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EMR Slideshow 4
Modules 31 to 40 - basic EMR course
90
Medical
Not Applicable
07/25/2013
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Term
What is the difference between an open and closed fracture?
 Definition
 Closed fracture – a fracture that does not break the skin
 Open fracture – external wound associated with fracture
 Nondisplaced fracture – break with no deformity
 Displaced fracture – fracture in which there is actual deformity
Term
What is a comminuted fracture?
 Definition
Comminuted Fracture - When the bone is broken into more than two fragments
Other types of fractures:
 Greenstick Fracture – incomplete fracture only partway through shaft of bone, may still cause angulations, often in children
 Pathological Fracture – A fracture of weakened or diseased bone: osteoporosis, osteogenesis imperfecta
 Epiphyseal Fracture – occurs in growth section at end of child’s bone - may prematurely stunt growth if not properly treated
Term
How do you reduce or manipulate a dislocation?
 Definition
You don't - immobilise in the position found
Term
What are the signs of compartment syndrome?
 Definition
Hallmark Signs / Symptoms:
 Pain disproportionate to injury
Other Signs / Symptoms
 Pallor
 Decreased sensation
 Decreased power
Term
What is scoliosis and what are the signs?
 Definition
Abnormal 'S' shaped curvature of spine
Hallmark Signs / Symptoms:
 Uneven waist and shoulders
Other Signs / Symptoms
 Prominent shoulder blade(s)
 Elevated hips
 Leaning to one side
 Pain from disc degeneration
 Possibility of nerve pinching or slipped disc
Term
What is kyphosis and what may cause it?
 Definition
Unusual hunched forward curvature of upper spine
Osteoporosis - risk factors
 Age > 65
 Family history
 Post-menopausal
 Low dietary calcium intake
Term
What is the difference between osteoarthritis and rheumatoid arthritis?
 Definition
 Osteoarthritis Arthritis : due to cartilage loss and wear and tear of joints (common in the elderly)
 Rheumatoid Arthritis: destructive autoimmune disorder that damages joints and surrounding tissues
Term
In a general musculoskeletal assessment, what is CMS function?
 Definition
Examination of the injured limb should include assessment of the:
 Circulation
 Motor function
 Sensation
Term
What is normal capillary refill?
 Definition
Capillary refill (relevant in children and infants)
 Should be less than 2 seconds
 Should be the same as the uninjured limb
Term
What are the criteria for critical musculoskeletal injuries?
 Definition
Multiple open fractures of limbs
 Pelvic fractures with hemodynamic instability
 Bilateral femur fractures
Term
When do you use a traction splint? What is the maximum force?
 Definition
Midshaft femur fractures only (provides traction to stabilize and align the femur)
 Max 10% of body weight
 Max 15 lbs of traction for any sized patient (even for bilateral femur fractures)
Term
What does RICE stand for?
 Definition
R - rest
I - immobilize
C - cold
E - elevate
Immobization needs one EMS practitioner to maintain stabilization as the other applies splinting materials. Assess pulse, motor & sensory function and cover the minimum amount of anatomy required, ensure visibility of deformity site
Term
When must you NOT use a traction splint?
 Definition
 Injury must be one hand-width distal to the hip joint or one hand-width proximal to the knee
Contraindications:
 Hip, knee, lower-leg or ankle injury on affected side
 Inability to properly size the device (really tall Pt’s)
 Ensure the rear-ambulance doors to not impact the splint as it sticks out 12” past the Pt’s heel
Term
When is an EMR allowed to consider trying to realign a fracture?
 Definition
If circulation is impaired in any grossly deformed mid-shaft fractures of extremities
 Never realign if it could be a joint
 Only 1 attempt can be made
 Midshaft is defined as more than 1 hand-width away from any joint
 Assess and document circulation, motor function and sensation before and after
Term
What tissues require constant blood supply?
 Definition
 Brain
 Heart
 Lungs
 Kidneys
(Muscles and GI tract require a significant supply of blood when active)
Term
How much blood loss can the body tolerate? (% and volume)
 Definition
The body will tolerate 10% rapid loss of blood, or 20% loss of blood over a period of time
 Adults: 10% is ≈ 500 mL
 Children: 10% is ≈ 150 mL
Term
What are the signs of arterial bleeding?
 Definition
Hallmark Signs / Symptoms:
 Spurting, bright red blood
 A lot of blood around the patient
Other Signs / Symptoms:
 Tachycardia
 Tachypnea
 Hypotension
 Altered LOC
Term
What are the signs of venous bleeding?
