Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer OKeefe Grant Murray Bergeron Dickinson

Copyright ©2012 by Pearson Education, Inc.All rights reserved.

Emergency Care, Twelfth EditionDaniel J. Limmer • O’Keefe • Grant • Murray • Bergeron • Dickinson

Emergency Medical Responder: First on Scene, Ninth EditionLe Baudour • Bergeron • Wesley

CHAPTERCHAPTER

Caring for Common Medical Caring for Common Medical EmergenciesEmergencies

1515




1. Define the following terms:a. Altered mental statusb. Behavioral emergencyc. Convulsionsd. Diabetese. Epilepsyf. Febrileg. Generalized seizure h. Hemodialysisi. Hyperglycemiaj. Hypoglycemia

(continued)




1. Define the following terms :k. Overdose l. Partial seizurem. Postictaln. Sepsiso. Stroke (brain attack)

(continued)




2. Explain the common causes of altered mental status.

3. Describe the signs and symptoms of a patient with an altered mental status.

4. Explain the appropriate assessment and care for a patient with an altered mental status.

5. Describe the signs and symptoms of a patient experiencing a generalized seizure.

(continued)




6. Explain the appropriate assessment and care for a patient experiencing a generalized seizure.

7. Describe the signs and symptoms of a patient experiencing a stroke (brain attack).

8. Explain the appropriate assessment and care for a patient experiencing a stroke (brain attack).

9. Describe the signs and symptoms of a patient experiencing a diabetic emergency.

(continued)




10.Differentiate between the signs and symptoms of hyperglycemia and hypoglycemia.

11.Explain the appropriate assessment and care for a patient experiencing a diabetic emergency.

12.Describe the signs and symptoms of a patient experiencing an overdose or poisoning.

13.Describe the signs and symptoms of a patient experiencing carbon monoxide poisoning.

(continued)




14.Explain the appropriate assessment and care for a patient experiencing an overdose or poisoning.

15.State when it is most appropriate to contact the poison control center.

16.Describe the signs and symptoms of a patient experiencing an emergency related to renal failure.

17.Explain the special considerations when caring for a hemodialysis patient.

(continued)




18.Describe the signs and symptoms of a patient experiencing a generalized infection (sepsis).

19.Explain the appropriate assessment and care for a patient experiencing a generalized infection (sepsis).

20.Describe the signs and symptoms of an allergic reaction.

21.Explain the appropriate assessment and care for a patient experiencing a severe allergic reaction.

(continued)




22.Describe the signs and symptoms of a patient experiencing a suspected behavioral emergency.

23.Explain the appropriate assessment and care for a patient experiencing a suspected behavioral emergency.

24.Demonstrate the ability to appropriately assess and care for a patient experiencing an altered mental status.

(continued)




25.Value the significance of an altered mental status as a sign of an unstable patient.




MediaMedia

Slide 27 Introduction to Seizures VideoSlide 29 Complex Partial Seizures VideoSlide 30 Tonic-Clonic Seizures VideoSlide 44 Diabetes AnimationSlide 61 Poisoning Video




TopicsTopics

• Medical Emergencies• Evaluating Mental Status• Overdose and Poisoning• Behavioral Emergencies




MEDICAL EMERGENCIESMEDICAL EMERGENCIES




Medical EmergenciesMedical Emergencies

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

• Signs and Symptoms:– Altered mental status– Abnormal pulse rate and rhythm– Abnormal breathing rate and character– Abnormal skin signs– Abnormal pupil size or response

(continued)





• Signs and Symptoms:– Unusual breath odors– Tenderness or rigidity in abdomen– Abnormal muscular activity (spasms or

paralysis)– Bleeding or discharges from body– Pain– Shortness of breath

(continued)





• Signs and Symptoms: – Fever or chills– Upset stomach and/or vomiting– Dizziness or feeling faint– Chest or abdominal pain– Unusual bowel or bladder activity– Thirst, hunger, odd tastes in mouth





• Assessment– Take appropriate BSI precautions; complete

a scene size-up.– Perform primary assessment.– Perform secondary assessment. – Complete reassessments.– Comfort and reassure patient while

awaiting additional EMS resources.




Think About ItThink About It

• You respond to a single-vehicle MVC with minor MOI. Your patient is unresponsive. What conditions could have preceded the collision?

• How might the EMR proceed with assessment and treatment in this case?




