescuer
   2. Mouth-to-nose
      1. Ventilating through nose rather than mouth
      2. Indications
         1. Apnea from any mechanism
      3. Contraindications
         1. Awake patients
      4. Advantages
         1. No special equipment required
      5. Disadvantages
         1. Direct blood/ body fluid contact
         2. Psychological limitations of rescuer
      6. Complications
         1. Hyperinflation of patient's lungs
         2. Gastric distension
         3. Blood/ body fluid manifestation
         4. Hyperventilation of rescuer
   3. Mouth-to-mask
      1. Adjunct to mouth-to-mouth ventilation
      2. Indications
         1. Apnea from any mechanism
      3. Contraindications
         1. Awake patients
      4. Advantages
         1. Physical barrier between rescuer and patient blood/ body fluids
         2. One-way valve to prevent blood/ body fluid splash to rescuer
         3. May be easier to obtain face seal
      5. Disadvantages
         1. Useful only if readily available
      6. Complications
         1. Hyperinflation of patient's lungs
         2. Hyperventilation of rescuer
         3. Gastric distention
      7. Method for use
         1. Position head by appropriate method
         2. Position and seal mask over mouth and nose
         3. Ventilate as appropriate
   4. One person bag-valve-mask
      1. Fixed volume self inflating bag can deliver adequate tidal volumes and O₂ enrichment
      2. Indications
         1. Apnea from any mechanism
         2. Unsatisfactory respiratory effort
      3. Contraindications
         1. Awake, intolerant patients
      4. Advantages
         1. Excellent blood/ body fluid barrier
         2. Good tidal volumes
         3. Oxygen enrichment
         4. Rescuer can ventilate for extended periods without fatigue
      5. Disadvantages
         1. Difficult skill to master
         2. Mask seal may be difficult to obtain and maintain
         3. Tidal volume delivered is dependent on mask seal integrity
      6. Complications
         1. Inadequate tidal volume delivery
         2. Poor technique
         3. Poor mask seal
         4. Gastric distention
      7. Method for use
         1. Position appropriately
         2. Choose proper mask size - seats from bridge of nose to chin
         3. Position, spread/ mold/ seal mask
         4. Hold mask in place
         5. Squeeze bag completely over 1.5 to 2 seconds for adults
         6. Avoid overinflation
         7. Reinflate completely over several seconds
      8. Special considerations
         1. Medical
            1. Observe for
               1. Gastric distension
               2. Changes in compliance of bag with ventilation
               3. Improvement or deterioration of ventilation status (i.e., color change, responsiveness, air leak around mask)
         2. Trauma
            1. Very difficult to perform with cervical spine immobilization in place
   5. Two-person bag-valve-mask ventilation method
      1. Most efficient method
      2. Indications
         1. Bag-valve-mask ventilation on any patient
            1. Especially useful for cervical spine immobilized patients
            2. Difficulty obtaining or maintaining adequate mask seal
      3. Contraindications
         1. Awake, intolerant patients
      4. Advantages
         1. Superior mask seal
         2. Superior volume delivery
      5. Disadvantages
         1. Requires extra personnel
      6. Complications
         1. Hyperinflation of patient's lungs
         2. Gastric distention
      7. Method for use
         1. First rescuer maintains mask seal by appropriate method
         2. Second rescuer squeezes bag
      8. Special considerations
         1. Observe chest movement
         2. Avoid overinflation
         3. Monitor lung compliance with ventilations
   6. Three-person bag-valve-mask ventilation
      1. Indications
         1. Bag-valve-mask ventilation on any patient
            1. Especially useful for cervical spine immobilized patients
            2. Difficulty obtaining or maintaining adequate mask seal
      2. Contraindications
         1. Awake, intolerant patients
      3. Advantages
         1. Superior mask seal
         2. Superior volume density
      4. Disadvantages
         1. Requires extra personnel
         2. "Crowded" around airway
      5. Complications
         1. Hyperinflation of patient�s lungs
         2. Gastric distention
      6. Method for use
         1. First rescuer maintains mask seal by appropriate method
         2. Second rescuer holds mask in place
         3. Third rescuer squeezes bag and monitors compliance
      7. Special considerations
         1. Avoid overinflation
         2. Monitor lung compliance with ventilations
   7. Flow-restricted, oxygen-powered ventilation devices
      1. The valve opening pressure at the cardiac sphincter is approx. 30 cm H₂O
      2. These devices operate at or below 30 cm H₂O to prevent gastric distention
      3. Indications
         1. Delivery of high volume/ high concentration of O₂ (1 L/ sec)
         2. Awake compliant patients
         3. Unconscious patient with caution
      4. Contraindications
         1. Noncompliant patients
         2. Poor tidal volume
         3. Small children
      5. Advantages
         1. Self administered
         2. Delivers high volume/ high concentration O₂
         3. O₂ delivered in response to inspiratory effort (no O₂ wasting)
         4. O₂ volume delivery is regulated by inspiratory effort minimizing overinflation risk
         5. O₂ volume delivery is also restricted to less than 30 cm H₂O
      6. Disadvantages
         1. Cannot monitor lung compliance
         2. Requires O₂ source
      7. Complications
         1. Gastric distention
         2. Barotrauma
      8. Method
         1. Mask is held manually in place
         2. Negative pressure upon inspiration triggers O₂ delivery or medic triggers release button
         3. Patient is monitored for adequate tidal volume and oxygenation
   8. Automatic transport ventilators
      1. Volume/ rate controlled
      2. Indications
         1. Extended ventilation of intubated patients
         2. In situations in which a BVM is used
         3. Can be used during CPR
      3. Contraindications
         1. Awake patients
         2. Obstructed airway
         3. Increased airway resistance
            1. Pneumothorax (after needle decompression)
            2. Asthma
            3. Pulmonary edema
      4. Advantages
         1. Frees personnel to perform other tasks
         2. Lightweight
         3. Portable
         4. Durable
         5. Mechanically simple
         6. Adjustable tidal volume
         7. Adjustable rate
         8. Adapts to portable O₂ tank
      5. Disadvantages
         1. Cannot detect tube displacement
         2. Does not detect increasing airway resistance
         3. Difficult to secure
         4. Dependent on O₂ tank pressure
   9. Cricoid pressure - Sellick�s maneuver
      1. Pressure on cricoid Ring
      2. Occludes esophagus
      3. Facilitates intubation by moving the larynx posteriorly
      4. Helps to prevent passive emesis
      5. Can help minimize gastric distention during bag-valve-mask ventilation
      6. Indications
         1. Unconscious patients receiving BVM ventilations
         2. Patient cannot protect own airway
      7. Contraindications
         1. Use with caution in cervical spine injury
      8. Advantages
         1. Noninvasive
         2. Minimizes risk of aspiration as long as pressure is maintained
      9. Disadvantages
         1. May have extreme emesis if pressure is removed
         2. Second rescuer required for bag-valve-mask ventilation
         3. May further compromise injured cervical spine
      10. Complications
          1. Laryngeal trauma with excessive force
          2. Esophageal rupture from unrelieved high gastric pressures
          3. Excessive pressure may obstruct the trachea in small children
      11. Method
          1. Locate the anterior aspect of the cricoid ring
          2. Apply firm, posterior pressure
          3. Maintain pressure until the airway is secured with an endotracheal tube
   10. Artificial ventilation of the pediatric patient
       1. Flat nasal bridge makes achieving mask seal more difficult
       2. Compressing mask against face to improve mask seal results in obstruction
       3. Mask seal best achieved with jaw displacement (two person bag-valve-mask)
       4. Bag-valve-mask ventilation
          1. Bag size
             1. Full-term neonates and infants - minimum of 450 ml tidal volume (pediatric BVM)
             2. Children up to eight years of age - pediatric BVM preferred but adult-sized BVM (1500 ml) may be used
             3. Children over eight years of age require adult-sized BVM for adequate ventilation
             4. Proper mask fit
             5. Length based resuscitation tape
             6. Bridge of nose to cleft of chin
          2. Proper mask position and seal (EC-clamp)
             1. Place mask over mouth and nose; avoid compressing the eyes
             2. Using one hand, place thumb on mask at apex and index finger on mask at chin (C-grip)
             3. With gentle pressure, push down on mask to establish adequate seal
             4. Maintain airway by lifting bony prominence of chin with remaining fingers forming an "E"; avoid placing pressure on the soft area under chin
             5. May use one or two rescuer technique
          3. Ventilate according to current standards
          4. Obtain chest rise with each breath
             1. Begin ventilation and say "squeeze"; provide just enough volume to initiate chest rise; DO NOT OVERVENTILATE
          5. Allow adequate time for exhalation
             1. Begin releasing the bag and say "release, release"
          6. Continue ventilations using "squeeze, release, release" method
          7. Assess BVM ventilation
             1. Look for adequate chest rise
             2. Listen for lung sounds at third intercostal space, midaxillary line
             3. Assess for improvement in color and/ or heart rate
          8. Apply cricoid pressure to minimize gastric inflation and passive regurgitation
             1. Locate cricoid ring by palpating the trachea for a prominent horizontal band inferior to the thyroid cartilage and cricothyroid membrane
             2. Apply gentle downward pressure using one fingertip in infants and the thumb and index finger in children
             3. Avoid excessive pressure as it may produce tracheal compression and obstruction in infants
   11. Ventilation of stoma patients
       1. Mouth-to-stoma
          1. Locate stoma site and expose
          2. Pocket mask to stoma preferred
             1. Seal around stoma site, check for adequate ventilation
             2. Seal mouth and nose if air leak evident
       2. Bag-valve-mask to stoma
          1. Locate stoma site and expose
          2. Seal around stoma site, check for adequate ventilation
          3. Seal mouth and nose if air leak evident

• Provide care to a patient experiencing cardiovascular compromise.
• Attempt to resuscitate a patient in cardiac arrest.
• Provide post-resuscitation care to a cardiac arrest patient.