 Definition
Hallmark Signs / Symptoms:
 Oozing or flowing, dark red blood
Other:
 Anxious patient
Term
What is "road rash"?
 Definition
Capillary bleeding from abrasion following moving contact with road surface - esp bikers - small volume blood loss but more painful
Term
What methods are there to control external haemorrhage?
 Definition
 Direct Pressure
 Pressure Point
 Cryogenic Therapy
 Tourniquet
 Pressure Dressing
 Elevation
 Patient Position
Term
Name three pressure points used to reduce blood flow
 Definition
 Radial
 Brachial
 Femoral
Term
Should you apply a tourniquet under online or offline direction?
 Definition
 Consult with on line medical direction first
 Place as close to injury as possible, but not over joint
 Never use narrow material
 Use wide padding under the tourniquet
 Never cover a tourniquet with a bandage
 Do not loosen the tourniquet once applied, ever
 Reconsider your need to use a tourniquet
Term
What are the signs of internal bleeding?
 Definition
Hallmark Signs / Symptoms:
 Signs of hypovolemic shock without obvious cause, like bleeding or blood around the patient
Other:
 Tachycardia
 Tachypnea
 Hypotension
 LOC
 Discoloration, usually in abdomen or femoral areas
 Hematoma: bleeding beneath the skin, the EMR may see the formation of the hematoma
 Hematemesis: blood in vomit
 Melena: black, tarry stool
 Hematochezia: red, runny stool
 Hemoptysis: coughing up blood
 Pain, tenderness, bruising, guarding, or swelling
 Broken ribs, bruises over the lower chest, or rigid, distended abdomen
Term
What are the signs of a skull fracture?
 Definition
Hallmark Signs / Symptoms:
 Blood or CSF from ears
 Ecchymosis (patchy bruising) behind ears (Battle’s sign)
 Ecchymosis around eyes (raccoon eyes)
Other Signs / Symptoms
 Altered LOC
 Possibly Cushing’s Triad
 Nausea and vomit
 Seizures
Term
What is the major concern in a facial injury?
 Definition
Maintenance of an adequate airway
Term
How long do you wait to find out if an epistaxis stops? Describe what you should do
 Definition
10 minutes
 Sit upright, leaning forward
 Apply direct pressure by pinching the patient’s nostrils close together, or "place a piece of gauze bandage under the patient’s upper lip and gum" (????)
 Apply ice over the nose
Term
In a gunshot wound, if the bullet goes right through, is the exit wound larger or smaller than entrance?
 Definition
Larger
(anticipate massive internal bleeding in a gunshot wound)
Term
If you find an amputated part of the body, should you freeze it for transport?
 Definition
No - keep it clean, dry and cool
Term
If there has been an impalement, how quickly should you remove the foreign object?
 Definition
Don't try to remove it
 stablize the object and transport carefully
Term
What is the major concern with a neck injury?
 Definition
An open neck injury can be life threatening
 Air can get into veins causing air embolism
(also beware blood loss, cervical spine damage and damage to trachea and, if low down, the lung)
Term
What degree of burn is partial thickness?
 Definition
2nd degree
Term
How many deaths per year are caused by burns?
 Definition
Over 10,000 deaths/year
Burns are the most serious and painful injuries
Term
What are the two rules for estimating extent of a burn?
 Definition
Rule of nines (9% for head, chest, abdo, upper back, lower back, arms x2, upper legs x2, lower legs x2, and 1% for groin (child's head is 18% and legs 13.5% each)
Rule of palms - palm (not including fingers) = 1%
Term
Define a critical burn
 Definition
 Full thickness to hands, feet, face, airway or genitalia
 Full thickness to more than 10% of body area
 Partial thickness to more than 30% of body area
 Burns with respiratory emergencies
Term
Define a moderate burn
 Definition
 Full thickness over 2% of body
 Partial thickness to 30% of body
 Superficial to more than 50% of body
Term
Define a minor burn
 Definition
 Full thickness to 2%
 Partial thickness to 15%
Term
What are the specific concerns in children with burns?
 Definition
 Considered more serious because they have more surface area relative to body mass
 Many burns result from abuse (report all suspect cases of abuse to the authorities)
Term
What are the three types of radioactive particles?
 Definition
 Alpha particles - skin stops them entering body but dangerous if ingested or inhaled
 Beta particles penetrate subcutaneous tissue - Full PPE, including SCBA needed
 Gamma rays and x-rays are most dangerous - lead shields needed
Term
What safety issues do you need to consider with a radiation exposure incident?
