Professional Documents
Culture Documents
Paramedic Care 01 Nodrm
Paramedic Care 01 Nodrm
Volume 1
Introduction to Paramedicine
Legacy Author
ROBERT S. PORTER
Notice
The author and the publisher of this book have taken care to make certain that the information given is correct
and compatible with the standards generally accepted at the time of publication. Nevertheless, as new informa-
tion becomes available, changes in treatment and in the use of equipment and procedures become necessary.
The reader is advised to carefully consult the instruction and information material included in each piece of
equipment or device before administration. Students are warned that the use of any techniques must be autho-
rized by their medical advisor, where appropriate, in accordance with local laws and regulations. The publisher
disclaims any liability, loss, injury, or damage incurred as a consequence, directly or indirectly, of the use and
application of any of the contents of this book.
Copyright © 2017, 2013, 2009 by Pearson Education, Inc. All rights reserved. Manufactured in the United States
of America. This publication is protected by Copyright, and permission should be obtained from the publisher
prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form by any means,
electronic, mechanical, photocopying, recording, or likewise. To obtain permission(s) to use material from this
work, please submit a written request to Pearson Education, Inc., Permission Department, One Lake Street,
Upper Saddle River, New Jersey 07458, or you may fax your request to 201-236-3290.
Brady
is an imprint of
10 9 8 7 6 5 4 3 2
ISBN 10: 0-13-457203-3
www.bradybooks.com ISBN 13: 978-0-13-457203-1
This text is respectfully dedicated to all EMS personnel
who have made the ultimate sacrifice. Their memory
and good deeds will forever be in our thoughts and prayers.
BEB, RAC
This page intentionally left blank
Contents
Preface to Volume 1 xi Medical Oversight 25
Acknowledgments xiii Public Information and Education 26
About the Authors xv Effective Communications 27
Initial and Continuing Education Programs 28
Licensure, Certification, Registration, and Reciprocity 29
Staying Abreast 30
Effective Patient Transportation 30
Appropriate Receiving Facilities 32
Mutual Aid and Mass-Casualty Preparation 33
1 Introduction to Quality Assurance and Improvement 33
Paramedicine 1 Research 36
Evidence-Based Medicine 37
Introduction 2
System Financing 38
Description of the Profession 3
The Modern Paramedic 3
Paramedic Characteristics 5
The Paramedic: A True Health Professional 5
3 Roles and Responsibilities
Expanded Scope of Practice 6
of the Paramedic 42
Critical Care Transport (CCT) 6
Helicopter Air Ambulance (HAA) 7 Introduction 43
Tactical EMS 7 Primary Responsibilities 43
Mobile Integrated Health Care 7 Preparation 43
Industrial Medicine 8 Response 44
Sports Medicine 8 Scene Size-Up 44
Corrections Medicine 8 Patient Assessment 45
Hospital Emergency Departments 9 Recognition of Illness or Injury 45
Patient Management 46
Appropriate Disposition 46
2 EMS Systems 12
Patient Transfer
Documentation 48
48
v
vi Contents
4 Workforce Safety
What to Look for When Reviewing a Study
Applying Study Results to Your Practice
100
101
and Wellness 58
Participating in Research 101
Introduction 59 Evidence-Based Decision Making 103
Prevention of Work-Related Injuries 60
Basic Physical Fitness 60
Core Elements 60
Nutrition 61 6 Public Health 106
Habits and Addictions 63
Back Safety 63 Introduction 107
Personal Protection from Disease 65 Basic Principles of Public Health 107
Infectious Diseases 65 Accomplishments in Public Health 108
Standard Safety Precautions 65 Public Health Laws 108
Infection Control Measures 65 Epidemiology 108
Death and Dying 71 EMS Public Health Strategies 110
Loss, Grief, and Mourning 72 Public Health and EMS 111
What to Say 73 Organizational Commitment 111
When It Is Someone You Know 74 EMS Provider Commitment 112
Stress and Stress Management 74 Prevention in the Community 114
Phases of Stress Response 75 Areas of Need 114
Shift Work 76 Implementation of Prevention Strategies 115
Signs of Stress 76
Common Techniques for Managing Stress 77
Specific EMS Stresses 77
Post-Traumatic Stress Disorder 77 7 Medical–Legal Aspects
Mental Health Services 78 of Out-of-Hospital Care 119
Disaster Mental Health Services 78
General Safety Considerations 79 Introduction 121
Interpersonal Relations 79 Legal Duties and Ethical Responsibilities 121
Roadway Safety 79 The Legal System 122
Anatomy of a Civil Lawsuit 122
Laws Affecting EMS and the Paramedic 123
Legal Accountability of the Paramedic 125
5 EMS Research 84 Negligence and Medical Liability 125
Introduction 86 Special Liability Concerns 127
Research and the Scientific Method 87 Paramedic–Patient Relationships 128
Types of Research 88 Confidentiality 128
Quantitative versus Qualitative Research 89 Consent 130
Prospective versus Retrospective Studies 89 Legal Complications Related to Consent 134
Experimental Design 89 Patient Transportation 135
Specific Study Types 90 Resuscitation Issues 136
Study Validity 93 Advance Directives 136
Ethical Considerations in Human Research 93 Death in the Field 139
Institutional Review Boards 94 Crime and Accident Scenes 139
An Overview of Statistics 94 Duty to Report 139
Descriptive Statistics 94 Documentation 140
Inferential Statistics 95 Employment Laws 141
Contents vii
9 EMS System
Electronic Patient Care Records
Closing 205
204
Communications 159
Introduction 162
Effective Communications 162
Basic Communication Model 163
Verbal Communication 163
Reporting Procedures 164
Standard Format 164
General Radio Procedures 164
11 Human Life Span
Written Communication 165
Development 208
Terminology 165
Introduction 209
The Importance of Communications in EMS Response 166
Sequence of Communications in an EMS Response 166 Infancy 210
Physiologic Development 210
Information and Communications Technology 171
Psychosocial Development 212
Technology Today 172
New Technology 177 Toddler and Preschool Age 213
Physiologic Development 213
Public Safety Communications System
Planning and Funding 180 Psychosocial Development 214
Public Safety Communications Regulation 180 School Age 215
Physiologic Development 215
Psychosocial Development 216
13
Cellular Response to Stress 280
Cellular Adaptation 280
Emergency Pharmacology 351
Cell Injury and Cell Death 281 Introduction 354
PART 4: Disease at the Tissue Level 284 PART 1: Basic Pharmacology 354
Tissues 284 General Aspects 354
Origin of Body Tissues 284 Names 354
Tissue Types 286 Sources 355
Neoplasia 291 Reference Materials 355
PART 5: Disease at the Organ Level 295 Components of a Drug Profile 355
Genetic and Other Causes of Disease 295 Legal Aspects 356
Genetics, Environment, Lifestyle, Age, and Gender 295 Federal 356
Family History and Associated Risk Factors 296 State 357
Hypoperfusion 299 Local 357
The Physiology of Perfusion 299 Standards 357
The Pathophysiology of Hypoperfusion 303 Drug Research and Bringing a Drug to Market 357
Types of Shock 307 Phases of Human Studies 358
Multiple Organ Dysfunction Syndrome 312 FDA Classification of Newly Approved Drugs 359
Contents ix
14 Intravenous Access
Units
Medical Calculations
503
503
and Medication
Calculating Dosages for Oral Medications 504
Administration 440 Converting Prefixes 504
Introduction 443 Calculating Dosages for Parenteral Medications 505
PART 1: Principles and Routes of Medication Calculating Weight-Dependent Dosages 505
Administration 443 Calculating Infusion Rates 506
x Contents
M
odern EMS is based on sound principles and emphasizes the importance of medical direction in all
practice. Today’s paramedic must be knowledge- aspects of prehospital care.
able in all aspects of EMS. This begins with a fun- New in the 5th Edition: A new section Healthcare
damental understanding of EMS operations, basic medical System Integration, emphasizing, per newest AHA
science, and basic procedures. We have followed the National guidelines, the role of EMS in all types of cardiac
EMS Education Standards and the accompanying Paramedic emergencies, especially in the identification of acute
Instructional Guidelines to provide the appropriate introduc- coronary syndrome and ST-segment myocardial
tory material in Volume 1, Introduction to Paramedicine. infarction (STEMI).
This volume provides paramedic students with the
principles of advanced prehospital care and EMS opera- CHAPTER 3 Roles and Responsibilities of the Para-
tions. The first four chapters detail EMS systems and para- medic is a detailed discussion of the expectations and
medic roles and responsibilities with added emphasis on responsibilities of the modern paramedic. It empha-
personal wellness and injury and illness prevention. The sizes the various aspects of professionalism as they
next chapters deal with EMS research and the importance pertain to the paramedic.
of evidence-based medicine, the EMS role in public health, New in the 5th Edition: A note acknowledging
the medical/legal aspects of emergency care, and ethics in that aspects of the Affordable Care Act of 2010 have
paramedicine. The next two chapters deal with EMS sys- changed health care in numerous ways.
tem communications and documentation of patient care.
CHAPTER 4 Workforce Safety and Wellness presents
The final chapters of this volume cover life span develop-
material crucial to the survival of the paramedic in
ment, pathophysiology, emergency pharmacology, intra-
EMS. It addresses such important issues as prevention
venous access and medication administration, and airway
of work-related injuries, personal protection from dis-
management and ventilation.
ease, and safety concerns. It discusses physical fitness
and nutrition. It discusses ways of dealing with death
and dying, details the role of stress in EMS, and pres-
xi
xii Preface to Volume 1
CHAPTER 7 Medical/Legal Aspects of Prehospital Care CHAPTER 12 Human Life Span Development provides
is a detailed treatise on law and emergency care. In an overview of physiologic and psychosocial develop-
addition to an overview of the law and the legal sys- mental and age-related changes from infancy to late
tem, this chapter discusses how the legal system can adulthood.
impact the paramedic. It also provides important tips CHAPTER 13 Emergency Pharmacology is a compre-
on how the paramedic can avoid liability in a malprac- hensive chapter covering the various medications
tice action. used in medical practice, especially paramedic prac-
New in the 5th Edition: Emphasis that EMS laws tice. It presents an overview of pharmacology, fol-
and regulations differ between states and even lowed by a discussion of drug classifications.
between cities and counties. Emphasis on the impor- New in the 5th Edition: Tables listing antiar-
tance of individual liability insurance. Emphasis on rhythmic and hormone-related drugs updated per
invasion of privacy issues concerning cell phone latest American Heart Association guidelines.
cameras and social media. A new section on physi-
cian orders for life-sustaining treatment (POLST). CHAPTER 14 Intravenous Access and Medication
Administration is presented in three parts, the first
CHAPTER 8 Ethics in Paramedicine presents the fun- part detailing principles and routes of medication
damentals of medical ethics. As EMS becomes more administration; the second part concerning intrave-
sophisticated, the paramedic will be faced with an nous access, blood sampling, and intraosseous infu-
ever-increasing number of ethical dilemmas. This sion; and the final part giving an overview of medical
chapter provides the paramedic student with an mathematics and dose calculation.
overview of medical ethics so as to be able to make
New in the 5th Edition: An updated section on
sound decisions when confronted with ethical
Venous Access Devices, including tunneled catheters,
problems.
medication ports, and peripherally inserted central
CHAPTER 9 EMS System Communications discusses catheters (PICCs). A new section on Ultrasound-
communication as the key component linking all Guided Intravenous Access.
phases of an EMS run, discusses the current state of
EMS communications, and presents anticipated CHAPTER 15 Airway Management and Ventilation
advances in EMS communications and communica- presents the crucial prehospital skill of airway man-
tions technology. agement. The first part of the chapter deals with respi-
ratory anatomy, physiology, and assessment. The
CHAPTER 10 Documentation explains how to write a
chapter then goes on to address both basic manual and
prehospital care report (PCR), including examples of
advanced airway management techniques. In addition,
narrative report-writing styles, and discusses the ele-
this chapter details patient positioning, oxygenation,
ments and uses of electronic patient care records.
ventilation techniques, suction, rapid sequence intuba-
CHAPTER 11 Pathophysiology provides a detailed tion, surgical airways, the difficult airway, and other
description of basic pathophysiology. The first part airway and ventilation issues and techniques.
of the chapter introduces the concept of disease,
New in the 5th Edition: A segment on apneic
including predisposing factors to disease and classi-
oxygenation, a new strategy used to minimize the
fications of disease. The next parts of the chapter dis-
likelihood of hypoxia during endotracheal intubation.
cuss disease at the chemical level, the cellular level,
the tissue level, and the organ level. Finally, the
chapter details the body’s defenses against disease Bryan Bledsoe
and injury. Richard Cherry
Acknowledgments
Chapter Contributors the preparation and revision of the manuscript. The assis-
tance provided by these EMS experts is deeply appreciated.
We wish to acknowledge the remarkable talents of the fol-
lowing people who contributed to this five volume series. Fifth Edition
Individually, they worked with extraordinary commit- Michael Smith, MS, Educator, Kilgore College,
ment. Together, they form a team of highly dedicated pro- Longview, TX
fessionals who have upheld the highest standards of EMS
instruction. Edward Lee, A.A.S., BS, Ed.S., NRP, CCEMT-P, EMT
Paramedic Program Coordinator, Trident Technical
Paul Ganss, MS, NRP (Volume 1, Chapter 2) College, Summerville, SC
Michael F. O’Keefe (Volume 1, Chapter 5) Ryan Batenhorst, BA, NRP, EMS-I, Program Director,
Wes Ogilvie, MPA, JD, LP (Volume 1, Chapter 7) Paramedic Program, Southeast Community College,
Kevin McGinnis, MPS, EMT-P (Volume 1, Chapter 9) Milford, NE
Jeff Brosious, EMT-P (Volume 1, Chapter 10) Brett Peine, BS, NRP, Director, Southern State
W.E. Gandy, JD, NREMT-P (Volume 1, Chapter 15) University, Joplin, MO
Darren Braude, MD, MPH, FACEP (Volume 1,
Chapter 15) Fourth Edition
Joseph R. Lauro, MD, EMT-P (Volume 2, Chapter 6) Ronald R. Audette, NREMT-P
Vice President
Brad Buck, NRP, CCEMT-P (Volume 3, Chapter 10)
Educational Resource Group LLC
Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P
East Providence, RI
(Volume 4, Chapter 10)
Troy Breitag, BS, NREMT-P, Fire Lt.
Andrew Schmidt, DO, MPH (Volume 4, Chapter 10)
Department Supervisor – Med/Fire Rescue
Justin Sempsrott, MD (Volume 4, Chapter 10) Lake Area Technical Institute
David Nelson, MD, FAAP, FAAEM (Volume 5, Watertown, SD
Chapter 4)
Joshua Chan, BA, NREMT-P
Mike Abernethy, MD, FAAEM (Volume 5, Chapter 10) EMS Educator
Ryan J. Wubben, MD, FAAEM (Volume 5, Chapter 10) Cuyuna Regional Medical Center
Louis Molino, NREMT-I (Volume 5, Chapter 11) Crosby, MN
Dale M. Carrison, DO, FACEP, FACOEP (Volume 5, Thomas E. Ezell, III, NREMT-P,
Chapter 14) CCEMT-P, CHpT
Dan Limmer, AS, NRP (Volume 5, Chapter 14) Fire/Rescue Captain (Ret.)
Deborah J. McCoy-Freeman, BS, RN, NREMTP James City County Fire Department
(Volume 5, Chapter 15) Williamsburg, VA
Chapter 1
LEARNING OBJECTIVES
Introduction to
Paramedicine
Terminal Performance Objectives Bryan Bledsoe, DO, FACEP, FAAEM
CoMPETEnCy
210 Chapter 11 Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical–legal and
ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.
• Preschool age—3 to 5 years
• School age—6 to 12 years
• Adolescence—13 to 18 years
• Early adulthood—19 to 40 years
Learning Objectives
• Middle adulthood—41 to 60 years
• Late adulthood—61 years and older Terminal Performance Objective: After reading this chapter your should be able to discuss the characteristics of the pro-
fession of paramedicine.
Infancy KEY TERMS Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
physiologic development 1. Define key terms introduced in this chapter. 4. Discuss the traditional and emerging roles
Vital Signs Page numbers identify where of the paramedic in health care, public
Compare and contrast the four nationally
2.
the greatest changes in the range of vital signs are in the health, and public safety.
pediatric patient (table 11-1). each keytheterm first appears,
the younger child, the
recognized levels of EMS providers in the
more rapid are the pulse and respiratory rates. at birth, Figure 11-2 Infants double their weight by 4United States.
to 6 months old and 5. List and describe the various health care
boldfaced, in thetriplechapter.
the heart rate ranges from 100 to 180 beats per minute dur-
it by 9 to 12 months. settings paramedics may practice in with an
(© Michal Heron) Describe the requirements that must be met
3.
ing the first 30 minutes of life and usually settles to around expanded scope of practice.
120 beats per minute after that. the initial respiratory rate
for EMS professionals to function at the
is from 30 to 60 breaths per minute but tends to drop to 30 paramedic
fluid in the first week of life, the infant’s level.
weight usually
to 40 breaths per minute after the first few minutes of life. drops by 5 percent to 10 percent; however, infants usually
tidal volume is 6 to 8 mL/kg initially and increases to 10 to exceed their birth weight by the second week. during the
15 mL/kg by 12 months of age. first month, infants grow at approximately 30 grams per
as with the other vital signs, the normal range for
KEy TErMS
day, and they should double their birth weight by 4 to
blood pressure is related to the age and weight of the 6 months and triple it at 9 to 12 Advanced
months (Figure 11-2). the
Emergency Medical Emergency Medical Services (EMS) National Emergency Medical Services
infant, tending to increase with age. the average systolic infant’s head is equal to 25 percent of total body(AEMT),
Technician weight. p. 3 system, p. 2 Education Standards: Paramedic
blood pressure increases from a range of 60 to 90 at birth to Growth charts are good for comparing physical
Instructional Guidelines, p. 5
a range of 87 to 105 at 12 months. development to the norm, but community
parents andparamedicine,
health care p. 4 Emergency Medical Technician
providers should keep in mind thatcritical care
every transport,
child p. 7
develops (EMT), p. 3 Paramedic, p. 3
Weight at his own rate. Emergency Medical responder mobile integrated health paramedicine, p. 4
Content review
normal birth weight of an care, p. 4
➤ The younger the child, the (EMr), p. 3
infant usually is between Cardiovascular System
more rapid are the pulse
3.0 and 3.5 kg. Because of the as newborns make the transition from fetal to pulmonary
and respiratory rates. 1
excretion of extracellular circulation in the first few days of life, several important
YOU MAKE
It is a cold evening, and your county has experienced record rainfall in the last few days. you and
your emT partner are dispatched to the scene of “vehicle off the roadway”, along with a BLS
basic airway skills before using advanced procedures, and perform frequent reassessments, you
will give the patient his best chance for meaningful survival.
engine company. As you approach the reported location of the accident, you see a minivan that
THE CALL
appears to be on its side approximately 20 feet down the roadside embankment. The van sits in a
depression that is flooded with standing water reaching about halfway up the vehicle. As you
you Make the Call
pass the accident you see an adult female who appears to be attempting to climb out a passenger
side window. you and your paramedic partner, preston Connelly, are assigned to district 4, a quiet suburban
Describe how you would size up this scene. make sure you cover the following areas: neighborhood, on a warm Saturday in June. at 2:00 p.M., you are dispatched to care for a chok-
• Vehicle placement
A scenario at the end of ing child at the Happy Hotdog restaurant on Main Street. on your way to the location, the
dispatcher advises you that they are currently giving prearrival choking instructions to the
• Initial radio report each chapter promotes bystanders at the scene. on arrival, you find a frantic mother who tells you that her 6-year-old
• Assuming incident command son was eating a hot dog and drinking a soda when he started coughing and gasping for air. She
• Safety critical thinking by requiring keeps yelling for you to do something. Bystanders surround the child and are attempting to
perform the Heimlich maneuver without success. on your primary assessment, you find a
• Hazard control
students to apply principles 6-year-old boy lying on the floor, unconscious and apneic, with a pulse rate of 130. there is cya-
• Standard Precautions
nosis surrounding his lips and fingernail beds, with a moderate amount of secretions coming
• Location and triaging of patients to actual practice. from his mouth. there are no signs of trauma. you and preston immediately start management
• mechanism of injury of this child.
• resource determination 1. What is your primary assessment and management of this child?
See Suggested Responses at the back of this book. 2. What are your first actions?
3. What are your options for managing the airway after the obstruction is relieved?
4. What are the major anatomic differences between pediatric and adult patients in terms of
airway management?
See Suggested Responses at the back of this book.
17
review Questions
1. the depression between the epiglottis and the base c. respiratory rate.
of the tongue is called the _____________ d. total lung capacity.
M04_BLED9956_05_SE_C04.indd Page 68 2/29/16 7:21 PM s-w-149 /205/PH02050/9780134569956_BLEDSOE/BLEDSOE_PARAMEDIC_CARE_PRINCIPLES_AND_PRACTICE ...
68 Chapter 4
REFERENCES
2. national EMS Information System (nEMSIS). the nEMSIS gency ambulances.” Prehosp Emerg Care 6 (2002): 42–29.
1. Expert 10-Minute Physical Exams. 3rd ed. St. Louis: mosby Life- 5. Bates, B., L. S. Bickley, and R. A. Hoekelman. A Guide to Physical
technical assistance Center (taC). (available at http://www. 9. Billittier, a. J., 4th, E. B. Lerner, W. tucker, and J. Lee. “the Lay
line, 1997. Examination and History Taking. 11th ed. Philadelphia: Lippincott
nemsis.org//.) Public’s Expectations of Prearrival Instructions When dialing
2. Assessment Made Incredibly Easy. 5th ed. Springhouse, PA: Williams & Wilkins, 2005.
3. american College of Emergency Physicians (aCEP). “automatic 911.” Prehosp Emerg Care 4 (2000): 234–237.
Springhouse Corporation, 2008. 6. Epstein, O., et al. Clinical Examination. 3rd ed. St. Louis: mosby,
Crash notification and Intelligent transportation Systems.” Ann 10. Munk, M. d., S. d. White, M. L. Perry, et al. “Physician Medi-
3. Id. 2003.
Emerg Med 55 (2010): 397. cal direction and Clinical Performance at an Established
4. national Emergency number association (nEna). national Emergency Medical Services System.” Prehosp Emerg Care 13 4. Seidel, H. m. Mosby’s Guide to Physical Examination. 8th ed. St.
Emergency number association. (available at: http://www.
nena.org)
(2009): 185–192.
11. Cheung, d. S., J. J. Kelly, C. Beach, et al. “Improving Handoffs in
ThisLouis:
listing is a compilation of source
mosby, 2006.
Further reading
Bass, r., J. Potter, K. McGinnis, and t. Miyahara. “Surveying Emerg-
ing trends in Emergency-related Information delivery for the
EMS Profession.” Topics in Emergency Medicine 26 (april–June
national association of State EMS officials, national association
of EMS Physicians, June, 2010.
McGinnis, K. K. “the Future Is now: Emergency Medical Services
FURTHER READING
M04_BLED2031_05_SE_C04.indd Page 59 3/2/16 3:43 PM s-w-149 /203/PH02049/9780134572031_BLEDSOE_V1/BLEDSOE_V1_PRINCIPLES_AND_PRACTICE5_SE_9780 ...
Case Study
CASE STUDY Howard is a 15-year veteran of a high-volume, inner-
city emS service. When he first started his career, How-
sensitivity, patience, and gentleness. “Howard is the
man I’d want to tell bad news to my mother,” one of his
ard thought he knew what he was getting into, but the partners says. “He can handle people involved in just
years have taught him differently. about any circumstance—death situations, panicked
right now, Howard is in the spotlight for saving the parents, lonely elderly people, and even hostile drunks.
This feature at the start of each chapter draws life of a police officer who was shot in a hostage situa- I’ve never seen anyone treat others with such dignity
tion. “that call forced me to reflect on a few important and respect. He’s the best partner anyone could want,
students into the reading and creates a link things,” he says. “two years ago, I had a minor heart especially when we have to manage patients who are
problem, and it was a good wake-up call. Since then I’ve thrashing around. But that was not always so, was it,
between text content and real-life situations. been lifting weights and running, so I was able to get to
the officer with enough strength to carry him to safety.
Howard?”
“no, it wasn’t,” Howard replies. “there was a time
“another thing is that I always use personal protec- when no one wanted to work with me. I was a rebel,
tive equipment. I never go to work without steel-toed and I figured there was only one way to do things: my
boots and I never leave the ambulance without a pair of way. But an incident that occurred a few years ago
disposable gloves. Can you believe there are still para- changed all that. It’s a long story. But the upshot is that
medics who knock the concept of infection control? If when I recovered from the stress, my outlook had been
any one of my partners sticks a needle into the squad altered. I realized that though I couldn’t save the world,
bench in my ambulance, they know I’ll speak up.” I could save myself. that’s when I learned how to deal
Howard, a mild-mannered, nondescript man, with the effects of a stressful job. I started eating right,
doesn’t realize that his young colleagues regard him lost a lot of weight, and adopted a new attitude. any-
as a role model. they’ve seen him handle himself at way, if I can maintain my own well-being, I can do a lot
chaotic scenes as well as when a situation demands more to help others. right? Isn’t that what we’re about?”
Introduction and insidious infections. If you let your spirit appreciate the
fear and sadness on other faces, you will find ways to combat
the safety and well-being of the workforce is a fundamen- your prejudices and treat people with dignity and respect. By
tal aspect of top-notch performance in emS.1 as a para- doing all these things, you will also be able to promote the
medic, it includes your physical well-being as well as your benefits of well-being to your emS colleagues.
mental and emotional well-being. If your body is fed well death, dying, stress, injury, infection, fear—all these
and kept fit, if you use the principles of safe lifting, observe threaten your wellness and conspire to interfere with your
safe driving practices, and avoid potentially addictive and good intentions. However, you can do something about
harmful substances, you stand a chance of having the them. each person has choices about how to live. every
physical strength and stamina to do the job. choice has outcomes and consequences. many patients in
If you seize the information about safe practices and nursing homes are living with their choices, paying for life-
apply them to your life, you will be better able to avoid harm style decisions made decades ago when they were about
from violent people, roadway hazards, ambulance accidents, your age. Is that what you want for yourself?
M07_BLED9956_05_SE_C07.indd Page 241 2/29/16 7:16 PM s-w-149 /205/PH02050/9780134569956_BLEDSOE/BLEDSOE_PARAMEDIC_CARE_PRINCIPLES_AND_PRACTICE ...
PROCEDURE SCANS
Procedure 7-4 reassessment
7-4a reevaluate the ABCs. 7-4b Take all vital signs again.
7-4c perform your focused assessment again. 7-4d evaluate your interventions’ effects.
laryngospasm may be occurring. Airway and breathing oxygenation. Lip cyanosis indicates central hypoxia (over-
management requires constant reevaluation. all oxygen status), whereas peripheral cyanosis indicates
decreased oxygen to the tissues. pallor and coolness sug-
pulse rate and Quality gest decreased circulation to the skin, as seen in shock.
If your patient suddenly develops hives after you
Check central and peripheral pulses and compare the find-
M04_BLED9956_05_SE_C04.indd Page 58 2/29/16 7:21 PM s-w-149 /205/PH02050/9780134569956_BLEDSOE/BLEDSOE_PARAMEDIC_CARE_PRINCIPLES_AND_PRACTICE ... administer a medication, suspect an allergic reaction. A
ings with earlier measurements. A rising pulse rate could
localized redness and warmth could indicate bleeding
indicate shock, hypoxia, or cardiac dysrhythmia. A falling
under the skin or vasodilation. Cyanosis and coolness in a
rate could mean the terminal stage of shock or a rise in
Special Features
lower extremity suggest a peripheral vascular problem such
intracranial pressure. A sudden change in rate or regularity
as an arterial occlusion. A deep venous thrombosis will
58 Chapter 4 may suggest a cardiac dysrhythmia. The loss of peripheral
result in redness, swelling, and warmth in the lower leg.
pulses could mean decompensating shock.
This chapter presents the components of a comprehen- by the patient or a bystander, the primary problem is the
sive patient history in a systematic order. In practice, you will principal medical cause of the complaint. For example, Skin Condition Transport priorities
ultimately select only the components that apply to your your patient’s chief complaint may be leg pain, whereas
patient’s situation and status. For example, if you conduct the primary problem is a tibia fracture. When possible, Similar to mental status, the skin quickly reflects the body’s Sometimes, stable patients suddenly deteriorate en route
preemployment physical exams for a company, you may use report and record the chief complaint in your patient’s own hemodynamic status. reevaluate your patient’s skin color, to the hospital. For example, the formerly conscious and
the entire form. On the other hand, if you respond to a gasp- words. For example, “I am having a hard time breathing” temperature, and condition. Cyanosis suggests decreased alert head injury patient now responds only to pain. or
ing patient with acute pulmonary edema, you will focus on is better than “the patient has dyspnea.” For the uncon-
the present illness. Common sense and clinical experience
will determine how much of the following history to use.
scious patient, the chief complaint becomes what someone
else identifies or what you observe as the primary prob-
lem. In some trauma situations, for instance, the chief com-
PATHO PEARLS
plaint might be the mechanism of injury, such as “a
first responder, the police, or another health care worker? symptoms the patient describes. This will help you to fully com- M02_BLED2031_05_SE_C02.indd Page 31 3/2/16 3:44 PM s-w-149 /203/PH02049/9780134572031_BLEDSOE_V1/BLEDSOE_V1_PRINCIPLES_AND_PRACTICE5_SE_9780 ...
prehend the disease process or processes affecting the patient.
Do you have the medical record from a transferring facility?
For example, consider the following case. mrs. J. Frank-
After you have gathered the information, you should
lin is a 72-year-old pensioner, twice widowed, who lives in an
establish its reliability, which will vary according to the
42 Chapter 3 older section of town. She summons EmS with what initially
source’s knowledge, memory, trust, and motivation. Again, seem like vague complaints. She reports to the dispatcher,
reconfirm the information with the patient, if possible. This EMS Systems 31
when queried, that she is for“just
yousick.”
to letyou thearrive andstate
beginthe chief com-
Compassionate
is a judgment call TouchFor example, if
based on your experience. an assessment,
important
starting with a pertinent
patient
Another communication skill is touching. plaint in his own words. Ifhistory.
you were The to
patient
ask leading ques-
the patient information you received from a particular EmTThe ability to
reports that her symptoms began about two weeks ago after
first responderhold a hand,
has been or even
accurate hug,past,
in the in the
youright circumstances
probably canfamilytions
several
(ones that guide the patient’s replies), such as “Are
members came to her house with dinner, which
Legal Considerations
yield information that would otherwise not be given. Some you having difficulty breathing?” or “I see you’re limping.
will trust it again. On the other hand, if the nurse at a physi- included a baked ham. Since that time, she has developed some Emergency Department Closures. numerous factors
paramedics need to learnyouthiswith
skill erroneous
the way they learn Did you fall or hurt yourself?” you could easily miss a seri-
how progressive
cian’s office has repeatedly provided fatigue, dyspnea, and occasional chest pain. She have resulted in emergency department closures and ambu-
to use an IV.will
That is, itits
can be awkward at first, but nowitreports
is ous
that problem.
she often wakesSo, instead,
up at 3:00 open-ended
aska.m. with breath-questions, such lance diversions. this can have a significant impact on the
information, you probably doubt accuracy.
worth the effort. nothing builds trust and rapport, oring calms as “What
trouble that resolveshappened
when she that walks led you tothe
around call for an
room or ambulance?” EMS system. all systems must address this situation so that
patients, faster than the power of touch. How effective sleepsit is or “What’s
with three pillows. Shegoing alsoon today?”
cannot tie herQuestions
shoes, andsuch
she as these will patient care does not suffer.
depends on the patient’s age, gender, cultural background, allow your patient to respond
missed church last Sunday for this very reason. Her medica- in an unguided, spontane-
Chief Complaint past experience, and current setting. Timing is everything. ous way.
tions have remained They also
unchanged andencourage patients who
include furosemide, are reluctant to
nitro-
LEGAL CONSIDERATIONS
Deciding when and where to provide a glycerin paste,
compassionate digoxin,
speak aspirin, and
to describe lisinopril.
their complaint in a way that might not
The history begins with an open-ended question about In 1974, in response to a request from the dot, the
Clearly, bethere are physiologic
possible otherwise. cues in the patient’s medi-
your patient’stouch
chief is part of theThe
complaint. art chief
of medicine.
complaint Justislike
the eye contact, it
cal history. The symptoms began with
General Services administration (GSa) developed the
can demonstrate empathy and encourage trust. The patient’s chiefa complaint
ham dinner. should
you learnthen drive the
“KKK-a-1822 Federal Specifications for ambulances.”
pain, discomfort, or dysfunction that caused your patient that she keptevolution
the ham and hasother
been eating it daily. The ham isFor example, if
of all questions to be asked. this was the first attempt at standardizing ambulance
to request help. In a medical case, it may be a woman’s call salt cured. Thus, her sodium intake may have increased. Her
your patient’s chief complaint is chest pain, you are design to permit intensive life support for patients en route
for help because she has chest pain. In a trauma case, it medications have remained unchanged. Her symptoms seem to Figure 2-11 Patients may be transported by ground or air. Medical
Interviewing a patient
may be a bystander’s call for assistance to a “man down”
required to obtain answers to a specific set of questions.
indicate worsening heart failure with episodes consistent with to a definitive care facility. the act defined the following
Offer a snapshot of pathological
helicopter transport was introduced in the 1950s during the Korean War.
However, instead of interviewing a patient as if you were basic types of ambulance:
or a police officer’s reporting an injury in an auto collision. both left and right ventricular failure. Her nighttime dyspnea (© Ed Effron)
From the moment of your first contact with the patient, and orthopnea reading a shopping
are consistent with leftlist,heart
individualize
failure, whereasthe process. For
your patient may have called for more than one symptom. • Type I (Figure 2-13). this is a conventional cab and
your job is to find out all the information relevanther to inability
the example, you could
would be have
due toto find outedemawhether a patient
It is important to begin with a general question that
allows your patient to respond freely. Ask, for example,
considerations students will encounter in the field.
present emergency. you need to identify the patient’s from chief
to
with
right heart
tie her shoes
chestThe
failure. pain takescould
fatigue any be
peripheral
medications.
attributed toIfboth.
your patient tells Vietnam, and success of military evacuation procedures
led to their use in civilian ambulance systems. In 1970, the
chassis on which a module ambulance body is
complaint (the reason that 911 was called), learn Thus, the cir- you that
your physical his chief complaint
examination should either is support
“chest pain so bad even the
or con- mounted, with no passageway between the driver’s
“Why did you call us today?” or “What seems to be the Military assistance to Safety and traffic (MaSt) program and patient’s compartments.
cumstances that caused the emergency, evaluate tradicttheyour history
nitroglycerin
findings.tablets aren’t helping,” your question about
problem?” Avoid the tunnel vision that often biases para- was established. this demonstration project set up 35 heli-
patient’s condition, and determine the best course of action In fact, itmedications
was learned mightlater that bethe patient’s
worded heart medications
“What failure do you • Type II (Figure 2-14). a standard van, body, and cab
medics who focus on dispatch information that may or copter transportation programs nationwide to test the fea-
to mitigate his problem. much of this is accomplished had always
by been
take somewhat
in addition tenuous and the sodium
to nitroglycerin?” load
This she
tells the patient you form an integral unit. Most have a raised roof.
may not accurately describe the situation. As you inter- sibility of using military helicopters and paramedics in
asking questions, observing the patient, listeningreceived effec- fromhave the hambeen was all that was
listening, necessary
which to cause
can help con-a greater rap-
build
view and assess your patient, the chief complaint will gestive heart failure. She did well with two days of hospitaliza- civilian medical emergencies.29
tively, and using appropriate language. port. other questioning techniques include the following:
become more specific.1 tion, diuretic administration, and sodium restriction. today, trauma care systems use law enforcement,
The chief complaint differs from the primary problem. Dr. Osler was• Continue
correct. The tohistory
ask open-ended
is often the mostquestions.
impor- They do not municipal, hospital-based, private, and military helicopter
Asking
Whereas the chief Questions
complaint is a sign or symptom noticed tant part of patientlimit the patient’s responses, which can help to reveal
assessment. transport services to transfer patients. Fixed-wing aircraft
An important part of patient assessment is gathering infor- unexpected but important facts. For example, instead
also are used when patients must be transported long dis-
mation that is accurate, complete, and relevant to the pres- of asking your patient with abdominal pain, “Did you
tances, usually more than 200 miles (Figure 2-12).
CULTURAL CONSIDERATIONS
ent emergency. To begin, you must identify the patient’s have breakfast today?” which can be answered with
chief complaint. Although dispatch probably will have either a “yes” or a “no,” ask: “What have you eaten ambulance Standards
given you an idea of what the emergency is about, it is today?” all transport vehicles must be licensed and meet local and
• Use direct questions when necessary. Direct questions, state EMS requirements. Equipment lists should be consis-
or closed questions, ask for specific information. tent with systemwide standards. there are various national
(“Did you take your pills today?” or “Does the abdom- and regional standards regarding what equipment and
Cultural Considerations
eye contact is a major form of nonverbal communication.
inal pain come and go like a cramp, or is it constant?”)
These questions are good for three reasons: They fill in
Provide an awareness of beliefs technologies should be available on both emergency and
nonemergency ambulances. regional standardization of
Short eye contact is often seen as friendly, whereas prolonged information generated by open-ended questions. They equipment and supplies is most effective in facilitating
that might affect patient care.
Figure 2-13 type I ambulance.
eye contact may be interpreted as threatening. Thus, timing help to answer crucial questions when time is limited. interagency efforts during disaster operations.
is an important factor in how a person interprets eye contact.
And they can help to control overly talkative patients,
one’s culture also influences how eye contact is inter-
who might want to tell you about their gallbladder
preted. eye contact can mean respect in one culture and dis-
surgery in 1969 when their chief complaint is a
respect in another. often, Asians will avoid eye contact even
when they have nothing to hide. eye contact between people
sprained ankle.
of different sexes is problematic in muslim cultures, in which • Ask only one question at a time, and allow the patient
a prolonged look in the face of a member of the opposite sex to complete his answers. If you ask more than one
might be misinterpreted. Because of this, people in middle question, the patient may not know which one to
eastern countries might look a person of the same sex in the answer and may leave out portions of information or
eye and not look into the eyes of a person of the opposite sex. become confused. equally important is having one
If you work in a culturally diverse community, you person do the interview. Don’t force your patient to
should learn the customs of eye contact and other forms of
discern questions from multiple interviewers.
nonverbal communication of those you might encounter dur-
ing the course of your work. • Listen to the patient’s complete response before asking
Figure 2-12 Fixed-wing aircraft, as well as helicopters, have become
the next question. By doing so, you might find that
an important part of patient transport in the modern EMS system.
(© REACH Air Medical Services) Figure 2-14 type II ambulance.
of, or shortly before, the signs or symptoms developed. In
rib-fracture pain will not breathe deeply, whereas breath-
some cases, especially in trauma, you may have to gather
ing may not affect the pain of angina. Any patient with
information from a few weeks before the onset of symp-
respiratory pain will breathe with shallower but more fre-
toms. For example, the signs and symptoms of a subdural
quent breaths.
hematoma may not appear until weeks following an injury.
If your patient took a medication shortly before you
Was the patient exercising or exerting himself, or at rest or
arrived, its effect—or lack of effect—may help determine
sleeping? Was he eating or drinking? If so, what? In trauma
the problem. Drugs such as bronchodilators, hypoglycemic
cases, ensure that a medical problem did not cause the inci-
agents, antihypertensives, and anticonvulsants are com-
dent. For example, the sudden onset of an illness, such as a
monly prescribed and taken at home. Investigate any med-
seizure or syncope, may have caused a fall.
ication used to relieve a problem and note its effectiveness.
Ask about any activity, medication, or other circumstance
Provocation/Palliation that either alleviates or aggravates the chief complaint.
What provokes the symptom (makes it worse)? Does
anything palliate the symptom (make it better)? In many Quality
How does your patient perceive the pain or discomfort?
PEDIATRIC PEARLS
left nipple.
thetic nervous system stimulation as the body compen-
sates for another problem, such as blood loss, fear, pain,
fingers, compress the radial artery onto the radius, just
fever, drug overdose, or hypoxia. It is an early indicator of
below the wrist on the thumb side (procedure 5-1b). In the
shock and may indicate ventricular tachycardia, a life-
unconscious patient, begin by checking his carotid pulse.
threatening cardiac dysrhythmia.
To locate the carotid pulse, palpate medial to and just
The pulse’s quality can be weak, strong, or bounding.
Weak, thready pulses indicate a decreased circulatory status,
below the angle of the jaw. Locate the thyroid cartilage
(Adam’s apple) and slide your fingers laterally until they Offer tips, guidance, and information
such as shock. Strong, bounding pulses may indicate high
are between the thyroid cartilage and the large muscle in
blood pressure, heat stroke, or increasing intracranial pres-
sure. The pulse location may be another indicator of your
the neck (sternocleidomastoid). on how to deal with pediatric patients
First, note your patient’s pulse rate by counting the
patient’s clinical status. The presence of a carotid pulse gen-
erally means that his systolic blood pressure is at least 60
number of beats in 1 minute. If his pulse is regular, you can
count the beats in 15 seconds and multiply that number by encountered in the field.
mmHg. The presence of peripheral pulses indicates a higher
4. If his pulse is irregular, you must count it for a full min-
blood pressure; their absence suggests circulatory collapse.
ute to obtain an accurate total. Also note the pulse’s rhythm
practice locating each of the pulse locations (Figure 5-12). As
and quality.
with other vital signs, take your patient’s pulse frequently in
the emergency setting and note any trends. Blood pressure
To take the pulse of a conscious adult or large child, Blood pressure is the force of blood against the arteries’ M07_BLED9956_05_SE_C07.indd Page 223 2/29/16 7:16 PM s-w-149 /205/PH02050/9780134569956_BLEDSOE/BLEDSOE_PARAMEDIC_CARE_PRINCIPLES_AND_PRACTICE ...
the most accessible and commonly used location is the walls as the heart contracts and relaxes. It is equal to car-
radial artery. With the pads of your first two or three diac output times the systemic vascular resistance. Any
alteration in the cardiac output or the vascular resis-
Peripheral tance will alter the blood pressure.
Pulse Sites An important indicator of your patient’s condi- Patient Assessment in the Field 223
tion, blood pressure is measured during both sys-
tole and diastole. Systolic blood pressure (the your patient en route to the hospital to detect changes in
Temporal – lateral to eye orbit Customer Service Minute patient condition.
higher numeric value) measures the maximum
CUSTOMER SERVICE
force of blood against the arteries when the ventri- Following Up. Last week, a man took his dog to the vet for your proficiency in performing a systematic patient
Carotid – medial to and below angle of jaw
cles contract. Diastolic blood pressure (the lower an upper respiratory infection. The dog was pretty sick, but assessment will determine your ability to deliver the high-
numeric value) measures the pressure against the the vet assured the owner that she was not critical, and with est quality of prehospital advanced life support (ALS) to
MINUTE
antibiotics she would be better in a few days, so he brought sick and injured people. paramedic patient assessment is a
Brachial – just medial to biceps tendon arteries when the ventricles relax and are filling
her home. The next day, the veterinarian called to find out straightforward skill, similar to the assessment you might
with blood. The diastolic blood pressure is a
how the dog was doing. She called every day until the dog have performed as an emT. It differs, however, in depth
measure of systemic vascular resistance and corre-
M05_BLED9956_05_SE_C05.indd Page 102 2/29/16 7:18 PM s-w-149 /205/PH02050/9780134569956_BLEDSOE/BLEDSOE_PARAMEDIC_CARE_PRINCIPLES_AND_PRACTICE ... was back to normal. needless to say, the man was delighted
Radial – thumb side of wrist lates well with changes in vessel size. The sounds of and in the kind of care you will provide as a result.
in the service he received from that vet.
Ulnar – little finger side of wrist the blood hitting the arterial walls are called the your assessment must be thorough, because many ALS
physicians’ offices, dentists’ offices, and veterinary
Korotkoff sounds. procedures are potentially dangerous. Safely and appropri-
offices often call their patients a few days following a visit to
IN THE FIELD
condition. now, you will use your foundation of knowl-
retina, located at the back of the eye. Although it is most Try to keep both your eyes open and relaxed. The
often used to diagnose eye conditions, you can discover optic disk should come into view when you are about 1.5
edge, skills, and tools to assess the acutely ill or injured
patient. With time and clinical experience, you will learn Scene Size-Up
information that may be relevant to other medical and trau- to 2 inches from the eye while you are still aiming your which components of the comprehensive exam apply to Scene size-up is the essential first stage of every emergency
matic events. light 15 to 25 degrees nasally. If you are having difficulty
The ophthalmoscope is basically a light source with
each particular patient. It’s time to put it all together. call (Figure 7-1). Sizing up an emergency scene is a series of
finding the disk, look for a branching (bifurcation) in a your patient’s condition will determine which compo-
lenses and mirrors. It has a handle, which houses the batter- timely decisions you will make to ensure that you and
retinal blood vessel. Usually the bifurcation will point
Provides extra tips that can help ensure
ies, and a head, which includes a window through which nents you use and how you use them. For example, for your crew remain safe and to begin to secure the necessary
toward the disk. trauma patients with a significant mechanism of injury,
you visualize the internal eye; an aperture dial, which resources to manage the scene and care for your patient.
Follow the vessel in the direction of the bifurcation you will perform a primary assessment followed by a rapid
changes the width of the light beam; a lens dial to bring the you will base these informed, critical decisions on judg-
eye into focus; and a lens indicator, which identifies the lens
magnification number (i.e., 0 to +40 or 0 to –20). you examine
and you should arrive at the optic disk. The disk should
appear as a yellowish-orange to pink round structure. success in real-life emergency situations.
secondary assessment (a head-to-toe exam aimed at trau-
matic signs and symptoms) and, if time allows, a more
ment and instinct—the sum total of your education and
experience. They will be some of the most important deci-
the eye by looking through a monocular eyepiece into the eye Within the center of the disk there should be a central detailed secondary assessment en route to the hospital. For sions you will ever make as a paramedic.
of your patient. you can view different depths of the eye at physiologic cup, which normally appears as a smaller, patients with minor, isolated trauma, a primary assess- never skip this crucial component of an emergency
different magnifications by rotating a disk of varying lenses paler circle. The cup should be less than half the diameter ment followed by a problem-oriented exam is warranted. run just because the scene appears to be safe. The compo-
within the instrument itself. of the disk. An enlarged cup may indicate chronic open- For the responsive medical patient, you will conduct a pri- nents of a scene size-up include ensuring a safe environ-
angle glaucoma. Indistinct borders or elevation of the optic mary assessment followed by a focused history and physi- ment, taking the necessary precautions for personal
disk may indicate papilledema, which is a marker of cal exam. Finally, for the unresponsive medical patient, protection, determining what resources are needed, locat-
increased intracranial pressure. you will perform a primary assessment followed by a rapid ing all patients, and assessing the mechanism of injury or
next, look at the arteries and veins of the retina. The secondary assessment (a head-to-toe exam aimed at medi- nature of a medical illness.1 Although you must consider
arteries are usually brighter and smaller than the veins. cal signs and symptoms). In all cases, you will reassess all the elements of scene size-up important, circumstances
Spontaneous venous pulsations are normal. Abnormalities
of the retina such as hemorrhages, arteriovenous (AV)
nicking, and cotton wool spots may indicate local or sys-
temic disease such as retinal vein occlusion, hypertension,
or many other conditions.
Finally, look at the fovea and surrounding macula.
This area is where vision is most acute. It is located about
two disk diameters temporal to the optic disk. you may
also find the macula by asking the patient to look directly
into the light of your ophthalmoscope. prepare for a fleet-
ing glimpse as this area is very sensitive to light and may
be uncomfortable for your patient to maintain. A “cherry
red” macula with surrounding pallor of tissue in the set-
Figure 5-27 An ophthalmoscope is used to visualize the inte-
rior of your patient’s eyes. ting of acute painless monocular visual loss indicates a
central retinal artery occlusion. Irreversible damage occurs
Image by Christof VanDerWalt
MyLab & Mastering is the world’s leading collection of online homework, tutorial, and assessment
products designed with a single purpose in mind: to improve the results of higher education students,
one student at a time. Used by more than 11 million students each year, Pearson’s MyLab & Mastering
programs deliver consistent, measurable gains in student learning outcomes, retention, and
subsequent course success.
Standard
Preparatory (EMS Systems)
Competency
Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical–legal and
ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.
Learning Objectives
Terminal Performance Objective: After reading this chapter your should be able to discuss the characteristics of the pro-
fession of paramedicine.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this chapter. 4. Discuss the traditional and emerging roles
of the paramedic in health care, public
2. Compare and contrast the four nationally
health, and public safety.
recognized levels of EMS providers in the
United States. 5. List and describe the various health care
settings paramedics may practice in with an
3. Describe the requirements that must be met
expanded scope of practice.
for EMS professionals to function at the
paramedic level.
Key Terms
Advanced Emergency Medical Emergency Medical Services (EMS) National Emergency Medical Services
Technician (AEMT), p. 3 system, p. 2 Education Standards: Paramedic
community paramedicine, p. 4 Emergency Medical Technician Instructional Guidelines, p. 5
1
2 Chapter 1
Case Study
Marcus Ward is a 65-year-old attorney who is celebrat- arrives in the lab, the team goes to work. Marcus is
ing his recent retirement with a week-long trip to Las moved to the table. A nurse shaves his groin and applies
Vegas. He has taken in the shows, eaten the fine food, an antiseptic soap. An anesthesiologist sedates Marcus
and is spending his last night in town in one of the and monitors his vital signs. The cardiologist quickly
casinos on the famous Las Vegas strip. He sits down at inserts a catheter into Marcus’s femoral artery and
a blackjack table and lights a cigarette. As the dealer is threads it up the aorta to the heart. He injects a dye, and
shuffling the cards, Marcus starts to feel warm. He immediately Marcus’s coronary arteries can be seen on
turns to his friend Ray and says, “Does it feel warm in the monitor. As expected, part of the left anterior
here to you?” Then, without another word, Marcus descending coronary artery is blocked. The cardiologist
grasps at the collar of his shirt and collapses to the then inserts a balloon catheter into the diseased artery
floor. Initially, Ray thinks his friend has slipped on the and restores blood flow to the affected part of the heart.
stool. Quickly, though, he realizes the situation is much Some ventricular irritability and premature ventricular
worse. He starts screaming for help. The dealer presses contractions follow, but these soon abate and the cardi-
a security button and several security officers immedi- ologist then inserts a drug-eluting stent to keep the
ately come to the table. After a quick exam, the security artery open. Additional dye is injected, blood flow
staff moves Marcus to a beverage area off the casino through the stent looks good, and no other lesions
floor and calls 911. There they start CPR and immedi- require treatment. Marcus is moved to the coronary care
ately apply an automated external defibrillator (AED) unit, where he ultimately recovers and flies back to
to Marcus. The AED detects ventricular fibrillation and Irvine, California, four days later.
delivers a shock. Immediately, Marcus starts moving Marcus survived because the EMS and emergency
and soon opens his eyes. The security staff closely health care system worked together cohesively. When
monitors Marcus, and soon a paramedic fire crew he collapsed at the blackjack table, he was defibrillated
arrives. Shortly thereafter, paramedics from the ambu- within 3 minutes of his collapse. His STEMI was
lance service arrive. promptly identified and treated by prehospital person-
The paramedics assess Marcus and obtain a 12-lead nel, who also notified and activated the STEMI team at
ECG. The ECG is consistent with an acute anterior ST- the hospital. The time interval from Marcus’s arrival at
segment elevation myocardial infarction (STEMI). The the hospital until blood flow was restored to his dis-
ECG monitor electronically transmits Marcus’s ECG to eased artery (door-to-balloon time) was 31 minutes.
the hospital emergency department and the on-call Back in Irvine, Marcus has vowed to improve his
STEMI team. The cardiologist reviews the ECG and calls life and appears to be making important changes. He
for a “Code STEMI,” after which the team is activated. has quit smoking and has begun an exercise regimen.
Paramedics insert an IV and administer nitroglycerin He now sees a local cardiologist on a regular basis. He
and 325 mg of aspirin. Marcus is quickly moved to the and his wife have made major changes in their diet. His
ambulance and transported to the designated hospital. prognosis is good, and he should enjoy many more
Once Marcus arrives at the emergency department, years of his retirement. A month after his cardiac arrest,
he is quickly evaluated by the interventional cardiolo- Marcus purchased an AED and donated it to the fitness
gist and an emergency physician. Finding no contrain- center where he now exercises. Moreover, he has devel-
dications, the cardiologist has Marcus immediately oped a new understanding and appreciation for the
moved to the cardiac catheterization suite. After he EMS system.
• Emergency Medical
Content Review
Technician (EMT). The
➤➤ Levels of EMS Providers
primary focus of the
• Emergency Medical
Emergency Medical
Responder (EMR)
Technician (EMT) is
• Emergency Medical
to provide basic emer- Technician (EMT)
gency medical care • Advanced Emergency
and transportation for Medical Technician
critical and emergent (AEMT)
patients who access • Paramedic
the emergency medi- ➤➤ The paramedic is
cal system. The EMT the highest level of
possesses the basic prehospital care provider
knowledge and skills and the leader of the
prehospital care team.
necessary to provide
patient care and transportation. EMTs perform inter-
ventions with basic equipment and are an essential
link in the prehospital emergency care continuum.
EMTs must successfully complete an EMT educational
program.
• Advanced EMT (AEMT). The primary focus of the
Advanced Emergency Medical Technician (AEMT) is
to provide basic and limited advanced emergency
medical care and transportation for critical and emer-
gent patients who access the EMS system. The AEMT
possesses the basic knowledge and skills necessary to
provide patient care and transportation. In addition,
AEMTs perform interventions with both basic and
advanced equipment. The AEMT must successfully
Figure 1-1 The paramedic of the twenty-first century is a highly complete an accredited EMT educational program.
trained health care professional.
• Paramedic. The Paramedic is an allied health profes-
sional whose primary focus is to provide advanced
emergency medical care for critical and emergent
paramedic of the twenty-first century is a highly trained
patients who access the EMS system. The paramedic
health care professional who provides comprehensive,
possesses the complex knowledge and skills necessary
compassionate, and efficient prehospital emergency
to provide patient care and transportation. Paramedics
medical care.
function as part of a comprehensive EMS response
under medical oversight. Paramedics perform inter-
Description of the Profession ventions with both basic and advanced equipment
The paramedic is the highest level of prehospital care pro- typically found on an ambulance. The paramedic is an
vider and the leader of the prehospital care team.1 There essential link in the emergency care system. Because of
are four nationally recognized levels of EMS providers in the amount of complex decision making, paramedics
the United States: must successfully complete a comprehensive accred-
ited paramedic education program at the certificate or
• Emergency Medical Responder (EMR). The primary
associate’s degree level.2
focus of the Emergency Medical Responder (EMR)
is to initiate immediate lifesaving care to critical
Content Review
patients who access the emergency medical system. The Modern
This individual possesses the basic knowledge and ➤➤ Emerging Roles of the
skills necessary to provide lifesaving interventions
Paramedic Paramedic
while awaiting additional EMS response and to assist The roles and responsibili- • Public education
higher level personnel at the scene and during trans- ties of the paramedic are • Health promotion
diverse and encompass the • Illness and injury
port. EMRs must successfully complete an accredited
prevention
EMR educational program. disciplines of health care,
4 Chapter 1
Health Care
EMS
Legal Considerations
Which Hat Are You Wearing? The modern paramedic,
whether career or volunteer, must wear several hats. Many
paramedics are also cross trained as firefighters or police
officers. The role of each of these professions is different, but
there is often significant overlapping of duties. Paramedics
may participate in rescue operations, directing traffic, fire-
fighting, and other tasks on an emergency scene. However,
it is essential that, when functioning in the role of para-
medic, you remember that your primary responsibility is the
patient and patient care. You must also be an advocate for
the patient.
If you are cross trained, this can cause a certain degree of
Figure 1-4 The modern EMS system has begun a new nontraditional confusion and conflict. For example, if you are a cross-trained
role in nonemergent care through such programs as community para- police officer/paramedic who is treating an intoxicated
medicine and mobile integrated health care. driver, you may have conflicting responsibilities. However,
(Photo courtesy © Dallas Fire-Rescue Department) as already noted, when you are functioning as a paramedic
your priority should be the patient. Legal issues and other
tasks normally addressed by police officers must be handled
Paramedic Characteristics by other police officers on scene or dealt with after the patient
has been treated and transported. Similarly, paramedics who
There are many different types of EMS system designs and
are cross trained may learn information about a patient that is
operations. As a paramedic, you may work for a fire
protected from disclosure by the Health Insurance Portability
department, private ambulance service, third city service, and Accountability Act (HIPAA) and other medical privacy
hospital, police department, or other operation. Regard- laws and regulations. In a case like this, you may not be able
less of the type of service provider you work for, you must to disclose certain information to your law enforcement col-
be flexible to meet the demands of the ever-changing leagues despite the fact that you are also a police officer.
emergency scene. Laws regarding responsibilities of cross-trained indi-
As a paramedic, you must be a confident leader who viduals vary from state to state. You must be familiar with
can accept the challenge and responsibility of the position. the laws of the state where you are employed. Remember:
You must have excellent judgment and be able to prioritize When you function as a paramedic, you must put care of the
decisions to act quickly in the best interest of the patient. patient above all other tasks—and always remember which
hat you are wearing.
You must be able to develop rapport with a wide variety of
patients so that, for example, you can safely interview hos-
tile patients and communicate with members of diverse
cultural groups and the various ages within those groups. used to ensure competency when the skill is needed. As a
Overall, you must be able to function independently at an rule, the less a skill or procedure is used, the more frequent
optimum level in a nonstructured, constantly changing should be the review of that skill or procedure. Most qual-
environment. The job is never easy and always challenging. ity continuing education programs acknowledge this by
scheduling periodic review and practice of infrequently
The Paramedic: used skills or procedures. Professional development
should be a never-ending, career-long pursuit. Addition-
A True Health Professional ally, you should participate in routine peer-evaluation and
Despite its relative youth as a profession, the field of emer- assume an active role in professional and community orga-
gency medical services is now recognized as an important nizations (Figure 1-5).
part of the health care system. With this, paramedics are A major step toward the development of EMS as a true
now highly respected members of the health care team. As health care profession has been to raise the standards of
a paramedic, you must never take this status for granted. education for out-of-hospital personnel. A significant
Instead, you must always strive to earn your acceptance as advance was the 2009 publication by the U.S. Department of
a health care professional. Transportation of the National Emergency Medical Services
You should consider the completion of your initial Education Standards: Paramedic Instructional Guidelines.4
paramedic course to be the start of your professional edu- These instructional guidelines have taken paramedic edu-
cation, not the end. You should participate in various con- cation to a much higher level and were based on a national
tinuing education programs when they become available. EMS practice analysis completed by the National Registry
Frequently review and practice skills that are infrequently of Emergency Medical Technicians in 2004.5 An anatomy
6 Chapter 1
(b)
Sports Medicine
Another area in the expanded scope of paramedic practice
Figure 1-9 The tactical paramedic must often provide life-saving is sports medicine. Many teams, including those in profes-
care in austere and dangerous situations.
sional sports, have found that paramedics complement
(© Kevin Link/Science Source)
their athletic trainers. In this role, paramedics assume con-
siderably more responsibility for injury prevention. They
are also trained to deal with injuries specific to the sport in
Industrial Medicine question. For example, paramedics working with a football
Paramedics have long been the principal health care pro- team will assist in pregame preparation of players. During
viders on oil rigs, movie sets, and similar industrial opera- the game, they provide any needed emergency medical
tions. Paramedics are specially trained for the industry in care. They can also advise the staff whether an injured or ill
question and often assume additional responsibilities, player may return to the game. Paramedics working with
including safety inspection, accident prevention, medical hockey teams, for example, often learn to perform simple
screening of employees, and vaccinations and immuniza- laceration repairs and provide care for orthopedic injuries
tions. Many industries use paramedics to assist with sick to safely return the players to action as soon as possible
(Figure 1-12).
Corrections Medicine
Many states and the federal government have begun to
use paramedics as emergency and medical care providers
in jails and prisons. In these institutions, paramedics will
often do the initial prisoner medical intake assessment
and oversee the medical needs of the prison population.
They are also responsible for responding to emergencies
within the prison. Because of this, they must also have
training in correctional operations and similar issues.
Paramedics also play a major role in the U.S. Department
of Immigration and Customs Enforcement (ICE). Para-
medics often work with Border Patrol agents and Customs
Figure 1-10 Paramedics play an important role in ensuring the agents as they endeavor to maintain homeland security
health of the community they serve—especially high-risk patients. (Figure 1-13).
Introduction to Paramedicine 9
Summary
Even though it is still a young profession, EMS is now recognized as a staple in the health care
system. Paramedics have been identified as underutilized medical experts and are being offered
opportunities that were unheard of just a few years ago.
As the scope of practice for paramedicine continues to expand, so will the demand for
skilled practitioners. It is truly an exciting time for EMS and paramedicine. The paramedic of
the twenty-first century can have a more significant impact on health care than ever before.
The paramedic is often the first member of the health care system with whom the patient
10 Chapter 1
interacts, and the results of those interactions can affect the patient’s opinion of the health
care system in general.
EMS is a profession in which you can make a difference. Every call and every patient interac-
tion has the potential to make the difference between life and death for the patient. Few profes-
sions carry such awesome responsibility.
distance, and you and your friends go on to the hotel. You look at the local paper each day, hoping
to find out something about the crash victims, but you never find a story about the accident.
Although you are still upset about the accident and the unsophisticated level of medical care
you witnessed—and after your bags finally arrive—you, Dee Dee, and Eileen have a nice vacation
with no further adverse events.
1. Discuss the vast differences between EMS and paramedic care in the United States, Canada,
and other economically developed nations compared with those that exist in some less devel-
oped countries of the world. How should awareness of such differences affect your attitude
about your work?
See Suggested Responses at the back of this book.
Review Questions
1. Paramedics may function only under the direction 4. Which of the following is an aspect of professionalism?
and license of the EMS system’s ____________ a. Being well groomed
a. town council. c. medical director. b. Maintaining patient confidentiality
b. company owner. d. board of directors. c. Attending continuing education sessions
2. The emerging roles and responsibilities of the para- d. All of the above
medic include ____________ 5. All of the following are considered new, nontradi-
a. public education. tional roles for the paramedic except ______________
b. health promotion. a. primary care.
c. participation in injury and illness prevention b. sports medicine.
programs.
c. family practitioner.
d. all of the above.
d. industrial medicine.
3. The rules, standards, and expected actions governing See answers to Review Questions at the back of this book.
the activities of a group or profession are called
_____________
a. ethics. c. manners.
b. morals. d. etiquette.
References
1. U.S. Department of Transportation/National Highway Traffic 4. U.S. Department of Transportation/National Highway Traffic
Safety Administration. National EMS Scope of Practice Model. Safety Administration. National Emergency Medical Services
Washington, DC: 2006. Educational Standards: Paramedic Instruction Guidelines. Wash-
2. Patterson, P. D., J. C. Probst, K. H. Leith, S. J. Corwin, and M. P. ington, DC: 2009.
Powell. “Recruitment and Retention of Emergency Medical 5. National Registry of Emergency Medical Technicians. 2004
Technicians: A Qualitative Review.” J Allied Health 34 (2005): National EMS Practice Analysis. Columbus, OH: 2004.
153–162. 6. Cooper, S., B. Barrett, S. Black, et al. “The Emerging Role of the
3. Bigham, B., S. Kennedy, I. Drennan, L. Morrison, “Expanding Emergency Care Practitioner.” Emerg Med J 21 (2004): 614–618.
Paramedic Scope of Practice in the Community: A Systematic 7. Ball, L. “Setting the Scene for the Paramedic in Primary Care: A
Review of the Literature.” Prehosp Emerg Care (2013);17: 161–372. Review of the Literature.” Emerg Med J 22 (2005): 896–900.
Further Reading
Bledsoe, B. E. “EMS Needs a Few More Cowboys.” Journal of Page, J. O. The Magic of 3 A.M.: Essays on the Art and Science of Emergency
Emergency Medical Services (JEMS) 28(12) (2003): 112–113. Medical Services. Carlsbad, CA: JEMS Publishing, 2002.
Bledsoe, B. E. “Where Are the Wise Men?” Emergency Medical Page, J. O. The Paramedics. Morristown, N.J.: Backdraft Publications,
Services (EMS) 31(10) (2002): 172. 1979.
Grayson, S. En Route: A Paramedic’s Stories of Life, Death, and Everything Perry, M. Population 485: Meeting Your Neighbors One Siren at a Time.
in Between. New York, NY: Kaplan Publishing, 2009. New York: Harper-Collins, 2002.
Page, J. O. Simple Advice. Carlsbad, CA: JEMS Publishing, 2002.
Chapter 2
EMS Systems
Bryan Bledsoe, DO, FACEP, FAAEM
Paul Ganss, MS, NRP
Standard
Preparatory (EMS Systems)
Competency
Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical-legal and
ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.
Learning Objectives
Terminal Performance Objective: After reading this chapter you should be able to discuss the characteristics, components,
and functions of emergency medicine services (EMS) systems.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this chapter. 7. Discuss the contemporary problems facing
EMS as described in the Institute of
2. List the out-of-hospital and in-hospital
Medicine document, Emergency Medical
components of EMS systems.
Services: At the Crossroads.
3. Link key events in the history of EMS to 8. Provide examples of various configurations
the development of the modern EMS of EMS systems in the United States and
system. how they integrate into the chain of survival.
4. Discuss the importance of the 1966 9. List and describe the purposes of the
publication Accidental Death and Disability: national documents guiding EMS education
The Neglected Disease of Modern Society as it and practice.
relates to the development of EMS in the
United States. 10. Discuss typical components that should be
established for local and state-level EMS
5. Describe each of the ten components of EMS systems.
systems according to the Statewide EMS
11. Describe the similarities, differences, and
Technical Assessment Program.
general purposes of the professional
6. Identify and discuss the vision and documents organizations and professional journals
that are guiding EMS into the future. related to the practice of EMS.
12
EMS Systems 13
12. Describe the intent of the General Services 15. Describe how you can contribute to greater
Administration KKK-A-1822 Federal patient safety in emergency medical
Specifications for Ambulances. services.
13. Describe the purpose of categorizing receiving 16. Explain the role of research in EMS.
hospital facilities by their capabilities.
17. Discuss how evidence-based medicine is
14. Explain the purpose and components of an enhancing EMS.
effective continuous quality improvement
program.
Key Terms
accreditation, p. 28 licensure, p. 29 professionalism, p. 34
bystander, p. 14 medical director, p. 25 prospective medical oversight, p. 25
certification, p. 29 medical oversight, p. 25 quality improvement (QI), p. 20
chain of survival, p. 23 National Highway Traffic Safety reciprocity, p. 29
clinical protocols, p. 25 Administration (NHTSA), p. 20 registration, p. 29
Department of Homeland National Incident Management research, p. 36
Security, p. 21 System (NIMS), p. 21
retrospective medical
Emergency Medical Dispatcher National Transportation Safety oversight, p. 25
(EMD), p. 27 Board (NTSB), p. 22
rules of evidence, p. 34
ethics, p. 35 off-line medical oversight, p. 25
scope of practice, p. 24
evidence-based medicine on-line medical direction, p. 25
standing orders, p. 26
(EBM), p. 37 Ontario Prehospital Advanced Life
teachable moment, p. 26
helicopter air ambulances Support (OPALS) study, p. 20
tiered response, p. 14
(HAA), p. 20 peer review, p. 25
trauma, p. 33
interoperability, p. 27 prearrival instruction, p. 28
trauma center, p. 20
intervener physician, p. 25 profession, p. 29
Case Study
It is a beautiful Fourth of July. You and your family are provide the dispatcher with information that he, in turn,
traveling down the interstate on your way to a concert relays to the responding units.
and fireworks show. Just an hour from your destination, The local volunteer fire and rescue team arrives on
a tire blows out on the BMW ahead of you, and you see scene in about 7 minutes. You provide a verbal report to
it skid into the median and crash into some pine trees. the arriving rescuers. They do their own scene safety
You pull onto the shoulder. As an experienced para- check, approach the car, and determine that there are
medic, you ensure scene safety before approaching the four patients. Two are priority-1 patients (one of these is
mangled car. You see no movement inside the passenger a 2-year-old child), and two are priority-3 patients.
compartment. Based on the primary assessment, Rescuer Lt. C. J.
Your daughter grabs her cell phone and calls 911. Greenlee requests a medical helicopter and a second
The dispatcher asks for the location of the crash and paramedic unit. Approximately 2 minutes later, a fire
transfers your call to the 911 call center for that area. The truck crew arrives. They reroute traffic and establish a
emergency medical dispatcher gathers the appropriate landing zone for the helicopter.
information and dispatches the local volunteer fire ser- When all EMS personnel summoned are on scene,
vice and a paramedic ambulance. While you attempt to they decide that the 2-year-old patient will be flown to
gain access to the patients, your daughter continues to Children’s Hospital, a pediatric specialty center. The other
14 Chapter 2
immediate patient will be transported by ground to the and are en route to a receiving facility capable of
closest Level I trauma center. The patients with minor providing the level of care they need. Within 15 min-
injuries will be taken to the local hospital by ground trans- utes of arrival at the pediatric trauma center and just
port. Working as a team, the fire and ambulance person- 31 minutes after the crash, the 2-year-old is moved to
nel extricate the patients and package them for transport. surgery for the repair of a ruptured liver and spleen.
Approximately 22 minutes after the arrival of the The other patients are being treated at their destina-
first paramedic unit, all patients have been extricated tions as well.
Every EMS system must rely on the strength of its History of EMS
components. A weakness in one component will diminish The Emergency Medical Services (EMS) system, as we
the overall quality of patient care. For example, a typical know it today, developed from the traditional and scien-
EMS operation begins with citizen activation. That is, a tific beliefs of many cultures. To understand EMS today, it
EMS Systems 15
Tiered Response
Alternative Response
Fire/rescue
is first important to know its history. Certainly, the most One section, called the “Book of Wounds,” explains the
significant advances in EMS have occurred during the past treatment of injuries such as fractures and dislocations. It
50 years (see Table 2-1). includes descriptions of the materials needed for making
bandages and splints, as well as information about sutures
and solutions that may be used to clean wounds.
Early Development At about the same time, in another civilization in the
Ancient Times Mesopotamian region, King Hammurabi of Babylon com-
There is evidence that emergency medicine has a very long missioned a large painting of 282 case laws known today
history. In fact, it may be traced back to biblical times, as the “Code of Hammurabi.” That code governed crimi-
when it was recorded that a “good Samaritan” provided nal and civil matters, and it established strict penalties for
care to a wounded traveler by the side of a road. violations, a concept called lex talionis or “law of the claw”
Approximately 4,000 to 5,000 years ago, scribes in (very similar to the idea of “an eye for an eye”).
Sumer, a civilization in Mesopotamia (in southwest Asia), One section of the code was devoted to the regulation
inscribed clay tablets with some of the earliest medical of medical fees and penalties, which were based on the
records. Similar to protocols that EMS uses today, the social class of the patient. For example, if a surgeon oper-
ancient tablets provided healers with step-by-step instruc- ated successfully on a commoner, he would be paid only
tions for patient care based on the patient’s description of half of what his fee would be if he had operated on a rich
symptoms. The tablets also included instructions on how man. Social class was also the basis for penalties. If a sur-
to create the medications needed to cure the patient and geon caused the death of a rich man, the surgeon’s hand
explained how and when to administer them. The most would be cut off, but if a slave died under his care, he only
striking difference between these first “protocols” and had to replace the slave.
EMS today is the absence of a physical exam. EMS came from humble beginnings. Initially, out-of-
In 1862, the Egyptologist Edwin Smith purchased a hospital care involved nothing more than transport.
papyrus scroll dating back to about 1500 b.c.e. It con- Around 900 c.e., the Anglo-Saxons used a hammock
tained 48 medical case histories with data arranged in suspended across a horse-drawn wagon. By 1100, the
head-to-toe order and in order of severity, an arrangement Normans had devised a litter that was carried between
very similar to today’s patient assessment. Each case also two horses to transport patients. The first recorded use
had a particular format, including a title, specific instruc- of an ambulance was in the Siege of Malaga in 1487.
tions to the healer, and a projection of possible outcomes. Queen Isabella of Spain designated certain wagons for
16 Chapter 2
1860s Civilian ambulance services begin in Cincinnati and New York City.
1891 Dr. Friedrich Maass performs the first equivocally documented chest compression in humans.
1915 First-known air medical transport occurs during the retreat of the Serbian army from Albania.
1920 First volunteer rescue squads organize in Roanoke, Virginia, and along the New Jersey coast.
1947 Claude Beck develops first defibrillator and first human saved with defibrillation.
1965 J. Frank Pantridge converts an ambulance into a mobile coronary care unit with a portable defibrillator and recorded ten prehospital
resuscitations with a 50 percent long-term survival rate.
1966 The National Academy of Sciences, National Research Council publishes Accidental Death and Disability: The Neglected Disease of
Modern Society.
1966 Highway Safety Act of 1966 establishes the Emergency Medical Services Program in the Department of Transportation.
1972 Department of Health, Education, and Welfare allocates $16 million to EMS demonstration programs in five states.
1973 The Emergency Medical Services Systems (EMSS) Act provides additional federal guidelines and funding for the development of regional
EMS systems; the law establishes 15 components of EMS systems.
1981 The Omnibus Budget Reconciliation Act consolidates EMS funding into state preventive health and health services block grants, and
eliminates funding under the EMSS Act.
1981 International trauma life support (ITLS), formerly basic trauma life support (BTLS), is developed.
1984 The EMS for Children program, under the Public Health Act, provides funds for enhancing the EMS system to better serve pediatric
patients.
1985 National Research Council publishes Injury in America: A Continuing Public Health Problem, describing deficiencies in the progress of
addressing the problem of accidental death and disability.
1988 The National Highway Traffic Safety Administration initiates the Statewide EMS Technical Assessment program based on ten key
components of EMS systems.
1990 The Trauma Care Systems and Development Act encourages development of inclusive trauma systems and provides funding to states for
trauma system planning, implementation, and evaluation.
1993 The Institute of Medicine publishes Emergency Medical Services for Children, which points out deficiencies in our health care system’s
ability to address the emergency medical needs of pediatric patients.
1995 Congress does not reauthorize funding under the Trauma Care Systems and Development Act.
1999 President Clinton signs bill designating 911 as national emergency number.
2003 Health Insurance Portability and Accountability Act (HIPAA) becomes effective, strictly regulating the flow of confidential information.
2006 The National Highway Traffic Safety Administration publishes Emergency Medical Services: Agenda for the Future to guide the
development of EMS in the United States in the twenty-first century.
EMS Systems 17
the transport of injured soldiers. Her grandson, King Ohio, by Commercial Hospital. In 1869, Bellevue Hospital,
Charles V, reportedly again used field ambulances in on the island of Manhattan in New York City, began to
1553 in the Siege of Metz. operate an ambulance service. The ambulances of both ser-
vices were specially designed horse-drawn carts that were
The Napoleonic Wars staffed with physician interns from the various hospital
In the wars between Napoleon’s French Empire and other wards. By 1899, Michael Reese Hospital in Chicago began
European countries from 1803 to 1815, ambulances were to operate a motorized ambulance.4
often used to evacuate the wounded. Military surgeon
Dominique-Jean Larrey, one of Napoleon’s chief surgeons, The Twentieth Century
devised this idea. Larrey became distressed to see that
many of the wounded were neglected for a long period of From World War I to World War II
time and that most died before reaching a hospital. He sub- During World War I, a high mortality rate of soldiers was
sequently developed a light carriage that allowed the associated with an average evacuation time of 18 hours. As a
movement of injured soldiers from the battlefield. These result, in World War II a system of transportation to increas-
carriages came to be called ambulances volantes, or “Larrey’s ing echelons (levels) of care was created. Battlefield ambu-
Flying Ambulances,” because they were positioned with lance corps transported wounded soldiers from the front
the French “flying artillery” on the battlefield. Even though lines to the echelons of care. However, many of the echelons
the ambulance volante was little more than a covered horse- were so far from the battlefield and from each other that
drawn cart, Larrey is credited with the development of the there were huge delays in patient care. In many cases, it was
first prehospital system that used both triage and trans- often days from the injury itself to definitive surgery.
port. Larrey was also credited with being the first to place a There were some developments in American civilian
medical attendant in an ambulance.2 ambulance services after World War I. Some hospitals
Although the first use of aircraft for medical evacua- experimented with placing physician interns on ambu-
tion is lost to history, there are records of hot air balloons lances. In 1926, the Phoenix Fire Department began provid-
being used to evacuate wounded from the Prussian Siege ing “inhalator” service and officially entered into the realm
of Paris in 1870. During the retreat of the Serbian Army of medical care. In 1928, the first bona fide rescue squad,
from Albania in 1915, unmodified French fighter aircraft called the Roanoke Life Saving Crew, was started in Roa-
were used to ferry the injured. noke, Virginia. However, in 1929, the United States entered
the severe economic crisis known as the Great Depression,
The United States which lasted until the start of American involvement in
in the Nineteenth Century World War II in 1941. Little changed in the civilian ambu-
The development of ambulances in the United States lance service during this period.
occurred in the first part of the nineteenth century. In 1861,
Effects of World War II
during the Civil War, surgeon Jonathan Letterman reorga-
Following the bombing of Pearl Harbor on December 7,
nized battlefield medical care and initiated the use of
1941, the United States entered World War II. Because of
ambulances for the evacuation of battlefield casualties. In
the demands of war, many hospital-based ambulance ser-
1864, President Abraham Lincoln signed into law an act
vices shut down. Many city governments turned ambu-
that firmly established a uniform army ambulance plan.
lance services over to local police and fire departments.
This act separated ambulance transport from all other
Unfortunately, there were no requirements for minimal
transport services in the Army and placed it under the
training or care. In fact, ambulance work was often seen as
medical command.
a punishment, and many departments were quick to elimi-
Between 1861 and 1865, a nurse named Clara Barton
nate ambulance service as soon as they could.
coordinated care for the sick and injured at Civil War bat-
tlefield sites along the East Coast. Defying army leaders, Post-World War II
she persisted in going to the front, where wounded men The end of World War II brought prosperity to the United
suffered and often died from lack of the simplest medical States. Several medical advances occurred subsequently,
attention. She continued the concept of the ambulance improving the lives of the public. Not long after World War II,
volante by organizing the triage and transport of injured however, the United States found itself at war again—this
soldiers to improvised hospitals in nearby houses, barns, time on the Korean peninsula.
and churches away from the battlefield.3
Following the success of ambulances in the Civil War, The 1950s
several communities and hospitals began to develop civil- Korea is a mountainous country that lacked an organized
ian ambulance services. The first civilian ambulance was system of highways and roads. Because of this, the U.S.
established in 1860 (before the Civil War) in Cincinnati, Army began using helicopters to move the injured from
18 Chapter 2
the front lines to mobile army surgical hospitals (MASHs) few areas of the United
Content Review
located fairly close to the front lines. Thus, injured soldiers States provided adequate
➤➤ 1973 EMSS Act: Fifteen
were being promptly evacuated to a surgical center and civilian prehospital emer-
Components of EMS
were receiving emergency care and surgery shortly after gency care similar to what
Systems
their injury. This practice resulted in significant improve- was provided to soldiers
• Manpower
ments in battlefield mortality.5 and sailors during war. • Training
Similarly, in the late 1950s the United States entered the The prevailing thought • Communications
Vietnam War. This time, the battles took place in the jungles was that medical care • Transportation
of Southeast Asia. As in Korea, there were few roads, and began in the hospital • Emergency facilities
jungles slowed movement of the injured. Again, helicopters emergency department. • Critical care units
were called on to evacuate the wounded to forward-placed Rescue techniques were • Public safety agencies
surgical hospitals. In Vietnam, in many cases, evacuation crude, ambulance atten- • Consumer participation
occurred within 10 to 20 minutes of injury (Figure 2-2). Once dants poorly educated, • Access to care
stabilized and able to be moved (generally within 24 to 48 and equipment minimal. • Patient transfer
• Standardized record
hours), the patients would be flown by jet to Clark Air Force Police, fire, and EMS per-
keeping
Base in the Philippines, where they would receive any nec- sonnel often had no radio
• Public information and
essary further treatment. The decrease in the amount of time communication. Proper
education
to definitive care plus advances in medical procedures sig- medical direction was not • System review and
nificantly reduced mortality rates. This strategy also set the available, and the only evaluation
stage for trauma system development in the United States.6 interaction between phy- • Disaster management
Several significant medical developments occurred in sicians and EMS person- plans
the 1950s. In 1956, physicians Peter Safar and James Elam nel was at the receiving • Mutual aid
pioneered the use of mouth-to-mouth resuscitation. In facility.
1959, the first portable defibrillator was used at Johns Hop- Eventually, as costs and demand for additional ser-
kins Hospital in Baltimore.7 In 1960, cardiopulmonary vices forced many rural mortician-operated ambulances to
resuscitation (CPR) was refined and deemed to be effective withdraw, local police and fire departments found that
for human resuscitation.8 they had to provide the ambulance service. In many areas,
volunteer ambulance services made up of local, indepen-
The 1960s dent EMS provider agencies proliferated. In urban settings,
Throughout history, significant advances in trauma care
the increased demand on hospital-based EMS systems
occurred during wartime. However, until the late 1960s,
resulted in the development of municipal services, which
were operated on city, county, or regional levels. However,
because they could not communicate with one another, it
was impossible to coordinate a response to any but the
simplest local calls.
In 1966, the publication of Accidental Death and Disabil-
ity: The Neglected Disease of Modern Society by the National
Academy of Sciences, National Research Council, focused
attention on the problem. The “White Paper,” as the report
was called, spelled out the deficiencies in prehospital emer-
gency care.9 It suggested guidelines for the development of
EMS systems, the training of prehospital emergency medi-
cal providers, and the upgrading of ambulances and their
equipment. The problems identified in the study included:
Civilian EMS, as we know it today, started to evolve This enabled the develop-
Content Review
significantly in the 1960s. In 1960, the Los Angeles Fire ment of regional EMS sys-
➤➤ 1988 NHTSA: Ten System
Department placed medical personnel with every engine, tems that took place from
Elements
ladder, and rescue company. It was one of the first large 1974 through 1981. A total
• Regulation and policy
fire departments to embrace the concept of emergency of $300 million was allo-
• Resources
medical care. cated to study the feasi- management
In 1966, the Highway Safety Act promulgated initial bility of EMS planning, • Human resources and
EMS guidelines for the United States. The same year, Dr. J. operations, expansion, training
Frank Pantridge developed a mobile coronary response and research.13 • Transportation
unit in Belfast, Northern Ireland. Using a portable defibril- To be eligible for this • Facilities
lator, he treated ten cardiac arrest patients, five of whom funding, an EMS system • Communications
enjoyed long-term survival.10 In 1969, the first paramedic had to include the following • Trauma systems
program began in Miami, Florida, by Dr. Eugene Nagel.11 15 components: manpower, • Public information and
training, communications, education
The 1970s transportation, emergency
• Medical direction
The 1970s were the decade when EMS truly came into its • Evaluation
facilities, critical care units,
own. The National Registry of Emergency Medical Tech-
public safety agencies, consumer participation, access to
nicians was established in 1970. Interestingly, EMS got
care, patient transfer, standardized record keeping, public
one of its biggest boosts from Hollywood. On January 15,
information and education, system review and evaluation,
1972, the television show Emergency! made its debut on
disaster management plans, and mutual aid. As farsighted
NBC. The show, produced by Hollywood legend Jack
as these criteria were, the designers of the legislation unfor-
Webb, featured two Los Angeles County Fire Department
tunately omitted two key components: system financing
paramedics and the new paramedic program in southern
and medical direction.
California (Figure 2-3). The show brought public atten-
When federal funding was significantly reduced in the
tion to the concept of prehospital care and provided con-
early 1980s, many EMS systems faced economic disaster.
siderable encouragement for development of the modern
Subsequently, the Emergency Medical Services Systems Act
EMS system.12
was amended in 1976 and again in 1979, and a total of $215
Then, in 1973, Congress passed the Emergency Medi-
million was appropriated over a seven-year period toward
cal Services Systems Act, which provided funding for a
the establishment of regional EMS systems. However, many
series of projects related to the delivery of trauma care.
systems were still operating without medical direction.
The 1980s
In 1981, the passage of the Consolidated Omnibus Budget
Reconciliation Act (COBRA) essentially wiped out federal
funding for EMS. The small amount of funding that remained
was placed into state preventive-health and health-services
block grants. The National Highway Traffic Safety Adminis-
tration (NHTSA) attempted to sustain the efforts of the
Department of Health and Human Services, but with its
other EMS responsibilities and no additional funding, the
momentum for continued development was lost.
In 1988, the Statewide EMS Technical Assessment Pro-
gram was established by the NHTSA. It defines elements
necessary to all EMS systems. Briefly, they are:
personnel who transport patients in the prehospital By the late 1990s, EMS systems and EMS practice had
setting should be adequately trained. started to mature. It was at this point that self-assessment
• Transportation. Patients must be safely and reliably of EMS began to occur. Researchers and systems began to
transported by ground or air ambulance. link patient outcomes (morbidity and mortality—illness
and death) with various EMS practices. Surprisingly, some
• Facilities. Every seriously ill or injured patient must
practices that had seemed intuitive did not hold up to the
be delivered in a timely manner to an appropriate
test of science. One of the largest studies of prehospital
medical facility.
practices and outcomes was the Ontario Prehospital
• Communications. A system for public access to the Advanced Life Support (OPALS) study that was con-
EMS system must be in place. Communication among ducted in various regions of the province of Ontario, Can-
dispatchers, the ambulance crew, and hospital person- ada. The study has provided significant information about
nel must also be possible. early defibrillation, response times, advanced life support
• Trauma systems. Each state should develop a system procedures, and much more.14
of specialized care for trauma patients, including one
or more trauma centers and rehabilitation programs. It EMS Agenda for the Future
also must develop systems for assigning and trans- The National Highway Traffic Safety Administration
porting patients to those facilities. (NHTSA) published the EMS Agenda for the Future in
1996.15 This document examined what had been learned
• Public information and education. EMS personnel
during the prior three decades of EMS and endeavored to
should participate in programs designed to educate
create a vision for the future of EMS in the United States. It
the public. The programs are to focus on the preven-
was published at an important time, when those agencies,
tion of injuries and how to properly access the EMS
organizations, and individuals that affect EMS were evalu-
system.
ating their respective roles in the context of a rapidly evolv-
• Medical direction. Each EMS system must have a phy- ing health care system—a process of evaluation that is
sician as its medical director. This physician delegates ongoing.
medical practice to nonphysician caregivers and over- NHTSA is a division of the U.S. Department of Trans-
sees all aspects of patient care. portation (DOT) and the Health Resources and Services
• Evaluation. Each state must have a quality improve- Administration (HRSA), Maternal and Child Health
ment (QI) system in place for continuing evaluation Bureau. The EMS Agenda for the Future focused on aspects
and upgrading of its EMS system. of EMS related to emergency care outside traditional
health care facilities. It recognized the changes that
Helicopter air ambulances (HAA) began to develop occurred in the health care system of which EMS is a part.
in the early 1980s. A hospital or consortium of hospitals The document recommended that EMS of the future
operated most helicopter programs. These services initially would be a community-based health management system
used all-nurse crews. However, as the operations matured, that would be fully integrated into the overall health care
a paramedic was often used in place of one of the nurses on system. EMS of the future would have the ability to iden-
the flight. HAA is primarily used for both scene-to-hospital tify and modify illness and injury risks, provide acute ill-
and interhospital transfer of critically ill or injured patients. ness and injury care and follow-up, and contribute to the
treatment of chronic conditions and to community health
The 1990s
monitoring. EMS would be integrated with other health
Further improvements were made to EMS during the
care providers and public health and public safety agen-
1990s. In 1990, Congress passed the Trauma Care Systems
cies in the effort to improve community health, which
and Development Act. This Act provided funding to states
would result in more appropriate use of acute health care
for trauma system planning, development, implementa-
resources. Overall, EMS would remain the public’s emer-
tion, and evaluation.
gency medical safety net.