COGNITIVE OBJECTIVES
At the completion of this unit, the EMT-Intermediate will be able to:

PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the EMT-Intermediate will be able to:

DECLARATIVE

1. Management of the patient with arrhythmias
   1. Assessment
      1. Symptomatic
      2. Hypotensive
      3. Hypoperfusion
   2. Treatment
      1. Mechanical interventions
         1. Vagal maneuvers - if the heart rate is too fast
         2. Stimulation - if heart rate is too slow
         3. Precordial thump
         4. Cough
      2. Pharmacological interventions (for example)
         1. Aspirin
         2. Atropine
         3. Adenosine
         4. Epinephrine
         5. Furosemide
         6. Lidocaine
         7. Morphine
         8. Nitroglycerin
         9. Oxygen
      3. Electrical
         1. Defibrillation
         2. Transcutaneous pacing
            1. Implanted pacemaker functions
               1. Characteristics
               2. Pacemaker artifact
               3. ECG tracing of capture
               4. Failure to sense
                  1. ECG indications
                  2. Clinical significance
               5. Failure to capture
                  1. ECG indications
                  2. Clinical significance
               6. Failure to pace
                  1. ECG indications
                  2. Clinical significance
      4. Transport considerations
      5. Psychological support / communications strategies
         1. Explanation for patient, family, significant others
         2. Communications and transfer of data to the physician
2. Management of chest pain that may be myocardial infarction
   1. Position of comfort
   2. Pharmacological interventions (for example)
      1. Oxygen
      2. Aspirin
      3. Nitroglycerin
      4. Morphine
   3. ECG
   4. Transport considerations
      1. Sense of urgency for reperfusion
         1. No relief with medications
         2. Hypotension / hypoperfusion
   5. Psychological support / communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
3. Cardiac Arrhythmias
   1. Common management modalities
      1. Assessment of LOC, airway, breathing and circulation (ABCs)
      2. High flow oxygen
      3. Question medical and medication history, allergies
      4. Communicate with the physician
      5. Intravenous (IV) access
      6. Consider aspirin
      7. Pain management
         1. Nitroglycerin
         2. Morphine
      8. Transport considerations common to all conditions
      9. Psychological support / communications strategies
         1. Explanation for patient, family, significant others
         2. Communications and transfer of data to the physician
   2. Tachycardias, narrow-QRS complex
      1. Sinus tachycardia
         1. Management - ABCs, oxygen (as in III.A)
         2. Identify and treat the cause - e.g., fever, pain, anxiety, anger
         3. Transport and support (as in III.A.8 and .9)
      2. Supraventricular tachycardia
         1. Management - ABCs, oxygen (as in III.A)
            1. Vagal maneuvers
            2. Consider adenosine
               1. Ventricular rate greater than 150
               2. Use with caution, if at all, in atrial flutter
                  1. Fear of catastrophic event resulting from acceleration of ventricular rate, that is, from 2:1 to 1:1 conduction
                  2. Every attempt must be taken to clarify that the patient is not in atrial flutter
               3. When in doubt, do not use adenosine
         2. Transport and support (as in III.A.8 and .9)
      3. Wide-complex (see Ventricular tachycardia)
      4. Bradycardia
      5. Narrow complex
         1. Sinus
         2. Junctional
         3. AV blocks
      6. Management - ABCs, oxygen (as in III.A)
         1. Consider atropine if symptomatic, hypotensive and hypoperfusion
            1. Transport and support (as in III.A.8 and .9)
      7. Wide complex
         1. May have a preexisting complication (identified by history)
            1. Accessory pathway
            2. Bundle branch block
         2. New onset
            1. AV blocks
      8. Management - ABCs, oxygen (as in III.A)
         1. Atropine may be contraindicated
      9. Transport for pacemaker
      10. Support (as in III.A.9)
   3. Ventricular arrhythmias
      1. Ectopics (PVCs)
         1. Management - ABCs, oxygen (as in III.A)
         2. Consider lidocaine
         3. Transport and support (as in III.A.8 and .9)
      2. Ventricular tachycardia
         1. Stable, LOC, blood pressure not impaired
            1. Management - ABCs, oxygen (as in III.A)
            2. Consider lidocaine
            3. Consider adenosine
            4. Transport and support (as in III.A.8 and .9)
         2. Unstable
            1. LOC altered, diminished or unresponsive
            2. Chest pain/pressure
            3. Consider sedation
            4. Consider defibrillation
            5. Transport and support (as in III.A.8 and .9)
         3. Pulseless
            1. Defibrillation as soon as possible
            2. Transport and support (as in III.A.8 and .9)
      3. Ventricular fibrillation
         1. Management
            1. Confirm pulselessness
            2. Cardiopulmonary resuscitation (CPR) until defibrillation is available
               1. Confirm pulses with CPR
               2. High flow oxygen
                  1. Bag-valve-mask
                  2. Intubate
            3. Defibrillation as soon as possible
               1. Energy dosage
                  1. In accordance with local medical protocol
                  2. In accordance with type and model of defibrillator
            4. Pharmacological interventions (for example)
               1. Epinephrine
               2. Lidocaine
            5. Transport and support (as in III.A.8 and .9)
   4. Pulseless electrical activity (PEA)
      1. Management
         1. Confirm pulselessness
         2. Cardiopulmonary resuscitation (CPR)
         3. Confirm pulses with CPR
         4. High flow oxygen
            1. Bag-valve-mask
            2. Intubate
         5. Monitor ECG
            1. Basic ECG rhythm, sinus, atrial, junctional, AV blocks
            2. Ventricular rate
         6. Intravenous (IV) fluids
            1. Fluid challenge
               1. Normal saline
               2. Lactated ringers
         7. Pharmacological interventions (for example)
            1. Epinephrine
            2. Atropine if rhythm is bradycardic
         8. Attempt to identify and treat the cause (for example)
            1. Hypovolemia
            2. Pneumothorax
            3. Tamponade
            4. Hypothermia
            5. Pulmonary embolus
            6. Drug overdose
      2. Transport and support (as in III.A.8 and .9)
   5. Asystole (confirmed in second ECG lead)
      1. Management
         1. Cardiopulmonary resuscitation (CPR)
         2. Confirm pulses with CPR
         3. High flow oxygen
            1. Bag-valve-mask
            2. Intubation
         4. Monitor ECG
            1. Basic ECG rhythm, sinus, atrial, junctional, AV blocks
            2. Ventricular rate
         5. Intravenous (IV) fluids
            1. Fluid challenge
               1. Normal saline
               2. Lactated ringers
         6. Pharmacological interventions (for example)
            1. Epinephrine
            2. Atropine
         7. Attempt to identify and treat the cause (for example)
            1. Hypovolemia
            2. Pneumothorax
            3. Tamponade
            4. Hypothermia
            5. Hyperkalemia
            6. Hypokalemia
            7. Drug overdose
      2. Transport and support (as in III.A.8 and .9)
4. Management of pulmonary edema
   1. Position of comfort
   2. Pharmacological interventions (for example)
      1. Oxygen
      2. Nitroglycerin
      3. Lasix
      4. Morphine
   3. Transport considerations
   4. Psychological support / communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
5. Management of hypertensive emergencies
   1. Pharmacological interventions (for example)
      1. Oxygen
   2. Non-pharmacological interventions
      1. Position of comfort
      2. Airway and ventilation
   3. Transport considerations
   4. Psychological support / communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
6. Management of cardiogenic shock
   1. Position of comfort
      1. Patient may prefer sitting upright with legs in dependent position
   2. Pharmacological interventions (for example)
      1. Oxygen
      2. Nitroglycerin
      3. Lasix
      4. Antiarrhythmic as indicated
      5. Fluid therapy
   3. Transport considerations
   4. Psychological support / communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
7. Management of cardiac arrest
   1. Related terminology
      1. Resuscitation - to provide efforts to return spontaneous pulse and breathing to the patient in cardiac arrest
      2. Survival - patient is resuscitated and survives to hospital discharge
      3. Return of spontaneous circulation (ROSC) - patient is resuscitated to the point of having pulse without CPR; may or may not have return of spontaneous respirations; patient may or may not go on to survive
   2. Indications for NOT initiating resuscitative techniques
      1. Signs of obvious death
         1. Rigor, fixed lividity, decapitation
      2. Local protocol
         1. Out of hospital advance directives
   3. Airway and ventilatory support
      1. High flow oxygen
         1. Bag-valve-mask
         2. Intubation
   4. Circulatory support
      1. CPR in conjunction with defibrillation
      2. IV therapy
   5. Pharmacological interventions (for example)
      1. Oxygen
      2. Epinephrine
      3. Lidocaine
   6. Transport considerations
   7. Psychological support / communications strategies
      1. Explanation for patient, family, significant others
      2. Communications and transfer of data to the physician
   8. Termination of resuscitation
      1. Identify local protocols
      2. Criteria for inclusion (for example)
         1. 18 years old or older
         2. Arrest is presumed cardiac in origin and not association with a condition potentially responsive to hospital treatment (e.g., hypothermia, drug overdose, toxicologic exposure)
         3. Endotracheal intubation has been successfully accomplished and maintained
         4. Standard advanced cardiac life support measures have been applied throughout the resuscitative effort
         5. On-scene ALS resuscitation efforts have been sustained for 25 minutes or the patient remains in asystole through four rounds of appropriate ALS drugs
         6. Patient has a cardiac rhythm of asystole or agonal rhythm at the time the decision to terminate is made and this rhythm persists until the arrest is actually terminated
         7. Victims of blunt trauma in arrest whose presenting rhythm is asystole or who develop asystole while on scene
      3. Exclusion criteria (for example)
         1. Under the age of 18
         2. Etiology for which specific in-hospital treatment may be beneficial
         3. Persistent or recurrent ventricular tachycardia or fibrillation
         4. Transient return of pulse
         5. Signs of neurological viability
         6. Arrest was witnessed by EMS personnel
         7. Family or responsible party opposed to termination
      4. Criteria NOT to be considered as inclusionary or exclusionary
         1. Patient age (e.g., geriatric)
         2. Time of collapse prior to EMS arrival
         3. Presence of a non-official do-not-resuscitate (DNR) order
         4. Quality of life valuations
      5. Procedures (according to local protocol)
         1. Direct communication with on-line medical direction
            1. Medical condition of the patient
            2. Known etiologic factors
            3. Therapy rendered
            4. Family present and apprised of the situation
            5. Communicate any resistance or uncertainty on the part of the family
            6. Maintain continuous documentation to include ECG
            7. Mandatory review after the event
               1. Grief support (according to local protocol)
                  1. EMS assigned personnel
                  2. Community agency referral
               2. Law enforcement (according to local protocol)
                  1. On-scene determination if the event/patient requires assignment of the patient to the medical examiner
                  2. On-scene law enforcement communicates with attending physician for the death certificate
                  3. If there is any suspicion about the nature of the death or if the physician refuses or hesitates to sign the death certificate
                  4. No attending physician is identified (the patient will be assigned to the medical examiner)