 Definition
 Do not enter scene until it is secured
 Rescue personnel, emergency vehicles, and command post positioned 200-300 ft upwind of site
 Must not eat, drink, or smoke
Term
What are the signs of concussion?
 Definition
Hallmark:
 Repetitive questioning
Other Signs / Symptoms
 MOI
 Altered LOC
 Apnea
 Memory loss (retrograde or anterograde)
 Dizziness
 Weakness
 Visual changes
 Repetitive questioning
Term
What are the signs of cerebral contusion?
 Definition
Hallmark:
 Altered LOC
Other Signs / Symptoms
 MOI
 Convulsions
 Signs of Cushing’s Triad
 Nausea / Vomiting
 Leakage of blood or CSF from ears/eyes/nose
 Altered CNS functionality
 Unequal pupils
(may mimic a stroke)
Term
What are the signs of an intracranial bleed?
 Definition
Hallmark Signs / Symptoms:
 Subdural: may not present for many days or even weeks (venous bleed)
 Epidural: brief period of unconsciousness and headache, followed by a lucid period, then rapid decline in LOC, to a point where the patient is unresponsive (arterial bleed)
 Intracerebral: varies with location within the brain (stroke-like symptoms)
Other:
 MOI
 N/V
 Altered LOC
Term
What is Cushing's triad and what causes it?
 Definition
 Hypertension, BP above normal, often over 180 systolic
 Bradycardia, heart rate decreasing from normal, often 60 BPM or lower
 Cheyne Stokes breathing (deep and irregular breathing pattern)
Term
What do you do if you suspect raised intracranial pressure?
 Definition
If signs of ICP present (unconscious, irregular breathing, slowing down of pulse and unequal pupils), hyper-oxygenate using BVM with a O2 flow rate of 15 LPM making sure the reservoir bag is never less than 2/3 full, ventilating 1 breath every 3 seconds or 20/min. Head end of back-board or stretcher should be elevated 15-20 degrees.
Term
What does cerebral herniation mean?
 Definition
Abnormal protrusion of brain tissue through an opening due to increased intracranial pressure. (e.g. through foramen magnum at base of skull into spinal column)
Term
What are the signs of light burns to the eyes? What other names does this have?
 Definition
 Burning (eyelids feel like “sandpaper”)
 Possibly no pain (initially)
 Excessive tear production
 Conjunctivitis
 Possible temporary blindness (3 to 5 days)
 Also known as welders flash, snow blindness (may also be caused by looking into the sun or a laser)
Term
What does hyphema mean and what causes it?
 Definition
Blunt trauma to the eye results in blood in anterior chamber (i.e. in front of the iris)
Term
What is a blowout fracture?
 Definition
 A fracture of the bones that form the floor and support the globe of the eye
 Bone fragments may entrap muscles that control eye movement leading to double vision
Term
What are the causes, signs and symptoms of a retinal detachment?
 Definition
 Blunt injury, commonly seen in sports, causes the retina to detach from the choroid
Signs / Symptoms
 Usually painless
 Flashing lights or “floaters” in the field of vision floaters
 Cloud or shade over the patient’s vision - "like a curtain coming down or up"
Term
If a tooth is knocked out, how should you transport it?
 Definition
In saline (EMRs don't carry milk around!)
Term
What are two significant concerns with a facial injury?
 Definition
Airway and spinal injury
Term
How do you remove a foreign body from the ear?
 Definition
You don't - transport.
(it is easy to end up pushing it further in if you don't have the correct equipment)
Term
What is a sucking chest wound?
 Definition
Penetrating chest wound through to lung tissue, preventing thoracic negative pressure which is necessary for ability to inhale
 May be a foreign object or the end of a broken rib
Term
What are the signs of a sucking chest wound?
 Definition
Hallmark Signs / Symptoms:
 Sucking or gurgling sound
 Blood “bubbles” on chest
 Penetration wound in the chest
Other Signs / Symptoms
 Dyspnea
 Hemoptysis
 Unequal chest expansion
 Cyanosis
 Tachypnea / apnea
 Tachycardia
 Tracheal shift
Term
How do you manage a sucking chest wound?
 Definition
 Plug the hole ASAP with something occlusive (e.g. your gloved hand)
 Seal with an occlusive dressing on 3 sides (open side down)
 High O2 + Transport
Term
What is the difference between a pneumothorax and a tension pneumothorax?