In 1993, the Institute of Medicine published Emergency
To realize this vision, The EMS Agenda for the Future
Medical Services for Children. This document pointed out the
proposed continued development of 14 core EMS attri-
deficiencies in pediatric emergency care in the United
butes. They were:
States. A small amount of federal funding subsequently
financed the Emergency Medical Services for Children • Integration of health services
(EMSC) program. • EMS research
In 1995, Congress did not reauthorize the Trauma Care
• Legislation and regulation
Systems and Development Act, and the funding for trauma
systems fell back on the states. This resulted in significant • System finance
variability in trauma system care across the United States. • Human resources
EMS Systems 21
• Disparities in response times. The speed with which • Limited evidence base. The evidence base for many
ambulances respond to emergency calls is highly vari- practices routinely used in EMS is limited. Strategies
able. In some cases, this variability is related to geogra- for EMS have often been adapted from settings that
phy. In dense population centers, for example, the differ substantially from the prehospital environment
distances ambulances must travel are small, but traffic and, consequently, their value in the field is question-
and other problems can cause delays. In contrast, rural able, and some may even be harmful. For example,
areas involve longer travel times, sometimes over dif- field intubation of children, still widely practiced, has
ficult terrain. This is further worsened by problems in been found to do more harm than good in many situa-
the organization and management of EMS services, tions.17 Although some recent research has added to
the communications and coordination between 911 the EMS evidence base, a host of critical clinical ques-
dispatch and EMS responders, and the priority placed tions remain unanswered because of limited federal
on response time given the resources available. research support, as well as inherent difficulties associ-
• Uncertain quality of care. Very little is known about the ated with prehospital research due to its sporadic
quality of care delivered by EMS services in the United nature and the difficulty of obtaining informed con-
States because there are no standardized measures of sent for the research.18
EMS quality, no nationwide standards for the training National Report Card on the State
and certification of EMS personnel, no accreditation of
of Emergency Medicine
institutions that educate EMS personnel, and virtually
The American College of Emergency Physicians (ACEP) in
no accountability for the performance of EMS systems.
2006 published a study similar to EMS at the Crossroads.
Even though most Americans assume that their commu-
The paper, The National Report Card on the State of Emergency
nities are served by competent EMS services, the public
Medicine: Evaluating the Environment of Emergency Care Sys-
has no idea whether this is true, and no way to know.
tems State by State, pointed out the significant problems that
• Lack of readiness for disasters. Although EMS person- existed in all aspects of emergency care.19 This paper pri-
nel are among the first to respond in the event of a marily addressed problems in hospital emergency depart-
disaster, they are the least prepared component of ments but also addressed EMS issues. Overall, the report
community response teams. Most EMS personnel have detailed that emergency services in the United States are so
received little or no disaster response training for ter- overstressed that the quality of care has been compromised.
rorist attacks, natural disasters, or other public health Multiple causes were indentified and included such things
emergencies. Despite the massive amounts of federal as inadequate funding, patient overcrowding, lack of alter-
funding directed to homeland security, only a tiny pro- nate care facilities, problems with medical liability, the
portion of those funds have been directed to medical effect of illegal immigration, and many other factors. Each
response. Furthermore, EMS representation in disaster state was given a letter grade that reflected the reported
planning at the federal level has been highly limited. standard of emergency care in that state.
• Divided professional identity. EMS is a unique profes-
Helicopter Air Ambulance
sion, one that straddles both medical care and public
safety. Among public safety agencies, however, EMS is
Recommended Improvements
In 2001, federal reimbursement for medical helicopters
often regarded as a secondary service, with police and
improved, and the national medical helicopter fleet
fire taking more prominent roles; within medicine,
expanded from 300 aircraft to almost 900 in a matter of
EMS personnel often lack the respect afforded to other
years. With the increase in helicopters came an increase in
professionals, such as physicians and nurses. Despite
accidents and overutilization. In 2008, there were a record
significant investments in
number of helicopter air ambulance crashes with related
Content Review education and training,
fatalities. As a result, the National Transportation Safety
➤➤ Types of EMS Services
salaries for EMS personnel
Board (NTSB) held hearings in 2009 and later recom-
• Fire-based are often well below those
mended sweeping improvements for the helicopter air
• Third service for comparable positions,
ambulance industry.
• Private such as police officers, fire-
• Hospital-based fighters, and nurses. In
addition, there is a cultural
Today’s EMS Systems
• Volunteer
➤➤ Regardless of the delivery divide among EMS, public
type, all emergency safety, and medical care The EMS system of today remains a mixture of various
operations must be workers that contributes to types of operations. The modern EMS system is now fairly
closely integrated and
the fragmentation of these well integrated with the health care system and, to a lesser
work together.
services. degree, with the public safety system. Despite some federal
EMS Systems 23
• Third service
• Private (profit or nonprofit)
• Hospital-based
Essential Components
• Volunteer for Continuum of Care
• Hybrid (combination of any of these)
Health Care System Integration
Regardless of the delivery type, the lessons of 9/11 have
It is now recognized that EMS is a major component of the
shown that all emergency operations must be closely inte-
modern health care system. Interestingly, the original pur-
grated and able to work together. The rapid development
pose of EMS was to address cardiac emergencies—particu-
of EMS technology is making this possible and has simpli-
larly cardiac arrest. Now, almost forty years later, there is
fied many aspects of EMS.
renewed emphasis of the roles and responsibilities of the
EMS system in all types of cardiac emergencies. These
Chain of Survival responsibilities begin with the public service access points
Traditionally, emergency health care was considered to (PSAPs) that are typically the 911 call centers. PSAPs are
begin at the time of the emergency. More recently, however, now the primary interface between the EMS system and
it has been shown that emergency health care may actually the communities it serves. Now, dispatchers can give basic
begin long before an emergency occurs. In this regard, EMS first aid and emergency care instructions, including CPR
and emergency medicine practitioners are embracing pre- instructions, to the caller until the EMS providers arrive
ventive health care measures that may help to reduce (Figure 2-5).
emergency illnesses and accidents. It also now includes The role of the EMS system is now extremely impor-
such innovative measures as EMS personnel periodically tant in the identification of acute coronary syndrome and
visiting high-risk and homebound citizens
and assessing their health status and needs.
Aside from such preventive activities,
the EMS system is part of a continuum of
care that begins once an emergency occurs
and ends when the patient completes care
and returns to his normal activities of daily
living. This continuum is often referred to
as the chain of survival. As defined by the
American Heart Association (AHA), the
chain of survival consists of the five most
important factors affecting survival of a car-
diac arrest patient: (1) immediate recogni-
tion and activation of EMS; (2) early CPR;
(3) rapid defibrillation; (4) effective
advanced life support; and (5) integrated
post-cardiac arrest care. A similar contin-
uum of events, essential to the optimal care
of any emergency patient, might include,
but would not be limited to, the following:
• Bystander care
• Dispatch Figure 2-5 Emergency Medical Dispatchers can give prearrival instructions to a caller,
including how to perform CPR.
• Response
(From Advanced MPDS v13.0 © 1979-2015 International Academies of Emergency Dispatch and ProQA
• Prehospital care Paramount v5.1 © 2007–2015 Priority Dispatch Corp. All Rights Reserved. Used by permission.)
24 Chapter 2
ST-segment elevation myocardial infarction (STEMI). The body of knowledge, skills, and abilities desired in EMS
standard of care has quickly shifted—now, in many cases, personnel. It was followed shortly thereafter by The
paramedics make the decision to activate a cardiac cathe- National EMS Scope of Practice, also published in 2005,
terization team based on their interpretation of a prehospi- which helped to define the future roles of EMS providers.
tal ECG. This has significantly decreased the time from This consensus document supported a system of EMS per-
onset of symptoms to primary percutaneous coronary sonnel licensure that was common in other allied health
intervention (PPCI). Evidence is beginning to show that professions and was designed to serve as a guide for states
many cardiac arrest patients may benefit from PPCI, and and territories in developing their scope of practice legis-
certain health care facilities are now devoting resources to lation, rules, and regulations. States following the National
the specific care of cardiac arrest that may include PPCI. EMS Scope of Practice model as closely as possible would
Finally, EMS is stepping up and assuming an impor- increase the consistency of the nomenclature and compe-
tant role as the initial component and gatekeeper of the tencies of EMS personnel nationwide, facilitate reciprocity,
modern health care system. improve professional mobility, and enhance the name rec-
ognition and public understanding of EMS. Some states
Levels of Licensure/Certification have adopted the National EMS Scope of Practice model in
its entirety, whereas others have adopted only parts of it.
As noted in the preceding chapter, the National EMS Scope
of Practice Model defines and describes four levels of EMS
licensure: Oversight by Local-
• Emergency Medical Responder (EMR)
and State-Level Agencies
The efficient delivery of emergency medical care requires a
• Emergency Medical Technician (EMT)
systematic approach and team effort to make the best use
• Advanced EMT (AEMT)
of existing resources. That means each community must
• Paramedic develop an EMS system that best meets its needs. Although
Each level represents a unique role, set of skills, and knowl- EMS systems across the country and the world will vary,
edge base.20 In 2009,National EMS Education Instructional certain elements are essential to ensure the best possible
Guidelines were developed and published for each of these patient care.
four levels.21 These instructional guidelines replace the At the municipal and regional levels, the first step in
various curricula that had been previously published to developing a comprehensive EMS system is to establish an
guide EMS education. The use of instructional guidelines, administrative oversight agency. This agency is responsi-
as opposed to a rote curriculum, allows EMS educators to ble for managing the local system’s resources, developing
adapt their educational strategies to the specific student operational protocols, and establishing standards and
population they serve. When used in conjunction with the guidelines. Within the agency, a planning board is often
National EMS Core Content, national EMS certification, and formed. The planning board should be composed of com-
National EMS Education program accreditation, the munity representatives, including emergency physicians,
National EMS Scope of Practice Model and the National EMS the emergency nurse association, the firefighter associa-
Education Standards create a strong and interdependent sys- tion, state and local police, and consumers. The planning
tem that provides the foundation to ensure the competency board develops a budget and selects a qualified adminis-
of out-of-hospital emergency medical personnel through- trative staff capable of managing an EMS agency.
out the United States. Once established, the agency designates who may
function within the system and develops policies consis-
tent with existing state requirements. It also creates a qual-
Quality of Education ity assurance or quality improvement program to evaluate
One of the fundamental principles of quality EMS is a solid the system’s effectiveness and to ensure that the best inter-
education program for providers. EMS education has ests of the patient are always a top priority. State EMS
evolved significantly in the past two decades. Now, there agencies are typically responsible for allocating funds to
are more educators with advanced degrees and EMS is local systems, enacting legislation concerning the out-of-
being recognized in the academic community. Despite the hospital practice of medicine, licensing and certification of
advances, however, there remains considerable variation field providers, enforcing all state EMS regulations, and
in EMS educational programs across the country. appointing regional advisory councils.
In response to The EMS Agenda for the Future, several In essence, EMS is made up of a series of systems
documents have been prepared to guide EMS education. within a system. The integration of these systems and the
The first of these was the National EMS Core Content, pub- cooperation of all participants help to result in the best
lished by NHTSA in 2005.22 This document defined the quality of emergency care.
EMS Systems 25
Public Information and Education hospital. Such arrests are called “sudden death” because
The public is an essential, yet often overlooked, compo- most happen within 2 hours of the onset of cardiac symp-
nent of an EMS system. EMS should have a plan to edu- toms. Many patients delay calling for help when symp-
cate the public on recognizing an emergency, accessing the toms occur. If the patient and bystanders are taught to
system, and initiating basic life support procedures. recognize the emergency and call for help in time, many
Because of this, public education has become an increas- cases of sudden death could be prevented.
ingly important role for EMS. As already noted, patient The second aspect of public education is system access.
education can occur before the emergency occurs (preven- Citizens must know how to activate EMS in an emergency
tion) through activities such as bicycle safety programs, to prevent life-threatening delays. Whether access is by
infant car seat programs, and similar strategies (Figure 2-7). way of 911 or a local seven-digit phone number, the num-
In addition, it has been found that patients are more likely ber should be well publicized, and citizens should be
to listen to advice and consider lifestyle changes following taught how to give the necessary information to the emer-
an emergency. This is often referred to as a teachable gency medical dispatcher.
moment. A teachable moment is an unplanned opportu- Finally, after recognizing an emergency and activating
nity to present information when the circumstances are EMS, citizens must know how to provide basic life support
such that a person is likely to understand and accept the assistance, such as cardiopulmonary resuscitation (CPR)
information. EMS public education can take several forms, and bleeding control after major trauma. Abundant
including role modeling, community involvement, leader- research indicates that a relationship exists between rapid
ship, and prevention. emergency care and mortality (death) rates of patients—
One of the most fundamental components of EMS especially with cardiac arrest. Communities have proven
public education is to help members of the public to recog- that when many citizens are trained in basic life support
nize an emergency when it occurs and to learn how to and early defibrillation—and there is a rapid paramedic
access the EMS system. Prompt recognition of an emer- response—a larger number of patients can be successfully
gency can save lives. For example, the American Heart resuscitated. The AHA estimates that thousands of lives
Association (AHA) estimates that more than 300,000 car- could be saved each year with implementation of bystander
diac arrests per year occur before the patient reaches the CPR programs and rapid paramedic response. Because of
EMS Systems 27
Effective
Communications
The communications network is the
heart of a regional EMS system
(Figure 2-8). Coordinating the com-
ponents into an organized response
to urgent medical situations requires Figure 2-8 The EMS communications center is truly the heart of the modern EMS system.
a comprehensive, flexible communi-
cations plan. Such a plan should include the following: • Communications hardware. The North American
communications infrastructure has changed drasti-
• Citizen access. A well-publicized universal number,
cally. The utility of the Internet has changed the way
such as 911, provides direct citizen access to emer-
we send and receive information. The massive devel-
gency services. Multiple community numbers only
opment of the cell telephone network has affected this
add life-threatening minutes to emergency response
as well. EMS communications uses all these technolo-
times. Enhanced 911, or E-911, gives automatic loca-
gies as well as more typical radio communications sys-
tion of the caller, instant routing of the call to the
tems. Most ambulances now have notebook computers
appropriate emergency service (fire, police, or EMS),
and global positioning system (GPS) and vehicle track-
and instant callback capability. The proliferation of cell
ing system capabilities. As a result of the terrorist
telephone and Internet-based phone lines (voice over
attacks of 2001, there has been considerable federal
Internet protocol, or VOIP) has made caller location
emphasis on updating and improving the national
more difficult, although strategies have been devel-
emergency and public safety communications system.
oped to address these issues.
An important related directive has been to ensure
• Single control center. One control center that can com- interoperability—a feature that allows personnel from
municate with and direct all emergency vehicles different jurisdictions and systems to communicate
within a large geographical area is best. Ideally, all with one another effectively.
public service agencies should be dispatched from the
• Communications software. This includes the radio
same communications center to ensure the best use of
frequencies needed for in-system communication
resources in an emergency response.
and, in many systems, the satellite and high-tech com-
• Operational communications capabilities. With these,
puter programs that track ambulances. Radio proce-
EMS dispatch can manage all aspects of system
dures, policies consistent with FCC standards and
response and assess the system’s readiness for the next
local protocols, and backup communication plans for
response. Emergency units can communicate with one
disaster operations are essential to the modern EMS
another and with other agencies during mutual aid
operation.
and disaster operations. Hospitals also can communi-
cate with other hospitals in the region to assess spe- An EMS system must have an effective and efficient com-
cialty capabilities. munications network in place. Because no single design
• Medical communications capabilities. EMS providers will meet the needs of all communities, each system should
can communicate with the receiving facility and, in design a network that is simple, flexible, and practical.
many areas, transmit ECG and other patient informa-
tion to the hospital or a physician’s office. Newer tech- Emergency Medical Dispatcher
nologies can send patient information to designated The activities of the Emergency Medical Dispatcher (EMD)
sites at the same time the information is obtained. The are crucial to the efficient operation of EMS (Figure 2-9).
growth in communications technology has been one of EMDs not only send ambulances to the scene, but they also
the biggest advances in EMS in recent years. make sure that system resources are in constant readiness
28 Chapter 2
Committee on Accreditation of Educational Programs for the privilege. The paramedic should never assume that any-
Emergency Medical Services Professions (CoAEMSP), an entity one else would take over this responsibility for him.
of the Commission on Accreditation of Allied Health Pro- Certification is the process by which an agency or
grams (CAAHEP). Some states have their own program association grants recognition to an individual who has
accreditation processes. met its qualifications. Many states certify paramedics.
After attaining state certification, paramedics are permit-
Continuing Education ted to work within an established EMS system under the
Once a paramedic has completed the initial education pro- direct supervision of a physician medical director.
gram, he must remain current on changes in EMS care. To Registration is accomplished by entering one’s name
achieve this, a continuing education program is essential. and essential information within a particular record. Para-
Various methods are available for a paramedic to attain medics are registered so the state can verify the provider’s
the necessary continuing education. These include tradi- initial certification and monitor recertification. Almost
tional lectures and prepackaged programs but also include every state has an EMS office that tracks the registration of
innovative strategies such as web-based programs, pod- emergency care providers. Whereas some states track only
casts, videos, and similar alternative delivery models. paramedic providers, others maintain registers on the cer-
Most continuing education programs must be accredited tifications of Emergency Medical Responders, EMTs,
or approved by an oversight body. The Continuing Educa- Advanced EMTs, and Paramedics.
tion Coordinating Board for Emergency Medical Services Reciprocity is the process by which an agency grants
(CECBEMS) is a national continuing education certifying automatic certification or licensure to an individual who
body, although some states provide their own continuing has comparable certification or licensure from another
education certifying process. agency. For example, some states grant reciprocity to para-
Continuing education is mandatory and is just as medics who are certified in another state. In some states,
important as the initial paramedic education program. certification or licensure is not automatic. In these cases,
EMS is a relatively young profession and information the state may grant certification or licensure through equiv-
and technology changes rapidly. More important, con- alence or legal recognition, under which the state determines
tinuing education allows you to stay abreast of the that the out-of-state paramedic’s initial education meets
changes in emergency care procedures to ensure that you the requirements of the state, and the paramedic is then
are providing the best patient care possible. The best allowed to participate in a licensure examination or other
paramedics are those who seek and complete quality con- activity to gain licensure or certification.
tinuing education.
National Registry of EMTs
Licensure, Certification, Registration, The National Registry of Emergency Medical Technicians
(NREMT) is a nonprofit entity based in Columbus, Ohio. It
and Reciprocity prepares and administers standardized tests for the vari-
Once initial education is completed, the paramedic will ous EMS provider levels. The National Registry establishes
become either certified or licensed, depending on the laws the qualifications for registration and biennial reregistra-
governing EMS in the particular state. tion and serves as a vehicle for establishing a national min-
Licensure is a process of occupational regulation. imum standard of competency. Through these services, the
Through licensure, a governmental agency (usually a state National Registry serves as a major tool for reciprocity by
agency) grants permission to engage in a given trade or providing a process for paramedics to become certified
profession to an applicant who has attained the degree of when moving from one state to another. The National Reg-
competency required to ensure the public’s protection. istry also supports the development and evaluation of
Some states choose to license paramedics instead of certify- EMS education programs with the goal of developing
ing them. (There is an unfounded general belief that a nationwide professional standards for EMS providers.
licensed professional has greater status than one who is Currently, in the majority of states, National Registry
certified or registered. However, a certification granted by examinations are being used at some level by EMS regula-
a state, conferring a right to engage in a trade or profes- tors. Several states offer locally developed examinations
sion, is, in fact, a license.) because their levels of certification or licensure differ from
Regardless of what it is called, the paramedic must those recognized by the National Registry. The states that
realize that the authority granted to him by the state is a use the National Registry examinations benefit from sav-
privilege and his personal responsibility. He must take a ings that result from spreading exam development costs
proactive role in maintaining his good standing through over a large user base as well as from the assurance that
continuing education, conduct his practice in a manner to the examinations are widely recognized as providing a
uphold the public trust he has been given, and protect this national standard.
30 Chapter 2
Legal Considerations
Emergency Department Closures. Numerous factors
have resulted in emergency department closures and ambu-
lance diversions. This can have a significant impact on the
EMS system. All systems must address this situation so that
patient care does not suffer.
Ambulance Standards
All transport vehicles must be licensed and meet local and
state EMS requirements. Equipment lists should be consis-
tent with systemwide standards. There are various national
and regional standards regarding what equipment and
technologies should be available on both emergency and
nonemergency ambulances. Regional standardization of
equipment and supplies is most effective in facilitating Figure 2-13 Type I ambulance.
interagency efforts during disaster operations.
Figure 2-15 Type III ambulance. Figure 2-17 The diesel, unibody ambulance is becoming increas-
ingly popular because of cost, fuel economy, and safety.
(© Acadian Ambulance Services)
• Type III (Figure 2-15). This is a specialty van with for-
ward cab and integral body. It has a passageway from
the driver’s compartment to the patient’s compartment. led to a trend to consider vehicle emissions (exhaust and
Only these certified ambulances may display the regis- carbon footprint) in ambulance design.
tered “Star of Life” symbol as defined by the National In 1980, the revision “KKK-A-1822A” aimed at improv-
Highway Traffic Safety Administration (NHTSA). The ing ambulance electrical systems by designing a low-amp
word ambulance should appear in mirror image on the front lighting system to replace antiquated light bars and bea-
of the vehicle so that other drivers can identify the ambu- cons. This standard helped to reduce electrical system over-
lance in their rear-view mirrors. loads. In 1985, another revision, “KKK-A-1822B,” specified
Many services now place a variety of specialized changes based on the National Institute for Occupational
equipment on board ambulances, including specialty res- Safety and Health (NIOSH) standards. These include
cue, hazardous materials (hazmat), and additional reduced internal siren noise, high engine temperatures, and
advanced life support equipment. This has often meant exhaust emissions; safer cot-retention systems; wider axles;
exceeding the gross vehicle weight and has resulted in handheld spotlights; battery conditioners for longer life;
introduction of a medium-duty truck chassis built for rugged and venting systems for oxygen compartments. In 2002,
durability and large storage and work areas (Figure 2-16). revision “KKK-A-1822E” provided guidelines to improve
Another newer type of ambulance, developed for fuel occupant protection in the patient compartment, including
economy and enhanced safety, is the diesel ambulance additional occupant restraints, more rounded interior cor-
(Figure 2-17). Ambulance standards will continue to ners, and more secure locations of the sharps container for
evolve. Concerns about the future of the environment have needles and other potentially dangerous items. Revision
“KKK-A-1822F” was published in 2007 and primarily
addressed electrical systems, signage, and safety.30
All ambulances purchased with federal funds during
the 1970s were required to comply with the KKK criteria.
Since then, however, some states have adopted their own
criteria.
Legal Considerations
9/11/01 and Beyond. Since the attacks on the United States
on September 11, 2001, disaster response and EMS have
taken on significantly more and different responsibilities. All
EMS personnel must be prepared for disasters, regardless of
the cause. Biological and chemical agents pose significant
risks to EMS personnel. Preparation and education are the
keys to survival if such events are encountered.
can also occur when a provider thinks his judgment is who has what appears to be obviously mortal injuries.
“error proof”—a narcissistic trait.34 However, EMS personnel often arrive minutes after
the onset of the problem and initial findings may not
Although medical errors can occur at any time, some
accurately indicate what will eventually happen to
high-risk areas of EMS practice have been identified. These
the patient. There have been many reports where
include:
paramedics have declared a patient dead and the
• Hand-off. The transfer of patient care and the patient patient was later found to be alive. Such an error is
from an EMS crew to hospital staff is called the hand- fodder for the media. EMS systems should have a pro-
off. During this time, essential information about the tocol and practices to ensure that death pronounce-
patient must be communicated. The failure to provide ment is accurate.
information by the EMS crew and the failure to receive Medical error prevention is an important part of EMS.
(or ask for) information by the hospital staff can lead to Several practices will help with this. One is to address pos-
misunderstanding and possible errors.35 sible EMS environmental issues that can lead to errors. To
• Communications issues. As with hand-off, the failure minimize these, an EMS system must have clear protocols,
to communicate with family members, other respond- and they must be fully understood by all providers. When
ers, and hospital personnel can lead to misunderstand- procedures are performed, there must be adequate lighting
ings and medical errors. to ensure that the procedure can be carried out safely. There
• Medication issues. Medications can heal, but they can should be minimal interruptions (to the degree possible).
also kill. Because of the large number of medications Standardization and organization of drugs and their pack-
used in EMS, there is always the potential for error. aging can help to minimize medication errors—a major
Common errors include administering the wrong problem in EMS and health care.
medication, administering the wrong dose of the right Besides environmental strategies, the individual pro-
medication, or failing to administer a medication. vider must also address medical error prevention. Medical
Every paramedic must understand his responsibilities errors can be minimized if providers always reflect on
when given the authority to administer medications what they are planning to do. They should also constantly
and treatment. question assumptions. Often initial assumptions as to
patient condition and necessary treatment change as more
• Airway issues. Prehospital airway management has is learned about the patient and his condition. Tools to help
come under increased scrutiny following several stud- in decision making and prompts (checklists, electronic
ies that showed that patient outcomes are often not reminders) can help reduce medical errors (a strategy
improved with endotracheal intubation.36 The failure gleaned from the aviation industry). Simply asking for
to recognize improper placement of an endotracheal help when a question arises can also effectively reduce
tube (e.g., esophageal intubation) has been an ongoing medical errors. Although there has been a decrease in the
issue in EMS and a source of malpractice litigation. routine use of on-line medical oversight, virtually all EMS
Airway management is a skill that must be mastered, systems have a medical director available to answer ques-
performed flawlessly, and documented carefully. Air- tions. A practice called “time outs” is now routinely used
way errors are often fatal and can be prevented. in the operating room to help minimize errors—particu-
• Dropping patients. Physically dropping a patient is larly when high-risk procedures are involved. Before
not uncommon and not limited to emergency beginning the actual procedure, all involved take a “time
responses. There are several occasions in emergency out” and ensure that everything is in order—the right
care when patients are dropped—the most common patient, the correct supplies, the correct personnel, and so
being loading and unloading the patient into and out on. This methodology can be applied to certain aspects of
of the ambulance. EMS, particularly high-risk procedures.
• Ambulance crashes. There has been an alarming Medical errors are common and pose a clear and pres-
increase in ambulance crashes in the past decade and ent danger for our patients. Just as airline pilots use strate-
the causes appear multifactorial. We are learning that gies to maximize safety, EMS providers should also actively
most modern American ambulances are not particu- employ strategies and procedures that will help to mini-
larly crashworthy, and strategies are being developed mize medical errors. One of the best strategies is simply:
to address this. Most ambulance crashes can be when in doubt, ask for help!
avoided by following established guidelines and pro-
cedures. Research
• Death pronouncements. It is not uncommon for para- A formal, ongoing research program is an essential compo-
medics to encounter a patient who is clearly dead or nent of the EMS system for moral, educational, medical,
EMS Systems 37
Summary
The evolution of EMS has occurred over thousands of years. Many of its innovations are the result
of lessons learned from military conflicts. EMS today is also largely the result of federal legislation
and investment from private foundations.
A comprehensive EMS system has many components. EMS provides a continuum of care that
extends from the EMT who conducts public education classes to the mechanic who keeps the
ambulance fleet running; from the emergency medical dispatcher who calms a distressed caller to
the emergency department physician, surgeon, and physical therapist who see the patient through
to definitive care and rehabilitation. No one component, no one person, is more important than
another. EMS is a total team effort.
EMS systems are designed with the patient as the highest priority. Each system has an admin-
istrative agency, which structures the system around the community’s needs and grants the medi-
cal director ultimate authority in all issues of patient care.
Most EMS systems may be activated by way of a single, universal number (911). They rely on
a centralized communications center, which handles all medical emergencies in the area and coor-
dinates all levels of communication—operational and medical—within a region. The goal of an
emergency response is BLS care in less than 4 minutes and advanced life support (ALS) care in less
than 8 minutes after the onset of an event. Coordination of ground and air transport follows estab-
lished protocols at the communications center.
Mutual-aid agreements ensure a continuum of care during multiple-casualty incidents.
Disaster plans are formalized, rehearsed regularly, continuously evaluated, and revised when
EMS Systems 39
necessary. Hospitals are categorized according to their readiness to provide essential and spe-
cialty services within a region. EMS providers are trained according to the U.S. DOT Instruc-
tional Guidelines. Continuing education programs encourage providers to achieve excellence.
A continuous quality improvement program documents the EMS system’s performance.
Ongoing research validates the actions of prehospital providers through scientific evaluation.
Finally, EMS systems flourish because of strong, stable financial plans that ensure consistent
development on a regional, state, and national basis.
Review Questions
1. EMS trauma care generally evolves following 3. _______________ is a project published in 1996 and
__________ supported by the National Highway Traffic Safety
a. studies and scientific reviews. Administration.
b. military conflicts. a. Emergency Medical Services for Children (EMS-C)
c. medical consortiums. b. EMS Agenda for the Future
d. quality improvement reviews. c. White Paper
d. OPALS
2. Which document published in 1966 outlined the
deficiencies in prehospital emergency care? 4. The _______________ was established following the
a. National Standard Curriculum terrorist attacks of September 11, 2001.
b. Accidental Death and Disability: The Neglected a. National Highway Transportation and Safety Act
Disease of Modern Society b. Department of Homeland Security
c. EMS Agenda for the Future c. National Incident Improvement and Mitigation
d. Consolidated Omnibus Budget Reconciliation Act d. Federal Emergency Management Agency
40 Chapter 2
5. An essential, yet often overlooked, component of an 8. There are two types of education in EMS:
EMS system is __________ _____________________ education.
a. the QI process. a. prehospital and hospital
b. the public. b. initial and continuing
c. the medical director. c. clinical and field
d. the training officer. d. initial and hospital
6. All of the following are components of the commu- 9. The act of receiving a comparable certification or
nications network of a regional EMS system except licensure from another state or agency is known as
___________ _________________________
a. citizen access. a. registration.
b. dual control center. b. reciprocity.
c. operational communications capabilities. c. regulation.
d. medical direction. d. reciprocation.
7. Crucial to the efficient operations of EMS, 10. Professional organizations that help shape the public
______________ are responsible for sending ambu- perception of EMS include all of the following except
lances to the scene and ensuring that system ______________
resources are in constant readiness. a. NASAR. c. NAEMSP.
a. Emergency Medical Radio Technicians b. NAEMSE. d. NFPA.
b. Emergency Telecommunications Operators
See answers to Review Questions at the back of this book.
c. Emergency Medical Dispatchers
d. Paramedical Telecommunications
References
1. Stout, J., P. E. Pepe, and V. N. Mosesso, Jr. “All Advanced-Life 12. Page, J. O. The Paramedics. Morristown, NJ: Backdraft Publica-
Support vs. Tiered Response Ambulance Systems.” Prehosp Emerg tions, 1979.
Care 4 (2000): 1–6. 13. Harvey, J. C. “The Emergency Medical Services Act of 1973.”
2. Skandalakis, P. N., P. Lainas, O. Zoras, et al. “‘To Afford the JAMA 230 (1974): 1139–1140.
Wounded Speedy Assistance’: Dominique Jean Larrey and 14. Stiell, I. G., D. W. Spaite, G. A. Wells, et al. “The OPALS Study:
Napoleon.” World J Surg 30 (2006): 1392–1399. Rationale and Methodology for Cardiac Arrest Patients.” Ann
3. Evans, G. D. “Clara Barton: Teacher, Nurse, Civil War Heroine, Emerg Med 32 (1998): 180–190.
Founder of the American Red Cross.” Int Hist Nurs J 7 (2003): 75–82. 15. National Highway Traffic Safety Administration. The EMS
4. Barkley, K. T. The Ambulance. Kiamesha Lake, NY: Load N Go Agenda for the Future. Washington, DC: National Highway Traffic
Press, 1978. Safety Administration, 1996 [available at http://www.nhtsa.dot.
5. Apel, O. F., Jr. and P. Apel. MASH: An Army Surgeon in Korea. gov/people/injury/ems/agenda/emsman.html].
Lexington: University of Kentucky Press, 1998. 16. Department of Homeland Security, Federal Emergency Manage-
6. Allison, C. E. and D. D. Trunkey. “Battlefield Trauma, Traumatic ment Agency (FEMA). About the National Incident Management
Shock and Consequences: War-Related Advances in Critical System (NIMS) [available at http://www.fema.gov/emergency/
Care.” Crit Care Clin 25 (2009): 31–45, vii. nims/AboutNIMS.shtm].
7. Elam, J. O., E. S. Brown, and J. D. Elder, Jr. “Artificial Respiration 17. Gausche, M., R. J. Lewis, S. J. Stratton, et al. “Effect of Out-of-
by Mouth-to-Mask Method: A Study of the Respiratory Gas Hospital Pediatric Endotracheal Intubation on Survival and
Exchange of Paralyzed Patients Ventilated by Operator’s Expired Neurological Outcome: A Controlled Clinical Trial.” JAMA 283
Air.” NEJM 250 (1954): 749–754. (2000): 783–790.
8. Safer, P., T. C. Brown, W. J. Holtey, and J. Wilder. “Ventilation and 18. Institute of Medicine of the National Academies. Emergency
Circulation with Closed-Chest Cardiac Massage in Man.” JAMA Medical Services at the Crossroads. Washington, DC: National
176 (1961): 574–576. Academies Press, 2006.
9. National Academy of Sciences, National Research Council. Acci- 19. American College of Emergency Physicians. The National Report
dental Death and Disability: The Neglected Disease of Modern Society. Card on the State of Emergency Medicine. Irving, TX: American
Washington, DC: U.S. Department of Health, Education, and College of Emergency Physicians, 2006.
Welfare, 1966. 20. U.S. Department of Transportation/National Highway Traffic
10. Pantridge, J. F. and J. F. Geddes. “A Mobile Intensive Care Unit in Safety Administration. National EMS Scope of Practice Model.
the Management of Myocardial Infarction.” Lancet 290 (1967): Washington, DC, 2006.
271–273. 21. U.S. Department of Transportation/National Highway Traffic
11. Hirschman, J. C., S. R. Nussenfeld, and E. L. Nagel. “Mobile Phy- Safety Administration. National Emergency Medical Services Edu-
sician Command: A New Dimension in Civilian Telemetry-Res- cational Standards: Paramedic Instruction Guidelines. Washington,
cue Systems.” JAMA 230 (1974): 255–258. DC, 2009.
EMS Systems 41
22. U.S. Department of Transportation/National Highway Traffic 30. United States General Services Administration. Federal Specifica-
Safety Administration. National EMS Core Content. Washington, tion for the Star-of-Life Ambulance: KKK-A-1822F. Washington, DC:
DC, 2005. General Services Administration, 2007.
23. Munk, M. D., S. D. White, M. L. Perry, et al. “Physician Medical 31. Demetriades, D., M. Martin, A. Salim, et al. “Relationship
Direction and Clinical Performance at an Established Emergency between American College of Surgeons Trauma Center Designa-
Medical Services System.” Prehosp Emerg Care 13 (2009): 185–192. tion and Mortality in Patients with Severe Trauma (Injury Sever-
24. Jensen, J. L., D. A. Petrie, A. H. Travers, and PEP Project Team. ity Score >15).” J Am Coll Surg 202 (2006): 212–215.
“The Canadian Prehospital Evidence-Based Protocols Project: 32. Goldstone, J. “The Role of Quality Assurance versus Continuous
Knowledge Translation in Emergency Medical Services Care.” Quality Improvement.” J Vasc Surg 28 (1998): 378–80.
Acad Emerg Med 16 (2009): 668–673. 33. National Academies of Science, Institute of Medicine. To Err Is
25. Wilson, S., M. Cook, R. Morrell, et al. “Systematic Review of the Human: Building a Safer Health System. Washington, DC: National
Evidence Supporting the Use of Priority Dispatch of Emergency Academies Press, 2000.
Ambulances.” Prehosp Emerg Care 6 (2002): 42–49. 34. Banja, J. Medical Errors and Medical Narcissism. Sudbury, MA:
26. Pons, P. T., J. S. Haukoos, W. Bloodworth, et al. “Paramedic Jones and Bartlett, 2005.
Response Time: Does It Affect Patient Survival?” Acad Emerg Med 35. Yong, G., A. W. Dent, and T. J. Welland. “Handover from Para-
12 (2005): 594–600. medics: Observations and Emergency Department Clinical Per-
27. Blackwell, T. H., J. A. Kline, J. J. Willis, and J. M. Hicks. “Lack of ceptions.” Emerg Med Australas 20 (2008): 149–155.
Association between Prehospital Response Times and Patient 36. Davis, D. P., J. Peay, M. J. Sise, et al. “The Impact of Prehospital
Outcomes.” Prehosp Emerg Care 13 (2009): 144–150. Endotracheal Intubation on Outcome in Moderate to Severe
28. Dickinson, P., D. Hostler, T. E. Platt, and H. E. Wang. “Program Traumatic Brain Injury.” J Trauma 58 (2005): 933–939.
Accreditation Effect on Paramedic Credentialing Examination 37. Sayre, M. R., L. J. White, L. H. Brown, et al. National EMS
Success Rate.” Prehosp Emerg Care 10 (2006): 224–228. Research Agenda. Prehosp Emerg Care 6 (2002): S1–S43.
29. Schneider, C., M. Gomez, and R. Lee. “Evaluation of Ground
Ambulance, Rotor-Wing and Fixed-Wing Aircraft Services.” Crit
Care Clin 8 (1992): 533–564.
Further Reading
Bledsoe, B. E. “The Golden Hour: Fact or Fiction?” Emergency Medical National Academies of Emergency Dispatch. Emergency Telecommunica-
Services (EMS) 31 (2002): 105. tor Course Manual. Sudbury, MA: Jones and Bartlett Publishers, 2001.
Bledsoe, B. E. “Searching for the Evidence behind EMS.” Emergency Walz, B. Introduction to EMS Systems. Albany, NY: Delmar/Thompson
Medical Services (EMS) 32 (2003): 63–67. Learning, 2002.
Chapter 3
Roles and Responsibilities
of the Paramedic Bryan Bledsoe, DO, FACEP, FAAEM
Standard
Preparatory (EMS Systems)
Competency
Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical–legal and
ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to explain the roles and responsibilities of
paramedics.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this 4. Define and discuss how to integrate
chapter. expected characteristics of professionalism
into the practice of paramedicine.
2. Discuss each of the primary responsibilities
of paramedics. 5. Give examples of behaviors that
demonstrate the expected professional
3. Give examples of additional responsibilities
attitudes and attributes of paramedics.
of paramedics.
Key Terms
allied health professions, p. 51 nature of the illness (NOI), p. 45 pathophysiology, p. 43
mechanism of injury (MOI), p. 45 paramedicine, p. 43 primary care, p. 48
42
Roles and Responsibilities of the Paramedic 43
Case Study
The central dispatch center for your city receives a call a stroke. The patient is immediately moved to the
for a medical emergency. The patient’s name, address, stretcher and placed into the ambulance. Paramedics
and street number appear on the computer monitor, so determine that the onset of the stroke was probably
the dispatcher clicks a mouse and a map of the city within the past 45 minutes and the patient is well within
appears on screen. In this EMS system, satellites are the stroke interventional window of 4½ hours.
used continuously to track and monitor the location and In the ambulance, the paramedics complete a more
availability of emergency vehicles using Automatic detailed assessment and determine that the patient
Vehicle Location (AVL). The dispatcher selects Medic requires transport to a hospital with interventional neu-
49, the unit closest to the scene, and, by way of the com- rology and fibrinolytic capabilities. During transport,
puter-aided dispatch (CAD) system, gives the unit spe- they radio the hospital and report the patient’s condi-
cific directions and patient information. tion and estimated time of arrival. The hospital activates
While the ambulance is responding, the dispatcher its “Code Stroke” team to await the patient’s arrival.
talks to the caller and provides him with emotional sup- Vital signs and pulse oximetry are continuously moni-
port and prearrival instructions for immediate patient tored and an ECG is performed.
care. After approximately 18 minutes en route, the
On arrival, the ambulance personnel find a 66-year- patient is delivered to the emergency department,
old female patient lying in bed, unable to speak clearly where the stroke team—the emergency physician, a
or move the right side of her body. The primary assess- neurologist, and a radiologist—is waiting for her. Forty-
ment reveals her to be disoriented. It also finds that she five minutes later, after an emergency CT scan of the
has an open airway, a normal rate of breathing, and brain, the patient is receiving interventional therapy to
strong radial and carotid pulses. help minimize the size of the infarct in her brain. One
Paramedic Bobby Moore decides to work with his week later, the patient is discharged to her home with a
partner to rapidly prepare the patient for transport. schedule of appointments for rehabilitation. A home
Then he performs a rapid stroke assessment scoring sys- health nurse is also scheduled to perform follow-up
tem, after which he determines that the patient has had assessments twice each week.
Response
During an emergency response, remember that personal
safety is your number one priority. If your ambulance
crashes en route to an incident because of speeding or run-
ning red traffic lights, you will be of no benefit to the
patient. Responding safely to an emergency will reduce the
risk to you, your partners, and other agencies responding
to the same incident. Always follow basic safety precau-
tions en route to an incident. Wear a seat belt, obey posted
speed limits, and monitor the road for potential hazards.
Just as important as getting to the scene safely is get-
ting to the scene in a timely manner. Make certain you
know the correct location of the incident and that the
appropriate equipment is en route. Also while you are en
route, request any additional personnel or services that
you think may be needed—for example, with alcohol- or
drug-related issues. Waiting to ask for such assistance until
you get to a chaotic scene can only delay the appropriate
response. Learn to anticipate potential high-risk situations
based on dispatch information and experience. For exam-
ple, if any of the following is reported, you may need to
call for assistance:
• Multiple patients
• Motor vehicle collisions
Figure 3-1 A paramedic provides emergency care to ill and injured
• Hazardous materials
patients—at the scene and in the ambulance.
• Rescue situations
able to meet the demands of the patient, the family, and • Violent individuals (patients or bystanders)
other health care providers. Your ongoing training should • Use of a weapon
include aerobics for cardiovascular fitness, exercises for
• Knowledge of previous violence
muscle strength and endurance, stretching for increased
flexibility, and an understanding of the biomechanics of
lifting for prevention of lower-back injuries. Other keys to Scene Size-Up
a successful career are recognizing the effects of stress and Your primary concern during scene size-up is the safety of
practicing ways to alleviate it. your crew, the patient, and bystanders. Identify all potential
You must be prepared. This means making sure that hazards such as fire, smoke, traffic, bystanders, angry or
inspection and routine maintenance have been completed distraught family members, unstable structures or vehicles,
on your emergency vehicle and on all equipment. It means and hazardous materials (Figure 3-2). Never enter an unsafe
restocking medications and intravenous solutions and scene until the hazards have been dealt with. Remember
checking their expiration dates. In addition, you must be that any scene has the potential to deteriorate, so learn to
very familiar with the following: anticipate problems and be prepared for anything.
When the scene is safe to enter, determine the number
• All local EMS protocols, policies, and procedures
of patients. In medical emergencies, there usually is only
• Communications system hardware (radios) and one. However, in some cases—such as carbon monoxide
software (frequency utilization and communication poisoning or exposure to other toxic substances—it may be
protocols) necessary to search the entire area for patients. Once the
• Local geography, including populations during peak number of patients and the severity of their illnesses or
utilization times, and alternative routes during rush injuries are determined, quickly request any additional or
hours specialized services required to manage the incident.
Roles and Responsibilities of the Paramedic 45
Figure 3-2 Always assess the scene for potential hazards as you Figure 3-3 During the primary assessment of your patient,
approach. you will look for and immediately treat any life-threatening
(© Ed Effron) conditions.
The mechanism of injury (MOI) or the nature of the step of assessment is gathering the facts of the patient’s
illness (NOI) also must be identified. For a trauma patient, medical history from the patient and/or bystanders and
some mechanisms of injury can be a cause for alarm. For performing a physical examination of the patient, with all
example, a child struck by a fast-moving car is likely to information recorded and reported to the hospital. It is also
have serious, multiple injuries. Knife and gunshot wounds the paramedic’s responsibility to continuously monitor the
suggest severe injury to internal organs and life-threaten- patient and provide any additional emergency care needed
ing internal bleeding. How far a patient is found from a until the patient is transferred to the care of the hospital’s
collision or explosion, or how far a patient fell from a emergency department staff.
height, will also indicate how severe an injury may be. For
a medical patient, clues identified at the scene can provide Recognition of Illness or Injury
important insights into the nature of the illness. Identifying
Recognizing the nature of the illness or severity of injury,
medications, such as insulin, or devices, such as an inhaler,
accomplished during the scene size-up and the primary
may prevent misdiagnosis and speed the proper treatment
assessment, is the first aspect of patient prioritization. Most
of the patient.
commonly, patient priority is based on the urgency for
transport. No matter what method of prioritization your
Patient Assessment EMS system uses, it is essential that you learn and practice
One of the most critical skills you will learn is patient it. Note that the method should be standardized so that all
assessment. Although the order of the steps may vary for health care professionals within your system understand
trauma and medical patients, the basic components are the each other and can respond appropriately.
same: primary assessment, patient history, secondary
assessment, and ongoing assessment. (Volume 2 deals with
patient assessment in detail.) Patho Pearls
The primary assessment of a patient is usually per- Research in EMS. As each year passes, we are learning more
formed in a scant minute or so. During this assessment, and more about EMS through research and scientific inquiry.
you must note your general impression of the patient’s Interestingly, some prehospital practices that seemed intuitive
appearance. Then assess the patient’s responsiveness— have not held up to scientific scrutiny. Because of this, EMS is
that is, determine whether the patient is alert, responding adjusting so current practices reflect the current status of the sci-
to verbal or painful stimuli, or not responding at all. ence. Several things are becoming increasingly clear, especially
in regard to the importance of early intervention: Paramedic-
Finally, you will assess the patient’s airway, breathing,
level measures appear to be most beneficial when provided
and circulation (Figure 3-3). If the patient is in cardiac
early in the disease process. More lives are saved with the pre-
arrest, circulation takes priority over airway and breath-
hospital administration of aspirin than by all resuscitation mea-
ing. If you discover any life threats, you will treat them sures combined. Other treatments, such as pain control and the
immediately. use of continuous positive airway pressure (CPAP), benefit
As part of the primary assessment, you will decide many more patients than once thought. As EMS evolves, there
whether to continue the assessment on scene or immedi- will be a decreased emphasis on raising the dead and a greater
ately transport the patient to a medical facility. The next emphasis on intervening earlier in the disease spectrum.
46 Chapter 3
Receiving facilities are categorized based on the level institution. Level III trauma centers can provide
of care they can provide. For example, the American Col- prompt assessment, resuscitation, emergency opera-
lege of Surgeons categorizes trauma centers by levels: tions, and stabilization, and also arrange for possible
transfer to a facility that can provide definitive trauma
Level I—The Level I facility is a regional resource trauma
care. General surgeons are required in a Level III facil-
center and serves as a tertiary care facility for the
ity. Planning for care of injured patients in these hospi-
trauma care system. Ultimately, all patients who
tals requires transfer agreements and standardized
require the resources of the Level I center should have
treatment protocols. Level III trauma centers are gen-
access to it. This facility must have the capability of
erally not appropriate in an urban or suburban area
providing leadership and total care for every aspect of
where Level I and/or Level II resources are available.
injury, from prevention through rehabilitation. In its
central role, the Level I center must have adequate Level IV—Level IV trauma facilities provide advanced
depth of resources and personnel. trauma life support before patient transfer in remote
A Level I trauma center requires a large number areas where no higher level of care is available. Such a
of personnel and an adequate facility for patient care, facility may be a clinic rather than a hospital and may or
education, and research. Most Level I trauma centers may not have a physician available. Because of geo-
are university-based teaching hospitals. Other hospi- graphic isolation, however, the Level IV trauma facility
tals willing to commit these resources, however, may is often the de facto primary care provider. If it is willing
meet the criteria for Level I recognition. to make the commitment to provide optimal care, given
In addition to patient care responsibilities, Level its resources, the Level IV trauma facility should be an
I trauma centers have the major responsibility of pro- integral part of the inclusive trauma care system. As at
viding leadership in education, research, and system Level III trauma centers, treatment protocols for resusci-
planning. This responsibility extends to all hospitals tation, transfer protocols, data reporting, and participa-
caring for injured patients in their regions. tion in system performance improvement are essential.
Medical education programs include residency A Level IV trauma facility must have a good work-
program support and postgraduate training in trauma ing relationship with the nearest Level I, II, or III trauma
for physicians, nurses, and prehospital providers. Edu- center. This relationship is vital to the development of a
cation can be accomplished through a variety of mech- rural trauma system in which realistic standards must
anisms, including classic continuing medical, trauma, be based on available resources. Optimal care in rural
and critical care fellowships, preceptorships, person- areas can be provided by skillful use of existing pro-
nel exchanges, and other approaches appropriate to fessional and institutional resources supplemented by
the local situation. Research and prevention programs, guidelines that result in enhanced education, resource
as defined in this document, are essential for a Level I allocation, and appropriate designation for all levels of
trauma center. providers. It is also essential for the Level IV facility
to have the involvement of a committed health care
Level II—The Level II trauma center is a hospital that also
provider who can provide leadership and sustain the
is expected to provide initial definitive trauma care,
affiliation with other centers.3
regardless of the severity of injury. Depending on geo-
graphic location, patient volume, personnel, and In addition to designated trauma centers, other facili-
resources, the Level II trauma center may not be able ties may offer unique services. They include burn, pediatric,
to provide the same comprehensive care as a Level I psychiatric, perinatal, cardiac, spinal, and poison centers.
trauma center. Therefore, patients with more complex The best receiving facility is the one best able to care for
injuries (for example, patients requiring advanced and your patient. Most patients request transportation to the
extended surgical critical care) may have to be trans- nearest medical facility. However, patients enrolled in man-
ferred to a Level I center. Level II trauma centers may aged care programs, such as health maintenance organiza-
be the most prevalent facilities in a community, how- tions (HMOs) or designated provider groups, may request
ever, managing the majority of trauma patients. transport to a facility approved by their group, which may
The Level II trauma center can be an academic be a facility other than the nearest hospital. Other patients
institution or a public or private community hospital may ask you to transport them to a facility outside your run
located in an urban, suburban, or rural area. In some area. Even though the requested facility may be appropriate
areas where a Level I center does not exist, the Level II for the patient, there may be an equally appropriate hospi-
center should take on the responsibility for education tal that is closer. Remember, you are responsible for patient
and system leadership. care and therefore ultimately responsible for selecting the
Level III—The Level III trauma center serves communities transport destination. When in doubt, contact on-line medi-
that do not have immediate access to a Level I or II cal direction for advice and support.
48 Chapter 3
Other Types of Disposition care while finding ways to control costs) may change that.
In some areas, paramedics provide primary care. They Innovative programs such as these are setting standards
have well-defined protocols that allow them to treat for the future of EMS.
patients at the scene and transfer them to facilities other
than a hospital. For example, consider a child who cuts Patient Transfer
his arm on a rusty nail. The father activates EMS by call- The managed care environment has caused many people—
ing 911. When the paramedics arrive, they control the both laypersons and health care providers—to occasion-
bleeding and perform a patient assessment. They find a ally question whether certain actions that are intended to
simple 2-inch laceration on the child’s forearm. Instead of reduce the cost of medical care are actually in the patient’s
transporting the patient to the hospital and using best interest. For example, to avoid the cost of duplicating
resources that are not needed for the treatment of this equipment and services in a number of facilities that serve
patient, the paramedics contact medical direction and the same geographic area, managed care systems have
request permission to transport the child to a local outpa- encouraged facilities to specialize and, often, to transfer
tient center for treatment. This decision saves the family patients to a facility that can provide the specific care
from paying a costly emergency department fee, and it needed.
keeps the emergency department available for a more Occasionally, there may be a question as to whether
serious emergency. the transfer of a patient from one facility to another has
Another type of disposition is called “treat and release.” been approved for cost reasons but may not actually be in
In this type of program, paramedics arrive on scene, assess the patient’s best interest. When you are assigned to
the patient, and provide emergency care. If they determine transport a patient, you share responsibility—with the
that there is no need for further medical attention, they con- receiving and accepting physician—for the treatment and
tact medical direction and request orders not to transport. care of the patient. When you are in doubt about the
In some systems, paramedics may then contact a special- patient’s stability for the duration of transport, or about
ized dispatch center, where an office appointment is made the capabilities of the receiving facility, contact medical
with a physician in the patient’s area.4 direction.
While disposition systems such as these are not widely Before removing the patient from a hospital, request a
accepted, the increasing numbers of people in managed verbal report from the primary care provider (usually a
care programs (which generally attempt to achieve optimum registered nurse or a physician). This report is often called
the “hand-off.” Also request a copy of essential parts of the
patient’s chart, including a summary of the patient’s past
Legal Considerations and present medical history. However, if the results of
What Is a Patient? Although this may seem like a rhetori- diagnostic tests taken at the facility are not ready when you
cal question, the answer is not as easy as one would think. are prepared to leave, do not delay patient transport. The
For example, you arrive at the scene of a motor vehicle colli- data can be faxed, e-mailed, or telephoned to the receiving
sion to find three people exchanging insurance information. facility.
All three deny injury and refuse assistance. Are they legally Your first priority during transport is the patient.
EMS patients? What if one of the drivers appears intoxicated? While en route, contact the receiving facility and provide
Is he a patient? What if one of the people is a 16-year-old
them with an estimated time of arrival (ETA) and an
female riding with an 18-year-old boyfriend? Is she a patient?
update on the patient’s condition. On arrival at your desti-
The issue is certainly cloudy and most EMS systems have
nation, seek out the contact person (usually a registered
developed a statement in this regard. One example, devel-
oped by EMS medical directors in Texas, states: nurse or physician). Provide that person with an updated
patient report, including any treatment or changes in sta-
A patient is any person who, on contact with an EMS system,
tus while en route. All documents provided by the sending
presents with a complaint, circumstance, and/or condition that
might require further assessment or treatment. facility should be turned over to the receiving care pro-
The standard of judgment is that of a reasonable and prudent vider along with a copy of your run report. If required by
medic. your service, obtain appropriate billing/insurance infor-
The designated system Medical Director is responsible mation at this time.5
for promulgating specific criteria for designation of a patient
within the above general guideline. Documentation
Certainly, the definition in your area may vary. How-
Maintaining a complete and accurate written patient care
ever, EMS systems are encouraged to define this tricky issue,
report is essential to the flow of patient information, to
and EMS personnel should be aware of the definition used by
their EMS system. research efforts, and to the quality improvement of your
EMS system. The patient care report should be completed
Roles and Responsibilities of the Paramedic 49
safety campaign directed at the safe crossing of railroad an existing one, community members should help to
tracks may thus be appropriate. Once an EMS service has establish what is needed. After all, they are your “cus-
identified a problem and the target audience, EMS per- tomers,” and their needs are your priority.8
sonnel should seek out community agencies—including
the local political structure—to assist in the development, Personal and Professional
promotion, and delivery of the campaign.
Among the benefits of community involvement are
Development
the following: It enhances the visibility of EMS, promotes a Only through continuing education and recertification
positive image, and puts forth EMS personnel as positive can the public be assured that quality patient care is
role models. It also creates opportunities to improve the being delivered consistently. Therefore, after you are cer-
integration of EMS with other health care and public safety tified and/or licensed, you have an important responsi-
agencies through cooperative programs. bility to continue your personal and professional
development. Remember, everyone is subject to the
decay of knowledge and skills over time. Use this as a
Support for Primary Care rule of thumb: As the volume of calls decreases, training
Promoting wellness and preventing illness and injury should correspondingly increase. Refresher requirements
will be important components of EMS in the future. and courses vary from state to state, but the goal is the
Some systems have already begun to direct resources same: to review previously learned materials and to
toward the development of prevention and wellness receive new information.
programs that decrease the need for emergency services. Because EMS is a relatively young industry, new tech-
The theory is to reduce the cost of the services provided nology and data emerge rapidly. Make a conscious effort to
to the community by decreasing the burden on the keep up. A variety of journals, seminars, computer news
system.7 groups, and learning experiences are available to help. So
One strategy is to establish protocols that specify the are professional EMS organizations, which exist at the
mode of transportation for nonemergency patients. local, state, and national levels.
Some systems already operate vans rather than ambu- There are other options for keeping up your interest
lances to transport such patients to and from nursing and staying informed, too. By participating in activities
facilities or from their residences to a doctor ’s office. designed to address work-related issues—such as case
Although it is an additional expense to the system, this reviews and other quality improvement activities, mentor-
service reduces emergency equipment costs and the ing programs, research projects, multiple-casualty incident
demand for emergency personnel. The result is a drills, in-hospital rotations, equipment in-services,
decrease in the overall operating expense, which results refresher courses, and self-study exercises—you can expect
in an increase in revenue. substantial career growth.
Another strategy being used in many areas of the Alternative career paths may be open to you as well.
country is having EMS and hospitals team up to provide For example, a career paramedic may decide to explore
an alternative to the emergency department. They trans- management by applying for a supervisory position or
port patients to freestanding outpatient centers or clin- may take a critical care class to prepare for a job on a trans-
ics, which ultimately reduces the cost of care to the port unit. Nontraditional careers for paramedics include
patient and the system. The development of such alli- working in the primary care setting, providing emergency
ances will undoubtedly continue. However, caution care on offshore oil rigs, and taking on the occupational
should be taken to ensure that the patient always safety role in an industrial setting.
receives the appropriate emergency care based on need,
not cost.
Professionalism
Citizen Involvement in EMS A paramedic is a member of the health care professions.
Citizen involvement in EMS helps to give “insiders” an Note that the word profession refers to the existence of a
outside, objective view of quality improvement and specialized body of knowledge or skills. Generally self-
problem resolution. Whenever possible, members of the regulating, a profession will have recognized standards,
community should be used in the development, evalua- including requirements for initial and ongoing education.
tion, and regulation of the EMS system. When consider- When you have satisfied the initial education requirements
ing the addition of a new service or the enhancement of for your training as a paramedic, you may then be either
Roles and Responsibilities of the Paramedic 51
OATH OF GENEVA
I solemnly pledge myself to consecrate my life to the service of humanity; I will give
to my teachers the respect and gratitude which is their due; I will practice my profes-
sion with conscience and dignity; the health of my patient will be my first considera-
tion; I will respect the secrets which are confided in me; I will maintain by all the
means in my power the honor and noble traditions of the medical profession; my col-
leagues will be my brothers; I will not permit considerations of religion, nationality,
race, party, politics, or social standing to intervene between my duty and my patient;
I will maintain the utmost respect for human life from the time of conception; even
under threat, I will not make use of my medical knowledge contrary to the laws of
humanity. I make these promises solemnly, freely and upon my honor.
The Emergency Medical Technician provides services based on human need, with respect for human dignity, unrestricted by
consideration of nationality, race, creed, color, or status.
The Emergency Medical Technician does not use professional knowledge and skills in any enterprise detrimental to the public
well being. The Emergency Medical Technician respects and holds in confidence all information of a confidential nature
obtained in the course of professional work unless required by law to divulge such information.
The Emergency Medical Technician, as a citizen, understands and upholds the law and performs the duties of citizenship; as a
professional, the Emergency Medical Technician has the never-ending responsibility to work with concerned citizens and other
health care professionals in promoting a high standard of emergency medical care to all people.
The Emergency Medical Technician shall maintain professional competence and demonstrate concern for the competence of
other members of the Emergency Medical Services health care team. An Emergency Medical Technician assumes responsi-
bility in defining and upholding standards of professional practice and education.
The Emergency Medical Technician assumes responsibility for individual professional actions and judgement, both in
dependent and independent emergency functions, and knows and upholds the laws which affect the practice of the Emergency
Medical Technician.
The Emergency Medical Technician has the responsibility to be aware of and participate in matters of legislation affecting the
Emergency Medical Technician and the Emergency Medical Services System.
The Emergency Medical Technician adheres to standards of personal ethics which reflect credit upon the profession.
Emergency Medical Technicians, or groups of Emergency Medical Technicians, who advertise professional services, do so in
conformity with the dignity of the profession.
The Emergency Medical Technician has an obligation to protect the public by not delegating to a person less qualified, any
service which requires the professional competence of an Emergency Medical Technician.
The Emergency Medical Technician will work harmoniously with and sustain confidence in Emergency Medical Technician
associates, the nurse, the physician, and other members of the Emergency Medical Services health care team.
The Emergency Medical Technician refuses to participate in unethical procedures, and assumes the responsibility to expose
incompetence or unethical conduct of others to the appropriate authority in a proper and professional manner.
A paramedic functions
Table 3-1 Attributes of a Health Care Professional Content Review
as an extension of the sys-
➤➤ Professional Attributes
Respects the patient tem’s medical director,
• Leadership
with authority delegated
Provides quality patient care • Integrity
by the medical director.
• Empathy
Advocates for the patient (and the family) Because you may be prac- • Self-motivation
Instills pride in the profession ticing in an area that is • Professional appearance
remote from your medical and hygiene
Strives for high standards and has a commitment to excellence
director, you will be • Self-confidence
Earns respect of others depended on to follow • Communication skills
Minimizes pain and suffering protocols and accurately • Time-management skills
document all patient care. • Diplomacy in teamwork
Places patient safety above all but personal safety
• Respect
Maintains a professional image and behavior Empathy • Patient advocacy
Successfully interacting • Careful delivery of
Is an excellent time manager
service
with a patient and family is
Works well with other team members
a challenging skill to mas-
ter. One of the most important components is empathy. To
have empathy is to identify with and understand the cir-
The successful team leader knows the members of the cumstances, feelings, and motives of others. To be consid-
crew, including each one’s capabilities and limitations. Ask ered a professional, you will often have to place your own
crew members to do something beyond their capabilities feelings aside to deal with others, even when you are hav-
and they will question your ability to lead, not their ability ing a bad day. Paramedics who act in a professional man-
to perform.11 ner can show empathy by:
Figure 3-7 As leader of the EMS team, the paramedic must interact Appearance and Personal Hygiene
with patients, bystanders, and other rescue personnel in a professional Society has high expectations for everyone in the allied
and efficient manner. health professions. From the moment you arrive at the
54 Chapter 3
scene of an emergency, you are being judged by the way Time Management
you present yourself. Good appearance and personal Good time management skills are important to the para-
hygiene are critical. If you do not look like a health care medic. The experienced paramedic who plans ahead, pri-
provider, then your patient may feel you must not be one. oritizes tasks, and organizes them to make maximum use
If you have a sloppy appearance, your patient may suspect of time will generally be more effective in the field. A para-
that your medical care will be sloppy, too. Using slang, medic with good time management skills is punctual for
foul, abusive, or off-color language is not acceptable and shifts and meetings and completes tasks such as paper-
will alienate you from your patients. Your appearance, as work and maintenance duties on or ahead of schedule.
well as your behavior, is vital to establishing credibility Some simple time management techniques that you
and instilling confidence. can use are making lists, prioritizing tasks, arriving at
A paramedic should always wear a clean, pressed meetings or appointments early, and keeping a personal
uniform and should always be well groomed. Hair calendar. By implementing just one or two of these tech-
should be kept off the collar. If facial hair is allowed, it niques, you may find your schedule to be more manage-
should be kept neat and trimmed. A light-colored t-shirt able and less stressful.
may be worn under your uniform shirt, which should be
buttoned up, with only the top collar button open. Jew- Teamwork and Diplomacy
elry—other than a wedding ring, a watch, or small plain The paramedic is a leader. Leadership implies the ability
earrings—is unprofessional. Long fingernails that have to work with other people—to foster teamwork. Team-
the potential to puncture protective gloves also should work requires diplomacy, or tact and skill, in dealing with
be avoided. people, even when you are under siege from the patient or
family.
Self-Confidence Diplomacy requires the paramedic to place the interest
Having confidence in yourself and your abilities is very of the patient or team ahead of his own interests. It means
important. The patient and family will not trust you if they listening to others, respecting their opinions, and being
sense you do not trust yourself. A lack of self-confidence open-minded and flexible when it comes to change. A
shows and is the basis of many lawsuits. The easiest way to strong leader of any team realizes that he will be successful
gain self-confidence is to accurately assess your strengths only if he has the support of all team members. A confident
and limitations, and then seek every opportunity to leader will do the following:
improve any weaknesses. Also, keep in mind that self-con-
fidence does not equal cockiness. A self-confident para- • Place the success of the team ahead of personal self-
medic who is presented with a complex situation will ask interests
for assistance. • Never undermine the role or opinion of another team
member
Communication • Provide support for members of the team, both on and
Communication is a skill often underestimated in EMS off duty
services. Providing emergency care in the out-of-hospital
• Remain open to suggestions from team members and
environment requires constant communication with the
be willing to change for the benefit of the patient
patient, family, and bystanders, as well as with other EMS
providers and rescuers from other public agencies. • Openly communicate with everyone
To be an effective communicator, the paramedic • Above all, respect the patient, other care providers,
should remember to gather all patient information and and the community he serves
present it in a clear and concise format. Speaking clearly,
listening actively, and writing legibly are obviously very Respect
important skills. Remember, too, to speak in a way that To respect others is to show—and feel—deferential regard,
is appropriate for your audience. For example, just as consideration, and appreciation for others. A paramedic
you would not refer to a laceration as a “booboo” when respects all patients, and provides the best possible care to
consulting with a physician, you should not use compli- each and every one of them, no matter what their race, reli-
cated medical terminology to explain a procedure to an gion, sex, age, or economic condition. Showing that you
injured child. care for a patient’s or family member’s feelings, being
Being able to adjust your communication strategies to polite, and avoiding the use of demeaning or derogatory
various situations is also an important skill. For example, language toward even the most difficult patients are sim-
learning a manual alphabet (sign language) or learning ple ways to demonstrate respect. By demonstrating respect,
simple medical questions in foreign languages common in you will earn credit for yourself, your service, and the EMS
your area are just two ways to prepare yourself. profession.
Roles and Responsibilities of the Paramedic 55
Patient Advocacy the proper care in the proper setting. Most EMS agencies
A paramedic is also an advocate for patients—defending have adopted or developed continuous quality improve-
them, protecting them, and acting in their best interests. ment (CQI) programs to identify and correct substandard
For example, as a paramedic you should not allow your patient care.
personal biases (religious, ethical, political, social, or
legal) to interfere with proper emergency care of your Continuing Education
patients. Except when your safety is threatened, you
Maintaining certification is the responsibility of the para-
should always place the needs of your patient above your
medic. Most paramedics use continuing education pro-
own self-interests. In addition, always keep a patient’s
grams to develop further knowledge or skills in a particular
health care information confidential. (Refer to the chap-
area of emergency health services. This type of education is
ters “Medical/Legal Aspects of Emergency Care” and
most often acquired by attending lectures, seminars, con-
“Ethics in Emergency Medical Services” for details about
ferences, and demonstrations. Each state, region, and local
patient confidentiality.)
system may have its own policies, regulations, and proce-
dures for recertification. Paramedics cannot work without
Careful Delivery of Service
satisfying those requirements.
Professionalism requires the paramedic to deliver the high-
There are many benefits to participating in as much
est quality of patient care with very close attention to
continuing education as possible. The most obvious is the
detail. Examples of behaviors that demonstrate a careful
expansion of the paramedic’s own personal knowledge
delivery of service include:
and skills. Another important reason is to keep up with an
• Mastering and refreshing skills emergency health care delivery system that is constantly
• Performing complete equipment checks being updated with more technologically advanced equip-
• Careful and safe ambulance operations ment and procedures.
Finally, the skills you learn in this course will need to
• Following policies, procedures, and protocols
be practiced. Continuing education programs provide the
Review of individual performance—and attitude—is opportunity to review material and address weak points in
also important in ensuring that all patients are receiving patient care.
Summary
To become a paramedic, you must be willing to accept the responsibility of being a leader in the
prehospital phase of emergency medical care. Your responsibilities include on-call emergency
duties and off-duty preparation. When the emergency call comes in, you must already be pre-
pared to respond. If not, you are likely to be too late.
Most of your time as a paramedic will be spent on preparing yourself to do the job properly—
not providing emergency care. If you can accept this reality, and if you are willing to undertake the
responsibility of preparing for this dynamic occupation, then you are ready to proceed with your
education. Remember: The best paramedics are those who make a commitment to excellence.
him. As soon as you and your partner get out of the unit, the son runs to you and starts yelling,
“Hurry!” and “Just get him to the hospital!”
While you are performing a primary assessment of the patient, the son continuously exclaims,
“Just load my father and get him to the damn hospital!” In 2 minutes, the primary assessment is
complete. Because of the cold weather, you decide to move the patient into the unit. Once inside
the ambulance, you quickly complete the history and physical exam and begin to treat the patient.
Meanwhile, the patient’s wife and son are outside the ambulance yelling at your partner, “Leave
immediately, or we’ll sue you!” Your partner attempts to calm them, but is unsuccessful.
After assessing the patient and connecting him to the monitor, you open the door and ask the
family if they are going to ride in the ambulance to the hospital. Mrs. Yates tells you that she will,
and she attempts to enter the unit. She is stopped by your partner, who explains that if she is going
to ride with the ambulance, she must ride up front in the passenger seat. She immediately and
loudly protests. At this point, you ask your partner to sit with the patient. You exit the unit as your
partner enters, and you close the unit door. You quickly but calmly explain to Mrs. Yates that First
Response Ambulance Service has a policy that requires her to ride in a seat with a seat belt in place,
and that the passenger seat is the only seat available. After you explain that during the transport
you will keep her updated on her husband’s condition, she reluctantly gets into the front seat.
While en route to the hospital, you establish an IV, administer nitroglycerin and aspirin, run
numerous ECG strips, and maintain a close watch on the patient’s vital signs. Every few minutes
you stick your head up front to inform Mrs. Yates about her husband’s condition. About 10 min-
utes from the hospital, you consult with the emergency department, providing an estimated time
of arrival, the patient’s medical history, and the patient’s current status.
On arrival, your partner assists you in unloading the patient. After allowing her to talk with
her husband, your partner escorts Mrs. Yates to the hospital waiting area. In the emergency depart-
ment, you provide the hospital staff with a verbal report and assist them in moving the patient to
a stretcher. Then you give a copy of the run report to the unit clerk who is responsible for placing
it on the patient’s chart. You then walk to the waiting area, where you find Mrs. Yates and her son.
You take a minute to tell them that Mr. Yates is now in the care of Dr. Zimmer, and that he or one of
the staff members will be out to speak with them as soon as an assessment is completed.
You and your partner meet outside the hospital and prepare the unit for the next call. The
stretcher is made up, and the unit is cleaned and restocked. While driving back to the station, you
discuss the difficulty you both had dealing with Mrs. Yates and her son.
1. What were your key responsibilities in the previously detailed scenario?
2. How should you have prepared yourself mentally and physically for this call?
3. Did you and your partner act professionally? Explain how you did or did not.
See Suggested Responses at the back of this book.
Review Questions
1. During an emergency response, remember that 3. ___________ is the ability to identify with and under-
___________ ___________ is your number one priority. stand the needs, motives, and emotions of others..
a. patient care a. Empathy
b. personal safety b. Sympathy
c. documentation c. Ethics
d. medical direction d. Equality
2. The force or forces that caused an injury define the 4. A ___________ trauma center provides the highest
_____________ level of trauma care.
a. nature of illness. a. Level I
b. chief complaint. b. Level II
c. mechanism of injury. c. Level III
d. primary illness. d. Level IV
Roles and Responsibilities of the Paramedic 57
5. Maintaining a complete and accurate written patient 7. The term ___________ refers to the conduct or quali-
care report is essential to __________________ ties that characterize a practitioner in a particular
a. research efforts. field or occupation.
b. the flow of patient information. a. licensure
c. the quality improvement of EMS systems. b. registration
d. all of the above. c. professionalism
d. certification
6. Nontraditional careers for paramedics include
________________ 8. ___________ are the rules or standards that govern
a. working in the primary care setting. the conduct of members of a particular group or pro-
b. providing emergency care on offshore rigs. fession.
References
1. U.S. Department of Transportation/National Highway Traffic 7. Lerner, E. B., A. R. Fernandez, and M. N. Shah. “Do Emer-
Safety Administration. National EMS Scope of Practice Model. gency Medical Services Professionals Think They Should
Washington, DC, 2006. Participate in Disease Prevention?” Prehosp Emerg Care 13
2. National Registry of Emergency Medical Technicians. 2004 (2009): 64–70.
National EMS Practice Analysis. Columbus, OH: National 8. Poliafico, F. “The Role of EMS in Public Access Defibrillation.”
Registry of EMTs, 2005. Emerg Med Serv 32 (2003): 73.
3. American College of Surgeons. Verified Trauma Centers. (Available 9. Streger, M. R. “Professionalism.” Emerg Med Serv 32 (2003): 35.
at http://www.facs.org/trauma/verified.html.) 10. Klugman, C. M. “Why EMS Needs Its Own Ethics. What’s Good
4. Feldman, M. J., J. L. Lukins, P. R. Verbeek, et al. “Use of Treat- for Other Areas of Healthcare May Not Be Good for You.” Emerg
and-Release Directives for Paramedics at a Mass Gathering.” Med Serv 36 (2007): 114–122.
Prehosp Emerg Care 9 (2005): 213–217. 11. Touchstone, M. “Professional Development. Part 1: Becoming an
5. American College of Emergency Physicians. “Interfacility Trans- EMS Leader.” Emerg Med Serv 38 (2009): 59–60.
portation of the Critical Care Patient and Its Medical Direction.” 12. Bledsoe, B. E. “EMS Needs a Few More Cowboys.” JEMS 28
Ann Emerg Med 47 (2006): 305. (2003): 112–113.
6. Harkins, S. “Documentation: Why Is It So Important?” Emerg
Med Serv 31 (2002): 93–94.
Further Reading
Bailey, E. D. and T. Sweeney. “Considerations in Establishing Emer- Washington, DC: U.S. Department of Health, Education, and
gency Medical Services Response Time Goals.” Prehosp Emerg Welfare, 1966.
Care 7 (2003): 397–399. Page, J. O. The Magic of 3 AM. San Diego, CA: JEMS Publishing, 2002.
Bledsoe, B. E. “Searching for the Evidence behind EMS.” Emerg Med Page, J. O. The Paramedics. Morristown, N.J.: Backdraft Publica-
Serv 31 (2003): 63–67. tions, 1979. [No longer available for purchase except as a used
Heightman, A. J. “EMS Workforce. A Comprehensive Listing of book. Entire book can be viewed online at www.JEMS.com/
Certified EMS Providers by State and How the Workforce Has Paramedics.]
Changed Since 1993.” JEMS 5 (2000): 108–112. Page, J. O. Simple Advice. San Diego, CA: JEMS Publishing, 2002.
Jaslow, D. J., J. Ufberg, and R. Marsh. “Primary Injury Prevention in Persse, D. E., C. B. Key, R. N. Bradley, et al. “Cardiac Arrest Survival
an Urban EMS System.” J Emerg Med 25 (2003): 167–170. as a Function of Ambulance Deployment Strategy in a Large
National Academy of Sciences, National Research Council. Acciden- Urban Emergency Medical Services System.” Resusc 59 (2003):
tal Death and Disability: The Neglected Disease of Modern Society. 97–104.
Chapter 4
Workforce Safety
and Wellness Bryan Bledsoe, DO, FACEP, FAAEM
Standard
Preparatory (Workforce Safety and Wellness)
Competency
Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical–legal and
ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to select behaviors that promote EMS
workforce safety and wellness.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this 7. Discuss various patient, family, and EMS
chapter. provider responses to death and dying.
2. Explain the importance of preventing EMS 8. Explain the pathophysiology of stress,
workforce injuries and illnesses. including stressors, phases of the stress
response, signs and symptoms, and
3. Describe the role and elements of basic
consequences of prolonged exposure to
physical fitness and nutrition in EMS stressors.
workforce safety and wellness.
9. Describe effective stress management
4. Explain the consequences of addictions and strategies the EMS provider can employ.
unhealthy habits as it pertains to the EMS
provider. 10. Discuss post-traumatic stress disorder
(PTSD) as it relates to EMS providers and
5. Discuss techniques to ensure good back the role of mental health services.
strength, and identify work habits that
11. Given a variety of scenarios, take steps to
minimize the risk of back injuries.
protect your personal safety, including
6. Given a variety of scenarios, select proper effective interpersonal relationships and
Standard Precautions for infection control. roadway safety precautions.
58
Workforce Safety and Wellness 59
Key Terms
anchor time, p. 76 incubation period, p. 65 post-traumatic stress
burnout, p. 76 infectious disease, p. 65 disorder, p. 77
Case Study
Howard is a 15-year veteran of a high-volume, inner- sensitivity, patience, and gentleness. “Howard is the
city EMS service. When he first started his career, How- man I’d want to tell bad news to my mother,” one of his
ard thought he knew what he was getting into, but the partners says. “He can handle people involved in just
years have taught him differently. about any circumstance—death situations, panicked
Right now, Howard is in the spotlight for saving the parents, lonely elderly people, and even hostile drunks.
life of a police officer who was shot in a hostage situa- I’ve never seen anyone treat others with such dignity
tion. “That call forced me to reflect on a few important and respect. He’s the best partner anyone could want,
things,” he says. “Two years ago, I had a minor heart especially when we have to manage patients who are
problem, and it was a good wake-up call. Since then I’ve thrashing around. But that was not always so, was it,
been lifting weights and running, so I was able to get to Howard?”
the officer with enough strength to carry him to safety. “No, it wasn’t,” Howard replies. “There was a time
“Another thing is that I always use personal protec- when no one wanted to work with me. I was a rebel,
tive equipment. I never go to work without steel-toed and I figured there was only one way to do things: my
boots and I never leave the ambulance without a pair of way. But an incident that occurred a few years ago
disposable gloves. Can you believe there are still para- changed all that. It’s a long story. But the upshot is that
medics who knock the concept of infection control? If when I recovered from the stress, my outlook had been
any one of my partners sticks a needle into the squad altered. I realized that though I couldn’t save the world,
bench in my ambulance, they know I’ll speak up.” I could save myself. That’s when I learned how to deal
Howard, a mild-mannered, nondescript man, with the effects of a stressful job. I started eating right,
doesn’t realize that his young colleagues regard him lost a lot of weight, and adopted a new attitude. Any-
as a role model. They’ve seen him handle himself at way, if I can maintain my own well-being, I can do a lot
chaotic scenes as well as when a situation demands more to help others. Right? Isn’t that what we’re about?”
Introduction and insidious infections. If you let your spirit appreciate the
fear and sadness on other faces, you will find ways to combat
The safety and well-being of the workforce is a fundamen- your prejudices and treat people with dignity and respect. By
tal aspect of top-notch performance in EMS.1 As a para- doing all these things, you will also be able to promote the
medic, it includes your physical well-being as well as your benefits of well-being to your EMS colleagues.
mental and emotional well-being. If your body is fed well Death, dying, stress, injury, infection, fear—all these
and kept fit, if you use the principles of safe lifting, observe threaten your wellness and conspire to interfere with your
safe driving practices, and avoid potentially addictive and good intentions. However, you can do something about
harmful substances, you stand a chance of having the them. Each person has choices about how to live. Every
physical strength and stamina to do the job. choice has outcomes and consequences. Many patients in
If you seize the information about safe practices and nursing homes are living with their choices, paying for life-
apply them to your life, you will be better able to avoid harm style decisions made decades ago when they were about
from violent people, roadway hazards, ambulance accidents, your age. Is that what you want for yourself?
60 Chapter 4
Most paramedic injuries are caused by lifting and the provider ’s circadian rhythms, causing sleepiness,
being in and around motor vehicles. Those who train to be mental clouding, and lack of energy.2 These factors can
physically prepared for their jobs as paramedics stand a contribute to injury and increase the likelihood of pro-
better chance of avoiding early forced retirement because vider injury and illness.3
of injured backs or knees. Those who train themselves to In addition to sleep, nutrition and physical fitness play
be mentally alert in the ambulance and at roadway scenes a role in long-term survival in EMS. Although the fire ser-
stand a better chance of staying alive and uninjured. Those vice has long embraced physical fitness, it has only recently
who can inspire their colleagues to work toward a state of been emphasized in EMS. Obese EMS providers caring for
well-being are role models of the highest order. and lifting obese patients is a disaster waiting to happen.
This chapter introduces the many elements of well- As EMS providers, it is time we embrace a healthy lifestyle.
being. If you listen now and enhance your knowledge However, this decision is one that must be made by each
later, you stand a good chance of enjoying a long and individual.
rewarding career of helping others—all because you
helped yourself.
Injuries ers, researchers found that many EMS providers were sig-
nificantly overweight. This and a lack of general physical
Fortunately, in the twenty-first century there has been a fitness were associated with an increase in back injuries.4
renewed interest in EMS provider safety and injury pre- Another study found that physical fitness and satisfaction
vention. Studies have shown that ambulance collisions are with current job assignment were modifiable risk factors
a major source of injury for paramedics. Strategies to mini- associated with improvement of back health among EMS
mize this have included improving the structural integrity personnel.5
and crashworthiness of emergency vehicles. In addition, The benefits of achieving acceptable physical fitness
restraint systems are now available to secure paramedics in are well known. They include a decreased resting heart
the patient compartment while the vehicle is in motion. rate and blood pressure, increased oxygen-carrying
Because many ambulance accidents occur when emer- capacity, increased muscle mass and metabolism, and
gency lights and sirens are in use, protocols and call screen- increased resistance to illness and injury. Exercise also
ing schemes have been devised to limit the need for these slows the progression of osteoporosis, a condition that
types of responses to patients who actually have a time- affects women more often than men. Quality of life is
critical condition. enhanced by physical fitness, too, because of the ability to
The physical act of lifting and moving patients can do more, and there are positive correlations among fit-
injure paramedics—especially given the current obesity ness, personal appearance, and self-image. Other benefits
epidemic in North America. Fortunately, power-lift stretch- of physical fitness are improved mental outlook and
ers are now widely available. However, in many cases, reduced anxiety levels. Finally, a physically fit body
paramedics must still lift patients onto the stretcher and lift enhances a person’s ability to maintain sound motor skills
the stretcher into the ambulance. Then, once at the hospi- throughout life.
tal, they must lift the stretcher from the ambulance and
Content Review
move it to the ground. Finally, at the bedside, the crew
must help move the patient to the hospital bed. Sometimes Core Elements ➤➤ Basics of Physical
Fitness
these lifts and moves are awkward and can result in injury Core elements of physical
• Cardiovascular
to the provider. Specialized bariatric ambulances with fitness are muscular
endurance
large stretchers, a ramp, and a mechanical winch can help strength, cardiovascular • Strength and flexibility
to move morbidly obese patients fairly safely. Properly and endurance (aerobic capac- • Nutrition and weight
safely lifting and moving patients is an essential provider ity), and flexibility. As with control
skill—regardless of level of training. a three-legged stool, if any • Freedom from addictions
Historically, many EMS systems have placed person- one of the three is defi- • Back safety
nel on long shifts, often 24 hours or more, to ensure cient, the whole becomes ➤➤ Eat well, stay fit, and avoid
24-hour emergency coverage. However, as the volume of unstable. Each is equally addictive and harmful
EMS calls continues to rise, many paramedics are finding important. substances so you have
themselves physically and mentally tired long before their Be careful about plung- the strength and stamina
to do your job.
shift is over. The lack of sleep has also been found to affect ing into a well-intended but
Workforce Safety and Wellness 61
misguided effort to get into shape. For example, before Flexibility seems to be the forgotten element of fitness.
starting an exercise or stretching regimen, it can be help- Without an adequate range of motion, your joints and
ful to measure your current state of fitness. There are var- muscles cannot be used efficiently or safely. A body builder
ious methods of assessing the three core elements of with tight hamstrings may be as much at risk for back
fitness. Many EMS agencies have access to facilities where injury as anyone else. To achieve (or regain) flexibility,
precise assessment methods—with trained personnel— stretch the main muscle groups regularly. Try to stretch
are available. Take advantage of any information avail- daily. Never bounce when stretching; this causes micro
able to you. tears in muscle and connective tissues. Hold a stretch for at
Muscular strength is achieved with regular exercise least 60 seconds. A side benefit of good flexibility is pre-
that trains muscles to exert force and build endurance. vention or reduction of back pain. Stretching is an excellent
Exercise may be isometric or isotonic. Isometric exercise is TV-time activity. If you are interested, consider studying
active exercise performed against stable resistance, where yoga for improved flexibility.
muscles are exercised in a motionless manner. Isotonic
exercise is active exercise during which muscles are
worked through their range of motion. Take time to get in-
Nutrition
depth information about the best approach from a trainer It is a myth that people in EMS cannot maintain an ade-
or other knowledgeable person. quate diet. Even so, the “hit-and-run” nature of emergency
Weight lifting is an obvious way to achieve muscular care requires planning and awareness of your options. The
strength, and it is excellent all-around training for the body. most difficult part of improving nutrition is altering estab-
You can vary the amount of weight lifted, the number of lished bad habits. A change in your behavior requires some
times it is lifted, and the frequency of the demands on the commitment and self-discipline, understanding the change
muscle. Whatever type of strength-building exercise is best process, and patience with what will become long-term
for you, consider rotating between training the muscles of self-improvement. Set realistic goals, and understand that
your upper body and shoulders, muscles of the chest and backsliding happens. Whatever your goals may be, such as
back, and muscles of the lower body. Do abdominal exer- reducing excess weight, gaining weight, or regularly eat-
cises daily. ing more wholesome foods, it is helpful to be able to ana-
Cardiovascular endurance results from exercising at lyze your progress by using charts or daily intake tallies.
least three days a week vigorously enough to raise your
pulse to its target heart rate (Table 4-1). Many people shy
away from aerobic exercise, thinking the effort will be too
Patho Pearls
great or the results will take too long. However, there is no Obesity. Obesity has become a major problem in the United
need to become a marathon runner to gain aerobic capac- States and other industrialized countries. EMS personnel are
ity. Try a brisk walk or ride a stationary bike while watch- not immune to this trend. In fact, EMS personnel are becoming,
ing TV. Make it a daily habit. on the average, progressively more overweight. There are sev-
eral factors inherent in EMS that can contribute to obesity. First,
Even modest exercise programs, which can be done
much of EMS work is sedentary. A great deal of time is spent
most days of the week, will improve cardiovascular endur-
seated in an ambulance or in a station. Second, physical activity
ance and muscular strength. Walking briskly from the
on the job is usually limited to short periods of sometimes
outer reaches of the employee parking lot, using stairs intense effort. Although these periods of work can be strenu-
whenever possible, and playing actively with your chil- ous, they seldom last long enough to provide any significant
dren can all “count” toward physical fitness. degree of exercise. Third, the duties of the job often require
EMS personnel to “eat on the run,” which often means relying
on fast food or processed food. These meals provide plenty of
Table 4-1 Finding Your Target Heart Rate “empty calories” and contribute significantly to obesity.
1. Measure your resting heart rate. (You will use this total later.) Obesity can lead to numerous health problems, such as back
pain, and can place paramedics at increased risk of sustaining a
2. Subtract your age from 220. This total is your estimated maximum
back injury. Obesity can also lead to cardiovascular disease, dia-
heart rate.
betes, and other long-term chronic problems. As an EMS profes-
3. Subtract your resting heart rate from your maximum heart rate, and sional, you must recognize that, to provide the best care for your
multiply that figure by 0.7.
patients—and to provide a good role model for your patients
4. Add the figure you just calculated to your resting heart rate. and the public—you must first care for yourself. This includes
watching your weight, finding ways to eat a reasonable diet, and
EXAMPLE: For a 44-year-old woman whose resting heart rate is 52, her
maximum heart rate would be 176 (220 – 44). Her maximum heart rate obtaining an adequate amount of exercise. More and more EMS
minus resting heart rate is 124 (176 – 52). Multiply 124 by 0.7 for a value of employers are recognizing the obesity epidemic and are develop-
86.8. The resting heart rate plus the calculated figure is 138.8 (52 + 86.8). ing employee assistance and physical fitness programs designed
Rounded up, this person’s target heart rate is 140 beats per minute.
to minimize the chances of obesity cutting an EMS career short.
62 Chapter 4
Pelvis is slightly
tucked forward.
Hepatitis B, C Blood, stool, or other body fluids, or contaminated objects. Weeks or months
Pneumonia, bacterial and viral Oral and nasal droplets and secretions. Several days
Staphylococcal skin infections Contact with open wounds or sores or contaminated objects. Several days
Chicken pox (varicella) Airborne droplets, or contact with open sores. 11 to 21 days
German measles (rubella) Airborne droplets. Mothers may pass it to unborn children. 10 to 12 days
SARS (severe acute respiratory Airborne droplets and personal contact. 4 to 6 days
syndrome)
Standard Precautions
Standard Precautions are strategies that include the major
features of what were once called universal precautions
(UP)—blood and body fluid precautions designed to
reduce the risk of transmission of bloodborne pathogens—
and body substance isolation (BSI)—precautions designed
to reduce the risk of transmission of pathogens from moist
body substances. Standard Precautions apply UP and BSI
concepts to all patients receiving care regardless of their
diagnosis or presumed infection status. Standard Precau-
tions apply to:
• Blood
• All body fluids, secretions, and excretions except sweat, Figure 4-6a To remove gloves, first hook the gloved fingers of one
regardless of whether or not they contain visible blood hand under the cuff of the other glove. Then pull that glove off with-
out letting your gloved fingers come in contact with bare skin.
• Nonintact skin
• Mucous membranes
Figure 4-7 Proper gloves, mask, and eyewear prevent a patient’s blood and body fluids from contacting a break in your skin or spraying into
your eyes, nose, or mouth. (A) Combined mask and eye shield; (B) Mask and protective eyewear.
skin or mucous membranes in, for example, the eyes, nose, with thumb hooks are not available, personnel may
or mouth) by direct contact with: consider taping the sleeve of the gown or coverall over
the inner glove to prevent potential skin exposure from
• Blood or body fluids (including but not limited to urine,
separation between sleeve and inner glove during activ-
saliva, sweat, feces, vomit, breast milk, and semen) of a
ity. However, if taping is used, care must be taken to
person who is sick with or has died from EVD
remove tape gently. Experience in some facilities sug-
• Objects (such s needles and syringes) that have been gests that taping may increase risk by making the doff-
contaminated with body fluids from a person who is ing process more difficult and cumbersome.
sick with EVD or the body of a person who has died
• Single-use (disposable) nitrile examination gloves with
from EVD
extended cuffs. Two pairs of gloves should be worn. At a
• Infected fruit bats or primates (apes and monkeys) minimum, outer gloves should have extended cuffs.