1. Assessment findings of allergic reaction
   1. Not all signs and symptoms are present in every case
   2. History
      1. Previous exposure
      2. Previous experience to exposure
      3. Onset of symptoms
      4. Dyspnea
   3. Level of consciousness
      1. Unable to speak
      2. Restless
      3. Decreased level of consciousness
      4. Unresponsive
   4. Upper airway
      1. Hoarseness
      2. Stridor
      3. Pharyngeal edema/ spasm
   5. Lower airway
      1. Tachypnea
      2. Hypoventilation
      3. Labored - accessory muscle use
      4. Abnormal retractions
      5. Prolonged expirations
      6. Wheezes
      7. Diminished lung sounds
   6. Skin
      1. Redness
      2. Rashes
      3. Edema
      4. Moisture
      5. Itching
      6. Urticaria
      7. Pallor
      8. Cyanotic
   7. Vital Signs
      1. Tachycardia
      2. Hypotension
      3. Assessment tools
      4. Cardiac monitor
2. Management of anaphylaxis
   1. Remove offending agent (i.e. remove stinger)
   2. Airway and ventilation
      1. Positioning
      2. Oxygen
      3. Assist ventilation
      4. Advanced airway
   3. Circulation
      1. Venous access
      2. Fluid resuscitation
   4. Pharmacological interventions
      1. Oxygen
      2. Epinephrine - main stay of treatment
         1. Bronchodilator
         2. Decreases vascular permeability
         3. Vasoconstriction
      3. Bronchodilator
   5. Transport considerations
   6. Psychological support / communications strategies
3. Management of acute allergic reaction without dyspnea or hypotension
   1. Remove offending agent (i.e., stinger)
   2. Airway and ventilation
   3. Circulation
   4. Transport considerations
   5. Psychological support / communications strategies
4. Specific pathology, assessment and management - near-drowning
   1. Definitions
      1. Drowning - suffocation due to submersion in water or other fluids.
      2. Near-drowning - near suffocation due to submersion in water or other fluids with a recovery event that lasts at least 24 hours.
   2. Pathophysiology
      1. Hypothermic considerations in near-drownings
         1. Common concomitant syndrome
         2. May be organ protective in cold-water near-drownings
         3. Always treat hypoxia first
         4. Treat all near-drowning patients for hypothermia
   3. Treatment
      1. Establish airway
         1. Conflicting recommendations regarding prophylactic abdominal thrusts
         2. Questionable scientific data to support prophylactic abdominal thrusts
      2. Ventilation
      3. Oxygen
   4. Trauma considerations
      1. Immersion episode of unknown etiology warrants trauma management
   5. Post-resuscitation complications
      1. Adult respiratory distress syndrome (ARDS) or renal failure often occur post-resuscitation
      2. Symptoms may not appear for 24 hours or more, post-resuscitation
      3. All near-drowning patients should be transported for evaluation
5. Specific toxicology, assessment and management
   1. Definition / advantages
      1. Grouping of toxicologically-similar agents
      2. Useful for remembering the assessment and management of toxicological emergencies
      3. Does not consider how or why the toxin has been introduced to the body
      4. Be sure to include the general management on route of entry in addition to specific treatments
   2. Cholinergics
      1. Common causative agents
         1. Pesticides (organophosphates / carbamates)
         2. Nerve agents (sarin, Soman)
      2. Assessment findings
         1. Headache
         2. Dizziness
         3. Weakness
         4. Nausea
         5. SLUDGE (Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis)
         6. Bradycardia, wheezing, bronchoconstriction, myosis, coma, convulsions
         7. Diaphoresis, seizures
   3. Anticholinergics
      1. Common causative agents
      2. Assessment findings
   4. Narcotics / opiates
      1. Common causative agents
         1. Heroin
         2. Morphine
         3. Codeine
         4. Meperidine
         5. Propoxyphene
         6. Fentanyl
      2. Assessment findings
         1. Euphoria
         2. Hypotension
         3. Respiratory depression / arrest
         4. Nausea
         5. Pinpoint pupils
         6. Seizures
         7. Coma
   5. Carbon monoxide
      1. Source
      2. Common causative agents
      3. Pharmacodynamics
      4. Pharmacokinetics
      5. Assessment findings
   6. Psychiatric medications
      1. Tricyclic antidepressants
         1. Clinical use
         2. Common causative agents
            1. Amitriptyline
            2. Amoxapine
            3. Clomipramine
            4. Doxepin
            5. Imipramine
            6. Norptyline
         3. Pharmacodynamics
         4. Pharmacokinetics
         5. Assessment findings
            1. Early findings (dry mouth, confusion, hallucinations)
            2. Late findings (delirium, respiratory depression, hypotension, hyperthermia, seizures, coma)
            3. Cardiotoxicity - dysrhythmias
   7. Bites and stings
      1. Common offendings organisms
         1. Hymenoptera
         2. Spiders
         3. Other anthropods
         4. Snakes
         5. Marine animals
      2. Pharmacodynamics
      3. Pharmacokinetics
      4. Assessment findings

• Perform a rapid trauma assessment
• Provide care to a patient with shock (hypo-perfusion)
• Provide care to a patient with a suspected spinal injury
• Provide care to a patient with a chest injury

Cognitive Objectives
At the completion of this unit, the EMT-Intermediate will be able to:

Psychomotor Objectives
At the completion of this unit, the EMT-Intermediate will be able to:

1. Focused history and physical exam - trauma patients
   1. Re-consider mechanism of injury
      1. Helps to identify priority patients
      2. Helps to guide the assessment
      3. Significant mechanism of injury
         1. Ejection from vehicle
         2. Death in same passenger compartment
         3. Falls > 20 feet
         4. Roll-over of vehicle
         5. High-speed vehicle collision
         6. Vehicle-pedestrian collision
         7. Motorcycle crash
         8. Unresponsive or altered mental status
         9. Penetrations of the head, chest, or abdomen
         10. Hidden injuries
             1. Seat belts
                1. If buckled, may have produced injuries
                2. If patient had seat belt on, it does not mean they do not have injuries
             2. Airbags
                1. May not be effective without seat belt
                2. Patient can hit wheel after deflation
                3. Lift the deployed airbag and look at the steering wheel for deformation
                   1. "Lift and look" under the bag after the patient has been removed
                   2. Any visible deformation of the steering wheel should be regarded as an indicator of potentially serious internal injury, and appropriate action should be taken
                   3. Child safety seats
                      1. Injury patterns with airbags
                      2. Proper use in vehicles with airbags
      4. Additional infant and child considerations
         1. Falls >10 feet
         2. Bicycle collision
         3. Vehicle in medium speed collision
   2. Perform rapid trauma physical examination on patients with significant mechanism of injury to determine life-threatening injuries
      1. In the responsive patient, symptoms should be sought before and during the trauma assessment
      2. Continue spinal stabilization
      3. Reconsider transport decision
      4. Assess mental status
      5. As you inspect and palpate, look and feel for injuries or signs of injury
      6. Examination
         1. Assess the head, inspect and palpate for injuries or signs of injury
         2. Assess the neck, inspect and palpate for injuries or signs of injury
         3. Apply cervical spinal immobilization collar (CSIC)
         4. Assess the chest
         5. Assess the abdomen, inspect and palpate for injuries or signs of injury
         6. Assess the pelvis, inspect and palpate for injuries or signs of injury
         7. Assess all four extremities, inspect and palpate for injuries or signs of injury
         8. Roll patient with spinal precautions and assess posterior body, inspect and palpate, examining for injuries or signs of injury
         9. Look for medical identification devices
         10. Assess baseline vital signs
         11. Assess patient history
         12. Chief complaint
         13. History of present illness
         14. Past medical history
         15. Current health status
2. Shock
   1. Epidemiology
   2. Pathophysiology
   3. Stages of Shock
   4. Assessment
   5. Management/ treatment plan
      1. Airway and ventilatory support
         1. Ventilate and suction as necessary
         2. Administer high concentration oxygen
         3. Reduce increased intrathoracic pressure in tension pneumothorax
      2. Circulatory support
         1. Hemorrhage control
         2. Intravenous volume expanders
            1. Types
               1. Isotonic solutions
               2. Hypertonic solutions
               3. Synthetic solutions
               4. Blood and blood products
               5. Experimental solutions
               6. Blood substitutes
            2. Rate of administration
               1. External hemorrhage that can be controlled
               2. External hemorrhage that can not be controlled
            3. Internal hemorrhage
               1. Blunt trauma
               2. Penetrating trauma
         3. Pneumatic anti-shock garment
            1. Effects
               1. Increased arterial blood pressure above garment
               2. Increased systemic vascular resistance
               3. Immobilization of pelvis and possibly lower extremities
               4. Increased intra-abdominal pressure
            2. Mechanism
               1. Increases systemic vascular resistance through direct compression of tissues and blood vessels
               2. Negligible autotransfusion effect
            3. Indications
               1. Hypoperfusion with unstable pelvis
               2. Conditions of decreased SVR not corrected by other means
               3. As approved locally, other conditions characterized by hypoperfusion with hypotension
               4. Research studies
            4. Contraindications
               1. Advanced pregnancy (no inflation of abdominal compartment)
               2. Object impaled in abdomen or evisceration (no inflation of abdominal compartment)
               3. Ruptured diaphragm
               4. Cardiogenic shock
               5. Pulmonary edema
         4. Needle chest decompression of tension pneumothorax to improve impaired cardiac output
         5. Recognize the need for expeditious transport of suspected cardiac tamponade for pericardiocentesis
      3. Pharmacological interventions
         1. Hypovolemic shock
            1. Volume expanders
         2. Cardiogenic shock
            1. Volume expanders
            2. Positive cardiac inotropes
            3. Vasoconstrictor
            4. Rate altering medications
         3. Distributive shock
            1. Volume expanders
            2. Positive cardiac inotropes
            3. Vasoconstriction
            4. PASG
         4. Obstructive shock
            1. Volume expanders
         5. Spinal shock
            1. Volume expanders
      4. Psychological support/communication strategies
      5. Transport considerations
         1. Indications for rapid transport
         2. Indications for transport to a trauma center
         3. Considerations for air medical transportation
3. Thoracic trauma
   1. General Introduction
      1. Epidemiology
      2. Mechanism of injury
      3. Anatomy and physiology review of the thorax
      4. Pathophysiology
      5. Assessment findings
      6. Management
         1. Airway and ventilation
            1. Oxygen therapy
            2. Endotracheal intubation
            3. Needle cricothyrotomy
            4. Surgical cricothyrotomy
            5. Positive pressure ventilation
            6. Occlude open wounds
            7. Stabilize chest wall
         2. Circulation
            1. Manage cardiac dysrhythmias
            2. Intravenous access
         3. Pharmacologic
            1. Analgesics
            2. Antiarrhythmics
         4. Non-pharmacologic
            1. Needle thoracostomy
            2. Tube thoracostomy - in hospital management
            3. Pericardiocentesis - in hospital management
         5. Transport considerations
            1. Appropriate mode
            2. Appropriate facility
   2. Chest wall injuries
      1. Rib fractures
         1. Epidemiology
         2. Anatomy and physiology review
         3. Pathophysiology
         4. Assessment findings
         5. Management
            1. Airway and ventilation
               1. Oxygen therapy
               2. Positive pressure ventilation
               3. Encourage coughing and deep breathing
            2. Pharmacological
               1. Analgesics
            3. Non-pharmacological
               1. Splint - but avoid circumferential splinting
            4. Transport consideration
               1. Appropriate mode
               2. Appropriate facility
            5. Psychological support/ communication strategies
      2. Flail segment
         1. Epidemiology
         2. Pathophysiology
         3. Assessment findings
         4. Management
            1. Airway and ventilation
               1. Positive pressure ventilation may be needed
               2. Oxygen (high concentration)
               3. Evaluate the need for endotracheal intubation
               4. Stabilize flail segment (may be controversial locally)
               5. Positive end expiratory pressure (PEEP)
            2. Circulation
               1. Restrict fluids
            3. Pharmacologic
               1. Analgesics
            4. Non-pharmacologic
               1. Positioning
               2. Endotracheal intubation and positive pressure ventilation for internal splinting effect
            5. Transport considerations
               1. Appropriate mode
               2. Appropriate facility
            6. Psychological support/ communication strategies
      3. Sternal fracture
         1. Epidemiology
         2. Pathophysiology
         3. Assessment findings
         4. Management
            1. Airway and ventilation
            2. Circulation
               1. Restrict fluids if pulmonary contusion is suspected
            3. Pharmacologic
               1. Analgesics
            4. Non-pharmacologic
               1. Allow chest wall self-splinting
            5. Transport considerations
               1. Appropriate mode
               2. Appropriate facility
            6. Psychological support/ communication strategies
   3. Injury to the lung
      1. Simple pneumothorax
         1. Epidemiology
         2. Pathophysiology
         3. Assessment findings
         4. Management
            1. Airway and ventilation
               1. Positive pressure ventilation if necessary
               2. Monitor for development of tension pneumothorax
            2. Non-pharmacologic
               1. Needle thoracostomy
            3. Transport consideration
               1. Appropriate mode
               2. Appropriate facility
            4. Psychological support/ communication strategies
      2. Open pneumothorax
         1. Epidemiology
         2. Pathophysiology
         3. Assessment findings
         4. Management
            1. Airway and ventilation
               1. Positive pressure ventilation if necessary
               2. Monitor for development of tension pneumothorax
            2. Non-pharmacologic
               1. Occlude open wound
               2. Tube thoracostomy - in hospital management
            3. Transport consideration
               1. Appropriate mode
               2. Appropriate facility
            4. Psychological support/ communication strategies
      3. Tension pneumothorax
         1. Epidemiology
         2. Pathophysiology
         3. Assessment findings
         4. Management
            1. Airway and ventilation
               1. Positive pressure ventilation if necessary
            2. Circulation
               1. Relieve tension pneumothorax to improve cardiac output
            3. Non-pharmacologic
               1. Occlude open wound
               2. Needle thoracentesis