 Definition
Pneumothorax is air in pleural space (maybe due to penetrating trauma or fractured rib)
Tension pneumothorax means an increasing amount of air in pleural space, compressing other lung and mediastinum (tracheal shift)
Term
What are the signs of a tension pneumothorax?
 Definition
Hallmark Signs / Symptoms:
 Absent breath sounds on affected side
 JVD
 Tracheal deviation (usually towards good side)
Other Signs / Symptoms
 Hypotension
 Dyspnea
 Unequal chest expansion
 Cyanosis
 Tachypnea / apnea
 Tachycardia
Term
What are the signs of a hemothorax?
 Definition
Hallmark Signs / Symptoms:
 Muffled or absent breath sounds on affected side
Other Signs / Symptoms
 Hypotension
 Dyspnea
 Unequal chest expansion
 Cyanosis
 Tachypnea / apnea
 Tachycardia
Term
What does paradoxical chest movement mean?
 Definition
Rib or sternal fractures at two separate places cause chest wall to move in with inspiration and out with exhalation
Other Signs
 Hypotension
 Dyspnea
 Unequal chest expansion
 Cyanosis
 Tachypnea / apnea
 Tachycardia
Term
How do you treat flail chest?
 Definition
 Immobilize flail area ASAP with your hand, then delegate your partner to stabilize with bulky dressing taped north to south (never encircling)
 High O2, history question, vital signs & Transport
 Consider the
probability of other injuries
Term
What is cardiac tamponade?
 Definition
Blood or other fluid in pericardium (sac encasing heart), pressure builds preventing filling of heart during diastole, further compressing the heart, terminating in cardiac arrest
Term
What is Beck's triad?
 Definition
Hallmark Signs of cardiac tamponade:
 Jugular Venous Distension
 Narrowing pulse pressures (systolic and diastolic pressures close together)
 Muffled heart sounds
Other Signs / Symptoms
 Hypotension
 Tachycardia
Term
What makes you suspect laceration of the great vessels?
 Definition
 Unexplained signs of hypovolemia
 Lack of ecchymosis (blood remains in chest cavity)
 MOI so violent that the major vessels of the heart could have been torn away
Term
What is the mesentery?
 Definition
Membranous folds that attach the intestines to the abdominal cavity wall and the posterior abdominal wall of the body - contains the blood vessels
Term
What are the signs of peritonitis?
 Definition
 Abdominal pain
 Tenderness
 Muscle spasm
 Nausea/vomiting
 Distention
 Guarding
Term
What does evisceration mean and what do you do?
 Definition
When an open abdominal wound has organs or tissue protruding through the opening
 Do not touch the organs
 Keep them moist
 Apply moist, non-stick dressings
 Keep them warm
 Cover with occlusive dressing & blanket
 High flow O2 + AMPLE/OPQRSTA + vital signs + transport
Term
What makes you suspect kidney damage?
 Definition
 An abrasion, laceration or contusion to the flank
 A penetrating wound in the region of the lower rib cage or upper abdomen
 Penetrating wound lower rib cage / upper abdomen
 Fractures of lower rib cage or of lower thoracic / upper lumbar vertebrae
Signs / Symptoms:
 MOI
 Hematuria
 Hypovolemic shock
Term
What makes you suspect bladder injury?
 Definition
 Blood at the urethral opening
 Lower abdominal trauma
Note that in males, a MVC can shear the bladder from the urethra (so don't drive with an overfull bladder!)
Term
What are the differences in a child's airway?
 Definition
 Larger tongue relative to the mouth
 Less well-developed rings of cartilage in the trachea
 Head tilt-chin lift may occlude the airway
 Larger, rounder occiput
 Larger epiglottis
 Narrower, lower airway
Term
What are the fontanelles and what timescale is of relevance to them?
 Definition
Fontanels are the gaps between the plates of the skull bones - larger one at front, smaller at back
They close by 18 months
Term
What are normal respiration rate, pulse and systolic BP for different age ranges in children?
 Definition
Respirations / Pulse / Systolic BP
 0-1 month
30 – 60 / 90 -180 / 50 – 70
 1 month – I year
25 – 50 / 100 – 160 / 70 – 95
 1 – 3 years
20 – 30 / 90 – 150 / 80 – 100
 3 – 6 years
20 – 25 / 80 – 140 / 80 – 100
 6 – 12 years
15 – 20 / 70 – 120 / 80 – 110
 12 – 18 years
12 – 16 / 60 – 100 / 90 – 110
 18 years +
12 - 20 / 60 - 100 / 90 - 140
Term
How do you measure the pulse in children?