EVALUATING MENTAL STATUSEVALUATING MENTAL STATUS




Evaluating Mental StatusEvaluating Mental Status

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

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





• Common causes:– Trauma to head– Seizures– Stroke (brain attack)– Diabetic emergencies– Poisonings and overdose– Hypoxia

(continued)





• Common causes:– Shock– Infection– Trauma– Psychiatric condition– Liver failure





• Signs and Symptoms:– Confusion– Seizures– Inappropriate behavior– Lack of awareness of surroundings– Combativeness– Syncope (collapse or fainting)– Unresponsiveness





• Assessing the Patient– Focus on observation.– Obtain complete medical history.– Use AVPU scale:

Alert Verbal Painful Unresponsive





• Specific Conditions: Seizures– Irregular electrical activity in brain that can

cause sudden change in mental status and behavior.

– Can have many causes.





• Causes of Seizures:– Epilepsy (disorder of brain)– Ingestion of drugs, alcohol, poisons– Alcohol withdrawal– Brain tumors– Infections, high fever (febrile)– Diabetic problems; stroke– Heat stroke; head injury




Click here to view a video on the topic of seizures.BACK TO DIRECTORY





• Seizures – Types:

Generalized: loss of consciousness and full body convulsions (uncontrolled muscular contractions).

Partial: temporary loss of awareness with no dramatic body movements.




Click here to view a video on the topic of complex partial seizures.BACK TO DIRECTORY




Click here to view a video on the topic of tonic-clonic seizures.BACK TO DIRECTORY





• Generalized Seizure:– Sudden loss of responsiveness– Report of bright light, bright colors,

sensation of strong odor prior to losing responsiveness

– Convulsions– Loss of bladder and/or bowel control

(continued)





• Generalized Seizure:– Labored breathing (frothing at mouth)– Complaint of headache prior to or following

seizure– Following seizure, patient's body

completely relaxes– Postictal: the phase of seizure following

convulsions




Protect the patient from injury by removing objects that he may strike and by placing something soft beneath his head.





• Seizure Care– Move objects away; place something soft

under head.– Do not attempt to restrain patient or force

anything into mouth.– Loosen restrictive clothing.– After convulsions have stopped, place

patient in recovery position.





• Specific Conditions: Stroke– Cerebrovascular accident (CVA) or brain

attack.– Blood flow to brain disrupted. – Causes: obstruction or rupture of blood

vessel.– Portion of brain does not receive adequate

supply of oxygenated blood.





• Stroke Signs and Symptoms– Headache– Syncope (fainting)– Altered mental status– Numbness or paralysis (extremities or face)– Difficulty with speech or vision– Confusion, dizziness





• Cincinnati Prehospital Stroke Scale (CPSS)– Facial droop– Arm drift– Abnormal speech




Altered Mental Status—Stroke: Cerebrovascular Accident




Altered Mental Status—Stroke: Cerebrovascular Accident




A patient suffering a stroke may have facial droop on one side or the other.




An inability to hold both arms up may be a sign of possible stroke.





• Stroke Care– Maintain open airway; be prepared to

provide ventilations or CPR.– Keep patient at rest; protect all paralyzed

parts.– Provide emotional support.– Place patient in recovery position.– Do not administer anything by mouth.





• Specific Conditions: Diabetic Emergencies– Diabetes: disease that prevents individuals

from producing enough insulin or from using insulin effectively.

– Insulin: hormone released by pancreas; allows glucose (blood sugar) to enter cells so glucose can be used.




Click here to view an animation on the topic of diabetes.BACK TO DIRECTORY





• Hypoglycemia (low blood sugar): – Diabetic who has taken too much insulin,

eaten too little sugar, overexerted himself/herself, or experienced excessive emotional stress may develop low blood sugar.

– Alert patient: provide oral glucose or suitable substitute, if allowed by protocol.

– Non-alert patient: do not provide anything orally if the patient is unable to swallow.





• Hypoglycemia: Signs and Symptoms – Altered mental status– Pale, cool skin; often moist– Rapid, strong pulse– Dizziness– Headache– Normal or shallow breathing– Very hungry– Some patients develop seizures





• Hyperglycemia: Signs and Symptoms– Extreme thirst– Abdominal pain– Dry, warm skin– Rapid, weak pulse– Sweet or fruity odor (ketone) breath– Dry mouth– Restlessness– Altered mental status, including coma





• Care for Hyperglycemia– If patient is alert and you are not certain if

problem is too much sugar or too little sugar, give patient sugar, candy, orange juice, or soft drink.