• Equipment
• Technique
• Assess the need for a second or third needle insertion

1. Tube thoracostomy - in hospital management
2. Transport consideration
   1. Appropriate mode
   2. Appropriate facility
3. Psychological support/ communication strategies

1. Hemothorax
   1. Epidemiology
   2. Pathophysiology
   3. Assessment findings
   4. Management
      1. Airway and ventilation
         1. Positive pressure ventilation if necessary
      2. Circulation
         1. Re-expand the affected lung to reduce bleeding
      3. Non-pharmacological
         1. Needle chest decompression
         2. Tube thoracostomy - in hospital management
      4. Transport considerations
         1. Appropriate mode
         2. Appropriate facility
      5. Psychological support/ communication strategies
2. Hemopneumothorax
   1. Epidemiology
   2. Pathophysiology
   3. Assessment findings
   4. Management
      1. Management is the same as a hemothorax
3. Pulmonary contusion
   1. Epidemiology
   2. Pathophysiology
   3. Assessment findings
   4. Management
      1. Airway and ventilation
         1. Positive pressure ventilation if necessary
      2. Circulation
         1. Restrict intravenous fluids (use caution restricting fluids in hypovolemic patients)
      3. Transport considerations
         1. Appropriate mode
         2. Appropriate facility
      4. Psychological support/ communication strategies

1. Myocardial injuries
   1. Pericardial tamponade
      1. Epidemiolgy
      2. Anatomy and physiology
      3. Pathophysiology
      4. Assessment findings
      5. Management
         1. Airway and ventilation
         2. Circulation
            1. Fluid challenge
         3. Non-pharmacological
            1. Pericardiocentesis - in hospital management
         4. Transport considerations
            1. Appropriate mode
            2. Appropriate facility
         5. Psychological support/ communication strategies
   2. Myocardial contusion (blunt myocardial injury)
      1. Epidemiology
      2. Anatomy and physiology
      3. Pathophysiology
      4. Assessment findings
      5. Management
         1. Airway and ventilation
            1. Oxygen therapy
         2. Circulation
            1. Intravenous fluid volume
         3. Pharmacological
            1. Antiarrhythmics
            2. Vasopressors
         4. Transport considerations
            1. Appropriate mode
            2. Appropriate facility
         5. Psychological support/ communication strategies
   3. Myocardial rupture
      1. Epidemiology
      2. Anatomy and physiology
      3. Pathophysiology
      4. Assessment findings
      5. Management is supportive
2. Vascular injuries
   1. Aortic dissection/ rupture
      1. Epidemiology
      2. Anatomy and physiology
      3. Pathophysiology
      4. Assessment findings
      5. Management
         1. Airway and ventilation
         2. Circulation
            1. Do not over hydrate
         3. Transport considerations
            1. Appropriate mode
            2. Appropriate facility
         4. Psychological support/ communication strategies
   2. Penetrating wounds of the great vessels
      1. Epidemiology
      2. Anatomy and physiology
      3. Pathophysiology
      4. Assessment findings
      5. Management
         1. Manage hypovolemia
            1. PASG not recommended
         2. Relief of tamponade if present
         3. Expeditious transport
3. Other thorax injuries
   1. Diaphragmatic injury
      1. Epidemiology
      2. Pathophysiology
      3. Assessment
      4. Management
         1. Airway and ventilation
            1. Positive pressure ventilation if necessary
            2. Caution IPPB may worsen the injury
         2. Non-pharmacologic
            1. Do not place patient in Trendelenburg position
         3. Transport consideration
            1. Appropriate mode
            2. Appropriate facility
         4. Psychological support/ communication strategies
   2. Esophageal injury
      1. Epidemiology
      2. Pathophysiology
      3. Assessment
      4. Management
         1. Airway and ventilation
         2. Transport consideration
            1. Appropriate mode
            2. Appropriate facility
         3. Psychological support/ communication strategies
   3. Tracheo-bronchial injuries
      1. Epidemiology
      2. Pathophysiology
      3. Assessment
      4. Management
         1. Airway and ventilation
         2. Circulation
         3. Transport consideration
            1. Appropriate mode
            2. Appropriate facility
   4. Traumatic asphyxia
      1. Epidemiology
      2. Pathophysiology
      3. Assessment
      4. Management
         1. Airway and ventilation
         2. Circulation
            1. Expect hypotension once compression is released
         3. Pharmacological
            1. Sodium bicarbonate should be guided by ABGs in hospital
         4. Transport considerations
            1. Appropriate mode
            2. Appropriate facility

• Assess an infant or child w/ cardiac arrest
• Provide care to an infant or child w/ cardiac arrest
• Assess an infant or child w/ respiratory distress
• Provide care to an infant or child in respiratory distress
• Assess an infant or child with shock (hypoperfusion)
• Provide care to an infant or child with shock (hypoperfusion)
• Assess an infant or child with trauma
• Provide care to an infant or child with trauma

Cognitive Objectives
At the completion of this unit, the EMT-Intermediate will be able to:

PSYCHOMOTOR OBJECTIVES
At the completion of this unit, the EMT-Intermediate will be able to:

1. Assessment
   1. General considerations
      1. Many components of the initial patient evaluation can be done by observing the patient. Utilize the parent/ guardian to assist in making the infant or child more comfortable as appropriate.
      2. Interacting with parents and family
         1. Normal responses to acute illness and injury
         2. Parent/ guardian and child interaction
         3. Intervention techniques
   2. Physical exam
      1. Scene survey
         1. Observe the scene for hazards or potential hazards
         2. Observe the scene for mechanism of injury/ illness
            1. Ingestion
               1. Pills, medicine bottles, household chemicals, etc.
            2. Child abuse
               1. Injury and history do not coincide, bruises not where they should be for mechanism of injury, etc.
            3. Position patient found
         3. Observe the parent/ guardian/ caregiver interaction with the child
            1. Do they act appropriately
            2. Is parent/ guardian/ caregiver concerned
            3. Is parent/ guardian/ caregiver angry
            4. Is parent/ guardian/ caregiver indifferent
      2. Initial assessment
         1. General impression
            1. General impression of environment
            2. General impression of parent/ guardian and child interaction
            3. General impression of the patient/ Pediatric Assessment Triangle
               1. A structure for assessing the pediatric patient
                  1. Focuses on the most valuable information for pediatric patients
                  2. Used to ascertain if any life-threatening condition exists
                  3. Components
                     1. Appearance
                        1. Mental status
                        2. Muscle tone
                     2. Work of breathing
                        1. Respiratory rate
                        2. Respiratory effort
                     3. Circulation
                        1. Skin signs
                        2. Skin color
            4. Initial triage decisions
               1. Urgent - proceed with rapid ABC assessment, treatment and transport
               2. Non urgent - proceed with focused history, detailed physical exam after initial assessment
         2. Vital functions
            1. Determine level of consciousness
               1. AVPU scale
                  1. Alert
                  2. Responds to verbal stimuli
                  3. Responds to painful stimuli
                  4. Unresponsive
               2. Modified Glasgow Coma Scale
               3. Signs of inadequate oxygenation
            2. Airway
               1. Determine patency
            3. Breathing
               1. Adequate chest rise and fall
               2. Use of accessory muscles
               3. Nasal flaring
               4. Tachypnea
               5. Bradypnea
               6. Irregular breathing pattern
               7. Head bobbing
               8. Grunting
               9. Absent breath sounds
               10. Abnormal sounds
            4. Circulation
               1. Pulse
                  1. Central
                  2. Peripheral
                  3. Quality of pulse
               2. Blood pressure
                  1. Measuring blood pressure is not necessary in children < 3 years of age
               3. Skin color
               4. Active hemorrhage
            5. Vital signs
               1. Infant
               2. Toddler
               3. Preschool
               4. School aged
               5. Adolescent
      3. Transition phase
         1. Utilized to allow the infant or child to become familiar with you and your equipment
         2. Use of transition phase depends on the seriousness of the patient's condition
         3. For the conscious, non-acutely ill child
         4. For the unconscious, acutely ill child do not perform the transition phase but proceed directly to the treatment and transport
      4. Focused history
         1. Approach
            1. For infant, toddler, and preschool age patient, obtain from parent/ guardian
            2. For school age and adolescent patient, most information may be obtained from the patient
            3. For older adolescent patient question the patient in private regarding sexual activity, pregnancy, illicit drug and alcohol use
         2. Content
            1. Chief complaint
               1. Nature of illness/injury
               2. How long has the patient been sick/injured
               3. Presence of fever
               4. Effects on behavior
               5. Bowel/ urine habits
               6. Vomiting/ diarrhea
               7. Frequency of urination
            2. Past medical history
               1. Infant or child under the care of a physician
               2. Chronic illnesses
               3. Medications
               4. Allergies
      5. Detailed physical exam
         1. Examine all body regions
            1. Head-to-toe in older child
            2. Toe-to-head in younger child
         2. Some or all of the following may be appropriate, depending on the situation
            1. Pupils
            2. Capillary refill
               1. Normal - two seconds or less
               2. Valuable to assess on patients less than six years of age
               3. Less reliable in cold environment
               4. Blanch nailbed, base of the thumb, sole of the feet
            3. Hydration
               1. Skin turgor
               2. Sunken or flat fontanelle in an infant
               3. Presence of tears and saliva
            4. Pulse oximetry
               1. Should be utilized on any moderately injured or ill infant or child
                  1. Hypothermia and shock can alter reading
            5. Cardiac monitor
      6. On-going exam - continually monitor the following
         1. Respiratory effort
         2. Color
         3. Mental status
         4. Pulse oximetry
         5. Vital signs
         6. Patient temperature
   3. General management
      1. Airway management in pediatric patients
         1. Basic airway management
            1. Manual positioning
               1. Allow medical patients to assume position of comfort
               2. Support under the torso for trauma patients less than 3 year old
               3. Occipital elevation for supine medical patients 3 years of age or older
            2. Foreign body airway obstruction - basic clearing methods
               1. Infants
                  1. Back blows
                  2. Chest thrusts
               2. Children
                  1. Abdominal thrusts
               3. Suction
                  1. Avoid hypoxia
                  2. Avoid upper airway stimulation
                  3. Decrease suction negative pressure (100 mm/Hg) in infants
               4. Oxygenation
                  1. Non-rebreather mask
                  2. Blow-by oxygen if mask is not tolerated
                     1. Utilize the parent or guardian to deliver oxygen if (patient condition warrants)
                  3. Maintain proper head position
               5. Oropharyngeal airway
                  1. Sizing
                  2. Preferred method of insertion uses the tongue blade to depress the tongue and jaw
               6. Nasopharyngeal airway
                  1. Sizing
                  2. No major differences in sizing or use compared to adults
               7. Ventilation
                  1. Bag size
                  2. Proper mask fit
                  3. Proper mask position and seal (E-C clamp)
                  4. Ventilate at age appropriate rate (squeeze-release-release)
                  5. Obtain chest rise with each breath
                  6. Allow adequate time for exhalation
                  7. Assess BVM ventilation
                  8. Apply cricoid pressure to minimize gastric inflation and passive regurgitation
         2. Advanced airway management
            1. Foreign body airway obstruction - advanced clearing methods
               1. Direct laryngoscopy with Magill forceps
               2. Attempt intubation around foreign body
            2. Endotracheal intubation in pediatric patients
               1. Laryngoscope and appropriate size blade
                  1. Length based resuscitation tape to determine size
                  2. Straight blade is preferred
               2. Appropriate size endotracheal tube and stylet
                  1. Sizing methods
                     1. Length based resuscitation tape
                        1. Numerical formulas
                        2. Anatomical clues
                  2. Stylet placement
               3. Technique for pediatric intubation
               4. Depth of insertion
               5. Endotracheal tube securing device
      2. Circulation
         1. Vascular access
            1. Intraosseous access in children < 6 years of age in cardiac arrest or if intravenous access fails
         2. Fluid resuscitation
            1. 20 ml/kg of lactated ringer�s or normal saline bolus as needed
      3. Pharmacological
         1. Rapid sequence intubation per medical direction
      4. Non-pharmacological
         1. C-spine immobilization for traumatic cause
      5. Transport considerations
         1. Appropriate mode
            1. Transport should not be delayed to perform procedures that can be done en route
            2. Proper BLS care must be performed prior to any ALS interventions
         2. Appropriate facility
            1. The availability of a receiving hospital with expertise in pediatric care may improve the patient�s outcome
      6. Psychological support/ communication strategies
         1. Utilize the parent/ guardian to assist in making the infant or child more comfortable
         2. Encourage parents to help calm the child during painful procedures
         3. Infants, toddlers, preschool and school aged patients do not like to be separated from parent/ guardian
         4. Infants and children have a natural fear of strangers; for stable patients, allow them to become accustomed to you before your hands-on assessment
         5. Give some control of what is going to happen to the patient (which arm to have their IV)
         6. When possible and practical, physically position your face at the same level as the patient�s face to facilitate communication and minimize fear
         7. Use age-appropriate vocabulary
         8. Keep patient warm
         9. Allow child to take their favorite toy/ blanket if possible
         10. Permit the child to express their feelings (e.g., fear, pain, crying,)
         11. Let the child know that certain physical actions (e.g., hitting, biting, spitting) are not permitted
2. Specific pathophysiology, assessment and management
   1. Respiratory compromise
      1. Introduction
         1. Epidemiology
            1. Incidence
            2. Morbidity/ mortality
            3. Risk factors
            4. Prevention strategies
         2. Categories of respiratory compromise
            1. Upper airway obstruction
            2. Lower airway disease
      2. Pathophysiology
         1. Respiratory illnesses cause respiratory compromise in airway/ lung
            1. Severity of respiratory compromise depends on extent of respiratory illness
            2. Approach to treatment depends on severity of respiratory compromise
         2. Severity
            1. Respiratory distress
               1. Increased work of breathing
               2. Carbon dioxide tension in the blood initially decreases, then increases as condition deteriorates
               3. If uncorrected, respiratory distress leads to respiratory failure
            2. Respiratory failure
               1. Inadequate ventilation or oxygenation
                  1. Respiratory and circulatory systems are unable to exchange enough oxygen and carbon dioxide
               2. Carbon dioxide tension in the blood increases, leading to respiratory acidosis
               3. Very ominous condition; patient is on the verge of respiratory arrest
            3. Respiratory arrest
               1. Cessation of breathing
               2. Failure to intervene will result in cardiopulmonary arrest
               3. Good outcomes can be expected with early intervention that prevents cardiopulmonary arrest
         3. Assessment
            1. Chief Complaint
            2. History
            3. Physical findings
               1. Signs and symptoms of respiratory distress
                  1. Normal mental status => irritability or anxiety
                  2. Tachypnea
                  3. Retractions
                  4. Nasal flaring
                  5. Good muscle tone
                  6. Tachycardia
                  7. Head bobbing
                  8. Grunting
                  9. Cyanosis which improves with supplemental oxygen
               2. Signs and symptoms of respiratory failure
                  1. Irritability or anxiety ==> lethargy
                  2. Marked tachypnea ==> bradypnea
                  3. Marked retractions ==> agonal respirations
                  4. Poor muscle tone
                  5. Marked tachycardia ==> bradycardia
                  6. Central cyanosis
               3. Signs and symptoms of respiratory arrest
                  1. Obtunded ==> coma
                  2. Bradypnea ==> apnea
                  3. Absent chest wall motion
                  4. Limp muscle tone
                  5. Bradycardia ==> asystole
                  6. Profound cyanosis
            4. On-going assessment - improvement indicated by
               1. Improvement in color
               2. Improvement in oxygen saturation
               3. Increased pulse rate
               4. Increased level of consciousness
         4. Management
            1. Graded approach to treatment
            2. Consider separating parent and child
            3. Airway
               1. Manage upper airway obstructions as needed
               2. Insert airway adjunct if needed
            4. Ventilation and oxygenation
               1. Respiratory distress/ early respiratory failure
                  1. Administer high flow oxygen
                  2. Late respiratory failure/ respiratory arrest
                     1. BVM - ventilate patient with 100% oxygen via age- appropriate sized bag
                     2. ETT - intubate patient if positive pressure ventilation does not rapidly improve patient condition
                     3. Consider gastric decompression if abdominal distention is impeding ventilation
                     4. Consider needle decompression per medical direction if tension pneumothorax is present
                     5. Consider cricothyroidotomy per medical direction only as a last resort if complete upper airway obstruction is present
            5. Circulation
            6. Supportive care
            7. Transport considerations
               1. Appropriate mode
               2. Appropriate facility
            8. Psychological support/ communication strategies
      3. Upper airway obstruction
         1. Croup
            1. Epidemiology
               1. Incidence
                  1. Very common in infants and children (6 months to 4 years of age)
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. An inflammatory process of the upper respiratory tract involving the subglottic region
                  1. Main cause is viral infection of the upper airway
                  2. Another form is spasmodic croup
                     1. Occurs mostly in the middle of the night
                     2. Usually without prior upper respiratory infection
            3. Assessment
               1. Signs and symptoms of respiratory distress or failure, depending on severity, plus
                  1. Appears sick
                  2. Stridor
                  3. Barking (seal or dog-like) or brassy cough
                  4. Hoarseness
                  5. Fever (+/-)
               2. History
                  1. Usually with history of upper respiratory infection in classic croup (1-2 days)
                  2. Rarely progresses to respiratory failure
            4. Management
               1. Airway and ventilation
                  1. Humidified or nebulized oxygen
                  2. Cool mist oxygen at 4-6 L/min
               2. Circulation
               3. Pharmacological
               4. Non-pharmacological
                  1. Keep child in position of comfort
               5. Transport considerations
               6. Psychological support/ communication strategies
                  1. Do not agitate the patient (no IVs, blood pressure, etc.)
                  2. Keep the parent/ guardian/ caregiver with the infant or child if appropriate
         2. Foreign body aspiration
            1. Epidemiology
               1. Incidence
                  1. Usually occurs in toddlers and pre-schoolers (1 to 4 years of age, but can occur at any age)
                  2. Common
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. Partial or complete blockage of the upper airway by a foreign body
               2. Objects are usually food (hard candy, nuts, seeds, hot dog) or small objects (coins, balloons)
               3. If no interventions or if interventions are unsuccessful, respiratory arrest followed by cardiopulmonary arrest will ensue
            3. Assessment
               1. Partial obstruction
                  1. Signs and symptoms of respiratory distress or failure, depending on severity, plus
                     1. Appears irritable or anxious, but not toxic
                     2. Inspiratory stridor
                     3. Muffled or hoarse voice
                     4. Drooling
                     5. Pain in throat
                  2. History
                     1. Usually a history of choking if observed by adult
               2. Complete obstruction
                  1. Signs and symptoms of respiratory failure or arrest, depending on severity, plus
                     1. Appears agitated or lethargic
                     2. No or minimal air movement
                  2. History
                     1. History often lacking
                     2. Inability to ventilate despite proper airway positioning
            4. Management
               1. Airway and ventilation