 Definition
In infants, feel over the brachial or femoral area
In older children use the carotid artery
Term
What size of BP cuff do you use for children?
 Definition
A properly fitted child's cuff covers 2/3 of the upper arm and the sizing line falls within sizing
Term
What is a gastrostomy tube?
 Definition
Tube through abdo wall directly into stomach needed when feeding by mouth not possible
Complications include breathing problems from food backing up
esophagus, and hypoglycemia
Term
What is a shunt?
 Definition
Tubes that drain excess fluid from
around brain
If shunt becomes clogged, changes in mental status may occur and may go into respiratory arrest
Term
Who should hold a child during transport?
 Definition
Do not allow parents or EMR to hold child during the actual transport - unsafe
Term
What oxygen concentration does a paediatric non-rebreathing mask supply?
 Definition
Nonrebreathing mask at 10 to 15 L/min provides up to 90% oxygen concentration
(Blow-by technique at 6 L/min - over 21%
Nasal cannula at 1 to 6 L/min - 24% to 44%
Simple face mask at 6 to 10 L/min - 35% to 60%
BVM device at 15 L/min - nearly 100%)
Term
How do you insert an airway into a child with suspected epiglottitis?
 Definition
Don't!
You can cause additional swelling and possible complete airway obstruction, try and keep your patient from crying or screaming, air turbulence can cause more swelling.
Term
What is status epilepticus?
 Definition
Continuous seizure, or multiple seizures without a return to consciousness for 5 minutes or more
Term
What is Neisseria Meningitidis?
 Definition
The bacterium that causes meningococcal meningitis
 Often associated with small pinpoint cherry-red spots or larger purple/black rash
 Children at serious risk for sepsis, shock, and death
 meningitis - headache, neck stiffness, vomiting, photophobia
Term
What are the circulatory signs of shock?
 Definition
 Pulse: greater than 160
 Skin signs: assess temperature and moisture
 Color: is skin pink, pale, ashen or blue?
 Capillary refill: normally should be less than 2 seconds in a child/infant
Term
What is skin turgor?
 Definition
Skin is usually very elastic and firm in children
If dehydrated, skin becomes looser and less elastic - if you pinch it gently and release, it is slow to return to normal position
Term
What are the risk factors for sudden infant death syndrome?
 Definition
 Mother younger than 20 years old
 Mother smoked during pregnancy
 Low birth weight
Term
What do you have to consider in suspected child abuse?
 Definition
 Is the injury typical for the child’s developmental stage?
 Is the reported method of injury consistent with injuries?
 Is the caregiver behaving appropriately?
 Is there evidence of drinking or drug abuse?
 Was there a delay in seeking care for the child?
 Is there a good relationship between child and caregiver?
 Does the child have multiple injuries at various stages of healing?
 Does the child have any unusual marks or bruises?
 Does the child have several types of injuries?
 Does the child have burns on the hands or feet?
 Is there unexplained decreased level of consciousness?
 Is the child clean and an appropriate weight?
 Is there any rectal or vaginal bleeding?
 What does the home look like Clean or dirty? Warm or cold? Is there food?
Term
What will the elderly population be by 2030?
 Definition
By 2030, the elderly population will be greater than 70 million
(In 2000, it was almost 35 million)
Term
What risk factors affect geriatric mortality?
 Definition
 Isolation (#1 factor - no outside contact)
 Age greater than 75 years
 Recent hospitalization ?infections
 Incontinence
 Recent death of significant other (decreased motivation to
stay alive...)
 Immobility - bedsores
 Unsound mind - medications, food
Term
What can cause vaso-vagal syndrome and what is it?
 Definition
Bowel obstructions
Vagus nerve (parasympathetic) is stimulated resulting in slowing heart rate and a dropping blood pressure with dizziness and fainting
Term
What might be the difference in presentation of a myocardial infarct in the elderly?
 Definition
 Classic symptoms often not present
 Often no pain or pressure
 Also know as a silent MI
Term
What is Alzheimer's?
 Definition
 Nerve cells in cerebral cortex die and brain shrinks
 Commonest cause of dementia
 Cause not known, possible due to:
 Chronic infection
 Toxic poisoning by metals (lead)
 Reduction in brain chemicals
 Genetics
Term
What specific medical condition needing action should you consider in dementia?
 Definition
Hypoglycaemia
(and alcohol if disturbed)
Also think about CO poisoning, medication problems, recent bereavement, recent move to new home, other illnesses e.g. UTI, silent MI
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