Hyperglycemia




Hypoglycemia





• How might hypoxia change mental status?

• What steps might the EMR take to immediately rule out hypoxia as a potential cause?




OVERDOSE AND POISONINGOVERDOSE AND POISONING




Overdose and PoisoningOverdose and Poisoning

• Poison– Any substance that can be harmful to the

body.

• Overdose– When person takes in more medication

than is normal.




Commonly Abused Substances (continued)





(continued)





(continued)





(continued)




Commonly Abused Substances

(continued)





• Routes of Exposure– Ingestion: taken into body by mouth.– Inhalation: taken in by breathing.– Absorption: taken into body through skin

and body tissues.– Injection: delivered directly into

bloodstream.





• Over 60 regional poison control centers in the United States.

• Note and report any containers at scene.

• Check if patient has vomited; describe. • Check for substances on clothes or if

patient is wearing clothing that indicates nature of work.




Click here to view a video on the topic of poisoning.BACK TO DIRECTORY





• Ingested Poisons: Signs and Symptoms – Burns or stains around mouth– Unusual breath odors, body odors, or odors

on clothing or at scene– Abnormal breathing– Abnormal pulse rate and rhythm– Sweating– Dilated or constricted pupils

(continued)




Poisons come in colorful containers that are appealing to children.





• Ingested Poisons: Signs and Symptoms – Excessive saliva; foaming at mouth– Burning in mouth, throat, painful

swallowing– Abdominal pain; upset stomach or nausea,

vomiting, diarrhea– Convulsions (seizure)– Altered mental status, including

unresponsiveness




The American Association of Poison Control Centers maintains an easy to remember 800 number.





• Inhaled Poisons: gases, fumes, vapors, dust.– Sources: automobile exhaust systems,

stoves, charcoal grills, industrial solvents, spray cans.

– Indicators: shortness of breath, coughing, pulse rate fast or slow, eyes irritated.

– Smoke inhalation and carbon monoxide poisoning present at fires scenes.





• Absorbed Poisons: Signs and Symptoms– Skin reactions (mild irritations to severe

burns)– Hives– Itching– Eye irritation– Headache– Increased skin temperature





• Injected Poisons– Sources: insect stings, spider bites, stings

from marine life, snakebites, hypodermic needle, drug overdose or contamination.

– Signs and Symptoms Noticeable stings or bites to skin Pain at or around wound site Itching

(continued)





• Injected Poisons– Signs and Symptoms

Weakness, dizziness, or collapse Difficulty breathing; abnormal pulse rate Headache Nausea Anaphylactic (allergy) shock





• Injected Poison Care (Bites and Stings)– Scrape away bee and wasp stingers and

venom sacs. – Do not pull out stingers; always scrape

from patient's skin; plastic credit card works well as scraper.

– Place ice bag or cold pack over bitten or stung area.





• Alcohol Abuse– Can lead to illness, poisoning of body,

abnormal behavior, even death.– Diabetes, epilepsy, head injuries, high

fevers, other medical problems can make patient appear drunk.

(continued)





• Alcohol Abuse – Delirium Tremens (DTs)

High blood pressure, rapid heart rate Confusion and restlessness Abnormal behavior Hallucinations Tremors (obvious shaking) of hands Convulsions (seizure activity)





• Signs of Alcohol Intoxication– Odor of alcohol on breath or clothing– Swaying, unsteady, uncoordinated

movements– Slurred speech; inability to carry on

conversation– Flushed appearance.– Nausea, vomiting, or feeling need to vomit





• Drug Abuse– Uppers: stimulants affect nervous system

to excite user– Downers: depressants affect central

nervous system to relax user– Narcotics: affect nervous system; change

many normal activities of body

(continued)





• Drug Abuse – Hallucinogens (mind-altering drugs): act on

nervous system to produce intense state of excitement or distortion of user's surroundings.

– Volatile chemicals: initial rush but then depress central nervous system.





• Drug Abuse – Withdrawal from drugs varies patient to

patient and drug to drug. – Signs and symptoms: shaking, anxiety,

nausea, confusion, irritability, sweating, increased pulse and breathing rates.

(continued)





• Drug Abuse – Take BSI precautions and perform a

primary assessment.– Maintain an open airway and ensure

adequate breathing.– Administer oxygen as per local protocols.– Monitor vital signs and be alert for

respiratory arrest.