                  1. Partial obstruction
                     1. Place patient in sitting position
                     2. Deliver oxygen by non-rebreather mask or blow-by
                     3. DO NOT ATTEMPT TO LOOK IN MOUTH
                     4. Interventions other than oxygen and transport may precipitate complete obstruction
                  2. Complete obstruction
                     1. Open airway and attempt to visualize the obstruction
                     2. Sweep visible obstructions with your finger (do NOT perform blind finger sweeps)
                     3. Perform BLS FBAO maneuvers
                     4. Attempt BVM ventilations
                     5. Perform laryngoscopy if BVM is unsuccessful
                     6. Remove object if possible with pediatric Magill forceps
                     7. Intubate if possible
                     8. Continue BLS FBAO maneuvers if ALS is unsuccessful
                     9. Consider needle cricothyroidotomy per medical direction only as a last resort
               2. Circulation
               3. Pharmacological
               4. Transport considerations
                  1. Notify hospital of patient status
                  2. Transport expeditiously
               5. Psychological support/ communication strategies
                  1. Do not agitate patient
                     1. No IVs or medications
                     2. Do not look in patient�s mouth
                  2. Keep caregiver with child, if appropriate
         3. Bacterial tracheitis
            1. Epidemiology
               1. Incidence
                  1. Usually occurs in infants and toddlers (1-5 years old), but can occur in older children
                  2. Very uncommon
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. Bacterial infection of the upper airway, subglottic trachea, usually following viral croup
            3. Assessment
               1. Signs and symptoms - respiratory distress or failure depending on severity, plus
                  1. Appears agitated, sick
                  2. High-grade fever
                  3. Inspiratory and expiratory stridor
                  4. Coughing up pus/ mucous
                  5. Hoarse voice
                  6. Pain in throat
            4. History
               1. Usually a history of croup in the preceding few days
               2. May progress to respiratory failure or arrest
            5. Management
               1. Assure airway and ventilation
               2. Administer oxygen by non-rebreather or blow-by
               3. Complete obstruction or respiratory failure/ arrest
                  1. BVM ventilation
                  2. May require high pressure to adequately ventilate
                  3. Intubate patient
                  4. Suction endotracheal tube to reduce pus or mucous
               4. Circulation
               5. Pharmacological
               6. Transport considerations
                  1. Place patient in sitting position
                  2. Notify hospital of patient status as early as possible
                  3. Transport quickly
               7. Psychological support/ communication strategies
                  1. DO NOT AGITATE THE PATIENT - no IVs, no BP, do not look in patient�s mouth
                  2. Keep caregiver with child if appropriate
         4. Epiglottitis
            1. Epidemiology
               1. Incidence
                  1. Usually occurs in pre-school and school-age children (3-7 years of age) but can occur at any age
                  2. Extremely uncommon due to the H. flu vaccine
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. Rapidly forming cellulitis of the epiglottis and its surrounding structures
               2. Bacterial infection, usually Hemophilus influenza type B
               3. Can be a true life-threatening emergency
            3. Assessment
               1. Signs and symptoms of respiratory distress or failure depending on severity, plus
                  1. Appears agitated, sick
                  2. Stridor
                  3. Muffled voice
                  4. Drooling
                  5. Sore throat
                  6. Pain on swallowing
                  7. High fever
               2. History
                  1. Usually no previous history but a rapid onset of symptoms (6-8 hours)
                  2. Can quickly progress to respiratory arrest
            4. Management
               1. Airway and ventilation
                  1. NEVER ATTEMPT TO VISUALIZE THE AIRWAY IF THE PATIENT IS AWAKE
                  2. Allow the parent to administer oxygen
                  3. If airway becomes obstructed, two rescuer ventilation with BVM is almost always effective
                  4. If BVM is not effective, attempt intubation with stylet in place
                  5. Intubation should not be attempted in settings with short transport times
                  6. Performing chest compression upon glottic visualization during intubation may produce a bubble at the tracheal opening
                  7. Consider needle cricothyroidotomy per medical direction as a last resort if complete upper airway obstruction is present
               2. Circulation
               3. Pharmacological
               4. Transport considerations
                  1. Allow patient to assume position of comfort
                  2. Notify hospital of patient status early
                  3. Transport to the hospital without delay, keeping child warm
               5. Psychological support/ communication strategies
                  1. DO NOT AGITATE THE PATIENT - no IVs, BP, do not look in patient�s mouth
                  2. Keep the caregiver with the child if appropriate
      4. Lower airway disease
         1. Asthma
            1. Epidemiology
               1. Incidence
                  1. Usually occurs in children older than 2 years of age
                  2. Very common
               2. Risk factors
                  1. Typically in child with known history of asthma
                  2. Triggered by upper respiratory infections, allergies, changes in temperature, physical exercise and emotional response
                  3. Children that experience prolonged asthma attacks tire easily; watch for signs of respiratory failure
               3. Prevention strategies
            2. Pathophysiology
               1. Bronchospasm
               2. Excessive mucous production
               3. Inflammation of the small airways
            3. Assessment
               1. Signs and symptoms - respiratory distress or failure depending on severity, plus
                  1. Appears anxious
                  2. Wheezes
                  3. Prolonged expiratory phase
                  4. A silent chest means danger
               2. History
                  1. Usually follows exposure to known trigger
               3. Bronchiolitis and asthma may present very similarly
            4. Management
               1. Airway and ventilation
                  1. Administer oxygen by tolerated method
                  2. BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort)
                  3. Endotracheal intubation for respiratory failure/ arrest with prolonged BVM ventilations, or inadequate response to BVM ventilations
               2. Circulation
               3. Pharmacological
                  1. Albuterol nebulizer
                  2. Subcutaneous epinephrine 1:1000 - only with severe respiratory distress or failure
                  3. Medications can be repeated if no effect
               4. Transport considerations
                  1. Allow patient to assume position of comfort
               5. Psychological support/ communication strategies
                  1. Keep caregiver with child if appropriate
         2. Bronchiolitis
            1. Epidemiology
               1. Incidence
                  1. Usually occurs in children less than 2 years of age
                  2. Very common
               2. Risk factors
                  1. Usually occurs in winter months
               3. Prevention strategies
            2. Pathophysiology
               1. An inflammatory process of the lower respiratory tract including the terminal airways
               2. Main cause is respiratory syncytial virus infection of the lower airway
            3. Assessment
               1. Signs and symptoms - respiratory distress or failure depending on severity, plus
                  1. Appears anxious
                  2. Wheezing
                  3. Rales (diffuse)
               2. History
                  1. Usually a history of upper respiratory infection symptoms
                  2. Bronchiolitis and asthma may present very similarly
            4. Management
               1. Airway and ventilation
                  1. Administer oxygen by tolerated method
                  2. BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort)
                  3. Endotracheal intubation for respiratory failure/ arrest with prolonged BVM ventilations, or inadequate response to BVM ventilations
               2. Circulation
               3. Pharmacological
                  1. Albuterol nebulizer
               4. Transport considerations
                  1. Allow patient to assume position of comfort
               5. Psychological support/ communication strategies
                  1. Keep caregiver with child if appropriate
         3. Pneumonia
            1. Epidemiology
               1. Incidence
                  1. Usually occurs in infants, toddlers and pre-schoolers (1-5 years of age), but can occur at any age
                  2. Common
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. Infection of the lower airway and lung
               2. May be caused by bacteria or virus
            3. Assessment
               1. Signs and symptoms - respiratory distress or failure depending on the severity, plus
                  1. Appears anxious
                  2. Decreased breath sounds
                  3. Rales
                  4. Rhonchi (localized or diffuse)
                  5. Pain in the chest
                  6. Fever
               2. History
                  1. Usually a history of lower respiratory infectious symptoms
            4. Management
               1. Airway and ventilation
                  1. Administer oxygen by tolerated method
                  2. BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort)
                  3. Endotracheal intubation for respiratory failure, prolonged BVM ventilations, or inadequate response to BVM ventilations
               2. Circulation
               3. Pharmacological
               4. Transport considerations
                  1. Allow patient to assume position of comfort
               5. Psychological support/ communication strategies
                  1. Keep caregiver with child if appropriate
         4. Foreign body lower airway obstruction
            1. Epidemiology
               1. Incidence
                  1. Usually occurs in toddlers and preschool age children (1-4 years of age), but can occur at any age
                  2. Uncommon
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. Foreign body in the lower airway or lung
               2. Objects are usually food (nuts, seeds, etc.) or small objects
            3. Assessment
               1. Signs and symptoms - respiratory distress of failure depending on the severity, plus
                  1. Appears anxious
                  2. Decreased breath sounds
                  3. Rales
                  4. Rhonchi (localized or diffuse)
                  5. Pain in the chest
               2. History
                  1. May be a history of choking if witnessed by an adult
            4. Management
               1. Airway and ventilation
                  1. Administer oxygen by tolerated method
                  2. BVM ventilations for respiratory failure/ arrest (progressive lethargy, poor muscle tone, shallow respiratory effort)
                  3. Endotracheal intubation for respiratory failure/ arrest with prolonged BVM ventilations, or inadequate response to BVM ventilations
                  4. Do not attempt to retrieve foreign body if it is beyond the reach of Magill forceps
               2. Circulation
               3. Transport considerations
                  1. Allow patient to assume position of comfort
               4. Psychological support/ communication strategies
                  1. Keep caregiver with child if appropriate
   2. A. Shock
      1. Introduction
         1. Epidemiology
            1. Incidence
            2. Morbidity/ mortality
            3. Risk factors
            4. Prevention strategies
         2. Categories of shock
            1. Non-cardiogenic
            2. Cardiogenic
      2. Pathophysiology
         1. An abnormal condition characterized by inadequate delivery of oxygen and metabolic substrates to meet the metabolic demands of tissues
         2. Severity
            1. Compensated (early)
               1. Patient�s blood pressure is normal although signs of inadequate tissue perfusion are present
               2. Reversible
            2. Decompensated (late)
               1. Hypotension and signs of inadequate organ perfusion are present
               2. Often irreversible
         3. Assessment
            1. Chief complaint
            2. History
            3. Physical findings
               1. Signs and symptoms of compensated shock
                  1. Irritability or anxiety
                  2. Tachycardia
                  3. Tachypnea
                  4. Weak peripheral pulses, full central pulses
                  5. Delayed capillary refill
                  6. Cool, pale extremities
                  7. Systolic blood pressure within normal limits
                  8. Decreased urinary output
               2. Signs and symptoms of decompensated shock
                  1. Lethargy or coma
                  2. Marked tachycardia or bradycardia
                  3. Marked tachypnea or bradypnea
                  4. Absent peripheral pulses, weak central pulses
                  5. Markedly delayed capillary refill
                  6. Cool, pale, dusky, mottled extremities
                  7. Hypotension
                  8. Markedly decreased urinary output
         4. Management
            1. Graded approach to treatment
            2. Consider separating parent and child
            3. Airway
               1. Trauma - immobilize c-spine
            4. Ventilation and oxygenation
               1. Compensated shock
                  1. Oxygen
               2. Decompensated shock
                  1. BVM - consider ventilating patient with 100% oxygen via appropriate-sized bag
                  2. ETT - consider intubating patient if positive pressure ventilation does not rapidly improve patient�s condition
            5. Circulation
               1. Compensated shock
                  1. Oxygen
               2. Decompensated shock
                  1. Non-cardiogenic
                     1. Fluid
                  2. Cardiogenic
                     1. No fluid
                     2. Dysrhythmia management as indicated
            6. Supportive care
            7. Transport considerations
               1. Appropriate mode
               2. Appropriate facility
            8. Psychological support/ communication strategies
      3. Noncardiogenic
         1. Hypovolemia
            1. Epidemiology
               1. Common
            2. Pathophysiology
               1. Intravascular volume depletion
                  1. Severe dehydration
                     1. Vomiting
                     2. Diarrhea
                  2. Blood loss
                     1. Trauma
                     2. Other, e.g., GI bleed
            3. Assessment
               1. Signs and symptoms of compensated or decompensated shock depending on severity, plus
                  1. Blood loss
                     1. External hemorrhage
                     2. Major trauma
                  2. Dehydration
                     1. Poor skin turgor
                     2. Decreased saliva and or tears
                     3. Sunken fontanelle (infants)
               2. History
            4. Management
               1. Airway and ventilation
                  1. Oxygen
                  2. Trauma - immobilize c-spine
               2. Circulation
                  1. Compensated shock
                     1. Oxygen
                  2. Decompensated shock
                     1. Oxygen
                     2. Vascular access
                     3. 20 ml/kg of lactated ringers or NS bolus as needed
               3. Supportive care
               4. Transport considerations
               5. Psychological support/ communication strategies
         2. Distributive
            1. Epidemiology
               1. Uncommon
            2. Etiology
               1. Septic
               2. Neurogenic
               3. Anaphylactic
            3. Pathophysiology
               1. Peripheral pooling due to loss of vasomotor tone
            4. Assessment
               1. Signs and symptoms of compensated or decompensated shock depending on severity, plus
                  1. Septic
                     1. Early - warm skin
                     2. Late - cool skin
                  2. Neurogenic
                     1. Warm skin
                     2. Bradycardia
                  3. Anaphylactic
                     1. Allergic rash
                     2. Airway swelling
               2. History
            5. Management
               1. Airway and ventilation
                  1. Oxygen
                  2. Trauma - immobilize c-spine
               2. Circulation
                  1. Compensated shock
                     1. Oxygen
                  2. Decompensated shock
                     1. Oxygen
                     2. Vascular access
                     3. 20 ml/kg of lactated ringers or NS bolus as needed
                  3. Anaphylactic - secure airway
               3. Supportive care
               4. Transport considerations
               5. Psychological support/ communication strategies
      4. Cardiogenic
         1. Cardiomyopathy
            1. Epidemiology
               1. Infection