• Possibly, semen from a man who has recovered from • Single-use (disposable), fluid-resistant or imperme-
EVD (for example, by having oral, vaginal, or anal sex). able boot covers that extend to at least mid-calf or
Standard PPE alone is not sufficient to ensure protec- single-use (disposable) shoe covers. Boot and shoe
tion from EVD. For protection from possible EVD the PPE covers should allow for ease of movement and not
must be such that no skin is exposed. Recommended PPE present a slip hazard to the worker.
for EVD includes: • Single-use (disposable) fluid-resistant or impermeable
shoe covers are acceptable only if they will be used in
• PAPR (powered air purifying respirator) or N95 respi-
combination with a coverall with integrated socks.
rator. If a NIOSH-certified PAPR and a NIOSH-certified
disposable N95 respirator are used in local protocols, • Single-use (disposable), fluid-resistant or imperme-
ensure compliance, including fit testing, medical evalu- able apron that covers the torso to the level of the
ation, and training of the health care worker. mid-calf should be used if patients with EVD have
vomiting or diarrhea. An apron provides additional
• PAPR: PAPR with a full face shield, helmet, or head-
protection against exposure of the front of the body to
piece. Any reusable helmet or headpiece must be cov-
body fluids or excrement. If a PAPR will be worn, con-
ered with a single-use (disposable) hood that extends
sider selecting an apron that ties behind the neck to
to the shoulders, fully covers the neck, and is compat-
facilitate easier removal during the doffing procedure.
ible with the selected PAPR. The facility should follow
the manufacturer’s instructions for decontamination The CDC provides recommendations for PPE protec-
of all reusable components and, based on those tion levels for EMS personnel based on a threat level deter-
instructions, develop local protocols that include the mined by two major factors:
designation of responsible personnel who ensure that • The PPE wearer’s possible exposure to Ebola
the equipment is appropriately reprocessed and that
• Proximity to symptomatic patients (Table 4-3)
batteries are fully charged before reuse.
• A PAPR with a self-contained filter and blower
unit integrated inside the helmet is preferred. Table 4-3 Ebola PPE Protection
• A PAPR with an external belt-mounted blower Patient’s Ebola
unit requires adjustment of the sequence for Exposure Level Definition
donning and doffing. Known or suspected Known disease, known contact with Ebola
exposure patient or travel within 21 days to an area with
• N95 Respirator: Single-use (disposable) N95 respi- current Ebola cases
rator in combination with single-use (disposable)
Possible exposure Environmental or interpersonal exposure in an
surgical hood extending to shoulders and single- area with suspect or recent cases, except as
use (disposable) full face shield. If N95 respirators outlined in previous box
are used instead of PAPRs, careful observation is No known exposure No known exposure to EVD patients or travel
required to ensure that health care workers are not to areas with a known outbreak of the disease
Bloodborne Infection
Airborne Infection
Such as HIV (AIDS virus)
Such as TB (Tuberculosis)
or HBV (Hepatitis B virus)
You transport a patient who is infected You come into contact with blood or
with a life-threatening airborne disease, body fluids of a patient, and you
such as TB, but you are not aware that wonder if that patient is infected with a
the patient is infected. life-threatening bloodborne disease
such as HIV or HBV.
The medical facility diagnoses the You seek immediate medical attention
disease in the patient you transported. and document the incident for worker’s
compensation.
The medical facility must notify your You ask your designated officer to
designated officer within 48 hours. determine if you have been exposed to
an infectious disease.
Your designated officer notifies you that Your designated officer (DO) must gather
you have been exposed. information and, if DO determines it is
warranted, consult the medical facility
to which the patient was transported.
Your employer arranges for you to be The medical facility must gather
evaluated and followed up by a doctor information and report findings to your
or other appropriate health care designated officer within 48 hours.
professional. Your DO notifies you of the findings.
Figure 4-11 A federal regulation called the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act outlines procedures to
follow after an occupational exposure to human immunodeficiency virus (HIV), hepatitis B, diphtheria, meningitis, plague, hemorrhagic fever,
rabies, and tuberculosis.
Ages 3 to 6 Believes death is a temporary state, and may ask continually Emphasize that the child was not responsible for the death.
when the person will return. Believes in magical thinking, and Reinforce that when people are sad, they cry, and that crying is
may feel responsible for the death or that it is punishment for own normal and natural.
behavior. May be fearful of catching the same illness and die, or
may believe that everyone else he loves will die also.
Watch for changes in behavior patterns with friends and at Encourage the child to talk about and/or draw pictures of his
school, difficulty sleeping, and changes in eating habits. feelings, or to cry.
Ages 6 to 9 May prefer to hide or disguise feelings to avoid looking babyish. Talk about the normal feelings of anger, sadness, and guilt.
Is afraid significant others will die. Seeks out detailed explanations Share your own feelings about death.
for death, and differences between fatal illness and “just being
sick.” Has an understanding that death is real, but may believe Do not be afraid to cry in front of the child. This and other
that those who die are too slow, weak, or stupid. Fantasizes in expressions of loss help to give the child permission to express
an effort to make everything the way it was. Denial is the most his feelings.
helpful coping skill.
Ages 9 to 12 Begins to understand the irreversibility of death. May seek details Set aside time to talk about feelings.
and specifics of the situation, and may need repeated, explicit Encourage sharing of memories to facilitate grief response.
explanations. Hard-won sense of independence becomes
fragile, and may show concern about the practical matters of his
lifestyle. May try to act “adult,” but then regress to earlier stage of
emotional response. When threatened, expresses anger toward
the ill/deceased, himself, or other survivors.
Ages 12 to 18 Demanding developmental processes are an awkward fit with Encourage talking, but respect need for privacy.
the need to take on different family roles. Retreats to safety of See if a trusted, reliable friend or adult can provide appropriate
childhood. Feels pressure to act as an adult, while still coping support.
with skills of a child. Suppresses feelings in order to “fit in,”
leaving teen isolated and vulnerable. Locate support group for teens.
There are a wide variety of responses to death among dif- or five) to step aside with you to a private place. Let them
ferent peoples and cultures as well. Be flexible, and be tell the others in their own way.
ready for anything. Find out who is who among the survivors. Do not
make assumptions. Then address the closest survivor, pref-
erably in a way that shows compassion. That is, avoid
What to Say standing above the survivor. Instead, sit or squat so that
As “Do Not Resuscitate” orders and other out-of-hospital your eyes are at the same level. If the survivor is alone, call
death situations increase, EMS personnel are more often for a friend, neighbor, clergy member, or relative. If possi-
placed in the position of telling people that someone has ble, wait to tell the survivor the news until that person has
died. It would be nice to have a script for those difficult arrived.
moments, but the reality is that you have to assess the Introduce yourself by name and function (“My name
scene and the people in each situation to determine the saf- is Kate. I’m a paramedic with MedicWest EMS.”) A careful
est and most compassionate way to deliver the sad news. choice of words is helpful. Although it may seem blunt, use
In terms of safety, you never know how people will the words “dead” and “died,” rather than euphemisms
respond, even if you know them. Most people accept the that may be misinterpreted or misunderstood. Use gentle
news quietly. However, some allow their grief to flood out eye contact and, if appropriate, the comforting power of
of them in very physical ways, such as throwing things, touching an arm or holding a hand. Basic elements of your
kicking walls, screaming, or running in circles. Before message should include the following:
speaking to any survivors, consciously position yourself
• A loved one has died.
between them and the door or other escape route. Remem-
ber, initially the grief spike has its grip on the survivors. • There is nothing more anyone could have done.
There is little you can do but give them a safe, private place • You and your EMS service are available to assist the
to get through it. Also, for safety, do not deliver the news to survivors if needed. (Sometimes, medical emergencies
a large group. Ask the primary people (no more than four occur in survivors in the wake of such stressful news.)
74 Chapter 4
ar
Al
us
tio
and exhaustion. At the end there may be a period of rest and Stress baseline
recovery. Rest/Recovery
• Stage I: Alarm. The alarm phase is the “fight-or-flight” Figure 4-12 Phases of stress response.
phenomenon. It occurs when the body physically and (Adapted from J. Mitchell and G. Bray’s Emergency Services Stress. Englewood Cliffs,
rapidly prepares to defend itself against a perceived NJ: Prentice Hall, 1990, p. 11)
76 Chapter 4
Common Techniques Say “no!” to the next offer of an overtime shift. Listen to
music, meditate, and learn positive thinking. Try the sooth-
for Managing Stress ing techniques of guided imagery and progressive relax-
There are two main types of defense mechanisms and tech- ation. Some paramedics have even quit EMS for a while. In
niques for managing stress: beneficial and detrimental. general, you have many choices. The key principle is to
Detrimental techniques may provide a temporary sense of generate positive options for yourself, and keep choosing
relief, but they will not cure the problem. In fact, they make them until you have recovered.
things worse. They include substance abuse (alcohol, nico-
tine, illegal and prescription drugs), overeating or other
compulsive behaviors, chronic complaining, freezing out Specific EMS Stresses
or cutting off others and the support they could give you, There are three clearly defined types of EMS stresses:
avoidance behaviors, and dishonesty about your actual
state of well-being (“I’m just fine!”). • Daily stress. Most EMS stress is unrelated to critical
It is far better for you to spend your energy on benefi- incidents and disasters. Instead, it is related to such
cial, or healthy, techniques that dissipate the accumulation things as pay, working conditions, dealing with the
of stress and promote actual recovery. When your stress public, administrative matters, and other hassles of
response threatens your ability to handle the moment, try day-to-day living and working. To help deal with daily
the following: stress, all emergency personnel should develop per-
sonal stress management strategies, such as a personal
• Use controlled breathing. Focus attention on your support system made up of coworkers, family, clergy,
breathing. Take in a deep breath through your nose. and others.
Then exhale forcefully but steadily through your • Small incidents. Incidents involving only one or two
mouth, so that you can hear the air rush out. Press all patients, including incidents that result in injuries or
the air out of your lungs with your abdomen. Do this deaths of emergency workers, are best handled by
two or more times until you feel steadier. This tech- competent mental health personnel in individual or
nique helps to reduce your adrenaline levels and slow small-group settings. Mental health professionals
your heart rate, so you can do your job appropriately. should be familiar with EMS and be ready to respond
• Reframe. Mentally reframe interfering thoughts, such when needed. They should then continue to screen
as “I can’t do this” or “I’m scared.” Consciously restate affected emergency workers for signs and symptoms
your negative thought in a positive way. For example, of abnormal response to stress. If these are detected,
when you start to think “I can’t do this,” you might tell they can refer these workers, as appropriate, to other
yourself, “I will do the best I can and ask another crew competent mental health professionals who use
member or call medical direction if I need help.” When accepted treatment methods.
you think, “I’m scared,” you might replace that • Large incidents and disasters. Most EMS personnel
thought with “This is challenging, but I can get will never encounter a disaster situation. However, all
through it OK.” Be sure to deal with the negative must be ready in case such a catastrophe occurs. The
thoughts later, however, or they may continue to inter- stress of large-scale disasters can be mitigated by a
fere with the performance of your duties. well-coordinated and organized response. Use of the
• Attend to the medical needs of the patient. Even if you National Incident Management System (NIMS) or
know the people involved, do not let those relation- Incident Command System (ICS) in large incidents
ships interfere with your responsibilities as an EMS and disasters serves to appropriately direct respond-
provider. Later, when it is appropriate to do so, address ing personnel. It also provides for rotating personnel
your stress about the call in some way, such as talking through rehabilitation and surveillance stations. Those
it over with family or fellow crew members or seeking who are showing signs of stress or fatigue are removed
spiritual solace or counseling. from duty, at least temporarily. Here, too, there is a role
for competent mental health professionals, who should
For long-term well-being, one of the best stress manage- be readily available to provide psychological first aid.
ment techniques is to simply to take care of you—physically,
emotionally, and mentally. Remember that regular exercise
does not have to be extreme. Do something that you enjoy Post-Traumatic Stress Disorder
and find relaxing. At stressful times, pay especially close In recent years, there has been an increased emphasis on
attention to your diet. If you smoke, make it a goal to quit. the long-term effects of stress on EMS providers. One pos-
Create a non-EMS circle of friends, and renew old sible outcome of recurrent or unmitigated stress is the
friendships or activities. Take a vacation or a few days off. development of post-traumatic stress disorder (PTSD).
78 Chapter 4
PTSD is an anxiety disorder that develops following expo- • Safety and comfort. Taking steps to provide as safe an
sure to traumatic events. It was commonly seen in military environment as situations permit; providing as much
personnel exposed to the horrors of war and has been rec- comfort as circumstances allow.
ognized for years under various names (e.g., shell shock, • Stabilization. Attenuating anxiety, providing a calm-
combat exhaustion, survivor’s guilt). Symptoms of PTSD ing presence, helping ground and orient the dis-
include intrusive memories that may manifest, for exam- traught, referring for emergency care where and when
ple, in the following ways: clearly indicated.
• Recurrent, unwanted distressing memories of the trau- • Information gathering (current needs and concerns).
matic event(s) Determining what the pressing needs are, as seen by the
• Reliving the traumatic event as if it were happening person in need; tailoring assistance efforts to address
again (flashbacks) current needs while anticipating emerging situations.
• Recurring and unsettling dreams about the traumatic • Practical assistance. Providing practical, instrumental
event(s) help with identified needs; assisting with problem-
solving strategies and access to helping resources.
• Severe emotional distress or physical reactions to
something that reminds the person of the event • Connection with social supports. Helping those
affected make contact with sources of social support
PTSD may also include avoidance of situations and important to them (e.g., friends, family, and commu-
places that can bring back thoughts and images of the trau- nity and spiritual resources); integrating their support
matic event or events. Ultimately, PTSD can result in into problem solving and recovery.
changes in how an individual reacts emotionally and can
• Information on coping. Providing simple, practical,
adversely affect the person’s mood and thinking. PTSD, in
proven tips on managing stress and coping with
some instances, can result in suicide or suicidal ideation.
demands of recovery—timed to match the situations
The research is unclear as to whether there is an
and challenges at hand at any given juncture. Such tips
increased incidence of PTSD in EMS personnel. However,
can be useful and well received, especially when deliv-
recurrent exposure to traumatic events in EMS is common.
ered in the context of practical assistance and social
Even though not every person exposed to traumatic events
support.
will develop PTSD, it is definitely a risk.
Several strategies have evolved to help identify and • Link to collaborative services. Because many people
prevent PTSD in EMS providers and other public safety may be unfamiliar with resources available to help
personnel. One of these is the Code Green Campaign, with their various needs, providing assistance in navi-
founded in 2014 by a group of EMS professionals, which gating the resource network community can be partic-
serves to raise awareness of mental health issues (e.g., ularly important.
PTSD, substance abuse, suicide) in first responders. It also
Psychological first aid is not a treatment or packaged
provides education for responders on how to provide care
proprietary intervention technique. It is an attempt to pro-
for themselves and recognize issues in their peers. A simi-
vide practical palliative care and contact while respecting
lar organization in Canada is the Tema Conter Memorial
the wishes of those who may not be ready to deal with the
Trust, which provides peer and psychological support for
possible onslaught of emotional responses in the early
public safety personnel.
days following an incident. It entails providing comfort
and information and meeting people’s immediate practical
Mental Health Services and emotional needs.15
treatment is potentially harmful.”16,17 Instead, mental In particular, learn about the different cultural back-
health practitioners now recommend resiliency-based care. grounds of people in your area and how to work with
This program includes techniques and activities that pro- them effectively. For example, although you may like a
mote emotional strength, while at the same time decreas- lot of eye contact, understand that it is regarded as more
ing vulnerability to stress, adversity, and challenges. polite in several cultures to avoid eye contact. Therefore,
However, an important role remains for competent someone showing you esteem might avoid eye contact
mental health professionals in any multiple-casualty inci- with you. This is not wrong; it is just different. Listen
dent. Mental health personnel should be available on scene well to the stories of other people and see what you can
to provide psychological first aid (as already described) to learn. When you learn to accept differences easily, it will
all those affected by an incident—including EMS person- become easier for you to work toward win–win situa-
nel. At the same time, they can survey rescuers and victims tions on the streets.
for the development of abnormal stress-related symptoms.
In addition, mental health professionals should be avail-
able during the two months following a critical incident to Roadway Safety
screen and assist anyone who may be developing stress- Motor vehicle collisions are the greatest hazard for EMS
related symptoms. Persons so affected may be referred for personnel. The incidence of ambulance and emergency
additional counseling or mental health care.18 response vehicle collisions is increasing (Figure 4-13). Sev-
eral factors seem to play a role in ambulance crashes. First,
ambulances have become larger and more difficult to oper-
ate. Most modern ambulances are built on a commercial
General Safety truck chassis. Many are built on a heavy truck chassis. With
for the safe use of emergency rescue equipment. Learn the vests. In fact, you also may be issued other protective gear,
principles of: especially if you are in the fire service. Using respiratory
protection, gloves, boots, turnout coat and pants (or cover-
• Safely following an emergency escort vehicle
alls), and other specialty safety equipment is the mark of
• Intersection management, when traffic is moving in
an aware, professional paramedic. Ask nonmedical per-
several directions
sonnel to set out flares or cones, if needed. Leave some
• Noting hazardous conditions, such as spilled hazard- emergency lights flashing, although you should be careful
ous materials (gasoline, industrial chemicals, and so not to blind oncoming drivers.
on), downed power lines, and proximity to moving To park safely at a roadway incident, make it a habit to
traffic. Also notice adverse environmental conditions. scan each individual setting. Notice curves, hilltops, and
• Evaluating the safest parking place when arriving at a the volume and speed of surrounding traffic. Ideally, you
roadway incident should park in the front of a crash site on the same side of
• Safely approaching a vehicle in which someone is the street. This facilitates access to the patient compart-
slumped over the wheel ment and equipment, and it protects you from traffic com-
• Patient compartment safety—in particular, bracing ing from behind. However, when responding to an incident
yourself against sudden deceleration or swerving to such as “person slumped behind wheel,” maintain the
avoid roadway hazards; and making a habit of hang- defensive advantage by staying behind the vehicle, and
ing on consistently, especially when changing posi- use spotlights to “blind” the person until you know there
tions. Restraint systems have been developed to help are no hostile intentions. Walk to the vehicle with cautious
protect EMS personnel while riding in the patient alertness until you are sure it is not a trap.
compartment of the ambulance. The use of seat belts in the front of an ambulance
should be an obvious habit, both for safety and for role
• Safely using emergency lights and siren
modeling. Less obvious is the use of safety restraints in the
An ambulance escort can create additional hazards. patient compartment. An improper assumption is that the
Inexperienced ambulance operators often follow the escort paramedic is too busy attending to the patient and passen-
vehicle too closely and are unable to stop when the escort gers to wear a seat belt. However, buckling into a seat belt
does. Inexperienced operators also may assume that other for a safer ride is, in fact, possible during much or most of
drivers know that the ambulance is following an escort. In ambulance transport times. Death and major disability is
fact, other drivers frequently do not know that another common when someone is in the patient compartment
emergency vehicle is coming and often pull out in front of during a crash. For your well-being, wear a seat belt when-
the ambulance just after the escort vehicle passes. ever possible, even “in back.”20
Multiple-vehicle responses can be just as dangerous, Because ambulances represent help and hope, it is
especially when responding vehicles travel in the same doubly tragic when a paramedic crew is involved in a
direction close together. When two vehicles approach the motor-vehicle crash caused by the misuse of lights and
same intersection at the same time, not only may they fail siren. Lights and siren are tools, not toys. They are the
to yield, one to the other, but other drivers may also yield paramedic’s means for gaining quick access to people in
for the first vehicle only, not the second one. Extreme cau- dire need. Those who misuse the mandate to operate them
tion must be taken when approaching intersections. chip away at the public’s trust in EMS. Whether using
Certain equipment is intended to promote your safety lights and siren or not, the paramedic has a responsibility
on roadways. For example, to be visible to oncoming driv- to drive with due regard for the safety of others. As a pro-
ers, who may have dirty, smeared, or pitted windshields fessional, you are obligated to study and use safe driving
and may not be sober, wear ANSI/ISEA compliant safety practices at all times.
Summary
The paramedic has the training and responsibility to manage the most complicated health prob-
lems posed by out-of-hospital citizens. This makes the paramedic a leader within the prehospi-
tal care community. Paramedics who attend to their own well-being are not only helping
themselves, but they are also providing a positive role model for other EMS providers and the
community at large.
Workforce Safety and Wellness 81
Continuous assessment of personal lifestyle ranges from practices that affect the immediate
future to practices that affect the paramedic in old age. They range from wearing PPE and parking
safely at a crash site to managing stress daily, eating right, and exercising.
There are numerous elements to the topic of well-being, and the paramedic must strive con-
tinually to address each one. Take your knowledge beyond the introduction offered in this chap-
ter. Be a lifelong student of well-being, and you are more likely to have a healthy long life. Your
biggest challenge is this: Be well, so that you can help others be well, too.
Review Questions
1. Most paramedic injuries are caused by ___________ c. Increased resting heart rate and blood
and being in and around motor vehicles. pressure
a. falls d. Increased resistance to illness and injury
b. stress
3. According to the U. S. Department of
c. lifting Agriculture dietary guidelines, you should
d. violence make ____________ of the food on your plate
fruits and vegetables.
2. Which of the following is not a benefit of achieving
acceptable physical fitness? a. one-fourth
a. Increased muscle mass and b. one-third
metabolism c. one-half
b. Increased oxygen-carrying capacity d. two-thirds
82 Chapter 4
4. Which of the following is not an important principle 8. The most common initial stage of the grieving pro-
of lifting? cess, as identified by Elisabeth Kübler-Ross, is
a. Avoid twisting and turning whenever possible. _________________________
b. Keep your palms up whenever possible. a. anger.
c. Move a load only if you can handle it safely. b. denial.
d. Position the load far away from your body and c. depression.
center of gravity. d. bargaining.
5. A strict form of infection control that is based on the 9. What is an active process during which a person
assumption that all blood and other body fluids are confronts the stressful situation?
infectious, combining aspects of universal precau- a. Coping
tions and body substance isolation, is termed
b. Resistance
____________
c. Defensive strategies
a. personal protective equipment.
d. Problem-solving skills
b. mode of transmission.
c. incubation period. 10. For safety at a roadway incident it is appropriate to
do all of the following except
d. Standard Precautions.
______________________
6. ___________ is the use of a chemical or a physical a. ask nonmedical personnel to set out flares or cones.
method, such as pressurized steam, to kill all micro-
b. wear reflective tape and an orange or lime-green
organisms on an object. vest.
a. Cleaning c. Sterilizing c. blind a slumped-over passenger with a spotlight
b. Disinfecting d. Decontaminating as you approach.
7. How many stages in the grief process have been d. park on the opposite side of the street from the
identified by Elisabeth Kübler-Ross? crashed vehicle.
a. 3 c. 7 See answers to Review Questions at the back of this book.
b. 5 d. 8
References
1. Maguire, B. J., K. L. Hunting, G. S. Smith, and N. R. Levick. 9. Centers for Disease Control and Prevention. Standard Precautions.
“Occupational Fatalities in Emergency Medical Services: A Hid- (Available at http://www.cdc.gov/HAI/settings/outpatient/
den Crisis.” Ann Emerg Med (40) 2002: 625–632. outpatient-care-gl-standared-precautions.html.)
2. Boudreaux, E., C. Mandry, and P. J. Brantly. “Emergency Medical 10. Kübler-Ross, E. On Death and Dying. (Originally published 1969.)
Technician Schedule Modification: Impact and Implications on Scribner Classics reprint edition. New York: Simon & Schuster,
Short- and Long-Term Follow-Up.” Acad Emerg Med (5) 1998: 1997.
128–133. 11. Olsen, J. C., M. L. Buenefe, and W. D. Falco. “Death in the Emer-
3. Mitani, S., M. Fujita, and T. Shirakawa. “Circadian Variation on gency Department.” Ann Emerg Med (31) 1998: 758–765.
Cardiac Autonomic Nervous System Profile Is Affected in Japa- 12. Boudreaux E., C. Mandry, and P. J. Brantley. “Stress, Job Satisfac-
nese Men with a Working System of 24-H Shifts.” Int Arch Occup tion, Coping, and Psychological Distress among Emergency
Environ Health (79) 2006: 27–32. Medical Technicians.” Prehosp Disaster Med (12) 1997: 242–249.
4. Crill, M. T. and D. Hostler. “Back Strength and Flexibility of EMS 13. Selye, H. “A Syndrome Produced by Diverse Nocuous Agents.”
Providers in Practicing Prehospital Providers.” J Occup Rehabil Nature (138) 1936: 32.
(15) 2005: 105–111. 14. Cydulka, R. K., C. L. Emerman, B. Shade, and J. Kubincanek.
5. Studnek, J. R. and J. M. Crawford. “Factors Associated with Back “Stress Levels in EMS Personnel: A Longitudinal Study with
Problems among Emergency Medical Technicians.” Am J Ind Med Work-Schedule Modification.” Acad Emerg Med (1) 1994:
(50) 2007: 464–469. 240–246.
6. United States Department of Agriculture (USDA). ChooseMyPlate. 15. World Health Organization (WHO). Psychological First Aid:
(Available at http://www.choosemyplate.gov. For “10 Tips to a Guide for Field Workers. (Available at http://www.who.int/
Great Plate,” go to http://www.choosemyplate.gov/downloads/ mental_health/publications/guide_field_workers/en/.)
TenTips/DGTipsheet1ChooseMyPlate.pdf.) 16. Bledsoe, B. E. “Critical Incident Stress Management (CISM):
7. Bledsoe, B. E., T. Dick, J. O. Page, and M. Taigman. “The Missing Benefit or Rise for Emergency Services.” Prehosp Emerg Care 7(2)
Drugs.” JEMS (29) 2004: 30–36. 2003: 272–329.
8. Friese, G. and K. Owsley. “Backbreaking Work: What You Need to 17. McNally, R. J., R. A. Bryant, and A. Ehlers. “Does Early Psycho-
Know about Lifting and Back Safety in EMS.” EMS Mag (37) 2008: logical Intervention Promote Recovery from Posttraumatic
63–72. Stress?” Psych Sci Pub Int (4) 2003: 45–79.
Workforce Safety and Wellness 83
18. Devilley, G. J., R. Gist, and P. Cotton. “Ready! Fire! Aim! The Status 20. Slattery, D. E. and A. Silver. “The Hazards of Providing Emer-
of Psychological Debriefings and Therapeutic Interventions: In the gency Care in Emergency Vehicle: An Opportunity for Reform.”
Work Place and After Disasters.” Rev Gen Psych 10(4) 2006: 318–345. Prehosp Emerg Care (13) 2009: 388–397.
19. Ray, A. M. and D. F. Kupas. “Comparison of Rural and Urban
Ambulance Crashes in Pennsylvania.” Prehosp Emerg Care (11)
2007: 416–420.
Further Reading
Becknell, J. Medic Life. St. Louis: Mosby Lifeline, 1996. Dernocoeur, K. B. Streetsense: Communication, Safety, and Control.
3rd ed. Redmond, WA: Laing Research Services, 1996.
Chapter 5
EMS Research
Bryan Bledsoe, DO, FACEP, FAAEM
Michael F. O’Keefe
Standard
Preparatory (Research)
Competency
Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical–legal and
ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to critically evaluate published reports of
EMS research.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
84
EMS Research 85
Key Terms
abstract, p. 97 institutional review board post hoc, p. 102
analysis of variance (IRB), p. 94 principal investigator (PI), p. 102
(ANOVA), p. 95 internal validity, p. 93 prospective study, p. 89
bench research, p. 93 iterative process, p. 88 PubMed, p. 87
bias, p. 89 mean, p. 94 qualitative research, p. 88
case report, p. 92 measures of central tendency, p. 94 qualitative statistics, p. 95
case series, p. 92 median, p. 94
quality of life, p. 86
chi square test, p. 95 meta-analysis, p. 90
quantitative research, p. 88
cohort study, p. 91 mixed research, p. 88
quantitative statistics, p. 95
confidence interval, p. 95 mode, p. 95
quasiexperimental study, p. 89
control group, p. 89 morbidity, p. 86
random sampling, p. 100
convenience sampling, p. 100 mortality, p. 86
randomized controlled trial
cross-sectional study, p. 92 National EMS Research (RCT), p. 90
Agenda, p. 86
data dredging, p. 100 research, p. 86
nominal data, p. 95
data mining, p. 100 retrospective study, p. 89
nonrandomized controlled
dependent variable, p. 89 sampling error, p. 95
trial, p. 91
descriptive statistics, p. 94 science, p. 87
null hypothesis, p. 101
double blind study, p. 90 observational study, p. 90 scientific method, p. 87
experiment, p. 87 odds ratio, p. 97 single blind study, p. 90
experimental group, p. 89 open access journals, p. 98 standard deviation (SD or s), p. 95
experimental study, p. 89 ordinal data, p. 95 statistics, p. 94
external validity, p. 93 outcomes-based research, p. 86 systematic sampling, p. 100
hypothesis, p. 87 P value, p. 100 t test, p. 95
in vitro, p. 93 parameter, p. 95 time sampling, p. 100
in vivo, p. 93 peer review, p. 98 treatment group, p. 89
independent variable, p. 89 placebo, p. 91 validity, p. 93
inferential statistics, p. 94 population, p. 95 variance, p. 95
Case Study
One slow day, two EMS crews were sitting in the station, work in the field. The research showed that the outcomes
and the conversation soon drifted back to “the way we from cardiac arrest were not any better for those who
used to do it.” Robert, the most senior paramedic in the received sodium bicarbonate when compared to those
agency, had logged more than 30 years in the field. The who did not. So the American Heart Association took it
younger crew members began to question Robert about out of their recommendations, and we stopped giving it.”
the various antiquated practices that once were common- Steve, a new EMT, said inquisitively, “What about
place in EMS. MAST pants for shock or bleeding control?” Robert leaned
Robert said, “Well, one thing we routinely did was to back in the chair and said, “Ah, MAST pants. We used
give large doses of sodium bicarbonate to cardiac arrest them all the time for trauma. I’ll swear I’ve seen them
victims.” A young EMT piped in and asked, “Why did it work. But a research study from Houston found them
stop?” Robert thought for a minute and said, “Well, it was ineffective, if not harmful, and they went the way of the
one of those things that looked good on paper but did not covered wagon.”
86 Chapter 5
Robert went on, “We also used calcium chloride in was that we did not always know what was best for the
cardiac arrests. I remember giving 100 milligrams of patient. Many of the things that seemed so intuitive as
Decadron to head-injured patients—not sure why they an EMS practice have been proved through research to
had us do that. I have to admit that EMS has changed, be ineffective. Even though I hate to see old practices go
and I think it has changed for the better.” by the wayside, it is for the best, I guess. Research is
“What do you mean?” asked Steve. Robert looked what will drive EMS into the future, and I’m all for
pensive and said, “In those days, we did what we did that.”
because it seemed like a good idea at the time. Now, The group sat quietly for a while, and finally the
EMS is more based on sound scientific principles devel- conversation took a different turn when Steve looked at
oped through quality research. The goal has always his watch, jumped up, and said, “Hey, the Cowboys are
been to do what was best for the patient. The problem playing. Turn on the TV.”
determine whether it is true or false. The experiment emergencies are slightly less common during full
must be a fair test and must be reproducible (that is, moons, both when defined as a five-day period and
someone else could conduct the same test in the same when defined as only the day of the true full moon. So
way). You can conduct a fair test only by changing just now you must revise your hypothesis again, to state
one variable in your experiment at a time, while keep- “Psychiatric emergencies are not more common when
ing all other conditions the same. In your investiga- the lunar cycle is in the full moon phase.” Now your
tion of psychiatric calls, you must clearly define the hypothesis is correct according to the data you col-
parameters of the experiment, which may not be as lected.
simple as it seems. First, you must define what consti- • Report results. The practice in scientific research, espe-
tutes a psychiatric call. It could be as easy as stating cially medical research, is to share your findings
that a psychiatric call is any call that is marked on a regardless of whether your hypothesis was found to
patient run report as psychiatric. Next, you must be true or false. In medicine, this primarily occurs
define a full moon. Different people can look at the through publishing the results in a peer-reviewed
moon and have differing opinions about whether it is journal. The publishing of your data opens scientific
full. Thus, you might define a full moon as a five-day discussion that will add further insight to your find-
period that begins two days before the absolute day of ings and hypothesis.
the full moon, as stated in a reliable almanac or calen-
dar, and two days after. During this five-day window, As you run your experiment or review the results, new
the moon will appear full to most people. Finally, you information will often become available, causing you to
must define the time interval for the study, which stop and revise some of the steps in your experimental pro-
might cover, say, three or six months of full-moon tocol. Stopping, backing up, and repeating a step in the sci-
periods. entific method is common and called an iterative process.
Behavior Studied under controlled conditions Studied in more than one context Studied in natural environment
study that starts now and examines what happens from existing data. For example, in our ongoing discussion of
this point forward (or to a predetermined ending date). the psychiatric patients and full moon study, the design
Occasionally, some studies will have both prospective and could either be retrospective or prospective. In a retrospec-
retrospective components (e.g., a before-and-after study). tive study, all EMS run sheets for a predetermined period
of time (e.g., one year) would be carefully reviewed for
Quantitative versus psychiatric calls. When found, the date of the call and other
necessary information would be recorded. In a prospective
Qualitative Research design, starting on a given day, all psychiatric calls would
Quantitative research is objective and specific. It is be flagged and the date recorded. The study would con-
designed to determine the relationship between one thing tinue until a target date has been reached or a predeter-
(independent variable) and another (dependent or out- mined number of call records have been obtained.
come variable) and describe it with numbers (statistics). Generally speaking, prospective studies have greater
The independent variable is the variable that affects the validity than retrospective studies. There are several rea-
dependent variable under study. The dependent variable sons for this. First, prospective studies use a research form
(or outcome variable) is the variable being affected or pre- or instrument specifically designed for the study. These
sumed affected by the independent variable. For example, tend to make the study more objective, accurate, and com-
a study that seeks to determine whether faster EMS plete. When looking at historical data, it is often difficult
response times affect patient survival would be considered to identify the specific data being sought. In addition,
quantitative research. The EMS response time would be there is more chance for the introduction of bias in the
the independent variable and mortality would be the data gathering for retrospective studies. Despite these
dependent variable. problems, there are benefits to retrospective studies. First,
In addition to experimental quantitative research, as the data already exist and are available immediately. Sec-
just described, one can find nonexperimental and survey- ond, retrospective studies are generally less expensive
quantitative research. Nonexperimental quantitative than prospective methodologies.
research is often used when there are independent vari-
ables that cannot be manipulated for one reason or another
(e.g., ethical concerns). Nonexperimental research mea-
sures primarily what naturally occurs or what has already Experimental Design
occurred. Our study of psychiatric patients and the full Not all studies are created equal. As a rule, the closer a
moon is an example of nonexperimental quantitative study adheres to the scientific method, the more valid the
research. Survey-quantitative research is a common strat- study, and the more valid the study, the closer it is to the
egy that is widely used outside medicine and the hard sci- truth.
ences. It is also considered a form of nonexperimental There are several types of experimental designs and
quantitative research. Typically, a survey (either a written these have varying degrees of validity. They include exper-
questionnaire or an interview) will be performed in the tar- imental studies, quasiexperimental studies, and observa-
get population. Then, the results will be analyzed and tional studies. An experimental study will have both a
reported. Surveys are commonly used to reflect public control group (a group of subjects who do not have manip-
opinion and for marketing and social science research. ulation of the independent variable) and a treatment
Qualitative research primarily relies on collection of group, also called an experimental group. Subjects are ran-
qualitative (nonnumeric) data. It primarily seeks the “why” domly assigned to one of the groups. The researcher does
and not the “how” of the phenomena being studied. Quali- not assign subjects or affect the assignment of subjects to
tative research primarily occurs in a natural setting. For the groups. The goal of randomization is to ensure that the
example, many of the studies on stress in EMS have used demographics between the groups are similar. Experimen-
qualitative methodologies. These studies often evaluate tal studies in which subjects are randomized into either the
how an individual feels. Qualitative research has an impor- treatment group or the control group are considered among
tant role in quality assurance. Customer surveys and patient the most valid of studies.
satisfaction programs rely heavily on qualitative methods. A similar experimental design is the quasiexperimen-
tal study. A quasiexperimental study is one in which the
Prospective versus scientist does not randomly assign subjects to the study
groups. With quasiexperimental studies, there is a greater
Retrospective Studies chance of having groups that are demographically differ-
A research project, regardless of whether it has a quantita- ent. Also, there is a greater chance of the introduction of
tive or a qualitative design, will be either a retrospective bias (even subconsciously) into the study when subjects
study or a prospective study. Retrospective studies look at are not randomly assigned to the groups. Because of this,
90 Chapter 5
Specific Study Types Figure 5-3 Meta-analysis is an analysis of the combined results of
several prior studies.
Within the three general categories of scientific research
just described (experimental, quasiexperimental, and they assimilate the raw data from all these studies
observational), you will encounter various specific types of into a single database. They subsequently analyze
study in the medical literature. These are presented in a the data and draw conclusions. This is the most valid
descending order of validity (Figure 5-2). type of study because it represents a much larger
• Meta-analysis of randomized controlled trials. The part of the population and often represents a more
advent of modern computing has made meta-analysis diverse demographic than each individual study. It
possible. In this study type, researchers locate all avail- is possible to do a meta-analysis of observational
able appropriate randomized controlled trials studies, but these study types are not common. A
(described next) of a particular area of study. Then, meta-analysis is labor intensive and difficult to per-
form (Figure 5-3).
• Randomized controlled trials (RCTs). The randomized
Levels of Validity controlled trial (RCT) closely adheres to the scientific
Meta-analysis of method and is extremely valid. Subjects are random-
randomized ized into a treatment group (or groups) and a control
controlled trials
Randomized group (Figure 5-4). The randomization can be achieved
controlled trials (RCTs)
in different ways and the researchers cannot have a role
Nonrandomized
controlled trials
in group assignment. One method of avoiding the
introduction of bias into an RCT is to “blind” the scien-
Cohort study
tist, the subject, or both. In a single blind study, the
Cross-sectional study subjects do not know whether they are in the treatment
group or the control group. This helps to prevent them
Case series from changing behavior during the experiment. In a
double blind study, both the subjects and the experi-
Case report
menters are blinded as to who is in the control group
Expert opinions, editorials, rational conjecture and who is not (Figure 5-5). An example of a double
blind study is one that was used to determine whether
In vivo (animal) research
the administration of morphine affected subsequent
Bench research (also called in vitro or “test tube” research) emergency department assessment of patients with
possible appendicitis. A pharmacist prepared identical-
Figure 5-2 Hierarchy of validity of study types. The most valid looking vials, one containing the morphine and the
type of study is at the top of the pyramid, the least valid at the bottom. other containing normal saline. When ordered, neither
EMS Research 91
Randomized Controlled Trial (RCT) does not receive the new device, whereas the other
Treatment group battalion receives the device. At a given point in time,
the IV success rate between the groups will be ana-
lyzed and compared. The problem in this study design
Patients is that there is an increased chance that the two study
groups will be different. For example, one battalion is
from San Antonio and, incidentally, 25 percent of their
soldiers had prior medical training. The other battal-
ion is from Las Vegas and only 12 percent of their
group had prior medical training. The prior experi-
ence of the San Antonio battalion could affect the
Assigned
randomly results and not give a clear picture of the true effective-
Control group
ness of the device.
• Cohort study. A cohort study is an observational study
in which subjects who have a certain condition and/or
who receive a particular treatment are followed over
time and compared with another group who are not
affected by the condition under investigation (Fig-
ure 5-7). For research purposes, a cohort is any group
of individuals who are linked in some way or who
have experienced the same significant life event within
a given period. A commonly cited example of a cohort
study is twin studies. When most twins reach adult-
Figure 5-4 In a randomized controlled trial, a treatment group and hood, they typically go their separate ways. Scientists
a control group that is not receiving the treatment are being studied. will look at behaviors or characteristics that are differ-
The results of the two groups can be compared.
ent in one twin (e.g., smoking, homosexuality) and
compare them to the other twin (who is genetically
the doctor nor the patients knew whether they were identical or similar). This can help us to better under-
getting the drug or the placebo. When the experiment stand what factors (genetic, social, environmental) are
was over the date were “unblinded,” the analysis com- causing the differences.
pleted, and the hypothesis tested.
• Nonrandomized controlled trials.
Nonrandomized controlled tri- Double Blind Study
als, also called quasiexperimen- Two kinds of pills:
tal studies, as described earlier,
Pill X
have a control group and a treat-
ment group—but assignment to
these groups is not randomized
(Figure 5-6). This type of study
has less validity than an RCT, Pill Y
but it has utility in some circum-
Half the patients
stances. For example, two bat- are given Pill Y
talions of soldiers are going to
be tested to determine whether
a new IV access device is effective
on the battlefield. One battalion
serves as the control group and Physician gives the
pills to the patients.
Treatment group:
Group being studied
Patients from Centerville the Centerville patients
(Example: identical twin siblings)
Assigned
nonrandomly Control group:
the Newtown patients Comparison group Compare results
Patients from Newtown
(Example: nontwin siblings)
Figure 5-6 In a randomized controlled trial, assignments to the Figure 5-7 A cohort is a group of subjects who share a certain
treatment group and the control group are made at random. In a characteristic. For example, all may be cancer patients. A cohort
nonrandomized study, assignments to the two groups are, as the study observes and compares the cohort group with a group whose
name indicates, not randomized. members do not have the cohort characteristic.
• Cross-sectional study. A cross-sectional study, also similarities and differences between these patients in
called a cross-sectional analysis, is an observational order to isolate a possible cause.
study and similar to a cohort study in that various • Case report. A case report is a structured study of a
groups are compared without a control. However, single patient who is unique or interesting to the medi-
unlike a cohort study (which is a longitudinal study cal community in general. These are usually short
that looks at measurements over time), a cross-sec- reports and have limited scientific validity.
tional study looks at a single point in time. For exam- • Expert opinions, editorials and rational conjecture.
ple, a study of EMS providers was completed on a When modern EMS was being planned, there was no
certain date to determine the average number of years identifiable body of knowledge to guide the develop-
of formal education by training level existed within ment of the profession. Instead, physicians and other
the group at that time. This would be an example of a experts were consulted, and they provided their best
cross-sectional study. opinion about needed practices and procedures.
• Case series. A case series is a study that looks at a Although this strategy is suitable for use before scientific
group of patients (typically a smaller number than research is available or while scientific research is occur-
found in an RCT) with a similar condition. This is how ring, it can be problematic when research finally shows
the AIDS epidemic in San Francisco was first identi- that the resulting practices are ineffective or harmful.
fied. An epidemiologist noted a cluster of patients Many modern EMS practices (e.g., spinal immobiliza-
with similar disease findings (AIDS) and looked at the tion practices, critical incident stress debriefings)
EMS Research 93
An Overview of Statistics The mean and the median tell only one part of the
story. They are called measures of central tendency,
Statistics is the mathematics of collecting and analyzing because they indicate the center of the group. A different
data to draw conclusions and make predictions. It is an but very important quality to know about a group is how
essential part of scientific study. There are two general spread out it is, or how dispersed the data are.
EMS Research 95
There are two closely related measures of dispersion a particular study. But since the study looked at a sample
that you are likely to see. The first is called the variance. To of patients in VF, this proportion is only an estimate and
get it, we take each value and subtract the mean from it. We may, in reality, be higher or lower in the entire group with
cannot take the average of these numbers and get anything cardiac arrest. Investigators can calculate how much vari-
useful, because the negative numbers will cancel out the ability exists in this percentage based on the number of
positive numbers and we will get zero. To overcome this, observations, the actual data, and how reliable they wish
we multiply each number by itself (square it) and add up the estimate to be.
the squared numbers. We then divide this sum by the num- This variability (not the same as the variance) can then
ber of values we started with. (For reasons statisticians can be added and subtracted to the original proportion to give
describe, when we are working with samples, we usually what is called a confidence interval. For example, suppose
divide by one less than the number of values.) This is the the investigators calculated the variability in the previous
variance. example with 95 percent confidence and found it was
To get the standard deviation (SD or s), the other 6 percent. Then we would have a 95 percent confidence
common measure of dispersion, we take the square root of interval of 20 percent, plus or minus 6 percent. This means
the variance. Figure 5-10 shows two examples of variance that, assuming the hypothesis is true, we can be 95 percent
and standard deviation. The standard deviation gives us confident that the actual rate of survival under the condi-
valuable information about the data. If two groups of data tions studied was between 14 percent and 26 percent.
have the same mean, but the second has a standard devia- Confidence intervals are very important in interpret-
tion much larger than the first, the data in the second group ing the value of the research results. If the confidence inter-
are much more spread out than the data in the first group. val for a proportion such as the previous one included
The SD is also used in many statistical formulas. zero, then there would be a real possibility that there is no
Another way we can describe data is to give the mode. actual difference between the study group outcome and
This is simply the most common value in a set of data. If the control group outcome. We would conclude that the
you graph the data, with the data value on the horizontal results are not statistically significant and that there is
axis and the frequency of occurrence on the vertical axis insufficient reason to believe there is a difference between
(also known as a frequency distribution), the mode is the the two groups.
value associated with the highest point on the graph.
Quantitative and
Inferential Statistics Qualitative Statistics
As noted earlier, the mean, median, variance, standard There are many tests for finding differences between
deviation, and mode are examples of descriptive statistics. groups. Statisticians frequently classify them into qualita-
They describe the nature of a sample of data taken from a tive and quantitative tests. Qualitative statistics usually
population, a group we are interested in. deal with data that are nonnumeric in nature (e.g., female,
Descriptive statistics are related to, but quite different male) or that are nonnumeric in nature and have been
from, inferential statistics. Here, instead of describing the assigned a number indicating ranking or ordering of
sample, we wish to draw inferences about the population importance or severity (stage I, II, and III of certain cancers,
the sample came from. In this case, we say we are estimat- for example). These are sometimes called nominal data
ing parameters of the population. For example, if the sam- and ordinal data. Finding the mean of such data may be
ple is of sufficient size and we make certain assumptions impossible or absurd since they are categorical in nature.
about the population and how the sample was selected, we Quantitative statistics, however, are numerical in nature,
can estimate the mean value of the population from which such as temperature measured in degrees on a thermome-
we drew our sample. Polling organizations commonly use ter or height of an individual measured in centimeters or
these techniques in reporting results of their surveys. We inches. They are sometimes referred to as continuous data.
must keep in mind, however, the phenomenon of sam-
pling error. This is an estimation of the difference between
the value obtained from the sample and the value that Other Types of Data
would be obtained from the entire population, stemming Commonly used tests you may see in research include
solely from the fact that only a sample of the population t test, the analysis of variance (ANOVA), and the chi
was included. square test. Which test is used depends to a great extent on
When researchers find that something occurs with a the kind of data involved and the kinds of differences the
certain frequency, they usually report this proportion as a investigators are looking for. We will not describe these
percentage. For example, survival from cardiac arrest tests here, but the interested reader can consult some of the
caused by ventricular fibrillation (VF) may be 20 percent in sources listed at the end of this chapter.
96 Chapter 5
Class 1
Score Mean Score Mean (Score Mean)2
78 85 7 49
81 85 4 16
82 85 3 9
84 85 1 1
87 85 2 4
89 85 4 16
94 85 9 81
Sum 595 0 176
Recall that to get the variance we must find the mean, then find the differences between
the scores and the mean, square these differences, add them up, and divide by one less
than the number of scores. The mean is included in the second column to make it easier to
calculate the difference between each score and the mean. The variance is then 176/6
29.3. The standard deviation is the square root of 29.3, which is 5.4.
Class 2
Score Mean Score Mean (Score Mean)2
82 85 3 9
83 85 2 4
84 85 1 1
85 85 0 0
86 85 1 1
87 85 2 4
88 85 3 9
Sum 595 0 28
Again, to get the variance, we sum the squared differences in the last column and divide by
one less than the number of scores: 28/6 4.7. The standard deviation is the square root of 4.7,
or 2.2, less than half the standard deviation of the first class.
This implies that the scores in the first class are much more spread out than the scores
in the second class. When we graph the scores, we can see that this is true:
Class 1 Scores
78 81 82 84 87 89 94
Standard deviation 5.4
Class 2 Scores
82 83 84 85 86 87 88
Standard deviation 2.2
Figure 5-12 Secondary scene of the PubMed database search engine after entering search term “paramedic.”
What to Look for When • What inclusion and exclusion criteria did the research-
ers use? If the investigators excluded the patients most
Reviewing a Study likely to have a condition or patients very similar to the
ones you see, the study may have very little to tell you.
Questions to ask when reviewing a study include the fol-
• How did the investigators draw their sample? Did
lowing (Table 5-3):
they use true random sampling? systematic sam-
• Was the research peer reviewed? This is no guarantee of pling? time sampling? convenience sampling?
quality, but it at least indicates that experts have reviewed • How many groups were patients divided into, and
the study and found it to have some merit. Keep in mind were patients assigned to control and study groups
that some journals will deliberately publish papers that properly? The effects of bias and confounding must be
they know to be of lower quality than usual in order to taken into account for the study to yield worthwhile
stir up debate about an important subject. results. In particular, ask yourself:
• Was there a clear hypothesis or study purpose? The • For case-control and cohort studies, were selection
paper should have a clear description of exactly what bias and recall bias taken into account?
the investigators were evaluating and what their study
• For randomized controlled studies, were random-
hypothesis was. When a hypothesis is not clearly
ization and blind assignment maintained?
spelled out, it is very easy for the investigators to draw
• Were the control and study groups the proper size? Did
unjustified conclusions.
the investigators describe the sample size necessary to
• Was the study approved by an IRB, and was it con-
produce sufficient power to avoid a type II error (a
ducted ethically? An IRB is a group of people, usually
false negative)? What was the power of the study?
at a hospital or university, who review study proposals
(Was the study adequately performed to accurately test
to ensure that patients are protected when they partici-
the hypothesis in question?)
pate in research as study subjects. Virtually all medical
• Were the effects of confounding variables (other things
journals require IRB approval for research involving
that may have affected the study outcome) taken into
human subjects.
account? Did the investigators describe potential con-
• Was the study type appropriate? Not every investiga- founders and how they prevented them from interfer-
tion lends itself to the format of the randomized con- ing with the study?
trolled clinical trial. It may be necessary, for ethical or
• What kind of data did the investigators collect, and did
financial reasons, to use another format. Evaluate
they analyze the data with the proper statistical tests?
whether the questions the investigators asked were
There are many tests available and more than one may be
well suited to the type of study they conducted.
appropriate for the conditions at hand. You may need to
• What population were the researchers studying? Is the consult a statistician or researcher to determine whether
population similar to the one you see in your commu- the investigators used the right tests on the data. Did the
nity and work? investigators clearly determine before data collection
took place which tests they were going to use, or was
there data mining? When the data fail to provide statisti-
Table 5-3 Questions to Ask When Reviewing a Study
cally significant results, it is very tempting to perform
• Was the research peer reviewed? more tests until one shows significant results. This kind
• Was there a clear hypothesis or study purpose? of retrospective testing is called data snooping or data
• Was the study approved by an institutional review board (IRB), and dredging. If one continues to perform statistical tests,
was it conducted ethically?
eventually one will be significant just by chance alone.
• Was the study type appropriate?
This inappropriate use of statistics is to be avoided.
• What population were the researchers studying?
• What inclusion and exclusion criteria did the researchers use?
• Were the results reported properly? When a paper
includes a proportion or an odds ratio, is there also a
• How did the investigators draw their sample?
95 percent confidence interval?
• How many groups were patients divided into, and were patients
assigned to control and study groups properly? • How likely is it that the study results would occur by
• Were the control and study groups the proper size? chance alone? Remember that a P value reflects only the
• Were the effects of confounding variables taken into account? odds of seeing the results of a particular piece of research
• What kind of data did the investigators collect, and did they analyze the if the study hypothesis is true. A small P value may be
data with the proper statistical tests?
very impressive, but it does not prove the study hypoth-
• Were the results reported properly? esis. In addition, keep in mind the difference between
• How likely is it that the study results would occur by chance alone? association and causation. For example, it would be easy
• Are the authors’ conclusions logical and based on the data? to show that the number of drownings increases with
EMS Research 101
sales of ice cream. An inattentive reader might conclude study. Was the difference found in the study large enough to
that the sale of more ice cream causes more drownings make a real difference to patients?
to occur. In reality, this is an example of association, not When investigators conduct their experiments, they
causation. Ice cream sales go up when the weather gets have the luxury of selecting patients who meet their crite-
warmer, which is also when more people go swimming ria and excluding patients who do not. In the real world,
and drown. This is also an example of confounding. things are not quite so tidy. Before we can apply the results
• Are the author’s conclusions logical and based on the of a piece of research to a particular patient, we must be
data? Occasionally a journal publishes a paper that sure the patient is similar enough to the study group to
goes against everything you know. It can then be diffi- benefit from the intervention.
cult to determine whether you need to change your Finally, EMS providers do not function in a vacuum.
approach to a particular problem or consider the paper Before implementing any significant changes in your prac-
an aberration. After all, by chance alone, some studies tice, speak to the management of your organization, and
will show statistically significant results that are the especially to your medical director. You are responsible not
result of chance or coincidence. Sometimes, the pru- only to your patients, but also to your bosses and your medi-
dent course is to see whether anyone else can replicate cal director. Including them in decision making of this nature
the experiment before changing your practice. This is a is essential and will pay off in better patient care overall.
good example of how you should be very cautious in
changing your practice based on just one study. If the
conclusion is a real one and not spurious, someone
Participating in Research
else should be able to come up with it, too. Many EMS systems are not content to watch other people
advance their field. They have decided to conduct research
And here is one more consideration that is very important
themselves. They have found that, by executing well-
in EMS research:
designed studies, they can not only improve care in their
• How “good” was the EMS system in which the study coverage areas, but also improve out-of-hospital care
was done? This factor can have a profound effect on the throughout the nation, sharpen the skills of their provid-
validity of a study. As an extreme example, how valid ers, and rekindle their providers’ interest by doing some-
would be the results of a study of the impact of AED thing new and potentially groundbreaking.
use if the time from arrest to first responder arrival Before you participate in such a study, there are certain
were 15 minutes? In this scenario, there would likely be things you should do and find out (Table 5-4). Usually, the
no survivors, no matter what intervention was used! first step is to ask a question. This should involve some-
thing of practical importance. Determining the value of a
base to make an informed decision about how to interpret • Get the approval of the proper authorities.
a piece of research. • Determine how you will get informed consent from study subjects.
• Gather data, perhaps after conducting pilot trials.
The clinical significance is another important piece of
• Analyze the data.
the puzzle to consider.
• Determine what you will do with your results (publish, present at a
A P value with lots of zeroes (e.g., P < 0.0001) may be conference, follow up with more studies).
very impressive, but not very pertinent. Distinguish between Source: American College of Cardiology and the American Heart Association, Manual
the statistical significance and the clinical significance of the for ACC/AHA Guideline Writing Committees.
102 Chapter 5
groups you are sampling from. The research hypothesis or and will be able to guide you through them. The PI should
alternate hypothesis is a statement that there is a difference also gain the approval of other appropriate agencies, includ-
between the groups. This is often, though not always, what ing the medical director and the head of the service involved.
you would like to show. After you have determined how to gain informed con-
Once you know what you are evaluating, you need to sent, you need to gather your data. Sometimes a pilot trial is
decide what you want to measure and how you will do it. undertaken first so you can find unforeseen obstacles to data
You also need to define the population you will be study- gathering. Seemingly trivial matters can become very
ing—that is, the group from which you draw your subjects important (such as whether busy EMS providers are reluc-
and to which you plan to generalize your results. tant to fill out any more forms). A good PI will meet with the
Closely associated with this step is determining the limi- EMS providers who are administering the study interven-
tations of your study. This might include limited ability to tion and collecting the data. The PI should make sure they
generalize your results because of the patient selection meth- know how long the study is expected to last. This allows
ods you used, even though you had little or no choice in the them to make plans and perhaps reschedule certain future
methods available to you. Similarly, the population you draw activities they had anticipated. The providers collecting data
from might be significantly different from other populations. need to know the name of the PI and how to contact him.
For example, if you wished to test for improved survival The PI is usually, though not always, a physician. Many
in hypotensive trauma patients, some of whom received a EMS physicians who conduct field research will recruit a
large volume of IV fluids as treatment and some of whom field provider to coordinate and assist with data collection.
did not, you would need to describe your EMS and trauma Other things to tell participants are the inclusion and
care system very carefully. You might have a primarily urban exclusion criteria for enrolling patients in the study, the
population with predominantly penetrating trauma, short effect of the study on patient care in general, and the risks
transport times to Level I trauma centers, and experienced and potential benefits to patients in the study. Once every-
paramedics. Your results would have limited applicability to one understands these factors, you will be prepared to go
a rural population with predominantly blunt trauma, long ahead with the study.
transport times to small community hospitals, and less expe- After you have collected the data and reached your pre-
rienced Emergency Medical Responders and EMTs. determined sample size, it is time to analyze the data. Use
The best studies limit themselves to a single question the tests you described in your description of the methods
or hypothesis. This is desirable because it allows you to for your study. Be very careful about performing additional
focus better on the question at hand. The downside is that tests, especially if your results do not show what you hoped
you may not find out everything you wanted to. This is or expected. Data snooping is a dangerous activity. If you
usually considered an acceptable trade-off. No single study perform enough statistical tests, you will eventually find
can answer every question. one or more that give you “significant” results. Unfortu-
The next step in conducting a study is usually to get nately, these results may very well be a product of chance
approval from an IRB. This allows you to get an outside eval- rather than your intervention. When multiple statistical tests
uation of your study methodology and reduces considerably are planned for the same set of data, statisticians adjust for
the chance you will be accused of conducting an unethical this with multiple testing procedures to avoid such false
study. One of the items the IRB will undoubtedly be inter- results. Similarly, post hoc analysis of subgroups that were
ested in is the issue of informed consent (consent given by not defined before the study can also be dangerous. This can
the patient based on full disclosure of information regarding be a good way of generating hypotheses for future studies,
the nature, risks, and benefits of the procedure or study). but it is not a good basis for drawing conclusions now.
Several reports in the media over the past few years have Once you have finished your data analysis, you must
described unethical studies in which subjects were not given decide what to do with your results. If you feel that your
the opportunity to give or refuse consent because they were study addresses a pertinent timely issue, and you think
not informed of the risks and benefits of participating in the your methods were well thought out and your study was
study. In some cases, subjects actually died because they did carefully conducted, you should seriously consider submit-
not receive standard treatment available at the time of the ting your results to a peer-reviewed journal. This is the best
study. These stories have prompted an understandable reluc- way to get such information out to the EMS community.
tance on the part of many individuals to participate in research. Alternatively, you may decide to present your findings
The U.S. government even came out with standards for gov- at a conference. This usually involves summarizing your
ernment-funded research that describe stringent requirements methods and results either orally or in the form of a poster,
for informed consent. The IRB process will also determine or both. This is less time consuming than writing up a paper
what kind of consent will be required for your study. for publication, but it can still get the word out about your
A good principal investigator (PI), the person who results and stimulate others to investigate the same phe-
oversees the study, will be familiar with these requirements nomenon.
EMS Research 103
Do not feel that a “negative” study is worthless. If quite important, technology and science change. Thus,
your study shows no difference in outcomes between medical practice and the use of technology should focus on
groups that did and did not receive an intervention, you procedures and practices proven effective in improving
may have reached important conclusions about the value, patient outcomes. EMS is now at the point at which evi-
or lack of value, of an intervention. dence-based decision making and practice are becoming
A common result of a well-conducted study is more standard. The use of “best practices” and “clinical path-
questions. This frequently stimulates the investigator and ways” that are based on the best available clinical and sci-
others to perform further studies. Once you get involved entific evidence ensures that the care provided is safe,
with researching the answers to questions, you may find efficacious, and cost effective. The problem that remains, at
yourself a little more skeptical about accepted, untested treat- least in the EMS setting, is that the available research is, at
ments and more interested in finding out what really works. present, scant or of limited quality. Hopefully, as EMS
evolves, this will change.
Evidence-based decision making involves first formu-
Evidence-Based lating a question about appropriate treatments. Then the
evidence supports a change in the practice, the change is applied to the proper group of patients. In addition, an
made. However, the process does not end there. Once the ongoing outcomes study should occur to determine
practice has been changed, ongoing evaluation must be whether the change in practice is improving essential
carried out to determine whether the practice is correctly parameters such as mortality, morbidity, and costs.
Summary
The paramedic of the twenty-first century must have more than a passing knowledge of research.
Solid, well-conducted scientific research is the key to improving prehospital care. It is also essen-
tial to prove that paramedics make a difference in terms of reducing mortality, morbidity, and pain
and suffering. A side benefit to demonstrating the effectiveness of EMS will be an increased (and
more appropriate) revenue stream. The future of EMS depends on an aggressive research pro-
gram, and prehospital research depends on knowledgeable and engaged paramedics.
Review Questions
1. Proving that the care and service provided by EMS c. standard variable.
to the community is worthy of funding and support d. quantitative variable.
is demonstrated primarily through
5. A study that looks primarily at existing data is the
_____________________
____________________
a. scientific research.
a. retrospective study. c. independent study.
b. outcomes-based research.
b. prospective study. d. scientific study.
c. the scientific method.
d. quantitative research. 6. The closer a study adheres to _______________, the
more valid is the study.
2. _____________ research describes phenomena in
a. independent variables
numbers.
b. dependent variables
a. Qualitative c. Mixed
c. the general hypothesis
b. Quantitative d. Scientific
d. the scientific method
3. _____________ research describes phenomena in
7. Which of the following is NOT a randomized con-
words.
trolled trial?
a. Qualitative c. Mixed
a. Qualitative study
b. Quantitative d. Scientific
b. Single blind study
4. The variable that affects the dependent variable c. Double blind study
under study is the _________________
d. Prospective study with randomization
a. individual variable.
See answers to Review Questions at the back of this book.
b. independent variable.
References
1. Wang, H. E. and D. M. Yealy. “Out-of-Hospital Endotracheal 7. World Medical Association. WMA Declaration of Helsinki—
Intubation: Where Are We?” Ann Emerg Med 47 (2006): 532–541. Ethical Principles for Medical Research Involving Human Sub-
2. Lateef, F. and T. Kelvin. “Military anti-shock garment: Historical jects. (Available at http://www.wma.net/
relic or a device with unrealized potential?” J Emerg Trauma Shock en/30publications/10policies/b3/index.html.)
1 (2008): 63–69. 8. National Institutes of Health. The Belmont Report: Ethical
3. Sayre, M. R., L. J. White, L. H. Brown, S. D. McHenry; National Principles and Guidelines for the Protection of Human Subjects
EMS Agenda Writing Team. “National EMS Research Agenda.” in Research. (Available at http://ohsr.od.nih.gov/guidelines/
Prehosp Emerg Care 6 (2002): S1–S43. belmont.html.)
4. National Libraries of Medicine. PubMed. (Available at http:// 9. Mann, H. “Research Ethics Committees and Public Dissemination
www.ncbi.nlm.nih.gov/pubmed/.) of Clinical Trial Results.” Lancet 360 (2002): 406–408.
5. National Institutes of Health. Directives for Human Experi- 10. Goodacre, S. “Critical Appraisal in Emergency Medicine 2:
mentation. (Available at http://ohsr.od.nih.gov/guidelines/ Statistics.” Emerg Med J 394 (2008): 1–6.
nuremberg.html.) 11. Waeckerle, J. F. and M. L. Callaham. “Medical Journals and the
6. White, R. M. “Unraveling the Tuskegee Study of Untreated Science of Peer Reviewing: Raising the ‘Standard.’” Ann Emerg
Syphilis.” Arch Int Med 160 (2000): 585–598. Med 28 (1996): 75–77.
Further Reading
Brown, L. H., E. L. Criss, and N. H. Prasad. An Introduction to EMS Wiersma, W. Research Methods in Education: An Introduction. 7th ed.
Research. Upper Saddle River, NJ: Pearson/Brady, 2002. Boston, MA: Allyn and Bacon, 2000.
Rumsey, D. Statistics for Dummies. Hoboken, NJ: Wiley, 2003.
Chapter 6
Public Health
Bryan Bledsoe, DO, FACEP, FAAEM
Standard
Public Health
Competency
Applies fundamental knowledge of principles of public health and epidemiology, including public health emergencies,
health promotion, and illness and injury prevention.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to apply principles of public health in
your role as a paramedic.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this chapter. 4. Explain basic concepts of epidemiology.
2. Identify EMS roles that are within the 5. Give examples of how EMS providers can
domain of public health, and components be involved in public health strategies.
that must be in place for EMS and public
6. Describe the roles of EMS organizations and
health to work together.
EMS providers in the prevention of EMS
3. Define the three categories of public health provider illness and injury.
laws and discuss public health efforts that
7. Identify areas of need for prevention
have improved the quality of life.
programs in the community.
Key Terms
epidemiology, p. 108 injury surveillance program, p. 109 secondary prevention, p. 109
injury, p. 109 primary prevention, p. 109 tertiary prevention, p. 109
injury risk, p. 109 public health, p. 107 years of productive life, p. 109
106
Public Health 107
Case Study
It’s a hot July day and Timmy is spending it with John, It takes you and your partner 6 minutes to respond.
whose family has an in-ground pool. At approximately While waiting, John’s mother stays with Timmy, turning
9:00 am, John’s mom receives a phone call. The two boys, him on his side to let the water drain from his mouth
who had been watching cartoons in the living room, run and lungs and pleads with him softly to “hang in there.”
out to the patio, grab the large inflatable alligator raft, When you arrive on scene, you perform a scene size-up
and head for the water. Timmy pronounces himself “king and a primary assessment and start CPR. Timmy begins
of the alligator killers” as he jumps on the raft. John says to breathe in about a minute, but he does not regain con-
he is the “true king” and plops himself down on top of sciousness. You rush him to the hospital emergency
Timmy. In the resulting tussle, Timmy rolls off the raft department. There, the staff praises your actions and tell
and into the water. He tries, but is unable, to get a good you, “You did the best you could.”
enough grasp on the edge of the concrete pool. John Almost a year later, Timmy has still not regained
watches his friend struggle and, terrified, runs to the side consciousness. The costs for Timmy’s care so far have
of the house to hide. All this takes about 7 minutes. reached more than $650,000. It is difficult to predict
At approximately 9:10 am, John’s mom hangs up the total cost. With good medical care, Timmy could
the phone. As she steps out onto the patio, she sees live for many years. This unfortunate situation could
Timmy’s small form floating face down in the pool. have been prevented through the use of relatively
She races to the pool, jumps in, and pulls Timmy out. inexpensive alarms and locks on doors leading to the
She checks to see whether he is breathing, but he is not. swimming pool, as well as a pool alarm that detects
She starts for the phone, but stops short. Where is changes in water displacement when an object falls
John? It takes her another minute to find him and into the pool.
another 30 seconds to get to the phone to dial 911.
Public Health Functions Table 6-1 Public Health Accomplishments (United States)
m
Motor vehicle safety
Monitor
en
Evaluate
health
t
Safer workplaces
Assure
ce
P
laws
ol i
partnership
Develop Recognition of tobacco as a health hazard
policies
y c
d
ev
el
op health accomplishments of the past century are detailed in
me
nt Table 6-1.
Accomplishments Epidemiology
in Public Health Epidemiology is the branch of medicine that deals with
the incidence and prevalence of disease in large popula-
Public health has improved both the quality of life and the tions. It also works to detect the source and cause of epi-
lifespan of humankind. These improvements have occurred demics of infectious disease and other health events.
through research, epidemiology, surveillance, prevention, Epidemiology is concerned primarily with the frequency
and other strategies. Some of the most important public and pattern of health events that occur in a population.
Public Health 109
A number of concepts and terms are used in epidemi- • Analytic studies. In most situations, surveillance and
ology. One such concept is years of productive life, a field investigations can identify the causes, modes of
calculation made by subtracting the age at death from 65. transmission, and appropriate control and preven-
(For example, in a liability lawsuit concerning the death of tion measures for most public health problems. How-
a 45-year-old, a jury might assess damages based on the ever, when the health problem is more complex (e.g.,
deceased’s loss of 20 years as a wage earner.) Another con- epidemic), analytic methods are often employed. An
cept is injury, which refers to the intentional or uninten- example of this was the investigation and detection
tional damage to a person resulting from acute exposure to of AIDS (acquired immunodeficiency syndrome) in
thermal, mechanical, electrical, or chemical energy or from 1981. Researchers in both New York and California
the absence of such essentials as heat and oxygen. An acci- began to see an unusual form of skin cancer (Kaposi’s
dent is an unintentional injury, but an injury that is pur- sarcoma) and an unusual form of pneumonia (Pneu-
posefully inflicted either on oneself (e.g., suicide) or on mocystis pneumonia) among gay men in their com-
another person (e.g., homicide) is an intentional injury. munities. This resulted in significant public health
Intentional injuries make up about a third of all injury efforts to identify the disease and its cause and
deaths. Other categories of intentional injury include rape, required the use of analytic methods. In 1983,
assault, and domestic, elder, and child abuse. researchers at the Pasteur Institute in France isolated
Another concept related to epidemiology is injury the human immunodeficiency virus (HIV) that was
risk, which is a hazardous or potentially hazardous situa- believed to be the causative agent of what is now
tion that puts people in danger of sustaining injury. As called HIV/AIDS. Researchers subsequently back-
medical professionals, EMS providers should assess every tracked the cases of AIDS that were known at the
scene and situation for injury risk and maintain statistics as time and found that a Canadian flight attendant, who
part of an injury surveillance program, which is the ongo- was nicknamed “patient zero,” was the most likely
ing systematic collection, analysis, and interpretation of source for introducing the HIV virus into the general
injury data essential to the planning, implementation, and population. By 1985, a test kit for HIV was available
evaluation of public health practice. and approved by the FDA. In 1987, treatment regi-
An injury surveillance program must also include a mens were developed for HIV. Today, although HIV/
component for the timely dissemination of data to those AIDS remains a serious infection, the incidence has
who need to know. The final link in the injury surveillance declined and people with the disease are living
chain is the application of these data to prevention and almost-normal lifespans.3
control. “Teachable moments” occur shortly after an injury, • Evaluation. Evaluation, from an epidemiological
when the patient and observers remain acutely aware of standpoint, is an ongoing process that determines the
what has happened and may be more receptive to learning effectiveness, efficiency, and impact of activities
about how a similar injury or illness could be prevented in related to public health initiatives. In other words, it
the future. is a system to verify that public health policies are
By becoming involved in injury prevention, EMS pro- doing what they were intended to do and are cost
viders can focus on primary prevention, or keeping an effective.
injury from ever occurring.2 Medical care and rehabilita-
• Linkage. A true public health system requires interac-
tion activities that help to prevent further problems from
tion among various agencies and other entities. As
occurring are referred to, respectively, as secondary pre-
public health policies have been refined, there has
vention and tertiary prevention.
been a push to integrate other disciplines, such as
Epidemiology has six major roles in public health
emergency medical services, into public health efforts.
practice:
Interactions include developing preestablished proto-
• Public health surveillance. Public health surveillance cols and agreements, memoranda of understanding,
is the ongoing and systematic collection, analysis, and the sharing of information between organiza-
interpretation, and dissemination of health data to aid tions. These strategies tie in to the interoperability
the public and to aid in health care decision making agreements recommended by the Department of
and action. Homeland Security (DHS) and the National Incident
Management System (NIMS).
• Field investigation. Following detection of a health
concern through public health surveillance, a field • Policy development. In many situations, epidemiolo-
investigation is typically begun. This investigation gists and other public health professionals have the
may be limited to a simple phone call or may involve needed expertise to assist in development of policies,
fieldwork to identify the extent and cause of the health rules, and regulations that have a positive impact on
problem in question. the health and welfare of the population.
110 Chapter 6
Content Review EMS Public health care because of cost or transportation issues.
Many EMS systems, usually in conjunction with social
➤➤ EMS Roles in Public Health Strategies service organizations, periodically assist in helping
Health
Although there are clear these high-risk communities.
• Disease prevention
differences between EMS • Disease surveillance. EMS is often the first to encoun-
• Disease surveillance
practice and public health, ter an evolving public health emergency such as an
• Disaster management
• Injury prevention at its most fundamental epidemic or terrorist activity. By its nature, the EMS
➤➤ The primary tenet of public level, EMS is a public system can be an effective monitor of the community.
health is to identify and health system. Over the An increase in EMS calls for certain medical conditions
prevent injury and illness. past few years, based on or injuries is often an indicator of an evolving larger
the EMS Agenda for the issue. Several programs provide real-time surveil-
Future, there has been a concerted effort to integrate EMS lance. For example, FirstWatch® provides ongoing,
into public health, and vice versa.4 live analysis of data to identify patterns and trends as
The numerous roles for EMS in the public health arena they emerge. This early detection allows actions to be
include the following: taken quickly, hopefully saving lives and protecting
• Health promotion. EMS personnel can play several property. When a threat is detected, FirstWatch auto-
important roles in public health. These include such matically sends alerts to authorized, appropriate per-
primary prevention strategies as providing health care sonnel via e-mail, pager, SMS (short message service)
screenings and vaccinations. With these services, there text messaging, or fax. Alerts can contain summary
is an educational component, an opportunity for EMS reports, charts, graphs, maps, and other important or
personnel to inform the public about injury and illness mission-critical information (Figure 6-3).
prevention. This can be taken a step further to target • Disaster management. The EMS system is at the core
high-risk populations in an effort to ensure that they of disaster response. As disasters play out, the mission
are receiving needed medical care. Many elderly, changes from rescue to recovery. Although EMS per-
homeless, and destitute individuals avoid seeking sonnel are well prepared for rescue and emergency
Figure 6-3 EMS is often a harbinger for public health events. Early warning systems, such as that provided by FirstWatch, are now more
commonplace.
(www.FirstWatch.net)
Public Health 111
medical care endeavors, they are less prepared for resources and your responsibilities in preventing illness
recovery efforts. From a medical standpoint, recovery and injury.
efforts include prevention of disease and further injury
• Protection of EMS providers. The leadership of EMS
and definitive care of injuries that may have been sta-
agencies must ensure that policies are in place to pro-
bilized during the initial hours and days after the onset
mote response, scene, and transport safety. The
of the disaster. EMS personnel may be called on to
appropriate Standard Precautions and personal pro-
assist in recovery and need the knowledge and skills
tective equipment (PPE) should be issued to protect
required to achieve these tasks.
against exposure to bloodborne and airborne patho-
• Injury prevention. Although many people believe that gens, as well as environmental hazards. An overall
injuries “just happen,” evidence shows that injuries commitment to safety and wellness should be empha-
often result from interaction with identifiable potential sized and supported.
hazards in the environment. Thus, it has been sug- • Education of EMS providers. EMS personnel must
gested that motor vehicle accidents (MVAs) should be understand the need for involvement in prevention
called motor vehicle collisions (MVCs), because driv- activities. A “buy-in” from employees at every level is
ing drunk or at 80 mph and crashing is no accident. In key to the success of any prevention program. EMS
other words, many injuries may be predictable and, managers have the responsibility of instructing their
thus, preventable. EMS can play an important role in personnel in the fundamentals of primary prevention
injury prevention. Common strategies include child during initial training and in continuing education
safety seat classes, bicycle safety training, drunk driv- courses. Public and private sector specialty groups may
ing education programs, smoking prevention, and be called on for specific EMS education and training.
swimming pool safety programs.5 EMS providers should also have the skills and training
necessary to defend against violent patients or other
Public Health and EMS hostile attackers. Classes in on-scene survival tech-
niques should be commonplace in every EMS agency.
Other than the victims or survivors and their families, no • Data collection. Monitoring and maintaining records
one experiences the aftermath of illness and trauma more of patient illnesses and injuries is essential in deter-
directly than EMS providers. Every day, paramedics wit- mining trends and in developing and measuring the
ness the tragic effects of preventable injuries and illnesses. success of prevention programs. Each agency should
Even armed with the best equipment and technology, they contribute data to local, regional, state, and national
cannot save every life. However, by being first on the scene systems that track such information.
of emergencies, EMS personnel have become prime candi-
• Financial support. An agency’s internal budget should
dates to be advocates of injury prevention.
reflect support for prevention strategies as a priority. If
EMS providers perform CPR and other life-saving pro-
necessary, support must be sought from outside the orga-
cedures as part of an everyday routine. In addition, as part-
nization. Large corporations are often willing to donate
ners in public health and safety, members of the EMS
funds in exchange for stand-by coverage at an event or
community must go beyond their normal daily routine and
company function. State highway safety offices can offer
work cooperatively with members of the public to prevent
funding for traffic-related projects, such as those involv-
avoidable illness and injury.6
ing child safety seats, seat belts, and drunk driving.
EMS providers are widely distributed in the population,
Advertising agencies may contribute billboards for safety
often reflecting the composition of their communities. They
messages and public service announcements (Figure 6-4).
are often considered to be champions of the health care con-
Partnerships with local hospitals can result in advertising
sumer and are welcome in schools and other community
safety messages in newsletters and flyers. Community
institutions. Medical personnel are high-profile role models
groups such as Mothers against Drunk Driving (MADD)
and, as such, can have a significant impact on the reduction
and junior auxiliaries also are great resources for initiat-
of injury rates in this country. In rural areas, EMS providers
ing community and school programs.
may be the most medically educated individuals, and are
• Empowerment of EMS providers. The ultimate factor
often looked to for advice and direction. Essentially, the more
in achieving success in a prevention program lies in
than 600,000 EMS providers in the United States comprise a
the hands of the frontline personnel. Managers should
great arsenal in the war to prevent injury and disease.
identify, encourage, and foster employee interest, sup-
port, and involvement. Likewise, such involvement
Organizational Commitment should be recognized and rewarded from top manage-
EMS organizational commitment is vital to the develop- ment. It is also recommended that managers rotate
ment of any prevention activities. As a member of the EMS assignment to prevention programs and provide sal-
community, you should become familiar with available ary for off-duty injury prevention activities.
112 Chapter 6
Stress Management
Members of today’s workforce, par-
ticularly EMS providers, must learn
to control, or at least handle, the
stress in their lives. It is often diffi-
cult for even the healthiest individ-
ual to balance personal, family, and
work life. Know your limits and
take time out when necessary. Take
Figure 6-4 EMS in the United States needs to be proactive in public education programs. time to relax. Pick a pastime or
(Dr. Bryan E. Bledsoe) hobby that alleviates stress. If work
becomes too stressful, speak with a
supervisor to prevent burnout or future conflicts. Balance
EMS Provider Commitment your life with exercise, good nutrition, and healthy activi-
Illness and injury prevention should begin at home and ties to keep stress in check.
be carried over into the workplace.7 The priority for
EMS providers is to protect themselves from harm.
Seeking Professional Care
EMS providers should not be ashamed of needing or ask-
Employers have an obligation to provide a safe working
ing for professional counseling. Paramedics are called in to
environment. Written guidelines and policies should
assess and treat people during the worst times of their
promote wellness and safety among employees. (See the
lives. Facing tragedy, disease, death, and despair are part
chapter “Workforce Safety and Wellness” for more
of the daily routine for EMS personnel. Do not forget that
information on the points discussed in the following
paramedics are vulnerable to the same stressors, emotions,
sections.)
illnesses, and injuries as everyone else. If your job or life
Standard Precautions becomes overwhelming, you may choose to seek counsel-
Under the guidelines of the Occupational Safety and ing from a trained professional.
Health Administration (OSHA), employers and employees Many employers will offer employee assistance pro-
share responsibility for ensuring that Standard Precautions grams that include counseling, stress management, nutri-
are used to assist in preventing contamination from blood tion, healthy lifestyle inventories, and general wellness. It
and other bodily fluids. PPE, such as gloves and eyewear, is often a great benefit for employees to take advantage of
plays a major role in EMS operations and is one of the pro- these opportunities to help themselves through a crisis or
vider’s basic lines of defense (Figure 6-5). stressful time.
Prevention in the between the ages of 5 and 9 who are struck by cars typi-
cally have darted out in front of traffic. Children riding
Community bicycles can be injured when they collide with cars or other
fixed objects or when they are thrown from the bicycle. The
As a component of health care, EMS has a responsibility most serious bicycle-related injuries are head injuries,
not only to prevent injury and illness among EMS workers, which can cause death or permanent brain damage. Bicycle
but also to promote prevention among the members of the safety programs, which promote helmet use and safe rid-
public. EMS providers can be an appropriate and effective ing, can help attenuate this problem.
means of prevention in several situations. Falls are the most frequent cause of injury to children
younger than 6 years old. About 200 children die from falls
each year. Fire and burn injuries occur in the highest num-
Areas of Need bers in the very young. Most are caused by scalding from a
Infants and Children hot liquid, as when children grab pot handles and spill the
Each year, nearly 290,000 infants are born weighing less contents.
than 5.5 pounds (2,500 grams), often as a result of inade- In this modern age of media and the Internet, children
quate prenatal care. Low birth weight is a key indicator of and young adults are bombarded with an incredible
poor health at the time of birth. Babies born too small or amount of information and are often faced with some of
too soon are far more likely to die in the first year of life. the same stressors as adults. Sometimes those stressors
Annually, more than 4,000 die of low birth weight and become overwhelming.
prematurity. Among those who survive, an estimated 2 to One of the most troubling recent trends is the
5 percent have a disability, and one-quarter of the smallest increased number of violent acts among young people,
survivors (born weighing less than 1,500 grams) have seri- occurring in the form of self-destructive behavior, gang
ous disabilities such as mental retardation, cerebral palsy, violence, and assaults. In addition, firearm injury is
seizure disorders, or blindness.8 becoming more common as a result of the accessibility of
One of every three deaths among children in the handguns to children. An increasing number of injuries
United States results from an injury. The number of inju- and deaths occur when children and adolescents take
ries, of course, far exceeds the number of deaths. The most guns to school. The number of firearm deaths has doubled
common causes of fatal injuries in children include motor since 1953. About 15 percent of all firearm-related deaths
vehicle collisions, pedestrian or bicycle injuries, burns, are unintentional, often resulting from improper handling
falls, and firearms. Injuries generally can be classified into and lack of safety mechanisms.
intentional events (such as shootings and assaults), unin-
tentional events (such as motor vehicle collisions), and Motor Vehicle Collisions
alleged unintentional events (such as suspicious injury For years, the EMS industry and law enforcement have
patterns that suggest possible abuse). referred to collisions among trucks and automobiles as
In motor vehicle collisions, young children are easily motor vehicle accidents (MVAs). However, that term does
thrown on impact. Because a young child’s head is large in not accurately reflect the circumstances of the incident.
proportion to the body, unrestrained children tend to fly The term motor vehicle collision (MVC) more accurately
head first into the windshield or out of the car when a reflects the fact that few collisions are accidents: Some-
collision occurs. The back seat is the best seat for children thing caused the crash to occur. Such crashes are respon-
12 years old or younger. In this location, a properly sible for more than half of all deaths from unintentional
restrained child is least likely to sustain injuries in a crash. injuries. Alcohol use is a factor in about half of all motor
Car safety seats, booster seats (for older children), and seat vehicle fatalities.
belts can prevent most severe injuries to passengers of all
ages if they are used cor- Geriatric Patients
Content Review rectly. Air bags are designed Falls account for the largest number of preventable injuries
➤➤ Areas Where EMS Can to save people’s lives when for persons over 75 years of age. As a result of slower
Be Active in Prevention used with seat belts, and reflexes, failing eyesight and hearing, and arthritis, the
• Infants and children they can protect drivers elderly are at increased risk of injury from falls. Falls fre-
• Motor vehicle collisions and passengers who are quently result in fractures, as the bones become weaker
• Geriatric patients correctly buckled. and more brittle with age. Because the aging brain begins
• Work and recreation Cars backing up in to shrink and stretch the vessels connected to the inner
hazards driveways or parking lots skull, falls in which the head strikes the floor or other
• Medications
commonly injure infants object are more likely to cause dangerous bleeding inside
• Early discharge
and toddlers. Children the cranium in an elderly person than in a younger person.
Public Health 115
Summary
Each member of EMS shares the responsibility of promoting wellness and preventing illness and
injury among coworkers and the community. EMS services have gone beyond the traditional
treatment-and-transport-only and have followed the steps of the fire service by adding prevention
to their repertoire. It is commonplace for EMS services to offer programs to the public such as first
aid and CPR classes, infectious disease prevention classes, safe driving classes, child safety seat
classes, and even swimming lessons. You should begin to partner with members of your commu-
nity in new and innovative ways to make everyone more aware of how to prevent avoidable ill-
ness and injury. If we can prevent one injury, one disabling disease, or one avoidable death, it will
have been more than worth the effort.
1. How will you counter the arguments the two paramedics made?
2. Why is prevention an important responsibility of being a paramedic?
3. List ten ideas for an illness and injury prevention program that may be appropriate in your
area.
See Suggested Responses at the back of this book.
118 Chapter 6
Review Questions
1. The study of the factors that influence the frequency, 4. Under the guidelines of ___________, employers
distribution, and causes of injury, disease, and other and employees share responsibility for Standard
health-related events in a population is called Precautions.
______________________________ a. DOT c. OSHA
a. logistics. b. FEMA d. HIPAA
b. census gathering.
5. What has been found to still be a leading cause of
c. epidemiology. disability among EMS workers?
d. pathophysiology. a. Fall injuries
2. Intentional injuries make up about ___________ of b. Back injuries
all injury deaths. c. Head injuries
a. 1/4 c. 2/3 d. Extremity injuries
b. 1/3 d. 1/2
6. What have public health studies found to be the
3. Rehabilitation after an injury or illness that helps to type of accidental injury that is the most common
prevent further problems from occurring is referred preventable injury in people over 75 years of age?
to as _______________________ a. Burns
a. primary prevention. b. Falls
b. tertiary prevention. c. MVCs
c. secondary prevention. d. Head injuries
d. teachable moments. See answers to Review Questions at the back of this book.
References
1. Public Health Law Research Program. Public Health Law Research. 6. Weiss, S. J., R. Chong, M. Ong, A. A. Ernst, and M. Balash.
(Available at http://www.publichealthlawresearch.org.) “Emergency Medical Services Screening of Elderly Falls in the
2. Jaslow, D., J. Ufberg, and R. Marsh. “Primary Injury Prevention Home.” Prehosp Emerg Care 7 (2003): 79–84.
in an Urban EMS System.” J Emerg Med 25 (2003): 167–170. 7. Maguire, B. J., K. L. Hunting, G. S. Smith, and N. R. Levick.
3. Shilts, R. And the Band Played On: Politics, People, and the AIDS Epi- “Occupational Fatalities in Emergency Medical Services: A
demic. New York: Stonewall Inn Editions/St. Martins Press, 2000. Hidden Crisis.” Ann Emerg Med 40 (2002): 625–632.
4. National Highway Traffic Safety Administration. Emergency Med- 8. Streger, M. “Keeping Kids Safe: Injury Prevention Programs in
ical Services: Agenda for the Future. (Available at http://www. EMS.” Emerg Med Serv 36 (2002): 24.
nhtsa.dot.gov/people/injury/ems/agenda/.) 9. Mosesso, V. N., Jr, C. R. Packer, J. McMahon, T. E. Auble, and
5. Yancey, A. H., 2nd, R. Martinez, and A. L. Kellermann. “Injury P. M. Paris. “Influenza Immunizations Provided by EMS
Prevention and Emergency Medical Services: The ‘Accidents Agencies: The MEDICVAX Project.” Prehosp Emerg Care 7
Aren’t’ Program.” Prehosp Emerg Care 6 (2002): 204–209. (2003): 74–78.
Further Reading
Angle, J. S. Occupational Safety and Health in the Emergency Services, Sachs, G. M. The Fire and EMS Department Safety Officer. Upper Saddle
2nd ed. Florence, KY: Delmar/Cengage Learning, 2004. River, NJ: Pearson/Prentice Hall, 2001.
Chapter 7
Medical–Legal Aspects
of Out-of-Hospital Care Bryan Bledsoe, DO, FACEP, FAAEM
Wes Ogilvie, MPA, JD, LP
Standard
Preparatory (Medical–Legal and Ethics)
Competency
Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical–legal and
ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to recognize and appropriately respond
to medical–legal issues in the practice of paramedicine.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this 7. Name and describe the defenses that can be
chapter. used by the paramedic against a claim of
negligence.
2. Describe the four primary sources of law.
8. Describe the special liability situations
3. Differentiate between the categories of
encountered in the prehospital environment.
law—civil and criminal—and how they
relate to the paramedic. 9. Take measures to protect patients’
confidentiality and privacy and comply
4. Outline the events that occur in a civil lawsuit
with HIPAA.
in which a paramedic may be involved.