(continued)





• Drug Abuse – Talk to the patient to gain his/her

confidence and to maintain his/her level of responsiveness.

– Protect the patient from further harm.– Continue to reassure the patient

throughout all phases of care.





• Generalized Infections (Sepsis)– Signs and Symptoms

Fever Chills Rapid breathing Rapid heart rate Low blood pressure Altered mental status

(continued)





• Generalized Infections (Sepsis)– Types of Patients

Transplant Infants and elderly Radiation or chemotherapy Burn Diabetes AIDS





• Allergic Reactions/Anaphylactic– Signs and Symptoms

Burning, itching, or breaking out of skin Breathing difficult and rapid Altered mental status Pulse rapid and weak Cyanosis of lips, nail beds Swelling of tongue and throat Restlessness

(continued)





• Allergic Reactions/Anaphylactic– Treatment

Take appropriate BSI precautions and perform a primary assessment.

Ensure a clear airway and adequate breathing.

Administer oxygen as per local protocols.

(continued)





• Allergic Reactions/Anaphylactic– Treatment

Assist the patient with his/her prescribed epinephrine autoinjector. (Follow local protocols.)

Monitor vital signs and ABCs until EMS units arrive.





• Kidney (Renal) Failure: when person's kidneys fail to function normally.– Signs and Symptoms

Weakness Altered mental status Generalized swelling Increased heart rate Increased blood pressure Decrease in urination





• Hemodialysis– Mechanically filtering blood to remove

wastes; excess fluid.

• Patient with renal failure must receive dialysis at frequent intervals; connected to machine through surgically implanted access point beneath skin of arm.




During hemodialysis the dialysis machine is connected to an access site such as a shunt beneath the skin.




During hemodialysis the dialysis machine is connected to an access site such as a shunt beneath the skin.





• You respond to a home to find an elderly female with fingernail polish on her fingers and around her lips. Her daughter reports that her mother suffers from Alzheimer's and ingested the nail polish. The patient is pleasant and cooperative. How will you proceed?




BEHAVIOR EMERGENCIESBEHAVIOR EMERGENCIES




Behavioral EmergenciesBehavioral Emergencies

• Behavior– Manner in which person acts or performs.

• Behavioral emergency– Situations where patient exhibits abnormal

behavior that is unacceptable or intolerable to patient, family, or community.





• Assessment/Care– Approach with caution; observe for signs of

agitation or violence. – Do not approach patient if it is not safe.– Identify yourself; let patient know you are

there to help.– Inform patient of what you are doing at all

times.

(continued)





• Assessment/Care – Ask questions; calm, reassuring voice.– Without being judgmental, allow patient to

tell what happened.– Show you are listening by rephrasing or

repeating part of what is said.– Be aware of your posture and body

language.

(continued)




Encourage the emotionally distraught patient to tell you what is troubling her.





• Assessment/Care – Assess patient's mental status.– Always consider need for law enforcement.– Do not make quick moves; threaten,

challenge, or argue; play along with hallucinations or auditory disturbances.

– Answer questions honestly.




Law enforcement officers may be needed to approach and control a behavioral patient who may become violent.





• Assessing the Potential for Violence– Scene size-up– History– Posture– Verbal activity– Physical activity

• Restraining Patients– Sometimes necessary to protect patient,

yourself, and others.




Use restraint only as a last resort.





• You respond to a home where a woman reports that her brother has threatened suicide. He is clearly agitated and aggressively refuses contact with you and your partner. How should you proceed?




SUMMARYSUMMARY




SummarySummary

• Conditions that cause patient to experience altered mental status:– Seizures– Strokes– Diabetic emergencies– Poisonings– Breathing problems– Cardiac events




Summary Summary

• Presents with range of signs and symptoms: confusion and dizziness to seizures and syncope (fainting).

• Assessment and care dependent on observing patient's environment and asking questions.




Summary Summary

• Seizures present with:– Sudden unresponsiveness– Convulsions– Headaches– Unusual breathing patterns

• Clear area around seizing patient.




Summary Summary

• Stroke signs and symptoms: – Syncope– Confusion– Partial or full paralysis– Headache– Difficulty speaking or swallowing– Altered mental status

• Closely monitor for airway compromise, breathing difficulty, cardiac arrest.