               2. Congenital abnormalities
            2. Pathophysiology
               1. Mechanical pump failure
               2. Usually biventricular
            3. Assessment
               1. Signs and symptoms of compensated or decompensated shock, depending on severity, plus
                  1. Rales
                  2. Jugular venous distention
                  3. Hepatomegaly
                  4. Peripheral edema
               2. History
            4. Management
               1. Airway and ventilation
                  1. Oxygen
               2. Circulation
                  1. Compensated shock
                     1. Oxygen
                  2. Decompensated shock
                     1. Oxygen
                     2. Vascular access
                     3. Restrict fluid
                     4. Consider diuretic
                     5. Consider vasopressor
               3. Supportive care
               4. Transport considerations
               5. Psychological support/ communication strategies
         2. Dysrhythmias
            1. Epidemiology
               1. Bradydysrhythmias - common
               2. Supraventricular tachydysrhythmias - uncommon
               3. Ventricular tachydysrhythmias - very uncommon
            2. Pathophysiology
               1. Electrical pump failure
                  1. Results in cardiogenic shock or cardiopulmonary arrest depending on type
            3. Assessment
               1. Signs and symptoms of cardiogenic shock (compensated or decompensated) or cardiopulmonary arrest, depending on type
               2. History
            4. Management
               1. Specific to each type
   3. Dysrhythmias
      1. Tachydysrhythmias
         1. Supraventricular tachycardia
            1. Epidemiology
               1. Incidence
                  1. Usually in infants with no prior history
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. Stable (compensated shock) - patient will usually remain stable during transport with oxygen
               2. Unstable (decompensated shock) - PATIENT REQUIRES IMMEDIATE TREATMENT
               3. Children may be able to sustain increased rates for a while, but after several hours, they will decompensate
            3. Assessment
               1. Signs and symptoms - compensated or decompensated shock, depending on severity, plus
                  1. Narrow complex tachycardia with rates of greater than 220 beats per minute (too fast to count)
                  2. Poor feeding
                  3. Hypotension
               2. History
            4. Management
               1. Stable - supportive care
               2. Unstable
                  1. Airway and ventilation
                     1. Oxygen
                  2. Circulation
                  3. Pharmacological
                     1. Consider adenosine
                  4. Non-pharmacological
                     1. Synchronized cardioversion
                  5. Transport considerations
                  6. Psychological support/ communication strategies
         2. Ventricular tachycardia with a pulse
            1. Epidemiology
               1. Incidence
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. Stable (compensated shock) - patient will usually not tolerate for long periods of time
               2. Unstable (decompensated shock) - PATIENT REQUIRES IMMEDIATE TREATMENT
               3. Most VT with a pulse is secondary to structural heart disease and responds poorly to lidocaine
            3. Assessment
               1. Signs and symptoms - signs of compensated or decompensated shock, depending on severity, plus
                  1. Rapid, wide complex tachycardia
                  2. Poor feeding
                  3. Hypotension
               2. History
            4. Management
               1. Stable - supportive care
               2. Unstable
                  1. Airway and ventilation
                     1. Administer high flow oxygen
                  2. Circulation
                  3. Pharmacological
                     1. Consider lidocaine
                  4. Non-pharmacological
                     1. Synchronized cardioversion
                  5. Transport considerations
                  6. Psychological support/ communication strategies
      2. Bradydysrhythmias
         1. Epidemiology
            1. Incidence - most common dysrhythmia in children
            2. Risk factors
            3. Prevention strategies
         2. Pathophysiology
            1. Usually develops as a result of hypoxia
            2. May develop due to vagal stimulation (rare)
         3. Assessment
            1. Signs and symptoms - compensated or decompensated shock, depending on severity, plus
               1. Bradycardia
               2. Slow, narrow complex heart rhythm, QRS duration may be normal or prolonged
            2. History
         4. Management
            1. Stable - supportive care
            2. Unstable
               1. Airway and ventilation
                  1. Ventilate patient with 100% oxygen via BVM
                  2. Intubate patient if poor response to BVM ventilations
               2. Circulation
                  1. Perform chest compressions if oxygen does not increase heart rate
               3. Pharmacological
                  1. Medications can be given down the endotracheal tube
                  2. Administer epinephrine
                  3. Administer atropine for vagally induced bradycardia
               4. Non-pharmacological
               5. Transport considerations
               6. Psychological support/ communication strategies
      3. Absent rhythm
         1. Asystole
            1. Epidemiology
               1. Incidence - may be the initial cardiac arrest rhythm
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. Bradycardias may degenerate into asystole
               2. High mortality rate
            3. Assessment
               1. Signs and symptoms
                  1. Pulseless
                  2. Apneic
                  3. Cardiac monitor indicating no electrical activity
               2. History
            4. Management
               1. Confirm in two leads
               2. Airway and ventilation
                  1. Ventilate the patient with 100% oxygen via BVM
                  2. Intubate patient if poor response to BVM ventilations
               3. Circulation
                  1. Perform chest compressions
               4. Pharmacological
                  1. Medications can be given down the endotracheal tube
                  2. Administer epinephrine
               5. Non-pharmacological
               6. Transport considerations
               7. Psychological support/ communication strategies
         2. Ventricular fibrillation/ pulseless ventricular tachycardia
            1. Epidemiology
               1. Incidence - rare
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. Possibly due to electrocution and drug overdoses
               2. High mortality rate
            3. Assessment
               1. Signs and symptoms
                  1. Pulseless
                  2. Apneic
                  3. Cardiac monitor indicating no organized electrical activity or rapid wide complex tachycardia
               2. History
            4. Management
               1. Unmonitored - perform basic life support
               2. Monitored - defibrillate up to three consecutive shocks
               3. Airway and ventilation
                  1. Ventilate the patient with 100% oxygen via BVM
                  2. Intubate patient if poor response to BVM ventilations
               4. Circulation
                  1. Perform chest compressions
               5. Pharmacological
                  1. Medications can be given down the endotracheal tube
                  2. Administer epinephrine
                  3. Administer lidocaine
                  4. Administer bretylium
                  5. After administration of a medication, allow it to circulate for one minute before repeat defibrillation
               6. Non-pharmacological
               7. Transport considerations
               8. Psychological support/ communication strategies
         3. Pulseless electrical activity
            1. Epidemiology
               1. Incidence - look for a treatable cause
               2. Risk factors
               3. Prevention strategies
            2. Pathophysiology
               1. Pneumothorax
               2. Cardiac tamponade
               3. Hypovolemia
               4. Hypoxia
               5. Acidosis
               6. Hypothermia
               7. Hypoglycemia
            3. Assessment
               1. Signs and symptoms
                  1. Pulseless
                  2. Apneic
                  3. Cardiac monitor indicating organized electrical activity
               2. History
            4. Management
               1. Resuscitation should be directed toward relieving cause
               2. Airway and ventilation
                  1. Ventilate the patient with 100% oxygen
                  2. Intubate patient
               3. Circulation
                  1. Perform chest compressions
               4. Pharmacological
                  1. Medications can be given down the endotracheal tube
                  2. Administer epinephrine
               5. Non-pharmacological
               6. Transport considerations
               7. Psychological support/ communication strategies
3. Pediatric trauma
   1. Pathophysiology
      1. Blunt
         1. Thinner body wall allows forces to be readily transmitted to body contents
         2. Predominant cause of injury in children
      2. Penetrating
         1. Becoming an increasing problem in adolescents
         2. Higher incidence in the inner city (mostly intentional), but significant incidence in other areas (mostly unintentional)
   2. Mechanism of injury
      1. Fall
         1. Single most common cause of injury in children
         2. Serious injury or death resulting from truly accidental falls is relatively uncommon unless from a significant height
         3. Prevention strategies
      2. Motor vehicle crash
         1. Leading cause of permanent brain injury and new cases of epilepsy
         2. Leading cause of death and serious injury in children
         3. Prevention strategies
      3. Pedestrian vehicle crash
         1. Particularly lethal form of trauma in children
         2. Initial injury due to impact with vehicle (extremity/ trunk)
         3. Child is thrown from force of impact causing additional injury (head/ spine) upon impact with other objects (ground, another vehicle, light standard, etc.)
         4. Prevention strategies
      4. Near-drowning
         1. Third leading cause of injury or death in children between birth and 4 years of age
         2. Causes approximately 2000 deaths annually
         3. Severe, permanent brain damage occurs in 5-20% of hospitalized children for near drowning
            1. Prevention strategies
      5. Penetrating injuries
         1. Risk of death from firearm injuries increase with age
         2. Stab wounds and firearm injuries account for approximately 10-15% of all pediatric trauma admissions
         3. Visual inspection of external injuries can not evaluate the extent of internal involvement
         4. Prevention strategies
      6. Burns
         1. The leading cause of accidental death in the home for children under the age of 14 years
         2. Burn survival is a function of burn size and concomitant injuries
            1. Modified "rule of nines" is utilized to determine percentage of surface area involved
         3. Prevention strategies
      7. Physical abuse
         1. Has been classified into four categories - physical abuse, sexual abuse, emotional abuse and child neglect
         2. Social phenomena such as increased poverty, domestic disturbance, younger aged parents, substance abuse, and community violence have been attributed to increase of abuse
         3. Document all pertinent findings, treatments and interventions
         4. Prevention strategies
   3. Special considerations
      1. Airway control
         1. Maintain in-line stabilization in neutral, not sniffing position
         2. Administer 100% oxygen to all trauma patients
         3. Patent airway must be maintained via suctioning and jaw thrust
         4. Be prepared to assist ineffective respirations
         5. Intubation should be performed when the airway remains inadequate
         6. Gastric tube should be placed after intubation
         7. Needle cricothyroidotomy is rarely indicated for traumatic upper airway obstruction
      2. Immobilization
         1. Indications for stabilization and immobilization of cervical spine
         2. Utilize appropriate sized pediatric immobilization equipment
            1. Rigid cervical collar
            2. Towel/ blanket roll
            3. Child safety seat
            4. Pediatric immobilization device
            5. Vest-type/ short wooden backboard
            6. Long backboard
            7. Straps, cravats
            8. Tape
            9. Padding
         3. Maintain supine neutral in-line position for infants, toddlers, and pre-schoolers by placing padding from the shoulders to the hips
      3. Fluid management
         1. Management of the airway and breathing take priority over management of circulation because circulatory compromise is less common in children than adults
         2. Vascular access
            1. Large-bore intravenous catheter should be inserted into a large peripheral vein
            2. Do not delay transport to gain access
            3. Intraosseous access in children < 6 years of age if intravenous access fails
            4. Initial fluid bolus of 20 ml/kg of an lactated ringers or NS
            5. Reassess vital signs and rebolus with 20 ml/kg if no improvement
            6. If improvement does not occur after the second bolus, there is likely to be significant blood loss and the need for rapid surgical intervention
      4. Traumatic brain injury
         1. Early recognition and aggressive management can reduce mortality and morbidity
         2. Severity
            1. Mild - GCS is 13 to 15
            2. Moderate - GCS is 9 to 12
            3. Severe - GCS is less than or equal to 8
         3. Signs of increased intracranial pressure
            1. Elevated blood pressure
            2. Bradycardia
               1. Rapid deep respirations (Kussmaul) progressing to slow, deep respirations alternating with rapid deep respirations (Cheyne-Stokes)
            3. Bulging fontanelle (infant)
         4. Signs of herniation
            1. Asymmetrical pupils
            2. Posturing
         5. Specific management
            1. Administer high concentration of oxygen for mild to moderate head injuries (GCS 9-15)
            2. Intubate and ventilate at normal breathing rate with 100% oxygen for severe head injuries (GCS 3-8)
               1. Use of lidocaine may blunt rise in ICP (controversial)
               2. Consider RSI per medical direction
            3. Indications for hyperventilation
               1. Asymmetric pupils
               2. Active seizures
               3. Neurologic posturing
   4. Specific injuries
      1. Head and neck injury
         1. Larger relative mass of the head and lack of neck muscle strength provides increased momentum in acceleration-deceleration injuries and a greater stress to the cervical spine region
         2. Fulcrum of cervical mobility in the younger child is at the C2-C3 level
         3. 60% to 70% of pediatric fractures occur in C1 or C2
         4. Head injury is the most common cause of death in pediatric trauma victim
         5. Diffuse injuries are common in children, focal injuries are rare
         6. Soft tissues, skull and brain are more compliant in children than in adults
            1. Due to open fontanelles and sutures, infants up to an average age of 16 months may be more tolerant to an increase of intracranial pressure and can have delayed signs
         7. Subdural bleeds in a infant can produce hypotension (extremely rare)
         8. Significant blood loss can occur through scalp lacerations and should be controlled immediately
         9. The Modified Glasgow Coma scale should be utilized for infants and young children
      2. Chest injury
         1. Chest injuries in children under 14 years of age are usually the result of blunt trauma
         2. Due to the compliance of the chest wall, severe intrathoracic injury can be present without signs of external injury
         3. Tension pneumothorax is poorly tolerated and is an immediate threat to life
         4. Flail segment is an uncommon injury in children; when noted without a significant mechanism of injury, suspect child abuse
         5. Many children with cardiac tamponade will have no physical signs of tamponade other then hypotension
      3. Abdominal injury
         1. Musculature is minimal and poorly protects the viscera
         2. Organs most commonly injured are liver, kidney and spleen
         3. Onset of symptoms may be rapid or gradual
         4. Due to the small size of the abdomen, be certain to palpate only one quadrant at a time
            1. Any child who is hemodynamically unstable without evidence of obvious source of blood loss should be considered as having an abdominal injury until proven otherwise
      4. Extremity
         1. Relatively more common in children than adults
         2. Growth plate injuries are common
         3. Compartment syndrome is an emergency in children
         4. Any sites of active bleeding must be controlled
         5. Splinting should be performed to prevent further injury and blood loss
         6. PASG may be useful in unstable pelvic fractures with hypotension
      5. Burns
         1. Thermal burns in children
         2. Chemical burns in children
         3. Electrical burns in children
         4. Management priorities
            1. Prompt management of the airway is required as swelling can develop rapidly
            2. If intubation is required, an endotracheal tube up to two sizes smaller than what would normally be used may be required
            3. Thermally burned children are very susceptible to hypothermia; maintain normal body temperature