10. Discuss the various ways that defamation of
5. Discuss the application of legal concepts
the patient could occur, and how the
such as scope of practice, licensure and
paramedic can avoid these occurrences.
certification, motor vehicle laws, mandatory
reporting, and others that are pertinent to 11. List and describe the levels of patient
paramedic practice. consent that can be employed by the
paramedic, and how to properly handle
6. Discuss the four components that must be
refusal of consent.
present in a negligence claim.
119
120 Chapter 7
12. Define how professional boundaries pertain likely to encounter in the prehospital
to the paramedic, and identify ways in environment.
which the paramedic can maintain these
15. Take appropriate actions to avoid destroying
boundaries.
evidence at potential crime scenes.
13. Define and identify situations that could
16. Discuss what the paramedic typically has a
lead to claims of abandonment, assault,
duty to report, and explain the elements of
battery, false imprisonment, and excessive
excellent documentation.
force.
17. Discuss employment laws as they pertain to
14. Identify and discuss the various forms of
the paramedic and his or her employer.
advanced directives that the paramedic is
Key Terms
abandonment, p. 134 employment laws, p. 141 minor, p. 131
actual damages, p. 126 excited delirium syndrome misfeasance, p. 126
advance directive, p. 136 (ExDS), p. 128 negligence, p. 125
assault, p. 134 expressed consent, p. 130 negligence per se, p. 126
battery, p. 134 false imprisonment, p. 135 nonfeasance, p. 126
breach of duty, p. 125 Good Samaritan laws, p. 124 physician orders for life-sustaining
civil law, p. 122 Health Insurance Portability treatment (POLST), p. 138
and Accountability Act positional asphyxia, p. 128
civil rights, p. 128
(HIPAA), p. 129
common law, p. 122 professional boundaries, p. 134
immunity, p. 124
competent, p. 130 proximate cause, p. 126
implied consent, p. 131
confidentiality, p. 128 reasonable force, p. 135
informed consent, p. 130
consent, p. 130 regulatory law, p. 122
intentional tort, p. 125
constitutional law, p. 122 res ipsa loquitur, p. 126
invasion of privacy, p. 130
criminal law, p. 122 restraint asphyxia, p. 128
involuntary consent, p. 131
defamation, p. 129 scope of practice, p. 123
liability, p. 121
Do Not Resuscitate (DNR) slander, p. 129
libel, p. 129
order, p. 136 standard of care, p. 126
living will, p. 136
duty to act, p. 125 statuatory law, p. 122
malfeasance, p. 126
emancipated minor, p. 131 tort law, p. 122
Case Study
A police officer has pulled a 27-year-old female driver As the paramedics are assessing scene safety, they see
off to the side of the road at the intersection of Quincy the patient turn and lunge at the officer. The officer sub-
Place and Route 122. Because of the dangerous driving dues the patient, who thrashes around briefly before
he witnessed and the driver’s erratic behavior, unsteady losing consciousness.
gait, and slurred speech, the officer suspects that the At the officer’s signal, the paramedics run in to do
driver is intoxicated. To be safe, the officer requests their jobs. They perform a primary assessment,
immediate EMS backup. quickly determining that the patient’s airway is clear
EMS 117 paramedics arrive on scene in 2 minutes and breathing and circulation are adequate. They do
and find a young woman arguing with the police officer. not detect any immediate life threats, and they begin
Medical–Legal Aspects of Out-of-Hospital Care 121
to review possible causes of the altered mental status. she has recently scheduled a physician’s appointment
To rule out hypoglycemia, they perform a rapid glu- and that she is late for a meeting. The paramedics advise
cose determination using a glucometer. Then, while the patient of the risks of refusing care. Nevertheless,
one paramedic conducts a physical exam of the patient, she continues to refuse assistance. The paramedics
the other notes that her blood sugar is 22 mg/dL. Per assure themselves that the patient is fully conscious, ori-
approved standing orders, an IV is established and ented, and capable of refusing consent. They instruct
50 mL of 50 percent dextrose is administered. The the patient to go immediately to the mini-mart across
patient responds quickly, becomes fully oriented, and the street to get something to eat, and she agrees. They
thanks the paramedics for their help. She then men- then aseptically discontinue the IV and have the patient
tions that she has been ill for a few days and has not sign a release-from-liability form, which is witnessed by
been eating well. the police officer. They return their equipment to the
The paramedics urge the patient to go to the hospi- ambulance, and notify the dispatcher that they are back
tal for additional evaluation. She declines, stating that in service.
Introduction
To practice competent prehospital care today, paramedics
must become familiar with the legal issues they are likely
to encounter in the field. As a paramedic, you must be pre-
pared to make the best medical decisions and the most
appropriate legal decisions. This chapter addresses general
legal principles in addition to specific laws and legal con-
cepts that affect the paramedic’s daily practice.
Note that because laws vary from state to state, and
protocols can vary from county to county, the information
contained in this chapter cannot be used as a substitute for
competent legal advice. Just as with the practice of medi-
cine, the practice of law involves some art and some sci- Figure 7-1 Each EMS response has the potential of involving
ence, and is always heavily dependent on the unique facts paramedics in the legal system.
present in each situation. If you are faced with a specific
legal question, you must rely on the advice of your attorney. members of a particular group. Your ethical responsibili-
ties include the following:
Legal Duties and Ethical • Respond promptly to both the physical and emotional
needs of every patient.
Responsibilities • Treat all patients and their families with courtesy and
respect.
As a paramedic, you have specific legal duties to your
• Maintain mastery of your skills and medical knowl-
patient, crew, medical director, and the public (Figure 7-1).
edge.
These duties are based on generally accepted standards
and are often set by statutes and regulations. The failure of • Participate in continuing education programs, semi-
a paramedic to perform his or her job appropriately can nars, and refresher training.
result in civil or criminal liability. Your best protection from • Critically review your performance, and constantly
liability (legal responsibility) is to perform a systematic seek improvement.
patient assessment, provide the appropriate medical care, • Report honestly and with respect for patient confi-
and maintain accurate and complete documentation of all dentiality.
incidents.
• Work cooperatively with and respect other emergency
A paramedic also is responsible for meeting the ethical
professionals.
standards expected of a professional emergency medical
care provider. (See the chapter “Ethics in Paramedicine” In addition to the legal and ethical duties, the para-
for a detailed discussion.) Ethical standards are not laws. medic will encounter moral issues on a day-to-day basis.
They are principles that identify desirable conduct by Morality, unlike legal obligations, is the principle of right
122 Chapter 7
and wrong as governed by individual conscience. Remem- the authority to make regulations based on that statute;
ber, always strive to meet the highest legal, ethical, and enforce rules, regulations, and statutes under its authority;
moral standards when providing patient care.1 and hold administrative hearings to carry out penalties for
any violations of its rules.
surrounding the incident decides the amount of damages to award the plaintiff,
Content Review
to determine if the case if any.
➤➤ Components of a Civil
has merit. • Appeal. After the jury’s decision is entered by the
Lawsuit
• Incident • Filing of the complaint. court, either party may be entitled to an appeal. Gener-
• Investigation The injured driver (now ally, grounds for an appeal are limited to errors of law
• Filing of complaint called the plaintiff) com- made by the court. Appeals are typically heard by an
• Answering of complaint mences the lawsuit by fil- appellate court.
• Discovery ing a complaint with the • Settlement. This can occur at any stage of the lawsuit.
• Trial court. In some states, the Generally, the defendant will offer the plaintiff an
• Decision complaint may also be amount of money that is less than the amount for
• Appeal called a petition. The com- which he is being sued. The plaintiff may then agree to
• Settlement
plaint contains informa- accept the reduced amount on the condition, for exam-
➤➤ Your best protection
tion such as the names of ple, that he will no longer pursue the case.
from liability is to perform
the parties, the legal basis
systematic assessments,
for the claim, and the
provide appropriate
damages sought by the
Laws Affecting EMS
care, and maintain
accurate and complete plaintiff. A copy of the and the Paramedic
documentation. complaint is served on Most of the laws that affect EMS and paramedics are state
the defendant. In some laws. Although these laws vary from state to state, they
locations, law enforcement, particularly a sheriff’s share common principles.
office, may be responsible for serving the complaint on
the defendant. Scope of Practice
The range of duties and skills paramedics are allowed and
• Answering the complaint. The defendant’s attorney
expected to perform is called the scope of practice. Usu-
then prepares an answer, which addresses each allega-
ally, the scope of practice is set by state law or regulation
tion made in the complaint. The answer is then filed
and/or by local medical direction. Often, a state will have
with the court, and a copy is given to the plaintiff’s
a general “medical practice act” that governs the practice
attorney.
of medicine and all health care professionals. These acts
• Discovery. Before any lawsuit appears in front of a prescribe how and to what extent a physician may dele-
judge or jury, both parties to an action participate in gate authority to a paramedic. As you learned in the chap-
pretrial discovery. In this stage of the lawsuit, all rele- ter “Roles and Responsibilities of the Paramedic,”
vant information about the incident is shared so the paramedics may function only under the direct supervi-
parties can prepare their trial strategies. Discovery sion of a licensed physician through a delegation of
may include: authority. Generally, paramedics should follow orders
• An examination before trial, which is also called a given by on-line and off-line medical direction. However,
“deposition,” allows a witness to answer questions you should not blindly follow orders that you know are
under oath with a court stenographer present. medically inappropriate.
• An interrogatory, used by either side, is a set of Circumstances in which an order from medical direc-
written questions that requires written responses. tion may be legitimately refused include when you are
ordered to provide a treatment that is beyond the scope of
• Requests for document production entitle each side
your training or inconsistent with established protocols or
to request relevant documents, including the
procedures, and when you are ordered to administer a
patient care report, records of the receiving hospi-
treatment that you reasonably believe would be harmful to
tal, any subsequent medical records, police records,
the patient. If you are confronted with a situation in which
and other records necessary to help prove or defend
an ordered treatment might possibly harm your patient,
the lawsuit.
you should take appropriate action. First, raise the concern
• Trial. A trial will be commenced at the appropriate with the physician. If the physician still insists, you should
level of trial court. (Some states have different trial refuse to follow the order and document the incident thor-
courts depending on the type of case and/or amount oughly on the patient care report.
of money involved.) At the trial, each side will be In addition, every EMS system should have a policy in
given the opportunity to present all relevant evidence place to guide paramedics in dealing with intervener phy-
and testimony from witnesses. sicians (on-scene physicians who are professionally unre-
• Decision. After deliberations, the judge or jury deter- lated to the patient and who are attempting to assist with
mines the guilt or liability of the defendant and then patient care). Generally, such a policy requires that certain
124 Chapter 7
conditions be met before the paramedic should allow the reported to law enforce-
Content Review
intervener physician to assume control of patient care. That ment. Emergencies that
➤➤ Commonly Mandated
is, the physician must be properly identified to the para- threaten public health,
Reports
medic, licensed to practice medicine in the state, willing to such as animal bites and
• Spouse abuse
accept the responsibility of continuing medical care until communicable diseases,
• Child abuse and neglect
the patient reaches the hospital, and willing to document also must be reported to • Elder abuse
the intervention as required by the local EMS system. the proper authorities. The • Sexual assault
content of such reports and • Gunshot or stab wound
Licensure and Certification to whom they must be • Animal bite
Other laws that directly affect the paramedic’s ability to made is set by law, regula- • Communicable disease
practice relate to certification and licensure requirements. tion, or policy. Become
Certification refers to the recognition granted to an individ- familiar with the circumstances under which you are
ual who has met predetermined qualifications to partici- required to make a report. If you fail to make a required
pate in a certain activity. It is usually given by a certifying report, you may be criminally and civilly liable for your
agency (not necessarily a government agency) or profes- inaction. In addition, such inaction may place your licen-
sional association. For example, after completing an sure or certification in jeopardy.
approved paramedic program in New York State, a student
who passes an approved written and practical examination Legal Protection for the Paramedic
will become a certified New York State paramedic. In addition to the laws that protect patients, legislative
Licensure is a process used to regulate occupations. bodies have enacted laws to protect paramedics. For exam-
Generally, a governmental agency, such as a state medical ple, some jurisdictions have enacted laws that criminally
board, grants permission to an individual who meets punish a person who commits assault or battery against a
established qualifications to engage in a particular profes- paramedic while he is providing medical care. Others have
sion or occupation. Certification or licensure, or perhaps laws prohibiting the obstruction of paramedic activity.4
both, may be required by your state or local authorities for Immunity, or exemption from legal liability, is another
you to practice as a paramedic. form of protection. Governmental immunity is a judicial
Most states have laws that govern paramedic practice doctrine that prohibits a person from bringing a lawsuit
and set forth the requirements for certification, licensure, against a government without its consent. This type of
recertification, and relicensure. It is your responsibility to liability protection, even if allowed under law, generally
understand fully the EMS laws and regulations in your serves to protect only the government agency, not the
state. Again, it should be noted that the EMS laws and individual paramedic, although the specific protections
regulations of various states differ. In some cases, the rel- vary from state to state. Therefore, you should not rely on
evant regulations may differ even among cities or counties governmental immunity to protect you from claims of
in one state. negligence. Additionally, governmental immunity would
not typically protect a paramedic working for a nongov-
Motor Vehicle Laws
ernment employer. It should be noted that, even with
As with other EMS-related laws, motor vehicle laws vary
immunity, a plaintiff may still file a lawsuit, which will
from state to state. Generally, there are special motor vehicle
typically require the paramedic to hire an attorney to
laws that govern the operation of emergency vehicles and
defend the claim.
the equipment they carry. These laws apply to areas such as
Virtually every state has Good Samaritan laws, which
vehicle maintenance and use of the siren and emergency
provide immunity to people who assist at the scene of a
lights. It is important that you become familiar with the laws
medical emergency. Although these laws vary from state to
of your state. Keep up to date with local regulations, too.
state, they generally protect a person from liability if that
Many states and local jurisdictions have enacted laws
person acts in good faith, is not negligent (most states will
and ordinances governing the use of mobile devices such
cover acts of simple negligence but not ones of gross negli-
as phones, tablets, and GPS devices. These may or may not
gence), acts within his scope of practice, and does not
apply when operating an emergency vehicle.
accept payment for services. The Good Samaritan laws of
Reporting Requirements many states have been expanded to protect both paid and
Each state enacts different laws designed to protect the volunteer prehospital personnel.5
public. For example, most states have laws that require a As a paramedic, you should also become familiar with
health care worker to report to local authorities any sus- local laws and regulations governing the use of physical
pected spousal abuse, child abuse and neglect, or abuse of restraints for dangerous or violent patients. There also may
the elderly. In many states, violent crimes—such as sexual be regulations governing entry into restricted areas, such
assault, gunshot wounds, and stab wounds—must be as military installations, nuclear power plants, and sites
Medical–Legal Aspects of Out-of-Hospital Care 125
would be expected under like circumstances by a similarly theory of negligence per se, or automatic negligence. For
trained, reasonable paramedic in the same community. example, if a paramedic who is driving in nonemergency
The standard of care specific to the paramedic’s practice is mode fails to stop at a red light and hits a pedestrian, the
generally established by court testimony and referenced paramedic’s negligence is obvious. He violated vehicle and
to published codes, standards, criteria, and guidelines traffic statutes that prohibit a vehicle from running a red
applicable to the situation. In a civil lawsuit, the trier of light, and he is therefore guilty of negligence per se.
fact (most often, the jury) decides what the standard of After a duty to act and a breach of that duty have been
care is. A breach of duty may occur by malfeasance, mis- proven, actual damages is the third required element of
feasance, or nonfeasance: proof in a negligence claim. That is, the plaintiff must prove
that he was actually harmed in a way that can be compen-
• Malfeasance is the performance of a wrongful or sated by the award of damages. This is an essential compo-
unlawful act by the paramedic. For example, a para- nent. A lawsuit cannot be won if the paramedic’s action
medic commits malfeasance if he assaults a patient. caused no ill effects. The plaintiff must prove that he suf-
• Misfeasance is the performance of a legal act in a man- fered compensable physical, psychological, or financial
ner that is harmful or injurious. For example, a para- damage, such as medical expenses, lost wages, lost future
medic commits misfeasance when he inadvertently earnings, conscious pain and suffering, or wrongful death.
intubates a patient’s esophagus, fails to confirm tube In addition, the plaintiff may seek punitive (punishing)
placement, and leaves the tube in place. damages. These are awarded only when a defendant com-
• Nonfeasance is the failure to perform a required act or mits an act of gross negligence or willful and wanton mis-
duty. For example, it would be an act of nonfeasance to conduct. An act of ordinary negligence, such as accidentally
fail to properly secure a patient to the stretcher and in allowing an IV to infiltrate, will not support an award of
the ambulance prior to transport. punitive damages. If punitive damages are awarded to the
plaintiff, most insurance policies will not cover them. There-
In some cases, negligence may be so obvious that it fore, the paramedic may become personally liable for any
does not require extensive proof. Unlike criminal cases, punitive damages awarded to the plaintiff.
which require proof “beyond a reasonable doubt,” civil Finally, to prove negligence, the plaintiff must show
cases require only a proof of guilt by a “preponderance of that the paramedic’s action or inaction was the proximate
evidence.” In most cases, the burden of proving negligence cause of the damages; that is, the action or inaction of the
rests on the plaintiff. As a result, when it is difficult to do paramedic immediately caused or worsened the damage
so, a plaintiff may sometimes invoke the doctrine of res ipsa suffered by the plaintiff. For example, a cardiac patient
loquitur, which is Latin for “the thing speaks for itself.” who breaks his arm during an ambulance collision while
To support a claim of res ipsa loquitur, the complainant en route to the hospital will likely be able to prove that his
must prove that the damages would not have occurred in the injuries resulted from the incident; that is, the collision was
absence of someone’s negligence, the instruments causing the proximate cause of his injuries. However, a patient
the damages were under the defendant’s control at all times, with a sprained wrist who happens to suffer a stroke while
and the patient did nothing to contribute to his own injury. in the ambulance would have difficulty proving that the
After the doctrine of res ipsa loquitur is invoked in court, the ambulance ride was the proximate cause of the stroke.
burden of proof shifts from the plaintiff to the defendant. Proximate cause may also be thought of in terms of
For example, a classic situation in which res ipsa loqui- “foreseeability.” To show the existence of proximate cause,
tur might be used occurs when a patient has an appendec- the plaintiff needs to prove that the damage to the patient
tomy and wakes to find that a surgical instrument has been was reasonably foreseeable by the paramedic. This is usu-
left inside his abdomen. To prove negligence in this case, ally established by expert testimony. For example, imagine
the plaintiff’s attorney would show that the damage would that a paramedic negligently crashes into a telephone pole
not have occurred without the physician’s negligence, that with the ambulance. As a result, two people are injured—
the surgical instrument was under the physician’s control the patient who was in the back of the ambulance and, two
at all relevant times, and that the patient did not contribute blocks away, a baby who was dropped by his mother when
to the injury. Many cases involving incorrect intubations or the loud crash startled her. It should be easy for the patient
airway management have a res ipsa loquitur claim. Many to prove proximate cause, because it was reasonably fore-
cases in which res ipsa loquitur would be successful are set- seeable that an ambulance crash could hurt passengers.
tled out of court. However, if the woman who dropped her baby sued the
Another situation in which little proof is required paramedic, she probably would not be able to establish
occurs when the paramedic violates a statute and injury to proximate cause. Although the crash was the reason her
a plaintiff results. Some laws state that if a statute is vio- baby was injured, it was not a foreseeable injury resulting
lated and an injury results, a person will be liable under the from the ambulance crash.
Medical–Legal Aspects of Out-of-Hospital Care 127
paramedic accused of negligence must have taken the to his own health and safety and/or that of others. The
employees of another employer under his control and cause may be a medical condition, a psychiatric condition,
exercised supervisory powers over them. substance abuse, or any combination of these.
Over recent decades, several phenomena have been
Civil Rights identified that place restraint patients at risk. Excited delir-
In addition to suing you for negligence, a patient may be ium syndrome (ExDS) is most commonly seen in conjunc-
able to sue you under certain circumstances for violating tion with abuse of stimulant drugs. It typically presents as
his civil rights if you fail to render care for a discrimina- a triad of delirium, psychomotor agitation, and physiologi-
tory reason. As a paramedic, you may not withhold medi- cal excitation. It has been estimated that approximately 8 to
cal care for reasons such as race, creed, color, gender, sexual 14 percent of people with ExDS die. An associated phe-
orientation, national origin, or, in some cases, ability to pay. nomenon is called restraint asphyxia or positional
Also, all patients should be provided with appropriate care asphyxia. This type of asphyxia may occur alone or in the
regardless of their status, condition, or disease (including presence of ExDS. During the process of being restrained,
AIDS/HIV, tuberculosis, and other communicable dis- for the reasons just cited or for other reasons, some patients
eases). may sustain injury or death. Some studies indicate that
restraint maneuvers may impair respiratory excursion.
Off-Duty Paramedics Other studies indicate that the cause is multifactorial. Posi-
Liability may also arise in a situation in which an off-duty
tional asphyxia often occurs in patients who have used
paramedic renders assistance at the scene of an illness or
CNS depressants (e.g., alcohol, opiates) and results from
injury.7 Generally, any person who provides basic emer-
the patient being in a physical position that interferes with
gency first aid to another person would be protected from
his airway or with ventilation.9
liability under a Good Samaritan law. Again, it should be
There has been an increase in negligence suits against
noted that few states have established a legal duty for a
EMS and law enforcement personnel related to deaths and
paramedic to provide care in an off-duty capacity, regard-
injuries that occur during restraint. Paramedics must
less of the paramedic’s personal moral or ethical beliefs.
understand and practice safe restraint techniques. The use
However, when the off-duty paramedic provides advanced
of medications, especially in ExDS, can help to minimize
life support, a problem may arise. In many states and in
problems. Paramedics must understand that medical
many EMS systems, paramedics cannot practice advanced
restraint is a high-risk issue and ensure that it is performed
skills unless they are practicing within an EMS system. To
safely (for all involved, both patient and rescuers), the
perform paramedic skills and procedures that require del-
restrained patient is carefully monitored, and that the cir-
egation from a physician while off duty may constitute the
cumstances of the call are documented in exquisite detail.
crime of practicing medicine without a license. Learn the
(See the section “Reasonable Force” later in this chapter, as
law in your jurisdiction as well as your EMS system’s defi-
well as the chapter “Psychiatric and Behavioral Disorders,”
nition of what constitutes being “on duty.”
for additional information on patient restraint.)
Airway Issues
Issues related to airway management have always been
problematic.8 Failure to secure an airway or failure to rec- Paramedic–Patient
ognize that an airway has been improperly placed can
result in devastating or fatal injuries for the patient. Relationships
Numerous lawsuits and settlements have been filed related The relationship you establish with your patient is a very
to airway management, especially failure to recognize that important one. Not only must you provide the best medi-
an endotracheal tube has been improperly placed. The cal care, but you also have legal and ethical duties to pro-
topic of intubation has been further complicated by several tect the patient’s privacy and treat him with honesty,
studies that question the overall benefit of prehospital respect, and compassion.
endotracheal intubation.
Paramedics must know that intubation is a high-risk
procedure and ensure that it is performed properly, that
Confidentiality
placement is verified by objective measures (e.g., capnog- All records related to the emergency care rendered to a
raphy), and that the procedure is properly documented. patient must be kept strictly confidential. Keeping patient
confidentiality means that any medical or personal infor-
Restraint Issues mation about a patient—including medical history, assess-
Almost inevitably, as a paramedic, you will eventually ment findings, and treatment—will not be released to a
encounter a patient who must be physically or chemically third party without the express permission of the patient
restrained because the patient’s behavior is a direct threat or legal guardian. However, there are specific circum-
Medical–Legal Aspects of Out-of-Hospital Care 129
stances under which a patient’s confidential information slander), breach of confidentiality, or invasion of privacy.
may be released: If found guilty, the paramedic may be made responsible
for paying monetary damages to the patient.
• Patient consents to the release of his records. A patient
may request a copy of his medical records for any rea-
Health Insurance Portability
son. If the patient is a child, consent for release of med-
ical records must be obtained from the child’s parent
and Accountability Act
The Health Insurance Portability and Accountability Act
or other legal guardian. The request should be accepted
of 1996 (HIPAA) changed the methods EMS providers use
only if it is in writing, specifically authorizes the
to file for insurance and Medicare payments. It also adds
agency to release the records, and contains the patient’s
important new layers of privacy protection for EMS
signature (or other authorized signature). If the request
patients. The privacy protections provide, among other
so directs, it is permissible to forward the records to
things, that all EMS employees be trained in HIPAA com-
the patient’s physician, insurance company, attorney,
pliance. Furthermore, EMS providers must develop admin-
or any other party the patient specifies. Be sure your
istrative, electronic, and physical barriers to unauthorized
agency retains a copy of the consent document.
disclosure of patients’ protected health information. Dis-
• Other medical care providers have a need to know. For
closures of information—except for purposes of treatment,
example, it is not a breach of patient confidentiality to
obtaining payment for services, health care operations, and
discuss the patient’s condition with on-line medical
disclosures mandated or permitted by law—must be pre-
direction or to give a patient report to an emergency
authorized in writing. HIPAA requires providers to post
department nurse on arrival at the hospital. This is
notices in prominent places advising patients of their pri-
permitted because it allows medical care appropriate
vacy rights and provides both civil and serious criminal
for the patient to be continued. It is not acceptable,
penalties for violations of privacy.10
however, to discuss confidential patient information
Patients are given the right to inspect and copy their
with medical providers who have no responsibility for
health records, restrict use and disclosure of their individu-
the patient’s care.
ally identifiable health information, amend their health
• EMS is required by law to release a patient’s medical records, require a provider to communicate with them con-
records. Records may be requested by a court order fidentially, and account for disclosures of their protected
that is signed by a judge, or they may be requested by health information except for treatment, payment, health
subpoena (a command to appear at a certain time and care operations, and legally required reporting purposes.
place to give testimony). When an agency receives a The requirements of HIPAA are detailed and every EMS
court order or subpoena, it is good practice to consult provider must become familiar with them.
with an attorney to make sure that the order is valid
and for assistance with compliance. Failure to comply Defamation
with a court order or subpoena may result in severe Defamation occurs when a person makes an intentional
penalties. false communication that injures another person’s reputa-
• There are third-party billing requirements. For EMS tion or good name. A patient may sue a paramedic for def-
agencies that bill patients for services, it is generally amation if the paramedic communicates an untrue
necessary to release certain confidential information to statement about a patient’s character or reputation without
receive reimbursement from private insurance compa- legal privilege or consent. Defamation can occur in written
nies, Medicaid, or Medicare. If possible, the agency form or through verbal statements.
should obtain patient authorization for this purpose. Libel is the act of injuring a person’s character, name,
or reputation by false statements made in writing or
The law provides penalties for the breach of confiden-
through the mass media with malicious intent or reckless
tiality. The improper release of information may result in a
disregard for the falsity of those statements. Allegations of
lawsuit against the paramedic for defamation (libel or
libel can be avoided by completing an accurate, profes-
sional, and confidential patient care report. Do not use
Legal Considerations slang and value-loaded words or phrases in your report
(for example, do not refer to a patient as “stupid” or use any
HIPAA. The Health Insurance Portability and Accountability derogatory race-based terms). Because many states con-
Act (HIPAA) enhances the confidentiality of medical records and
sider the patient care report part of the public record, never
mandates that EMS personnel be educated as to the requirements of
write anything on it that could be considered libelous.
the law. HIPAA also provides methods to ensure that EMS person-
Slander is the act of injuring a person’s character,
nel who have been exposed to a communicable disease are notified
in a timely fashion. name, or reputation by false or malicious statements spo-
ken with malicious intent or reckless disregard for the
130 Chapter 7
falsity of those statements. An allegation of slander can permission to touch. It is based on the concept that every
be avoided by limiting oral reporting of a patient’s con- adult human being of sound mind has the right to deter-
dition to appropriate personnel only. Note that many mine what should be done with his own body. Touching a
EMS systems record ambulance–hospital radio transmis- patient without appropriate consent may subject you to
sions. In addition, scanners, which give the public access charges of assault and battery.11
to EMS transmissions, are common in the United States. A patient must be competent to give or withhold con-
Therefore, information transmitted over the radio should sent. A competent adult is one who is lucid and able to
be limited to essential matters of patient care. In most make an informed decision about medical care. He under-
cases, the patient’s name and insurance status should not stands your questions and recommendations, and he
be transmitted over the radio. understands the implications of his decisions made about
medical care. Although there is no absolute test for deter-
Invasion of Privacy mining competency, keep the following factors in mind
A paramedic may be accused of invasion of privacy for the when making a determination: the patient’s mental status,
release of confidential information, without legal justifica- the patient’s ability to respond to questions, statements
tion, regarding a patient’s private life, which might reason- regarding the patient’s competency from family or friends,
ably expose the patient to ridicule, notoriety, or evidence of impairment from drugs or alcohol, or indica-
embarrassment. That includes, for example, the release of tions of shock or hypoxia.
information regarding HIV status, other sensitive medical
information, or even a potentially embarrassing set of cir- Informed Consent
cumstances in which the patient was found. The fact that Conscious, competent patients have the right to decide
released information is true is not a defense to an action for what medical care to accept. However, for consent to be
invasion of privacy. legally valid, it must be informed consent, or consent
Invasion of privacy has taken on a new level of impor- given based on full disclosure of information. That is, a
tance with the rise of cell phone cameras and social media. patient must understand the nature, risks, and benefits of
Paramedics should never allow social media or network- any procedures to be performed. Therefore, before provid-
ing to interfere with a patient’s privacy. Many EMS ing medical care, you must explain the following to the
employers have social media policies that govern the use patient in a manner he can understand:
of social media when on duty or representing the employer.
• Nature of the illness or injury
Violating these policies may lead to loss of one’s job. Par-
ticularly in the case of non-government employers, First • Nature of the recommended treatments
Amendment free speech protections are unlikely to apply • Risks, dangers, and benefits of those treatments
(Figure 7-2). • Alternative treatment possibilities, if any, and the
related risks, dangers, and benefits of accepting each
Consent one
By law, you must get a patient’s consent before you can • Dangers of refusing treatment and/or transport
provide medical care or transport. Consent is the granting
Informed consent must be obtained from every compe-
of permission to treat. More accurately, it is the granting of
tent adult before treatment may be initiated. Conscious,
competent patients may revoke consent at any time during
care and transport. In most states, a patient must be 18 years
of age or older in order to give or withhold consent. Gener-
ally, a child’s parent or legal guardian must give informed
consent before treatment of the child can begin.
Expressed, Implied,
and Involuntary Consent
There are three more types of consent: expressed, implied,
and involuntary. Expressed consent is the most common.
It occurs when a person directly grants permission to
treat—verbally, nonverbally, or in writing. Often, the act
of a patient requesting an ambulance is considered an
expression of a desire to be treated. However, just because
Figure 7-2 The use of social media can pose risks if protected the patient consents to a ride to the hospital does not
patient information or employment information is distributed. mean he has consented to all types of treatment (such as
Medical–Legal Aspects of Out-of-Hospital Care 131
the initiation of an IV and/or the administration of medi- treatment necessary to save life or limb, or treatment
cations). You must obtain consent for each treatment you ordered by the court. Be sure that you are familiar with
plan to provide. Consent from the patient does not always your local protocols and laws on this issue.
need to be granted verbally. It may be expressed by allow-
ing care to be rendered. Special Consent Situations
Unconscious patients cannot grant consent. When In the case of a minor (depending on state law, this is usu-
treating them or any patient who requires emergency ally a person under the age of 18), consent should be
intervention but is mentally, physically, or emotionally obtained from a parent, legal guardian, or court-appointed
unable to grant consent, treatment depends on implied custodian. The same is true of a mentally incompetent
consent (sometimes called “emergency doctrine”). That adult. If a responsible person cannot be located, and if the
is, it is assumed that the patient would want lifesaving child or mentally incompetent adult is suffering from an
treatment if he were able to give informed consent. apparent life-threatening injury or illness, treatment may
Implied consent is effective only until the patient no lon- be rendered under the doctrine of implied consent.
ger requires emergency care or until the patient regains Generally, an emancipated minor is considered an
competence. adult. This is a person under 18 years of age who is mar-
Occasionally, a court will order patients to undergo ried, pregnant, a parent, a member of the armed forces, or
treatment, even though they may not want it. This is financially independent and living away from home. As an
called involuntary consent. It is most commonly encoun- adult, an emancipated minor may legally give informed
tered with patients who must be held for mental health consent. Anyone else under the age of 18 may not grant
evaluation or as directed by law enforcement personnel informed consent.
who have the patient under arrest. It also is used on
occasion to force patients to undergo treatment for a dis- Withdrawal of Consent
ease that threatens the community at large (tuberculosis, A competent adult may withdraw consent for any treat-
for example). Law enforcement personnel often will ment at any time. However, refusal must be informed. That
accompany patients who are undergoing court-ordered is, the patient must understand the risks of not continuing
treatment. treatment or transport to the hospital in terms he can fully
Consent issues also can arise when a paramedic is understand. A common example of a patient withdrawing
called by law enforcement officials to treat a sick or injured consent occurs after a hypoglycemic patient regains full
prisoner or arrestee. The officers may tell you that they consciousness with the administration of dextrose. The
have the legal authority to give consent to treatment for the patient should be encouraged—but may not be forced—to go
patient simply because the patient is in police custody. to the emergency department. If he is competent, the
However, a competent adult in police custody does not patient may refuse transport. In such cases, advanced life
necessarily lose the right to make medical decisions for support measures, such as IV fluids, which were initiated
himself. In fact, many prisoners have successfully sued when the patient was unconscious should be discontinued.
health care providers for rendering treatment without con- The patient also should complete a release-from-liability
sent. Generally, forced treatment is limited to emergency form (Figure 7-3).
________________________________________
SIGNATURE OF PATIENT
________________________________________
WITNESSED BY
________________________________________
DATE SIGNED
Figure 7-4 Some EMS systems have checklists for procedures to follow when a patient refuses care and/or transport.
134 Chapter 7
False Imprisonment
False imprisonment may be charged by a patient who is
transported without consent or who is restrained without
proper justification or authority. It is defined as intentional
and unjustifiable detention of a person without his consent
or other legal authority, and may result in civil or criminal
liability. Like assault and battery, a charge of false impris-
onment can be avoided by obtaining appropriate consent.
This is a particular problem with psychiatric patients.
In most cases, you can avoid allegations of false imprison-
ment by having a law enforcement officer apprehend the Figure 7-5 Patient restraint is a high-risk endeavor. The safety of
patient and accompany you to the hospital. If no officer is personnel and the patient should be the highest priority.
available, you should attempt to consult with medical
direction and carefully judge the risks of false imprison-
indicated, involve law enforcement officials (Figure 7-5).
ment against the benefits of detaining and treating the
For more information on the use of restraints, see the “Psy-
patient. You should determine whether medical treatment
chiatric and Behavioral Disorders” chapter.
is immediately necessary and whether the patient poses a
threat to himself or to the public when you are making
your decision to treat or transport. Patient Transportation
The transportation of patients to a health care facility is an
Reasonable Force integral part of the patient care continuum. During trans-
If it is safe to do so, you may use a reasonable amount of portation to a health care facility, be sure to maintain the
force to control an unruly or violent patient. Reasonable same level of care as was initiated at the scene. This means
force is the minimum amount of force necessary to ensure that if you, as a paramedic, initiate advanced emergency
that the patient does not cause injury to himself, you, or care procedures, you must either ride with the patient to
others. Use of excessive force can result in liability for the the hospital or ensure that another paramedic will accom-
paramedic. Force used as punishment will be considered pany the patient. If you fail to do so, and the patient is
assault and battery, for which the patient may be able to harmed as a result, you may be liable for abandonment.
recover damages, and the paramedic may face criminal One of the greatest areas of potential liability for para-
charges. medics is emergency vehicle operations. It is essential that
The use of restraints may be indicated for a combative you become familiar with your state and local laws. The
patient. Restraints must conform to your local protocols. laws that provide exceptions from driving rules and regu-
Restraining devices typically used by EMS providers lations may allow you, for example, to drive at a rate of
include straps, jackets, and restraining blankets. Paramed- speed in excess of a posted speed limit, but if you are neg-
ics should take special care to prevent positional asphyxia ligent at any time during the operation of your vehicle, you
in restrained patients. As discussed under the section will not be protected from liability.
“Restraint Issues” earlier in this chapter, positional Another issue that will arise is patient choice of destina-
asphyxia occurs when a patient’s position prevents him tion. If you work in a small area with only one hospital, you
from being able to breathe or to breathe adequately. In are not likely to encounter difficulties. However, many para-
some EMS systems, paramedics are authorized to use medics work in areas that have many hospitals and medical
chemical restraints, such as benzodiazepines and antipsy- centers to choose from.
chotics, in lieu of or in addition to physical restraints. In Over the past few years, Content Review
most EMS systems, paramedics are not authorized to apply increasing numbers of law- ➤➤ Advance Directives
law enforcement restraints such as handcuffs or leg irons. suits involving facility • Living wills
If a paramedic accompanies a patient who is handcuffed, it selection have been brought • Durable powers of
is imperative that a law enforcement officer also accom- by patients. Some have attorney for health care
pany the patient in case the restraints need to be removed. sued paramedics them- • DNR orders
For the combative patient, an EMS team’s goal is to use selves, claiming negligence • POLST orders
the least amount of force necessary to safely control the based on the failure to • Organ donor cards or
directives (such as found
patient while causing him the least amount of discomfort. transport to the nearest or
on a driver’s license)
Whenever the use of force and/or the use of restraints is most appropriate hospital.
136 Chapter 7
An additional issue you may need to address have established protocols for termination of resuscitation
involves the patient’s insurance company protocols. In efforts in the field.
some situations, it may be appropriate to respect a patient’s Always follow your state laws, local protocols, and
choice of facility based on his insurance company’s facility- medical direction. The role of medical direction should be
choice protocols. Local restrictions by insurance companies clearly delineated and included in your agency’s protocols.
and health maintenance organizations may determine If you are authorized to determine that resuscitative efforts
under what conditions and to what facilities patient trans- are not indicated, be sure to thoroughly document your
port may be authorized and paid for. Although most areas decision and the criteria on which it was based.
are not yet being confronted with restrictions on service
provision, it may be only a matter of time. However, never Advance Directives
put patient care in jeopardy by transporting to a less-
To improve communication among patients, their family
appropriate facility because of insurance concerns.
members, and physicians regarding such matters, the fed-
In general, facility selection should be based on patient
eral government enacted the Patient Self-Determination
request, patient need, and facility capability. Local written
Act of 1990. This act requires hospitals and physicians to
protocols, the paramedic, on-line medical direction, and
provide patients and their families with sufficient informa-
the patient should all play a role in facility selection. The
tion to make informed decisions about medical treatment
patient’s preference should be honored unless the situation
and the use of life support measures, including cardiopul-
or the patient’s condition dictates otherwise. Become famil-
monary resuscitation (CPR), artificial ventilation, nutri-
iar with your system’s protocols regarding hospital desti-
tion, hydration, and blood transfusions.
nations as well as the capabilities of specialty care facilities
Patients and their families are therefore more likely
such as trauma centers or stroke centers.
than ever to have prepared a written statement of the
patient’s own preference for future medical care, or an
advance directive. An advance directive is a document cre-
Resuscitation Issues ated to ensure that certain treatment choices are honored
when a patient is unconscious or otherwise unable to
Advances in medical technology have saved and prolonged
express his choice of treatments. Advance directives come
thousands of lives. However, in some instances, the use of
in a variety of forms. The most common encountered in the
sophisticated medical technology may only prolong pain,
field are living wills, durable powers of attorney for health
suffering, and death. When a person is seriously injured or
care, Do Not Resuscitate orders, and organ donor cards.
gravely ill, family members must make difficult decisions
The types of advance directives recognized in each
regarding the intensity of medical care to be provided,
state are governed by state law and local protocols. Medi-
including the use or withdrawal of life-support systems.
cal direction must establish and implement policies for
Generally, you are under obligation to begin resuscita-
dealing with advance directives in the field. Those policies
tive efforts when summoned to the scene of a patient who
should clearly define the obligations of a paramedic who is
is unresponsive, pulseless, and apneic (not breathing).
caring for a patient with an advance directive. They should
There are times, however, when you will determine that
also provide for reasonable measures of comfort to the
resuscitation is not indicated. This occurs with patients
patient and emotional support to the patient’s family and
who have a valid Do Not Resuscitate (DNR) order, with
loved ones. Some states do not allow paramedics to honor
patients who are obviously dead (decapitated, for exam-
living wills in the field but do allow them to honor valid
ple), with patients with obvious tissue decomposition or
Do Not Resuscitate orders. Be sure you are familiar with
extreme dependent lividity (gravitational pooling of blood
your state law and local policies.
in dependent areas of the body), or with a patient who is at
a scene that is too hazardous to enter. Living Will
As more is learned about resuscitation, it is now A living will is a legal document that allows a person to
becoming common practice, in selected cases, either not to specify the kinds of medical treatment he wishes to receive,
begin resuscitation or to terminate resuscitative efforts in should the need arise (Figure 7-6). For example, many
the field. For example, pulseless victims of blunt trauma states allow patients to include in living wills their wishes
have virtually no chance of survival. Because of this, many concerning dying in a hospital or at home, receiving CPR,
EMS systems now have protocols in place whereby resus- and donation of their organs and other body parts. In addi-
citation of pulseless blunt trauma victims is not attempted. tion, patients with prolonged illnesses sometimes invoke
Likewise, resuscitation research has shown that patients the right to choose a person who may make health care
who are not resuscitated from standard ALS measures in decisions for them in the event that their mental functions
the prehospital setting will not benefit from transportation become impaired. They might formalize this decision by
to the hospital. In this circumstance too, many EMS systems way of a special notation in a living will. (They may also do
Medical–Legal Aspects of Out-of-Hospital Care 137
LIVING WILL
I, _______________ _______________ , make the following Living Will
declaration to my family, physicians, hospitals, and other health care providers and
any Court or Judge:
After thoughtful consideration and while I am of sound mind, I make this
statement as an expression of my settled and firm wishes if the time comes when I
can no longer take part in decisions about my own future health.
My Wishes. If at any time I have a terminal condition, and in the opinion of my
attending or treating physician there is no reasonable probability that I will recover
and the condition can be expected to cause my death within a relatively short time if
medical procedures which serve only to prolong the process of dying are not used,
or if I am in a persistent vegetative state in which I have no voluntary action or
cognitive behavior and cannot communicate or interact purposefully and which is a
permanent and irreversible condition of unconsciousness, I request that I be
allowed to die naturally and not be kept alive by artificial means. I ask that all
life-prolonging procedures, including medical assistance to eat and drink when it is
highly unlikely that I will regain the capacity to eat and drink without medical
assistance, be withheld or withdrawn in such a situation.
Resuscitation. It is my further wish that no cardiopulmonary resuscitation shall
thereafter be administered to me if I sustain a cardiac or respiratory arrest. In those
circumstances I consent to an order not to resuscitate, and direct that such an order
be placed in my medical record.
I direct that these decisions shall be carried into effect even if I am unable to
personally reconfirm or communicate them, without seeking judicial approval or
authority.
I recognize that there may be instances besides those described above for
which life-sustaining treatment should be withheld or withdrawn and this instrument
shall not be construed as an exclusive enumeration of these circumstances.
Revocation and Responsibility. This instrument and its instructions may be
revoked by me at any time and in any manner. However, no physician, hospital, or
other health care provider who withholds or withdraws life-sustaining treatment in
reliance upon this Living Will or upon my personally communicated instructions shall
have any liability or responsibility to me, my estate, or any other persons for having
withheld or withdrawn treatment.
I intend this declaration to be accepted in the circumstances described as an
exercise of my legal right to refuse medical treatment even if I am unable to
personally reconfirm or communicate that. It is made in the presence of the
witnesses who have signed below.
Signature: ___________________________________________________________
Witness: _____________________________________________________________
Witness: _____________________________________________________________
ATTENDING PHYSICIAN
In completing this prehospital DNR form, please check Part A if no intervention by prehospital
personnel is indicated. Please check Part A and options from Part B if specific interventions by
prehospital personnel are indicated. To give a valid prehospital DNR order, this form must be
completed by the patient's attending physician and must be provided to prehospital personnel.
______________________________________________ ____________________________________________
Attending Physician's Signature
______________________________________________ ____________________________________________
Print Attending Physician's Name Print Patient's Name and Location
(Home Address or Health Care Facility)
______________________________________________
Attending Physician's Telephone
______________________________________________ ____________________________________________
Date Expiration Date (6 Mos from Signature)
DNR orders generally direct EMS personnel to withhold been summoned. Even so, people tend to panic and will
CPR in the event of a cardiac arrest. When you honor a call for help. Valid DNR orders should be honored as
DNR order, do not simply pack up your equipment and your protocols allow. Note, however, that if there is any
leave the scene. You still may have the patient’s family doubt as to the patient’s wishes, resuscitation should be
and loved ones to attend to. Provide emotional support as initiated.
appropriate.
DNR orders pose a particular problem in the field. Physician Orders
Paramedics are often called to nursing homes or resi- for Life-Sustaining Treatment
dences where they find a patient in cardiac arrest and in A newly emerging paradigm in end-of-life directives is
need of resuscitation. As a rule, you are legally obligated physician orders for life-sustaining treatment (POLST).
to attempt resuscitation. If a physician has written a spe- POLST orders are designed for terminally ill patients. In
cific order to avoid it, the paramedics should not have the POLST paradigm, the terminally ill patient and the
Medical–Legal Aspects of Out-of-Hospital Care 139
Duty to Report
As a paramedic, you have an ethical duty to protect those
at risk—especially the more vulnerable among us. During
the course of your work, you may encounter patients who
may have been abused or neglected. When abuse or neglect
is suspected, you must balance the need to protect patient
confidentiality against the need to notify the proper
authorities. As a rule, you should always act with the
patient’s best interest in mind.
Abuse of the elderly, children, and invalids is all too
common. Many states have rules that require EMS personnel
Figure 7-8 Transporting organs for transplantation. to report suspected abuse to the proper authorities. If abuse
(© LifeGift Organ Donation, Houston, TX) or neglect is suspected, you should report your concerns to
140 Chapter 7
Documentation
The importance of developing and maintaining superior
documentation skills and habits cannot be overempha-
Figure 7-9 Template-driven electronic patient records are becoming
sized. As a paramedic, you must recognize that the treat- more common in modern EMS.
ment of your patient does not end until you have properly
documented the entire incident, from initial response to • It is objective. Avoid the use of emotional and value-
the transfer of patient care to the hospital emergency loaded words. Not only are they irrelevant to patient
department staff. care, but they also may be the cause of a libel suit
A complete, well-written patient care report is your against you.
best protection in a malpractice action. In fact, a well-writ-
• It is accurate. Be as precise as possible, avoiding the
ten report may actually discourage a plaintiff from filing a
use of abbreviations and jargon that are not commonly
malpractice case in the first place. In general, a plaintiff’s
understood or are approved within your EMS system.
attorney will request copies of all medical records, includ-
Also try to limit your report to information that you
ing the paramedic’s report, before filing a lawsuit. If the
have personally seen or heard. If you need to docu-
paramedic’s report is sloppy, incomplete, or otherwise not
ment something of which you do not have personal
well written, this may encourage the plaintiff to sue, even if
knowledge, be sure to indicate the source of your
the paramedic’s conduct was not negligent.
information. Document your observations, not your
A well-documented patient care report has the follow-
assumptions, and do not draw a medical conclusion
ing characteristics:
that you are not competent to make. For example, you
• It is completed promptly after patient contact. It are unlikely to conclusively diagnose a patient as hav-
should be made in the course of business, not long ing pneumonia. You can, however, report your suspi-
after the event. Any delay could cause you to forget cion of pneumonia and document findings that are
important observations or treatments. If possible, a consistent with this condition.
copy of the completed report should be left with the • It maintains patient confidentiality. Your agency
emergency department staff before you leave the hos- should have well-defined policies regarding the release
pital. This copy will become part of the patient’s per- of patient information. Whenever possible, patient con-
manent medical records. Proper documentation is so sent should be obtained prior to release of information.
important that some EMS systems now require para-
medics to dictate their reports, which are later tran- The medical record should never be altered. An inten-
scribed and placed in the patient’s permanent records. tional alteration amounts to an admission of guilt by the
Some systems use template-driven electronic records paramedic. If a patient care report is found to be incom-
(Figure 7-9). plete or inaccurate, a written amendment should be
attached to the report. The date and time the amendment
Note: Never delay patient care to attend to a patient
was written, not the date of the original report, should be
care report.
noted on the addendum. Also, be sure to send a copy of the
• It is thorough. The report should paint a clear and addendum to the receiving hospital so it will become a part
complete picture of the patient’s condition and the of the patient’s medical records. For computerized medical
care that was provided. Its main purpose is not simply records, amendments and corrections are generally auto-
to record patient data, but also to support the diagno- matically flagged and dated as such.
sis and treatment that you provided to the patient. All Medical records need to be maintained for a period of
actions, procedures, and administered medications time that is prescribed by state law. For example, in New
should be documented as well. Remember this saying: York State patient care reports must be maintained by an
“If you didn’t write it down, you didn’t do it.” EMS agency for a period of six years, or for three years
Medical–Legal Aspects of Out-of-Hospital Care 141
after the patient reaches the age of 18, whichever is longer. employment illegal. Equal Employment Opportunity
Be sure to become familiar with the record retention programs include affirmative action for employment as
requirements in your state. well as processing of and remedies for discrimination
complaints. All employees, including supervisors, man-
agers, former employees, and applicants for employ-
Always act in good faith and use your common sense. High-quality patient care and high-
quality documentation are always your best protection from liability.
Review Questions
1. ______________ ______________ originated with the 6. In a negligence claim against a paramedic, the plain-
English legal system and was adopted by Americans tiff must establish and prove four particular ele-
in the 1700s. ments to prevail. Which of the following is not one
a. Common law of those elements?
b. Civil law a. Proximate cause
c. Criminal law b. Duty to act
d. Constitutional law c. Level of compensation
d. Breach of the duty to act
2. ______________ ______________ is enacted by an
administrative or governmental agency at either the 7. The law provides penalties for the breach of confi-
federal or state level. dentiality. The improper release of information
a. Civil law c. Legislative law may result in a lawsuit against the paramedic for
b. Criminal law d. Administrative law ___________________
a. defamation.
3. The ______________ ______________ is the location
b. invasion of privacy.
of most of the cases in which a paramedic may
become involved. c. breach of confidentiality.
c. Good Samaritan laws. See Suggested Responses at the back of this book.
References
1. Sine, D. M. and N. Northcutt. “A Qualitative Analysis of the Cen- 6. Hall, S.A. “Potential Liabilities of Medical Directors for Actions
tral Values of Professional Paramedics.” Am J Disaster Med 3 of EMTs.” Prehosp Emerg Care 2 (1998): 76–80.
(2008): 335–343. 7. Erich, J. “Where Duty Ends: The Perils and Pitfalls of the Off-
2. United States of America. Constitution of the United States. (Available Duty Response.” Emerg Med Serv 33 (2004): 49–52.
at http://www.archives.gov/exhibits/charters/constitution.html.) 8. Wang, H. E. and D. M. Yealy. “Out-of-Hospital Endotracheal
3. Miranda v. Arizona, 384 U.S. 436 (1966). Intubation: Where Are We?” Ann Emerg Med 47 (2006): 532–541.
4. Hoffman, S., R. A. Goodman, and D. D. Stier. “Law, Liability and 9. Chan, T. C., G. M. Vilke, and T. Neuman. “Reexamination of
Public Health Emergencies.” Disaster Med Public Health Prep 3 Custody Restraint Position and Positional Asphyxia.” Am J
(2009): 117–125. Forensic Med Pathol 19 (1998): 201–205.
5. Nagorka, F. W. and C. Becker. “Immunity Statutes: How State 10. Department of Health and Human Services. Health Information
Laws Protect EMS Providers.” Emerg Med Serv 36 (2005): 47–52. Privacy Act. (Available at http://www.hhs.gov/ocr/privacy/.)
144 Chapter 7
11. Ayres, R. J., Jr. “Legal Considerations in Prehospital Care.” Emerg 13. Maggiore, W. A. “Professional Boundaries: Where They Are &
Med Clin North Am 11 (1993): 853–867. Why We Cross Them.” JEMS 32(12): 68–76, 2007. (This article is
12. Graham, D. H. “Documentation of Patient Refusals.” Emerg Med available online at http://www.jems.com. Click on “JEMS/issues”
Serv 30 (2001): 56–60. to locate a PDF of this article in Vol. 32, No. 12, December 2007.)
Further Reading
The Ambulance Service Guide to HIPAA Compliance. Mechanicsburg, Page, J. O. “Anatomy of a Lawsuit.” JEMS 1989: 14.
PA: Page, Wolfberg, & Wirth, 2003. Schneid, Thomas D. Fire and Emergency Law Case Book. Albany, NY:
Cohn, B. M. and A. J. Azzara. Legal Aspects of Emergency Medical Ser- Delmar Publishing, 1997.
vices. Philadelphia: W. B. Saunders, 1998. Wang, H. E., R. J. Fairbanks, M. N. Shah, and D. M. Yealey. “Tort
Lee, N. G. Legal Concepts and Issues in Emergency Care. Philadelphia: Claims from Adverse Events in Emergency Medical Services.”
W. B. Saunders, 2001. Prehosp Emerg Care 11 (2007): 96–97.
Louisell, D. and H. Williams. Medical Malpractice. New York: Matthew
Bender, 1995.
Chapter 8
Ethics in Paramedicine
Bryan Bledsoe, DO, FACEP, FAAEM
Standard
Preparatory (Medical–Legal and Ethics)
Competency
Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical–legal and
ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to apply the ethical principles of para-
medicine to your work as a paramedic.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this chapter. 5. Explain the fundamental principles of
ethics—beneficence, maleficence,
2. Describe the relationship between ethics
autonomy, and justice.
and morals, laws, and religion.
6. Given a variety of scenarios involving
3. Compare and contrast different approaches
ethical dilemmas, take actions you can
to ethical decision making.
defend on the basis of ethical principles of
4. Identify codes of ethics that serve to guide paramedicine and tests of ethical
health care professionals, including EMS decisions.
providers.
Key Terms
autonomy, p. 149 ethics, p. 146 morals, p. 146
beneficence, p. 149 justice, p. 149 nonmaleficence, p. 149
145
146 Chapter 8
Case Study
Mrs. Weinberg has fractured her hip. Her right lower After the call, the two of you discuss what hap-
extremity is obviously shortened and externally rotated. pened. “Boy,” you say, “I’ve never had a patient make a
Fortunately, she has no apparent life-threatening inju- request like that. I think it was really great of you to
ries. As you and your partner tend to her, you notice accommodate her. Did it make you uncomfortable?”
that she seems more anxious than other patients you “No,” he says, “but it surprised me. The Holocaust was
have seen with a similar problem. When your partner long before my time. It remains an embarrassment for
goes to the ambulance to retrieve additional pillows, she all of us in my country.” You agree that the best way to
whispers to you, “I would really prefer if you took care make Mrs. Weinberg comfortable was to switch places.
of me.” You also agree that the two of you handled a difficult
“Why?” you ask. situation gracefully.
She rolls up her sleeve and shows you a tattoo of a Later, when you think about the call a little more,
number on her left forearm. “This is why,” she says. you realize that this situation was truly a first for you. Is
“When I was a little girl back in Germany, I was in a it right, you wonder, to accommodate a request like
Nazi concentration camp. Your partner reminds me of this? Heinz was not going to harm her. Were you assuag-
the men who worked there. They killed my family, and ing her fears or validating her prejudices? What if the
they almost killed me. Could you take care of me on the patient had been an elderly white man who asked you
way to the hospital?” to switch places with your black partner? Would the
You do not have much time to think about this patient’s ignorance have been enough of a reason to
question, but you promise to help. Before you leave the accommodate him? What if the patient had been a neo-
scene, you approach your partner discreetly. “Heinz,” Nazi skinhead who insisted on having a white person
you say to him, “this patient is a concentration camp care for him?
survivor. Apparently your blond hair, blue eyes, and Was the situation just a matter of being courteous,
German accent remind her of the men who killed her as you first thought? After all, no one was hurt, and it
family. Would you mind driving to the hospital on this was only a minor inconvenience for you and your
call? I realize you enrolled in an exchange program to partner to switch positions. Or was it actually a matter
gain experience in patient care here in the United States, of ethics? You realize you are not quite sure how to
but there will be other calls.” Heinz has no objection, so determine the best thing to do under circumstances
he drives to the hospital, and you take care of Mrs. like these. It is time, you realize, to brush up on your
Weinberg in the back of the ambulance. ethics.
A very simple example of this approach is someone who • Respect for intellectual property
says, “Just follow the Ten Commandments.” Unfortu- • Human subjects protection
nately, although the Ten Commandments provide useful
instruction, they do not provide enough guidance for med- Many of the areas listed above have direct application to
ical professionals who must make difficult ethical deci- EMS.4
sions in health care situations.
A very different approach is consequentialism. Follow- Impact of Ethics
ers of this school of thought believe that actions can be on Individual Practice
judged as good or bad only after we know the conse-
Only by consistently displaying ethical behavior will para-
quences of those actions. Utilitarians, who believe that
medics gain and maintain the respect of their colleagues
the purpose of an action should be to bring the greatest
and their patients. It is vital that individual paramedics
happiness to the greatest number of people, are conse-
exemplify the principles and values of their profession.
quentialists. One difficulty with the utilitarians’ approach
Paramedics must understand and agree to abide by the
is determining what constitutes happiness. Another chal-
responsibilities, both implicit and explicit, of their profes-
lenge arises when the happiness of one person is in con-
sion. Occasionally, this can be a problem. A paramedic is
flict with the happiness of another person. Utilitarianism
expected to work, for example, in an uncontrolled environ-
offers a “bankbook” approach to resolving these conflicts,
ment that is sometimes dangerous. A person who is unwill-
asking the decision maker to weigh relative “amounts” of
ing to enter a scene until every risk has been totally
happiness.
eliminated is not acting in accordance with the expecta-
tions of the profession. Conversely, a paramedic is expected
Codes of Ethics to refrain from entering a hazardous area until the risks
Over the years, a number of organizations have drafted have been made manageable. Common sense should help
codes of ethics for the members of their organizations. in resolving conflicts such as these.
The American Medical Association and the American
Osteopathic Association have codes of ethics for physi- The Fundamental Questions
cians. The American College of Emergency Physicians The single most important question a paramedic must
has a code of ethics specifically for emergency physi- answer when faced with an ethical challenge is “What is in
cians. 3 The American Nurses Association and Emer- the patient’s best interest?” Most of the time the answer to
gency Nurses Association both have codes for this question is obvious: The patient wants reassurance,
practitioners in their fields. The National Association of relief from pain, and prompt, safe transport to a hospital
EMTs adopted a code of ethics for EMTs in 1978 (see the emergency department. However, sometimes the answer
chapter “Roles and Responsibilities of the Paramedic”). to this question is not so obvious. For example, what is in
Most codes of ethics address broad humanitarian con- the best interest of a terminally ill patient who goes into
cerns and professional etiquette. Few, however, provide cardiac arrest? Is it to resuscitate him? Or is it to not start
solid guidance on the kind of ethical problems com- resuscitation in order to prevent further suffering?
monly faced by practitioners. Under ideal circumstances, a written statement
Ethical codes often address the following areas: describing the patient’s desires will be available. In many
• Honesty states, such a statement (which meets other specified state
and local requirements) is, in fact, required before a para-
• Objectivity
medic may elect not to start resuscitation efforts. In less
• Integrity extreme circumstances, the patient may state verbally what
• Carefulness he wishes you to do and not do. As long as the patient is
• Openness competent and the desires are consistent with good prac-
tice, the paramedic is obligated to respect the patient’s
• Legality
desires.
• Confidentiality
Traditionally, family members have been an impor-
• Responsible publication tant source of information for physicians in determining
• Responsible mentoring the wishes of a patient. This approach, however, is not
• Respect for colleagues necessarily appropriate in the field. In the hospital or
especially in the years before a hospital admission, physi-
• Social responsibility
cians are able to spend time with the patient and the
• Nondiscrimination patient’s family and develop a relationship with them. In
• Competence the field, paramedics typically do not know the patient or
Ethics in Paramedicine 149
the family. There is usually not enough time for a para- benefits of treatment for it. It also implies respect for the
medic to develop the same kind of relationship that physi- patient’s privacy.
cians do in their practices. Additionally, the family is Justice refers to the paramedic’s obligation to treat all
under a great deal of stress when the paramedic encoun- patients fairly. For example, the paramedic should provide
ters them. necessary emergency care to all patients without regard to
For these reasons and others, a paramedic must be sex, race, ability to pay, or cultural background, among
very cautious in accepting a family’s description of what a other conditions.
patient desires. The paramedic must also take into consid-
eration the state and local laws regarding patient resuscita- Resolving Ethical Conflicts
tion desires and documentation of those desires.
Even if everyone agreed on the same principles and proce-
It may sometimes be difficult for a paramedic to agree
dures for resolving ethical difficulties, there would still be
with a patient’s wishes, but it is important that he respect
disagreements in specific situations. These disagreements
them. Only by demonstrating “good faith” in following a
can be resolved at different levels. Even the government
patient’s wishes does a paramedic show respect for the
sometimes takes action when issues become very impor-
patient. A paramedic must also realize that the family may
tant to the public. For example, there are now laws to pro-
not agree with the patient’s desires. This may lead family
tect the rights of hospitalized patients and members of
members to substitute their own desires for the patient’s.
managed care organizations. Many states have imple-
This is another reason that the paramedic should not nec-
mented laws or regulations that allow for the use of
essarily accept a family’s description of a patient’s desires
advance directives. The federal government has instituted
at face value.
rules to protect the rights of patients in emergency research
when they are unable to consent.
Fundamental Principles The health care community has also responded to the
challenge. Long before the federal government instituted
A common approach to resolving problems in bioethics
rules regarding consent in emergency research, hospitals
today is to employ four fundamental principles or values.
and universities set up institutional review boards (IRBs).
These principles are beneficence, nonmaleficence, auton-
These groups serve to protect the rights of subjects partici-
omy, and justice.
pating in research projects. Hospitals throughout the world
Beneficence is related to a more familiar term, benevo-
have had ethics committees for many years to assist in clar-
lence. Both come from Latin and concern doing good. How-
ifying patients’ desires and in weighing competing inter-
ever, benevolence means the desire to do good (usually the
ests in ethically challenging situations.
main reason people become paramedics), whereas benefi-
The paramedic, however, cannot depend on these
cence means actually doing good (the paramedic’s obliga-
institutions to assist in the field. He needs to have a system
tion to the patient).
for resolving these conflicts, one that will allow him to
Maleficence means doing harm, the opposite of benefi-
weigh the various factors, including all relevant facts, prin-
cence. Nonmaleficence means not doing harm. Few medical
ciples, and values, that lead to responsible, defensible
interventions are without risk of harm. Under the principle
actions. One such system or method of resolving ethical
of nonmaleficence, however, the paramedic is obligated to
issues before or after they arise is illustrated in the follow-
minimize that risk as much as possible. This includes, for
ing scenario:
example, making the scene safe and protecting the patient
from impaired or unqualified health care providers. The You are the official representative of your service to the
Latin phrase primum non nocere, which means “first, do no regional EMS coordinating agency. At the most recent
harm,” sums up nonmaleficence very well. meeting, the head nurse for the emergency depart-
Autonomy refers to a competent adult patient’s right ment (ED) of the largest hospital in the county men-
to determine what happens to his own body, including tioned how recent cutbacks in support staff had led to
treatment for medical illnesses and injuries. The para- more difficulty retrieving patients’ medical records in
medic has an obligation to respect this right of self-deter- a timely manner. This has led to a number of difficul-
mination. Under ordinary conditions, a patient must give ties in treating patients. As a result, the ED was con-
consent before the paramedic can begin treatment. There sidering asking incoming ambulances to give patients’
are, of course, exceptions to this, including the patient names and dates of birth on the radio. This would give
who is not competent and for whom the doctrine of the ED staff additional time to search for the patient’s
implied consent applies. However, the competent patient medical records.
must receive accurate information to make an informed After the meeting, you consider the issue’s ethical
decision. This implies that the paramedic must be truthful aspects. First, you identify the problem, which in this
in describing to the patient his condition and the risks and case is: Is it justifiable to breach patient confidentiality
150 Chapter 8
to expedite the retrieval of medical records? Second, The immediate implications are that the ED will be able
you list the possible actions that might be taken in this to get records sooner for patients who have records at that
situation. Possibilities include: hospital. There will be no change for most patients because
hospital records are often irrelevant to emergency care. The
• Provide all patients’ names and dates of birth on the
ED admitting staff may be able to admit patients more
radio.
quickly. However, patients’ names and dates of birth will be
• Continue the current policy of identifying patients broadcast to thousands of people listening with scanners.
only by age and sex. The long-term consequences are that people with scanners
• Provide selected patients’ names and dates of birth will learn more about patients who go to the hospital via
on the radio. EMS. Because private information may be broadcast, patients
may become reluctant to call EMS. Conceivably, there may be
To reason out an ethical problem, first state the action
more burglaries at homes of patients who use EMS.
in a universal form. Then list the implications or conse-
Finally, compare those consequences to values that are
quences of the action. Finally, compare them to relevant
relevant. A list of values that pertain to this case might
values (Figure 8-2). The application of this method to the
include beneficence, nonmaleficence, autonomy, and confi-
scenario described would be as follows:
dentiality. That is, if EMS provided names and dates of
To state an action in a universal form, describe what should birth for all patients on the radio, what would be the bene-
be done, who should do it, and under what conditions. fit to the patient (beneficence)? A few patients might be
For example, EMS (who) will volunteer names and dates cared for sooner because their records arrived sooner. Most
of birth for all patients (what) on the radio (condition). patients will see no benefit because they have no records at
(Adapted from Iserson, K. V., et al. Ethics in Emergency Medicine. 2nd ed. Tucson, AZ: Galen Press, 1995.
Iserson adapted from Brady H.: Ethical Decisions in Medicine. 2nd ed. Boston: Little, Brown & Co., 1981, p. 10.)
that hospital or time is not a significant issue (such as for a for selected patients, a
CONTENT REVIEW
laceration that requires sutures). Furthermore, from a legal breach of confidentiality
➤➤ Quick Ways to Test Ethics
standpoint, such a practice would probably violate patient for patients who might
• Impartiality test
confidentiality laws such as HIPAA. benefit, and no breach of
• Universalizability test
Autonomy suffers under this arrangement because the confidentiality for patients
• Interpersonal
patient is not given the opportunity to consent (or decline). who would not benefit. justifiability test
The patient’s name and date of birth go out over the air Therefore, the scenario may
without his permission. And, in this case, nonmaleficence conclude as follows:
and confidentiality are intertwined. There is potential for
The third option sounds closer to being acceptable, but
harm to the patient and to future patients who lose faith in
you might wonder if there is a way to further limit loss of
the EMS system’s ability to maintain privacy.
confidentiality. You revise your rule to read, “EMS broad-
Therefore, because the possible consequences of pro-
casts the initials and dates of birth of selected patients
viding all patients’ names and dates of birth on the radio
who meet predetermined criteria when there is no other
are not compatible with the values we consider important
private means of communication available.” This strictly
and relevant, you must go back and test another action
limits the loss of confidentiality to patients who may
using this same method.
benefit from it and encourages both EMS and the ED to
When you evaluate the choice of continuing the current
find other less public means of identifying patients. For
policy of identifying all patients over the radio only by age
example, paramedics could broadcast a patient’s age,
and sex, you may find the following consequences: People
sex, and hospital card number or, if the patient does not
listening to scanners can learn facts about patients EMS is
have a hospital identification card available and time
transporting, but no more than they have in the past; a few
allows, someone at the scene could telephone the ED to
patients may get care that is delayed or less than optimal
relay the patient’s name and date of birth privately.
because their hospital records do not arrive quickly enough;
and the ED staff are still stressed because they cannot get The method just described is useful when you come
records in a timely manner. A comparison with relevant val- upon a new ethical problem and time is not an issue. In
ues reveals that patient confidentiality and patient confi- situations where time is limited, an abbreviated method
dence in EMS are unchanged, but the patients who might can sometimes be used (Figure 8-3). First, ask yourself
benefit from earlier arrival of their records may be suffering. whether the current problem is similar to other problems
Continue to evaluate any other options you listed. In for which you have already formulated a rule. Then, if the
this case, the third and final one is: Provide selected patients’ answer is yes, follow that rule. If the answer is no, deter-
names and dates of birth on the radio. A comparison with mine whether you can do something to buy time. Finally, if
relevant values shows that there is some potential benefit you can find a reasonable way to postpone dealing with
*Do you already have a rule for dealing with this problem?
*Or, can you reasonably extend a rule to apply to the situation?
If no to the above,
*Can you buy time to consider a solution without causing significant risk to the
patient?
*If you cannot, then apply the impartiality test, the universalizability test, or the
interpersonal justifiability test.
(Based on Iserson, K. V., et al. Ethics in Emergency Medicine. 2nd ed. Tucson, AZ: Galen Press, 1995.)
the issue for a while, do so. If you cannot, analyze the best appears unresponsive. Your instincts say, treat her now
rule you have against three tests suggested by Iserson: the and let the hospital sort things out later if she survives.
impartiality test, the universalizability test, and the interper-
sonal justifiability test: In this case, your instincts are probably steering you in
the right direction for a number of reasons. First, every
• Impartiality test—asks whether you would be will- state that has laws or rules regarding Do Not Resuscitate
ing to undergo this procedure or action if you were (DNR) orders requires that you see the order and verify its
in the patient’s place. This is really a version of the legitimacy in some manner. In this case, the order is not
Golden Rule (do unto others as you would have available for you to see, so you are under no legal obliga-
them do unto you), which helps to reduce the pos- tion to withhold care.
sibility of bias. Second, if the patient is alive (as she appears to be),
• Universalizability test—asks whether you would even a valid DNR order would not prevent you from
want this action performed in all relevantly similar assessing the patient and administering basic care, includ-
circumstances, which helps the paramedic to avoid ing comfort care.
shortsightedness. Third, the principle of nonmaleficence says do no
• Interpersonal justifiability test—asks whether you harm. Refraining from helping her might cause irreversible
can defend or justify your actions to others. It helps harm, including perhaps death. The principles of benefi-
to ensure that an action is appropriate by asking the cence and nonmaleficence both urge you to help the
paramedic to consider whether other people would patient. The potential conflict arises when you consider
think the action reasonable.5 autonomy. The competent patient of legal age has a right to
determine what happens to her body. You have some rea-
When there is little time to consider a new ethical son to believe she has determined that she does not wish
problem, these three questions can help a paramedic navi- resuscitation efforts if her heart stops but, in this case, the
gate murky waters, allowing him to find an acceptable accuracy of this information cannot be verified.
solution in a short time. The conclusion of the scenario is as follows:
Ethical Issues severe time limitations you are facing, you and your
partner go ahead and assess the patient. You find that
in Contemporary she responds to verbal stimuli by moaning, her air-
way is open, ventilations are adequate, and she has
Paramedic Practice several lacerations and apparent fractures. Because
you are literally in front of the hospital, you limit
The first part of the chapter built a foundation for ethical
your interventions to quick immobilization on a spine
decision making by describing and demonstrating meth-
board with bleeding control and oxygen by mask. You
ods for dealing with these types of issues. The following
rapidly move her to the ED and turn her over to the
discussion is meant to help you apply those principles to
team there.
several commonly encountered situations. It also describes
Later, you discover that she had originally been
some of the ethical considerations to take into account in
admitted for evaluation of new-onset seizures. When
less common situations you may face.
the doctors told her that she might have a brain tumor,
she signed a DNR form. Fortunately, no tumor was
Resuscitation Attempts found and her prognosis is actually quite good. The
Consider the following scenario: trauma team finds no life-threatening injuries from
her fall and expects her to be able to begin psychiat-
You are leaving the ED in your ambulance when an
ric treatment before she leaves the hospital. This addi-
approximately 50-year-old woman jumps out of a win-
tional information makes you very glad you decided
dow on the third floor of the hospital and lands on the
to go ahead with treatment.
road in front of you. Your partner stops the vehicle,
and you get your equipment to begin assessment and More states are passing laws or regulations allowing
management of the patient. As you reach her, a breath- prehospital personnel to withhold certain treatment when
less aide runs out the door and says, “Don’t do any- the patient has a DNR order. A valid order consists of a
thing! She’s got a DNR order!” How does this affect the written statement describing interventions a particular
care you administer? patient does not wish to have that is recognized by the
You have virtually no time to think about what to authorities of that state. Before following a DNR order, the
do for this woman, who is bleeding on the street and paramedic must be aware of several things.
Ethics in Paramedicine 153
First, the order must meet state and local requirements received a good deal of attention and the conclusion is that,
regarding wording and witnesses (a standardized form is except at the extreme ends of the spectrum, there is no con-
usually available). Also, there may be a time limit on how sensus on what constitutes a futile attempt at resuscitation.
long a DNR order is valid in certain jurisdictions. A patient In addition, there is the issue of who would actually
with a valid prehospital DNR order may be required to make the decision that a resuscitation attempt is futile in a
wear or have nearby a particular means of identification, particular case. Is it the experienced paramedic who has
such as a bracelet with a special symbol. There should be a seen very few lives saved under similar circumstances or
clear description of which interventions are to be withheld the new paramedic who is still excited about the prospect
and under which circumstances. And finally, every patient of saving lives every day? How can it be fair to have such
is still entitled to reasonable measures intended to make wide disparities in such an important decision? Clearly, the
the patient more comfortable (comfort care). Similarly, the concept of futility does not provide a useful guide for
family and loved ones are entitled to emotional support whether or not to attempt resuscitation.
from EMS providers. (See the chapter “Medical/Legal Another related topic is what to do when an advance
Aspects of Preshospital Care” for legal aspects of DNR directive is presented to you after you have begun resusci-
orders.) tation. Once you have verified the validity of the order and
Paramedics spend a great deal of time and energy the identity of the patient, you are obligated ethically (and
learning how to assess and treat patients with life-threaten- perhaps legally, depending on your state) to cease resusci-
ing problems. It becomes difficult, then, for a paramedic to tation efforts. This can be a very difficult situation for you
watch someone die without doing something to try to stop emotionally, but you have an obligation to respect the
it. You must nonetheless respect the patient’s wishes when patient’s autonomy and stop doing something to him that
a competent patient has clearly communicated what he he did not want. Follow your local protocols regarding
really wants. DNR orders make this easier because they procedures for cessation of resuscitation efforts.
typically must be signed or approved by a physician,
increasing the likelihood that the decision was thoroughly Confidentiality
thought through.
Consider this scenario:
When there is no such order, however, it becomes more
difficult for the paramedic to determine what the patient’s You are called at one o’clock in the morning to a local
wishes truly are. Family members may be able to describe hotel for a man reported to be unresponsive (but
the patient’s desires, but they can have conflicts of interest breathing) at the front desk. When you arrive, one of
that make their statements less credible. For example, the the guests at the hotel meets you at the front door.
patient may have accepted his impending death before his He tells you that he tried to call the front desk from
family has. They may want you to attempt resuscitation his room to request a wake-up call but got no answer.
when that was clearly against the patient’s expressed When he went to the front desk, he found the clerk
wishes. A less common situation is one in which the patient slumped over in his chair, apparently unconscious,
wishes all resuscitation efforts, but the family does not with what smelled like alcohol on his breath.
because they do not wish to prolong their own suffering or When you approach the patient, you see an
they have other, less noble, motivations. approximately 25-year-old male who appears to be
The general principle for paramedics to follow in cases unresponsive. His skin appears normal, and he is mov-
such as these is: “When in doubt, resuscitate.” This usually ing air well. He does not respond when you call him by
satisfies the principles of beneficence and nonmaleficence, the name on his name plate, which is Howard. He has
admittedly perhaps at the expense of autonomy, but one of a strong, regular radial pulse that is within normal lim-
the biggest advantages to this approach is that, unlike the its. You do not smell anything except for a faint minty
alternative, it is not irreversible. If you refrain from odor. When you shake his shoulder and call his name
attempting resuscitation, it is certain that the patient will again, he moans. Further shaking and shouting even-
die. If you attempt resuscitation, there is no guarantee that tually bring him to the point where his eyes are open,
the patient will survive, but the patient can be removed he is looking around, and he asks, “Who are you?”
from life-sustaining equipment later if that is deemed You explain to Howard that you were called by a
appropriate. Another advantage is that there will be more concerned guest who could not wake him up. Howard
time later to sort out competing interests. says he is fine now and does not want to go to a hospi-
What about not attempting resuscitation when the sit- tal. He is alert and oriented to person, place, and time.
uation appears futile? This option may appear attractive at He denies any complaints, takes no medications, and
first glance. After a little investigation, though, the issue has no past medical history. His vital signs are within
becomes much more complex. How would a reasonable normal limits. He denies any alcohol intake or use of
person or society define “futile”? This is an issue that has any other drugs. The physical exam is unremarkable.
154 Chapter 8
By your protocols and standard operating pro- are considered justifiable reasons to breach confidential-
cedures, you have no reason to attempt to force the ity because, in the eyes of society, the benefit to someone
patient to go to a hospital. You complete the appropri- who is defenseless (protection from harm and perhaps
ate documentation for a refusal of transport and are even death) and to the public (a safer environment for
leaving the lobby when the guest who called 911 stops children) outweighs the right to privacy of a particular
you. “Aren’t you going to take him to the hospital?” he person. A valid court order is also considered a reason-
asks. No, you reply, he does not want to go. “But what able justification for breaching confidentiality. So is a
if there’s a fire in the hotel and he’s passed out and clear threat by a patient to a specific person, as well as
unable to help guests evacuate?” informing other health care professionals who will care
This makes you stop and think, and you begin to for the patient.
weigh the rights of the hotel guests against the rights Clearly, patient confidentiality is an important princi-
of your patient. ple, but not an inviolable one. When determining whether
it is appropriate to breach confidentiality, take into account
Your obligation to the patient is to maintain as confi-
the probability of harm, the magnitude of the expected
dential the information you obtained as a result of your
harm, and alternative methods of avoiding harm that do
participation in this medical situation. Clearly, the most
not require encroaching on confidentiality.
beneficial thing you can do for his privacy is not to notify
In the previous scenario, factors do not justify breach-
anyone about his condition. Additionally, there are ques-
ing confidentiality. The person who called 911 for emer-
tions regarding what you could accurately report. The
gency assistance, however, is under no such obligation.
patient denies alcohol and drug intake, and you could find
The scenario comes to an end as follows:
no objective signs to dispute his claim. He might just be a
heavy sleeper. Reporting that he is or may be under the When you inform the guest that you are unable to dis-
influence of alcohol or drugs might lead to the loss of his cuss the case with anyone because of confidentiality,
job and to legal trouble for you. he replies, “Well, you may not be able to do anything
However, what if there is an emergency in which the about it, but I can. I’m calling the manager!”
desk clerk’s assistance is needed and he is unable to pro-
vide it? That is an unlikely, though certainly a conceivable,
possibility. However, there is no clear and present danger Consent
that would require you to report. In fact, depending on the Consider this scenario:
state you’re in, you may have a legal obligation to maintain
Bob, a 58-year-old male, has been having crushing sub-
confidentiality under circumstances such as these.
sternal pain radiating to his left arm for several hours.
There are a number of reasons to respect confidential-
He also is pale, sweaty, and nauseated. He denies short-
ity in general. In an emergency, a patient typically has little
ness of breath. His condition remains unchanged after
choice about who is going to come to his aid. He is assum-
you give him oxygen and nitroglycerin. When you ask
ing that he can be honest with these strangers who have
Bob which hospital he wants to go to, he tells you, “I’m
come to help him because they will protect his privacy. If
not going to any hospital.” Surprised, you find it dif-
that trust was routinely violated without sufficient cause,
ficult to understand why someone in this much pain
patients might very well be embarrassed or humiliated.
would not want to go to a hospital. You try to enlist the
This would undermine the public’s trust in EMS and any
help of relatives over the telephone (Bob lives alone),
particular patient’s trust in the paramedics and others
but they are unable to persuade the patient. He has
coming into his home. If word got around that private
no regular physician, so that option is not available to
information was being made public, patients might not be
you. Finally, you decide to try on-line medical direc-
forthcoming in giving their medical histories, potentially
tion. While you are waiting for the physician to come
leading to disastrous consequences. For example, a man
to the phone, you wonder: If the patient continues to
who had recently taken sildenafil (Viagra) for erectile dys-
refuse, can you force him to go? How can you act in
function might deny taking it before you give him nitro-
the best interest of a patient who refuses to accept what
glycerin. This drug interaction is potentially serious,
you feel certain is best for him?
possibly even fatal.
There are, nonetheless, times when it is appropriate A competent patient of legal age has the fundamental
and necessary to breach confidentiality. Every state has right to decide what health care he will receive and will not
laws requiring the reporting of certain health facts such as receive. This is at the core of patient autonomy. To exercise
births, deaths, particular infectious diseases, child neglect this right, a patient must have the information necessary to
and abuse, and elder neglect and abuse. These last make an informed decision, the mental faculties to weigh
requirements have the most applicability to EMS. They the risks and benefits of various treatment options, and the
Ethics in Paramedicine 155
freedom from restraints that might hamper his ability to disorder brought to the ED by the presence of a celebrity
exercise his options (such as threats). and the need to get the person out of the ED as quickly as
It is sometimes appropriate to use the doctrine of possible to restore normal operation. The argument against
implied consent to force the patient to go to the hospital. takes the position that giving preferential treatment to a
For the paramedic to use this approach, the patient must be celebrity is an affront to justice and fairness.
unable to give consent. Typically, the doctrine is invoked All these methods have their proponents for different
when the patient is unable to communicate, but it also can situations. The key to resolving the issue of allocation of
be employed when the patient is incapacitated because of scarce resources is to examine the competing theories in
drugs, illness, or injury. In this scenario, however, the light of the circumstances at hand.
patient shows no signs of being incapacitated. He is alert;
oriented to person, place, and time; aware of his surround- Obligation to Provide Care
ings; and making judgments and answering questions in a
By virtue of membership in a profession, a paramedic takes
manner completely compatible with competence. The fact
on a responsibility to help others. The public, through the
that the patient refuses something you recommend does
government, grants certain privileges to professionals in
not, in itself, necessarily indicate that he is incompetent.
return for the expectation of professional behavior. As a
Before you leave the patient, you must not only do the
practitioner of paramedicine, the paramedic has even
things you need to do to protect yourself legally, but you
greater responsibilities. Those who provide emergency
must also assure yourself that the patient truly under-
care have a special obligation to help all those in need.
stands the issues at hand and is able to make an informed
Many other health care professionals are free to pick and
decision. As difficult as it may be for the paramedic, if the
choose their patients, accepting only those who have health
patient is able to do these things, the paramedic may have
insurance or who can themselves pay for the services
to accept the patient’s desires and leave him.
delivered by the health care professional. This is not the
case in emergency medicine.
Allocation of Resources Paramedics, like other emergency professionals, are
Paramedics do not usually think of themselves as guard- obligated to provide medical care for those in need without
ians of finite resources, but occasionally they are. The regard to ability to pay. They also have an ethical obliga-
most obvious example of this is when there are more tion to prevent and report instances of patient “dumping,”
patients present than the paramedic is able to manage, where those without insurance are transferred against their
such as in a multiple-casualty incident (MCI). While will to public or charity hospitals.
learning how to provide emergency medical care for mul- A particular issue arises regarding the patient who is a
tiple patients at the same scene, you might ask: What are member of a managed-care organization such as a health
the ethics of triage? maintenance organization (HMO). The HMO may insist
There are several possible approaches to consider in that the patient be treated at a particular facility with which
parceling out scarce resources. Patients could all receive the HMO has a contract. This must not be allowed to inter-
the same amount of attention and resources (true parity). fere with the patient’s emergency care. The paramedic, like
They could receive resources based on need. Or they could every other member of the EMS system, has an obligation
receive what someone has determined they’ve earned. to act in the patient’s best interest, even when that goes
The civilian method of triage, in which the most seri- against the HMO’s economic interests.
ously injured patients receive the most care, is based on A very different aspect of providing care has to do
need. This is intended to produce the most good for the with offering assistance when off duty. Although only two
most people. However, other methods of triage are in use. states require paramedics, among others, to stop and ren-
Military triage, for example, has traditionally concentrated der help when they come upon someone in need of emer-
on helping the least seriously injured because this approach gency care, there is still a strong ethical obligation to do so.
produces the greatest number of soldiers who can return to This does not extend to situations in which the paramedic
duty. When the president or vice president visits a town or would put himself in danger (such as getting into a car
city, there is typically an ambulance dedicated for the dig-
nitary’s use, if needed. The ambulance is not to be used for
anyone else. Because these officials are so important and Legal Considerations
because so many others need them, the typical order of Intervening Outside Your EMS System. The paramedic
care is changed. functions under the auspices of the EMS medical director as
A controversy exists in emergency medicine as to detailed in system protocols and standing orders. Providing
whether or not celebrities should be treated ahead of oth- ALS skills or interventions outside your EMS system can
ers. The argument for doing so typically emphasizes the lead to possible legal problems and litigation.
156 Chapter 8
teetering on the edge of a cliff), if assisting would interfere competing interests can sometimes make life difficult. Each
with important duties owed to others (such as leaving can lead to ethical challenges.
young children unattended in a car), or when someone else In general, there are three potential sources of conflict
is already providing assistance. In return, society offers between paramedics and physicians. One possibility is a
limited liability in the form of Good Samaritan statutes in case in which a physician orders something the paramedic
every state in the United States. believes is contraindicated. For example, suppose a physi-
cian ordered a paramedic to transport a critical blunt-
Teaching trauma patient without attempting any intravenous access,
either at the scene or en route during the anticipated
Many paramedics act as preceptors or mentors in their
45-minute transport. This order runs counter to standard
EMS systems. Two issues raised by this role are whether or
medical practice. The patient will have spent more than an
not patients should be informed that a student is working
hour since the trauma without receiving any intravenous
on them, and how many attempts a student should be
fluid or intravenous access.
allowed to have in performing critical interventions before
A different situation arises when the physician orders
the preceptor steps in.
something the paramedic believes is medically acceptable
When patients call for EMS, they generally expect to
but not in the patient’s best interests. For example, imagine
receive care from individuals who have finished their edu-
you are transporting a patient with stable vital signs who is
cation and who hold credentials qualifying them to work.
complaining of abdominal pain. In accordance with your
If a system decides not to inform patients of the presence of
protocols, you and your partner have each tried twice to
students, the system runs the risk of being accused of con-
start an IV line without success. The patient’s veins are
cealing important information from patients.
some of the worst you have ever seen, and you have no
To avoid this problem, EMS systems with students
expectation that you will be successful on further attempts.
working in them should make sure students are clearly
The patient experienced considerable pain with each
identified as such by the uniform they wear. The preceptor
attempt and is now crying, asking you not to try anymore.
should also, when appropriate, inform patients of the pres-
The physician, however, insists that you continue attempts
ence of a student and request the patient’s consent before
to gain access.
the student performs a procedure. This sounds more cum-
A third potential source of conflict is the situation in
bersome than it actually is. Patients who are unable to con-
which the physician orders something the paramedic
sent obviously do not fall into this category; implied
believes is medically acceptable, but morally wrong. For
consent is invoked in this case. And patients who are able
example, say you are ordered to stop CPR on a young male
to consent are frequently very understanding of the stu-
patient found in cardiac arrest after blunt trauma. His initial
dent’s need for experience. As long as the preceptor stresses
rhythm of asystole has remained unchanged, and you know
that he is overseeing the student, the vast majority of
it is almost always associated with death. Nonetheless,
patients usually give their consent.
although there is a very slim chance of recovery for the
Another issue related to students is how many
patient if you continue your resuscitation efforts, you would
attempts they should be allowed in order to perform pro-
not be able to live with yourself if you did not at least try.
cedures such as intravenous placement and endotracheal
In each of the three cases, it is certainly appropriate for
intubation before the preceptor steps in. Factors to consider
the paramedic to start by confirming the order and asking
include the student’s skill level (as determined by class-
the physician to repeat it. If the order is confirmed, the medic
room practice on mannequins and previous field experi-
would be prudent to ask the physician for an explanation,
ence), the anticipated difficulty of the procedure (some
given the controversial nature of the orders in the first two
patients are obviously going to be more difficult to intu-
situations (in the third, the physician’s thoughts and goals
bate or start an IV on), and the relative importance of the
are fairly clear). The next steps will depend on the physi-
procedure (not all IVs are equally important). It is impor-
cian’s explanation, the patient’s condition, the need for the
tant to have a limit, at least initially, for the number of times
intervention in the judgment of the paramedic, the feasibil-
a student will be allowed to attempt a procedure. Such a
ity of performing the intervention (like gaining IV access),
number will need to be decided by each system in consul-
and the amount of time available to discuss the issue.
tation with the medical director.