Summary Summary

• Diabetic emergencies present with:– Difficult or unusual breathing– Abdominal pain– Seizures– Dry mouth– Extreme thirst– Fruity breath odor– Altered mental status– Unresponsiveness




Summary Summary

• Hyperglycemia (high blood sugar)– Complain of abdominal pain– Extreme thirst and dry mouth

• Hypoglycemia (low blood sugar) – Extreme hunger; may resist eating– Strong, rapid pulse; shallow breathing– Seizures– Pale, cool, and moist skin




Summary Summary

• When EMR cannot determine if diabetic emergency is caused by hypo- or hyperglycemia, care should be same.

• Administer real sugar, provide oxygen, activate EMS system.

• Monitor patient's ABCs and make comfortable.




Summary Summary

• Signs and symptoms of poisoning:– Altered mental status– Vomiting; abdominal pain– Sweating– Abnormal pulse and/or breathing– Unresponsiveness– Pain when breathing or swallowing– Dilated or constricted pupils– Weakness or dizziness




Summary Summary

• Carbon monoxide poisoning– Headaches– Dizziness– Confusion– Seizures– Coma




Summary Summary

• Carbon monoxide poisoning– Primary indicator is patient's surroundings. – If patient presents with signs and

symptoms and has been near any sort of combustion, suspect carbon monoxide poisoning.




Summary Summary

• Care for poison or overdose patient: protect airway, administer oxygen, activate EMS system, monitor ABCs.

• Local, regional, or national poison control center should be contacted.




Summary Summary

• Sepsis– Condition where a once isolated infection

spreads through patient's bloodstream it becomes a system-wide problem.

• Indicators– Fever, chills, confusion, unresponsiveness,

rapid breathing, rapid heart rate, low blood pressure.




Summary Summary

• Septic patients must be treated at a hospital.

• EMR should activate EMS system, provide oxygen, monitor patient's ABCs.




Summary Summary

• Anaphylaxis: life-threatening allergic reaction.– Altered mental status– Difficulty breathing– Swelling of throat

• Support ABCs and assist with prescribed auto injector if available.




Summary Summary

• Renal failure– When kidneys no longer function normally.

• Dialysis– Artificially filtering blood and removing

excess water and waste products.




Summary Summary

• Behavioral emergency: patient is behaving in manner that is intolerable to himself/herself, his/her family, or community.– EMRs should ensure their own safety and

safety of others near patient. – Clearly and calmly identify themselves to

patient, ensure EMS system activated, engage patient with clear, effective communication.




REVIEW QUESTIONSREVIEW QUESTIONS




1. What are the common causes of altered mental status?

2. What are the signs and symptoms of a patient with an altered mental status?

3. What is the appropriate assessment and care for a patient with an altered mental status?

4. What are the signs of a patient experiencing a generalized seizure?

5. What is the appropriate assessment and care for a patient experiencing a generalized seizure?

(continued)




6. What are the signs and symptoms of a patient experiencing a stroke?

7. What is the appropriate assessment and care for a patient experiencing a stroke?

8. What are the signs and symptoms of a patient experiencing a diabetic emergency?

9. How do the signs and symptoms of hyperglycemia and hypoglycemia differ?

(continued)




10.What is the appropriate assessment and care for a patient experiencing a diabetic emergency?

11.What are the signs and symptoms of a patient experiencing an overdose or poisoning?

12.What is the appropriate assessment and care for a patient experiencing an overdose or poisoning?

13.When it is most appropriate to contact the poison control center?

(continued)




14.What are the signs and symptoms of a patient experiencing carbon monoxide poisoning?

15.What are the signs and symptoms of a patient experiencing an emergency related to renal failure?

16.What are the special considerations when caring for a hemodialysis patient?

17.What are the signs and symptoms of a patient experiencing a generalized infection (sepsis)?

(continued)




18.What is the appropriate assessment and care for a patient experiencing sepsis?

19.What are the signs and symptoms of an allergic reaction?

20.What is the appropriate assessment and care for a patient experiencing a severe allergic reaction?

21.What are the signs and symptoms of a patient experiencing a suspected behavioral emergency?

(continued)




22.What is the appropriate assessment and care for a patient experiencing a suspected behavioral emergency?




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Copyright ©2012 by Pearson Education, Inc. All rights reserved. Emergency Care, Twelfth Edition Daniel J. Limmer OKeefe Grant Murray Bergeron Dickinson