MODULE VI: OTHER RECOMMENDED CONTENT AREAS

• Prepare the emergency vehicle and equipment before responding to a call
• Drive the emergency vehicle in an emergency situation
• Assess scene safety
• Provide for safety of self, patient and fellow workers
• Take infection control precautions (body substance isolation), Dispose of sharps (needles, auto-injector, etc.), Dispose of materials contaminated with body fluids
• Use body mechanics when lifting and moving a patient

1. Diagnostic ECG
2. EMS Agenda for the Future issues (such as prevention)
3. Geriatrics
4. Local clinical & technology / equipment update
5. Local quality improvement issues
6. Nationally recognized guidelines / programs for out-of-hospital care (ACLS, AMLS, BTLS, PALS, PEPP, PHTLS, etc)
7. Skills updates / maintenance

APPENDIXES

NREMT Practice Analysis (1999)
Below is a list of the tasks extracted from the 1999 NREMT Practice Analysis. Each participant involved in the random survey was asked to indicate the frequency in which they utilized an identified task. In addition to frequency, the participants were asked to provide input on the potential of harm and difficulty they experienced in accomplishing each task. The chart below identifies those task, based on either frequency and/or potential for harm, that was used in the creation of this document. The task force utilized those task that were identified as having low frequency of performance and a high potential for harm along with the tasks that had a high frequency of performance and a high potential for harm. 24 of the 123 tasks were identified as meeting the above criteria and were utilized as the basis for the mandatory portion of this refresher curriculum.

The practical skill sheets included in this appendix were modeled after the National Registry of Emergency Medical Technicians� (NREMT) Advanced Level Practical Examination for the 1999 EMT-Intermediate National Standard Curriculum. These skill sheets should not be used as a substitute during a NREMT Advanced Level Practical Examination. The sheets were designed to be used as a standardized evaluation instrument for determining an individual�s competency for an identified psychomotor skill.

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Set # _______________________

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Note: Check here ( ) if candidate did not establish a patent IV and do not evaluate IV Bolus Medications

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