Ultimately, the paramedic must determine for himself
how the patient’s interests are best served. This typically
Professional Relations does not lead to conflict, but on occasion the paramedic
As a health care professional, the paramedic answers to the may run into situations similar to the ones previously
patient. As a physician extender, the paramedic answers to described. In these cases, the medic must consider the
a physician medical director. As an employee (or volun- competing interests of beneficence, nonmaleficence,
teer), the paramedic answers to the EMS system. These autonomy, and justice; the roles of the physician and the
Ethics in Paramedicine 157
paramedic; the relative confidence (or lack thereof) the implementing research protocols and gathering data. It is
paramedic has in his own medical and ethical judgment; essential that a paramedic participating in a research proj-
how far the paramedic is willing to go as an advocate for ect understand the importance of gaining expressed patient
his patient; and the degree of risk acceptable to the para- consent or following federal, state, and local regulations
medic in contravening physician orders. regarding implied consent.
It is important for the paramedic to understand that no The goal of patient care is to improve the patient’s con-
matter what decision he makes, he will have to defend it. dition. The goal of research, however, is to help future
The explanation that he was just following the doctor’s patients by gaining knowledge about a specific interven-
orders (or, conversely, just doing what he felt was right) will tion. The two goals are not the same, so patients must be
not be sufficient in and of itself. A paramedic is expected to protected from untoward outcomes as much as possible.
be more than a robot. He or she is expected to simultane- One very important way of protecting the patient is by
ously be a physician extender, working under a physician’s gaining the patient’s expressed consent. There are several
license, and a clinician with the ability and independence to difficulties with this. One is the concern that a patient expe-
recognize and question inappropriate orders. The para- riencing an emergency may not be able to truly consent
medic should also understand that he is not expected to act because of the emotional pressures he is feeling. This pres-
in ways he feels are immoral. However, if the individual’s sure may occur in spite of the paramedic’s best efforts to
morals are significantly out of step with the expectations of explain matters calmly and impartially.
the profession, he needs to reconsider his profession. Another concern is with the patient who is unable to
Disagreements with physician orders happen rarely. consent. An excellent example of this occurs in cardiac
Usually they are the result of poor communication (such as arrest research. By the very nature of the problem being
saying one thing while meaning another or static interfer- studied, the investigators will be unable to gather consent
ing with the radio transmission) or lack of sufficient infor- from the patient. In this case, the federal government has
mation. Conflicts with physicians that reach the level in the strict rules—for example, about community notification
previous examples are fortunately rare. When they hap- before the study begins and gaining consent from the
pen, the paramedic must be willing to be an advocate for patient or an appropriate family member as soon as possi-
the patient and act in the patient’s best interests. ble after a patient is entered into the study. A paramedic
participating in such a study needs to be familiar with
these rules and their implications.
Research Although many interventions have been tested and
EMS research is relatively new but absolutely important found to be life saving, there are unfortunately docu-
for the profession to advance. Research is the foundation mented instances of patients denied treatment for life-
on which all scientific endeavors, including medicine, are threatening conditions in the name of research in the
built. Research will help introduce new innovations that United States (e.g., the Tuskegee syphilis research project).
improve patient outcomes and remove those that do not. The paramedic has an obligation to prevent such things
As this occurs, paramedics will become instrumental in from happening in EMS research.
Summary
Should you start CPR or withhold it? Do you allow the patient to refuse essential care or not?
These are some of the most challenging and most common ethical challenges seen in EMS.
As a paramedic, you must learn to make ethical decisions that will have an effect on you, your
patient, or others. Your decision-making process should always be based on the patient’s best
interest. Keep in mind that the patient’s best interest includes more than lifesaving procedures.
Cultural sensitivity should also be included in the decision and respected, even if it is against your
personal beliefs. Remember, the patient has autonomy; that is, he has a right to determine what
happens to his own body and can legally dictate that. Remember there is a clear distinction
between ethics, religion, and law even though there is common ground between them.
At some point in your career you may be called on to defend a decision you made. The best
defense results from being able to state that your actions were legal and within your scope of prac-
tice (justice), helpful (beneficence), not harmful (nonmaleficence), and the direct wishes of the
158 Chapter 8
patient (autonomy). As long as you can defend your decision using these staples of ethics, your
decision is correct.
Review Questions
1. ___________ are generally considered to be one’s 4. Which quick way to test ethics asks whether you
personal social, religious, or other standards of right would be willing to undergo a particular procedure
and wrong. or action if you were in the patient’s place?
a. Ethics c. Standards a. Impartiality test
b. Morals d. Principles b. Navigation test
b. HMOs d. CQI See answers to Review Questions at the back of this book.
References
1. Adams, J. G., R. Arnold, L. Siminoff, and A. M. Wolfson. “Ethical 3. American College of Emergency Physicians. “Code of Ethics for
Conflicts in the Prehospital Setting.” Ann Emerg Med 21 (1992): Emergency Physicians.” Ann Emerg Med 52 (2008): 581–590.
1259–1265. 4. Touchstone, M. “Part 3: How to Adhere to a Code of Ethics in
2. Hilicser, B., C. Stocking, and M. Siegler. “Ethical Dilemmas in EMS.” EMS Magazine 39 (2010): 75–76.
Emergency Medical Services: The Perspective of the Emergency 5. Iserson, K. V., et al. Ethics in Emergency Medicine. 2nd ed. Tucson,
Medical Technician.” Ann Emerg Med 27 (1996): 239–243. AZ: Galen Press, 1995.
Further Reading
Hope, T. Medical Ethics: A Very Short Introduction. Oxford, New York: Larkin, G. L. and R. L. Fowler. “Essential Ethics for EMS: Cardinal Virtues
Oxford University Press, 2004. and Core Principles.” Emerg Med Clin North Am 20 (2002): 887–911.
Chapter 9
EMS System
Communications Bryan Bledsoe, DO, FACEP, FAAEM
Kevin McGinnis, MPS, EMT-P
STANDARD
Preparatory (EMS System Communication)
COMPETENCY
Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical–legal and
ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to use technology and knowledge of EMS
communications systems and skills to communicate effectively in carrying out your responsibilities as a paramedic.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
159
160 Chapter 9
KEY TERMS
accelerometers, p. 168 duplex, p. 173 prearrival instructions, p. 169
ad hoc database, p. 172 echo procedure, p. 165 prehospital care report (PCR), p. 165
advanced automatic crash emergency medical dispatcher priority dispatching, p. 169
notification (AACN), p. 168 (EMD), p. 169 public safety answering point
automatic crash notification Federal Communications (PSAP), p. 167
(ACN), p. 167 Commission (FCC), p. 180 radio band, p. 172
automatic location information geographic information system radio frequency, p. 172
(ALI), p. 167 (GIS), p. 172
repeaters, p. 172
automatic number identification global positioning systems (GPS),
(ANI), p. 167 SafeCom, p. 163
p. 167
bandwidth, p. 177 semantic, p. 163
hand-off, p. 170
call routing, p. 167 simplex, p. 173
hotspot, p. 175
cells, p. 175 situational awareness (SA), p. 171
information communications
cellular telephone system, p. 175 technology (ICT), p. 172 smart phone, p. 175
cognitive radio, p. 177 mission-critical communications, 10-code, p. 163
common operating picture p. 175 terrestrial-based triangulation,
(COP), p. 171 mobile data unit (MDU), p. 175 p. 167
communication, p. 163 multiband radio, p. 177 trunking, p. 174
communication protocols, p. 164 ultrahigh frequency (UHF), p. 173
multiplex, p. 174
data dictionary, p. 165 very high frequency (VHF), p. 173
National Emergency Medical
dead spot, p. 171 Services Information System voice over Internet protocol (VOIP),
digital communications, p. 174 (NEMSIS), p. 165 p. 168
Case Study
TODAY helicopter will land in 20 minutes. As the ambulance
departs, he relays the following by radio to Dr. Doyle,
On a dry, warm Sunday afternoon, a 31-year-old man
the medical direction physician at the regional trauma
loses control of his car at 50 miles per hour and strikes a
center:
bridge abutment. No one witnesses the incident, as it is
on a remote stretch of secondary roadway. The first Paramedic: Depew Ambulance to Mercy Hospital.
motorist happens on the crash 20 minutes later and
dials 911 on his mobile phone. Emergency medical dis- Dr. Doyle: Go ahead, Depew.
patcher Vern Holland takes the necessary information Paramedic: We are leaving the scene of a car accident
and dispatches a basic life support engine company and on Route 17 in Mount Vernon. We have one
an advanced life support ambulance. As Holland dis- patient, a male in his thirties, the driver of
patches the emergency units, his partner, paramedic a car that went off the roadway and struck
dispatcher Fred Hughes, instructs the caller in basic a bridge abutment. He responds to pain
emergency care. only, with obvious facial and chest trauma.
The units receive the call via a computer printout There is a large laceration above the right
of essential information. They arrive at the scene eye with an exposed skull fracture. There
20 minutes later, initiate the appropriate care, and call is also blood draining from the right ear.
for a medical helicopter. Because the patient has a Vital signs are blood pressure 110/60,
severe head injury, the paramedic performs only a pulse 110 and regular, respirations 10 and
limited assessment and immediately initiates trans- labored. Pupils are dilated and minimally
port to a preplanned remote landing site, where the reactive, yet equal. Palpation of the cervical
EMS System Communications 161
spine does not reveal any obvious defor- the crash, the type of vehicle, its location, speed, and
mity. There is no tracheal deviation. Breath direction of impact. Seeing a “potential major injury”
sounds are symmetrical, yet diminished. warning displayed, he initiates a response protocol
There is subcutaneous emphysema on the keyed to that warning. He dispatches a heavy rescue/
right side of his chest and several palpable extrication truck, a support engine company, and an
rib fractures. The abdomen is soft, and the advanced life support ambulance. Simultaneously, he
pelvis appears stable. There may be some requests LifeFlight 2 to launch and puts the Mercy Hos-
lower extremity fractures. A rigid C-collar pital Trauma Center on alert. The responding vehicle
is in place.. An endotracheal tube has been crews have all the AACN data on their mobile data
placed. Respirations are being assisted units (MDUs) as they leave their quarters (location data
with a BVM using supplemental oxygen. are automatically fed to the onboard GPS and a best
We will attempt an IV en route to the remote route provided by a local transportation authority
landing site where LifeFlight 2 is 15 min- hourly update). The extrication crew en route views on
utes out. The patient’s ETA to your facility their MDU a “just in time training” review of the haz-
is 40 minutes. ards and best entry and cutting points for the identified
Dr. Doyle: We copy, Depew. Attempt an IV, but expe- crash vehicle. The helicopter and trauma center staffs
dite transport and notify us of any further receive the AACN information as well.
problems. The ground units arrive at the scene 20 minutes
later. The paramedic performs a primary survey and
Paramedic: We copy. Attempt an IV and we will notify
simultaneously speaks his patient findings into a throat
you with any changes.
microphone (same report as given in the first, “today,”
Dr. Doyle: The trauma team will be in the ED awaiting version of the case study), activates the video camera
the patient’s arrival. on his safety glasses, and places a wireless multi–
Paramedic: Copy that, Mercy. Depew clear. vital-sign monitor with probes on the patient’s chest.
He inserts a flash memory card, the size of thumbnail
A rapid transfer to the helicopter and exchange of
and worn by the patient, into his public safety commu-
information with its crew is accomplished. On arrival
nications device (PSCD—a combined very smart phone
at the trauma center, the trauma team and a neurosur-
and push-to-talk radio device) and downloads the
geon meet the patient. The time interval from injury
patient’s pertinent medical history. The paramedic’s
to surgical intervention is 1 hour and 40 minutes.
patient report is translated to a text file and stored on
Despite comprehensive care, the patient dies as a
his PSCD and sent to the ambulance MDU, as are the
result of his head injury. At the family’s request, the
patient video, multi–vital-sign data, and medical his-
patient’s organs are harvested. They are sent to cities
tory. Immediately, the MDU sends a signal to dis-
more than 1,500 miles away and used in two trans-
patcher Holland, who notifies LifeFlight 2 and Mercy
plant operations.
Hospital of the patient data feed availability. Dr. Doyle
taps into the four data feeds from his electronic tablet
THE NOT-TOO-DISTANT FUTURE and sends a message confirming the IV order. The heli-
On a dry, warm Sunday afternoon, a 31-year-old man copter medical crew reviews the patient feeds and doc-
loses control of his car at 50 miles per hour and strikes a tor’s order, then messages the ground paramedic of
bridge abutment. No one witnesses the incident, as it is their three-minute estimated time of arrival (ETA) and
on a remote stretch of secondary roadway. The vehicle’s willingness to get the IV going in the air if not already
advanced automatic crash notification (AACN) device established.
immediately sends a data burst to the AACN call center, A rapid transfer to the helicopter and exchange of
where the data message is identified as a crash and is information with its crew are accomplished. On its
automatically forwarded to the public safety answering arrival at the trauma center, the trauma team and a neu-
point (PSAP) for the global positioning system (GPS)- rosurgeon meet the patient. The time interval from
identified jurisdiction of the crash. Voice and video links injury to surgical intervention is 50 minutes. The patient
are also patched to the PSAP. leaves the hospital alive with months of intensive reha-
The emergency medical dispatcher, Vern Holland, bilitation ahead but a bright prognosis.
tries the voice and video links, with no voice response (AACN systems, PSAPs, GPS, smart phones, and
or useful pictures from the crashed car, while he reviews MDUs will be discussed in more detail later in the
the data from the vehicle. He knows, within a minute of chapter.)
162 Chapter 9
abbreviations, you have failed to communicate. The • Pertinent physical exam findings
receiver must be able to decode the sender’s message. • Treatment given so far/request for orders
• Estimated time of arrival at the hospital
Reporting Procedures • Other pertinent information
As a paramedic, you must effectively relay all relevant
The formats and contents of reports for medical
medical information to the receiving hospital staff. Initially,
patients and for trauma patients differ to include only the
you might do this over the radio or by mobile phone. Later,
information relevant to either type of emergency. Reports
when you deliver your patient to the emergency depart-
for medical patients emphasize the history in the begin-
ment, you can give additional information in person to the
ning of the report; reports for trauma patients emphasize
appropriate receiving hospital personnel.
the injuries and the physical exam.
One of your most important skills will be gathering
After transmitting your report, you will wait for fur-
essential patient information, organizing it, and relaying it
ther questions and orders from the medical direction phy-
to the medical direction physician. The medical direction
sician. On arrival, your spoken report will give essential
physician will then issue appropriate orders for patient
patient information to the provider who is assuming care.
care. The amount and type of information you relay to the
It should include a brief history, pertinent physical find-
medical direction physician will depend on the type of
ings, treatment you have provided, and the patient’s
technology you use, your patient’s priority, and your local
responses to that treatment.
communication protocols. For example, if communica-
tions in your region are not secure (private), you must limit
the type of information you can communicate without General Radio Procedures
breaching patient confidentiality. The acuteness of your
All radio transmissions must be clear and crisp, with con-
patient’s clinical status and the amount of local radio traffic
cise, professional content (Figure 9-2). Always follow these
also may determine the length of your report. For a critical
guidelines for effective radio use:
patient, you may give a brief report while you tend to your
patient’s medical needs. For a complicated medical emer- 1. Listen to the channel before transmitting to ensure that
gency, you may wish to communicate a greater share of the it is not in use.
results of your history and physical exam to the medical 2. Press the transmit button for one second before speaking.
direction physician.
3. Speak at close range, approximately 2 to 3 inches,
directly into, or across the face of, the microphone.
Standard Format
Communicating patient information to the hospital or to
the medical direction physician is a crucial function. Verbal
communications by radio or phone give the hospital
enough information on your patient’s condition so its staff
can prepare for his care. These communications also should
elicit the medical orders you need to treat your patient in
the field.
A standard format for transmitting patient assessment
information helps to achieve those goals in several ways.
First, it is efficient. Second, it helps the physician assimilate
information about the patient’s condition quickly. Third, it
ensures that medical information is complete.
In general, your verbal reports to medical direction
should include the following information:
Terminology
Written Communication Every industry develops its own terminology. Doing so
Written records are another important aspect of EMS com- makes communication within the industry more clear, con-
munications. Your prehospital care report (PCR) (also cise, and unambiguous for those within that industry. The
called patient care report) is a written or an electronic, key- airline industry, for example, uses the term payload to
board/mouse-entered record of events. The written report describe the total weight of everything (passengers, fuel,
includes administrative information such as times, loca- luggage, and other items) on an airplane. Musical compos-
tion, agency, and crew, as well as medical information. ers and arrangers use terms like allegro, fortissimo, or a cap-
Hospital staff, agency administrators, system quality pella to describe a specific tempo or style.
assurance/improvement committees, insurance and bill- The medical field also uses an extensive list of terms,
ing departments, researchers, educators, and lawyers, will acronyms, and abbreviations that allow quick, accurate
166 Chapter 9
Sequence of Communications
communication of complex information. (The chapter in an EMS Response
“Documentation” includes an extensive table of standard
The sequence of an EMS response illustrates the impor-
charting abbreviations.) An emergency physician may
tance of communications in prehospital care. A typical
request a CBC (complete blood count), ABGs (arterial
EMS response includes the chain of events described next.
blood gases), or a CMP (comprehensive metabolic panel)—
common terms describing diagnostic tests run on patients. Detection and Citizen Access
The emergency services industry has developed its own To begin the response to any emergency, someone must
terms for radio communication (Table 9-1). These words or detect the problem and summon EMS (Figure 9-4). Any
phrases shorten airtime and transmit thoughts and ideas citizen with an urgent medical need should have a simple
quickly. For example, “copy” means “I heard you and I and reliable mechanism for accessing the EMS system. In
understand what you said.” Using industry terminology the United States, most people access EMS by telephone;
appropriately is an important part of effective communica- thus, a well-publicized universal telephone number such
tion, providing a commonly understood means of communi-
cating with other emergency care professionals. Terminology
is considered to be plain English within the discipline in
which it is used; its use is not considered to be the same as
coded substitutions for plain English (such as 10-codes),
which were discussed earlier, and are discouraged.
The Importance
of Communications
in EMS Response
Your ability to communicate effectively during a stress-
ful EMS response is very likely to determine the success FIGURE 9-4 The EMS response begins when someone detects an
or failure of your efforts. A brilliant assessment and emergency and summons EMS assistance.
EMS System Communications 167
as 911 provides direct citizen access to the communica- connection with landline telephone service saves many
tions center. lives each year.
The 911 system has been available since the late 1960s. By 2010, however, a full third of the 240 million annual
The first 911 system simply provided the common, easy-to- 911 calls in the United States (half or more in some com-
remember access number and allowed 911 centers to auto- munities) have come from wireless/mobile phones. With-
matically “ring back” a caller ’s phone if there was a out a direct-wired connection to a physical location, ANI
disconnect. At newer Enhanced 911 (E911) communication and ALI did not work with the early wireless phone sys-
centers, a computer also displays the caller’s telephone tems. An emergency dispatcher who received a call from a
number (a feature called automatic number identification, cell phone had to rely on the caller’s ability to state his
[ANI]) and location (a feature called automatic location location and phone number. In many cases, the caller, who
information [ALI]). was traveling in an unfamiliar area or had an altered level
of consciousness or was incapacitated, could not provide
911 his location and number and could not be found. These
Currently, 99 percent of the population in the United States cases were often associated with bad patient outcomes.
and 96 percent of the nation’s geographic area have a 911 Further complicating the problem has been the issue of
system. Of the geography covered by 911 systems, 93 per- call routing. Typically, wire-line 911 calls are routed via a
cent has E911 service. Highway 911 call boxes, citizens trunk line and a specialized address database to the nearest
band (CB) radio, and amateur radio all provide alternative 911 center. Wireless 911 calls that do not carry address data-
means of accessing emergency help in some regions. base data with them cannot be automatically routed to the
Increasingly, manual and automatic alerting systems nearest 911 center. Thus, emergency calls from early wire-
are used by the elderly and those who are incapacitated, less telephone systems were often routed out of the caller’s
such as “Help, I’ve fallen and I can’t get up” devices. Other location to the location associated with the wireless service
types of patient home monitoring devices may have auto- provider—which may have been a different city, county,
matic alarms as well. Typically, all these types of devices state, region, or even country.
alert a monitoring center, which, in turn, calls 911, rather In many cases, the caller is simply too excited to pro-
than sending a message directly from the device to 911. vide the emergency dispatcher with the correct informa-
Automatic crash notification (ACN) is another type of tion. One such case involved a 19-year-old girl in a rural
automatic event alerting system that may result in EMS New York State community who called 911 to report an
dispatch. 3 (A more sophisticated version of ACN— oven fire. She was cooking dinner at her grandmother’s
advanced notification [AACN]—will be discussed later.) home when the fire began. She helped her grandmother
Most 911 centers are now called public safety answer- out of the home and dialed 911 on her wireless phone.
ing points (PSAPs). The PSAP routes the 911 call to the When the dispatcher asked her for her address, she gave
appropriate agency for dispatch and response if it does not her own home address, not the address of her grandmother’s
also do the dispatching itself. In some systems, the PSAP home. The resulting confusion over the location of the
call taker will elicit the information, determine the nature emergency was responsible for total loss of the structure.
of the needed response, and dispatch the appropriate Cases like this are still not unheard of, even with the
responding agencies. In others, the call taker will simply increasingly widespread installation of sophisticated E911
answer with the question “Is this a police, fire, or medical systems that can determine the location of a wireless or
emergency?” and transfer the caller to the appropriate dis- mobile phone (using triangulation or GPS technology, as
patcher, who will then elicit specific information. Many will be described next). This event happened not that long
systems use computerized technology at the PSAP to con- ago—in 2002.
nect the caller automatically with the appropriate agency. Recognizing the rapidly expanding popularity of cell
Some even provide language translation. phones in the last decades of the twentieth century, the
E911 technology has always worked well with land- Federal Communications Commission (FCC) began
line systems in which there is a wired connection all the phased implementation of rules requiring wireless provid-
way from the caller’s phone to the PSAP. The landline con- ers to enable ANI and one of two versions of an ALI appli-
nection also allows ANI and ALI (which identify the cation. PSAPs would also be required to accommodate the
phone number and location of the caller) to work because data to enable them to display and use this number and
of the unique, direct-wired connection to a telephone asso- location identification data.
ciated with a physical address to which EMS could Wireless phones can now be located by terrestrial-
respond. This automatic provision of ANI and ALI allows based triangulation, by global positioning systems (GPS),
dispatch of an emergency response even while emergency or by a combination of the two. Triangulation of a wireless
medical dispatch (EMD) prearrival instructions are being signal involves the use of three mobile phone towers. Based
given. Few EMS providers would disagree that E911 in on the strength of telephone signal and time of signal
168 Chapter 9
arrival at each of the towers, the signal location can be cal- spearheaded by NENA, APCO, and the EMS Office in the
culated to within several meters. This calculated location is National Highway Traffic Safety Administration (NHTSA),
identified as a longitude/latitude that is then translated to which has federal responsibility for the program.6
a map location and street address in a specialized database.
Because the call is recognized as having come from a phone Advanced Automatic Crash Notification
with a unique identifier, another specialized database The 2009 Centers for Disease Control and Prevention
assigns the correct callback number associated with that (CDC) report, Recommendations from the Expert Panel:
specific phone. This packet of information—a phone call Advanced Automatic Collision Notification and Triage of the
with a 911 prefix, ALI data, and ANI data—is then trans- Injured Patient,7 found that advanced automatic crash noti-
mitted digitally through selective routers and trunk lines fication (AACN) can improve outcomes among seriously
to the closest PSAP. injured patients by:
Geographic regions, such as individual counties, have
• Predicting the likelihood of serious injury among vehi-
had to decide to which PSAP they prefer to have these calls
cle occupants.
sent. Systems that use global positioning location data
require that the individual phones be fitted with hardware • Decreasing response times by prehospital care providers.
and software that allow them access to the GPS system. • Assisting with field triage destination and transporta-
Emergency 911 calls originating from such phones are still tion decisions.
routed in the same manner and require access to the ANI
• Decreasing the time it takes for patients to receive
database but not to an ALI database. Location information
definitive trauma care.
is transmitted automatically with the packet of data that
comes from the phone when a 911 prefix is associated with It further found that systems like AACN may be espe-
the call. The data from these phones are transmitted to the cially important in rural or isolated areas, where there may
appropriate PSAP. not be a passerby to report a crash and a Level I trauma
Call takers and dispatchers see the data from wireless/ center is too far away to treat the kind of injuries sustained
mobile phones in the same format as they see for landline in severe crashes. The Case Study at the beginning of this
E911 calls. In other words, the method of data transmission chapter illustrates just this kind of situation.
is inconsequential to the dispatch personnel, because data AACN systems are data collection and transmission
are provided in identical formats with both methods, ANI/ mechanisms that may change the way we assess and treat
ALI or landline. Putting these new communications tech- victims of car crashes. As the name implies, AACN sys-
nologies in place ensures the reliability of Enhanced 911 as tems can automatically contact a national call center or
cellular communications continue to increase. local PSAP and transmit crash-specific data.
A more recent 911 phenomenon has been the emer- For example, imagine a car with a driver and one pas-
gency access issue created by voice over Internet protocol senger traveling at 45 miles per hour along a highway. The
(VOIP) technology which, like cellular technology, has driver loses control of the vehicle, leaves the roadway, rolls
rapidly gained in popularity. VOIP uses both wired and over, and comes to rest against a tree. Because the AACN
wireless Internet access technology (e.g., cable, fiber-optics, system in the vehicle contains special sensors called accel-
wireless air card, wireless hotspot) through a computer or erometers, it can measure the change in total velocity
mobile Internet access device to provide voice communica- (“change in velocity” is written as delta V or ΔV), the forces
tions that are increasingly of comparable quality to other that were applied to the vehicle, the direction in which
forms of telephony. Low calling costs through VOIP have they were applied, whether or not the car rolled over,
helped drive its popularity. Unfortunately, as with early whether or not air bags were deployed, and the car’s final
cell phone systems, VOIP was not designed with ANI, ALI, resting position. The sensor also has a GPS-enabled chip
or best-routing-to-closest-PSAP capabilities. Technology that can transmit the exact location of the vehicle. In the
has become available to alleviate these issues, however, future, other data available from the system may contrib-
and organizations such as the National Emergency Num- ute to the determination of whether a severe injury was
ber Association (NENA)4 and the Association of Public likely to have occurred.
Safety Communications Officials-International (APCO) 5 As in the second Case Study at the beginning of this
are working to incorporate the capabilities required. chapter, protocols can be established for the automatic
The challenges of new technology with 911 center impli- notification and routing of AACN data to responders and
cations do not end with cell and VOIP phones. The ability to hospitals likely to be involved and for the automatic dis-
send photos, video, or text messages from a handheld device patch of resources, rather than waiting for a responder to
to a 911 number or to access or interact with social net- arrive at the scene and make that determination. In rural
working systems presents similar issues. As a result, an ini- responses, this can save minutes to hours in the time
tiative called Next Generation 911 (NG-911) is under way, required for definitive surgical intervention.
EMS System Communications 169
FIGURE 9-7 You may occasionally need to discuss a case with a physician to guide further care.
units involved. Your dispatcher can be your best friend. He radio will secure a large part of your professional reputation.
can assign the resources you need to manage an incident, The general radio procedures and standard format sections
such as additional medical personnel to help with a cardiac given earlier in this chapter offer guidelines for communicat-
arrest or the fire department to provide specialized rescue. ing with the medical direction physician and transmitting
He also may facilitate communication with other agencies, patient information (Figure 9-7).10
hospitals, communication centers, and support services.
Transfer Communications
Discussion with the Medical As you transfer care of your patient to the receiving facility
staff, you must give the receiving nurse or physician a for-
Direction Physician
mal verbal briefing (Figure 9-8). This report, commonly
After conducting your assessment and initiating care as
called the hand-off, should include your patient’s vital
outlined by your local protocols, you will contact the medi-
information, chief complaint and history, physical exam
cal direction physician to discuss the case. Following con-
findings, and any treatments that have been rendered.11
sultation, he may give you further orders for interventions
such as medications or other medical procedures. The
many ways to conduct this communication today include
radio, telephone, and mobile phone. Taping these commu-
nications for use later is advisable. For example, if a dis-
crepancy arose as to what your orders had been, you could
always refer to the tape, which never lies.
After consulting the medical direction physician, you
will continue treatment and prepare your patient for trans-
port. You will then contact your dispatcher, who will record
the time when you leave the scene and the time when you
arrive at your destination.
Your professional relationship with medical direction
physicians must be based on trust. Transmission of clear, con-
cise, controlled reports will encourage your medical direction FIGURE 9-8 The patient hand-off is an essential aspect of emergency
physicians to accept your assessments and on-scene treat- care and ensures continuity of care between the prehospital and
ment plans. Your ability to communicate effectively on the hospital environments.
EMS System Communications 171
Do not assume that the receiving nurse heard your radio (where communications transmission and reception are
report and knows about your patient or that this informa- poor), but aside from that they can talk to their dispatcher,
tion has been given to the physician you may first encoun- can talk with other resources (either directly or through a
ter. Some systems require the receiving nurse to sign the dispatcher), and can talk to the hospital staff as needed.
PCR to verify and document the transfer of care. Many sys- However, press those same average paramedics to
tems also require the medical direction physician to sign think about whether they could use additional pieces of
the PCR for any medications administered by paramedics, information that would benefit their next response and
especially if they included controlled substances such as patient if they could have that information earlier or more
morphine or diazepam. easily, and the answer also would probably be “yes.” When
Never leave your patient until you have completed EMS providers really think about it, they know they are
some type of formal transfer of care; otherwise, you may be often frustrated by the lack of information they passively
charged with abandonment. In all cases, end your PCR “wonder about” as they make their way through an emer-
documentation with information about the transfer of care. gency call.
It may also be appropriate to have a parting chat with your How often do we know how serious the call is only
patient, particularly if the patient is not receiving immedi- when we get there, and only then are able to call for addi-
ate care and has questions or anxiety. tional resources (which may or may not be available)? How
often do we wonder, en route to a call 20 minutes away, if a
resource will be available if the call turns out to be a “bad
one,” then take the initiative to ask for it, only to have that
Information and resource become unavailable by the time we reach the des-
tination? With the voice, data, and video technology avail-
Communications able today, “wondering” should become increasingly
Technology unnecessary.
Situational awareness (SA) and common operating
Modern EMS is approximately 40 years old. Prior to the picture (COP) are important considerations in EMS. These
EMS systems we know today, ambulances were, by and are concepts that address how prepared a paramedic and
large, “horizontal taxicabs” capable of little more than his team are to perform their jobs effectively at any given
transportation. Communications from the scene of the moment, particularly when time is a factor. Both aware-
injury or illness, or during transport to the receiving hospi- ness and operating procedure are improved by having just
tal, did not exist. the right amount of updated information exactly when it is
In the early era of modern EMS, radios were installed needed—information about resources the team can bring
in ambulances and hospital emergency departments. The to bear and events that may affect their current situation
1970s brought the practice of notifying a receiving hospital (Figure 9-9).
of an ambulance’s impending arrival. The 1970s also saw As EMS emergency call volumes continue to grow and
the widespread development of medical direction systems medical direction physicians become busier with ED
and the advance of field capabilities. Crews would send overcrowding, the opportunity for the paramedic in the
voice descriptions of patient condition by VHF radio, and field and the ED physician providing medical direction to
in some cases could send telemetry ECG data by UHF
radio, and in exchange receive real-time review and medi-
cal orders from an emergency physician. These develop-
ments constituted the birth of field medical intervention.
Unfortunately, the majority of EMS communications
systems have not kept pace with the blooming sophistica-
tion of EMS in general—nor have they kept pace with con-
current rapid developments in communications
technology. With some notable exceptions, often in a pilot
project or other experimental form, the methods by which
EMS providers are dispatched, communicate with
resources as needed for response and patient care, and
communicate with hospital medical supervisors and staff
are the same as they were 35 to 40 years ago.
If one asks average paramedics whether their commu- FIGURE 9-9 Situational awareness on the part of EMS providers
nications system adequately supports them, their fast helps ensure efficient patient care as well as provider and patient
answer often will be “yes.” They may describe dead spots safety.
172 Chapter 9
communicate becomes increasingly constrained. The like- break into the other’s process and revert to voice and data
lihood is rapidly diminishing that paramedic and physi- communication as needed.
cian are going to be available to talk at the same time. Voice Some of the capabilities described have been employed
communications then become a bottleneck to the emer- in the military. Hospital- and health-care-system–based
gency patient care process. electronic medical-records–sharing networks are being
Further, there are no generally available systems established in many states. These systems allow emer-
through which EMS providers can access real-time infor- gency department and primary care physicians to access
mation concerning events and resource status that may the records of patients in the system who present for care.
affect their work. For example, an EMS crew may have no Such systems would have application for providing perti-
information on the number and severity of the patients to nent medical history information to EMS providers in real
whom they are responding until they arrive at the scene, time during calls. At least one EMS system, one based in
no information about the availability of air medical or Indiana, has already implemented this capability.
extrication resources until they actually call for them, and Modern EMS communications needed to provide ade-
no information about the availability of the hospital to quate SA and COP require both voice and data communica-
which they want to transport until they call that hospital. tions support. This becomes a blending of two systems and
In the future, it will be necessary to develop networks sets of professional skills: (1) traditional communications
of databases that contain information about events and technology, which generally involves telecommunications
resources updated in real time and accessible through a engineers and (2) data systems technology, which involves
user-friendly geographic information system (GIS) capa- hardware and software development professionals. Infor-
ble of interface with smart phone/electronic tablet/com- mation communications technology (ICT) is the new con-
munication devices carried by responders and physicians, cept that blends traditional communications technology
mobile data units in EMS vehicles, and desktop units at (CT) systems and information technology (IT) systems.
responders’ bases of operations, dispatch centers, and
hospitals.
A GIS-based interface screen would show a rough Technology Today
depiction of an ambulance service’s relevant operations Depending on where you practice as a paramedic, you
area. It would represent the jurisdictions and catchment may be living in a communications world of 1970s tech-
areas of the user; list information about neighboring ser- nology (a VHF simplex voice radio system—with or with-
vices, hospitals, and other resources with which it com- out access to a UHF duplex system with biotelemetry
monly operates; and detail events occurring within those capability), or with hints of the 1990s technology (trunked
areas. Selecting an icon and opening a second screen would 800 MHz with lots of channels and talk groups; cell
access information not readily available on the initial screen. phones used routinely and perhaps transmitting 12-lead
This array of databases (e.g., the status of hospitals, ECGs) or hints of future technology (mobile data unit—a
ambulances, helicopter services, and EMS calls in current hardened laptop—that uses air-card access to wireless
operation) might be called an EMS Resource and Event phone providers and/or hotspot access to the Internet
Monitoring System (EMREMS). It would be one informa- and beyond; video transmission connection to the ED;
tion communications network that is linked with similar and multi-vital–sign transmission from your monitors to
networks for fire, police, departments of transportation, the ED using one of these connections).
and other responder colleagues. Although such a system Regardless, your communication network must con-
may now seem a thing of dreams, its concept has been sist of reliable equipment designed to afford clear commu-
repeatedly described in EMS and emergency planning lit- nication among all agencies within the system. This
erature as a necessary next step to ensure SA and COP in becomes a challenge in systems that cover large geographi-
the paramedic’s everyday work. cal areas or where terrain interferes with transmission and
In the new “EMREMS” systems to be developed, an ad reception. If you want to communicate with a unit clear
hoc database will be created each time a patient is encoun- across the county but your radio is not powerful enough to
tered. Multiple vital signs, video, electronic health record, transmit that far, communication will be difficult, if not
and voice-to-text translation of medic findings will be impossible. A system that covers a large geographical
pushed to those databases and parked until the intended expanse can place repeaters strategically throughout its
recipient (e.g., an incoming air medical crew or a medical service area. These devices receive transmissions from a
direction physician in the hospital) is available to review low-powered source and rebroadcast them at a higher
them. These recipients can then pull down those data to power (Figure 9-10).
their own screen and push queries or orders back to the Your regional EMS system may consist of many agen-
EMS crew for consumption and response when they are cies that have conducted business for decades on different
available. When an emergency dictates, either party could radio bands and radio frequencies. City units may transmit
EMS System Communications 173
Base
station
Dispatch center
Portabl e
Repeater Remote
console Repeater
EMS uni t
(mobile )
on ultrahigh frequency (UHF) radio waves because they SIMPLEX The most basic
CONTENT REVIEW
penetrate concrete and steel well and are less susceptible to communications systems use
➤➤ Types of Radio
interference. Rural and suburban units may use a lower simplex transmissions. These
Communication
band frequency—very high frequency (VHF)—because systems transmit and receive
• Simplex
those waves travel farther and better over varied terrain. In on the same frequency and
• Duplex
any event, communicating among agencies will be difficult thus cannot do both simultane- • Multiplex
unless all units share a common frequency. This is rarely ously (Figure 9-11). After you • Trunked
the case. Again, the spectrum of communications equip- transmit a message, you must • Digital
ment currently ranges from antiquated radios to mobile release the transmit button and
data units mounted inside emergency vehicles. wait for a response. This slows communication because
Geographically integrating communications networks you have to wait for all traffic to stop before you can speak.
would enable routine and reliable communication among It also makes the system more formal and prevents open
EMS, fire, law enforcement, and other public safety agen- discussion. Simplex communication systems are most
cies. This would, in turn, facilitate coordinated responses effective on the scene, when the incident commander or
during both routine and large-scale operations. Develop- EMS dispatcher must transmit orders or directions without
ing the necessary hardware (equipment and network) and interruption. Most dispatch systems and on-scene com-
software (language) will be essential to improving emer- munications use simplex transmissions.
gency communications.
See further discussion in the Public Safety Communica- DUPLEX Duplex transmissions allow simultaneous two-
tions System Planning and Funding section near the end of way communications by using two frequencies for each
this chapter. Portable unit Base station
Radio Communication
Many types of radio transmission
are possible, with new technolo- Voice and ECG
gies being developed every day.
Usage may vary from system to Voice
system. This section discusses Frequency 1
some of the more common tech-
nologies in use today.
FIGURE 9-11 Simplex communications systems transmit and receive on the same frequency.
174 Chapter 9
“3G”, “4G”) of development. The popularity of smart Because of all the limitations just described, no para-
phones, smart pads/tablets, and netbook devices, added to medic or EMS provider agency should ever rely solely on
the data transmission demands of laptop and desktop commercial wireless communications for mission-critical
computer users, creates a real issue of “pipe availability” to voice communications. This is also true of municipal or
send data. It is not uncommon, particularly in urban and other 2.4-GHz unlicensed hotspot systems that are com-
suburban environments, to see commercial wireless data mon in urban areas to provide Internet access to residents
sending and receiving rates fluctuate greatly with time of (4.9-GHz public safety licensed systems are another mat-
day and day of week. Occasional system “crashes” leave ter; they have limitations for voice communications, and
users of some wireless providers without data communica- have good potential for urban hotspot and “mesh”—inter-
tions for varying periods of time. As with older-generation, connected hotspot antennae to make citywide or area-wide
narrowband cell phones, availability of newer generations network operations).
of data communications varies with the commercial wire-
less provider company and the area of the country (with EXPANDING COMPUTER USES Computers have
large urban areas usually the first to be upgraded). entered every aspect of our daily lives. In emergency services
Like duplex radio transmissions, cell and smart phones communications, they have revolutionized system manage-
make communication less formal, promote discussion, and ment and incident data collection. Most dispatchers no lon-
reduce on-line times. They further allow the medical direc- ger enter data by pen and pencil, time-stamping machines,
tion physician to speak directly with the patient and offer or typewriters. They can make a permanent record of any
the additional advantages of being widely available and incident’s events in real time. Virtually all new PCR systems
highly reliable. The telephones themselves are inexpen- are no longer paper based, but rely on the electronic input of
sive, but commercial wireless providers charge a monthly patient and call data into ruggedized mobile laptops and/or
fee for their use, generally with additional charges for data computers at the ED or EMS quarters.
services and specific data applications. It is increasingly commonplace for an EMS unit to
As with data communications, even simple voice com- “dump” its electronic PCR data for recent calls to a central
munications are not always reliable in commercial wireless database at its quarters, using an air card in the computer
systems. Their major disadvantage is that each cell can and a commercial wireless provider’s network. Crews in
handle only a limited number of calls. Geography can the field will be able to use their smart phones, tablets, or
interfere with the cell phone’s signals, and in large metro- laptops to access regional health care system medical
politan areas the cells often fill up and become unavailable, record depositories for medical history data on their cur-
especially during peak hours. Cell congestion occurs fre- rent patient in real time. (The first well-publicized system
quently in times of disaster when many local, state, and of this kind is in Indiana, but such regional and statewide
federal response agencies, news media, and citizens all record systems are in development virtually everywhere,
require communications.12 The National Communications following the federal push for universal electronic health
System in the U.S. Department of Homeland Security, records use.)
however, has programs that local and state EMS agencies Computers also make research faster and easier. For
can subscribe to that provide priority access to wire line example, if you wanted to determine the day of the week
and wireless communications services in emergencies. when most cardiac calls happen, or what time of day is bus-
Further, although some commercial wireless providers iest, or which area of a city needs more coverage, you could
offer a “push to talk” (PTT) feature that resembles that of retrieve the pertinent data from your computerized records
your mobile EMS radio, no cell or smart phone is capable of immediately. You can program your system to provide
communicating directly with another phone even if the whatever type of data you want, in whatever format you
callers are standing next to one another. All calls must go desire. It also eliminates the need to enter retrospective data
through the cell system network. In addition, these phones when conducting research. For example, the times, loca-
are not capable of “one-to-many” communications, as tions, and particulars of a call will already be in the com-
radios are. If a caller wants to get a voice message to several puter files for immediate retrieval during a research project.
responders, the caller would have to call each individually.
Despite their limitations, commercial wireless phones SOFTWARE-DEFINED RADIO In many areas of the
have become a popular medium for on-scene and medical country, it is not unusual for ambulances to have multiple
direction communications. When using wireless phones communications devices. These may be required to talk
for on-line medical direction, it is important to contact the with other response agencies that use other bands (e.g.,
base station physician on a recorded line. On-line medical VHF versus 800 MHz), to overcome areas of bad reception,
direction recordings have been used as powerful allies in or for other reasons. In rural services, it would not be
cases of litigation. Be sure to find out how to do this in your unusual to find a VHF radio (to talk locally), a cell phone,
system. an 800-MHz trunked radio (to talk with hospitals in “the
EMS System Communications 177
big city”), and a satellite phone for areas that are totally Security’s SafeCom in its document Public Safety Communi-
“dead” for other forms of communications. The trick is cations Statement of Requirements” in 2006.
knowing which device to use at any given moment in the The following sections describe some of the new tech-
middle of an emergency. nologies that the expert panel and others have predicted.
Now imagine a communications device that combines These predicted technologies are being used by research-
all these bandwidths, is smart enough to “sniff” the air- ers, the FCC, and others to develop various projections of
waves covered for strong signals and no competing trans- bandwidth that will be needed for a public safety broad-
missions, and then obeys a protocol programmed into it for band system.
connecting the user with the desired target, say “Hospital One conclusion is clear: If any of these technologies
A.” The feature of combining a wide range of radio bands become used to any great degree by multiple EMS provider
is called multiband radio. The feature of “sniffing” the air- agencies in any given area, broadband access will be man-
waves for signal strength and clear channels among the datory. Current communications capabilities in the narrow-
bands in the device is called cognitive radio. Like trunked band frequencies EMS has traditionally used, and continues
radios, it can pick an open, strong frequency without the to use, cannot support these patient care operations.
user knowing which one was selected (they just know they
are talking to Hospital A). Finally, the ability to combine all Medical Quality Video and Imaging
these features and then program them with additional The use of video to send patient images from the scene or
operational protocols (e.g., “select satellite transmission ambulance to a physician consultant/medical director is
only if all other options are unreliable”—because satellite being used currently in Texas, Arizona, and Louisiana.13
use can be relatively expensive). Although the utility of video in EMS remains an open
Multiband radios are now available that cross bands question in the national EMS community, it is more likely
from high frequency to VHF, UHF, and 800 MHz in one to have a role in rural settings than in urban settings for
device. These radios can be programmed to jump from two reasons: a lesser call volume and the emerging concept
channels in one band to another very quickly and to scan of community paramedicine in rural areas.
channels throughout. Devices that combine the new public
safety broadband capability and satellite capability are CALL VOLUME First, urban systems have high call
expected to be produced to give universal public safety volumes, and can afford highly trained EMS personnel
interoperable broadband coverage. Cognitive and soft- (paramedics) who have a high level of patient interaction
ware-defined radios are widely available and beginning to experience. The combination in urban systems of a large
make inroads in the public safety arena. call volume, short transport times to hospitals, and the
training and experience of personnel means that true emer-
gencies are dealt with effectively and that subtleties in signs
New Technology and symptoms that may become a treatment factor later can
When planning got under way for a nationwide public be managed by a physician in the ED after a few minutes’
safety broadband system, between 2005 and 2010, planners transport.
watched popular commercial applications such as the Rural areas often do not have the call volume to be able
Apple iPhone cause a boom in broadband use that began to afford the cost of paramedic-level personnel or to provide
eating up an increasing share of available bandwidth. sufficient experience to maintain an effective emergency
Consequently, public safety communications planners in practice. Transport times are relatively long, and subtle signs
the FCC and the emergency services began to investigate and symptoms that may not be appreciated by personnel
how much bandwidth they were going to require. with a lesser amount of training and experience may become
One of the earliest efforts in this vein was sponsored a treatment factor before arrival at the hospital.
by the National Public Safety Telecommunications Council Therefore, in urban areas, injecting the expense and
(NPSTC), the National Association of State EMS Officials process of video transmission may not be as value-added
(NASEMSO), and the National Association of EMS Physi- as it could be in rural areas. In the rural areas, the interpre-
cians (NAEMSP), and was funded by the federal govern- tive eye of an emergency physician able to view the patient,
ment. An expert panel was created that produced a report see portable CT images (e.g., to determine the type of
in 2010. The panel was asked to consider: “What potential stroke a patient is suffering), or review portable ultrasound
diagnostic and treatment technologies may possibly be video/images of the patient (e.g., to determine the pres-
used in the next 10 years that have implications for voice ence of internal bleeding) may make a critical difference in
and data communications technology and bandwidth treatment and how and where the patient is transported.
use?” The panel’s report affirmed some national consensus Today, satellite-based and wired broadband audio/
work by the Intelligent Transportation Society of America video/imaging systems operate in military and civilian
(ITSA) in 2008 and the U.S. Department of Homeland applications to link remote and rural medical facilities with
178 Chapter 9
specialists in urban centers to provide intensive care moni- This could also be used to detect chemicals, gases,
toring and treatment and “tele-trauma” consultation. The radioactivity, and other hazards being encountered by
public safety broadband network, including satellite monitored responders.
backup and node links to telemedicine and other fiber net- • Stand-Off Vital-Signs Monitoring. The ability to wire-
works, could wirelessly provide these capabilities to ambu- lessly detect, receive, and wirelessly transmit multiple
lance and rural hospital/clinic personnel to effectively vital signs to a database without physically touching
intervene in life-threatening situations that they would the patient.
otherwise not be adequately trained or experienced to
accomplish. • Infrared Crowd Disease Detection. The ability to wire-
lessly scan, receive, and transmit to a database the
COMMUNITY PARAMEDICINE Second, an emerging body temperatures (and body area temperatures) of
concept in rural EMS and health care is community para- individuals in crowds that suggest illness.
medicine. Under a widely discussed “medical home” con-
• Wireless Speech-to-Text Translation. The ability to
cept of implementation and financing, paramedics and
speak into a microphone in a noisy emergency scene
other EMTs could become affordable in rural communities
environment and have that speech translated and
because they not only provide advanced life support ser-
wirelessly transmitted into an ad hoc patient-event
vices, but also help to fill gaps in primary health care ser-
database for real-time review by others on the scene,
vices. Working in and out of rural clinics and hospitals,
coming to the scene, or in a hospital ED supervising
paramedics and other EMTs could provide preventive care
care at the scene.
services in the community and other primary care and fol-
low-up services in patient homes. They would be respon- • Receipt of Electronic Patient Records in Real Time.
sible for patient remote monitoring and for visiting patients The ability of on-scene EMS staff to receive and poten-
in their homes, thereby reducing the need for clinic visits tially manipulate (to focus on pertinent records only)
and catching incipient problems before they necessitate an medical history for their patients, either wirelessly
ambulance call or a clinic or ED visit. from a regional health care medical record system or
Paramedics would be able to respond to some emer- by patient-carried data records.
gency calls and be able to address the patient’s needs with- • Creation of Ad Hoc Multi-Component Patient Data-
out transport to a hospital. (One study suggests that bases. This is simply transmission of electronic PCRs
transports could be reduced by 15 percent with such a sys- to hospitals before the patient arrives, augmented by
tem in an urban setting.)14 Because it would not be cost separate transmissions of 12-lead electrocardiogra-
effective to train these EMS providers at a level to make phy and simple vital sign transmission. Using tech-
them independent practitioners, the ability to conduct nologies already described, this system would have
wireless video consults with physicians and mid-level the ability to create, in a single-user interface win-
practitioners in rural clinics and hospitals will become cru- dow, data sent wirelessly from the scene that includes
cial for the benefits of community paramedicine to be video, multi-vital signs, voice-to-text translated
robustly realized. patient notes, and pertinent patient history compo-
This concept projects a need for ongoing and frequent nents. This database could be made available in real
broadband use by EMS in rural areas in years to come. time to authorized responders (e.g., incoming air-
medical crews who will transport the patient), spe-
Other EMS Applications cialists guiding care remotely (e.g., trauma surgeons
The following are other technology applications with directing a specialized procedure in the field), and
broadband implications that the national EMS communi- emergency physicians routinely supervising EMS
cations initiatives have suggested: calls.
• Patient Multi-Vital–Signs Monitoring. The ability to • EMS-Mediated Remote Patient-Monitoring Systems
attach one or more micro-monitors to a patient to wire- and “Just in Time” Patient Warning and Reference
lessly receive and transmit electrocardiograph, cap- Guidance. In community paramedicine and other set-
nography, blood pressure, and other vital signs tings, patients with post-hospital discharge and/or
packaged for display in a database. chronic health-monitoring needs can be remotely fol-
• Responder Multi-Vital–Signs Monitoring. Similar to lowed through the use of multi-vital–signs monitors
the patient multi-vital–sign monitoring but intended (as described earlier), video, or specialized monitors
for use by EMS responders monitoring fire, police, and appropriate to their condition. These could be moni-
other responders in hazardous circumstances (e.g., fire- tored at EMS dispatch and/or nurse advice service
fighters inside a burning building, SWAT team mem- centers and would have alarms should the vital signs
bers inside a building in a hostage-taking scenario). monitored go outside a preset range.
EMS System Communications 179
Although this kind of monitoring could be done to defuse/suppress hazards and remove patients
by wireline service in most settings, though less so in from hazardous settings. This application requires
rural areas, the ability to rebroadcast the monitoring audio, video, and robot-control data transmission.
device transmissions to responding EMS crews would • Wireless Vehicle Systems, Equipment and Supply
need to be wireless. In addition, based on the patient Monitoring. The ability now exists to monitor
history and current monitoring results, care warnings virtually every critical system of a public safety
pertinent to the particular patient and condition, along vehicle. Radio frequency identification (RFID)
with other relevant reference or medical protocol guid- and other tagging device technology make it pos-
ance, could automatically be sent to EMS responders sible to track the inventory of equipment and
in real time. In a similar fashion, “I’ve fallen and I can’t supplies in a vehicle. Wirelessly transmitting this
get up” emergency alerting systems, currently wire- information to the vehicle operator ’s communi-
line dependent and plaguing responders as a common cations unit, with event-linked special warnings
source of false alarms, could be set up with audio– (e.g., sending a “leaving scene to transport to
video and vital-signs–monitoring interfaces with not hospital” message while a critical patient care
only wireline support but also wireless retransmission device is registered as not having been returned
to responding EMS crews. to the vehicle; transmitting an “en route to scene”
• Advanced Automatic Crash Notification (AACN) message with a critically low air pressure in a tire
Data Rebroadcasting and “Just in Time” Training and or low inventory of a critical supply) would
Reference Material Rebroadcasting. AACN has the reduce delays in restocking and inventorying
potential to significantly reduce death and disability in vehicles and medical errors caused by missing
rural car crashes by eliminating the time now required equipment or supplies.
to “discover” that the crash has occurred, the time • Syndromic Surveillance and Quick Alerting to
required to determine the physical location of the Specific Populations. Real-time transmission of
crash, and the time now required to respond to a crash dispatch and ePCR data to monitoring systems
and determine whether specialty response (e.g., extri- that assess for specific patterns of patient com-
cation, special resources) is needed. plaints, signs, and symptoms in specific geo-
To take optimum advantage of these potential graphic areas. Transmission of these assessments
time savings, the AACN data should be transmitted to EMS responders and public health authorities
simultaneously to all potential responders and to hos- when specific outbreak or hazardous event occur-
pital and specialty care facilities that have requested to rence is predicted.
be notified of crashes exceeding a certain severity in a
specific geographic area. In addition, certain crash data
need to be automatically assessed and resulting infor- Legal Considerations
mation transmitted to responders and facilities based
Keeping It Private. Many modern EMS communication
on the assessment. For example, speed/rollover/
systems use encryption or similar technologies to ensure
impact-vector data may be among data used to deter-
privacy and security. However, people can monitor certain
mine the severity of the crash and result in automatic EMS communications, including some cell phone commu-
dispatch of airmedical and other specialty responders nications, with scanners or similar devices, which are
and notification of trauma centers. becoming as sophisticated as the radios and phones them-
Other vehicle data such as vehicle type and year/ selves. It was once thought that radio communication was
speed/rollover/impact vector could be used to send secure, but in fact it may not be. Furthermore, in many
an electronic vehicle access manual to responding emergency departments, EMS radios are within earshot of
extrication crews with diagrams and methods for patients, staff, and visitors. Thus, you should always
best accessing patients and avoiding hazards in that assume that someone other than the intended recipient
vehicle. might hear any EMS radio communication. Because of this,
you must carefully limit any information that might iden-
• Closed Circuit Television (CCTV) Scene Transmis- tify a particular patient. This includes such things as name,
sion. Wireless receipt of live video feeds of an emer- race, financial (insurance) status, and similar descriptors.
gency scene from traffic, police, homeland security, Transmission of such information does not enhance patient
and other public monitoring CCTV systems by care and may actually violate patient confidentiality laws,
responding crews will help plan approach and including the Health Insurance Portability and Account-
vehicle staging at the scene. ability Act and similar statutes. Always carefully plan your
radio communications—especially when they deal with a
• Robotic Remote Hazard Suppression and Patient particular patient.
Extrication. The use of remotely controlled robots
180 Chapter 9
Public Safety SIECs, and SWICs. (The funding initiatives through which
OEC provides funding generally require the states to pass 80
Communications System percent of the funds to local agency providers.) It is up to
local paramedics and agencies to take advantage of these
Planning and Funding opportunities to be heard and to have projects funded.
Summary
This is an extremely exciting time to be involved in EMS. Advances in communications technology
are dramatically improving the communications among patients, paramedics, and physicians. As
systems improve and technology becomes more affordable, paramedics will be able to arrive on
scene of an injury within just a few minutes and, with the click of a button, obtain all the necessary
medical information from the patient. As they load and transport the patient, the satellite commu-
nications system will link streaming video and audio with the emergency room doctor.
As one of the fundamental aspects of prehospital care, accurate and effective communications
help ensure an EMS system’s efficiency and improve a patient’s survivability. Communications
includes not only your radio traffic, but also your spoken and nonspoken (body language) mes-
sages. All your communications must be concise, professional, and complete and must conform to
national and local protocols. As communications systems and technology continue to advance, so
EMS System Communications 181
will patient care and survival rates. The paramedic will be able to quickly gain access to the appro-
priate facility and medical direction, allowing for a much quicker and more seamless treatment
plan through discharge at the hospital.
Review Questions
1. The process of exchanging information from one otification and Triage of the Injured Patient”
N
individual to another is _______________. discusses that _____________ shows promise in
a. encoding. c. communication. improving outcomes among severely injured crash
b. decoding. d. communion. patients.
a. ACANN c. ANCCA
2. General radio procedures include all of the follow-
b. AACN d. NCAS
ing except:
a. Listen for radio traffic before speaking. 5. A recent report titled “Recommendations from the
b. Depress the PTT button for 1 second before speaking. Expert Panel: Advanced Automatic Collision Notifi-
c. Speak slowly and clearly. cation and Triage of the Injured Patient” found that
d. Describe in detail your needs and the situations Advanced Collision Notification can improve out-
before releasing the transmit button. comes among seriously injured patients by provid-
ing all of the following except ___________
3. When receiving orders from a dispatcher or physi-
cian you should ________________ a. predicting the likelihood of serious injury among
vehicle occupants.
a. use the echo procedure.
b. decreasing response times by prehospital care
b. confirm the order.
providers.
c. write the order down.
c. assisting with field triage destination and
d. none of the above. transportation decisions.
4. A recent report titled “Recommendations from the d. notifying the receiving hospitals that they will be
Expert Panel: Advanced Automatic Collision getting a trauma patient.
182 Chapter 9
6. Which radio frequencies may be used by cities and 9. A communications system that uses a different
municipalities for their ability to better transmit transmit and receive frequency allowing for simulta-
through concrete and steel? neous communications between two parties is called
a. UHF c. 800-mHz _________________
b. VHF d. none of the above a. multiplex.
b. duplex.
7. Which frequency band is typically used by county
and suburban agencies due to its ability to transmit c. simplex.
over various terrains and longer distances? d. complex.
a. UHF c. 800-mHz 10. _________________ communications systems are
b. VHF d. none of the above capable of transmitting both voice and electronic
patient data simultaneously.
8. What is the name of the basic communications sys-
tem that uses the same frequency to both transmit a. Multiplex c. Simplex
and receive? b. Duplex d. Complex
a. Multiplex c. Simplex See answers to Review Questions at the back of this book.
b. Duplex d. Complex
References
1. Department of Homeland Security. SAFECOM. (Available at 8. Wilson, S., M. Cooke, R. Morrell et al. “A Systematic Review of
http://www.dhs.gov/safecom/) the Evidence Supporting the Use of Priority Dispatch of Emer-
2. National EMS Information System (NEMSIS). The NEMSIS gency Ambulances.” Prehosp Emerg Care 6 (2002): 42–29.
Technical Assistance Center (TAC). (Available at http://www. 9. Billittier, A. J., 4th, E. B. Lerner, W. Tucker, and J. Lee. “The Lay
nemsis.org//.) Public’s Expectations of Prearrival Instructions When Dialing
3. American College of Emergency Physicians (ACEP). “Automatic 911.” Prehosp Emerg Care 4 (2000): 234–237.
Crash Notification and Intelligent Transportation Systems.” Ann 10. Munk, M. D., S. D. White, M. L. Perry, et al. “Physician Medi-
Emerg Med 55 (2010): 397. cal Direction and Clinical Performance at an Established
4. National Emergency Number Association (NENA). National Emergency Medical Services System.” Prehosp Emerg Care 13
Emergency Number Association. (Available at: http://www. (2009): 185–192.
nena.org) 11. Cheung, D. S., J. J. Kelly, C. Beach, et al. “Improving Handoffs in
5. Association of Public-Safety Communications Officials (APCO). the Emergency Department.” Ann Emerg Med 55 (2010): 171–180.
[Available at: http://www.apco911.org/] 12. Chan, T. C., J. Killeen, W. Griswold, and L. Lenert. “Information
6. Department of Transportation, Research and Innovative Technol- Technology and Emergency Medical Care during Disasters.”
ogy Administration. Next Generation 911. (Available at: http:// Acad Emerg Med 11 (2004): 1229–1236.
www.its.dot.gov/ng911/.) 13. DREAMS Ambulance Project. (See article at: https://www.ems1.
7. Centers for Disease Control and Prevention. Recommendations com/ems-products/technology/articles/1183110-DREAMS-
from the Expert Panel: Advanced Automatic Collision Notifica- revolutionizes-communication-between-ER-and-ambulance/.)
tion and Triage of the Injured Patient. (See NHTSA summary at 14. Haskins, P. A., D. G. Ellis, and J. Mayrose. “Predicted Utilization
http://www.nhtsa.gov/Research/Biomechanics+&+Trauma/ of Emergency Medical Services Telemedicine in Decreasing
Advanced+Automatic+Collision+Notification+-+AACN) Ambulance Transports.” Prehosp Emerg Care 6 (2002): 445–448.
Further Reading
Bass, R., J. Potter, K. McGinnis, and T. Miyahara. “Surveying Emerg- National Association of State EMS Officials, National Association
ing Trends in Emergency-related Information Delivery for the of EMS Physicians, June, 2010.
EMS Profession.” Topics in Emergency Medicine 26 (April–June McGinnis, K. K. “The Future Is Now: Emergency Medical Services
2004): 2, 93–102. (EMS) Communications Advances Can Be as Important as
Fitch, J. “Benchmarking Your Comm Center.” JEMS 2006: 98–112. Medical Treatment Advances When It Comes to Saving Lives.”
McGinnis, K. K. “The Future of Emergency Medical Services Com- Interoperability Today (SafeCom, U.S. Department of Homeland
munications Systems: Time for a Change.” N C Med J 68 (2007): Security), Volume 3, 2005.
283–285. McGinnis, K. K. Rural and Frontier Emergency Medical Services
McGinnis, K. K. Future EMS Technologies: Predicting Communications Agenda for the Future. National Rural Health Association Press:
Implications. National Public Safety Telecommunications Council, October 2004.
Chapter 10
Documentation
Bryan Bledsoe, DO, FACEP, FAAEM
Jeff Brosious, EMT-P
Standard
Preparatory (Documentation)
Competency
Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical–legal and
ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to create complete, well-written patient
care reports.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this chapter. the acronyms suggested to help ensure
completeness of documentation.
2. Explain the purposes and goals of the
patient care report in EMS. 6. Discuss the differences in documentation
for special situations such as refusals of care
3. Explain the importance of proper spelling,
and mass casualty incidents.
terminology, abbreviations, and acronyms
(or as an alternative, plain English) in 7. Predict the consequences of inappropriate
written documentation. documentation.
4. Given a series of patient care reports, 8. Discuss the benefits and drawbacks of
identify the elements of good electronic patient care reports as compared
documentation. to paper patient care reports.
5. Identify the main sections of narrative
writing on a patient care report and discuss
183
184 Chapter 10
Key Terms
addendum, p. 196 field diagnosis, p. 198 response time, p. 185
against medical advice (AMA), jargon, p. 197 slander, p. 197
p. 201 libel, p. 197 triage tags, p. 202
bubble sheet, p. 186 prehospital care report (PCR), p. 184
Case Study
Tom Brewster is nervous. He has never been to a “Yes, I do,” Tom replies. He recounts that on their
deposition before, and even though everyone has arrival at the scene, the driver was out of the vehicle.
assured him that he is not the target of any legal Tom states that they managed him like any other trauma
action, he has to wonder what the lawyers want from patient, and he had no obvious injuries or indications of
him. illness.
As he sits outside the conference room, he goes over “Did the gentleman tell you he is diabetic?”
the call in his head. It was about 2:30 in the morning. He “No,” Tom answers, “but we checked his blood
and Eric Billings, his partner, had just finished cleaning sugar, and it was normal.”
up from a GI bleeder when they were dispatched to the “Did he tell you he has heart problems?”
single-vehicle crash. The driver had gone off the left “No,” Tom says again, “but we did put him on the
side of the road, crossed a ditch, and smashed into a heart monitor, and his rhythm was normal.”
tree. He had been lucky. He was out of the car, standing “Did he tell you he ran off the road because he
on the side of the road, and did not seem to have any passed out?”
serious injuries. He told Tom and Eric, “I think I’m fine, “No, he told me he fell asleep.” Tom feels better. He
I just fell asleep and ran off the road.” Still, they had has the answer to every question, and he has the PCR to
performed a primary assessment followed by a rapid back him up.
trauma assessment, immobilized the man, administered After a few more questions, the lawyers dismiss Tom
oxygen, and transported him to the emergency depart- and allow him to leave. He has no idea what they were
ment. Tom rode in the back with the patient. On the way getting at, but he does know that he answered every
to the hospital he checked the patient’s glucose level, question honestly. He wonders if he would have had all
started an IV as a precaution, and applied a cardiac the answers if the case had been from six or eight years
monitor. ago. He has really worked on his documentation in the
“Everything was normal,” Tom now thinks. “What past few years, and he knows he would have never
did I miss?” He has reread his prehospital care report a remembered all those details without the help of his PCR.
hundred times. Even though it has been three years, he Six weeks later Tom gets a letter from the lawyer
now remembers almost every detail of the call. Until thanking him for his testimony. It turned out that the
two weeks ago, however, he had almost completely for- patient was suing his private doctor for not “recogniz-
gotten about it. ing his obvious diabetes and heart problems. He claimed
All too soon, the lawyers call Tom into the confer- these illnesses caused him to be involved in the motor
ence room, introduce themselves, and swear him to vehicle accident, and it resulted in serious injury.” Tom’s
honesty. One of the lawyers begins. “Do you recall the testimony—and his PCR—have been pivotal in getting
crash that occurred on the evening in question?” the case dismissed.
have some recollections about the call—but your PCR will as a baseline for comparing
Content Review
always be considered the most comprehensive and reliable assessment findings and
➤➤ Uses for PCRs
record of the event. In addition, it reflects your profession- detecting trends that indi-
• Medical
alism. A well-written, thorough PCR suggests a thorough, cate improvement or deteri-
• Administrative
efficient assessment and quality care. A sloppy, incomplete oration. The surgical staff
• Research
PCR suggests sloppy, inefficient care. will want to know the • Legal
You will often be the first member of the health care mechanism of injury and
system with whom the patient interacts. At the very least, other pertinent findings during your primary assessment
the results of patients’ interactions with you and other of your patient and the scene.
EMS personnel will affect their opinion of the health care If your patient is admitted to the hospital, the floor or
system in general. EMS is a profession in which you can intensive care unit staff may need more information about
make a difference. Every call and every patient interac- his original condition than he can remember. In addition,
tion can literally mean the difference between life and your PCR provides them with information from people at
death for the patient. Few professions carry such awe- the scene to whom they might not have access—family,
some responsibility. bystanders, first responders, or other witnesses. Knowing
The PCR has three major goals: about the circumstances that led to the event or the mecha-
nism of injury may also help rehabilitation specialists to
• To provide information to subsequent health care pro-
provide better therapy. Your PCR becomes an important
fessionals about the patient and treatments provided
document that helps ensure your patient’s continuous
in the prehospital setting. This information helps the
effective care (Figure 10-1).
nursing staff, emergency physicians, and even physi-
cians who will be caring for the patient in the hospital.
• To provide essential information for proper billing of
Administrative
the patient. There is a direct correlation between the
detail of the report and the level of reimbursement sub- EMS administrators must gather information for quality
sequently provided for care and transport of the patient. improvement and system management. Information
regarding response times, call location, the use of lights
• To provide a legal record of the call’s circumstances.
and siren, and date and time is vital to evaluating your sys-
There have been many cases in which poor documen-
tem’s readiness to respond to life-threatening emergencies.
tation was a factor in EMS personnel losing a lawsuit
It also is essential to providing information about commu-
and many cases in which good documentation has
nity needs. The quality improvement or quality assurance
resulted in EMS personnel winning a lawsuit—or,
committee will use PCRs to identify problems with indi-
more likely, not being sued in the first place.
vidual paramedics or with the EMS system. In some agen-
cies, the billing department will need to determine which
services are billable. Insurance carriers may need to know
Uses for Documentation more about the illness or injury to process the claim. Some
states will use your PCR data to allocate funding for
Your PCR will be a valuable resource for a variety of people. regional systems.
They include medical professionals,
EMS administrators, researchers,
and occasionally, lawyers. Prehospital Care Report
Agency MILEAGE USE MILITARY TIMES
Name
Medical Dispatch
END CALL REC’D
Information BEGIN
Hospital staff (nurses and physi- ENROUTE
Call
Location TOTAL
cians) may need more information ARRIVED
CHECK Residence Health Facility Farm Indus. Facility AT SCENE
from you than they can get before ONE Other Work Loc. Roadway Recreational Other
FROM SCENE
you have to take another call. For CALL TYPE AS REC’D MECHANISM OF INJURY
Assessment Pearls
Don’t Write Patient Data on Your Gloves. Many EMS pro-
viders write vital signs and other essential information on their
medical exam gloves. There are several problems with this.
First, unless the gloves are properly disposed of, you could be
cited for a HIPAA violation. More important, if you are
involved in direct contact with a patient, you should take off
your gloves or change gloves before using such personal
objects as a clipboard or a pen. Leaving the gloves on (or laying
them on an ED countertop) to read the information you wrote
can contaminate your personal materials.
Instead, use a whiteboard or piece of tape to record your
information. If you use a whiteboard, use the pen only dur-
ing patient care and clean it often. If you use a piece of tape or
Figure 10-2 The handheld electronic clipboard enables you to something similar, have a dedicated pen that you use only dur-
enter your prehospital care report directly into a computer. ing the patient encounter (not the one you might stick in your
(Source: Kevin Link/Science Source) mouth when contemplating where you’ll eat later). Always
remember to wipe the whiteboard or properly dispose of the
tape after each call.
Research
Your PCR may give researchers useful data about many
aspects of the EMS call. For example, they may analyze your
recorded data to determine the efficacy of certain medical
devices or interventions such as drugs and invasive proce-
General Considerations
dures. They also may use the data to cut costs, alter staffing, Every EMS system has its own specific requirements for
and shorten response times. Some systems use computer- documentation. The type of call record used also varies
ized or electronic PCRs and a computerized database to ana- from system to system. Some systems use reports with
lyze the data (Figure 10-2). Regardless of the method you check boxes, some use bubble sheets, computer-scannable
use, your written documentation provides the basis for con- reports on which to record patient information by filling in
tinuously improving patient care in your EMS system. boxes or “bubbles” (Figure 10-3). Still others may use com-
puterized documentation. The particular type of opera-
tional data collected, such as time intervals, will also differ
Legal among systems. For example, proprietary EMS agencies
Your PCR becomes a permanent part of your patient’s may require more billing information than community-
medical record. Lawyers may refer to it when preparing based volunteer agencies. The general characteristics of a
court actions, and in a legal proceeding it might be your well-written PCR, though, remain constant among all
sole source of information about the case. You may be agencies and systems.
called on to testify in a case in which your PCR becomes
Content Review
the central piece of evidence in your testimony. Or your
Medical ➤➤ Characteristics of a Well-
PCR may serve as evidence in a criminal case and help
determine the accused’s innocence or guilt. Each state has Terminology Written PCR
• Appropriate medical
its own laws regarding the length of time the hospital must An essential component of
terminology
keep its records. good documentation is the
• Correct abbreviations
Always write your PCR as if you know you will have appropriate use of medical
and acronyms
to refer to it someday in a court proceeding. Describe your terminology. Medical • Accurate, consistent
patient’s condition when you arrived and during your care, terms, though sometimes times
and note his status on arrival at the hospital. Always docu- difficult to spell, transform • Thoroughly documented
ment his condition before and after any interventions, and your report into a univer- communications
avoid writing any subjective opinions such as “the patient sally accepted medical doc- • Pertinent negatives
is intoxicated, obnoxious, and looks like a crack addict.” ument. Learning the • Relevant oral statements
After your PCR is written, ask your partner to review it for meanings and correct spell- of witnesses,
completeness and accuracy. A complete, accurate, and ings of the medical terms bystanders, and patient
objective account of the emergency call may be your best that you will use in your • Complete identification
of all additional
and only defense against a plaintiff’s attorney who will try PCRs is essential. Misused
resources and personnel
to find inconsistencies and ambiguities in your account. or misspelled words reflect
Documentation 187
Figure 10-3 This prehospital care report’s format can be scanned into a computer.
(Scannable paper PCR form. Copyright © by EMS Data Systems, Inc. Used by permission EMS Data Systems, Inc.)
188 Chapter 10
poorly on your professionalism and may confuse the Using abbreviations and acronyms, the same report might
report’s readers. be written this way:
If you do not know how to spell a word, look it up or
Pt. is 54 y/o CAO male c/o sudden onset CP/SOB *
use another word. Many paramedics carry pocket-size
20 min. Pt took NTG * 2 Ø relief. n/v, dizziness. PH:
medical dictionaries in their ambulances for this purpose.
CAD, AMI * 3y, HTN. Meds: NTG prn, Procardia XL,
Using “plain English” is acceptable when you do not know
HCTZ and K+; NKDA.
the appropriate medical term or its correct spelling. Chest is
just as accurate as thorax and better than “thoracks.” Belly
is not as professional as abdomen, but it is still better than Times
“abodemin.” Incident times are another important but perilous part of
the PCR. The times you record on your PCR are considered
Abbreviations and Acronyms the official times of the incident. For medical and legal pur-
Both abbreviations and acronyms are formed from the poses, you must ensure their accuracy.1
initial letters of the words they stand for. An acronym, The PCR typically has spaces for the time the call was
however, is an abbreviation you can pronounce as a word. received, the dispatch time, the time of arrival at the scene,
For example, CPR, for cardiopulmonary resuscitation, is an time of departure from the scene, time of arrival at the hos-
abbreviation. AIDS, for acquired immune deficiency syn- pital, and time back in service (refer to Figure 10-1). Other
drome, is an acronym. time intervals are important, as well. The time you and
Medical abbreviations and acronyms allow you to your crew arrived at the patient’s side is often very differ-
increase the amount of information you can write ent from the time the ambulance arrived at the scene—
quickly on your report (Table 10-1). They also pose prob- when your patient is on the fourth floor of a building
lems, however, because they can have multiple mean- without an elevator, for example, or in a field several hun-
ings. For instance, their meanings can vary in different dred yards from the road. Whatever the reason, document
areas of medicine. Is CP chest pain, cardiovascular per- in your report any significant discrepancies between your
fusion, or cerebral palsy? Is CO cardiac output or carbon arrival at the scene and your arrival at the patient. The
monoxide? Is BLS basic life support or burns, lacera- times of vital signs assessment, medication administration,
tions, and swelling? These are all common abbreviations certain medical procedures as local protocols require, and
with more than one accepted meaning. Furthermore, changes in patient condition are also important and require
many abbreviations are specific to one community. You accurate documentation.
must be familiar with those used in your local EMS One common problem with documenting times is
system. inconsistencies among the dispatch center clock, the ambu-
Abbreviations and acronyms can cause considerable lance clock, and your watch. Imagine a report that docu-
confusion when someone unfamiliar with the call reads ments that the ambulance arrived on scene at 20:32
your report. Health care professionals who are not famil- according to the dispatch time, that CPR was started at
iar with local customs or with emergency medicine might 20:29 according to your watch, and the first defibrillation
not understand them. One way to clarify the meaning of a was administered at 20:43 according to the defibrillator’s
new abbreviation or acronym is to write it out the first internal clock. Even though we may recognize this phe-
time you use it, followed by the abbreviation or acronym nomenon and tend to discount the accuracy of the recorded
in parentheses. After that, you can use the abbreviation times, they are nonetheless the official, legal times. When-
alone throughout the report. The following examples ever possible, therefore, record all times from the same
illustrate how abbreviations and acronyms can shorten clock. When that is not possible, be sure that all the clocks
your narratives. In standard English the report might be and watches you use are synchronized. If they cannot be
written as follows: synchronized and the documented times seem to conflict
with each other, explain this in your narrative. A simple
The patient is a 54-year-old conscious and alert male statement such as the following will suffice: “All time
who complains of sudden onset of chest pain and intervals on the scene were documented using my watch;
shortness of breath that started 20 minutes ago. He all other times are those reported by the dispatch center.”
has taken two nitroglycerin with no relief. He denies
any nausea, vomiting, or dizziness. He has a past
history of coronary artery disease, a heart attack Communications
three years ago, and high blood pressure. He takes Your communications with the hospital are another impor-
nitroglycerin as needed, Procardia XL, hydrochlo- tant item to document. Your system may make voice
rothiazide, and potassium. He has no known drug recordings of those communications, but the recordings
allergies. are usually not kept indefinitely. Again, the PCR will likely
Documentation 189
Black B Newborn NB
Male ♂
Body Systems
Abdomen Abd Gynecological GYN
Common Complaints
Abdominal pain abd pn Lower back pain LBP
Diagnoses
Abdominal aortic aneurysm AAA Chronic obstructive pulmonary disease COPD
Adult respiratory distress syndrome ARDS Coronary artery bypass graft CABG
(Continued)
190 Chapter 10
Medications
Angiotensin-converting enzyme ACE Lactated Ringer’s, Ringer’s lactate LR, RL
Hydrochlorothiazide HCTZ
Anatomy/Landmarks
Abdomen Abd Anterior-posterior A/P
Physical Exam/Findings
Arterial blood gas ABG Heel-to-shin (cerebellar test) H→S
Heart sounds HS
(Continued)
192 Chapter 10
Approximate ≈ Per /
Celsius C Radiates to →
Change Δ Right R
Equal = Secondary to 2°
Increased ↑ Unequal ≠
Negative – Zero 0
Treatments/Dispositions
Advanced cardiac life support ACLS Intermittent positive-pressure ventilation IPPV
Medication Administration/Metrics
Centimeter cm Keep vein open KVO
Deciliter dL Liter L
Grain gr Milligram mg
Gram g, gm Milliliter mL
Intramuscular IM Orally PO
Intravenous IV Sublingual SL
Joules J
Cardiology
Atrial fibrillation AF Paroxysmal atrial tachycardia PAT
be the only permanent record of your discussion with the your PCR and, if possible, have him sign it to verify your
medical direction physician. Specifically, you should docu- treatments.
ment any medical advice or orders you receive and the
results of implementing that advice and those orders. In
some situations, you might need to document what you Pertinent Negatives
reported to the physician and/or discussed with him, so The patient assessment and medical interventions are the
the reader will be able to understand the decision-making essence of the EMS event and become the core of your
process. Finally, always document the physician’s name on PCR. We will discuss specific approaches to documenting
194 Chapter 10
assessment and interventions later in this chapter, but the coroner’s or medical examiner’s office for dead-on-
some general rules apply regardless of the method. arrival (DOA) scenes.
Document all findings of your assessment, even those If a physician stops to help, identify him by name and
that are normal. Although the positive findings are usually document his qualifying credentials. If one of your medical
of most interest, some negative findings—known as perti- direction physicians is on the scene and directs care, docu-
nent negatives—are also important. For example, if your ment his activities. Likewise document the names, creden-
respiratory distress patient does not have swollen ankles tials, and activities of any other medically qualified
or crackles, that helps rule out a field diagnosis of conges- personnel present who offer to help. Your clinical experi-
tive heart failure. Or if your patient with a broken leg does ence and local protocols will determine how you integrate
not have loss of sensory or motor function, it suggests he qualified health care workers into your emergency scene.
has no serious neurologic injury. You should include such Document that integration carefully.
information in your report.
The pertinent negatives vary for each chief complaint.
In general, if a positive assessment finding for any given
chief complaint would be important, a negative finding
Elements of Good
probably is pertinent. Even though these findings do not Documentation
warrant medical care or intervention, your seeking them
A well-written PCR is accurate, legible, timely, unaltered,
demonstrates the thoroughness of your examination and
and professional. Each of these traits is essential.
history of the event.
Figure 10-4 Complete both the narrative and check-box sections of every PCR.
(PCR with narrative and check-box sections. Copyright © by NYS Department of Health Bureau of EMS. Used by permission of NYS Department of Health Bureau of EMS.)
196 Chapter 10
the indicated action. Always make sure that the information entire documentation immediately following a call. If so,
in your checked boxes and in your narrative are consistent. make notes on scratch paper and write enough of the
Inconsistencies will be extremely difficult to explain later on, report that you will be able to finish it completely and
especially in front of a jury. accurately later. The sooner you finish it, the more details
Remember that proper spelling, approved abbrevia- you are likely to recall and the better the report will be.
tions, and proper acronyms also affect your PCR’s accuracy.
Misspelled words lose their meaning; many abbreviations
Absence of Alterations
are not universally recognized; and several acronyms have
more than one meaning. Make sure that the meaning of any Mistakes happen. During a busy shift or in the middle of
abbreviation or acronym is clear. the night you will check the wrong box, misspell a word, or
omit important information. You will be thinking of one
medication and write another’s name on your report. If
Legibility you make a mistake writing your report, simply cross
Poor penmanship and illegible reports lead to poor docu- through the error with one line and initial it (Figure 10-5).
mentation. Some EMS providers say, “I wrote it, and I can Some systems may expect you to date the correction as
read it. That’s all that matters.” This is simply not true. The well. Do not scribble over or blacken out any area of the
PCR does not exist solely for its author’s reference. It is a call report. Never try to hide an error. Such foolish tactics
permanent record that many different people use. Your only raise the reader’s curiosity about what you wrote
handwriting must be neat enough that other people can originally. After crossing out the error, continue with the
read and understand the report, especially the narrative. It correct information. If you find the error after you’ve
must also be neat enough that you can read and under- already written several more sentences, submit an
stand it yourself many years from now, long after the event addendum.
has faded from your memory. Your writing must be heavy Whenever possible, have everyone involved in the
enough to transfer to any carbon copies. Using a ballpoint call read or reread the PCR before you submit it. Make all
pen whenever possible makes carbon copies more legible corrections before you submit the report to the hospital or
and makes it difficult for someone to tamper with the doc- to the EMS administrative offices. Do not make changes
ument. Clearly mark the check boxes to eliminate any on the original report after you have submitted it. If for
doubt that a check mark is not just a meaningless scratch. any reason you need to make corrections after you have
Always remember that other members of the health care submitted the report, or some portion of it, place an
team may use the report for medical information, research, addendum. Simply note on the original report, “See
or quality improvement. addendum,” and attach the addendum to the original
report. Write the addendum on a separate sheet of paper
or on an official form if one exists. Likewise, if more infor-
Timeliness mation comes to your attention after you have submitted
As a rule, you should avoid writing your report in the the report, write a supplemental narrative on a separate
ambulance during transport of your patient for two rea- report form.
sons. First, the bumpy ride makes it difficult to write Write any addendum to your report as soon as you
neatly. More importantly, your time is better spent com- realize that you made an error or that additional informa-
municating with your patient and conducting ongoing tion is needed. Note the purpose of the revision and why
assessments. Most hospitals have an area where you can the information did not appear on your original report.
sit and complete your paperwork once patient care has The addendum should document the date and time that it
been transferred. was written, the reason it was written, and the pertinent
Ideally, you should complete your report immediately information. Only the original author of a report should
after you complete the emergency call, when the informa- attach an addendum, as it is part of the official call record.
tion is fresh in your mind and you can check with your Agencies should have separate forms for other EMS per-
partner or patient if you have any questions about the sonnel, supervisors, or citizens who, for some reason, want
events. At times you may be too busy to complete the to contribute to the documentation.
neurologic findings within the body area you are docu- would need intensive documentation of the affected body
menting. For example, when recording findings in the system or systems. The body systems approach can be one
extremities, include distal neurovascular function. When of the most comprehensive approaches to documentation.
documenting the head, include the results of cranial nerve The following illustrates a body systems approach for a
testing. The following illustrates the head-to-toe approach patient with chest pain and shortness of breath:
for a patient who has been in a collision:
General Patient is a healthy-looking female
General The patient presents in the front seat who presents sitting upright in her
of the car, in moderate distress with chair, able to speak in phrases only.
bruises to his forehead and some facial
Vital Signs Pulse—irregular, 90; BP—170/80;
lacerations. Pt. is alert and oriented to
resp—28 labored; skin—warm and
self, time, and place.
diaphoretic.
Vital signs Pulse—100 strong, regular radial;
HEENT + Lip cyanosis and pursing; some
BP—110/88; resp—24 nonlabored;
nasal flaring; pink, frothy sputum;
skin pale and cool.
jugular veins distended.
HEENT Depression to right frontal bone, Respiratory Labored respiratory effort; acces-
minor bleeding controlled prior to sory neck muscle use; trachea
arrival; no drainage from ears, nose. midline; + intercostal, supracla-
No periorbital ecchymosis or Battle’s vicular, suprasternal retractions; =
sign; pupils equal and reactive to chest expansion; diffuse crackles
light; extraocular movements intact, and wheezing in all lung fields,
cranial nerves II–XII intact. decreased breath sounds.
Neck Trachea midline; no jugular vein dis- Per. Vasc. + Ascites fluid wave; + 2 pitting
tention; + cervical spine tenderness. edema in lower extremities; strong
Chest Equal expansion; bruises across the peripheral pulses.
chest wall; no deformities; equal bilat- Labs Sinus tachycardia with occasional
eral breath sounds. unifocal premature ventricular
Abdomen Soft, nontender, nondistended. contractions. Pulse oximetry—92%
room air; 97% on supplemental
Pelvis Unstable pelvic ring; pain on palpation.
oxygen.
Extremities + Circulation, sensory, and motor
function in all four extremities; no Assessment/Management Plan
deformities noted. In the assessment/management section, you document what
you believe to be your patient’s problem. This is also known
Posterior No obvious injuries noted.
as your field diagnosis, or impression. For example, your
Labs Sinus tachycardia, no ectopy, pulse field diagnosis for a patient with chest pain may be “possible
oximetry 97% on supplemental oxygen. angina or rule out myocardial infarction.” You do not have to
make an exact diagnosis. When you are not sure, simply doc-
Body Systems Approach The body systems ument what you suspect is the general problem. Sometimes,
approach, as the name indicates, focuses on body systems for instance, your field impression might be “rule out acute
instead of body areas. It is best suited to screening and pread- abdomen, or seizures.” Rule out identifies possible diagnoses
mission exams in which you conduct a comprehensive exam that you believe the emergency physician should evaluate.
involving all body systems. Each body system has different Record your complete management plan from start to
key components that you should assess and document. finish. This includes how you packaged and moved your
When you use the body systems approach in emer- patient to the ambulance. Did you carry him on a stair-chair
gency medicine, you usually will focus only on the system, or on a backboard fully immobilized, or did he walk? List any
or systems, involved in the current illness or injury. For interventions you completed before contacting your medical
example, a patient having an asthma attack would require control physician. For example, did you control bleeding with
an in-depth evaluation of the respiratory system. Another direct pressure? Did you start an IV? Then describe any orders
patient with lower abdominal pain would need a close from the medical control physician, and always include his
examination of the gastrointestinal system. Neither patient name. Describe how you transported your patient and the
would require a full head-to-toe physical exam but, instead, effects of any interventions such as drug administration or
Documentation 199
Two types of patients might refuse care. The first type is • Patient’s understanding of statements and suggestions and apparent
competence to refuse care based on that understanding
the person who is not seriously ill or injured and simply
does not want to go to the hospital. For example, the belted
driver in a minor automobile crash has an abrasion on his Also document any involvement of the patient’s family or
knee from striking the dashboard. He is alert and oriented, friends.
has no other injuries, and claims he will seek medical atten- Because ruling out serious injury is all but impossible
tion if it bothers him later. This type of patient usually signs in the field, you may need to make clear the possibility of
your PCR in a special place marked “Refusal of Care,” and your patient’s dying. Although this might seem extreme, it
you return to service.3 plainly conveys that the risks are serious. A patient who
The second type of patient is more worrisome. This was informed that he was at risk of dying, refused care,
patient refuses care even though you feel he needs it. This is and subsequently had his leg amputated because of an
known as against medical advice (AMA). Some legal infection would have a hard time convincing a jury that he
experts regard AMA as your failure to convince your patient did not think the risks were serious.
to accept necessary treatment and transport. Such patient In many systems, you must contact the medical direc-
refusals are particularly troublesome because they have the tion physician before allowing a patient to refuse transport.
most potential to end badly. Still, patients retain the right to If you confer with a physician, document any information,
refuse treatment or transportation if they are competent to advice, or orders that the physician gives you. If your
make that decision and are not actively suicidal. patient speaks directly to the physician, document that as
Although you cannot make a legal determination of well. Once more, document that your patient understands
competence (sometimes it takes a court decision), docu- the circumstances and the risks and still chooses to refuse
ment that you believe your patient was competent to refuse transport. Note that you instructed him to call an ambu-
care. Although specific laws vary from state to state, your lance or go to the emergency department if his condition
patient will demonstrate competence by his understanding worsened, or if he just changed his mind. You can ask a
of the circumstances and the risks associated with refusing bystander or law enforcement officer to witness the patient
care and by accepting those risks and the responsibility for refusal, although this is not always required.4
refusing care. Assess your patient as thoroughly as possi- Your documentation also should include a complete
ble, with special emphasis on his mental status and behav- narrative with quotations and statements from others on
ior. Pay extra attention to any patient suspected of being the scene. For example, if your patient’s wife and son plead
under the influence of drugs or alcohol. Clearly document with him to go to the hospital, include their comments in
that your patient has an adequate mental status and under- your report. If your system uses a specific form for patient
stands your field diagnosis, alternative treatments, and the refusals, complete that paperwork as well (Figure 10-6).
consequences of refusing care. In addition, record his rea- The additional form, however, is not a substitute for a com-
son for refusing care (Table 10-2). plete documentation of the circumstances.
Even after you document your patient’s competence,
most patient refusals require more thorough documenta-
tion than the typical EMS run because the opportunity for Services Not Needed
and consequences of abandonment charges are tremen- Some systems allow you to determine that your patient
dous. Simply having your patient sign your PCR is not suf- does not need ambulance transport. Although such poli-
ficient. Again, document that you described your patient’s cies help to reduce ambulance utilization rates, the risks of
injuries to him and that he understood the risks of refusing denying transport are even greater than those of patient
treatment and transport. Inform him of potential complica- refusals. In these cases, the documentation must clearly
tions from injuries that might not be obvious. Discuss those demonstrate that transport was unnecessary. As with
associated risks as well, and document this discussion. patient refusals, document any discussion you have with
202 Chapter 10
the emergency physician and any advice you give to your may overwhelm you. Often, more than one ambulance
patient. crew cares for the many patients. Some EMS personnel
Transportation may not be needed for other reasons, may fill only support roles and never actually provide
as well. Ambulances are often called to minor accidents patient care. Obtaining complete patient information
where no injuries have occurred. When this happens, first might be impossible, and completing documentation for
responders such as the fire department rescue unit or a one patient before going on to care for others might be
police agency might cancel the ambulance. If the ambu- impractical.5
lance is canceled en route, document the canceling author- In these situations, you must weigh your patients’
ity and the time of notification. If you arrive on the scene needs against the demand for complete documentation.
and find no patients, document that. If, when you arrive, Document as much as possible—as quickly as possible—
you are canceled by on-scene personnel, document that on your PCR. You can complete the documentation later as
you made no patient contact and record the person and an addendum. If you cannot remember the particulars of a
agency that canceled you. The difference between “no specific patient or transport, do not guess. Document only
patients found” and “only minor injuries, patients refus- what you know to be factual and accurate. A simple note at
ing transport” is considerable. Although they might the end of the documentation explaining the circumstances
refuse transport, evaluate people with even the most will account for any missing information.
minor injuries. Consider them patients and document Some EMS agencies use special forms for multiple
them accurately. patient events, and most provide a general incident report
form or record that anyone connected with the call may
complete. You should become familiar with local policies
Multiple Casualty Incidents and procedures for documenting these situations. Many
Multiple patients, mass casualties, and disasters all pres- systems use triage tags to record vital information on each
ent special documentation problems. The number of patient quickly (Figure 10-7). A triage tag has just enough
patients needing care and transport during such situations room for your patient’s vital information—name, major
Documentation 203
Figure 10-7 A triage tag offers a quick way to record vital information.
(Triage Tag front and back. Copyright © by The American Civil Defense Association. Used by permission of The American Civil Defense Association.)
injuries, vital signs, treatment, and priority (urgent, nonur- guess about your patient’s medical problems if you are
gent). You affix it to your patient, and it remains there not certain. An inaccurate or incomplete report can affect
throughout the event; you can transfer its information to patient care for many
your PCR later. Whatever your local policies, document as hours, or even days, after
Content Review
completely and accurately as possible without detracting the ambulance call ends.
➤➤ Consequences of Poor or
from patient care. Failing to document a
Good Documentation
medication allergy or doc-
• Medical:
umenting an incorrect
Consequences medical history could
• Poor documentation
can result in poor
have grave effects. If no
of Inappropriate one can read your sloppy
care; good docu
mentation contributes
documentation are enormous. If poor documentation • Better quality assurance processes, chart reviews, and
results in inappropriate care, you may be held responsible. feedback to the EMT or paramedic.
Or if the documentation does not make it clear that you
Data within the ePCR software can be collected in sev-
informed a patient of the risks when he refused transport,
eral different ways. Some fields may include a simple “pick
you may be legally accountable for any harmful conse-
from” list, on which acceptable values are presented and
quences. If the documentation does not explicitly say the
the EMT can select the appropriate item or items from the
patient in ventricular fibrillation was defibrillated immedi-
list (Figure 10-8).
ately, you might be accused of providing inadequate care.
Other parts of the ePCR software may include a graphic
Even though you did everything appropriately, poor,
interface. For example, patient body surveys are often col-
incomplete, or inaccurate documentation will encourage
lected using a picture of a person and a list of clinical find-
anyone who is pursuing a frivolous lawsuit. Good docu-
ings. To record the proper findings, the EMT would select
mentation discourages such actions. Always remember
the body part and then the appropriate finding: “right
that if it is not documented, you did not do it.
lower leg—amputation,” as an example (Figure 10-9).
Inaccurate, incomplete, illegible documentation also
Another means for entering data is manual entry, in
reflects poorly on the EMS provider writing the report.
which the EMT types in the correct value. This is most
Missing information, misspelled words, and poor penman-
commonly seen in the “Vital Signs” or “Times” sections,
ship give the impression of a sloppy, incompetent provider.
where most values are numeric (Figure 10-10).
Good documentation, on the other hand, enhances the
There are many benefits to implementation and use of
EMS provider’s professional stature.
an ePCR system, as already noted, but there are drawbacks
as well. First, and most obvious, is the cost. Such programs
Electronic Patient vary in price, but all of them have a price tag that some EMS
agencies might find prohibitive. Once past the initial cost,
Legal Considerations
The PCR: Your Best Friend or Your Worst Enemy. It is
often difficult to sit and write a PCR after a long and difficult
call. However, the importance of this record cannot be over-
emphasized. Years later, when the call is nothing but a distant
memory, the PCR will be there to provide the facts and details
of the patient encounter. Thus, for accuracy and clarity, the
PCR must be completed as soon as possible after the call
when all the facts are known. Waiting even a few hours may
result in a PCR that is less than complete or is inaccurate.
The PCR is a valuable document. Not only does it pro-
vide medical personnel with the details of care provided in
Figure 10-10 Example of an ePCR manual entry screen. the prehospital setting, but it can also protect prehospital pro-
(© ESO Solutions) viders from negligence claims and malpractice allegations. In
a court of law, it has been said, what is not documented in
and continued support from the software vendor. Addition- the patient record was not performed. Although this may not
ally, as with any advanced software program, ePCR sys- always be the case, it is difficult to prove that a certain pre-
hospital procedure was performed if it was not documented
tems require that one or more people within the organization
in the PCR.
are technically savvy enough to administer and deal with
Although still relatively uncommon, malpractice suits
any day-to-day issues. Finally, there is often an institutional
against EMS personnel are on the rise. Most claims of negli-
reluctance or push-back from the field crews, who may be gence include such allegations as failure to secure and main-
resistant to change: “We’ve always done paper charts, so tain an airway, failure to follow accepted protocols, failure to
why do we need to change now?” or “We’re too busy to transport when care was necessary, and failure to properly
take time to get used to some new system.” The positives, restrain a combative or dangerous patient. You should be
negatives, costs, and benefits of ePCR software must be aware of the various aspects of EMS practice that can result
evaluated individually by each EMS operation. in allegations of negligence and document these accurately.
For example, proper placement of an endotracheal tube
should be verified by at least three methods and documented
Closing in the PCR. In addition, you should document that the tube
remained in proper position by repeated patient evaluations
As a paramedic, you will assume responsibility for your and through use of monitoring systems such as capnography
documentation. Although documentation is often a and pulse oximetry. You must also document care to show
that you followed appropriate protocols and standing orders.
begrudged task, it is one of the most important parts of an
If you deviated from these, you must document in detail why
EMS call. Ensuring that your documentation is complete,
this occurred and whether medical direction was contacted.
accurate, legible, and appropriate is one of your profes-
Patient refusal is a difficult area for EMS. Competent
sional responsibilities. As a professional, you should recog- patients have the right to refuse medical care, even when the
nize this responsibility and set a positive example for failure to obtain medical care may result in harm. However,
others as you fulfill it. paramedics cannot adequately determine which patients are
Your report’s confidentiality cannot be overempha- competent and which are not (competency is a finding of
sized. Confidentiality is your patient’s legal right. Do not law). Thus, when faced with a nontransport situation, docu-
discuss your report with anyone not medically connected ment the circumstances well and obtain a statement from a
directly with the case. Generally, you are allowed to share third-party witness to the refusal.
patient information with another health care provider who Patient restraint poses a significant risk for both the
will continue care, with third-party billing companies, patient and rescuers. Always follow local protocols regard-
ing patient restraint and document that these were followed.
with the police if it is relevant to a criminal investigation,
Try to involve law enforcement personnel in any situation in
and with the court if it issues a subpoena. Your report also
which restraint may be needed.
may be used for quality assurance or research. In these
If you are sued for negligence, the PCR can be either
cases, block out the patient’s name. your best friend or your worst enemy. If you prepared it well
Electronic charting will certainly become common in and documented details of the call, then you have little to
the future. Several systems now on the market allow you to worry about. If you prepared it sloppily or incompletely, then
enter data electronically, transmit that information to the be prepared to answer a lot of difficult questions. Always
receiving facility, and immediately receive a printed report. take the time to prepare an accurate patient report—you will
When you use such systems, remember that the principles not regret it when it is needed.
of effective documentation still apply.
Summary
Regardless of the system you use for documentation, all EMS records should possess the same
basic attributes. Appropriate terminology, proper spelling, accepted abbreviations and acronyms,
and accurate times are essential. A description of the patient assessment and interventions,
including pertinent negatives and communications with on-line physicians, is equally important.
Finally, all the personnel and resources involved in a call must be documented. The record must
be accurate and precise, free of jargon, and neatly written. Corrections should be made properly,
including the use of an addendum when appropriate.
Prehospital care providers may use many systems of documentation, including the CHART
and SOAP formats. Whatever system you use, it is best if you use the same one consistently.
This results in more reliable, complete documentation and reduces the chances of omitting
important information. Any of the existing documentation systems can incorporate a head-to-
toe assessment of the patient. Special situations, such as multiple patients and refusals of trans-
portation, require extra attention. They are often the most difficult calls to document, yet they
are also the calls for which good documentation can be most valuable. A complete narrative—in
addition to any check boxes—is the best way to ensure that all the necessary information is
documented.
Although EMS providers frequently dislike documentation, it is one of the most important
parts of the EMS call. Ensuring that the documentation is complete, accurate, legible, and appro-
priate is one of an EMS provider’s professional responsibilities. Your PCR, whether written or
electronic, is the only permanent record of the ambulance call and the only permanent reflection
of your professionalism.
Review Questions
1. Your prehospital care report will be a valuable 3. The proper way to correct an error in your
resource for _______________ handwritten prehospital care report is to
a. medical professionals. c. researchers. ___________________________
b. EMS administrators. d. all of the above. a. completely and immediately blacken out the
error.
2. You should always attempt to complete your PCR
b. draw a single line through the error, correct,
____________________
and initial.
a. at the scene.
c. highlight the error and place quotation marks
b. en route to the hospital. around it.
c. immediately after the call. d. erase the error completely and enter the correct
d. at the end of your duty shift. information.
206
Documentation 207
4. The call incident approach to documentation 7. The medical abbreviation that means “hyperten-
emphasizes _______________ sion” is ___________.
a. the mechanisms of injury. a. HBV
b. all the information you provided to the hospital b. HPTN
during your field report. c. HPI
c. patient assessment findings. d. HTN
d. the patient’s response to treatment.
8. The medical abbreviation that means that your
5. If your patient refuses transport and care, simply patient has difficulty breathing during physical
having him sign your PCR is not sufficient. effort is ___________.
a. True a. CHF
b. False b. MOI
6. Of the following abbreviations, which one means c. DOE
“drops”? d. DOA
a. Gtts c. Drps See Answers to Review Questions at the back of this book.
b. Dps d. Gms
References
1. Frisch, A. N., M. W. Dailey, D. Heeren, and M. Stern. “Precision 6. Wesley, K. “Write It Right: Keeping Your PCR Clinical and Fac-
of Time Devices Used by Prehospital Providers.” Prehosp Emerg tual.” JEMS 24 (2008): 190–196.
Care 13 (2009): 247–250. 7. Laudermilch, D. J., M. A. Schiff, A. B. Nathens, and M. R. Rosen-
2. Brice, J. H., K. D. Friend, and T. R. Delbridge. “Accuracy of EMS- gart. “Lack of Emergency Medical Services Documentation Is
Recorded Patient Demographic Data.” Prehosp Emerg Care 12 Associated with Poor Patient Outcomes: A Validation of Audit
(2008): 470–478. Filters for Prehospital Trauma Care.” J Am Coll Surg 210 (2010):
3. Graham, D. H. “Documenting Patient Refusals.” Emerg Med Serv 220–227.
30 (2001): 56–60. 8. Taigman, M. “Ending the Paper Trail. Electronic Documentation
4. Weaver, J., K. H. Brinsfield, and D. Dalphond. “Prehospital in EMS.” Emerg Med Serv 31 (2002): 65–68.
Refusal-of-Transport Policies: Adequate Legal Protection?” 9. Kuisma, M., T. Varynen, T. Hiltunen, K. Porthan, and J. Aal-
Prehosp Emerg Care 4 (2000): 53–56. tonen. “Effect of Introduction of Electronic Patient Reporting on
5. Barnhart, S., P. M. Cody, and D. E. Hogan. “Multiple Information the Duration of Ambulance Calls.” Am J Emerg Med 27 (2009):
Sources in the Analysis of Disaster.” Am J Disaster Med 4 (2009): 948–955.
41–47.
Further Reading
Snyder, J. EMS Documentation. Upper Saddle River, NJ: Pearson/Brady, 2007.
Chapter 11
Human Life Span
Development Bryan Bledsoe, DO, FACEP, FAAEM
Standard
Life Span Development
Competency
Integrates comprehensive knowledge of life span development.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to anticipate and respond to the physical,
physiologic, and psychosocial needs of patients across the life span.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
208
Human Life Span Development 209
Key Terms
anxious avoidant attachment, p. 213 life expectancy, p. 219 rooting reflex, p. 212
anxious resistant attachment, p. 213 maximum life span, p. 219 scaffolding, p. 213
authoritarian, p. 215 modeling, p. 215 secure attachment, p. 212
authoritative, p. 215 Moro reflex, p. 211 slow-to-warm-up child, p. 213
bonding, p. 212 palmar grasp, p. 212 sucking reflex, p. 212
conventional reasoning, p. 216 permissive, p. 215 terminal-drop hypothesis, p. 220
difficult child, p. 213 postconventional reasoning, p. 216 trust vs. mistrust, p. 213
easy child, p. 213 preconventional reasoning, p. 216
Case Study
You and your partner respond to an early morning call After asking some pertinent questions, you prepare
and find several people upset and milling around. As to examine the patient for crowning. Having done so,
you announce yourselves as paramedics, a woman you realize it will be necessary to allow the child to be
sticks her head out of a doorway down the hallway and delivered at home. Preparations are made, and within a
beckons you into a room. There you find a woman in short time, a beautiful baby girl is wrapped in warm
her early 20s who is lying in bed and seems very uncom- blankets and snuggled in her mother ’s arms. You
fortable. A young man, visibly pale, is sitting on the explain that you will now prepare the mother and baby
edge of the bed, holding her hand. to be transported to the hospital where they can be
The first woman tells you that the patient is in her examined to be sure there are no problems.
final month of pregnancy and that she has been experi- As you leave the room to get your stretcher, the first
encing mild contractions for about 12 hours. She spoke woman, who is the grandmother of the new baby, is
with her doctor several hours ago and was told to go to spreading the happy news to the rest of the family. By
the hospital when her contractions were approximately the time you return to the room, several family mem-
5 minutes apart. “Unfortunately, her water broke, and bers are gathered around a rocking chair where an
since that time the contractions have been really close elderly woman sits, holding her new great-grandchild
together; about 3 minutes apart,” the woman tells you. in her arms. You think to yourself: “Four generations.
They were afraid to attempt the drive to the hospital, so Wow.” Truly a beautiful family event, which you have
they decided to call the paramedics. been privileged to attend.
Introduction
Even though human anatomy and physiology basically
stay the same, people do change over the span of a lifetime
(Figure 11-1). Besides the obvious changes in size and
appearance, there are also changes in vital signs, body sys-
tems, and psychosocial development. Some of those
changes make it necessary for you to adjust your treatment
of patients. For example, the amount of medication a
patient receives is based on body size, weight, and the abil-
ity of the patient to process it. A child, therefore, usually
requires a smaller dosage than a full-grown adult does.
Many of the changes experienced over a lifetime can be
identified in developmental stages. Those discussed in this
chapter are:
• Infancy—birth to 12 months
• Toddler—12 to 36 months Figure 11-1 People change over the span of a lifetime.
210 Chapter 11
Infancy
Physiologic Development
Vital Signs
The greatest changes in the range of vital signs are in the
pediatric patient (Table 11-1). The younger the child, the
more rapid are the pulse and respiratory rates. At birth, Figure 11-2 Infants double their weight by 4 to 6 months old and
triple it by 9 to 12 months.
the heart rate ranges from 100 to 180 beats per minute dur-
(Source: Michal Heron)
ing the first 30 minutes of life and usually settles to around
120 beats per minute after that. The initial respiratory rate
is from 30 to 60 breaths per minute but tends to drop to 30 fluid in the first week of life, the infant’s weight usually
to 40 breaths per minute after the first few minutes of life. drops by 5 percent to 10 percent; however, infants usually
Tidal volume is 6 to 8 mL/kg initially and increases to 10 to exceed their birth weight by the second week. During the
15 mL/kg by 12 months of age. first month, infants grow at approximately 30 grams per
As with the other vital signs, the normal range for day, and they should double their birth weight by 4 to
blood pressure is related to the age and weight of the 6 months and triple it at 9 to 12 months (Figure 11-2). The
infant, tending to increase with age. The average systolic infant’s head is equal to 25 percent of total body weight.
blood pressure increases from a range of 60 to 90 at birth to Growth charts are good for comparing physical
a range of 87 to 105 at 12 months. development to the norm, but parents and health care
providers should keep in mind that every child develops
Weight at his own rate.
Content Review
Normal birth weight of an
➤➤ The younger the child, the infant usually is between Cardiovascular System
more rapid are the pulse
3.0 and 3.5 kg. Because of the As newborns make the transition from fetal to pulmonary
and respiratory rates.
excretion of extracellular circulation in the first few days of life, several important
changes occur. Shortly after birth, the ductus venosus, a period of time. Breathing becomes ineffective at rates
blood vessel that connects the umbilical vein and the infe- higher than 60 breaths per minute because air moves only
rior vena cava in the fetus, constricts. As a result, blood in the upper airway, never reaching the lungs. Rapid respi-
pressure changes and the foramen ovale, an opening in the ratory rates also lead to rapid heat and fluid loss.
interatrial septum of the fetal heart, closes. The ductus arte- The chest wall of the infant is less rigid than an adult’s,
riosus, a blood vessel that connects the pulmonary artery and the ribs are positioned horizontally, causing diaphrag-
and the aorta in the fetus, also constricts after birth. Once it matic breathing. Therefore, when you assess respiratory
is closed, blood can no longer bypass the lungs by moving rate and effort in an infant, it is important to observe the
from the pulmonary trunk directly into the aorta. abdomen rise and fall. An infant needs less pressure and a
These changes lead to an immediate increase in sys- lower volume of air for ventilation than an adult does, but
temic vascular resistance and a decrease in pulmonary vas- the infant has a higher metabolic rate and a higher oxygen
cular resistance. Although the constriction of the ductus consumption rate than an adult.
arteriosus may be functionally complete within 15 min-
utes, the permanent closure of the foramen ovale may take Renal System
from 30 days to 1 year. The left ventricle of the heart will Usually, the newborn’s kidneys are not able to produce
strengthen throughout the first year. concentrated urine, so the baby excretes a relatively dilute
(You may wish to note that in an adult, the ductus fluid with a specific gravity that rarely exceeds 1.0. (Spe-
venosus becomes a fibrous cord called the ligamentum veno- cific gravity is the weight of a substance compared to an
sum, which is superficially embedded in the wall of the equal amount of water. For comparison, water is consid-
liver. Also, in an adult, the site of the foramen ovale is ered to have a specific gravity of 1.0.) For this reason, the
marked by a depression called the fossa ovalis, and the duc- newborn can easily become dehydrated and develop a
tus arteriosus is represented by a cord called the ligamen- water and electrolyte imbalance.
tum arteriosum.)
Immune System
Pulmonary System During pregnancy, certain antibodies pass from the mater-
The first breath an infant takes must be forceful, because nal blood into the fetal bloodstream. As a result, the fetus
until that moment the lungs have been collapsed. Fortu- acquires some of the mother’s active immunities against
nately, the lungs of a full-term fetus continuously secrete pathogens. Thus, the fetus is said to have naturally
surfactant. Surfactant is a chemical that reduces the surface acquired passive immunities, which may remain effective
tension that tends to hold the moist membranes of the for six months to a year after birth. A breast-fed baby also
lungs together. After the first powerful breath begins to receives antibodies through the breast milk to many of the
expand the lungs, breathing becomes easier. diseases the mother has had.
In general, an infant’s airway is shorter, narrower, less
stable, and more easily obstructed than at any other stage Nervous System
in life. The infant is primarily a “nose breather” until at Sensation is present in all portions of the body at birth, so
least 4 weeks of age; therefore, it is important for the nasal a young infant feels pain but lacks the ability to localize it
passages to stay clear. A common complaint in infants less and isolate a response to it. As nerve connections develop,
than 6 months of age is nasal congestion. This occurs the response to pain becomes much more localized. In
because, as mentioned, young infants are obligate nasal addition, motor and sensory development are most
breathers. Even a mild nasal obstruction, as occurs with a advanced in the cranial nerves at birth, because of their
viral upper respiratory infection, can cause difficulty life-sustaining function and protective reflexes. Because
breathing, especially during feeding. the cranial nerves control such things as blinking, suck-
An infant’s lung tissue is fragile and prone to baro- ing, and swallowing, the infant has strong, coordinated
trauma (an injury caused by a change in atmospheric pres- sucking and gag reflexes. The infant also will have well-
sure). Because of this, prehospital personnel must be flexed extremities, which move equally when the infant is
careful when applying mechanical ventilation with a bag- stimulated.
valve-mask unit. There are fewer alveoli with decreased
collateral ventilation. In Reflexes The infant has several reflexes that disap-
Content Review addition, the accessory pear over time. These include the Moro, palmar, rooting,
➤➤ An infant’s airway is muscles for breathing are and sucking reflexes. The Moro reflex, which is sometimes
shorter, narrower, less immature and susceptible referred to as the “startle reflex,” is the characteristic reflex
stable, and more easily to early fatigue, so they of newborns. When the baby is startled, he throws his arms
obstructed than at any
cannot sustain a rapid wide, spreading his fingers and then grabbing instinctively
other stage in life.
respiratory rate over a long with the arms and fingers. The reflex should be brisk and
212 Chapter 11
symmetrical. An asymmetric Moro reflex (in which one Other Developmental Characteristics
arm does not respond exactly like the other) may imply a Expect rapid changes during an infant’s first year of life. At
paralysis or weakness on one side of the body. about 2 months of age, he is able to track objects with his
The palmar grasp is a strong reflex in the full-term new- eyes and recognize familiar faces. At about 3 months of
born. It is elicited by placing a finger firmly in the infant’s age, he can move objects to his mouth with his hands and
palm. The palmar grasp weakens as the hand becomes less display primary emotions with distinct facial expressions
continuously fisted. Sometime after 2 months, it merges into (such as a smile or a frown). At 4 months of age, he drools
the voluntary ability to release an object held in the hand. without swallowing and begins to reach out to people. By
The rooting reflex causes the hungry infant to turn his 5 months, he should be sleeping through the night without
head to the right or left when a hand or cloth touches his waking for a feeding, and he should be able to discriminate
cheek. If the mother’s nipple touches either side of the between family and strangers. Teeth begin to appear
infant’s face, above or below the mouth, the infant’s lips between 5 and 7 months of age.
and tongue tend to follow in that direction. Stroking the At 6 months, the baby can sit upright in a high chair
infant’s lips causes a sucking movement, or the sucking and begin to make one-syllable sounds, such as “ma,”
reflex, in the infant. Both the rooting and sucking reflexes “mu,” “da,” and “di.” At 7 months, he has a fear of strang-
should be present in all full-term babies and are most eas- ers and his moods can quickly shift from crying to laugh-
ily elicited before a feeding. They usually last until the ing. At 8 months, the infant begins to respond to the word
infant is 3 or 4 months old; however, the rooting reflex may “no,” he can sit alone, and he can play “peek-a-boo.” At
persist during sleep for 7 or 8 months. 9 months, he responds to adult anger.
At about 9 months old, the baby begins to pull himself
Fontanelles Fontanelles allow for compression of up to a standing position, and explores objects by mouth-
the head during childbirth and for rapid growth of the ing, sucking, chewing, and biting them. At 10 months, he
brain during early life. They are diamond-shaped soft spots pays attention to his name and crawls well. At 11 months,
of fibrous tissue at the top of the infant’s skull where three he attempts to walk without assistance and begins to show
or four bones will eventually fuse together. The fibrous frustration about restrictions. By 12 months, he can walk
tissue is strong and, generally, can protect the brain ade- with help, and he knows his own name.
quately from injury. The posterior fontanelle usually closes
in 2 or 3 months, and the anterior one closes between 9 and
18 months. You may wish to note that the fontanelles, espe- Psychosocial Development
cially the anterior one, may be used to provide an indirect Family Processes
estimate of hydration. Normally, the anterior fontanelle is and Reciprocal Socialization
level with the surface of the skull, or slightly sunken. With The psychosocial development of an individual begins at
dehydration, the anterior fontanelle may fall below the birth and develops as a result of instincts, drives, capaci-
level of the skull and appear sunken. ties, and interactions with the environment. A key compo-
nent of that environment is the family. The interactions
Sleep A newborn usually sleeps for 16 to 18 hours daily,
babies have with their families help them to grow and
with periods of sleep and wakefulness distributed evenly
change and help their families do the same. This is called
over a 24-hour period. Sleep time will gradually decrease to
“reciprocal socialization,” a model that recognizes the
14 to 16 hours per day, with a 9- to 10-hour period at night.
child’s active role in his own development.
Infants usually begin to sleep through the night within two to
Raising a baby requires a lot of hard work, but studies
four months. The normal infant is easily aroused from sleep.
show that healthy, happy, and self-reliant children are the
products of stable homes in which parents give a great deal
Musculoskeletal System of time and attention to their children.
The developing infant’s extremities grow in length from
growth plates, which are located on each end of the long Crying A newborn’s only means of communication is
bones. The infant also has epiphyseal plates, or secondary through crying. Although every cry may seem the same to
bone-forming centers that are separated by cartilage from a stranger, most mothers quickly learn to notice the differ-
larger (or parent) bones. As each epiphysis grows, it ences among a basic cry, an anger cry, and a pain cry.
becomes part of the larger bone. Bones grow in thickness
by way of deposition of new bone on existing bone. Factors Attachment Infants have their own unique time-
affecting bone development and growth include nutrition, tables and paths to becoming attached to their parents.
exposure to sunlight, growth hormone, thyroid hormone, Bonding is initially based on secure attachment, or an
genetic factors, and general health. Muscle weight in infants infant’s sense that his needs will be met by his caregivers.
is about 25 percent of the entire musculoskeletal system. Secure attachment is consistent with healthy development,
Human Life Span Development 213
and leads to a child who is bold in his explorations of the difficult child is characterized by irregularity of bodily
world and competent in dealing with it. It is important for functions, intense reactions, and withdrawal from new sit-
this sense of security to develop within the first 6 months uations. A slow-to-warm-up child is characterized by a
of an infant’s life. low intensity of reactions and a somewhat negative mood.
When an infant is uncertain about whether or not his
caregivers will be responsive or helpful when needed,
Situational Crisis
another type of attachment develops. It is called anxious and Parental-Separation Reactions
resistant attachment. It leads to a child who is always Infants who have good relationships with their parents
prone to separation anxiety, causing him to be clinging and usually follow a predictable sequence of behaviors when
anxious about exploring the world. they experience a situational crisis (a crisis caused by a par-
A third type of attachment is called anxious avoidant ticular set of circumstances), such as being separated from
attachment. It occurs when the infant has no confidence parents. The first stage of parental-separation reaction is
that he will be responded to helpfully when he seeks care. protest, the second stage is despair, and the last is detach-
In fact, the infant expects to be rebuffed. This causes him to ment or withdrawal.
attempt to live without the love and support of others. The Protest may begin immediately on separation and con-
most extreme cases result from repeated rejection or pro- tinue for about one week. Loud crying, restlessness, and
longed institutionalization and can lead to a variety of per- rejection of all adults show how distressed the infant is. In
sonality disorders, from compulsive self-sufficiency to the second stage, despair, the infant’s behavior suggests
persistent delinquency. growing hopelessness marked by monotonous crying,
inactivity, and steady withdrawal. In the final stage,
Trust vs. Mistrust Some psychologists believe that detachment or withdrawal, the infant displays renewed
human life progresses through a series of stages, each interest in its surroundings, even though it is usually a
marked by a crisis that needs to be resolved. Each of the remote, distant kind of interest. This phase is apathetic and
crises involves a conflict between two opposing characteris- may persist even if the parent reappears.
tics. From birth to approximately 1½ years of age, the infant
goes through the stage called trust vs. mistrust. Accord-
ing to psychologists, the infant wants the world to be an Toddler and Preschool Age
orderly, predictable place where causes and effects can be
anticipated. When this is true, the infant develops trust Physiologic Development
based on consistent parental care. When an infant begins life Vital signs for toddlers (12 to 36 months, Figure 11-3) and
with irregular and inadequate care, he develops anxiety and preschool-age children (3 to 5 years old, Figure 11-4) are
insecurity, which have a negative effect on family and other not the same as an infant’s. The heart rate for toddlers
relationships important to the development of trust. This
may lead to feelings of mistrust and hostility, which may in
turn develop into antisocial or even criminal behavior.
Scaffolding
Infants learn in many ways from their parents and others
around them. One way they learn—from infancy and
throughout their school years—is through scaffolding, or
building on what they already know. For example, parents or
caregivers usually talk to infants as a natural part of caring
for them. With scaffolding, the dialogue is maintained just
above the level at which the child can perform activities inde-
pendently. As the baby learns, the parent or caregiver
changes the nature of the dialogues so that they continue to
support the baby but also give him responsibility for the task.
In this way, infants continue to build on what they know.
Temperament
An infant may be classified as an easy child, a difficult
child, or a slow-to-warm-up child. An easy child is charac-
terized by regularity of bodily functions, low or moderate
intensity of reactions, and acceptance of new situations. A Figure 11-3 A toddler beginning to stand and walk on his own.
214 Chapter 11
• Immune system. By
Content Review
this point in life, the
➤➤ Young children have
passive immunity
immature chest muscles
born with the infant is
and cannot sustain an
lost, and the child
excessively rapid respira-
becomes more suscep- tory rate for long.
tible to minor respira-
tory and gastrointestinal infections. This occurs at the
same time the child is being exposed to the infections
of other children in child care and preschool. Fortu-
nately, the toddler and preschooler will develop their
own immunities to common pathogens as they are
exposed to them.
• Nervous system. The brain is now at 90 percent of
adult weight. Myelination (the development of the
covering of nerves) has increased, which allows for
effortless walking as well as other basic skills. Fine
motor skills, including the use of hands and fingers in
grasping and manipulating objects, begin developing
at this stage.
Figure 11-4 In the preschool-age child, exploratory behavior • Musculoskeletal system. Both muscle mass and bone
accelerates. density increase during this period.
(© Dr. Bryan E. Bledsoe)
• Dental system. All the primary teeth have erupted by
the age of 36 months.
ranges from 80 to 110 beats per minute. Respiratory rate • Senses. Visual acuity is at 20/30 during the toddler
ranges from 24 to 40 breaths per minute. Systolic blood years. Hearing reaches maturity at 3 to 4 years of age.
pressure ranges from 95 to 105 mmHg. For preschoolers, In addition, though children are physiologically capable
heart rate ranges from 70 to 110 beats per minute, respira- of being toilet trained by the age of 12 to 15 months, they are
tory rate from 22 to 34 breaths per minute, and systolic not psychologically ready until 18 to 30 months of age.
blood pressure from 75 to 110 mmHg. Normal temperature Therefore, it is important not to rush toilet training. Children
for both ranges from 96.8 to 99.6°F (36.3 to 37.9°C). In addi- will let their parents know when they are ready. The average
tion, the rate of weight gain is slowing dramatically. The age for completion of toilet training is 28 months.
average toddler or preschooler gains approximately 2.0 kg
per year.
Changes in body systems include the following: Psychosocial Development
• Cardiovascular system. The capillary beds are now Cognition
better developed and assist in thermoregulation of the Children begin to use actual words at about 10 months, but
body more efficiently. Hemoglobin levels approach they do not begin to grasp that words “mean” something
normal adult levels at this point. until they are about 1 year of age. Usually, by the time they
are 3 or 4 years old, they have mastered the basics of lan-
• Pulmonary system. The terminal airways continue to
guage, which they will continue to refine throughout their
branch off from the bronchioles and alveoli increase in
childhood. Between 18 and 24 months, they begin to under-
number, providing more surfaces for gas exchange to
stand cause and effect. Between the ages of 18 and 24 months,
take place in the lungs. It is still important to remem-
they develop separation anxiety, becoming clinging and
ber that children have immature chest muscles and
crying when a parent leaves. Between 24 and 36 months,
cannot sustain an excessively rapid respiratory rate
they begin to develop “magical thinking” and engage in
for long. They will tire quickly and their respiratory
play-acting, such as playing house and similar activities.
rate will decrease, indicating the onset of ventilatory
failure. Play
• Renal system. The kidneys are well developed by the Exploratory behavior accelerates at this stage. The child is
toddler years. Specific gravity and other characteris- able to play simple games and follow basic rules, and he
tics of urine are similar to those that would be found in begins to display signs of competitiveness. Play provides
an adult. an emotional release for youngsters, because it lacks the
Human Life Span Development 215
right-or-wrong, life-and-death feelings that may accompany and sexual behavior. They rarely punish or make
interactions with adults. Therefore, observations of children demands of their children, allowing them to make
at play may uncover frustrations otherwise unexpressed. almost all of their own decisions. They may be either
“permissive-indifferent” or “permissive-indulgent”
Sibling Relationships parents, but it is very difficult to make the distinction.
There are many positive aspects to growing up with sib- This parenting style may lead to impulsive, aggressive
lings, but there also may be negative ones, which can lead children who have low self-reliance, low self-control,
to sibling rivalry. The first-born child often finds it very dif- and low maturity, and lack responsible behavior.
ficult to share the attention of his parents with a younger
sibling. If the older child must also help care for the Divorce and Child Development
younger ones, he may become even more frustrated. Nearly half of today’s marriages end in divorce. As a result
Although first-born children usually maintain a special of divorce, a child’s physical way of life often changes (a
relationship with parents, they also are expected to exer- new home, for example, or a reduced standard of living).
cise more self-control and show more responsibility when The child’s psychological life is also touched. The effects on
interacting with younger siblings. Younger children often the child’s development, however, depend greatly on the
see only the apparent privileges extended to the older chil- child’s age, his cognitive and social competencies, the
dren, such as later bedtimes and more freedom to come amount of dependency on his parents, how the parents
and go. Still, when asked if they would be happier if their interact with each other and the child, and even the type of
siblings did not exist, most prefer to keep them around. child care. Toddlers and preschoolers commonly express
feelings of shock, depression, and a fear that their parents
Peer-Group Functions no longer love them. They may feel they are being aban-
Peers, or youngsters who are similar in age (within doned. They are unable to see the divorce from their par-
12 months of each other), are very important to the devel- ents’ perspective, and therefore believe the divorce centers
opment of toddler and school-age children. In fact, peer on them. The parent’s ability to respond to a child’s needs
groups actually become more important as childhood pro- greatly influences the ultimate effects of divorce on the
gresses. Peers provide a source of information about other child.
families and the outside world. Interaction with peers
offers opportunities for learning skills, comparing oneself Television and Video Games
to others, and feeling part of a group. Virtually every family has at least one television in the
home, and many have video game players of one kind or
Parenting Styles and Their Effects another. Most children watch television and/or play video
There are three basic styles of parenting: authoritarian, games for several hours each day—many with few, if any,
authoritative, and permissive. parental restrictions. Television violence increases levels of
aggression in toddlers and preschoolers, and it increases
• Authoritarian parents are demanding and desire passive acceptance of the use of aggression by others.
instant obedience from a child. No consideration is Parental screening of the television programs children
given to the child’s view, and no attempt is made to watch may be effective in avoiding these outcomes. Some
explain why. Frequently, the child is punished for even video games also feature violent scenarios that parents
asking the reason for some decision or directive. This may do well to monitor.
parenting style often leads to children with low self-
esteem and low competence. Boys are often hostile, Modeling
and girls are often shy. Toddlers and preschool-age children begin to recognize
• Authoritative parents respond to the needs and wishes sexual differences, and, through modeling, they begin to
of their children. They believe in parental control, but incorporate gender-specific behaviors they observe in par-
they attempt to explain their reasons to the child. They ents, siblings, and peers.1,2
expect mature behavior and will enforce rules, but
they still encourage independence and actualization of
potential. These parents believe that both they and
children have rights and try to maintain a happy bal-
School Age
ance between the two. This parenting style usually Physiologic Development
leads to children who are self-assertive, independent, Between the ages of 6 and 12 years, a child’s heart rate
friendly, and cooperative. is between 65 and 110 beats per minute, respiratory rate is
• Permissive parents take a tolerant, accepting view of between 18 and 30 breaths per minute, and systolic blood
their children’s behavior, including aggressive behavior pressure ranges from 97 to 112 mmHg. Body temperature
216 Chapter 11
is approximately 98.6°F right and punished for what their parents believe to be
Content Review
(37°C). The average child wrong. With cognitive growth, moral reasoning appears
➤➤ Vital signs in most children
of this age gains 3 kg per and the control of the child’s behavior gradually shifts
reach adult levels during
year and grows 6 cm per from external sources to internal self-control. According to
the school-age years.
year. In most children, vital one theory, there are three levels of moral development:
signs reach adult levels preconventional reasoning, conventional reasoning, and
during this period of time, but their lymph tissues are pro- postconventional reasoning, with each level having two
portionately larger than those of an adult. In addition, stages.
brain function increases in both hemispheres, and primary
• Preconventional reasoning. Stage one is punishment
teeth are being replaced by permanent ones.
and obedience; that is, children obey rules in order to
avoid punishment. There is no concern about morals.
Psychosocial Development Stage two is individualism and purpose: Children
School-age children (Figure 11-5) have developed deci- obey the rules, but only for pure self-interest. They are
sion-making skills, and usually are allowed more self- aware of fairness to others, but only as it pertains to
regulation, with parents providing general supervision. their own satisfaction.
Parents spend less time with school-age children than • Conventional reasoning. In stage three, children are
they do with toddlers and preschoolers. concerned with interpersonal norms, seeking the
The development of a self-concept occurs at this age. approval of others and developing the “good boy” or
School-age children have more interaction with both “good girl” mentality. They begin to judge behavior by
adults and other children, and they tend to compare them- intention. In stage four, they develop the social sys-
selves to others. They are beginning to develop self- tem’s morality, becoming concerned with authority
esteem, which tends to be higher during the early years of and maintaining the social order. They realize that cor-
school than in the later years. Often, self-esteem is based rect behavior is “doing one’s duty.”
on external characteristics and may be affected by popu- • Postconventional reasoning. Stage five is concerned
larity with peers, rejection, emotional support, and with community rights as opposed to individual
neglect. Negative self-esteem can be very damaging to rights. Children at this level believe that the best val-
further development. ues are those supported by law because they have
As children mature, moral development begins when been accepted by the whole society. They believe that
they are rewarded for what their parents believe to be if there is a conflict between human need and the law,
individuals should work to change the law. Stage six is
concerned with universal ethical principles, such as
that an informed conscience defines what is right, or
people act not because of fear, approval, or law, but
from their own standards of what is right or wrong.
According to this theory, individuals will move through
the levels and stages of moral development throughout
school age and young adulthood at their own rates.
Adolescence
Physiologic Development
Vital signs in adolescents (13 to 18 years old) are as follows:
heart rate is between 60 and 90 beats per minute, respira-
tory rate is between 12 and 26 breaths per minute, and sys-
tolic blood pressure is between 112 and 128 mmHg. Body
temperature is approximately 98.6°F (37°C). In addition,
the adolescent usually experiences a rapid 2- to 3-year
growth spurt, beginning distally with enlargement of the
feet and hands followed by enlargement of the arms and
Figure 11-5 School-age children are allowed more self-regulation legs. The chest and trunk enlarge in the final stage of
and independence as they grow older. growth. Girls are usually finished growing by the age of 16
Human Life Span Development 217
Development of Identity
FIGURE 11-6 Children reach reproductive maturity during
At this age, adolescents are trying to achieve more inde-
adolescence.
pendence. They take “time out” to experiment with a
variety of identities, knowing that they do not have to
and boys by the age of 18. In late adolescence, the average assume responsibility for the consequences of those iden-
male is taller and stronger than the average female. At this tities. As they attempt to develop their own identity, self-
age, both males and females reach reproductive maturity consciousness and peer pressure increase. They become
(Figure 11-6). Secondary sexual development occurs, with interested in others in a sexual way, and they find this
noticeable development of the external sexual organs. somewhat embarrassing. They really do not know how
Pubic and axillary hairs appear and, mostly in males, vocal to handle this increased interest. They want to be treated
quality changes. In females, menstruation has begun, like adults and do not know how to achieve this.
breasts and the ductal system of the mammary glands How well and how fast adolescents progress through
develop, and there is increased deposition of adipose tis- the various stages of identity development depends on
sue in the subcutaneous layer of the breasts, thighs, and how well they are able to handle crises. Minority adoles-
buttocks. In addition, in the female, endocrine system cents tend to have more identity crises than others. In gen-
changes include the release of follicle-stimulating hormone eral, antisocial behavior usually peaks at around the eighth
(FSH), luteinizing hormone (LH), and gonadotropin, which or ninth grade.
promotes estrogen and progesterone production. In the Body image is a great concern at this point in life.
male, gonadotropin promotes testosterone production. Peers continually make comparisons, and certainly the
Muscle mass and bone growth are nearly complete at media lead to unrealistic ideas of what the “perfect” body
this stage. Body fat decreases in early adolescence and should look like. This is a time when eating disorders are
increases later. Females require 18 to 20 percent body fat in common. It also is a time when self-destructive behaviors
order for menarche, or the first menstruation, to occur. begin, such as use of tobacco, alcohol, and illicit drugs.
Blood chemistry is nearly equal to that of an adult, and Depression and suicide are more common at this age
skin toughens through sebaceous gland activity. (You may group than in any other.
wish to note that a disorder of the sebaceous glands is
responsible for acne, which is common in adolescence. In Ethical Development
acne, the glands become As adolescents develop their capacity for logical, analyti-
overactive and inflamed, cal, and abstract thinking, they begin to develop a personal
CONTENT REVIEW
ducts become plugged, code of ethics. Just as they get disappointed when adults
➤➤ Adolescents have a keen and small red elevations do not live up to their expectations, they tend to get disap-
sense of modesty and
containing blackheads or pointed in anyone who does not meet their personal code
need for privacy.
pimples appear.) of ethics.
218 Chapter 11
may be prevented by good dental hygiene. With age, the age of 50 and the parts of the brain involved in smell
location of cavities in teeth changes and an increasing degenerate significantly so that by age 80, the detection of
amount of root cavities and cavities around existing sites of smell is almost 50 percent poorer than it was at its peak.
previous dental work are seen. Tooth loss can lead to Because taste and smell work together to make enjoyment
changes in diet, an increased chance of malnutrition, and of food possible, appetite often declines. Response to pain-
serious vitamin and mineral deficiencies. ful stimuli is diminished, as is kinesthetic sense, or the abil-
This is also true when the individual has false teeth, ity to sense movement.
which do not completely restore normal chewing ability Visual acuity and reaction time are diminished, and
and can reduce taste sensation. In addition, alterations in there are actual changes in the organs of hearing. The ear
swallowing are more common in older people without canal atrophies, the eardrum thickens, and there may be
teeth because they tend to swallow larger pieces of food. degenerative and even arthritic changes in the small joints
Swallowing takes 50 to 100 percent longer, probably connecting the bones in the middle ear. Significant changes
because of subtle changes in the swallowing mechanism. take place in the inner ear. These changes in structure sig-
Peristalsis is decreased and the esophageal sphincter is less nificantly affect hearing. Hearing loss for pure tones,
effective. which increases with age in men and women, is called
In general, the gastrointestinal system shows less age- “presbycusis.” With presbycusis, higher frequencies
associated change in function than other body systems. become less audible than lower frequencies. Pitch discrim-
Stomach contractions appear to be normal, but it does take ination plays an important role in speech perception so,
longer to empty liquids from the stomach. The amount of with age, speech discrimination declines. When exposed
stomach acid secretions decreases, probably because of the to loud background noise or indistinct speech, older peo-
loss of the cells that produce gastric acid. There is usually ple hear less, but at the same time, they may be very sensi-
a small amount of atrophy to the lining of the small intes- tive to loud sounds.
tine. In the large intestine, expect to see atrophy of the lin-
ing, changes in the muscle layer, and blood vessel Nervous System
abnormalities. Approximately one of every three people With aging, there is a decrease of neurotransmitters and a
over 60 has diverticula, or outpouchings, in the lining of loss of neurons in the cerebellum, which controls coordina-
the large intestine resulting from increased pressure inside tion, and the hippocampus, which is involved in some
the intestine. Weakness in the bowel wall also may be a aspects of memory function. The sleep–wake cycle also is
contributing factor. disrupted, causing older adults to have sleep problems.
The number of some opiate receptors increases with
aging, which may lead to significant constipation when
narcotics are ingested. Changes may occur in the metabo- Psychosocial Development
lism and in absorption of some sugars, calcium, and iron. Even though disease may reduce physical and mental
Highly fat-soluble compounds such as vitamin A appear to capabilities, the ability to learn and adjust continues
be absorbed faster with age. The activity of some enzymes throughout life, and is greatly influenced by interests,
such as lactase—which aids in the digestion of some sug- activity, motivation, health, and income (Figure 11-9).
ars, particularly those found in dairy products—appears to However, the terminal-drop hypothesis asserts that there
decrease. The absorption of fat also may change, and the is a decrease in cognitive functioning over a five-year
metabolism of specific compounds, including drugs, can period prior to death. The individual may or may not be
be significantly prolonged in elderly people. aware of diffuse changes in mood, mental functioning, or
the way his body responds to various stimuli.
Renal System
With aging, there is a 25 to 30 percent decrease in kidney Housing
mass. About 50 percent of nephrons are lost and abnormal Although most older adults would rather stay in their
glomeruli are more common. Reduced kidney function own homes, it is not always possible because home-care
leads to a decreased clearance of some drugs and decreased services are not affordably available in all communities as
elimination. The kidneys’ hormonal response to dehydra- a viable alternative to nursing homes. Home-care services
tion is reduced as is the ability to retain salt under conditions usually provide assistance with household chores such as
when it should be conserved. The ability of the kidneys to preparing meals, cleaning and laundry, and performing
modify vitamin D to a more active form may also lessen. personal care tasks such as feeding and bathing. Health
care services in the home are provided by nurses and
The Senses physical or speech therapists. To be eligible for these ser-
Taste buds diminish during this stage of life, which leads to vices under Medicare, the patient must be home-bound,
a loss of taste sensation. Smell declines rapidly after the need an intensive level of services, and be expected to
Human Life Span Development 221
Financial Burdens
The duration of each stage in the life cycle, and the ages of
family members for each stage, will vary from family to
family. Obviously, this will have an effect on the financial
status of families. For example, a couple who completes
their family while in their early adult years will have a dif-
ferent lifestyle when their last child leaves home than a
couple with a “change-of-life” child. Late children can
cause serious economic problems for retirees on fixed
incomes who are trying to meet the staggering costs of
education.
Retirement brings about changes for both spouses, but
it seems to be particularly stressful for wives who are not
prepared emotionally or financially. Retirement usually
Figure 11-9 The ability to learn and adjust continues through-
out life.
means a decrease in income and in the standard of living,
which can be very difficult to handle.
A decreasing level of interest in work is natural as one
benefit from such services over a reasonable amount of grows older, but it has a severe impact on the income of
time. Home-care services are usually time-limited. older people. Almost 22 percent of all older people live in
An alternative to home-care services is “assisted liv- households below the poverty level. More than 50 percent
ing,” or living in a facility that offers a combination of of all single women above age 60 live at or below the pov-
home care and nursing home facilities. There is a greater erty level. Older women in the United States make up the
sense of control, independence, and privacy in these facili- single poorest group in our society.3–6
ties because the older adult has more choices while still
being in an institutional setting. Bedrooms and bathrooms Dying Companions
can be locked by residents, but dining and recreational or Impending Death
facilities are usually shared. Whether it is the death of a companion or one’s own
About 95 percent of older adults live in communities, impending death, fear and grief seem to have a great deal
from simple groupings of homes where mostly older adults in common. Grief not only follows death, but when there
live to a relatively new type of living arrangement called is advance warning, grief may well precede death. Fre-
the “continuing-care retirement community.” The appeal quently, the death or impending death of a companion
of these communities is that future health care needs are leads us to fear for our own lives. Psychiatrist Elisabeth
covered in a setting that is an attractive residential campus Kübler-Ross believes that regardless of whether it is one’s
where cultural and recreational activities are available. own death or the death of a companion, everyone must
Entrance fees to this type of community are often rather go through certain emotions. Although the five stages in
expensive. her theory may sometimes overlap, everyone must deal
with each of the stages of death before the grieving pro-
Challenges cess ends. (Review the chapter “Workforce Safety and
One of the major challenges for the older adult is main- Wellness” for Kübler-Ross’s five stages.)
taining a sense of self-worth. Senior citizens are com-
monly seen as “over the hill,” less intelligent than Note: Human physiologic and psychosocial develop-
younger adults, and certainly less able to care for them- ment will be discussed in more detail in the chapters on
selves. Many older adults are forced into retirement patient assessment, medical emergencies, and trauma
because they are seen as less productive. In reality, emergencies, and especially in the chapters “Neonatol-
although older workers may have slowed down a bit, ogy,” “Pediatrics,” “Geriatrics,” and “The Challenged
they are often more concerned with producing quality Patient.”
Summary
The changes that take place during the span of a lifetime are innumerable. At some stages, espe-
cially birth through preschool, the changes seem to occur almost daily. The stages of infant through
adolescent constitute our pediatric population. By knowing the typical developmental character-
istics of each age group, you will be better prepared to evaluate a sick or injured pediatric patient.
This is especially important when a caregiver may not be readily available. You can compare the
child’s current state to an established norm and determine whether there is a significant differ-
ence. Remember, however, that not every person develops at the same rate and in the same way,
and established norms are only guidelines that should never take the place of a thorough assess-
ment and history obtained from someone who is intimately familiar with the patient.
Only through experience with patients at all the various stages of life—adult as well as pedi-
atric—will you come to feel comfortable dealing with patients at each of these stages. Remember
that no matter what the stage of development, a thorough assessment, patience, and a sincere
desire to help will guide you to make the right emergency care decisions for each patient.
Review Questions
1. At birth, the heart rate ranges from _______________ 3. The ______________________, a blood vessel that
beats per minute during the first 30 minutes of life. connects the pulmonary artery and the aorta in the
a. 90 to 120 c. 100 to 180 fetus, constricts after birth.
b. 100 to 120 d. 160 to 240 a. ductus venosus
b. foramen ovale
2. The infant’s head is equal to ___________ percent of
total body weight. c. ductus arteriosus
a. 10 c. 20 d. ligamentum venosum
b. 15 d. 25
222
Human Life Span Development 223
4. The ____________________, which is sometimes 8. As adults reach the age of ___________, ill health—
referred to as the “startle reflex,” is the characteristic as opposed to accidents, homicide, and suicide—
reflex of newborns. becomes the major cause of death.
a. Moro reflex c. sucking grasp a. 25 c. 40
b. rooting reflex d. palmar grasp b. 30 d. 60
5. Parents who are ___________ encourage indepen- 9. Which of the following would be an expected set of
dence but will enforce rules. vital signs for a patient who is 35 years old, without
a. dismissive c. authoritative any illness or injury?
b. permissive d. authoritarian a. Blood pressure of 124/80, heart rate of 72/min,
and respirations of 14/min
6. In this stage of moral development, children are
b. Blood pressure of 98/60, heart rate of 84/min,
concerned with interpersonal norms, seeking the
and respirations of 16/min
approval of others, and developing the “good boy”
c. Blood pressure of 166/76, heart rate of 82/min,
or “good girl” mentality.
and respirations of 10/min
a. permissive reasoning
d. Blood pressure of 220/180, heart rate of 70/min,
b. conventional reasoning and respirations of 12/min
c. preconventional reasoning
10. What is the age range for someone in “middle adult-
d. postconventional reasoning
hood”?
7. The theoretical, species-specific, longest duration of a. 21 to 45 years of age
life, excluding premature or “unnatural” death, is b. 32 to 55 years of age
called the ________________
c. 41 to 60 years of age
a. life expectancy.
d. 48 to 65 years of age
b. total age duration.
See Answers to Review Questions at the end of this book.
c. maximum life span.
d. maximum age.
References
1. American Academy of Pediatrics Section on Orthopaedics, Prehospital Care and Continuing Medical Education in Geriat-
American Academy of Pediatrics Committee on Pediatric Emer- rics.” J Am Geriatr Soc 57 (2009): 530–535.
gency Medicine, American Academy of Pediatrics Section on 4. Shah, M. N., J. J. Bazarian, E. B. Lerner, et al. “The Epidemiology
Critical Care, et al. “Management of Pediatric Trauma.” Pediatrics of Emergency Medical Services Use by Older Adults: An Analy-
121 (2008): 849-854. sis of the National Hospital Ambulatory Medical Care Survey.”
2. American College of Surgeons Committee on Trauma, American Acad Emerg Med 14 (2007): 441–447.
College of Emergency Physicians, National Association of EMS 5. Shah, M. N., T. V. Caprio, P. Swanson, et al. “A Novel Emer-
Physicians, Pediatric Equipment Guidelines Committee-Emer- gency Medical Services-Based Program to Identify and Assist
gency Medical Services for Children (EMSC) Partnership for Older Adults in a Rural Community.” J Am Geriatr Soc 58 (2010):
Children Stakeholder Group, and American Academy of Pediat- 2205–2211.
rics. “Policy Statement—Equipment for Ambulances.” Pediatrics 6. Weiss, S. J., R. Chong, M. Ong, A. A. Ernst, and M. Balash. “Emer-
124 (2009): e166–e171. gency Medical Services Screening of Elderly Falls in the Home.”
3. Peterson, L. K., R. J. Fairbanks, A. Z. Hettinger, and M. N. Shah. Prehosp Emerg Care 7 (2003): 79–84.
“Emergency Medical Service Attitudes toward Geriatric
Further Reading
Craig, G. J. and W. L. Dunn. Understanding Human Development. 2nd ed. Kall, R. V. and J. C. Cavanaugh. Human Development: A Life-Span View.
Upper Saddle River, NJ: Pearson, 2010. Florence, KY: Wadsworth Publishing, 2008.
Chapter 12
Pathophysiology
Bryan Bledsoe, DO, FACEP, FAAEM
STANDARD
Pathophysiology
COMPETENCY
Integrates comprehensive knowledge of pathophysiology of major human systems.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to describe the pathophysiology of
common patient disorders encountered by paramedics in the out-of-hospital setting.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this chapter. 8. Explain acid–base production, mechanisms
to manage acid, and common acid–base
2. Explain the hierarchical structure of the
imbalances.
body from cells to the biosphere.
9. Explain the basic structure and function of
3. Explain how the predisposing factors of age,
a typical human cell and the components
gender, genetics, lifestyle, and environment
of a cell.
affect the development of disease.
10. Explain the movement of water and solutes
4. List and describe each of the classifications
into and out of cells under various
of diseases by cause.
mechanisms, such as osmosis, diffusion,
5. Differentiate among covalent, ionic, and facilitated diffusion, active transport,
hydrogen bonds. endocytosis, and exocytosis.
6. Recognize the six major chemical elements 11. Describe the fluid and electrolyte
and four major chemical compounds that composition of the cellular environment,
make up the human body. and discuss imbalances of these.
7. Describe the nature and roles of 12. Describe the composition and function of
carbohydrates, proteins, nucleic acids, blood, including both plasma and formed
lipids, and water in the body. elements.
224
Pathophysiology 225
13. Predict the physiologic effects of infusing 20. Differentiate among cardiogenic,
various types of intravenous fluids. hypovolemic, neurogenic, anaphylactic, and
septic shock and discuss basic treatment
14. Explain the processes of cellular respiration
goals for each.
and energy production.
21. Describe the pathophysiology of multiple
15. Describe the different cellular responses to
organ dysfunction syndrome (MODS).
stress, cell injury, and cell death.
22. Describe the basic characteristics of bacteria,
16. Describe the embryonic origins of body
viruses, fungi, parasites, and prions that act
tissues and discuss the basic structure and as human pathogens.
function of epithelial, connective, muscle,
and nervous tissues. 23. Describe the body’s three lines of defense
against pathogens.
17. Describe the process of neoplasia, including
factors associated with cancer. 24. Explain the structure and function of the
immune system.
18. Discuss the risk factors and basic
25. Discuss the process of inflammation in the
pathophysiology of common disorders seen
by the out-of-hospital care provider. body.
26. Describe variances in immunity and
19. Describe the physiology of perfusion, the
inflammation.
pathophysiology of hypoperfusion, and
compensatory mechanisms employed by 27. Describe the stress response and how this
the body during periods of hypoperfusion. can contribute to disease states.
KEY TERMS
ABO blood groups, p. 320 anabolism, p. 247 bases, p. 249
acid–base reaction, p. 249 anaerobic metabolism, p. 303 basophils, p. 333
acidosis, p. 252 anaphylaxis, p. 310 benign, p. 233
acids, p. 249 anion, p. 238 buffer, p. 250
acquired immunity, p. 317 antibiotic, p. 314 carcinogenesis, p. 294
active transport, p. 259 antibody, p. 317 cardiac contractile force, p. 300
acute, p. 232 antigen, p. 317 cardiac output, p. 300
adenosine triphosphate antigen–antibody complexes, p. 322 cardiogenic shock, p. 307
(ATP), p. 245 antigen-presenting cells carrier proteins, p. 258
adipocytes, p. 289 (APCs), p. 325 cartilage, p. 290
adipose tissue, p. 289 antigen processing, p. 325 cascade, p. 330
aerobic metabolism, p. 303 apoptosis, p. 281 catecholamines, p. 300
afterload, p. 300 atom, p. 235 cation, p. 238
AIDS (acquired immunodeficiency atomic number, p. 235 cell, p. 254
syndrome), p. 340 atrophy, p. 281 cell-mediated immunity, p. 318
albumin, p. 270 autoimmune disease, p. 232 cell membrane, p. 255
alkalosis, p. 252 autoimmunity, p. 336 cellular adaptation, p. 280
allergy, p. 336 B lymphocytes, p. 317 cellular respiration, p. 276
amino acids, p. 241 bacteria (singular, bacterium), cellulose, p. 241
amylopectin, p. 240 p. 314 centrioles, p. 275
amylose, p. 240 basement membrane, p. 286 chemoreceptors, p. 252
226 Chapter 12
Case Study
Medic 14 is dispatched to 1514 Houston on the outskirts found to be hypoglycemic—as a result of either his alco-
of downtown. Paramedics quickly recognize the address holism or his medication.
as the Union Gospel Mission. It is a shelter for the home- They gently roll Bill to a supine position, and he
less and the location of many EMS calls. On arrival, the moans slightly. His airway, though, is patent and his
crew is met by Reverend Williams, the aged gentleman vitals are stable. They notice multiple bruises and a
who has operated the shelter for as long as anyone can nosebleed. Bill has virtually all the stigmata of alcohol-
remember. He recognizes Armando, the senior para- ism and is now jaundiced. Armando says, “I’ll bet he is
medic, and tells him, “It’s Bill Jamison again. He looks hypoglycemic again.” Armando’s partner and rookie
bad this time.” Paramedics roll the stretcher to the ele- paramedic, Sam, begins to look for a vein. Reverend
vator, only to learn that it is again broken. They grab the Williams holds a flashlight to help illuminate the dark
essential bags and climb four flights of stairs to reach and odorous room. No vein is identifiable. Armando
Bill’s room. switches places with Sam and takes a look. He, too, sees
Bill is a chronic inebriate well known to virtually all no veins. They then begin to discuss whether to give
EMS providers in the city. He is a former wrecker driver glucagon intramuscularly or place an intraosseous (IO)
who used to interact with paramedics on accident line. Armando decides on the IO. The line is placed
scenes. However, his disease, alcoholism, eventually without incident, and Bill awakens after receiving half
took his job, his family, his home, and now his health. an amp of D50W. Bill is transported to University Hospi-
EMS providers and the local county hospital have tal without incident.
watched Bill’s steady and predictable decline to his cur- On the way back from the hospital, Sam asks
rent condition. Bill is found prone on the floor in a dirty Armando why he chose the IO instead of the intramus-
sleeping bag. He is unresponsive with snoring respira- cular glucagon. Armando explains, “Glucagon is a hor-
tions. Paramedics know that Bill has type 2 diabetes and mone that stimulates the release of glucose from
is often noncompliant with his medications. He is often carbohydrate storage sites, such as glycogen in the liver.
Pathophysiology 229
Because of Bill’s liver disease and poor diet, he has little, factors, especially prothrombin, are made and stored in
if any, glycogen stores and glucagon is unlikely to work. the liver. As the liver fails, as is the case with Bill, his
Besides, I’ve tried it in the past and it never has worked.” body loses its ability to properly clot, and he is prone to
Sam pondered the statement for a minute and asked, bleeding. Actually, the bleeding points to severe, or even
“What was the bleeding from?” Armando answers, end-stage, liver disease.” Sam thinks for a minute and
“Not sure really. I could not see a source. But it is prob- states, “Wow. You can learn something from every call—
ably a bleeding disorder.” “What do you mean?” even at the Union Gospel Mission.” Armando smiles
inquires Sam. Armando responds, “Many of the clotting and nods gently.
biome is a geographic area with similar climatic condi- been mapped through the Human Genome Project.
tions, such as a desert biome, a forest biome, a grasslands Researchers are finding, with increasing frequency, that
biome, or a marine biome. Finally, all ecosystems, biomes, many diseases are due to expression of specific genes.
and by definition all living organisms, form a biosphere. A Certain diseases are more common in certain fam-
biosphere is the portion of Earth where life is found. Our ilies. For example, one family may have a history of
biosphere extends from the depths of the deepest oceans atherosclerotic heart disease that routinely kills male
(where life can be found) to approximately seven miles members in the fifth or sixth decade of life. Other fami-
above sea level. lies may routinely develop diabetes mellitus.
Because our ethnicity and race are also genetically
encoded, certain diseases are common in certain races.
smoking and lung cancer, we know that various factors are Classifications of Disease
involved in the development of the disease. In some
There are various ways to classify diseases. The most com-
patients, the cause may be repeated exposure to cigarette
mon is by disease cause. On this basis, the following sys-
smoke, whereas in others it may be due to genetic expres-
tem of disease classification will be used in this text:
sion. In the person who develops lung cancer from genetic
expression, genetics is the cause but cigarette smoking and • Infectious. Infectious diseases are those that result
age may be contributing factors. It has been suggested, but from invasion of the body and colonization by a patho-
not proven, that secondhand smoke may contribute to the genic organism. Most of these are microorganisms
development of lung cancer. In the example we have been such as prions, viruses, bacteria, and fungi. Others are
using, secondhand smoke exposure in a lung cancer patient larger multicelled pathogenic organisms such as tape-
who had never smoked might be simply correlated to the worms and liver flukes.
condition. That is, it is a suspected factor but cannot be • Immunologic. Overreactions of the immune system,
proven to either cause or contribute to the condition. commonly called allergies or hypersensitivity, can
The manifestation of a disease is known as the clinical cause diseases such as anaphylaxis. Sometimes the
presentation. The clinical presentation includes both signs immune system fails to recognize certain tissues as
and symptoms of the disease. A symptom is what the belonging to the host and mounts an immune response
patient tells you about the disease—a subjective complaint. as if the tissues were foreign. This phenomenon,
Symptoms are often detailed when you obtain the patient’s referred to as autoimmune disease, is responsible for
history. An objective finding that you can identify through such conditions as rheumatic heart disease and rheu-
physical examination is referred to as a sign. Some diseases matoid arthritis. Inadequate immune system function
have a specific constellation of commonly found signs and makes the human more susceptible to pathogenic
symptoms. These are referred to as a syndrome. However, organisms and can result in overwhelming infection,
some signs and symptoms are common among a variety of such as that seen with acquired immune deficiency
diseases and are referred to as being nonspecific symptoms syndrome (AIDS).
or generalized symptoms.
• Inflammatory. Inflammatory diseases are those that
The process of identifying and assigning a name to a
result from the body’s response to another disease
disease in an individual patient or a group of patients with
process (primary disease). For example, pelvic
similar signs and symptoms is termed diagnosis. A diag-
inflammatory disease (PID) in a female is secondary
nosis is a generalization and an assumption that a disease
to a bacterial infection in the reproductive tract—
will follow a prescribed course. However, just as people
often gonorrhea or chlamydia. The infection causes
are different, all diseases are different, and each follows its
inflammation of the organs and supporting struc-
own course. Some diseases have a sudden onset and are
tures in the pelvis.
referred to as acute, whereas others have a much slower
onset and are referred to as chronic or insidious. The • Ischemic. Many diseases are due to diminished blood
symptoms of a chronic disease are often milder and more supply. Thus, the affected tissues may be deprived of
difficult to initially identify. oxygen and essential energy substrates, which can
When a disease such as diabetes mellitus is first identi- lead to cell death. Common examples of ischemic
fied, the primary problem is impaired glucose metabolism. diseases include acute coronary syndrome (ACS),
However, as the disease progresses, other body systems ischemic stroke, and
ischemic bowel disease. CONTENT REVIEW
can be affected. With diabetes, the eyes and kidneys can be
➤➤ Disease Classified by
adversely affected, causing both blindness and renal fail- • Metabolic. Metabolic
Cause
ure. Such abnormalities that result from the original prob- diseases result when
• Infectious
lem are referred to as complications. When these resulting there is a disturbance
• Immunologic
complications are common, or even expected, they are in the biochemical and • Inflammatory
referred to as sequelae of the disease. metabolic processes • Ischemic
Many diseases are fairly well understood, and so we within the body. • Metabolic
can predict their outcome. This expected outcome is Examples include dia- • Nutritional
referred to as the prognosis. For example, we know that betes mellitus, which • Genetic
hepatitis A has an incubation period of approximately 28 results from decreased • Congenital
days and the disease lasts from two weeks to three months insulin secretion from • Neoplastic
with relatively mild symptoms. Whenever the disease var- the endocrine pan- • Trauma
ies from the expected prognosis, it is important to reevalu- creas, and thyrotoxico- • Physical agents
• Iatrogenic
ate the patient to ensure that the diagnosis was correct and sis that results from
• Idiopathic
that complications are not occurring. abnormally elevated
Pathophysiology 233
Neoplasia
The Big Bang theory proposes that the universe began with the explosion of a
primeval atom—resulting in both the formation of galaxies in a still-expanding
universe and the origin of life from simple chemicals.
FIGURE 12-4 Development of the universe originating from a rapid expansion (explosion) of hot, dense primeval material is known as the
“Big Bang theory.”
Pathophysiology 235
Arno Penzias and Robert Wilson, who later won the Nobel understand the chemical basis for life. In this section of the
Prize for this discovery. In 2006, a distant NASA space chapter, we will summarize the basics of chemistry as they
probe detected the light released just after the Big Bang. apply to pathophysiology. Then, we will detail the bio-
This cosmic afterglow, known as microwave background, chemical processes that are affected by injury and illness.
is further support for the Big Bang theory. It is the oldest The fundamental chemical unit is the atom. Within
radiation ever detected, still traveling almost 14 billion the atom are particles, referred to as subatomic particles,
years after it was emitted. which include electrons, protons, and neutrons. Protons and
A related component to the origin of the universe is the neutrons exist within the nucleus of the atom. Electrons
origin of life as we know it. The prevailing scientific theory are considerably smaller particles and orbit the nucleus
is that simple chemicals present in the primordial atmo- (Figure 12-5). Protons (p +) have a positive electrical
sphere and ocean combined to form larger, more complex charge, neutrons (n) are electrically neutral, and electrons
chemicals. This theory is referred to as chemical evolution. (e-) have a negative electrical charge. Opposite charges
Powered by the energy of the sun and other sources, the attract and like charges repel. When the number of pro-
chemistry of the atmosphere and oceans changed over time. tons and the number of electrons are the same, the atomic
This ultimately led to the formation of complex chemicals charge is electrically neutral.
that were able to self-replicate (produce identical copies of An element is a substance that cannot be separated into
themselves). The ability of a chemical to self-replicate simpler substances. The number of protons in the nucleus of
marked the transition from chemical evolution to biological an atom (the atomic number) defines the element. Elements
evolution. Once biological evolution began, natural selection are usually classified by their atomic number in a scheme
began. (Natural selection is the tendency of traits that help a known as the periodic table of elements (Figure 12-6).
species to adapt and survive to become common in a popu- Elements cannot be reduced to simpler substances by
lation by being passed down to succeeding generations.) As normal chemical means. That is, naturally occurring pro-
these chemicals replicated and multiplied, they became cesses cannot break them down into more elemental struc-
more complex. The self-replicating chemical soon became tures. While each element contains a characteristic number
surrounded by a membrane and cellular life began. of protons, the number of neutrons can vary. Elements that
have the same number of protons but vary in the number
of neutrons are referred to as isotopes, or variants of the
The Chemical Basis of Life same element. Some elements, such as uranium, can have
multiple isotopes. The number of protons in an atom’s
As stated previously, to understand pathophysiology, you nucleus is referred to as the atomic number, and the total
must first understand normal anatomy and physiology. To number of neutrons and protons in an atom is referred to
understand normal anatomy and physiology, you must as the mass number.
Electron shell
Proton (1)
Electron (2)
2
1 2p 8p
1 8n
2n
2 Nucleus
/CUUPWODGT
PWODGTQHRTQVQPU
C 0WODGTQH
PGWVTQPU JCNHNKXGU (TCEVKQP 2GTEGPVCIG
GNCRUGF TGOCKPKPI TGOCKPKPI
#VQOKEPWODGT
*
PWODGTQHRTQVQPU *G
.K
$G
$
%
0
1
(
0G
0C /I #N
5K
2
5
%N
#T
FIGURE 12-6 A portion of the periodic table of elements. Each element
has an atomic number (the number of protons), a mass number (the total
number of neutrons and protons), and a one- or two-letter symbol.
(Freeman, Scott, Biological Science, 4th Edition, © 2011. Reprinted by permission of
Pearson Education, Inc., Upper Saddle River, NJ.)
called the noble gases: helium, neon, argon, krypton, xenon, hydrogen atoms approach each other, they begin to share
and radon. Because their valence shells are full, the noble their two electrons, and then both atoms fill their valence
gases are extremely stable. shell and become stable.
Covalent Bonds
Chemical Bonding The equal sharing of electrons results in what is called a
Most atoms become stable by bonding to other atoms. For covalent bond, which tends to hold the atoms together. A
example, the simplest atom is hydrogen. Hydrogen con- substance made up of atoms held together by one or more
tains only one electron. However, the first orbital shell can covalent bonds is referred to as a molecule (Figure 12-9).
hold two electrons. Thus, to attain stability, hydrogen must Covalent bonds are the strongest of the three types of
find a second electron to fill the first shell. When two chemical bonds.
H Single
covalent
H
bonds
H H
C 1 H C H 5 H C H
H H
Single Single covalent bonds
covalent H
bonds
H
Double Double
covalent covalent
bond bond
O
C 1 O C O 5 O C O
Double covalent bonds
N 1 N N N 5 N N
Triple covalent bonds
FIGURE 12-9 Covalent bonds are formed when electrons are shared between atoms. Shown here are examples of single, double, and triple
covalent bonds. The structural formula of each is shown at the far right.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc.,
Upper Saddle River, NJ.)
238 Chapter 12
Ionic Bonds also quite reactive and usually exists as a salt in nature.
In addition to covalent bonds, atoms can be held together Sodium has one electron in its outer shell and chlorine has
when atoms with an electrical charge are attracted to each seven electrons in its outer shell. Thus, sodium (Na) must
other. An atom or molecule that has acquired an electrical lose an electron to reach stability, and chlorine (Cl) must
charge by either gaining or losing one or more electrons is gain an electron to reach stability. When the two atoms come
referred to as an ion. Neutral atoms have an equal number into close proximity, the sodium atom loses an electron to
of protons and electrons. When an atom or molecule loses the chlorine atom, thus becoming a positively charged cat-
one or more electrons, the number of protons exceeds the ion (abbreviated as Na+). The chlorine atom, gaining an elec-
number of electrons, thus giving the atom or molecule a tron, becomes a negatively charged anion (abbreviated as
net positive charge. (Remember that a proton has a posi- Cl-). The opposite ions are then attracted to each other, thus
tive charge, whereas an electron has a negative charge.) forming an ionic bond and becoming sodium chloride
Conversely, when an atom or molecule gains one or more (NaCl), a salt (the main ingredient in common table salt).
electrons, there are then more electrons than protons and
the atom or molecule has a net negative charge. An atom or Hydrogen Bonds
molecule with missing electrons and thus a net positive A hydrogen bond is the last type of chemical bonding. As
charge is called a cation. An atom or molecule with extra already noted, the equal sharing of electrons forms a cova-
electrons and a net negative charge is called an anion. lent bond. However, in selected cases, the sharing of elec-
Because opposite charges attract, bonds form between trons between two atoms is unequal. Thus, different parts
atoms of opposite (positive/negative) charges. This kind of of the same molecule can have an unequal charge. An
bond is referred to as an ionic bond (Figure 12-10). unequal covalent bond is called a polar bond, and the mol-
As with covalent bonds, ions will try to fill their outer- ecule is referred to as a polar molecule. This relationship
most shell in order to reach stability. Thus, certain atoms can be explained by looking at the water molecule. In water
tend to interact with other atoms to fill their outermost shell. (H2O), two hydrogen (H) atoms share their electrons with
Elements that are classified as metallic elements tend to lose a single oxygen (O) molecule, but the electrons spend more
electrons. Likewise, elements that are described as nonme- time orbiting the oxygen atom compared to the hydrogen
tallic elements tend to gain electrons. Thus, most ionic atoms. Thus, the oxygen atom has a slightly negative
bonds are between a metal and a nonmetal. The prototypical charge and each hydrogen ion has a slight positive charge,
example of this is the ionic bonding of the atoms sodium (a thereby making the entire water molecule polar. In nature,
metal) and chlorine (a nonmetal). Sodium is extremely reac- the hydrogen ions of a water molecule, because they have a
tive and occurs only in compounds in nature. Chlorine is slight positive charge, are attracted to the oxygen atoms of
Na 1 Cl Na1 Cl2
FIGURE 12-10 An ionic bond involves the transfer of electrons between atoms. Such a transfer creates oppositely charged ions that are attracted
to each other.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc.,
Upper Saddle River, NJ.)
Pathophysiology 239
H 2 2 2
1 O H 1
H O
H H
1 O O 1 1
2
H H O
H 1 1 H H
1 1 1 1
H O 2 2 O H
2 Hydrogen 1 Oxygen Water (H2O) H H
1 1
atoms atom
(a) Water is formed when an oxygen atom covalently bonds (shares (b) The hydrogen atoms from one water molecule are
electrons) with two hydrogen atoms. Due to unequal sharing of electrons, attracted to the oxygen atoms of other water molecules.
oxygen carries a slight negative charge and the hydrogen atoms carry a This relatively weak attraction (shown by dotted lines) is
slight positive charge. called a hydrogen bond.
FIGURE 12-11 The hydrogen bonds of water. (a) Shown at left, water is formed when an oxygen atom covalently bonds with two hydrogen
atoms. Because of unequal sharing of electrons, the oxygen atom has a slight negative charge and the hydrogen atoms have a slight positive
charge. (b) Shown at right, the hydrogen atoms of one water molecule are attracted to the oxygen atoms of other water molecules. This
relatively weak attraction (shown by dotted lines) is called a hydrogen bond.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc.,
Upper Saddle River, NJ.)
other water molecules (because they have a slight negative Because of the diversity of the world of biochemistry,
charge). This attraction between a slightly positively we will limit this discussion primarily to animals. Plants
charged hydrogen atom and a slightly negatively charged have very unique biochemical processes, but these are not
oxygen atom is referred to as a hydrogen bond. Hydrogen pertinent, for the most part, to the study of human patho-
bonds are much weaker than either covalent bonds or ionic physiology.
bonds. Collectively, they are important in that they give
water its special physical properties (Figure 12-11). Classes of Biological Chemicals
There are four major classes of biological chemicals. These
Inorganic and Organic Chemicals are the four major compounds already mentioned: carbo-
In general chemistry, chemicals are usually classified as hydrates, proteins, nucleic acids, and lipids (fats). Water,
organic or inorganic. Inorganic chemicals are chemicals as well, plays an extremely important role in biological
that do not contain the element carbon. Organic chemicals chemistry.
are all the chemicals that do contain the element carbon.
More than 90 percent of all known chemicals are organic,
and most chemicals found in plants and animals are
organic. Six elements (carbon, hydrogen, nitrogen, oxygen,
phosphorus, and sulfur) make up approximately 98 per-
cent of the body weight of most living organisms. Of these,
the four major elements of living systems are carbon (C),
hydrogen (H), oxygen (O), and nitrogen (N).
A compound is the chemical union of two or more ele-
ments. The four major compounds of living systems are car-
bohydrates, proteins, nucleic acids, and lipids. Molecules of
these compounds are composed mostly of atoms from the
four major elements, plus
CONTENT REVIEW some additional elements,
➤➤ Classes of Biological such as phosphorus (P), sul-
Chemicals fur (S), iron (Fe), magne-
• Carbohydrates FIGURE 12-12 Common table salt (sodium chloride, NaCl) is a
sium (Mg), sodium (Na),
• Proteins compound of sodium and chlorine. Sodium is a silver-colored solid
chlorine (Cl), potassium (K), metal; chlorine is a yellow gas. Table salt is, obviously, neither a
• Nucleic acids (DNA, RNA)
iodine (I), and calcium (Ca) silvery metal nor a yellow gas, but a grainy white compound that is
• Lipids (fats)
(Figure 12-12). quite different from its elements.
240 Chapter 12
The straight- A ring structure of glucose A ring structure of Sugars are the most important sources of energy for most
chain formula in which carbon atoms glucose in which the C
of glucose within the ring are for carbon atoms within cells. They are soluble in water.
designated with the letter C the ring is omitted
Disaccharides The disaccharides are complex sugars.
H CH2OH
They are combinations of the simple sugars joined together
CH2OH by a glycosidic bond to form a double-sugar molecule.
C O
H C O H O
H H Examples of disaccharides are sucrose, lactose, and maltose.
H C OH H H
C OH H C OH H • Sucrose is common table sugar. It is a combination of
HO C H HO OH
HO C C OH glucose and fructose (Figure 12-14).
H C OH
H OH H OH • Lactose is the principal sugar in milk. It is a combina-
H C OH tion of glucose and galactose.
H C OH • Maltose is a breakdown product of starch. It is a com-
H bination of two glucose molecules.
Figure 12-13 Glucose is a monosaccharide, a six-carbon sugar that Sucrose and maltose are frequently encountered in the diet.
is the principal energy source for the human body. As noted, maltose results from the degradation of starch.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts,
Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson
Polysaccharides Polysaccharides are the second
Education, Inc., Upper Saddle River, NJ.)
type of carbohydrates. Major polysaccharides are the
starches, cellulose, and glycogen. Plants store glucose in
Carbohydrates the form of starches or cellulose. Animals store glucose in
Carbohydrates are compounds that contain the elements the form of glycogen. Starches and cellulose are major parts
carbon (C), hydrogen (H), and oxygen (O). Typically, the of the human diet.
hydrogen and oxygen atoms occur in a 2:1 ratio. Carbo-
Starches Starches are polymers of glucose. A polymer
hydrates provide the majority of calories in most diets.
is a large organic molecule formed by combining many
They are typically divided into the sugars and the poly-
smaller molecules (monomers) in a regular pattern. In
saccharides.
the case of starch, the smaller molecule is glucose. Thus,
Sugars The sugars can be classified as either simple sug- starches are long chains of glucose molecules connected
ars (monosaccharides) or complex sugars (disaccharides). by glycosidic bonds. Unlike the monosaccharides, starches
are insoluble in water. This allows them to serve as storage
Monosaccharides The monosaccharides are simple reservoirs for glucose.
sugars. Examples of monosaccharides are glucose, fructose, There are two types of starches:
and galactose.
• Amylose is a linear, unbranched chain of several hun-
• Glucose is a six-carbon sugar and the principal energy dred glucose molecules. (Portions of larger molecules,
source for the human body (Figure 12-13). such as the glucose molecules that make up amylose,
• Fructose is a five-carbon sugar that is found in many are called residues.)
plants and vegetables as well as honey. • Amylopectin differs from amylose in that it is highly
• Galactose, also a six-carbon sugar, is primarily found branched, not linear like amylose. The glucose residues
in dairy products. in a molecule of amylopectin number several thousand.
*1%* *1%*
1 1
* * *1%* 1 * * * *1%* 1 *
* *
1* * 1 * *1 1* * * *1 1 *1
*1 1* *1 %*1* *1 1 %*1*
* 1* 1* * * 1* 1* *
)NWEQUG (TWEVQUG 5WETQUG
/QPQUCEEJCTKFG 1
/QPQUCEEJCTKFG
&KUCEEJCTKFG
Figure 12-14 Sucrose is a disaccharide made when two monosaccharides, glucose and fructose, combine.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc.,
Upper Saddle River, NJ.)
Pathophysiology 241
Proteins
Proteins, which are nitrogen-based complex compounds, are
the basic building blocks of cells. Proteins are essential for the
growth and repair of living tissues. They are the most abun-
dant class of biological chemicals in the body (Table 12-1).
Proteins consist of smaller building blocks called amino acids.
Glycogen
FIGURE 12-16 Glucagon administration may be ineffective in
patients with limited stores of glycogen, such as alcoholics
because of liver disease and malnutrition. If you suspect your
patient may have limited glycogen stores, administer glucose to
Liver cell increase blood glucose levels.
Side chains OH
FIGURE 12-17 Amino acid monomers combine to form polymers consisting of long chains called polypeptides.
(Freeman, Scott, Biological Science, 4th Edition, © 2011. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.)
The amino acids are held together in proteins by Proteins have four levels of structure: primary, sec-
peptide bonds. These bonds occur when two amino ondary, tertiary, and quaternary. The precise sequence of
acid molecules join and a molecule of water is released. amino acids in a protein is referred to as the primary
The shape and other properties of each protein are dic- structure. This sequence of amino acids in a protein is
tated by the precise sequence of amino acids it contains. determined by the person’s genes. The secondary struc-
Proteins consist of one or more unbranched chains of ture of a protein results from bending and folding of the
amino acids. Thus, like the polysaccharides already dis- amino acid chain. The shape results from hydrogen bonding
cussed, proteins are polymers. There are 20 types of between parts of the chain. The overall three-dimensional
amino acids (monomers) that are synthesized in protein shape of a protein is called the tertiary structure. Cova-
polymers. lent, ionic, and hydrogen bonds all play a role in a pro-
The typical protein will contain 200–300 amino acid tein’s tertiary structure. Finally, some proteins will have
molecules. A protein chain containing less than 10 amino more than one polypeptide chain. Each chain forms a
acids is often called a peptide and a chain of greater than subunit of the protein. The forces that hold the subunits
10 amino acids is called a polypeptide. Some proteins are together are the charges present on the side-chains. This
extremely large, consisting of more than 20,000 amino acid level of protein structure is referred to as the quaternary
monomers (Figure 12-17). structure (Table 12-2).
Changes in the environment of a protein can result in Step 2: The substrate binds to the
the protein losing its three-dimensional shape. Various active site of the enzyme, forming an
enzyme–substrate complex.
factors can cause this, including heat, chemicals, and pH.
These usually affect the secondary and tertiary structure, Step 1: The cycle begins Step 3: The substrate is
when the active site of the converted to products that are
although they can also affect the primary structure. The enzyme is unoccupied and released from the active site,
loss of a protein’s three-dimensional shape is called the substrate is present. and the cycle can begin again.
Patho Pearls
Enzyme Enzyme–substrate complex Enzyme
Congenital Metabolic Diseases. There are a large number
(a) A decomposition reaction involving an enzyme
of congenital genetic diseases that affect aspects of metabo-
lism. Formerly referred to as inborn errors of metabolism, they
are now more accurately referred to as congenital metabolic Substrates Product
diseases. These diseases can affect carbohydrate, protein, and
lipid metabolism, as well as other metabolic processes. Exam-
ples of these diseases include glycogen storage disease, phe-
nylketonuria, acute intermittent porphyria, congenital
adrenal hyperplasia, and many others. At present, treatment
is extremely limited and many conditions are ultimately fatal.
The use of gene therapy, when refined, holds great promise
for these conditions.
Enzyme Enzyme–substrate complex Enzyme
(b) A synthesis reaction involving an enzyme
ENZYMES Most enzymes are proteins. Enzymes are sub-
stances that speed up chemical reactions. They accomplish FIGURE 12-18 The working cycle of an enzyme.
this without being consumed in the process. Most chemical (Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts,
reactions that occur in the body occur too slowly to meet the Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson
Education, Inc., Upper Saddle River, NJ.)
needs of the body. Thus, we have multiple enzyme systems
that speed these necessary chemical reactions—sometimes
by as much as 10,000 to 1,000,000 times the rate at which that have an unpaired electron in an outer orbital that is not
such reactions would occur without the aid of the enzyme. contributing to molecular bonding (and is thus free). Atoms
The substance an enzyme works on is called a sub- or small molecules that are free radicals tend to be the most
strate. The substrate binds to the enzyme, forming the unstable. The free-radical theory of aging (FRTA), advanced
enzyme–substrate complex. The substrate is then con- by Denham Harman more than 50 years ago, posits the fol-
verted to the end product, the enzyme then binds to another lowing: Cells continuously produce free radicals, and constant radi-
substrate, and the process begins again (Figure 12-18). Some cal damage eventually kills the cell. When radicals kill or damage
enough cells in an organism, the organism ages.5 Aging occurs
enzyme systems require cofactors to function. Cofactors are
when energy-producing cells die, either when the mitochon-
nonprotein substances that aid in the conversion of sub-
dria begin to die out because of free radical damage or when
strate to end product. Some cofactors are found in inorganic
less functional mitochondria remain within these cells. (Free
substances, whereas others, such as vitamins, are organic. radicals are also discussed in the chapter “Airway Manage-
Organic cofactors are usually referred to as coenzymes. ment and Ventilation.”)
The body contains compounds called antioxidants that
are molecules that eliminate radicals. Thus, elevated levels
Patho Pearls
of antioxidants prevent much of the damage done by radi-
Free Radicals, a Side-Effect of Aging. The effects of age are cals. There are numerous antioxidant molecules found in
manifested throughout the body. Numerous metabolic pro- the body, including superoxide dismutase, catalase, gluta-
cesses, including metabolism as a whole, slow with age. This is thione, and others. It has been postulated that administra-
due to multiple factors, including a loss in muscle tissue, but is tion of antioxidant substances can help delay the effects of
also due to hormonal and neurologic changes. aging. Vitamins A, C, and E, as well as several cofactors and
One of the side-effects of aging is the development of free minerals, have antioxidant properties. Although the theory
radicals. Free radicals are highly reactive molecules or atoms seems appropriate, clinical studies have failed to show any
244 Chapter 12
C
G C
T A
T
C
A T
C G
C
Figure 12-19 Colorful fruits and vegetables (other than green)
A T
are rich in antioxidants, although, contrary to popular belief,
research has not shown that increasing their consumption has C G Hydrogen
any cancer-preventing benefit. bonds
Nucleic Acids C G
The class of molecules known as nucleic acids has two
members: deoxyribonucleic acid (DNA) and ribonucleic
Phosphate Deoxyribose Nitrogen- Phosphate
acid (RNA). Adenosine triphosphate (ATP) is an important containing
monomer of RNA. base
DNA and RNA Deoxyribonucleic acid (DNA) is the Figure 12-20 DNA is a nucleic acid in which two chains of nucleo-
tides twist around one another to form a double helix (spiral). The two
nucleic acid that contains the genetic instructions for life.
chains are held together by hydrogen bonds between the nitrogen-
containing bases. Each nucleotide of DNA contains the five-carbon sugar
deoxyribose a phosphate group, and one of four nitrogen-containing
Clinical Note nucleobases: adenine (A), thymine (T), cytosine (C), and guanine (G).
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts,
The ability to repair or replace abnormal genes will forever
Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson
change the practice of medicine. Genes, which are carried on Education, Inc., Upper Saddle River, NJ.)
chromosomes, contain the basic physical and functional units
of heredity. Genes are specific sequences of bases that encode It is composed of two long polymers called nucleotides
instructions to make proteins. The proteins perform most life
that are joined by paired substances called nucleobases.
functions and even make up the majority of cellular structures.
There are four nucleobases in DNA, and the sequence of
When genes are altered so that the encoded proteins are unable
these encodes information known as the genetic code (Fig-
to carry out their normal functions, genetic disorders can result.
Gene therapy is a technique for correcting defective genes
ure 12-20). DNA contains segments referred to as genes
responsible for disease development. Researchers may use one that code for the specific amino acid sequence that makes
of several approaches for correcting faulty genes. These up a specific protein. DNA is further organized into chro-
include inserting a normal gene into a nonspecific location mosomes. The number of chromosomes present in the cell
within the genome to replace a nonfunctional gene. This nucleus varies with the type of organism (e.g., humans
approach is most common. In addition, an abnormal gene have 46, dogs have 78).
could be repaired through selective reverse mutation, which The other member of the class of nucleic acids is
returns the gene to its normal function. Finally, the regulation ribonucleic acid (RNA), a chemical that is similar to DNA
(the degree to which a gene is turned on or off) of a particular (Figure 12-21). RNA plays a major role in protein synthesis,
gene could be altered. In most gene therapy studies, a “nor- serving as a template for protein synthesis.
mal” gene is inserted into the genome to replace an “abnor-
The fundamental building blocks of the nucleic acids,
mal,” disease-causing, gene. A carrier molecule, called a vector,
DNA and RNA, are nucleotides. Nucleotides are five-car-
must be used to deliver the therapeutic gene to the patient’s
bon sugar molecules that are bound to a nitrogen base and
target cells. Currently, the most common vector is a virus that
has been genetically altered to carry normal human DNA. a phosphate group (Figure 12-22). They form a long chain-
like molecule. There are only five nitrogen bases: adenine,
Pathophysiology 245
OH
Phosphate
ATP Adenosine triphosphate (ATP) is a nucleotide
Ribose that is one of the monomers of RNA. ATP is the principal
G
source of energy for most of the energy-using activities of
the cells. Often called the “energy currency” of the cells,
OH
Phosphate ATP consists of the base adenine, the sugar ribose, and
U three phosphate groups. Energy is stored in ATP when
Ribose
an energy-requiring chemical reaction adds an inorganic
phosphate molecule, through covalent bonding, to adenos-
OH
ine diphosphate (ADP), forming ATP.
FIGURE 12-21 RNA is a single-stranded nucleic acid formed by the The phosphate bonds in ATP are highly unstable.
linking together of nucleotides composed of the five-carbon sugar Thus, when cells require energy, the phosphate bond is
ribose, a phosphate group, and one of four nitrogen-containing broken, liberating the stored energy, and the ATP then
nucleobases: cytosine (C), adenine (A), guanine (G), and uracil (U).
returns to ADP and an inorganic phosphate (Figure 12-23).
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts,
The liberated energy can then be used for chemical reac-
Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson
Education, Inc., Upper Saddle River, NJ.) tions occurring within the cell.
In humans, ATP also acts outside the cell. It is released
from damaged cells and elicits pain. It is also released from
0WENGQVKFG the stretched wall of the urinary bladder and signals when
the bladder needs to be emptied.
Lipids
2JQURJCVG
The final major category of biological chemicals is the
0KVTQIGP lipids. Lipids are chemicals that do not dissolve in water.
2GPVQUG EQPVCKPKPI
DCUG Lipids are nonpolar, whereas water is polar. Thus, water
UWICT
is not attracted to lipids, and lipids are not attracted to
water.
FIGURE 12-22 Nucleotides consist of a five-carbon (pentose) sugar In the human, lipids function in the long-term storage
bonded to a phosphate molecule and one of five nitrogen-containing of biochemical energy, insulation, structure, and control.
bases: adenine, cytosine, guanine, thymine, and uracil. Nucleotides
The lipids that pertain to human pathophysiology are tri-
are the building blocks of the nucleic acids DNA and RNA.
glycerides, phospholipids, and steroids (Figure 12-24).
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts,
Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson
TRIGLYCERIDES Triglycerides are rich sources of
Education, Inc., Upper Saddle River, NJ.)
energy for the body. In fact, they provide approximately
twice as much energy per gram as do proteins or carbo-
cytosine, guanine, thymine (found only in DNA), and ura- hydrates. Triglycerides consist of one molecule of glycerol
cil (found only in RNA). It is the sequence of these bases in and three fatty acid molecules (Figure 12-25). Fatty acids
both DNA and RNA that subsequently determines the are long chains of carbon and hydrogen with an acid (car-
sequence of amino acids in a protein. boxyl) group at one end.
DNA is a double-stranded helical chain, whereas RNA Triglycerides can be classified as saturated or unsat-
is single-stranded. In DNA, the five-carbon sugar is deoxy- urated. A saturated fatty acid has a single bond between
ribose; in RNA, the five-carbon sugar is ribose. RNA does each pair of carbon atoms, leaving room on the atom for
not use the nitrogen base thymine, and DNA does not use two hydrogen atoms. Thus, the chemical is said to be
the nitrogen base uracil. DNA has the capacity for self-rep- saturated. When a double bond exists between carbon
lication (Table 12-3). atoms, there is space for only one hydrogen atom, and
246 Chapter 12
Adenine
Phosphate Phosphate Phosphate
Ribose
Triphosphate Adenosine
Adenine
Phosphate Phosphate
Ribose
Diphosphate Adenosine
Phosphate
1
Energy
Steroids have a unique shape consisting of
Figure 12-23 The nucleotide adenosine triphosphate (ATP) con-
four carbon rings
sists of the sugar ribose, the base adenine, and three phosphate
groups. The phosphate bonds of ATP are unstable. When cells need Figure 12-24 The lipids that pertain to human pathophysiology
energy, the last phosphate bond is broken, yielding adenosine are triglycerides, phospholipids, and steroids.
diphosphate (ADP), a phosphate molecule, and energy.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts,
Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson
Education, Inc., Upper Saddle River, NJ).
H H H
H C C C H
thus the molecule is said to be an unsaturated fatty O O O
acid. Double bonds produce a bend in the fatty acid Ester
linkages C O C O C O
molecule and give it a different physical property (Fig-
ure 12-26). Molecules with many of these bends cannot
be packed as closely together as straight molecules, so
these fats are less dense. As a result, triglycerides com-
posed of unsaturated fatty acids melt at lower tempera-
tures than those with saturated fatty acids. For example,
margarine contains more saturated fat than corn oil. At
room temperature it is solid, whereas corn oil remains
liquid.
Glycerol Glycerol
H H H H H H
H C C C H H C C C H
HO HO HO O O O
HO O C O C O C O
H2O CH2 CH2 CH2 CH2
CH2 CH2 CH2 CH2
CH2 CH2 CH2 CH2
CH2 CH2 CH2 CH2
CH2 CH2 CH2 CH2
CH2 CH2 CH2 CH2
Presence of a double
CH2 bond between carbon CH2 CH2 CH2
atoms indicates an
CH2 unsaturated fatty acid.
C CH2 CH2
H
CH2 C CH2 CH2
H
CH2 CH2 CH2 CH2
CH2 CH2
CH2 CH2
CH2
CH2 CH2 CH2
CH2
CH2 CH2 CH2
CH2
CH2 CH2 CH2 CH2
CH2 CH2 CH2 CH3
CH3 CH3
CH2
Fatty acid CH3
Unsaturated Saturated
fatty acid fatty acids
(a) A fatty acid bonds to glycerol through (b) This triglyceride contains one unsaturated fatty acid (note the presence of a double
dehydration synthesis. bond between the carbon atoms) and two saturated fatty acids (note the absence
of any double bonds between the carbon atoms).
FIGURE 12-26 The triglyceride shown here contains one unsaturated fatty acid (note the double bond between the carbon atoms) and two
saturated fatty acids (note the absence of any double bonds between the carbon atoms).
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc.,
Upper Saddle River, NJ.)
and a phosphate group that has a negative charge. Other (Figure 12-28). The tails form a protective region and hold
smaller variable molecules are linked to the phosphate the membrane together.
group. Thus, phospholipids have two distinct regions
with different physical characteristics. The region with STEROIDS The last major class of biological lipids is
the two fatty acid chains, essentially the tail, is nonpolar the steroids. Steroids have a unique shape. That is, they
and rejects water (hydrophobic). The phosphate region, have a four-carbon ring as the backbone of their struc-
essentially the head, is polar and thus attracts water ture (Figure 12-29). The basic unit is cholesterol, which
(hydrophilic). This feature is what makes phospholipids is a component of plasma membranes and the base for
an important part of biological membranes (Figure 12-27). synthesis of most of the steroid class of hormones (i.e.,
Two layers of phospholipids form the membrane. estrogen, testosterone, cortisol, and aldosterone). The
The hydrophobic tails are oriented to the inside of the synthesis of steroid compounds by the body is termed
membrane, and the hydrophilic heads are on the outside anabolism. Steroids became a part of the human diet
248 Chapter 12
Fatty acid
bonds of water are frequently broken and re-formed.
Its polarity makes water an excellent solvent that can
dissolve both polar and charged substances. Water also
plays a major role in the transport of substances through-
out the body and plays a significant role in maintaining a
constant body temperature. Water has a high heat capacity,
and therefore it can absorb a large amount of heat energy
FIGURE 12-27 The phospholipid has a nonpolar (hydrophobic) before the temperature elevates. This property plays a
“tail” consisting of two fatty acids and a polar (hydrophilic) “head” major role in keeping the body cool. In addition to a high
consisting of a phosphate region. heat capacity, water has a high heat of vaporization, mean-
(Freeman, Scott, Biological Science, 4th Edition, © 2011. Reprinted by permission of ing that it takes a great deal of heat energy to make water
Pearson Education, Inc., Upper Saddle River, NJ.)
CH2 CH 2
CH2 CH 2
CH2 CH 2
CH2 CH 2
CH2 CH 2
CH3 CH 3
Animal
Fatty acids
cells
(a) A phospholipid consists of a variable group designated by the (b) Within the phospholipid bilayer of the plasma
letter R, a phosphate, a glycerol, and two fatty acids. Because membrane, the hydrophobic tails point inward and
the variable group is often polar and the fatty acids nonpolar, help hold the membrane together. The outward-
phospholipids have a polar hydrophilic (water-loving) head pointing hydrophilic heads mix with the watery
and a nonpolar hydrophobic (water-fearing) tail. environments inside and outside the cell.
Pathophysiology 249
H3C CH3
CH3
OH CH3 OH
CH3 CH3
CH3
FIGURE 12-29 All steroids have a structure consisting of four carbon rings. Steroids such as cholesterol, estrogen, and testosterone differ in the
groups that are attached to the four carbon rings.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc.,
Upper Saddle River, NJ.)
(a) Water is polar. (b) Hydrogen bonds form By acting as a proton donor or proton acceptor, water has
– between water molecules. the unique ability to act as either an acid or a base. Most
Electrons are
pulled toward chemicals that are acids act only as acids, and most chemi-
O – +
oxygen cals that are bases act only as bases. Acid–base reactions
occur because of the number of protons present in the
H H
water solution at any given time.
+ +
The actual concentration of protons in water has been
FIGURE 12-30 Water is polar and participates in hydrogen bonds. scientifically measured. In a sample of pure water at 25°C
(Freeman, Scott, Biological Science, 4th Edition, © 2011. Reprinted by permission of (77°F), the number of protons (in the form of H+) is 1.0 *
Pearson Education, Inc., Upper Saddle River, NJ.) 10-7 M. (M represents molarity, or moles of solute per liter
of solution. A mole is a measure of mass or weight used in
vaporize. When water vaporizes, it carries away a signifi- chemistry. Mole is sometimes defined as “molecular
cant amount of heat, thus cooling the body. weight.”) Because the actual number of protons is so small,
it is best to use a logarithmic representation. (A logarithm
is a base number that is raised to a certain power. A com-
Acids and Bases mon example is 23 = 8. In other words, 2 to the third
In solution, water has a tendency to break up into ions. power—2 * 2 * 2—equals 8. In that example, 23 is a loga-
That is, the water molecule is not a completely stable rithm. With a positive exponent, like the 3 in 23, a logarithm
molecule. A water molecule, which is made up of hydro- simplifies working with very large numbers. With a nega-
gen and oxygen atoms, can break apart into ions. This is tive exponent, like the -7 in 1.0 * 1.0-7, a logarithm simpli-
a dissociation reaction. (A dissociation reaction is any fies working with very small numbers.)
reaction in which a compound or a molecule breaks apart The accepted convention to express the degree of acid-
into separate components.) This is reflected in the follow- ity or basicity (alkalinity) of a substance is to use the loga-
ing equation: rithmic pH scale. (A logarithmic scale is based on exponents
H2O 4 H + + OH - or powers that raise the value of the base number rather
than the base number itself.) The term pH comes from the
This equation indicates that water dissociates into a hydro- French term puissance d’hydrogène, which literally means
gen ion (H+) and a hydroxide ion (OH-). A hydrogen ion is “power of hydrogen.” In the pH scale, the greater the num-
a molecule that has lost its lone electron and is simply a ber of hydrogen ions, the higher the acidity.
proton. Substances that give up protons during chemical The pH of a solution is the negative of the base-10 log-
reactions are called acids. Likewise, substances that acquire arithm (log) of the hydrogen ion concentration [H+] and
protons during a chemical reaction are called bases. Any can be expressed in the following formula:
chemical reaction that results in the transfer of protons is
pH = - log [H + ]
referred to as an acid–base reaction.
Protons do not exist by themselves. In water, they It can also be written as:
actually associate with another water molecule to form a 1
pH = log
hydronium ion (H3O+). One of the water molecules gives [H + ]
up a proton and acts as an acid. The other water molecule
The pH scale ranges from 0 to 14. A drop in the pH
accepts the proton and acts as a base. This process is
scale of 1 unit indicates a 10-fold increase in the hydrogen
reflected in the following equation:
ion concentration, whereas a 2-unit drop indicates a 100-
H2O + H2O 4 H3O + + OH - fold increase in the number of hydrogen ions, and so on.
250 Chapter 12
dioxide is the weak acid in the carbonic acid–bicarbonate quantities of hemoglobin and the enzyme carbonic anhy-
system, the system cannot protect against changes in the drase. Thus, they can have a significant effect on the pH of
concentrations of one of its constituents (carbon dioxide). ECF. Carbon dioxide readily and rapidly diffuses into red
If this were to occur, elevated levels of carbon dioxide blood cells that take in carbon dioxide from the plasma.
would mix with water, forming carbonic acid, thus gener- There, they are rapidly converted into carbonic acid. When
ating hydrogen ions (driving the equation to the right). the carbonic acid dissociates, bicarbonate ions are excreted
This would be harmful, in that hydrogen ions would into the plasma (in exchange for chloride) in a phenome-
reduce the pH of the plasma. non called the chloride shift. The remaining hydrogen ions
Second, despite what has just been described, the car- are then buffered by the hemoglobin molecules present in
bonic acid–bicarbonate system can function only when the the red blood cells. Overall, the hemoglobin buffer system
respiratory system and respiratory control centers are plays a major role in preventing significant changes in ECF
functioning normally. When the carbonic acid–bicarbonate pH when the PaCO2 is either rising or falling.
buffer system buffers an organic or fixed acid, carbon diox-
ide is produced. This then elevates the partial pressure of PHOSPHATE BUFFER SYSTEM The last major buffer
carbon dioxide in the blood (PaCO2). The respiratory cen- system is the phosphate buffer system, which is somewhat
ters in the brain must detect this increase and increase res- similar to the carbonic acid–bicarbonate buffer system. The
pirations accordingly to remove the excess carbon dioxide phosphate buffer system uses the anion dihydrogen phos-
by exhaling it from the body. If this increase in respirations phate (H2PO4-), which is actually a weak acid. Dihydrogen
cannot occur, for whatever reason, the carbonic acid– phosphate (a weak acid) combines with hydrogen ion to
bicarbonate system becomes considerably less effective. form monohydrogen phosphate (HPO2- 4 ). Monohydrogen
Stated another way, the buffer system cannot remove the phosphate is an anion and can be represented by the fol-
hydrogen ions efficiently unless the respiratory system is lowing equation:
functioning properly.
H2PO4- 4 H + + HPO24 -
Third, the ability to buffer acids is limited by the
amount of available bicarbonate ions. Every time a hydro- The phosphate buffer system can be represented by the fol-
gen ion is removed from the blood, it takes a bicarbonate lowing equation:
ion with it. However, the body normally has an extremely
Base
large supply of bicarbonate ions, known as the bicarbonate pH = 6.8 + log
Acid
reserve.
HPO24 -
The normal pH of the blood can be calculated with the pH = 6.8 + log
Henderson-Hasselbalch equation, which states: H2PO4
Base [Note: In this equation, 6.8 is the pKa of this system (the
pH = 6.1 + log negative log of the ionization constant).]
Acid
HCO3- HCO3- The phosphate buffer system is limited in the ECF but
pH = 6.1 + log or pH = 6.1 log plays a major role in stabilizing the pH of urine.
H2CO3 α2PaCO2
20
pH = 6.1 + log Acid–Base Balance
1
pH = 6.1 + 1.3 As just presented, the acid–base balance must be tightly
controlled. Even though the buffer systems described are
pH = 7.4
effective in binding acids and rendering them harmless,
[Note: In this equation, 6.1 is the pKa of this system (the these acids must then be removed from the body. Thus,
negative log of the ionization constant) and α is the solubil- excess hydrogen ions must be bound to water molecules
ity coefficient of 0.226 mM/kPa. The equation is based on and removed through the exhalation of carbon dioxide
the fact that the normal ratio of base to acid is 20:1.] from the lungs or be removed from the body via secretion
by the kidneys. The maintenance of body pH is a constant
PROTEIN BUFFER SYSTEM Protein buffers depend on balance between gains and losses of hydrogen ion that is
the ability of select amino acids in the protein chain to react achieved through the use of the buffer system, the respira-
to changes in pH by accepting or releasing hydrogen ions. tory system, and the kidneys. These systems secrete or
Proteins in the plasma play an important role in buffering absorb hydrogen ions, control the excretion of acids and
pH changes in the blood. Similarly, protein fragments and bases, or create additional buffers when needed.
amino acids play a role in buffering the pH of the intersti- Whenever a change in pH occurs, the buffer systems
tial fluid. react fastest. However, soon the respiratory system will be
An important part of the protein buffer system is the activated to help correct the problem through its direct
hemoglobin buffer system. Red blood cells contain large effect on the carbonic acid–bicarbonate buffer system. This
252 Chapter 12
The kidney plays a major role in maintaining stable
pH levels. The kidney can retain acids and excrete HCO-3
as needed to maintain pH. Typically, bicarbonate levels in
the body are stable. Thus, when there is an increase in met-
abolic acids, HCO-3 buffers the excessive acid, keeping the
pH neutral. This results in a relative decrease in HCO-3
because body stores remain stable—they are just bound to
FIGURE 12-31 A capnogram associated with an acid–base dis- metabolic acids. Likewise, when the kidney retains acids,
order resulting from hypoventilation.
when the minute volume falls. The minute volume is the Clinical Note
amount of air moved into and out of the respiratory tract in There are many causes of hyperventilation, including seri-
one minute. It is reflected in the following formula: ous conditions such as acute pulmonary embolism and simi-
lar disorders. The time-honored practice of having the
Vmin = Vt * Respiratory Rate
hyperventilating patient rebreathe into a paper bag is not
where Vmin equals minute volume and Vt equals tidal vol- recommended. In acute pulmonary embolism, the patient is
ume (the amount of air moved through the respiratory sys- hypoxic because a blood clot is preventing oxygenated
tem with each breath). Thus, a decrease in respiratory rate, blood from leaving the lungs. Having a patient rebreathe
into a paper bag, though it will correct decreased CO2 levels,
tidal volume, or a combination of the two can cause respi-
will worsen hypoxia and the patient’s overall condition.
ratory acidosis.
Although most cases of hyperventilation are emotional in
nature, some are serious, and it is often difficult to detect
Respiratory Alkalosis these in the out-of-hospital setting. Because of this, having a
Respiratory alkalosis occurs when the respiratory system
patient rebreathe into a paper bag is a risky maneuver and is
eliminates too much carbon dioxide through hyperventila- not recommended.
tion, resulting in hypocapnia. Hyperventilation can result
254 Chapter 12
This discussion of acid–base disorders is simply an is the central portion of a cell that contains organelles and
overview of these conditions from a biochemical stand- other components. Organelles are structures within the
point. They will be discussed in considerable detail in the nucleus that carry out necessary biological processes. Pro-
respiratory and renal chapters of this text. karyotic cells do not contain a nucleus and do not contain
organelles. Most prokaryotic cells are surrounded by a rigid
cell wall. Many of the single-celled organisms, such as bac-
teria, are prokaryotes. Eukaryotic cells contain a nucleus
PART 3: Disease and organelles. The cells of most multicellular organisms,
Carbohydrate
Glycoprotein
Plasma membrane
Embedded Cholesterol Glycolipid Outer surface of
protein
plasma membrane
Extracellular
fluid
Plasma
membrane
Inner surface of
plasma membrane
Phospholipid
bilayer
Surface Filaments of
Cytoplasm protein cytoskeleton
FIGURE 12-33 The hydrophilic heads of the phospholipid molecules on the outer layer of the plasma membrane are in contact with extracel-
lular fluid. The hydrophilic heads of the phospholipid molecules on the inner layer of the plasma membrane are in contact with the cytoplasm.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc.,
Upper Saddle River, NJ.)
Cells are surrounded by a plasma membrane. This proteins). The membrane proteins and their functions (Fig-
membrane consists of several chemicals, of which the ure 12-34) include the following:
phospholipids are among the more important.
• Linkers. Some membrane proteins attach the mem-
As discussed earlier, phospholipid molecules have
brane to the cytoskeleton of the cell, thus allowing the
two distinct regions with different physical characteristics.
cell to maintain its shape and to secure the membrane
The region with the two fatty acid chains, essentially the
in a certain place when needed.
tail of the molecule, is nonpolar and rejects water (is hydro-
phobic). The phosphate region, essentially the head of the • Enzymes. Some proteins function as enzymes and
molecule, is polar and attracts water (is hydrophilic). Two carry out the different steps of the metabolic reactions
layers of phospholipids, referred to as a lipid bilayer, form that take place near the cell membrane.
the cell membrane. Some of the hydrophilic heads face • Receptors. Some membrane proteins act as receptor
outward toward the environment outside the cells. Other sites for messenger molecules that signal the cell to
hydrophilic heads face inward toward the inner contents start or stop a specific metabolic activity.
of the cell. In the middle of the membrane, the hydropho- • Transporters. These proteins make the membrane
bic tails of outward- and inward-facing phospholipids face semipermeable, also called selectively permeable, thus
each other and hold the layers of the membrane together. controlling the movement of substances into and out
The hydrophilic heads of the phospholipid molecules of the cell.
on the outer layer of the plasma membrane are in contact
with extracellular fluid. The hydrophilic heads of the phos- Membrane Proteins
pholipid molecules on the inner layer of the plasma mem-
Extracellular
brane are in contact with the cytoplasm (Figure 12-33). space
Cytoplasm, also called cytosol, fills the inside of cells and
consists of water, salts, organic molecules, and many
enzymes that catalyze numerous biochemical reactions.
The water component of the cytoplasm is referred to as
Cytosol
intracellular fluid.
Throughout the lipid bilayer are proteins that serve x y
numerous purposes. Some of these proteins span the entire Linkers Enzymes Receptors Transporters
membrane (integral proteins), whereas others may be FIGURE 12-34 Membrane proteins include linkers, enzymes, recep-
embedded on the membrane surface (peripheral membrane tors, and transporters.
256 Chapter 12
These varied membrane proteins give the cell Cell Adhesion Molecules
membrane a mosaic quality. Yet even with the
presence of proteins in the plasma membrane,
Cell to cell adhesions
the membrane still maintains a fluid quality.
Therefore, the structure of the membrane is
referred to as a fluid mosaic.
readily move across the plasma membrane. They pass second. Despite this large movement of water molecules,
either directly through the lipid bilayer or through pores the cell does not lose or gain water, because equal amounts
created by certain integral proteins. The rate of transport go in and out.
for a particular molecule is proportional to the lipid sol- The concentration of water on different sides of a semi-
ubility or hydrophobicity of the molecule in question. permeable membrane is a result more of the solutes pres-
(Hydrophobicity is the tendency of a molecule to be ent than of the amount of water present. That is, different
repelled by water. An example is molecules of fat or oil concentrations of solute molecules on different sides of the
that do not mix with water.) Oxygen, carbon dioxide, membrane result in different concentrations of molecules
and ethanol are highly lipid soluble and therefore diffuse of free water (water that is free of solute) on either side of
across the bilayer membrane almost as if it were not the membrane. On the side of the membrane with higher
there. free water concentration (which contains a lower solute
On the other hand, molecules that are large or contain concentration), more water molecules will strike the pores
a charge (are ionized) do not pass readily through the in the membrane in a given interval of time. The more
membrane and, in many cases, are repelled. The rate of dif- membrane strikes there are, the more molecules pass
fusion is generally proportional to the concentration gra- through the pores. This then results in a net diffusion of
dient across the membrane. (The concentration gradient is water from the compartment with high concentration of
the difference in the number of molecules or ions of the free water to that with a low concentration of free water.
substance on one side of the membrane from the number Looking at it a different way, water molecules will diffuse
of molecules on the other.) The greater the concentration from an area of lower solute concentration to an area of
gradient, the more rapid is the rate of diffusion. Osmotic greater solute concentration.
gradient is a similar term but applies specifically to the Water is the universal solvent and necessary for many
movement of water across a semipermeable membrane. biochemical processes.
Another example of concentration gradient is the move- When the concentrations of solutions on both sides of
ment of oxygen. For example, oxygen concentrations are a semipermeable membrane are equal, they are said to be
always higher outside a cell when compared to those isotonic. When a solution on one side of the membrane is
inside a cell. Therefore, oxygen diffuses down its concen-
tration gradient (from higher to lower concentration) into Osmosis (Water Movement)
the cell. Carbon dioxide, on the other hand, typically is at a
Unequal concentrations
higher concentration inside the cell and tends to diffuse across a membrane Water movement
out of the cell.
Osmosis
Osmosis is a specific type of diffusion. It is the movement
of water molecules from an area of high water concentra-
tion to an area of low water concentration (Figure 12-37).
Semipermeable membranes, such as the cell membrane,
allow the unrestricted movement of water across the mem-
brane, at the same time restricting the movement of solute Osmosis
molecules and ions. It has been estimated that an amount FIGURE 12-37 Osmosis is a specific type of diffusion in which water
of water roughly equivalent to 250 times the volume of molecules move from an area of high water concentration to an area
the cell diffuses across the red blood cell membrane every of low water concentration.
258 Chapter 12
Extracellular fluid
High
Glucose concentration
Carrier
protein
Low
concentration
Cytoplasm
ATP ADP
High
concentration
Cytoplasm Cytoplasm
FIGURE 12-41 Active transport moves a solute across the plasma membrane with the help of a carrier protein and energy in the form of ATP.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc.,
Upper Saddle River, NJ.)
260 Chapter 12
Sodium-Potassium Pump
'ZVTCEGNNWNCT
ƃWKF
2NCUOC
OGODTCPG
$CEVGTKWO
%[VQRNCUO 8GUKENG
'ZVTCEGNNWNCT
ƃWKF
Endocytosis
Substances can also enter the cell through a process called
endocytosis. With endocytosis, large molecules, single-celled 8GUKENG
organisms (bacteria), and fluid containing dissolved sub-
stances can enter the cell. During endocytosis, a section of the
plasma membrane encircles the substance to be ingested. &KUUQNXGF
Once the substance is completely encircled, the membrane UWDUVCPEGU
portion is pinched off from the cell membrane, resulting in a %[VQRNCUO
sac-like structure called a vesicle. When separated from the
cell membrane, the vesicle is released into the cell. FIGURE 12-44 Pinocytosis. The cell engulfs droplets of extracellular
Endocytosis is often divided into two categories: phago- fluid.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applica-
cytosis and pinocytosis. Phagocytosis is the process whereby
tions, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Educa-
the cell engulfs large particles or bacteria (Figure 12-43). tion, Inc., Upper Saddle River, NJ.)
Pinocytosis is the process by which the cell engulfs droplets
of fluid carrying dissolved substances (Figure 12-44). Both
mechanisms are necessary for cell survival.
The Cellular Environment:
Exocytosis
It is sometimes necessary for large molecules to leave the Fluids and Electrolytes
cells. For example, hormones are often large molecules that Many pathological conditions, both medical and trau-
cannot readily pass through the cell membrane. As with matic, adversely affect the fluid and electrolyte balance
endocytosis, large molecules can leave the cell by becom- of the body. Certain disease processes, such as diabetic
ing encircled in a membrane vesicle. This process, called ketoacidosis and heat emergencies, are associated with
exocytosis, occurs in a fashion opposite to that of endocy- certain electrolyte abnormalities. Severe derangements in
tosis. The membrane-bound vesicle containing the sub- fluid and electrolyte status can result in death. For this
stance to be released from the cell approaches the cell reason, as a paramedic, you need to have a good under-
membrane. There, it fuses with the cell membrane, and its standing of the fluids and electrolytes present in the
contents are released outside the cell (Figure 12-45). human body.
Pathophysiology 261
Water
Water is the most abundant substance
in the human body. In fact, water 70% of total body water: 60% of body weight:
Intracellular fluid Total body water
accounts for approximately 60 per-
cent of total body weight (the average
for all ages). The total amount of
water in the body at any given time is
referred to as the total body water
(TBW). In an adult weighing 70 kilo-
grams (154 pounds), total body water 5% of total body water:
would be approximately 42 liters Intravascular fluid
(11 gallons) (Figure 12-46).
Water is distributed among var-
ious compartments of the body
(Table 12-8). These compartments are
separated by cell membranes. The 25% of total body water:
Interstitial fluid
largest compartment is the intracellu-
lar compartment. This compartment
contains the intracellular fluid (ICF),
which is all the fluid found inside
body cells. Approximately 70 percent
of all body water is found within FIGURE 12-46 Water comprises approximately 60 percent of body weight. The water is distrib-
this compartment. The extracellular uted into three spaces: intracellular, intravascular, and interstitial.
262 Chapter 12
the circulatory system, making up about 25 percent of water that enters and is excreted from the body on a daily
body water. For example, minute amounts of fluid are basis. The water coming into the body is referred to as
found in the synovial fluid that lubricates the joints; the intake. The water excreted from the body is referred to as
aqueous humor of the eye; secretions including saliva, output. To maintain relative homeostasis, the intake must
gastric juices, and bile; and so on. equal the output, as shown in the following text.
Total body water and its distribution vary with age
and physiologic condition. At birth, an infant’s TBW is Intake
about 75 to 80 percent of its body weight, compared to the digestive system:
65 percent TBW of the average adult. Infants have a higher liquids 1,000 mL
TBW for two reasons. First, infants have less fat than food (solids) 1,200 mL
adults. (Fat does not absorb water, so the less fat in the metabolic sources: 300 mL
body, the more water.) Second, water is essential for the
TOTAL: 2,500 mL
high rates of metabolism that are necessary to promote
growth in the infant. The TBW slowly decreases to approx- Output
imately 70 to 75 percent by age 1. Diarrhea is especially lungs (water vapor): 400 mL
worrisome in the infant, because it can mean the loss of a kidneys (urine): 1,500 mL
significant percentage of TBW. In addition, body systems skin (perspiration): 400 mL
that compensate for fluid loss are still immature, so infants intestines (feces): 200 mL
can rapidly become dangerously dehydrated and subject
TOTAL: 2,500 mL
to electrolyte imbalances. By late childhood, the TBW
decreases to 65 to 70 percent. Several mechanisms work to maintain a relative bal-
By early adulthood, the TBW of males and females ance between input and output. For example, when the
begins to differ. In adult males, TBW constitutes approxi- fluid volume drops, the pituitary gland secretes antidi-
mately 65 to 70 percent of the body weight, whereas in uretic hormone (ADH), which causes the kidney tubules
adult females, the average TBW is 60 to 65 percent. The to reabsorb more water into the blood and to excrete less
gender difference is the result of hormonal differences that urine. This process helps to restore the fluid volume to
result in the male’s greater muscle mass and the female’s normal values.
greater percentage of body fat. Thirst also regulates fluid intake. The sensation of
As the human body ages, the loss of muscle mass, thirst normally occurs when body fluids decrease, stimu-
increased percentage of fat, and the body’s decreasing abil- lating the person to take in more fluids orally. Conversely,
ity to regulate fluid levels lowers the TBW to around 45 to when too many fluids enter the body, the kidneys are
55 percent. As a result of a decreasing ability to regulate activated and more urine is excreted, thus eliminating
electrolytes and fluid levels, the elderly, like the very excess fluid.
young, are at high risk for dehydration and disorders The body also maintains fluid balance by shifting
related to electrolyte imbalances. water from one body space to another.
fluid is typically lost from the intravascular compart- will be accompanied by an increased pulse rate, decreased
ment into the interstitial compartment, which effec- blood pressure, and orthostatic hypotension (increased
tively takes it out of the circulating volume. This can pulse and decreased blood pressure on rising from a
occur with peritonitis, pancreatitis, or bowel obstruc- supine position). In infants, the anterior fontanelle may be
tion. It can also occur in poor nutritional states in sunken and the diaper may be dry or reveal the presence
which there is not enough protein in the vascular sys- of highly concentrated (dark yellow, strong-smelling)
tem to retain water. urine. The absence of tears in a crying infant, a capillary
• Plasma losses occur from burns, surgical drains and fis- refill time greater than 2 seconds, dry mucosa, and a
tulas, and open wounds. decrease in urinary output are signs that indicate severe
dehydration. The treatment for dehydration is replace-
Dehydration rarely involves only the loss of water. ment of fluid.
More commonly, there is also a loss of electrolytes. At the
hospital, fluid replacement will be based on both fluid and OVERHYDRATION Overhydration can occur as well.
electrolyte deficits once the patient’s electrolyte abnormali- The major sign of overhydration is edema. Patients with
ties are determined through laboratory testing. heart disease may manifest overhydration much earlier
Clinically, the dehydrated patient will exhibit dry than patients without heart disease. In severe cases of over-
mucous membranes and poor skin turgor. There often is hydration, overt heart failure may be present. Treatment is
excessive thirst. As it becomes more severe, dehydration directed at removing the excessive fluid.
Electrolytes
How to Read Chemical Notation
To describe chemical substances and reactions, scientists use chemical notation, a kind of “shorthand.” Every chemical
element has a one- or two-letter abbreviation. Just four elements—hydrogen, oxygen, carbon, and nitrogen—make up
more than 99 percent of the body’s atoms. These are called the “major elements.” Nine “trace elements” account for
the remaining less than 1 percent.
An atom is the smallest particle of an element. A molecule is a combination of atoms. The notation for a molecule
combines the notations of the included elements. A subscript number after an element indicates the number of atoms
of that element. If there is just one atom, there is no number. For example:
NaCl (Sodium chloride, or table salt. A sodium chloride molecule has 1 sodium atom and 1 chlorine atom.)
H2O (Water. A water molecule has 2 hydrogen atoms and 1 oxygen atom.)
H2CO3 (Carbonic acid. A carbonic acid molecule has 2 hydrogen, 1 carbon, and 3 oxygen atoms.)
Ions
Each atom is made up of even smaller particles: electrons (that have a negative electrical charge), protons (that have a
positive electrical charge), and neutrons (that are uncharged). Protons and neutrons are in the inner core, or nucleus,
of the atom, and electrons occupy outer orbits around the nucleus. Sometimes an atom of an element can lose one or
more of its outer electrons or can capture one or more extra electrons from another element.
264 Chapter 12
An ion is an atom that has lost one or more negatively charged electrons and now has a positive charge, or an
atom that has gained one or more electrons and now has a negative charge. A superscript plus (+) indicates a positively
charged cation. A superscript minus (-) indicates a negatively charged anion. For example:
Na+ (A sodium ion has lost an electron and has a positive charge.)
Ca++ (A calcium ion has lost two electrons and has a double positive charge.)
Cl- (A chloride ion has gained an electron and has a negative charge.)
Electrolytes are substances that form ions when they break down, or dissociate, in water. Remember that the body
and its blood are mostly water. The ions formed by dissociation of electrolytes in the body’s fluids are a major factor
in body metabolism.
Chemical Reactions
Notations for chemical reactions use a plus sign (+) to indicate substances that are combined and an arrow (S) to show
the direction of the reaction. The reactants are usually on the left, with the product of the reaction on the right.
2H ∙ O u H2O
(2 hydrogen atoms + 1 oxygen atom = 1 water molecule)
In some circumstances, a reaction may be reversible. That is, separate elements may synthesize (combine), or the syn-
thesized substance may dissociate (break down) into separate components. A two-directional arrow (4) shows that a
reaction is reversible and can be read in either direction.
Notice that no atoms are gained or lost in a chemical reaction. In the previous example, the two oxygen atoms in CO2
and the single oxygen atom in H2O combine to equal the three oxygen atoms in H2CO3. The hydrogen and carbon
atoms are also equal on both sides of the reaction.
Up and down arrows (cT) are used to indicate an increase or decrease in the substance that follows the arrows. For
example:
Types of Electrolytes: Cations and Anions are many naturally occurring electrolytes present in the
The chemical substances present throughout the body can body.
be classified as either electrolytes or nonelectrolytes. Elec- The most frequently occurring cations include the
trolytes are substances that dissociate into electrically following:
charged particles when placed into water. The charged • Sodium (Na1). Sodium is the most prevalent cation in
particles are referred to as ions. Ions with a positive charge the extracellular fluid. It plays a major role in regulat-
are called cations; ions with a negative charge are called ing the distribution of water because water is attracted
anions. to and moves with sodium. In fact, it is often said that
An example of this would be the dissociation of the “water follows sodium.” Sodium is also important in
drug sodium bicarbonate when it is placed into water. the transmission of nervous impulses. An abnormal
Sodium bicarbonate is a neutral salt. When placed into increase in the relative amount of sodium in the body
water, it dissociates into two charged particles, as shown is called hypernatremia, whereas an abnormal decrease
here. is referred to as hyponatremia.
NaHCO3 S Na+ + HCO3- • Potassium (K1). Potassium is the most prevalent cat-
ion in the intracellular fluid. It is also important in the
Sodium bicarbonate S sodium cation
transmission of electrical impulses. An abnormally
+ bicarbonate anion neutral salt S cation + anion
high potassium level is called hyperkalemia, whereas
Sodium bicarbonate is an example of an electrolyte that an abnormally low potassium level is referred to as
is taken into the body as a medication. However, there hypokalemia.
Pathophysiology 265
• Calcium (Ca11). Calcium has many physiologic func- membrane. Electrolytes do not pass through the mem-
tions. It plays a major role in muscle contraction as brane as readily as water. This is due not so much to the
well as nervous impulse transmission. An abnormally size of electrolyte molecules as to their electrical charge.
increased calcium level is called hypercalcemia, whereas When solutions on opposite sides of a semipermeable
an abnormally decreased calcium level is called hypo- membrane are equal in concentration, the relationship is
calcemia. said to be isotonic. When the concentration of a given solute
• Magnesium (Mg11). Magnesium is necessary for sev- (dissolved substance) is greater on one side of the mem-
eral biochemical processes that occur in the body and brane than on the other, it is said to be hypertonic. When
is closely associated with phosphate in many pro- the concentration is less on one side of the cell mem-
cesses. An abnormally increased magnesium level is brane, as compared to the other, it is referred to as hypo-
called hypermagnesemia; an abnormally decreased tonic. This difference in concentration is known as the
magnesium level is called hypomagnesemia. osmotic gradient.
The natural tendency of the body is to keep the bal-
The most frequently occurring anions include the following: ance of electrolytes and water equal on both sides of the
• Chloride (Cl2). Chloride is an important anion. Its cell membrane. This is an example of homeostasis, the
negative charge balances the positive charge associ- body’s normal tendency to maintain its internal environ-
ated with the cations. It also plays a major role in fluid ment in a steady state of balance. If one side of a cell mem-
balance and renal function. Chloride has a close asso- brane has an increased quantity of a given electrolyte (is
ciation with sodium. hypertonic), there will be a shift of the electrolyte from that
side and a shift of water from the other side to restore a bal-
• Bicarbonate. Bicarbonate is the principal buffer of the
ance in concentration—the balanced state.
body. This means that it neutralizes the highly acidic
The tendency of molecules to move from an area of
hydrogen ion (H+) and other organic acids. (Buffering
higher concentration to an area of lower concentration is
will be discussed in more detail later in this chapter.)
referred to as diffusion (or simple diffusion), a passive pro-
• Phosphate. Phosphate is important in body energy
cess that does not require energy (Figure 12-47). The diffu-
stores. It is closely associated with magnesium in renal
sion of a solute (usually an electrolyte) across a cell
function. It also acts as a buffer, primarily in the intracel-
membrane from the area of higher concentration to the
lular space, in much the same manner as bicarbonate.
area of lower concentration continues until balance is
Many other compounds carry negative charges. attained. This movement from an area of higher concentra-
Among these are some of the proteins, certain organic tion to an area of lower concentration is termed a move-
acids, and other compounds. Electrolytes are usually mea- ment with the osmotic gradient.
sured in milliequivalents per liter (mEq/L). A milliequiva-
lent is one thousandth (10-3) of the relative weight of an Diffusion
element that has the same combining capacity as a given Higher concentration
weight of another element (e.g., element, molecule, ion). Interstitial
fluid
Nonelectrolytes are molecules that do not dissociate
into electrically charged particles. These include glucose,
urea, proteins, and similar substances.
into the space to balance the concentration of solutes and increased permeability of the capillary membrane, and
the osmotic pressure on both sides of the membrane. lymphatic obstruction.
However, there is a somewhat different osmotic mecha-
• A decrease in plasma oncotic force may result from a loss
nism that operates between the plasma inside a capillary
or decrease in production of plasma proteins (albu-
and the interstitial space outside the capillary. Blood
mins, globulins, and clotting factors). Plasma proteins
plasma generates oncotic force, which is sometimes called
are synthesized in the liver, so a liver disorder may be
colloid osmotic pressure. Plasma proteins are colloids—large
responsible for decreased production. Plasma loss
particles that do not readily move across the capillary
from open wounds, hemorrhage, and burns may also
membrane. They tend to remain within the capillary. At
cause a loss of plasma proteins. The result is that
the same time, there is very little water in the interstitial
oncotic force is reduced to the point that some of the
space. The small amount of water that does get into the
water lost through hydrostatic pressure is not regained.
interstitial space is usually taken up by the lymphatic sys-
tem. Therefore, because there is little water outside the • An increase in hydrostatic pressure can result from
capillary, and because plasma proteins do not readily venous obstruction, salt and water retention, thrombo-
move outside the capillary, the forces governing move- phlebitis, liver obstruction, tight clothing at the
ment of water between the capillary and the interstitial extremities, or prolonged standing. The increase in
space are almost all on one side, governed by the plasma hydrostatic pressure forces more water into the inter-
on the inside of the capillary. stitial space than the oncotic force can recover.
Another force inside the capillaries is hydrostatic • Increased capillary permeability generally results from
pressure, which is the blood pressure, or force against the the mechanisms of inflammation and immune
vessel walls, created by contractions of the heart. Hydro- response. These can result from allergic reactions,
static pressure does tend to force some water out of the burns, trauma, or cancer. The greater permeability
plasma and across the capillary wall into the interstitial allows plasma proteins to escape from the capillaries,
space, a process that is called filtration. Hydrostatic pres- permitting water to remain in the interstitial space
sure (a force that favors filtration, pushing water out of through the osmotic pressure of increased interstitial
the capillary) and oncotic force (a force opposing filtra- proteins and the reduction of oncotic force within the
tion, pulling water into the capillary) together are respon- capillaries.
sible for net filtration, which is described in Starling’s • Lymphatic channel obstruction can result from infection.
hypothesis: Lymphatic channels are also sometimes removed
Net filtration = (Forces favoring filtration) - (Forces opposing filtration) through surgery. The loss of lymphatic channels inter-
feres with the normal absorption of interstitial fluid by
Net filtration in a capillary is normally zero. It works the lymphatic system. For example, removal of axil-
this way: As plasma enters the capillary at the arterial end, lary lymph nodes in the treatment of breast cancer can
hydrostatic pressure forces water to cross the capillary result in edema of the arm.
membrane into the interstitial space. This loss of water
increases the relative concentration of plasma proteins. By Edema can be localized or generalized. Local swell-
the time the plasma reaches the venous end of the capillary, ing may appear at the site of an injury (e.g., a sprained
the oncotic force exerted by the increased concentration of ankle) or within a certain organ system such as the brain
plasma proteins is great enough to pull the water from the (cerebral edema), lungs (pulmonary edema), heart (peri-
interstitial space back into the capillary. The outcome is cardial effusion), or abdomen (ascites). A generalized
that water is retained in the intravascular space and does edema may present as dependent edema, in which grav-
not remain in the interstitial space. ity pulls water to the lowest areas (e.g., in the feet and
ankles when standing or in the sacral area when supine).
Edema You can identify dependent edema by pressing a finger
Edema is the accumulation of water in the interstitial over a bony prominence. A pit may remain after you
space. It occurs when there is a disruption in the forces and remove your finger (pitting edema).
mechanisms that normally keep net filtration at zero Edema is not only a sign of an underlying disease or
(retaining water in the vascular system as plasma flows problem; edema itself causes problems. It interferes with
through the capillaries, according to Starling’s hypothesis, the movement of nutrients and wastes between tissues and
previously described) or a disruption in the forces that capillaries. It may diminish capillary blood flow, depriving
would normally remove water from the interstitial space. tissues of oxygen. In turn, this may slow the healing of
The mechanisms that most commonly result in accu- wounds, promote infection, and facilitate formation of
mulation of water in the interstitial space are a decrease in pressure sores. Edema affecting organs such as the brain,
plasma oncotic force, an increase in hydrostatic pressure, lung, heart, or larynx may be life threatening.
268 Chapter 12
Eosinophil
Monocyte
White cells & platelets: 1%
Basophil
Neutrophil Electrolytes,
enzymes, fats,
proteins, and
carbohydrates
Lymphocyte
Platelets
Fluid Replacement
The most desirable fluid for blood loss replacement is
whole blood. There are several reasons for this. First,
blood contains hemoglobin, which can transport oxygen.
2NCUOC
In addition, it is the most natural replacement. However,
even in the hospital setting, the routine use of whole blood
is not practical (Table 12-9). Blood is a precious commod-
ity, and it must be conserved so it can benefit the most
EGNNU
9JKVG
packed red blood cells. The white cells are used for other
*GOCVQETKV
purposes. Plasma is packaged as fresh frozen plasma for
use when plasma or clotting factors are needed. Thus,
with the exception of true hemorrhagic shock (resulting
from blood loss), where whole blood is the fluid of first
choice, packed red blood cells are now more frequently
FIGURE 12-50 The percentage of the blood occupied by the red
used than whole blood.
blood cells is termed the hematocrit. Before blood, or blood products, can be administered
to a patient, they must be typed and cross-matched to pre-
iron-based compound that binds with oxygen in the pul- vent a severe allergic reaction. The exception to this is
monary (lung) capillaries and transports the oxygen to the fresh frozen plasma, which does not require cross-match-
peripheral tissues, where it can be unloaded and taken into ing. If there is not adequate time for typing and cross-
the cells. Factors such as pH (discussed later in this chapter) matching, O-negative blood (type O, Rh negative), the
and oxygen concentration affect the amount of oxygen that universal donor, can be administered.
can be transported by hemoglobin.
The leukocytes are responsible for immunity and Transfusion Reaction
fighting infection. The thrombocytes play a major role in Blood and blood products are rarely used in the field.
blood clotting. The viscosity (thickness) of the blood is However, on occasion, you may be called on to transport a
determined by the ratio of plasma to formed elements. The patient with blood infusing. Because of this, you must be
greater the proportion of formed elements within the able to recognize the signs and symptoms of a transfusion
plasma, the greater the viscosity. reaction. Transfusion reactions occur when there is a dis-
The plasma can be separated from the formed elements crepancy between the blood type of the patient and the
by centrifugation. That is, blood can be placed in a test tube blood type of the blood being transfused. In addition to the
inside a centrifuge and spun at high speed. The heavier ABO and Rh types, there are many minor types that can
cells—the erythrocytes—will be forced to the bottom of the cause a transfusion reaction. Common signs and symp-
tube, leaving the plasma portion at the top. Usually, the toms of a transfusion reaction include fever, chills, hives,
erythrocytes will account for approximately 45 percent of hypotension, palpitations, tachycardia, flushing of the
the blood volume. The percentage of blood occupied by skin, headaches, loss of consciousness, nausea, vomiting,
erythrocytes is referred to as the hematocrit (Figure 12-50). or shortness of breath.
Hypertonic
• Dextran is not a protein, but a large sugar molecule
with osmotic properties similar to albumin. It comes in
two molecular weights: 40,000 and 70,000 Daltons. (a) Crenated
Dextran 40 has 2 to 2.5 times the colloid osmotic pres-
sure of albumin.
• Hetastarch (Hespan), like dextran, is a sugar molecule
Isotonic
Increasing ion concentration in extracellular fluid
(c)
• Isotonic solutions have electrolyte composition similar
to the blood plasma. When placed into a normally Swollen
Net water
hydrated patient, they will not cause a significant fluid movement
or electrolyte shift. Examples include normal saline
(0.9 percent sodium chloride, also written as 0.9 per-
cent NaCl) and lactated Ringer’s.
• Hypertonic solutions have a higher solute concentration
than the cells. These fluids will tend to cause a fluid
shift out of the interstitial space and intracellular com-
(d)
partment into the intravascular space when adminis-
Lysed
tered to a normally hydrated patient. Later, there will
be a diffusion of solute in the opposite direction. An FIGURE 12-51 The effects of hypertonic, isotonic, and hypotonic
example is 7.5 percent sodium chloride solution. solutions on red blood cells.
Pathophysiology 271
Ribosomes
Ribosomes are spherical structures that can account for up
to 25 percent of the dry weight of a cell (Figure 12-54). The
primary role of the ribosomes is the synthesis of polypep-
tides and proteins. The ribosome consists of two subunits,
each consisting of rRNA and protein. These subunits leave
the cell nucleus, bind with mRNA, and become a func-
FIGURE 12-53 Chromosomes are composed of DNA and associated
tional ribosome in the cytoplasm. The ribosomes interpret
proteins. During cell division, as shown here, chromosomes shorten
and condense. the information from mRNA and translate it into an amino
acid sequence until the desired protein is formed. The nec-
essary conformational changes will occur (bending, fold-
molecule. DNA controls cell functions and the production ing) to make the protein fully functional.
of specific proteins. All cells in an organism contain pre-
cisely the same information. However, some cells will Endoplasmic Reticulum
express certain parts of the genetic information, whereas The endoplasmic reticulum is a network of tubules, vesi-
others express other parts. cles, and sacs that interconnect with the plasma membrane,
The genetic information is carried on threadlike struc- nuclear envelope, and many of the other organelles in the
tures called chromosomes made up of DNA and other pro- cell. Certain parts of the endoplasmic reticulum contain
teins (Figure 12-53). The number of chromosomes varies ribosomes during protein synthesis and are referred to as
from species to species. Humans have 46 chromosomes (23 rough endoplasmic reticulum (RER). The RER sends the
pairs), with one pair being the chromosomes that deter- proteins to the Golgi apparatus in vesicles called cisternae or,
mine sex. Typically, chromosomes are visible (with a light if they are membrane proteins, insert them into the plasma
microscope) only during the phase when cell division is membrane. (The Golgi apparatus and cisternae will be
occurring. During the process of division, chromosomes described next.)
shorten and condense. The remainder of the time they are The portion of the endoplasmic reticulum without
extended and are not visible. During this extended phase, ribosomes is called smooth endoplasmic reticulum (SER).
before shortening and condensation, the genetic material is SER has multiple functions, depending on the cell type.
called chromatin. The vast network of SER provides an increased surface
A double membrane encases the nucleus and is area for the action or storage of key enzymes and the
referred to as the nuclear envelope. The nuclear enve- products of these enzymes. For example, SER in muscle
lope contains the chromatin and
the other materials inside the Nucleus
nucleus that are collectively
referred to as nucleoplasm. Com- Proteins
munications between the inside of
the nucleus and the surrounding
cytoplasm occurs through open-
ings in the nuclear envelope called
nuclear pores.
There is a specialized region Rough
within the nucleus referred to as the endoplasmic
reticulum
nucleolus. As with the chromo-
somes, the nucleolus is visible only
during certain cell phases. The
nucleolus is not surrounded by a
Ribosome bound
membrane. The nucleolus is a region Free ribosome to rough endoplasmic
of the DNA that is active in the pro- reticulum
duction of a specialized type of RNA FIGURE 12-54 Ribosomes are spherical structures within the cell that function in the synthesis of
called ribosomal RNA (rRNA). The polypeptides and proteins. Some ribosomes are suspended in the cytoplasm (free ribosomes);
rRNA leaves the nucleus of the cell other ribosomes are attached to the endoplasmic reticulum (bound ribosomes).
Pathophysiology 273
Rough
endoplasmic
reticulum
Proteins
Ribosome
Golgi complex
Damaged
organelle Step 3: Lysosomal enzymes
Lysosome break the bacterium down
into smaller molecules that
Digestion diffuse into cytoplasm.
FIGURE 12-57 Lysosome formation and function in intracellular digestion. Lysosomes released from the Golgi complex digest a bacterium
engulfed by the cell (pathway shown on right). Lysosomes also digest obsolete parts of the cell itself (pathway shown on left).
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc.,
Upper Saddle River, NJ.)
Clinical Note
Pediatric
Tay-Sachs disease (pronounced tay-SACKS) is a genetic dis-
order that can result in paralysis, blindness, convulsions,
mental retardation, and death. It was first described in 1881, Outer
membrane
and in 1887 was found to be more prevalent in Ashkenazi
Jews (Jews of Central European descent). It is also seen, Inner
membrane
although on a more limited basis, in French Canadians of Mito-
southeastern Quebec and in Cajuns of southern Louisiana. chondrion
Cristae
These populations all tend to marry within their population,
leading to less genetic diversity and increased expression of
mutations. Tay-Sachs disease is quite rare in families of other
ethnic backgrounds.
It has been determined that a mutation on chromosome
15 causes the absence of the lysosomal enzyme hexosami-
dase (Hex A), which is responsible for breaking down lipids
in nerve cells. Without Hex A, nerve cells swell with undi-
gested lipids which ultimately causes a progressive and irre-
Diagram of a mitochondrion showing the double
versible deterioration in nervous system functioning. membrane that creates two compartments.
Tay-Sachs disease normally becomes noticeable around
the age of six months. Prior to that, the baby acts normally. FIGURE 12-58 Mitochondria are sites of energy conversion in
However, once the symptoms of Tay-Sachs begin to appear, the cell.
several noticeable changes occur. First, the baby will become (Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applica-
tions, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Educa-
listless and will stop interacting with other people and will
tion, Inc., Upper Saddle River, NJ.)
often develop a staring gaze. Even normal levels of noise
tend to startle the baby to an abnormal degree. Eventually,
the baby will develop dementia, mental retardation,
decreased muscle tone, seizures, and death. There is no mitochondria. (Cellular respiration will be described in
treatment, and the disease is 100 percent fatal—usually by more detail later.)
age 4 to 5. The number of mitochondria present varies from cell
to cell, depending on the specialized function of the cell.
Mitochondria, like the nucleus, are surrounded by a dou-
ble membrane forming two separate compartments. The
to generate and degrade hydrogen peroxide (H 2O 2). inner membrane folds form shelves within the mitochon-
Hydrogen peroxide is highly toxic to cells. However, it can dria, referred to as cristae, where the last phases of cellu-
be degraded to water and oxygen by the enzyme catalase. lar respiration occur. The mitochondria also can contain
Because of its toxicity, eukaryotic cells protect themselves some ribosomes and some of the cell’s genetic material
by placing the biochemical pathways that generate and (Figure 12-58).
degrade H2O2 into the isolated compartment called a
peroxisome.
Peroxisomes are found in virtually all cell types but
The Cytoskeleton and Other
are more prevalent in the liver and kidneys. They play an Internal Cell Structures
important role in detoxifying harmful substances such as Within eukaryotic cells is a complex system of filaments,
alcohols and formaldehyde. Peroxisomes are also impor- microtubules, and intermediate filaments referred to as the
tant in the breakdown of fatty acids. Because they can pro- cytoskeleton.
duce oxygen, peroxisomes play a role in the regulation of Microtubules are long, hollow rods made of the pro-
oxygen tension within the cell. tein tubulin. Microfilaments are made from the protein
actin. Intermediate filaments are made up of different pro-
Mitochondria teins, depending on the cell type. Near the cell nucleus are
The mitochondria are the “powerhouses” of the cells in two structures called centrioles, cylindrical structures
that they provide the energy needed for all of a cell’s bio- composed of groups of microtubules arranged in a ring
chemical processes. Cellular respiration, which is the con- pattern that are thought to play an important role in cell
version of food to energy, occurs primarily in the division (Figure 12-59).
mitochondria. Cellular respiration is a three-phase process The cytoskeleton forms a dynamic three-dimensional
that first begins in the cytoplasm and continues in the structure that fills the cytoplasm and serves as a skeleton
276 Chapter 12
Cellular Respiration
and Energy Production
The cell needs a constant supply of energy. We get the
energy our body needs through nutrients in our diet. Our
digestive system breaks down the three major classes of
nutrients—carbohydrates, proteins, and lipids—into sim-
Centriole pler compounds, typically simple sugars and amino
acids, that can enter the cell and be converted to energy.
Some of the energy is used to manufacture ATP and some
is given off as heat. Once nutrients reach the cells, they
will enter a metabolic pathway—either cellular respira-
tion or fermentation. Cellular respiration is aerobic and
requires oxygen. Fermentation is anaerobic and does not
require oxygen.
When nutrients are converted to energy by the cells,
there is a transport of electrons from one molecule to
Diagram of a centriole. Each centriole is
another. The loss of electrons from one atom to another is
composed of nine sets of triplet microtubules
arranged in a ring. called oxidation. The gain of electrons by one atom from
another is called reduction. In cellular respiration, glucose
FIGURE 12-59 Centrioles are thought to play an important role in
is oxidized to simpler compounds, producing energy in
cell division.
the process.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applica-
tions, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Educa-
tion, Inc., Upper Saddle River, NJ.)
Cellular Respiration
for cell stability and as a muscle for cell movement. In A glucose molecule must pass through three distinct bio-
addition to stability, the cytoskeleton plays an impor- chemical processes to produce energy through cellular res-
tant role in both intracellular transport and cellular piration: glycolysis, the citric acid cycle, and electron
division. transport (Figure 12-61). Glycolysis occurs in the cyto-
Two structures important in cell movement, cilia and plasm, whereas the citric acid cycle and electron transport
flagella, are made up of microtubules. Cilia are numerous occur in the mitochondria. The complete breakdown of
hairlike structures that move in a back-and-forth motion. glucose yields water, carbon dioxide, and energy in the
This motion can sweep debris away from the cell and form of ATP. This relationship is illustrated by the follow-
play an important role in protection of the respiratory ing equation:
system and in the reproductive system (Figure 12-60). C6H12O6 + 6O2 S 6CO2 + 6H2O + ≈ 36ATP
Flagella are much longer than cilia and move in an undu- Glucose Oxygen Carbon Water Energy
lating, wavelike manner. Human sperm move via the Dioxide
undulations of flagella.
Glycolysis
The first step in the breakdown of the six-carbon sugar glu-
cose is called glycolysis and occurs in the cytoplasm. In gly-
Cilium colysis, one molecule of glucose is oxidized through several
steps to two molecules of pyruvic acid. The process of gly-
colysis is anaerobic—that is, it does not require oxygen.
There are two phases of glycolysis: the energy-using
phase and the energy-yielding phase. During the first
phase, two molecules of ATP are used to prepare the glu-
cose molecule for splitting into two three-carbon subunits.
During the second phase, the two three-carbon molecules
FIGURE 12-60 Cilia are short hairlike structures on the surfaces of
are broken down to pyruvic acid (the anion of pyruvic acid
cells, such as those that line the respiratory tract, where they sweep is pyruvate). During this phase, four molecules of ATP are
away debris trapped in mucus. produced, giving a net yield of two molecules of ATP per
Pathophysiology 277
Electrons
transferred
by NADH
Cytoplasm
Blood Electrons
vessel transferred
by NADH
Citric Electron
Glycolysis Transition Transport
Acid
glucose pyruvate Reaction Chain
Cycle
Oxygen
Mitochondrion
FIGURE 12-61 Summary of cellular respiration in which a glucose molecule undergoes glycolysis, the citric acid cycle, and transport to produce
energy.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc.,
Upper Saddle River, NJ.)
molecule of glucose. The two molecules of pyruvic acid and flavin adenine nucleotide (FADH 2). NADH and
then move from the cytoplasm into the liquid matrix of the FADH2 carry high-energy electrons into the final part of
mitochondria, where the citric acid cycle occurs. Glycolysis cellular metabolism—the electron transport chain.
also produces two molecules of nicotine adenine dinucleotide
(NADH), which carry energy to the electron transport Electron Transport
chain (Figure 12-62). NADH and FADH2 derived from glycolysis and the citric
acid cycle donate their electrons to carrier proteins known
Citric Acid Cycle as the electron transport chain. The electron transport
Once the two molecules of pyruvic acid have entered the chain consists of five types of carriers. (All the carriers
mitochondria, they enter the second phase of glucose except one are proteins.) These proteins are embedded on
metabolism, called the citric acid cycle. The citric acid the cristae in the inner membrane of the mitochondria.
cycle, also called the Krebs cycle or the tricarboxylic acid When electrons are transferred from one molecule to the
(TCA) cycle, requires oxygen. In the first step, called the next, energy is released. This energy is then used to create
transition reaction, the pyruvic acid molecule reacts with a ATP for use as an energy source by the cells. The electrons
substance called coenzyme A (CoA) (Figure 12-63). This are ultimately passed to oxygen, which is the ultimate elec-
removes a carbon atom (in the form of carbon dioxide) tron acceptor. On accepting the electron, oxygen combines
from the pyruvic acid molecule. The resulting two-carbon with two molecules of hydrogen to form a molecule of
molecule (called an acetyl group) binds to the CoA mole- water. If there is insufficient oxygen, electrons begin to
cule and becomes acetyl CoA. Acetyl CoA then formally accumulate on the carrier proteins, and this will ultimately
enters the citric acid cycle. In an eight-step process, the cit- stop the citric acid cycle.
ric acid cycle completely oxidizes the remainder of the The electron transport chain, when functioning opti-
glucose molecule. On the completion of glucose oxidation, mally, can produce 32 molecules of ATP. Together, cellular
the citric acid cycle yields two molecules of ATP and respiration produces approximately 36 molecules of ATP
releases carbon dioxide as waste (Figure 12-64). It also (2 ATP from glycolysis, 2 ATP from the citric acid cycle,
yields several molecules of two other compounds: NADH and 32 ATP from electron transport). The actual number
278 Chapter 12
)N[EQN[UKU
KPE[VQRNCUO Transition Reaction (in mitochondrion)
%[VQRNCUO
CoA 0#&*
Oxaloacetate 0#&1 #UVJGGNGEVTQPUCTGVTCPUHGTTGF
C C C C Citrate HTQOQPGRTQVGKPVQVJGPGZV
GPGTI[KUTGNGCUGFCPFWUGFVQ
NADH C C C C C C G2 OCMG#62
CO2
NAD 1 C leaves
cycle (#&* /GODTCPG
G2
2QVGPVKCNGPGTI[
C C C C NAD1 RTQVGKPU
Malate Citric Acid Cycle (#& 'XGPVWCNN[VJG
NADH GNGEVTQPUCTGRCUUGF
FADH2 VQQZ[IGPYJKEJ
ATP ADP 1 Pi EQODKPGUYKVJVYQ
FAD G2 J[FTQIGPUVQHQTO
C C C C C G YCVGT
2
C C C C -Ketoglutarate
Succinate
C CO2 leaves cycle G2
NAD1 *1
FIGURE 12-64 The citric acid cycle is a series of reactions that yields FIGURE 12-65 The electron transport chain is the final phase of
two molecules of ATP and several molecules of NADH and FADH2 cellular respiration. This phase releases up to 32 molecules of ATP
and releases carbon dioxide as waste. per molecule of glucose.
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, (Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts,
Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson
Education, Inc., Upper Saddle River, NJ.) Education, Inc., Upper Saddle River, NJ.)
more cells (as would be the case with hyperplasia). Instead, that serves to protect the organism from stress. For exam-
the cells that are present have simply enlarged. If the cell is ple, portions of the respiratory tract are lined with colum-
capable of dividing in response to stress, both hyperplasia nar epithelial cells. These cells contain cilia that help to
and hypertrophy may develop. Some cells, such as cardiac move mucus and foreign materials up the airway to the
muscle cells, do not divide but simply hypertrophy in pharynx, from which they can be swallowed or expelled
response to stress. by sneezing or coughing. This action serves to protect the
Hypertrophy can be classified as physiologic or patho- airway. With exposure to a chronic irritant, such as ciga-
logical. Physiologic hypertrophy usually results from rette smoke, the ciliated columnar epithelial cells can tran-
increased physical demand. For example, say a person sition to stratified squamous epithelial cells, thereby
begins a vigorous exercise program. Because the cells of replacing delicate cells with hardier ones better able to
the heart cannot increase in number, the cells that are there withstand the irritant. When this occurs, the benefits of
increase in size to handle the added demand. Enlargement ciliary motion are lost.
of the uterus during pregnancy is due to both physiologic By itself, metaplasia is not harmful and does not lead
hypertrophy and hormonal hyperplasia. The uterus to cancer. When the irritant is removed (e.g., the person
returns to normal once the stress of pregnancy and the hor- stops smoking), the cells return to their normal state as cili-
monal influence are removed. ated columnar epithelial cells. However, when the irritant
Pathological hypertrophy results from abnormal continues to be present, the metaplastic cells may eventu-
stress, in contrast to physiologic hypertrophy, which is ally become cancerous. Thus, although metaplasia can be
associated with pregnancy or exercise. There is an observ- beneficial and protective for the organism, the precursors
able difference in the two types of cardiac hypertrophy. that cause metaplasia, if not corrected, can induce malig-
With physiologic hypertrophy, the cardiac septum (verti- nant cell transformation.
cal wall between halves of the heart) enlarges and so do
the sizes of the cardiac chambers. With pathological
hypertrophy, the septum thickens while the chambers Cell Injury and Cell Death
decrease in size. When cells are stressed to the point at which that they can
no longer adapt, or when they are exposed to toxic agents,
Atrophy cell injury can result. If cell injury is persistent or severe,
A decrease in the size of a cell is termed atrophy. Atrophy cell death may ultimately occur.
can result from several factors, including a decreased work- Cell injury may be classified as reversible or irrevers-
load, decreased blood supply, loss of nervous control, inad- ible. If the cell injury is irreversible, cell death will occur.
equate nutritional intake, lack of endocrine stimulation, Irreversibly damaged cells will undergo either necrosis or
and aging. As with hypertrophy, atrophy may be either apoptosis. If there is damage to the plasma membranes of
physiologic or pathological. For example, during the repro- the cell, enzymes released from the lysosomes will digest
ductive years, the vagina is soft and well lubricated. This is the contents of the cell, resulting in cellular necrosis, or
principally due to the effect of hormones (primarily estro- cell death caused by outside forces such as infection that
gen), an excellent blood supply, and periodic use. As a attack the cell membrane. Necrosis is sometimes called
woman ages, the vagina atrophies. The tissues of the vagina “cell murder.”
become thin and friable, and the overall size decreases. This However, cell death occurs as a normal process of keep-
is due primarily to a combination of the loss of hormonal stim- ing the body healthy by sloughing off old or damaged cells
ulation, aging, and decreased use. Some of the effects of vag- and making room for new, healthy cells. This prepro-
inal atrophy can be delayed through the use of hormonal grammed form of cell death occurs normally and is called
therapy (topical and oral estrogen). Vaginal atrophy with apoptosis. To distinguish it from necrosis, apoptosis is
aging is an example of physiologic atrophy. sometimes called “cell suicide.” In apoptosis, if toxic sub-
Pathological atrophy is a result of disease or injury. For stances damage the DNA of the cell, the nucleus will dis-
example, a person who has sustained a spinal cord injury solve, yet the membranes of the cell will remain intact.
will eventually develop atrophy in the muscles affected by Necrosis is always a patho-
the injury. This results from a combination of the loss of logical process, whereas CONTENT REVIEW
nervous control, a decreased workload, and, in some apoptosis is normally phys- ➤➤ Cellular Injury
instances, a change in blood supply. iologic but may also have a • Ischemic and hypoxic
pathological cause. injury
Metaplasia Numerous factors can • Oxidative stress
In certain situations, a cell can change from one adult cell cause cell injury and, pos- • Chemical injury
• Apoptosis
type to another adult cell type. This process is called meta- sibly, cell death. These
• Dysplasia
plasia and is reversible. Metaplasia is an adaptive response include hypoxia, physical
282 Chapter 12
agents, chemical agents, infection, immune reactions, However, some cells that are reversibly injured will die
genetic problems, and problems with nutrition. In some even after blood flow resumes—either by necrosis or by
cases, a single agent is all that is involved. In most cases, apoptosis. With the introduction of reperfusion, some tis-
cell death has a combination of causes. Overall, the way sues that were reversibly damaged may become irrevers-
the cell responds to injury depends on the type of injury, ibly damaged. This can be the result of new damage from
the duration of injury, and the severity of the injury. The oxygen free radicals, increased permeability of the mito-
response also depends on the cell type, current state of the chondria, and inflammation.
cell, and the cell’s ability to adapt to the injury. Oxygen free radicals (oxygen atoms with unpaired
electrons in the outer shell) steal electrons from other
Ischemic and Hypoxic Injury compounds and generate new species of free radicals.
The most common type of cellular injury is that due to This process can continue until the components of the
ischemia and hypoxia. Ischemia results from dimin- cell are used up. Increased mitochondrial permeability
ished blood flow, whereas hypoxia is due to a decreased results in the entry of macromolecules into the mitochon-
availability of oxygen. When cells face ischemia or dria, resulting in mitochondrial swelling and rupture
hypoxia, cellular respiration is usually impaired, and and eventually leading to cell death. The infiltration of
energy production is usually limited to glycolysis. The cells of the immune system, in the process of inflamma-
beneficial effects of glycolysis stop after all the pyruvate tion, also can cause secondary ischemic injury and cell
stores have been depleted, ATP is unavailable for the death.
first step, or metabolic products that would normally be
removed begin to accumulate. Because of this, ischemia Chemical Injury
tends to injure cells and tissues faster than does hypoxia Various chemicals, including drugs, can cause injury to a
(Figure 12-68). cell. This occurs through two mechanisms: direct action on
The extent of injury resulting from ischemia depends cells or through the creation of chemical precursors that are
on several factors. First, up to a certain point, cellular injury converted to a cytotoxic metabolite. (Cytotoxic means “poi-
from ischemia is reversible if the cell has not been signifi- sonous to cells.”) Numerous toxins are capable of cellular
cantly damaged before blood flow is restored. However, if injury. In addition, some substances used routinely in med-
the damage is not reversed, the cell eventually reaches a icine, such as acetaminophen, can cause cellular toxicity
point of no return at which cellular damage is so massive (mainly to the liver) if an overdose occurs.
that the cell cannot overcome it and survive. With ischemic
cell injury, the oxygen concentration of the blood falls. Apoptosis
Because oxygen is the ultimate electron acceptor, this stops Apoptosis occurs when a cellular program is activated
the action of the electron transport chain and that, in turn, that causes the release of enzymes that destroy the
stops the citric acid cycle. This
causes a markedly decreased
supply of ATP. The lack of ATP
causes failure of the sodium–
potassium pump. This allows
sodium to diffuse into the cell
and potassium to diffuse out.
Because water follows sodium
readily across the plasma
membrane, the cell will begin
to swell until it lyses (splits
open), causing cell death.
Oxidative Stress
Even when the blood supply
and oxygen are restored to
cells previously inadequately
perfused, these cells still may
die. Generally, cells that are
Area of infarct
reversibly injured may sur-
vive, whereas those that are FIGURE 12-68 Prolonged ischemia resulting from reduced flow of arterial blood to the heart muscle is
irreversibly injured will not. the chief cause of myocardial infarction (death of heart muscle).
Pathophysiology 283
Apoptosis Dysplasia
Abnormal or disordered growth in a cell is referred to as
dysplasia. Dysplasia is more common in cells that repro-
duce rapidly, such as epithelial cells, and is often a pre-
cursor to the development of cancer. With dysplasia, there
is a loss in the uniformity of the cells present, as well as in
their architectural orientation. In addition, the nucleus of
dysplastic cells tends to be abnormally large and abnor-
mally dense. When an entire cell layer contains dysplastic
cells, it is considered to be a preinvasive neoplasm and is
referred to as carcinoma in situ. Although dysplasia is
Cell shrinkage often associated with cancer, it does not necessarily prog-
ress to cancer.
Clinical Note
Cervical dysplasia is the presence of abnormal, precancerous
Cell disintegration
cells on the surface of the cervix or its canal (Figure 12-70).
Cervical cells are epithelial cells that turn over fairly rapidly
and thus grow rapidly. The interior of the cervix consists of
columnar epithelial cells, whereas the outer part of the cervix
consists of squamous epithelial cells. The demarcation
between these two cell types is called the squamocolumnar
junction. Distal to the squamocolumnar junction is an area of
Apoptotic body
Figure 12-69 The process of apoptosis. Once the cell is dead, Normal cervix
fragments called apoptotic bodies are cleared by scavenger cells
(phagocytosis).
Skin Ammon
Heart
Digestive tract
Brain
Chorion
Tail end
Gastrula
Zygote Blastocyst
Mesoderm Endoderm
(Middle Layer) (internal layer)
Cardiac muscle Lung cell (alveolar cell)
Skeletal muscle cells Thyroid cell
Tubule cell of the kidney Pancreatic cell
Red blood cells
Smooth muscle (in gut)
FIGURE 12-72 The germ layers give rise to the various differentiated tissues of the body.
tissues and organs of the body. There are three germ • Smooth muscle
layers (Figure 12-72): • Kidney tissue
• Endoderm. The endoderm is the innermost germ cell • Fibrous tissue
layer and gives rise to epithelial tissue, most of which • Bone and cartilage
is glandular epithelium. The endoderm is the first • Fat (adipose) tissue
germ layer to develop. Cells from the endoderm even-
• Blood and lymph vessels
tually form the entire epithelial lining of the digestive
tract with the exception of a portion of the mouth and • Blood cells
a portion of the rectum. In addition to the digestive • Ectoderm. The ectoderm is the outermost germ layer
tract, the endoderm gives rise to the epithelial cells and gives rise to all the tissues that cover the body
that line all the exocrine glands and structures that surfaces as well as the nervous system. The ecto-
open into the digestive tract. These include: derm has three parts, each resulting in different
• Liver and associated ducts tissues:
• Pancreas • External ectoderm
• Epithelium of the auditory tube and tympanic • Skin (along with glands, hair, nails)
cavity • Epithelium of the mouth and nasal cavity
• Trachea, bronchi, and alveoli (except the nasal cavity) • Lens and cornea of the eye
• Urinary bladder and part of the urethra • Neural crest
• Lining of follicles in the thyroid and thymus glands • Melanocytes (cells that produce melanin, or
• Mesoderm. The middle germ layer, or mesoderm, pigment)
gives rise to numerous body tissues. These include: • Peripheral nervous system
• Skeletal muscle • Adrenal medulla
• Cardiac muscle • Meninges
286 Chapter 12
Epithelial tissue covers both external and internal according to the number of cell layers present and the
body surfaces and lines any passageways that communi- shape of the exposed cells.
cate with the outside. The functions of epithelial tissue are Epithelial tissues can be classified as simple epithelium or
either protective or metabolic in nature. Specifically, they stratified epithelium. Simple epithelium is a single cell layer
include the following: thick and provides limited protection. Thus, it is found pri-
marily in internal body surfaces. Stratified epithelium is sev-
• Provides physical protection. Epithelial tissue effi-
eral layers thick and provides a greater degree of protection.
ciently protects both the external and internal surfaces
The shape of the cell is also used to describe and clas-
from injury, infection, and water loss.
sify epithelial tissues. Tissues with thin and flat cells are
• Controls permeability. Epithelial tissue is a selective called squamous epithelium. Cells that have a cubelike or
barrier in that it allows the passage of certain sub- square shape are called cuboidal epithelium. Finally, cells that
stances, such as proteins, but is impermeable to other are tall and more slender are called columnar epithelium.
substances. Using this classification system there are several types
• Provides special senses. Specialized epithelial cells of epithelial tissue, each with a different appearance and
provide information to the nervous system regarding function. These include (Table 12-10):
changes in the environment.
• Simple squamous epithelia—found in areas where
• Produces specialized secretions. Some types of epithe- absorption occurs or when friction reduction is neces-
lial tissue contain glands that produce secretions. sary, such as the renal tubules, the alveoli, the lining of
These secretions are classified by the mode of secre- body cavities, the lining of blood vessels, and the lin-
tion: exocrine or endocrine. Exocrine secretions are ing of the heart.
deposited on the surface of the skin or another epithe-
• Simple cuboidal epithelia—found in areas where secre-
lial surface through ducts. There are three types of exo-
tion or absorption is occurring. Simple cuboidal epi-
crine secretions:
thelium secretes enzymes and buffers in the pancreas
• Serous—watery secretions that contain enzymes and salivary glands and lines the ducts of these glands.
(e.g., digestive secretions) It is also found in portions of the kidney tubules.
• Mucous—thick, slippery secretions (e.g., nasal mucus) • Simple columnar epithelia—found in areas where secre-
• Mixed—contains secretions from more than one tion and absorption occur but where additional pro-
type of cell (e.g., salivary glands) tection is needed, such as the lining of the stomach
and digestive tract as well as in many excretory ducts.
Endocrine secretions are released into the blood-
stream or surrounding tissues and occur without the • Pseudostratified epithelia—found in areas where there is a
aid of ducts. mixture of cell types. Pseudostratified epithelium is not
really stratified, although it appears to be. In pseudostrat-
CLASSES OF EPITHELIUM As epithelial tissue arises ified epithelia, all cells are in contact with the basement
from embryonic germ layers, it becomes differentiated and membrane. This tissue type will often have cilia. It is
specialized. Each type of epithelium has a special purpose found in the respiratory tract (nasal cavity, trachea, bron-
in the organism. Epithelial tissues are usually classified chi) and portions of the male reproductive tract.
Cuboidal (cube-shaped cells) Simple Kidney tubules; secretary portions Secretion; absorption
of glands and ducts
Fat cells
Dermis (Adipose tissue)
Blood vessels
Loose Connective Tissue
Subcutaneous
Other layer
connective
tissue cells Areolar tissue
Fat cell
Bone
Tendon
Bone cells
Blood vessels
Cartilage Cartilage
covering
end of
bone
Cartilage
cells
together and support the tissues of the body. Unlike epithe- There are several cell types found in connective tis-
lial tissue, which consists primarily of cells, connective tis- sues. These include:
sue consists primarily of a substance called the extracellular
• Fibroblasts. Fibroblasts are the most abundant cell
matrix. Specific characteristics of connective tissue include
type found in connective tissue and are responsible for
the following:
the production of connective tissue fibers and ground
• Connective tissue consists of individual cells scattered substance.
within an extracellular matrix consisting of protein • Macrophages. Macrophages are scattered throughout
fiber and a noncellular material called ground sub- the connective tissues and engulf damaged cells or
stance. There are three types of protein fibers: pathogens.
• Collagen fibers—are strong and have great tensile • Adipocytes. Adipocytes, or fat cells, contain large
strength such as seen in ligaments and tendons. amounts of lipids and serve as energy stores.
• Elastic fibers—are randomly coiled and thus capable • Mast cells. Mast cells are small mobile cells that are
of stretch. They are common in the skin, lungs, and found in the connective tissues—often near blood ves-
blood vessels. sels. They release chemicals as part of the body’s
• Reticular fibers—are thin strands of collagen that defense system.
form interconnective networks that help support • Other cells. Occasionally other cells can be found in
other tissues. connective tissue such as white blood cells reacting to
Ground substance can be solid (as in bone), liquid injury or infection.
(as in blood), or flexible (as in cartilage). In ordi-
nary connective tissue, the ground substance CLASSES OF CONNECTIVE TISSUE Connective tis-
consists of water stabilized by proteins and glyco- sue is classified by the physical properties of the ground
proteins. In bone, the ground substance includes substance. It is often classified as connective tissue proper
minerals. In blood, the ground substance is liquid and specialized connective tissue.
(plasma). Connective tissue proper includes (Table 12-11):
• Cells of connective tissue are not directly attached to • Loose connective tissue. Loose connective tissue, also
one another (unlike epithelial cells). called areolar tissue, contains more cells and fewer
• Individual connective tissue cells are normally sepa- fibers than dense connective tissue. Loose connective
rated from one another by varying amounts of extra- tissue forms the layer that separates the skin from
cellular matrix. underlying muscle.
• Connective tissue is derived from the embryonic • Adipose tissue. Adipose tissue, or fat, is a form of
mesoderm (unlike most epithelial tissue, which is loose connective tissue that contains a large number
derived from ectoderm and endoderm). of fat cells (adipocytes).
Loose, areolar Between muscles, surround glands, Wraps and cushions organs
wrapping small blood vessels and nerves
Loose, adipose (fat) Under skin, around kidneys and heart Stores energy, insulates, cushions organs
Cartilage (semisolid) Nose (tip); rings in respiratory air tubules; Provides support and protection (by enclosing)
external ear and serves as lever for muscles to act on
Blood (fluid) Within blood vessels Transports oxygen and carbon dioxide, nutrients,
hormones, and wastes; helps fight infections
290 Chapter 12
• Dense connective tissue. Dense connective tissue, also with cartilage and joints, makes up the bulk of the
called fibrous tissue, consist mainly of collagen fibers. skeletal system. The matrix in bones contains cal-
They include: cium that gives the bones strength.
• Cartilage. Cartilage provides a cushion between • Ligaments. Ligaments hold bone together and con-
bones and helps maintain the structure of certain tain both elastic and collagen fibers.
body parts (ear, nose). Cartilage contains special- • Tendons. Tendons connect muscle to bone and allow
ized cells called chondrocytes that reside in pockets for movement of the organism. Collagen fibers run
of cells in the matrix called lacunae. These are sus- the length of tendons giving them strength.
pended in a firm gel extracellular matrix that con-
tains protein fibers for strength and ground Specialized connective tissues include:
substance for resilience. Cartilage does not contain • Blood. Blood is a collection of cells in a liquid matrix.
blood vessels, so the tissue obtains nutrients and The proteins in blood, under normal conditions, do
removes wastes through diffusion. There are three not form fibers. Approximately half of the cells in
types of cartilage: blood are red blood cells. The remaining cells are white
• Hyaline—found at the end of long bones and pro- blood cells and platelets.
vides support, flexibility, and reduces friction. It • Lymph. Lymph is the fluid within the lymphatic sys-
is the most abundant form of cartilage. tem. The lymphatic system is a network of organs,
• Elastic—more flexible than hyaline cartilage, lymph nodes, lymph ducts, and lymph vessels that
elastic cartilage is found in the pinna of the ear. produce and transport lymph from tissues to the
• Fibrocartilage—forms the outer part of the bloodstream. The lymphatic system is a major compo-
intervertebral disks that cushion the vertebral nent of the body’s immune system.
bodies. Fibrocartilage is also found between
the bones of the pelvis and in selected joints. It Muscle Tissue
contains fewer cells than hyaline or elastic Muscle tissues are specialized for contraction. They con-
cartilage. tain muscle cells that contract when stimulated. This
• Bone. Bone provides protection and support for allows for movement of the organism and for movement
the organism. Bone contains specialized cells of substances through the organism. There are three types
called osteocytes, situated in lacunae. Bone, along of muscle tissue (Figure 12-76 and Table 12-12):
Cardiac muscle
Intercalated disc
Muscle tissue
Nucleus
Striations
Internal organs Skeletal muscle
and vessels
Striated
Smooth muscle Involuntary
Heart
Nuclei
FIGURE 12-76 Diagram and chart of the three muscle tissue types.
Pathophysiology 291
Cardiac Branching, striated cells; one nucleus; Wall of heart Contracts and propels blood
specialized junctions between cells through the circulatory system
Smooth Cells taper at each end; single nucleus; Walls of digestive system, blood Propels substances or objects
arranged in sheets; no striations vessels, and tubules of urinary system through internal passageways
• Skeletal muscle. Skeletal muscle is usually attached to and neuroglia. Neurons are responsible for transmitting
bones—hence the name. When skeletal muscle con- electrical impulses (Figure 12-77). The neuroglia, often sim-
tracts, bones are moved. Skeletal muscles are under ply called glial cells, support, insulate, and protect neurons
voluntary control. Skeletal muscle contains striations (Figure 12-78).
(alternating dark and light bands) that give them a
characteristic appearance under the microscope. Neoplasia
• Smooth muscle. Smooth muscle does not contain the Neoplasia is an abnormal type of tissue growth where the
striations seen in skeletal muscle—hence the name. cells grow and multiply in an uncontrolled fashion. In neo-
Smooth muscle is under involuntary control and plasia, the factors that normally control cell and tissue
found in internal organs such as the digestive system, growth are lost, resulting in a continuing increase in the
blood vessels, and bladder. Smooth muscle plays a number of dividing cells. This mass of uncontrolled cell
major role in moving food through the digestive tract growth is referred to as a tumor.
and removing waste. It is also important in the control All cell lines go through the process of differentiation.
of blood pressure and perfusion. That is, primitive nonspecialized cells called stem cells
• Cardiac muscle. Cardiac muscle is found only in the mature into specific cell types, depending on function.
heart and contains striations. Cardiac muscle cells Some stem cells will mature to muscle cells, others will
are tightly connected to other cardiac muscle cells by become connective tissue cells, and so on. Cells that have
special junctions at the plasma membranes called not differentiated are those that have either remained in
intercalated discs. These discs allow the rapid trans- an early stage or regressed to an early stage in a process
mission of electrical impulses from one cell to called anaplasia. Neoplastic cells are often less differenti-
another. Cardiac muscle cells are almost totally ated than normal cells from the same tissue or are totally
dependent on aerobic metabolism to obtain the undifferentiated.
energy needed to continue contracting. Because of As discussed before, all cells go through differentia-
this, cardiac muscle cells contain large numbers of tion and adaptation. The processes of hypertrophy, hyper-
mitochondria and abundant reserves of oxygen plasia, atrophy, and metaplasia can all occur in response
stores in myoglobin. Energy
reserves are maintained in the Neuron
form of glycogen and lipid
inclusions.
Dendrite
Nervous Tissue
The last type of tissue is nervous tis- Soma (cell body)
sue, is found in the brain, spinal
cord, and peripheral nerves.
Approximately 98 percent of ner- Node of Ranvier
Axon terminal
vous tissue is located in the brain Axon
Nucleus
and spinal cord. Nervous tissue
conducts electrical impulses from
Myelin sheath Schwann cell
one part of the body to another and
controls numerous body functions.
There are two types of cells
found in nervous tissue: neurons FIGURE 12-77 Neuron.
292 Chapter 12
Hyperplasia
Dysplasia
Three kinds of neuroglia:
astrocyte (purple)
oligodendrocyte (blue)
microglia (green)
Basal cell Basal cell Basal cell adenoma Basal cell carcinoma
Supporting/Connective
Blood/Lymphatic
factors are carcinogens and radiation (Figure 12-81). (HBV) and hepatitis C virus (HCV) have been associated
Carcinogens are chemicals capable of causing cancer. with the development of hepatocellular carcinoma.
Radiation is also capable of causing cancer—most often Whether this results from the virus itself or the resultant
tumors of the skin and internal organs, and leukemia. infection and inflammation caused by the virus remains
Radiation can result from several sources and damages unclear.
the genetic material in the cell, possibly resulting in a Genetics is thought to be responsible for some cancers.
mutation. Some mutations repair themselves, others Although the link between genetics and cancer has not
remain but do not cause adverse effects, and yet others been definitively made, it is clear that some families tend
result in the development of cancer. Whereas carcino- to develop cancers, whereas others do not. In these cases,
gens and radiation have been proven to cause cancer, the environment may be a confounding variable. A num-
several other factors remain highly suspect. These ber of genes have been identified that play a role in the
include such possible causes of cancer as viruses, genet- development of some cancers. Persons born with one of
ics, environmental factors, hormones, and perhaps these genes may be more prone to cancer yet may not ulti-
chronic infection or irritation. mately develop cancer.
Viruses that produce cancers are called oncogenic The environment is a definite risk factor for the devel-
viruses. That is, genetic material within the virus (either opment of cancer. Some environmental factors have been
RNA or DNA), called an oncogene, can cause malignant documented to be carcinogenic. Asbestos exposure, for
transformation of host cells when they are incorporated example, has been linked to a rare form of cancer called
into the host cell DNA. The link between certain viruses mesothelioma. These tumors are more common in people
and cancer is fairly strong. As already noted, human papil- who have a history of significant exposures to asbestos.
lomavirus (HPV) has been found to be a cause of cervical Bladder cancer was noted to be more common in printing
cancer in women. Chronic infections with hepatitis B virus press operators. The cause was later linked to a chemical
294 Chapter 12
Carcinogenesis
Some diseases are thought to be purely genetic. For report disease data with three basic measures: inci-
example, cystic fibrosis, which affects mainly people of dence, prevalence, and mortality. Morbidity, a term com-
European origin, and sickle cell disease, which affects monly used in discussing disease statistics, can be
mainly people of African origin, are known to be caused by more precisely reported as incidence and prevalence.
disorders of single genes. They affect different populations Incidence is the number of new cases of the disease
to a different degree because of the evolutionary history of that are reported in a given period of time, usually
those populations. A genetic disease may be caused by a 1 year. Prevalence is the proportion of the total popu-
single defective gene or by several defective genes or chro- lation who are affected by the disease at a given point
mosomes. Single-gene causes are, obviously, easier for med- in time. (Prevalence is higher than incidence, as those
ical researchers to identify and potentially devise treatments who acquire the disease each year are added to those
for than are other, more complex genetic causes of disease. who already have the disease.) Mortality is the rate of
Other diseases are caused by a combination of genetic death from the disease.
and environmental factors and are called multifactorial dis-
orders. For example, type 2 (adult-onset) diabetes has a Epidemiologists and clinical practitioners are now col-
very high correlation with family history of the disease. laborating to study risk factors, such as the relationship
However, it is also affected by environmental and lifestyle between smoking and lung cancer. Risk factor analysis is
factors such as a high-fat or high-carbohydrate diet and both statistical and complex. Although the correlation of
lack of exercise, which result in obesity, and with age. smoking to lung cancer is extremely high, not everyone
(There is a higher incidence of type 2 diabetes in over- who smokes develops lung cancer, and not everyone who
weight people, and the disease tends to appear in middle develops lung cancer has been a smoker. Risk factor analy-
age or later.) Heart disease, which is highly correlated with sis would compare the number of smokers to nonsmokers
family history and age, also has a gender/hormonal factor: among lung cancer cases, the pack/year (number of packs
Women appear to be somewhat protected from heart dis- per day * number of years) history of the smokers with
ease before menopause, when their bodies are still produc- lung cancer, factors that might have aggravated or miti-
ing estrogen. Following menopause, women quickly “catch gated the effects of smoking, and so on.
up” with men in the development of heart disease.
Clinical practitioners and epidemiologists, respec-
Family History and
tively, study disease from the point of view of their effects
on individuals and from the point of view of their effects Associated Risk Factors
on populations as a whole. It is important for those who have a family history of a par-
ticular disease not to conclude that acquiring the disease is
• Effects on individuals. Physicians and other clinical their destiny and there is nothing they can do about it. This
practitioners study the effects of diseases on individu- is not always true. Most diseases with a genetic component
als, and find it instructive to view the development of that come on during adulthood also have associated risk
diseases as products of the interactions among three factors that can be modified to prevent, delay, or reduce the
factors: host, agent, and environment. This establishes a impact of the disease.
framework for determining how one, or a combina- Consider the variety of possible risk factors for dis-
tion, of these factors may precipitate a disease state. ease: People who live in less-developed countries are often
Genetic predisposition, gender, and ethnic origin are at higher risk for disease from microorganisms flourishing
determinants related to the host. These may interact in their water supply and disease transmission caused by
with a specific agent, in a specific type of environment, poor sanitation. Physical conditions commonly seen in
to cause illness. The agent may be a bacterium, toxin, larger U.S. cities as well as rural areas, such as inadequate
gunshot, or other pathophysiologic process. The envi- housing, poor nutrition, and little or no medical attention,
ronment may be defined by the local climate, socioeco- potentiate disease transmission. Chemical factors such as
nomic or demographic features, culture, religion, and smoke, smog, illicit drug use, occupational chemical expo-
associated factors. Determination of how the host, sure, and additives in our food are causative agents for a
agent, and environment interact may yield solutions to variety of diseases.
curing a disease process. Injury and trauma are now Personal habit is among the most publicized—and
being viewed as “diseases,” in the sense of how the controllable—causes of disease in our society. For exam-
interaction of host, agent, and environment may con- ple, predisposing factors for cardiovascular disease
tribute to an understanding of what, heretofore, have include smoking, excessive alcohol consumption, inactiv-
been perceived as social problems. ity, and obesity. Unfortunately, changes in individual life-
• Effects on populations. Epidemiologists, who study style often occur only after a disease has already
the effects of diseases on populations, generally manifested itself. As we age, the predisposing factors and
Pathophysiology 297
causative agents take their identifying genes for certain breast cancers. Lifestyle fac-
CONTENT REVIEW
toll. The body’s ability to tors such as lack of exercise and obesity may contribute
➤➤ Diseases Involving Genetic
defend itself against dis- slightly to the incidence of breast cancer, but this has not
and Other Risk Factors
ease decreases as a result been proven.
• Immunologic disorders
of the effects of aging on As with breast cancer, colorectal cancer risk factors
• Cancer
• Endocrine disorders our immunologic system include age (with the incidence rising after age 40 and
• Hematologic disorders and other compensatory peaking between 60 and 75) and family history (incidence
• Cardiovascular disorders mechanisms. in a first-degree relative increases the risk by two or three
• Renal disorders Following is a discus- times). There are gender factors, with rectal cancer being
• Rheumatic disorders sion of some of the most more common in men and colon cancer more common in
• Gastrointestinal disorders common diseases in which women. Diet may also be a risk factor, although recent
• Neuromuscular disorders both genetics and other studies have failed to confirm a link between a high-fat,
• Psychiatric disorders risk factors play a role. You low-fiber diet and colorectal cancer. (However, a high-fat,
will notice, as you read, low-fiber diet has been positively linked to heart disease
that the causation of various diseases varies widely, and and other health problems.)
that although the causes are known for some diseases, the The causes of lung cancer are overwhelmingly environ-
causes of other diseases are still not clearly understood. mental. Smoking has been identified as the main cause of
90 percent of lung cancers in men and 70 percent of lung
Immunologic Disorders cancers in women. Lung cancer can also be caused by
A number of immunologic disorders, such as rheumatic inhaling substances such as asbestos, arsenic, and nickel,
fever, allergies, and asthma, are more prevalent among usually in the workplace.
those with a family history of the disorder but also involve
other risk factors. Endocrine Disorders
Rheumatic fever is an inflammatory reaction to an infec- The most common endocrine disorder is diabetes mellitus,
tion but is not an infection itself. There seems to be a hered- which is a leading cause of blindness, heart disease, kidney
itary factor, but inadequate nutrition and crowded living failure, and premature death. The causes of diabetes are
conditions are contributing factors. complex and still not well understood.
Allergies often have a family history factor (and some There are two major types of diabetes: type 1 and
allergies can be passed from the mother to the fetus during type 2. Type 1 diabetes usually occurs before age 40,
pregnancy). However, allergic reactions are triggered by sometimes in childhood. Although it is less prevalent
exposure to allergens and can usually be controlled by than type 2 diabetes (accounting for about 20 percent of
avoiding or reducing the presence of allergens, as well as diabetes cases), it is more severe. In the type 1 diabetic,
with medication. the pancreas produces no or almost no insulin, which is
Asthma sufferers may inherit the propensity for air- required for the cellular utilization of glucose, the body’s
way-narrowing in response to various stimuli, but other chief source of energy. Type 1 diabetics must take insulin
triggering factors may be identified and, perhaps, con- daily. There is some association of type 1 diabetes with
trolled, including stress, overexertion, exposure to cold air, family history (siblings of type 1 diabetics have a
and stimuli such as pollens, dust mites, cockroach detritus, 6 percent risk, compared with 0.3 percent in the general
and smoke. population), and medical researchers have pinpointed
some possible genetic factors. Other causative factors
Cancer may include autoimmunity disorders and viral infec-
A wide variety of family history and environmental fac- tions that invade the pancreas and destroy the insulin-
tors are included among the risk factors for cancer. Some producing cells.
kinds of cancer, such as breast and colorectal cancer, tend Type 2 diabetes accounts for about 80 percent of all
to cluster in families and seem to have a combination of diabetes cases. It usually occurs after age 40 and the inci-
genetic and environmental causes. Others, such as lung dence increases with age. It clusters much more strongly in
cancer, are more strongly identified with environmental families than does type 1 diabetes (siblings of type 2 dia-
causes. betics have a 10 to 15 percent risk). In contrast to type 1
For breast cancer, the greatest risk factor is female gen- diabetes, in which there is a total lack of insulin, type 2 dia-
der. The second highest risk factor is age. Approximately betes is associated with a decreased insulin receptor
two out of three women with invasive breast cancer are response or a decrease in insulin production. Diet and
diagnosed after age 55. A history of breast cancer in a first- exercise may also be factors, as the majority of type 2 dia-
degree relative (mother, sister, or daughter) increases the betics are obese. Type 2 diabetes can often be controlled
risk by two or three times. Some progress has been made in with diet and exercise or with oral medications.
298 Chapter 12
similar disorder is ulcerative colitis, in which the large disease, diabetes, or multiple sclerosis. The schizophrenic
intestine becomes inflamed and develops ulcers. As with loses contact with reality and suffers from hallucinations,
Crohn’s disease, the cause is not known, but an overactive delusions, abnormal thinking, and disrupted social func-
immune response is suspected, and heredity seems to play tioning. People who develop schizophrenia are now
a role. thought to be “biologically vulnerable” to the disease, but
Peptic ulcers develop when the normal protective struc- what makes them vulnerable is not fully understood. The
tures and mechanisms, such as mucus production, break cause may be a genetic predisposition or some problem
down and areas in the lining of the stomach or duodenum that occurs before, during, or after birth or a viral infection
are inflamed by stomach acid and digestive juices. Envi- of the brain.
ronmental factors, bacterial infection (by Helicobacter Another common psychiatric disorder is manic-depres-
pylori), diet, stress, and alcohol consumption are thought to sive illness, now called bipolar disorder, in which the person
play roles in the development of peptic ulcers. Many medi- experiences alternating periods of depression and mania
cations, particularly nonsteroidal anti-inflammatory medi- or excitement. It can be mild or severe enough to interfere
cations, are associated with ulcer formation. with the patient’s ability to work or function socially.
Cholecystitis is an inflammation of the gallbladder that Manic-depressive illness affects about twice as many peo-
usually results from blockage by a gallstone. There may be ple as schizophrenia. It is believed to be hereditary, but the
a genetic predisposition for gallstone formation. Gallstones exact gene deficit has not yet been discovered.
are more prevalent in women and in some groups such as
Native Americans and Mexican Americans. Other risk fac-
tors include age, a high-fat diet, and obesity.
Obesity can be defined as being more than 20 percent Hypoperfusion
over the ideal body weight. Obesity has both an environ- Hypoperfusion (shock) is a condition that is progressive
mental and a familial risk of transmission. Research has (that is, it triggers a self-worsening cycle of pathophysio-
shown that children whose parents are obese have a much- logic events) and fatal if not corrected. It can occur for
increased chance of developing obesity. Environmental many reasons, such as trauma, fluid loss, myocardial
factors such as proper nutrition and exercise may not be infarction, infection, allergic reaction, spinal cord injury,
modeled or taught by obese parents, but there also seems and other causes. Although causes differ, all forms of shock
to be a genetic factor to many cases of obesity. Obesity has have the same underlying pathophysiology at the cellular
been linked to, or defined as a cause for, diseases such as and tissue levels.
hypertension, heart disease, and vascular diseases.
THE PUMP The heart is the pump of the cardiovascular Stroke volume * Heart rate = Cardiac output
system. It receives blood from the venous system, pumps
The preceding equation illustrates the factors that can
it to the lungs for oxygenation, and then pumps it to the
affect cardiac output. An increase in stroke volume or an
peripheral tissues. The amount of blood ejected by the heart
increase in heart rate can increase cardiac output. Con-
in one contraction is referred to as the stroke volume. Fac-
versely, a decrease in stroke volume or a decrease in heart
tors affecting stroke volume include:
rate can decrease cardiac output. The blood pressure is
• Preload dependent on both cardiac output and peripheral vascular
• Cardiac contractile force resistance.
Preload is the amount of blood delivered to the heart Peripheral vascular resistance is the pressure against
during diastole (when the heart fills with blood between which the heart must pump. Since the circulatory system
contractions). Preload depends on venous return. The is a closed system, increasing either cardiac output or
venous system is a capacitance, or storage, system. That is, peripheral vascular resistance will increase blood pres-
it can be contracted or sure. Likewise, a decrease in cardiac output or a decrease
CONTENT REVIEW expanded, to some extent, in peripheral vascular resistance will decrease blood
➤➤ Components of the as needed to meet the pressure.
Circulatory System physiologic demands of the The body strives to keep the blood pressure relatively
• Pump (heart) body. When additional constant by employing compensatory mechanisms and neg-
• Fluid (blood) oxygenated blood is ative feedback loops. As noted earlier, baroreceptors in
• Container (blood
required, the venous capac- the carotid sinuses and in the arch of the aorta closely
vessels)
itance is reduced, thus monitor blood pressure. If blood pressure increases, the
Pathophysiology 301
baroreceptors send signals to the brain that cause the Physiology of the Natriuretic Peptides
blood pressure to return to its normal values. This is
accomplished by decreasing the heart rate, decreasing the
preload, or decreasing peripheral vascular resistance.
Atrial distension
The baroreceptors are also stimulated if the blood Sympathetic stimulation
Degradation
pressure falls. The heart rate is increased, as is the strength Angiotensin II
of the cardiac contractions. There is also arteriolar constric- Aldosterone
tion, venous constriction (which results in decreased con- BNP
tainer size), and overall increased peripheral vascular Angiotensin II
resistance. Also, the adrenal medulla (the inner portion of SVR
Blood
THE FLUID Blood is the fluid of the cardiovascular sys- Arterial Volume GFR
tem. It is a viscous fluid; that is, it is thicker and more adhe- Pressure
sive than water. As a result, blood flows more slowly than Natriuresis
water. Blood, which consists of the plasma and the formed Diuresis
elements (red cells, white cells, and platelets), transports
FIGURE 12-84 Physiology of the natriuretic peptides.
oxygen, carbon dioxide, nutrients, hormones, metabolic
waste products, and heat.
An adequate amount of blood is required for perfusion. blood pressure primarily by decreasing peripheral vascu-
Because the cardiovascular system (the heart and blood lar resistance (Figure 12-84).
vessels) is a closed system, the volume of blood present BNP levels are elevated in congestive heart failure
must be adequate to fill the container, as described later. (CHF) and have become a marker for the presence of CHF.
BNP (marketed as nesiritide) can be administered as a
Natriuretic Peptides The heart has been found to treatment for acute decompensated CHF.
have endocrine functions, especially through substances
called natriuretic peptides (NPs). These substances are THE CONTAINER Blood vessels (arteries, arterioles,
involved in the long-term regulation of sodium and water capillaries, venules, and veins) serve as the container of the
balance, blood volume, and arterial pressure. There are cardiovascular system. The blood vessels can be thought
two of these substances of interest: atrial natriuretic peptide of as a continuous, closed, and pressurized pipeline by
(ANP) and brain natriuretic peptide (BNP). ANP is manu- which blood moves throughout the body. Whereas the
factured, stored, and released by the heart’s atrial muscle heart functions as the pump of the circulatory system, the
cells in response to such things as atrial distention and blood vessels—under the control of the autonomic ner-
sympathetic stimulation. BNP is manufactured, stored, vous system—can regulate blood flow to different areas of
and released by the heart’s ventricular muscle cells in the body by adjusting their size, as well as by selectively
response to ventricular dilation and sympathetic stimula- rerouting blood through the microcirculation.
tion. BNP was first identified in the brains of rats, which Whereas the arteries and veins, like the heart, are sub-
is why it was named brain natriuretic peptide, although it ject to direct stimulation from sympathetic portions of the
was later found to be manufactured in both the brain and autonomic nervous system, the microcirculation (comprising
in the ventricles. the small vessels: the arterioles, capillaries, and venules) is
Natriuretic peptides serve as a sort of counterregula- primarily responsive to local tissue needs. The capability of
tory system to the renin–angiotensin system. They are some vessels in the capillary network to adjust their diame-
involved in the long-term regulation of sodium and water ter permits the microcirculation to selectively supply under-
balance, blood volume, and arterial blood pressure. These nourished tissue, while temporarily bypassing tissues with
hormones decrease aldosterone release from the adrenal no immediate need. Capillaries have a sphincter at the ori-
cortex, which increases the glomerular filtration rate (GFR) gin of the capillary (between arteriole and capillary), called
and produces natriuresis (sodium loss) and diuresis (water the precapillary sphincter, and another at the end of the capil-
loss). It also decreases renin release by decreasing angio- lary (between capillary and venule), called the postcapillary
tensin II. This results in a reduction in blood volume and sphincter. The precapillary sphincter responds to local tissue
thus a reduction in central venous pressure (CVP), cardiac conditions, such as acidosis and hypoxia, and opens as more
output (CO), and arterial blood pressure. Chronic eleva- arterial blood is needed. The postcapillary sphincter opens
tion of natriuretic peptides appears to decrease arterial when blood is to be emptied into the venous system.
302 Chapter 12
Blood flow through the vessels is regulated by two fac- Another way of stating this is that the partial pressure
tors: peripheral vascular resistance and pressure within the of oxygen present in air in the alveoli of the lungs is
system. Peripheral vascular resistance, as noted earlier, is greater than the partial pressure of oxygen in the blood
the resistance to blood flow. Vessels with larger inside within the pulmonary circulation. (In a mix of gases, the
diameters offer less resistance, whereas vessels with portion of the total pressure exerted by each component
smaller inside diameters offer greater resistance. Periph- of the mix is known as the partial pressure of that compo-
eral vascular resistance is governed by three factors—the nent.) For this reason, oxygen from the alveoli diffuses
length of the vessel, the diameter of the vessel, and blood across the alveolar–capillary membrane and into the
viscosity. bloodstream—from the area of greater partial pressure to
There is very little resistance to blood flow through the the area of lower partial pressure.
aorta and arteries, but a significant change in peripheral The red blood cells “pick up” this oxygen while pass-
resistance occurs at the arterioles and precapillary sphinc- ing through the pulmonary capillary bed. Oxygen binds
ters. This is because the inside diameter of the arteriole is to the hemoglobin molecules of the red blood cells, which
much smaller, as compared to that of the aorta and arteries. serve as the primary carriers of oxygen within the blood-
Additionally, the arteriole has the ability to make a pro- stream. Normally, between 95 and 100 percent of the
nounced change in its diameter, as much as fivefold. It hemoglobin is saturated with oxygen. Approximately
tends to do this in response to local tissue needs and auto- 97 percent of oxygen is transported reversibly bound to
nomic nervous signals. hemoglobin, whereas the remaining 3 percent is trans-
Contraction of the venous side of the vascular system ported as a gas dissolved in the plasma. The oxygen-
results in decreased capacitance and increased cardiac pre- enriched blood then circulates back to the heart through
load. The arterial system, however, provides systemic vas- the venous side of the pulmonary circulation. Passing
cular resistance. An increase in arterial tone increases through the left atrium and into the left ventricle, the
resistance, which increases blood pressure. oxygen-enriched blood is pumped throughout the body
via the systemic circulation.
Oxygen Transport On reaching capillaries throughout the body, the
Oxygen is brought into the body via the respiratory sys- oxygen-rich blood interfaces with the tissues. The tissues
tem. During inspiration, approximately 500 to 800 mL of contain cells that are oxygen deficient as a result of nor-
atmospheric air is taken in through the upper and lower mal metabolic activity. Because the partial pressure of
airways, coming to rest in the alveoli of the lungs. oxygen is greater in the bloodstream than in the cells,
Surrounding the alveoli are capillaries that are per- oxygen will diffuse from the red blood cells across the
fused by the pulmonary circulation. The blood that comes capillary wall–cell membrane barrier, into the cells and
into the pulmonary capillaries is oxygen-depleted blood tissues.
that was returned from the body to the right atrium of the Overall, the movement and utilization of oxygen in
heart, then pumped by the the body is dependent on the following conditions:
CONTENT REVIEW right ventricle of the heart
• Adequate concentration of inspired oxygen
➤➤ Perfusion into the pulmonary arter-
• Inspired oxygen ies and thence into the pul- • Appropriate movement of oxygen across the alveolar–
T monary capillaries. capillary membrane into the arterial bloodstream
• Alveoli The air in the alveoli • Adequate number of red blood cells to carry the
T contains a concentration of oxygen
• Heart
about 13.6 percent oxygen. • Proper tissue perfusion
T
This is less than the 21 per-
• Arterial system • Efficient offloading of oxygen at the tissue level
cent concentration of oxy-
T
• Cells gen in atmospheric air The dependence on this set of conditions for oxygen
• Waste carbon dioxide because of various factors, movement and utilization is known as the Fick principle.
T including the fact that some
• Venous system air always remains in the Waste Removal
T alveoli from earlier respira- The waste products of cellular metabolism are expelled
• Heart tions and oxygen is con- from the cells and carried away by the blood. Carbon diox-
T stantly being absorbed from ide leaves the bloodstream during the oxygen–carbon diox-
• Lungs this air. Nevertheless, alveo- ide exchange, which occurs through the alveolar–capillary
T lar air is far richer in oxygen membranes. The majority of carbon dioxide (approximately
• Expired carbon
than blood that enters the 70 percent) is transported in the form of bicarbonate ion
dioxide
pulmonary capillaries. (HCO3-). Only 23 percent is reversibly bound to hemoglobin
Pathophysiology 303
(carbon dioxide binds to a different site on hemoglobin than nervous system dysfunc-
CONTENT REVIEW
oxygen does). Only 7 percent of carbon dioxide is trans- tion, and many others. But
➤➤ Causes of Hypoperfusion
ported as a gas dissolved in the plasma. Carbon dioxide is the outcome is always the
(Shock)
ultimately eliminated by exhalation from the lungs. Some same: inadequate delivery
• Inadequate pump
cellular waste products are expelled into the interstitial of oxygen and essential
(heart malfunction)
fluid and picked up by the lymphatic system. These ulti- nutrients to, and removal • Inadequate fluid
mately flow through the lymph channels into the thoracic of wastes from, all the tis- (hypovolemia)
duct. The thoracic duct empties the waste products into the sues of the body, especially • Inadequate container
venous side of the circulatory system. Other wastes are the critical tissues (brain, (dilated or leaking blood
cleansed from the blood by the kidneys and excreted as heart, kidneys). vessels)
urine. Finally, some cellular waste products are emptied
into the gastrointestinal system and expelled in the feces. Shock at the Cellular Level
There is some local control of both tissue perfusion Shock is a complex phenomenon. The causes vary. The
and waste removal. When the amounts of metabolic waste signs and symptoms vary. At the simplest level, however,
products (such as lactic acid) increase, the tissues subse- shock is inadequate tissue perfusion. Additionally, all
quently become acidotic. This local acidosis causes nearby types of shock have this in common: The ultimate outcome
precapillary sphincters to relax, thus opening the capillar- is impairment of cellular metabolism. Two characteristics
ies and increasing perfusion of the affected tissues. This of impaired cellular metabolism in any type of shock are
provides increased capacity for waste elimination and impaired oxygen use and impaired glucose use.
response to local metabolic demands.
IMPAIRED USE OF OXYGEN One characteristic of
The Pathophysiology any type of shock is that the cells are either not receiving
enough oxygen or are unable to use it effectively. This
of Hypoperfusion may be caused by hypoperfusion resulting from reduced
Causes of Hypoperfusion cardiac function, inadequate blood volume, or vasodila-
Hypoperfusion (shock) is almost always a result of inade- tion (pump, fluid, or container problems). It may result
quate cardiac output. A number of factors can decrease from insufficient red cells to carry the oxygen, from fever
effective cardiac output. These include: that increases cellular oxygen demand, or from chemical
disruption of cellular metabolism.
• Inadequate pump
When the cells don’t receive enough oxygen or cannot
• Inadequate preload use it effectively, they change from aerobic metabolism to
• Inadequate cardiac contractile strength anaerobic metabolism, a far less efficient means of pro-
• Inadequate heart rate ducing energy—as explained in the following text.
The primary energy source for the cells is glucose,
• Excessive afterload
taken into the cell with the aid of insulin. Glucose does not
• Inadequate fluid
provide energy until it is broken down inside the cell. The
• Hypovolemia (abnormally low circulating blood first stage of glucose breakdown, called glycolysis, is
volume) anaerobic (does not require oxygen). Glycolysis produces
• Inadequate container pyruvic acid as an end product but yields very little
• Dilated container without change in fluid volume energy. Thus, by itself, glycolysis is an inefficient utiliza-
(inadequate systemic vascular resistance) tion of glucose. Therefore, in a normal state of metabolism,
a second stage of glucose breakdown is required. During
• Leak in container
this second stage, which is aerobic (requires oxygen),
Occasionally, hypoperfusion can develop even when pyruvic acid is further degraded into carbon dioxide,
cardiac output is adequate. This can happen when cell water, and energy in a process termed the Krebs or citric
metabolism is so excessive that the body cannot increase acid cycle. The energy yield of this second-stage aerobic
perfusion enough to meet the cells’ metabolic require- process is much higher than from the first-stage anaerobic
ments. It can also happen when abnormal circulatory pat- process (Figure 12-85).
terns develop, so that circulating blood is bypassing During shock, or any condition in which the cells do
critical tissues. not receive adequate oxygen or cannot use it effectively,
As mentioned earlier, the conditions that lead to glucose breakdown can complete only the first-stage,
hypoperfusion can result from a number of underlying anaerobic process of glycolysis and cannot enter into the
causes, such as infection, trauma and hemorrhage, loss of second-stage, aerobic, citric acid cycle. This causes an accu-
plasma through burns, severe cardiac arrhythmia, central mulation of the end product of glycolysis, pyruvic acid. In
304 Chapter 12
(a) Stage one: Anaerobic metabolism (b) Stage two: Aerobic metabolism
Glucose Glucose
Small amount
of energy
Energy
Pyruvic
acid
Lactic acid
No oxygen
FIGURE 12-85 Glucose breakdown. (a) Stage one, glycolysis, is anaerobic (does not require oxygen). It yields pyruvic acid, with toxic byproducts
such as lactic acid, and very little energy. (b) Stage two is aerobic (requires oxygen). In a process called the Krebs or citric acid cycle, pyruvic acid
is degraded into carbon dioxide and water, which produces a much higher yield of energy.
these cases, pyruvic acid is quickly degraded to lactic acid. allowing lysosomal enzymes and other cellular contents to
If oxygen is promptly restored to the cells, lactic acid will leak into the interstitial spaces. Cellular death soon follows.
be reconverted to pyruvic acid. However, if time elapses
and the cellular hypoxia is not corrected, lactic acid and IMPAIRED USE OF GLUCOSE The same factors that
other metabolic acids will accumulate. One outcome is that reduce delivery of oxygen to the cells also reduce delivery
the acidic condition of the blood reduces the ability of of glucose to the cells. In addition, uptake of glucose by the
hemoglobin in red blood cells to bind with and carry oxy- cells may be disrupted by fever, cell damage, or the pres-
gen, which compounds the problem of cellular oxygen ence of bacteria, toxins, histamine, or other substances pro-
deprivation. duced or activated by the body’s immune and inflammatory
The energy that is produced during glucose break- responses to disease or injury. Compensatory mechanisms
down is in the form of the chemical adenosine triphosphate activated by shock may also be responsible for substances
(ATP), which is essential to all metabolic processes in the that inhibit glucose uptake, including catecholamines and
cells. As just noted, the amount of energy, or ATP, produced the hormones cortisol and growth hormone.
during first-stage, anaerobic glycolysis is very small. With- Glucose that is prevented from entering the cells
out oxygen, when the process of glucose breakdown stops remains in the blood, resulting in a condition of high serum
after glycolysis (during which very little energy has been glucose, or hyperglycemia. Because glucose is the sub-
produced), cellular stores of ATP are used up much faster stance from which cells produce energy, the consequences
than they can be replaced, so all the processes of cellular of reduced glucose delivery and uptake are critical.
metabolism are gravely impaired. In the absence of an adequate supply of glucose, cer-
Because of changes to the internal cell and because tain body cells can create fuel for energy production by
blood flow has been slowed by the decreased pumping converting other substances to glucose. One source is gly-
action and vasodilation, sludging of the blood occurs. This cogen, the form of glucose that cells store and hold in
further impedes blood flow. Thus, the normal diffusion of reserve. Cells convert glycogen to glucose in a process
nutrients and wastes in and out of the cells is disrupted called glycogenolysis. However, there is very little stored
and the balance of the cellular electrolytes is altered. Lyso- glycogen in cells other than the liver, kidneys, and mus-
somes, the organelles that assist in digestion of nutrients, cles. When glycogen reserves are depleted, which typi-
are normally enclosed by a membrane that prevents the cally occurs in 4 to 8 hours, the cells will then derive
digestive enzymes from damaging other cell components. energy from the breakdown of fats (lipolysis) and from the
Now the lysosomes rupture, releasing the lysosomal conversion of noncarbohydrate substrates, such as amino
enzymes into the cell. The sodium–potassium pumping acids from proteins, to glucose (gluconeogenesis). The
mechanism fails, changing the electrical charge of the cells’ energy costs of glycogenolysis and lipolysis are high and
internal environment. There is an increase in sodium and contribute to the failure of cells—but the depletion of pro-
water (because water follows sodium) inside the cells, teins in gluconeogenesis will ultimately cause organ fail-
causing cellular edema. The cell membrane then ruptures, ure (Figure 12-86).
Pathogenesis of Shock
Impaired Impaired
Glucose Inadequate Tissue Perfusion Oxygen
Usage Usage
Decreased Colloid
Cellular Rupture
Osmotic Pressure
305
306 Chapter 12
In addition, the anaerobic breakdown of proteins pro- The spleen, capable of storing more than 300 mL of
duces ammonia, which is toxic to the cells, and urea, which blood, can expel up to 200 mL of blood into the venous cir-
leads to uric acid, which is also toxic to cells. Finally, when culation and can contract, consequently increasing blood
cellular metabolism is impaired, the waste products of volume, preload, cardiac output, and blood pressure in
metabolism build up in the cells, further impairing cell response to a sudden drop in blood pressure.
function and damaging cell membranes. Some passive compensatory responses also occur, with
Impaired use of oxygen and glucose soon leads to cel- beneficial fluid shifts taking place as a result of simple dif-
lular death. Cellular death will ultimately lead to tissue fusion. With volume loss, the hydrostatic pressure in capil-
death, tissue death will lead to organ failure, and organ lary beds is reduced, and water from the interstitial spaces
failure will lead to death of the individual. diffuses into the capillaries.
All the aforementioned mechanisms work to compen-
Compensation and Decompensation sate for the shock state, and may be able to restore normal
Usually, the body is able to compensate for any of the circulatory volume—if excessive bleeding is managed and
changes previously described. However, when the compen- the shock state has not progressed too far. In this case, the
satory mechanisms fail, shock develops and may progress. patient is said to be in compensated shock.
Once normal circulatory function and blood pressure
COMPENSATION In shock, the fall in cardiac output, are reestablished, the blood pressure will “feed back” on
detected as a decrease in arterial blood pressure by the all the compensatory mechanisms so that all systems can
baroreceptors, activates several body systems that attempt return to normal. In this way, negative feedback loops
to reestablish a normal blood pressure—a process known work to maintain stability by “signaling” the systems to
as compensation. The sympathetic nervous system stimu- cease the compensatory responses. In this way, stability
lates the adrenal gland of the endocrine system to secrete and homeostasis are maintained.
the catecholamines epinephrine and norepinephrine. These
chemicals profoundly affect the cardiovascular system, DECOMPENSATION If the conditions causing shock
causing an increased heart rate, increased cardiac contrac- are too serious, or progress too rapidly, compensatory
tile strength, and arteriolar constriction—all of which serve mechanisms may not be able to restore normal function. In
to elevate the blood pressure. those cases, decompensation is said to occur, and the patient
Another compensatory mechanism, the renin–angio- is in a state of decompensated shock, also called progressive
tensin system, aids the body in maintaining an adequate shock. During decompensated or progressive shock, medi-
blood pressure. When the renin–angiotensin system is acti- cal intervention may still be able to correct the condition.
vated by a fall in blood pressure, the enzyme renin is Because all the “responding” systems have a point at
released from the kidneys into the systemic circulation. which they can no longer sustain their action (i.e., a lim-
Renin acts on a specialized plasma protein called angioten- ited duration of action), the shock state may progress to a
sin to produce a substance called angiotensin I. Angiotensin condition where correction, either by the body’s own com-
I is converted to angiotensin II by an enzyme found in the pensatory mechanisms or through medical intervention, is
lungs called angiotensin-converting enzyme (ACE). Angio- no longer possible. This condition is known as irrevers-
tensin II is a potent vasoconstrictor. As angiotensin II ible shock.
causes the diameter of the vascular container to decrease, A critical factor in the downward spiral of decompen-
the blood pressure increases. Angiotensin II also stimulates sation is cardiac depression. The compensatory mecha-
the production of aldosterone, a hormone secreted by the nisms that increase heart rate and contractile strength create
adrenal cortex (outer layer of the adrenal gland) that, in a greatly increased demand for oxygen by the myocardium.
turn, stimulates the kidneys to reabsorb sodium, and, sub- When arterial blood pressure has fallen sufficiently, how-
sequently, water (as noted earlier, “water follows sodium”) ever, coronary blood flow is reduced below the level neces-
into peritubular capillaries. The intravascular volume is sary to adequately perfuse the myocardium. The heart is
maintained, and elimination of water by the kidneys is weakened and cardiac output falls even further.
reduced. Depression of the vasomotor center of the brain is
Another endocrine another consequence of reduced blood pressure. In early
response by the pituitary shock, as previously discussed, the sympathetic nervous
CONTENT REVIEW gland results in the secre- system is stimulated to cause release of catecholamines
➤➤ Bodily Responses tion of antidiuretic hormone that support the function of the circulatory system. But
to Shock (ADH), which also causes when blood pressure falls to a certain point, in the late
• Compensated shock the kidneys to reabsorb stages of shock, reduced blood supply to the vasomotor
• Decompensated shock center results in a slowing, then stoppage, of sympathetic
water, creating an additive
• Irreversible shock
effect to that of aldosterone. activity.
Pathophysiology 307
Metabolic wastes, products of anaerobic metabolism, what the cause or type of shock is, but some differ in
are released into the slower-flowing blood. The blood in important ways. For example, providing IV fluid boluses,
the capillary beds becomes acidic, causing formation of which may be appropriate to support circulating volume
minute blood clots (“sludged” blood), which further slows in the hypovolemic patient, would not be indicated for the
the flow of blood. And a more generalized, systemic acido- patient in cardiogenic shock with pulmonary edema.
sis develops, causing further deterioration of cells and tis-
sues, including the capillary walls. Cardiogenic Shock
Capillary cells, like other cells, suffer from lack of oxy- An inability of the heart to pump enough blood to supply
gen and other nutrients, as well as from the ravages of aci- all body parts is referred to as cardiogenic shock. Cardio-
dosis. This begins to cause permeability of the capillaries genic shock is usually the result of severe left ventricular
and leakage of fluid into the interstitial spaces. This is failure secondary to acute myocardial infarction or conges-
another self-perpetuating process, as the decreased circu- tive heart failure. The reduced blood pressure that accom-
lating volume and anaerobic metabolism cause further cell panies this form of shock aggravates the situation by
hypoxia and increased permeability. decreasing coronary artery perfusion. With decreased cor-
Cellular deterioration progresses to tissue deteriora- onary perfusion, the heart muscle becomes even more
tion, which progresses to organ failure. (See Multiple damaged, thus establishing a vicious cycle that ultimately
Organ Dysfunction Syndrome, later in the chapter.) Medi- results in complete pump failure.
cal intervention may save the patient if initiated early During cardiogenic shock, as noted earlier, the activa-
enough, but when enough damage has been done to cells, tion of compensatory mechanisms can actually worsen the
tissues, and organs, no known treatment can help the situation. When the peripheral resistance increases in an
patient to recover. Medical therapies may support function attempt to maintain blood pressure, the myocardial work-
for a while, but death becomes inevitable. load increases. This, in turn, increases the myocardial oxy-
gen demand, further aggravating myocardial ischemia and
infarction. Cardiac output is further depressed and ejection
Types of Shock fraction (the percentage of blood in the ventricle that is
Shock is usually classified according to the cause. Some ejected with each beat) is decreased (Figure 12-87).
newer terminology classifies shock as cardiogenic (caused The most common cause of cardiogenic shock is severe
by impaired pumping power of the heart), hypovolemic left ventricular failure, but a number of other factors can
(caused by decreased blood or water volume), obstructive have the same result. These include chronic progressive
(caused by an obstruction that interferes with return of heart disease such as cardiomyopathy, rupture of the papil-
blood to the heart, such as a pulmonary embolism, cardiac lary heart muscles or intraventricular septum, and end-stage
tamponade, or tension pneumothorax), and distributive valvular disease (mitral stenosis or aortic regurgitation).
(caused by abnormal distribution and return of blood Most patients who experience cardiogenic shock will
resulting from vasodilation, vasopermeability, or both, as have normal blood volume. However, some patients will
in neurogenic, anaphylactic, or septic shock). be hypovolemic from an excessive use of prescribed
Another, more familiar terminology classifies shock diuretics or the severe diaphoresis that accompanies some
as cardiogenic, hypovolemic, neurogenic, anaphylactic, and acute cardiac events. Patients may also experience relative
septic. The following discussion of types of shock uses hypovolemia (neurogenic shock) from the vasodilatory
these classifications. (vessel dilation) effects of drugs such as nitroglycerin.
Although all types of
CONTENT REVIEW shock ultimately have the EVALUATION AND TREATMENT A major difference
➤➤ Two Classifications of same effects on the body’s between cardiogenic and other types of shock is the pres-
Shock cells, tissues, and organs, it ence of pulmonary edema (excess fluid in the lungs), which
Classification #1 is important to try to iden- will probably result in a complaint of difficulty breathing.
• Cardiogenic shock tify the underlying cause, There may be diminished lung sounds as fluid enters the
• Hypovolemic shock because correcting the interstitial spaces of the lungs. As fluid levels rise, wheezes,
• Obstructive shock cause is the most impor- crackles, or rales may be heard. A productive cough may
• Distributive shock tant element in reversing develop, characterized by white- or pink-tinged foamy
Classification #2 the condition and saving sputum. Cyanosis (a dusky blue-gray skin color) is typical,
• Cardiogenic shock the patient’s life. Many of resulting from the decreased diffusion of oxygen across
• Hypovolemic shock the treatments that you, as the alveolar–capillary interface, decreasing oxygen deliv-
• Neurogenic shock a paramedic, will provide ery to cells that are already hypoxic because of decreased
• Anaphylactic shock for the shock patient will blood pressure and perfusion. Other signs of shock include
• Septic shock
be the same, no matter altered mentation (resulting from reduced perfusion of the
308 Chapter 12
Increased
Increased Systemic
Blood Volume Vascular
Resistance
Increased Preload
Increased Heart Rate
Increased Stroke Volume
Decreased
Tissue Perfusion
Impaired Cellular
Metabolism
Anaphylactic Shock
When a foreign substance enters the body, the immune sys-
tem responds to rid the body of the invader. (See the dis-
Autonomic Nervous cussion of immunity later in this chapter.) This usually
System Imbalance
happens with no noticeable effects, and the person is not
even aware that an immune response is taking place. Some
foreign substances (antigens) provoke an exaggerated
immune response (allergic response) that will cause notice-
Massive
Vasodilation able symptoms such as a rash (as from contact with poison
ivy) or swollen, irritated airway passages (as with hay
fever). In rare cases, an allergic response is very severe and
Decreased Systemic
life threatening. This kind of severe allergic response is
Vascular Resistance called anaphylaxis, or anaphylactic shock (Figure 12-90).
An anaphylactic reaction usually occurs very rapidly.
Signs and symptoms most often appear within a minute or
Massive Massive less, but occasionally may appear an hour or more after
Vasodilation Vasodilation exposure. Generally, the faster the reaction develops, the
more severe it is likely to be. Death can occur before the
patient can get to a hospital, so prompt intervention is crit-
Inadequate Cardiac ical. This is a situation in which the paramedic at the scene
Output can make the difference between life and death.
Anaphylactic reactions can be triggered by a variety of
substances, including foods (especially nuts, eggs, and
Decreased Tissue shellfish), venoms, aspirin or nonsteroidal anti-inflamma-
Perfusion tory drugs (NSAIDS), hormones (animal-derived insulin),
preservatives, and others. The most rapid and severe reac-
tions are usually caused by substances injected directly
Impaired Cellular into the bloodstream, which is one reason that penicillin
Metabolism injections and hymenoptera stings (e.g., from bees, wasps,
and hornets) are the most common causes of fatal anaphy-
lactic reactions.
FIGURE 12-89 The pathogenesis of neurogenic shock.
EVALUATION AND TREATMENT Because the immune
responses involved in anaphylaxis can affect different
an injury that has resulted in severe spinal cord injury or body systems, the signs and symptoms can vary widely,
total transection of the cord (which may be called spinal as follows:
shock) or injury or deprivation of oxygen or glucose to the
medulla of the brain (Figure 12-89). • Skin
• Flushing
EVALUATION AND TREATMENT The vasodilation in
• Itching
neurogenic shock causes warm, red skin, and sweat gland
• Hives
malfunction causes dry skin—in contrast to the cool, pale,
sweaty skin associated with hypovolemic shock. Because of • Swelling
the lack of compensatory stimulation from catecholamine • Cyanosis
release, the patient will have a low blood pressure and a • Respiratory system
slow pulse even in the early stages—again, in contrast to
• Breathing difficulty
hypovolemic shock.
Treatment for neurogenic shock or spinal shock is • Sneezing, coughing
similar to treatment for other types of shock and includes • Wheezing, stridor
Pathophysiology 311
• Headache
Pathogenesis of Anaphylactic Shock
• Seizures
Exposure to Antigen • Tearing
at Some Point in Life
The patient may present
with an altered mental status
that can progress to unrespon-
siveness, so gather a brief history
Repeat Exposure as soon as possible, including
to Same Antigen previous allergic reactions and
Large Release of any information about what the
Antibody IgE patient may have ingested or
Massive Release of:
been exposed to that could have
Histamine caused the present reaction. Be
Bronchoconstriction
Prostaglandins sure the patient is no longer in
Kinins
contact with the allergen; if a
stinger is in the skin, scrape it
Increased Capillary Peripheral Laryngospasm away with a fingernail or scalpel
Permeability Vasodilation
blade.
Because laryngeal edema is
Decreased Systemic
Edema often a problem, protecting the
Vascular Resistance Gastrointestinal Cramps
Vomiting patient’s airway will be your
Diarrhea first concern. Administer oxygen
Relative
by nonrebreather mask or, as
Hypovolemia
necessary, by endotracheal intu-
bation. The anaphylactic
Decreased Cardiac
response causes depletion of cir-
Output
culatory volume by promoting
capillary permeability and leak-
Decreased Tissue ing of fluid into interstitial
Perfusion
spaces, so establish an IV of crys-
talloid solution (normal saline or
Impaired Cellular lactated Ringer ’s) for volume
Metabolism
support.
The primary treatment for
anaphylaxis is pharmacological.
FIGURE 12-90 The pathogenesis of anaphylactic shock. In addition to oxygen, epineph-
rine is usually administered (if
• Laryngeal edema the patient has a history of anaphylaxis, he may be carry-
ing a prescribed spring-loaded epinephrine injector), as are
• Laryngospasm
antihistamines (diphenhydramine), corticosteroids (meth-
• Cardiovascular system ylprednisolone, hydrocortisone, dexamethasone), and
• Vasodilation vasopressors (dopamine, norepinephrine, epinephrine).
• Increased heart rate Occasionally an inhaled beta agonist (albuterol) may be
required. Follow local protocols.
• Decreased blood pressure
• Gastrointestinal system
Septic Shock
• Nausea, vomiting Septic shock begins with septicemia (also called sepsis), an
• Abdominal cramping infection that enters the bloodstream and is carried
• Diarrhea throughout the body. The person may have septicemia for
some time before septic shock develops, but eventually
• Nervous system
toxins released by the invading organism overcome the
• Altered mental status compensatory mechanisms. Unless it is corrected, septic
• Dizziness shock will cause the dysfunction of more than one organ
312 Chapter 12
system, resulting in multiple organ dysfunction syndrome blood vessels to the point where great amounts of fluid
(discussed in the next section) (Figure 12-91). are lost from the vasculature and blood pressure falls
drastically.
EVALUATION AND TREATMENT The signs and Signs and symptoms can vary widely as the patient
symptoms of septic shock are progressive. In the begin- progresses from early to late stages of septic shock. Some
ning, cardiac output is increased, but toxins causing vaso- patients may have a high fever, but others, especially the
dilation may prevent an increase in blood pressure. The elderly or the very young, may have no fever or may even
person may seem to be sick, but not alarmingly so. By be hypothermic. The skin can be flushed, if fever is present,
the last stages, toxins have increased permeability of the or very pale and cyanotic in the late stages.
The most susceptible organ
system is the lungs and respira-
Pathogenesis of Septic Shock tory system, so the patient may
present with breathing difficulty
Systemic Inflammatory Response Syndrome and altered lung sounds. The
(SIRS) brain may be infected, resulting
in altered mental status. Suspi-
cion of septic shock is usually
Bacteremia
based on a history of recent
infection or illness.
Gram-Negative Gram-Positive
Bacteria Bacteria
Multiple Organ
Dysfunction
Release of Gram-Positive Syndrome
Endotoxins Bacteria
In the 1970s, a syndrome of mul-
Activates Numerous Cell Types tiple organ failure began to be
noticed in hospital intensive care
units. Medical advances were
allowing patients to survive seri-
Arachidoic
Neutrophil Platelet Macrophage Coagulation Complement ous illness and trauma—only to
Acid
Activation Activation Activation Activation Activation
Activation die later of complications of the
original disease or injury. The
syndrome was described in 1975
Release of Multiple Mediators as multisystem organ failure. In
1991, the American College of
Chest Physicians and the Society
Endothelial Damage of Critical Care Medicine named
it multiple organ dysfunction
syndrome (MODS).
MODS is the progressive
Lactic Decreased Pulmonary impairment of two or more
Hypotension Neutropenia
Acidosis Platelets Congestion organ systems resulting from an
uncontrolled inflammatory
response to a severe illness or
Decreased injury. Sepsis and septic shock
Tissue Cardiac Vascular Systemic
Necrosis Depression Leakage are the most common causes of
Vascular
Resistance MODS, with MODS being the
end stage. (The progression from
infection to sepsis to septic shock
Organ Dysfunction and Failure to MODS is known as systemic
inflammatory response syndrome,
or SIRS.)
Actually, MODS can result
FIGURE 12-91 The pathogenesis of septic shock. from any severe disease or injury
Pathophysiology 313
that triggers a massive systemic inflammatory response— vasopermeability, cardiovascular instability, endothelial
including trauma, burns, surgery, circulatory shock, acute damage, and clotting abnormalities.
pancreatitis, acute renal failure, and others. Risk factors As a result of the release of the inflammatory media-
include age (>65), malnutrition, and preexisting chronic tors and toxins and the plasma protein cascades, a massive
disease such as cancer or diabetes. With a mortality rate of immune/inflammatory and coagulation response devel-
60 to 90 percent, MODS is the major cause of death follow- ops. Vascular changes (vasodilation, increased capillary
ing sepsis, trauma, and burn injuries. permeability, selective vasoconstriction, and microvascular
thrombi) continue and worsen. Two metabolites that are
Pathophysiology of MODS released have opposing vascular effects: Prostacyclin, also
MODS occurs in two stages. In primary MODS, organ called prostaglandin I2 (PGI2), is a vasodilator, whereas
damage results directly from a specific cause such as isch- thromboxane A2 (TXA2) is a vasoconstrictor. They are
emia or inadequate perfusion resulting from an episode of released in differing amounts within different organ tis-
shock, trauma, or major surgery. There are stress and sues, contributing to a maldistribution of blood flow to
inflammatory responses (discussed in detail later in this organs and organ systems.
chapter) to this initial injury, but they may be mild and not As noted earlier, the release of catecholamines stimu-
readily detectable. However, during this response, neutro- lates hypermetabolism within the body cells, which, in
phils and macrophages (cells that attack and destroy bacte- turn, creates a greatly increased oxygen demand. Because
ria, protozoa, foreign cells, and cell debris) as well as mast of lung damage, hypoxemia and hypoperfusion, a severe
cells (cells that produce histamine and other components oxygen supply/demand imbalance, develop. As the cells
of allergic response) are thought to be “primed” by cyto- switch from aerobic to anaerobic metabolism, fuel supplies
kines (proteins released during an inflammatory or within the cells (ATP and glucose) are used up faster than
immune response). they can be replenished. Without adequate ATP, the cells
The next time there is an insult, such as an additional lose their ability to operate the sodium–potassium pump,
injury or ischemia or infection—even though the insult which is essential to cardiac function. The myocardium is
may be mild—the primed cells are activated, producing an profoundly weakened. Cellular lysosomes begin to break
exaggerated inflammatory response, known as secondary down, releasing lysosomal enzymes that damage the cell
MODS. membrane and the surrounding cells. Large amounts of
Now, the inflammatory response enters a self- lactic acid are released, contributing to acidosis, which fur-
perpetuating cycle. As inflammatory mediators are ther damages the cells. The overall response is similar to
released by the injured organ, they enter the circulation, that seen in septic and anaphylactic shock, except on a
activating inflammatory responses in organ systems larger scale.
throughout the body. These mediators, especially cyto-
kines such as tumor necrosis factor (TNF) and interleukin 1 Clinical Presentation of MODS
(IL-1), damage the endothelium (cells that line the blood The cumulative effects of MODS at the cellular and tissue
vessels, the heart, and body cavities). Gram-negative bacte- levels begin to cause the breakdown of organ systems: The
ria, if present, release endotoxins that also damage endo- organs that fail first are not necessarily the organs where
thelial cells. The injured endothelial cells release factors the initial insult occurred, and there is a lag time between
that aggravate the inflammation and cause vasodilation. the initial insult and the onset of organ failure. Dysfunction
The injured epithelium becomes permeable, allowing leak- may develop in the pulmonary, gastrointestinal, hepatic,
age of fluid into interstitial spaces, and loses much of its renal, cardiovascular, hematologic, and immune systems.
anticoagulation function, which allows formation of tiny There is decreased cardiac function and myocardial depres-
blood clots (thrombi) in the microvasculature. sion, caused by the factors discussed earlier, possibly abet-
The secondary insult also triggers an exaggerated neu- ted by release of myocardial depressant factor (MDF) and a
roendocrine response. Catecholamine release causes many decrease in beta-adrenergic receptors in the heart. The
of the manifestations of MODS, including tachycardia, smooth muscle of the vascular system fails with consequent
increased metabolic rates, and increased oxygen consump- release of capillary sphincters and increased vasodilation.
tion. Release of a variety of hormones contributes to the MODS does not occur in one intense crisis. It will usu-
hypermetabolism, and release of endorphins contributes to ally develop over a period of two, three, or more weeks.
vasodilation. Additionally, plasma protein systems are There is no specific therapy for MODS, and the only chance
activated: specifically, the complement system, the coagu- of rescuing the patient from its self-perpetuating spiral
lation system, and the kallikrein–kinin system. Plasma pro- toward death is early recognition and initiation of support-
teins are key mediators of the inflammatory response. ive measures. For this reason, it is important to understand
When activated, each of these systems triggers a cascade of how MODS usually presents in the first 24 hours after ini-
responses with the overall result of increased vasodilation, tial resuscitation.
314 Chapter 12
Although MODS will usually be detected in the hospi- homeostasis) and that medical intervention is needed only
tal rather than the out-of-hospital setting, there may be when, on occasion, these natural defense mechanisms are
occasions when a patient who has not been hospitalized or unequal to the task and become overwhelmed.
has returned home from the hospital is the subject of a call
to EMS, or when a patient being transported by EMS from
one facility to another is suffering from MODS.
Infectious Agents
The most common presentation of MODS over time is Bacteria
as follows: Bacteria are single-celled organisms that consist of internal
cytoplasm surrounded by a rigid cell wall. Bacteria are
24 hours after resuscitation
prokaryotic cells that, unlike the eukaryotic cells of the
• Low-grade fever human body, lack an organized nucleus and other intracel-
• Tachycardia (rapid heart rate) lular organelles. Bacteria can reproduce independently, but
• Dyspnea (breathing difficulty) they need a host to supply food and other support. Inside
the body, they achieve this by binding to host cells.
• Altered mental status
Bacteria can be cultured and identified readily in most
• General hypermetabolic, hyperdynamic state
hospital laboratories. Many bacteria are categorized accord-
Within 24 to 72 hours ing to their appearance under the microscope after staining
• Pulmonary (lung) failure begins with several dyes referred to as Gram stains. Some bacteria
stain blue, whereas others stain red. Bacteria that stain blue
Within 7 to 10 days are referred to as Gram-positive bacteria. They are somewhat
• Hepatic (liver) failure begins similar to one another in their structure. Bacteria that stain
• Intestinal failure begins red are referred to as Gram-negative bacteria. They are also
somewhat similar to one another in their structure.
• Renal (kidney) failure begins
Bacteria can cause many of the common infections in
Within 14 to 21 days medicine, including middle ear infections in children,
• Intensified renal and hepatic failure many cases of tonsillitis, and meningitis. (These kinds of
infections can also be caused by viruses, which are dis-
• Gastrointestinal collapse
cussed in the next section.) Most bacterial infections
• Immune system collapse
respond to treatment with drugs called antibiotics. Once
After 21 days administered, antibiotics kill or inhibit the growth of
• Hematologic (blood system) failure begins invading bacteria. As mentioned earlier, the bacterial cell
membrane is the site of action for many antibiotics. Once
• Myocardial (heart muscle) failure begins
the cell membrane is broken down, phagocytes (cells that
• Altered mental status resulting from encephalopathy ingest and destroy pathogens and other foreign and abnor-
(brain infection) mal substances) can begin to destroy the bacterium. A vari-
• Death ety of antibiotic drugs have been developed with
mechanisms of action tailored to different types of bacteria.
However, the broad variety of infectious bacteria, and their
PART 6: The Body’s Defenses ability to develop resistance to drugs, makes developing
antibiotics to battle them a difficult job.
Against Disease and Injury Some bacteria protect themselves by forming a capsule
outside the cell wall that protects the organism from diges-
enzymes and toxins that attack and injure cells and pro- microscope. In addition, they cannot grow without the
duce hypersensitivity reactions. assistance of another organism. In fact, viruses are referred
Simple infection is not the only consequence of a bac- to as intracellular parasites, since they must invade the cells
terial invasion. Many bacteria release poisonous chemicals, of the organism they infect.
or toxins. There are two types of toxins produced by bacte- A virus has no organized cellular structure except a
ria: exotoxins and endotoxins. Exotoxins are proteins protein coat (capsid) surrounding the internal genetic
secreted and released by the bacterial cell during its material, deoxyribonucleic acid (DNA) or ribonucleic acid
growth. They travel throughout the body via the blood or (RNA). With no organized cellular structure or cellular
lymph, ultimately causing problems. For example, botu- organelles, viruses are incapable of metabolism. Once
lism toxin, released by the bacterium Clostridium botulinum, inside a cell, they take over, using the cellular enzymes to
blocks the release of cholinergic neurotransmitters at neu- replicate and produce more viruses, which decreases syn-
romuscular junctions and elsewhere in the autonomic ner- thesis of macromolecules vital to the host cell.
vous system, causing systemic paralysis. Another example Some viruses develop a coating in addition to the cap-
is tetanus, which is caused by the bacterium Clostridium sid, called an envelope. The envelope and the protein capsid
tetani. The actual infection by the bacteria themselves is allow the virus to resist destruction by the phagocytes of
mild and may be limited, for example, to the site of a punc- the immune system. However, because viruses cannot
ture wound in the foot. However, on entering the body, the reproduce outside a host cell, if the virus does not find a
bacteria release their toxin, tetanospasmin. This toxin then host cell, it will die.
travels through the blood to the skeletal muscles, causing The symptoms of a virus may not be readily apparent
the spastic rigidity classically seen in tetanus. because it is hidden within the host cell. After replication is
Endotoxins are complex molecules that are contained complete, the virus will sometimes destroy the host cell. In
in the cell walls of certain Gram-negative bacteria. Endo- other cases, a virus will remain dormant within a cell for
toxins can be released during the destruction of the bacte- months or years. An example is the varicella zoster virus,
rial cell by phagocytes or even when the bacterial cell is which causes childhood chicken pox and may then remain
attacked by an antibiotic, so antibiotics cannot control the dormant, only to cause shingles in the adult decades later.
endotoxic effects of bacteria. When released, endotoxins Some viruses form a long-term symbiotic (living in close
trigger the inflammatory process and produce fever. In the association) relationship with the host cell, resulting in a
bloodstream, they can cause widespread clotting within persistent but unapparent infection.
the blood vessels, capillary damage, and hypotension, as Viruses do not produce toxins, but they can still cause
well as respiratory distress and fever—a condition known very serious illnesses. Some viruses are capable of altering
as endotoxin shock. Endotoxins can survive even when the the host cell to induce a malignancy (cancer). Others, such
cell that produced them is dead. as the human immunodeficiency virus (HIV), which causes
Depending on their amount and site of release, the AIDS, can proliferate, attacking cells of the immune system
effects of toxins can be local or systemic. When a bacterial and destroying its ability to ward off infections of all types.
organism enters the circulatory system, its released toxins Unlike bacteria, viruses are very difficult to treat. Once
can spread throughout the body. The systemic spread of a virus infects a cell, it can be killed only by destroying the
toxins through the bloodstream is known as septicemia, or infected cell. Drugs have not yet been developed that can
sepsis, and is a grave medical illness. selectively destroy cells infected by viruses while leaving
The body counters the bacterial invasion and release of uninfected cells unharmed. This partially explains the
enzymes and toxins through activation of the immune sys- dilemma facing researchers trying to find a cure for AIDS.
tem. The immune system will mobilize foreign-cell– An additional problem is that some viruses mutate
destroying macrophages (a type of white blood cell) to the (change) frequently, which is why a new flu vaccine must
site of infection in an attempt to rid the body of the foreign be developed for every flu season. Fortunately, most viral
pathogen. As the macrophages attempt to destroy the bac- illnesses are mild and fairly self-limiting. (Because viral
teria, they release substances known as pyrogens. Pyrogens agents must spread from cell to cell, the immune system is
are responsible for causing the increase in temperature eventually able to “catch” them outside a host cell and
known as fever. Pyrogens act on the thermoregulation cen- destroy them.) Even so, at present, viruses usually cannot
ter in the hypothalamus to cause the increased body tem- be treated with more than symptomatic care.
perature, which is thought to aid in the destruction of
pathogens. Other Agents of Infection
Other biological agents that cause human infection include
Viruses fungi (the plural of fungus) and parasites.
Most infections are caused by viruses. Viruses are much Fungi, which includes yeasts and molds, are more like
smaller than bacteria and can be seen only with an electron plants than animals. Fungi rarely cause human disease
316 Chapter 12
Inflammation and the immune response interact in person from an outside source. For example, a mother may
many ways. We will discuss the immune response first, transfer antibodies through the placenta to the fetus. Or
because understanding the immune response is neces- antibodies may be administered to a patient as an immune
sary for understanding some parts of the inflammatory serum to aid the body’s response to a dangerous invader
response. such as rabies, tetanus, or snake venom. Active acquired
immunity is long-lasting. Passive acquired immunity is
temporary.
IMMUNE
RESPONSE
Cell-
Humoral Based on activation of mediated
immunity specific lymphocytes immunity
by an antigen
(antigen recognition)
Regulatory Regulatory
activity activity
PLASMA CYTOTOXIC
CELLS T CELLS
the blood and other fluids of the body; humoral immunity side of the head, and the right side of the thorax. The larger
refers to the long-lasting antibodies and memory cells pres- is the thoracic duct, which is located in the left thorax and
ent in the blood and lymph.) (Figure 12-93) receives lymph from the rest of the body. These ducts drain
T lymphocytes do not produce antibodies. Instead, the lymph into the right and left subclavian veins, respec-
they recognize the presence of a foreign antigen and attack tively, and the lymph then travels through the bloodstream.
it directly. This type of immunity is called cell-mediated The cycle is completed as the lymph is returned from the
immunity (Figure 12-94). blood to the tissues to the lymphatic system. In this way,
lymph, and the lymphocytes it carries, are circulated
LYMPHOCYTES AND THE LYMPHATIC SYSTEM through the blood and lymphatic system again and again.
Lymphocytes—including B lymphocytes, T lymphocytes, The B lymphocytes and T lymphocytes carried by the
and secretory lymphocytes (discussed later)—are circu- blood and the lymphatic system are the key elements in
lated through the body as part of the lymphatic system. humoral and cell-mediated immunity, which will be dis-
Lymph (the fluid of the lymphatic system) consists primar- cussed in more detail in the next sections.
ily of interstitial fluid carrying proteins, bacteria, and other
substances. (As discussed earlier in the chapter, most inter-
stitial fluid reenters the bloodstream via the capillaries, but
Induction of the Immune Response
the small amount that does not reenter the capillaries is The immune response must be triggered, or induced. The
carried away by the lymphatic system.) following sections discuss the role of antigens and immu-
Lymph is carried through the lymphatic vessels, which nogens, histocompatibility, and blood groups in induction
are parallel to but separate from the blood vessels, and is of the immune response.
filtered through lymph nodes in various parts of the body.
Eventually, the lymph empties into one of two lymphatic Antigens and Immunogens
ducts in the thorax. The smaller of the two is the right lym- Antigens that can trigger the immune response are called
phatic duct, which drains lymph from the right arm, the right immunogens. Not every antigen is an immunogen. In
Pathophysiology 319
other words, not every antigen is capable of triggering the Receptor Helper T Cell
sites
immune response. As an example, antigens are present on
various helpful bacteria that reside within our bodies, but
the immune response is not triggered by these antigens.
What makes a molecule an antigen is a chemical struc-
ture that is capable of reacting with existing components of
the immune system, such as antibodies and T lympho-
cytes. However, having this chemical structure, the ability Foreign
to react once the immune system has been triggered, is not Antigen
• Sufficient foreignness
• Sufficient size
• Sufficient complexity
FIGURE 12-94 Cell-mediated
• Presence in sufficient amounts immune response.
320 Chapter 12
Histocompatibility Locus Antigens THE Rh SYSTEM The Rh blood group is named for the
The body recognizes whether a substance is self or non- rhesus monkey, in which it was first identified. One of sev-
self as a result of certain antigens that are present on eral antigens in this group is known as Rh antigen D, or the
almost all cells of the body, except the red blood cells. Rh factor. Rh factor is present in about 85 percent of North
These antigens are called HLA antigens (for histocompati- Americans (Rh positive), but absent in about 15 percent
bility locus antigens—or human leukocyte antigens, because (Rh negative).
these antigens were originally found on leukocytes). HLA Incompatibility between Rh positive and Rh negative
antigens are the antigens that the body recognizes as self blood can cause harmful immune responses. For example,
or foreign. The chief genetic source of HLA antigens has if a patient with Rh negative blood receives a transplant of
been identified as genes located at several sites (loci) on Rh positive blood, a primary immune response is trig-
chromosome 6 that are known as the major histocompat- gered. If there is a second transfusion of Rh positive blood,
ibility complex (MHC). a severe transfusion reaction may result.
HLA antigens determine the suitability, or compatibil- Hemolytic disease of the newborn may result from Rh
ity, of tissues and organs that will be grafted or trans- incompatibility between mother and fetus. Problems will
planted from a donor. The more closely related the donor usually not occur in a first pregnancy where the mother is
and recipient are, the more likely the recipient’s body is to Rh negative and the fetus is Rh positive, because few fetal
accept the graft or transplant. Why? Every person receives erythrocytes cross the placental barrier to the mother.
half his genetic inheritance from each parent. However, a significant number of fetal erythrocytes do
Like all genes, the genes that produce HLA antigens enter the mother’s bloodstream at birth when the placenta
occur as pairs (alleles) on corresponding loci on pairs of separates from the uterus. These may (depending on sev-
chromosomes. A group of alleles on one chromosome is eral factors) activate a primary immune response and
called a haplotype. Every person has two HLA haplotypes, development of Rh antibodies. If the fetus in her next preg-
one on each of the pair of chromosomes. Of each pair of nancy is also Rh positive, the mother’s Rh antibodies can
chromosomes (and the HLA haplotypes they carry), the cross the placenta and destroy the red blood cells of the
person inherits one from his father and one from his mother. fetus. This is actually a rare occurrence. Rh incompatibility
Because each parent has two haplotypes, but only one occurs in only about 10 percent of pregnancies, and because
gets passed along to each child (to pair up with one from not all such incompatibilities actually produce Rh antibod-
the other parent), various combinations of inherited haplo- ies in the mother, only about 5 percent of women ever have
types are possible among the children of those parents. In babies with hemolytic disease, even after numerous preg-
general, each child will share one haplotype with half his nancies.
siblings, both haplotypes with a quarter of his siblings, and
no haplotypes with a quarter of his siblings. THE ABO SYSTEM The ABO blood groups are formed
Siblings and other close relatives are generally consid- because there are two types of antigens that may be present
ered first as donors of tissues and organs because they on the surface of red blood cells. These antigens are named
have the highest likelihood of histocompatibility—hence A and B. Persons with blood type A carry only A antigens
the least likelihood of the immune system’s rejecting the on their red blood cells. Those with blood type B carry only
graft or transplant. (Identical twins, who come from the B antigens. Those with blood type AB carry both, and those
same egg fertilized by the same sperm, have identical with blood type O carry neither (Table 12-16).
genetic makeups and identical haplotypes. Therefore, they An immune response will be activated in a person
are the most reliable match for grafts and transplants.) with type A blood who receives a transfusion of type B
Other factors besides HLA makeup can affect the suc- blood, which is recognized as non-self. The same will hap-
cess of a graft or transplant, so they sometimes fail, even pen when a person with type B blood receives type A
when from a histocompatible donor. However, histocom- blood. People with type O blood are known as universal
patibility is the most important factor in graft and trans-
plant success.
Table 12-16 Blood Groups—ABO System
Blood Group Antigens Antigen Present Antibody Present
HLA antigens do not exist on the surface of erythrocytes Blood Type on Erythrocyte in Serum
(red blood cells), but other antigens, known as the blood
O None Anti-A, Anti-B
group antigens, do. There are more than 80 of these red
cell antigens that have been grouped into a number of dif- AB A and B None
ferent blood group systems. The two groups that trigger B B Anti-A
the strongest immune response are the Rh system and the
A A Anti-B
ABO system.
Pathophysiology 321
• Precipitation—The antigen–antibody
complex precipitates out of the blood
and is carried away by body fluids.
• Neutralization—The antibody, in
combining with the antigen, inacti-
vates the antigen by preventing it
Ig A Ig G from binding to receptors on the sur-
face of body cells.
• Enhancement of phagocytosis—Phago-
cytosis is one of the chief processes of
inflammation (described later in the
chapter) in which certain types of
white blood cells (neutrophils and
macrophages) ingest and digest for-
eign substances. The actions of anti-
bodies can encourage phagocytosis.
• Activation of plasma proteins—Anti-
Ig M bodies can activate plasma proteins
of the complement system (described
Figure 12-95 Some immunoglobulin (antibody) structures. later) that, in turn, attack and destroy
antigens.
agglutination or fostering phagocytosis. The effective- antibody molecules usually contain antigenic determinants
ness of antibodies against viruses depends on whether with which the antigen-binding sites on other antibodies
the virus circulates in the bloodstream (as with polio can combine.
and flu) or spreads by direct cell-to-cell contact (as The antigenic determinants on human antibody mole-
with measles and herpes). Antibodies against the latter cules are classified into three groups:
may help prevent the initial infection but cannot pre-
• Isotypic antigens are species-specific. That is, they are the
vent the spread or recurrence of an established infec-
same within a given species but differ from those within
tion. Vaccines are effective against some viral infections
other species. For example, isotypic antigens in human
such as influenza, rubella, and polio.
serum would function as antigens if injected into a rabbit.
• Opsonization of bacteria. Many bacteria have an
• Allotypic antigens can differ between members of the
outer capsule that is resistant to phagocytosis. Opso-
same species. The serum from a person with one form of
nization coats the bacteria with opsonin, a substance
allotype might function as an antigen in another person.
that makes them vulnerable to phagocytosis. Antibod-
ies themselves are opsonins, and they also cause opso- • Idiotypic antigenic determinants can differ within the
nization by a plasma protein that is a component of the same individual. For example, IgG subclass 3 molecules
complement system. produced against mumps and those produced against
tetanus in the same person will differ from each other.
• Activation of inflammatory processes. When the
antigen-binding sites at the “upper” tips of the
MONOCLONAL ANTIBODIES Most antigens have
Y-shaped immunoglobulin molecule bind to an anti-
multiple antigenic determinants, which stimulate a response
gen, the “lower” tip activates elements of the inflam-
from multiple clones of B lymphocytes. This is known as a
matory response, transmitting the information that a
polyclonal response. Each B cell clone secretes antibody that
foreign invader has entered the body. The inflamma-
is slightly different from that of the other clones. Recently,
tory response (which will be described later) enhances
researchers have been working with monoclonal antibod-
the attack by the immune system against the invader.
ies. A monoclonal antibody, produced in the laboratory,
is very pure and specific to a single antigen. Monoclonal
CLASSES OF IMMUNOGLOBULINS As noted earlier, antibodies are being put to a variety of cutting-edge and
there are five classes of immunoglobulins: experimental uses, including identification of infectious
IgM—the antibody that is produced first during the primary organisms, blood and tissue typing, and treatment of auto-
immune response. It is the largest immunoglobulin. immune diseases and some cancers.
IgG—the antibody that has “memory” and recognizes
repeated invasions of an antigen. IgG comprises 80 to The Secretory Immune System
85 percent of immunoglobulins in the blood. It is the The secretory immune system (also known as the external
major class of immunoglobulin in the immune or mucosal immune system) consists of lymphoid tissues
response and has four subclasses. IgG is responsible beneath the mucosal endothelium. These tissues secrete
for antibody functions such as agglutination, precipi- substances such as sweat, tears, saliva, mucus, and breast
tation, and complement activation. milk. Some antibodies are present in these secretions
(mostly IgA, with some IgM and IgG) and can help defend
IgA—the antibody present in mucous membranes. One
the body (or the nursing baby) against antigens that have
subclass of IgA is the predominant immunoglobulin in
not yet penetrated the skin or the mucous membranes.
body secretions. The other subclass of IgA is present
The secretory immune system’s primary function is to
mostly in the blood.
protect the body from pathogens that are inhaled or ingested.
IgE—the least-concentrated immunoglobulin in the circu- Other mechanisms must be functioning adequately to com-
lation. It is the principal antibody that contributes to plete that task. For example, gastric acid helps destroy
allergic and anaphylactic reactions and to the preven- pathogens, and mechanisms such as blinking, sneezing,
tion of parasitic infections. coughing, and peristalsis (the wavelike muscle contractions
IgD—an antibody that is present in very low concentra- that move substances through the passageways of the diges-
tions; little is known about its role. It is present princi- tive system) help move pathogens out of the system.
pally on the surfaces of developing B cells. The lymphocytes of the secretory immune system fol-
low a different developmental path after leaving the bone
ANTIBODIES AS ANTIGENS A molecule that func- marrow than do the lymphocytes of the systemic immune
tions as an antibody in the human body can function as an system. As they mature, systemic lymphocytes migrate
antigen if it enters the body of another person or a mem- through the spleen and lymph nodes, whereas lympho-
ber of another species. To function in the role of antigens, cytes of the secretory system travel through the lacrimal
324 Chapter 12
(tear-producing) and salivary glands and through muco- Five Types of Mature T Cells
sal-associated lymphoid tissues in the bronchi, breasts, • Memory cells induce secondary immune responses.
intestines, and genitourinary tract.
• Td cells transfer delayed hypersensitivity (allergic
Secretory lymphocytes circulate through the lym-
responses) and secrete proteins called lymphokines that
phatic system and bloodstream in a pattern that is different
activate other cells, such as macrophages.
from the circulatory pattern of the systemic lymphocytes.
• Tc cells are cytotoxic cells that directly attack and
Secretory lymphocytes are returned from the blood
destroy cells that bear foreign antigens.
through the tissues to the mucosal-associated lymphoid
tissues, rather than to the lymphoid tissues of the systemic • Th cells are helper cells that facilitate both cell-mediated
immune system. and humoral immune processes.
The secretory immune system is the body’s first line of • Ts cells are suppressor cells that inhibit both cell-mediated
defense against pathogens, whereas the systemic immune and humoral immune processes.
system is the body’s last line of defense.
As a result of this specialization, T cells are capable of
attacking an antigen in a variety of ways. The major effects
Cell-Mediated Immune Response of cell-mediated immune response result from the special-
ized functions of the four types of T cells: memory, delayed
Some lymphocytes develop into B cells, which are respon-
hypersensitivity, cytotoxicity, and control.
sible for humoral immunity, which we have discussed in the
prior sections. Other lymphocytes develop into T cells, MEMORY Memory cells “remember” an antigen and
which are responsible for cell-mediated immunity, the sub- trigger the immune response to any repeated exposure to
ject of this section (review Figure 12-94). that antigen.
A key difference between the two is that B cells do not
DELAYED HYPERSENSITIVITY Td cells (delayed hyper-
attack pathogens directly. Instead, they produce antibodies
sensitivity cells) are involved in allergic reactions and the
that combine with antigens on the surfaces of pathogenic
inflammatory response. They produce substances (lympho-
cells. The antibodies remain in the bloodstream for a long
kines) that communicate with and influence the behavior of
time and will attack the antigen again on any subsequent
other cells.
exposure. Thus, the humoral immunity created by B cells is
long-lasting. T cells, however, do not produce antibodies. CYTOTOXICITY Tc cells (cytotoxic cells) mediate the
Rather, they attack pathogens directly, and the immunity direct killing of target cells, such as cells that have been
they create, called cell-mediated immunity, is temporary. infected by a virus, tumor cells, or cells in transplanted
Another key distinction is that one kind of T cell organs (Figure 12-97).
(helper T cells) is responsible for activating both T cells (in CONTROL Th (helper) cells and Ts (suppressor) cells
cell-mediated immune response) and B cells (in humoral effect control of both humoral and cell-mediated immune
immune response). (To compare humoral and cell-medi- responses. Th cells facilitate the response; Ts cells inhibit
ated responses, review Figures 12-92 through 12-94. the response.
Contact with
antigen bound
to Class I HLA
Inactive Activated Cytotoxic
T cell T cell T cells
Destruction of
foreign or
Secretion of infected cells
lymphotoxin
Memory
T cells
The three key interactions that occur during an partially destroy an invading organism. As it does so, the
immune response (review Figures 12-93 and 12-94) are: invader’s antigens are released into the cytosol (fluid inte-
rior) of the macrophage cell. The ingestion of an invading
1. Antigen-presenting cells (macrophages) interact with
organism and breakdown of its antigens is the beginning
Th (helper) cells.
of antigen processing.
2. Th (helper) cells interact with B cells. Once the macrophage has broken down the antigens, it
3. Th (helper) cells interact with Tc (cytotoxic) cells. then expresses these antigen fragments and “presents” them
on its own surface, along with its own self-antigens. When
Cytokines these two markers on the surface of the macrophage—the
Cytokines, proteins produced by white blood cells, are the foreign antigens and the self-antigens—are recognized by
“messengers” of the immune response. When released by helper T cells, the helper T cells are activated.
one cell, they can bind with nearby cells, affecting their Because macrophages (and other macrophagelike
function. They can also bind with the same cell that pro- cells) present portions of antigen on their surfaces, they are
duced them and alter the function of that cell. They help to called antigen-presenting cells (APCs).
regulate cell functions during both inflammatory and The helper T cells recognize the presented antigen
immune responses. For example, a cytokine must be through receptors on their surfaces. There are two types of
released by a macrophage to facilitate activation of a helper receptors. One type, called a T cell receptor (TCR), is anti-
T cell. gen-specific; that is, it will respond to only one specific
A cytokine that is released by a macrophage is called a antigen. The other type, CD4 or CD8 receptors, will
monokine (“mono” because a macrophage is a kind of respond no matter what antigen is presented.
monocyte, a single-nucleus white blood cell). A cytokine As discussed earlier, the body recognizes whether an
that is released by a lymphocyte (a T cell or B cell) is called antigen is self or non-self as a result of HLA antigens. For
a lymphokine. Types of cytokines include proteins known presentation of an antigen to be effective, the antigen must
as interleukins, interferon, and tumor necrosis factor. be in a complex with either class I or class II HLA antigens.
Antigen Processing, The HLA class determines which cells will respond. Th
(helper) cells respond only to class II HLA antigens. Tc
Presentation, and Recognition (cytotoxic) cells and Ts (suppressor) cells respond only to
A sequence of three processes is necessary before an
class I HLA antigens.
immune response can begin:
In addition to the antigen–receptor interaction, another
1. Antigen processing (by macrophages) requirement for intercellular communication between the
2. Antigen presentation (by macrophages) macrophage cell and the T cell is an interaction between
self-adhesion molecules on the surface of the macrophage and
3. Antigen recognition (by T cells or B cells)
the T cell. These molecules, in connecting, strengthen the
More will be said later in the chapter about how mac- interactions between the cells.
rophages are released during the inflammatory response. The macrophage also produces the cytokine interleukin-1
For now, keep in mind that a macrophage is a large cell (a (IL-1), which helps the T cell respond to the presented
type of white blood cell) that will ingest and destroy or antigens.
326 Chapter 12
T Cell and B Cell Differentiation infants experience recurrent respiratory tract infections).
T cells and B cells are not differentiated until antigens pres- Then, as the immune system matures, the levels of immu-
ent in the system react with the appropriate receptors on noglobulin begin to rise.
the cell surfaces. As previously described, this reaction
occurs as a result of antigen processing and presentation Aging and the Immune Response
by macrophages and antigen recognition by the T or B cell.
As the human body ages, immune function begins to dete-
The presence of secreted cytokines is also usually neces-
riorate. B cell antibody production is affected, but the pri-
sary to facilitate the antigen–receptor reaction.
mary assault is on T cell function. The thymus, which is the
Once a reaction between antigen and T cell receptor
organ responsible for T cell development, reaches its maxi-
takes place, the immature T cells proliferate and differenti-
mum size at sexual maturity and then decreases in size
ate, depending on the specific receptors and antigens
until, in middle age, it has shrunk by 65 percent. Circulat-
involved, into Th, Tc, Td, Ts, and memory cells.
ing T cells do not decrease, but T cell function may dimin-
After stimulation by Th cells or direct recognition of
ish. Men and women over age 60 generally have decreased
antigen, B cells will proliferate and produce antibodies dif-
hypersensitivity (allergic) responses and decreased T cell
ferentiated as IgM, IgG, IgA, IgE, and IgD immunoglobulins.
response to infections.
For a summary of the immune response, see Figure 12-98.
Control of T Cell and B Cell Development
Several parameters control immune responses, activating
them when needed but stopping or inhibiting them when
not needed, thus preventing them from destroying the Inflammation
body’s own tissues. As noted earlier, Ts (suppressor) cells
Inflammation Contrasted
help suppress immune responses; so do some macro-
phages and other monocytes. to the Immune Response
The exact function of suppressor cells is still not fully Inflammation, also called the inflammatory response, is the
understood. Some suppressor cells seem to affect antigen body’s response to cellular injury. It differs from the
recognition, whereas others seem to suppress the prolifer- immune response in many ways. As you read the follow-
ation that follows antigen recognition. Tolerance of self- ing sections, keep in mind that:
antigens seems to be another function of suppressor cells.
• The immune response develops slowly; inflammation
develops swiftly.
Fetal and Neonatal Immune Function • The immune response is specific (targets specific anti-
The human infant develops some immune response capa- gens); inflammation is nonspecific (it attacks all
bilities, even in utero, but the immune response system is unwanted substances in the same way). In fact, inflam-
normally not fully mature when the infant is born. For mation is sometimes called “the nonspecific immune
example, in the last trimester, the fetus can produce a pri- response.”
mary immune response involving mostly IgM antibody to • The immune response is long-lasting (memory cells
some infections. The ability to produce IgG and IgA anti- will remember an antigen and trigger a swift response
bodies is underdeveloped. on reexposure, even years later); inflammation is tem-
To protect the child in utero and during the first few porary, lasting only until the immediate threat is con-
months after birth, maternal antibodies cross the placenta quered—usually only a few days to two weeks.
into the fetal circulation. In the placenta, specialized cells • The immune response involves one type of white blood
called trophoblasts separate maternal from fetal blood. The cell (lymphocytes); inflammation involves platelets and
trophoblastic cells actively transport the large immuno- many types of white blood cells (the granulatory cells
globulin cells from maternal to fetal circulation. This called neutrophils, basophils, and eosinophils; and the
transport is so effective that the level of antibodies in the monocytes that mature into macrophages).
umbilical cord is sometimes higher than in the mother’s
• The immune response involves one type of plasma pro-
blood.
tein (immunoglobulins, also called antibodies); inflam-
After birth, when antibodies can no longer be trans-
mation involves several plasma protein systems
ported from the mother’s blood, the levels of antibodies
(complement, coagulation, and kinin).
in the newborn’s blood begin to drop as the immuno-
globulins present at birth are catabolized, while the However, the immune response and inflammation are
infant’s ability to produce immunoglobulins on its own interdependent. For example, macrophages that are devel-
is still not fully developed. The levels are generally at oped during the inflammatory response must ingest anti-
their lowest at about 5 or 6 months of age (when many gens before helper T cells can recognize them and trigger
Pathophysiology 327
Nonspecific
Circulating defenses Cytotoxic
antibodies T cells
Complement NK cells
system Macrophages
Specific
defenses
(immune Stimulation,
response) enhancement,
and localization
via lymphokines
Antigen Antigen
sensitizes activates
Helper
Activation T cells Activation
of B cells of T cells
Production
Production
of memory
of memory
T cells and
B cells and
cytotoxic
plasma cells
T cells
Maturation
Maturation
of plasma
and migration
cells and
of cytotoxic
production
T cells
of antibodies
Humoral Cell-mediated
immunity immunity
the immune response. Conversely, IgE antibody produced finger, you will probably
CONTENT REVIEW
by B cells during an immune response can stimulate mast be acutely aware of the
➤➤ Phases of Inflammation
cells to activate inflammation. inflammatory process. You
• Phase 1: Acute
Although inflammation differs from the immune will actually see the red-
inflammation (if healing
response in many ways, inflammation and the immune ness and swelling and feel
not accomplished,
response are both considered to be part of the body’s the pain. You may observe move to Phase 2)
immune system. the formation of pus. As • Phase 2: Chronic
days go by, you will see inflammation (if healing
How Inflammation Works: An the progress of wound not accomplished,
healing and, perhaps, scar move to Phase 3)
Overview formation. • Phase 3: Granuloma
Inflammation is somewhat easier to understand than the This is not to say that formation
immune response, because we have all observed it. The inflammation is simple; in • Phase 4: Healing (may
immune response is often hidden; your body’s immune its way, it is as complex as take place after any of
the first three phases)
system may be knocking out an infectious antigen with- the immune response.
out your ever being aware of it. However, if you cut your There are several phases to
328 Chapter 12
Vascular
permeability
(edema)
Thrombosis
(clots)
Release of Stimulation of
cellular nerve endings
components (pain)
Nucleus
LEUKOTRIENES Leukotrienes are also known as slow- activated, the complement system takes part in almost all
reacting substances of anaphylaxis (SRS-A). They have actions the events of the inflammatory response. The last few com-
similar to those of histamines—vasoconstriction, vasodila- plements in the cascade have the ability to directly kill
tion, and increased permeability—as well as chemotaxis. microorganisms.
However, they are more important in the later stages of There are two chief pathways by which the comple-
inflammation, because they promote slower and longer- ment cascade is activated and proceeds: the classic path-
lasting effects than histamines. way and the alternative pathway (Figure 12-102).
means of stimulating the inflammatory response, the capillaries into the tis-
CONTENT REVIEW
including those of the plasma protein systems. sues to attack unwanted
➤➤ Inflammation Sequence
• Conversely, the inflammatory processes are powerful substances and promote
• Vascular response
and potentially very damaging to the body. Therefore, healing. This occurs in the
• Increased permeability
they must be controlled and confined to the site of sequence outlined below.
• Exudation of white cells
injury or infection. Obviously, there are a variety of Sequence of Events in
mechanisms that regulate or inactivate inflammatory Inflammation
responses.
1. Vascular Response. The first response of inflamma-
The inflammatory response is controlled at a number tion is vascular. First, arterioles near the site constrict,
of levels and by a variety of mechanisms. For example, followed by vasodilation of the postcapillary venules.
many components of inflammation are destroyed within The result is an increase in blood flow to the injury site.
seconds by enzymes from the blood plasma. Antagonists One result is increased pressure within the microcir-
(substances or actions that counteract other substances or culation (arterioles, capillaries, and venules), which
actions) exist for histamine, kinins, complement compo- helps to exude plasma and blood cells into the tissues.
nents, and other components of the inflammatory response. When plasma and blood cells move out of the
An example of antagonistic control of inflammation is microcirculation, pressure is decreased, and blood
the function of histamine receptors. Histamine works by moves more sluggishly, thickening and becoming sticky.
attaching itself to two types of receptors on the surface of White cells migrate to the vessel walls and adhere to
target cells, H1 and H2 receptors. H1 receptors, when con- them—a phenomenon known as margination that is
tacted by histamine, promote inflammation. H2 receptors important in the next two events.
are antagonistic to H1 receptors; when contacted by hista-
2. Increased permeability. At the same time, chemical
mine, H2 receptors inhibit inflammation, mainly by sup-
substances cause the endothelial cells of the vessel
pressing leukocyte function and mast cell degranulation.
walls to constrict, creating openings between the cells
In this way, the inflammatory action of histamine is trig-
in the vessel walls.
gered when needed, yet kept within bounds.
Most of the inflammatory processes interact; a sub- 3. Exudation of white cells. The white cells adhering to
stance or action that activates one element tends to activate the vessel walls now squeeze out through the open-
others as well. For example, plasmin, an important factor ings and into the tissues. Ordinarily, white cells are
in clot formation in the coagulation cascade, also has a role too large to move through vessel walls. The inflamma-
in activating the complement and kinin cascades. Con- tion-caused constriction of vessel-wall cells that cre-
versely, controls on inflammatory processes also tend to ates openings between them and allows white cells to
interact. For example, a substance known as C1 esterase squeeze through is known as diapedesis.
inhibitor inhibits plasmin activation that, in turn, tends to Earlier, we discussed lymphocytes, which are the cat-
inhibit the coagulation, complement, and kinin cascades. egory of white cells involved in the immune response. The
An example of what happens when interacting con- inflammatory response involves two other categories of
trols fail is the genetic deficiency of C1 esterase inhibitor. white cells: granulocytes and monocytes (Table 12-18).
Its absence seems to permit uncontrolled activation of plas- Granulocytes (like mast cells, discussed earlier) have the
min and triggering of the three plasma protein cascades appearance of a bag of granules, hence their name. They
when the patient undergoes emotional distress. This results are also called polymorphonuclear cells because they have
in out-of-control effects typical of inflammation, including
extreme edema of the gastrointestinal and respiratory
tracts and the skin. The patient may die as a result of laryn- Table 12-18 Types of White Blood Cells (Leukocytes)
geal swelling.
In other words, inflammatory processes have to be both Lymphocytes (25–30 percent of all white blood cells)*
T cells
reliably started and reliably stopped. Normally, this is ensured B cells
by the interacting processes of activation and control.
Granulocytes**
Neutrophils (55–70 percent of all white blood cells)
Cellular Components Basophils
Eosinophils
of Inflammation Monocytes**
An important term to remember in connection with inflam- Monocytes (immature) become macrophages (mature)**
mation is exudate, a collective term for all the helpful sub- *Involved in the immune response.
stances, including white cells and plasma, that move out of **Involved in inflammation.
Pathophysiology 333
multiple nuclei. There are three types of granulocytes: neu- matory responses. Cytokines produced by lymphocytes
trophils, eosinophils, and basophils. Monocytes, so named are called lymphokines. Cytokines produced by macro-
because they have a single nucleus, change and mature phages and monocytes are called monokines.
when they become involved in inflammation. Monocytes Actually, cytokines are produced by a wide variety of
are the largest normal blood cell. During inflammation, cells, including some that are not part of the immune sys-
they grow to several times their original size, becoming tem. They play a wide variety of roles. Cytokines can inter-
macrophages. act in a synergistic manner (so their combined effect is
All the granulocytes and monocytes are phagocytes, greater than the sum of their individual contributions) or
blood cells that have the ability to ingest other cells and they can interact in an antagonistic manner (so they inhibit
substances such as bacteria and cell debris. (The word or cancel out each other’s actions). Examples of the variety
comes from the Greek phagein, meaning “to eat,” and cyte, of sources and activities of cytokines can be found among
for “cell”—so a phagocyte is a cell that eats.) A phagocyte the interleukins, lymphokines, and interferon.
behaves something like Pac-Man® in the video game, Interleukins (ILs) are an important group of cytokines.
destroying its “enemies” by swallowing them up. The They are produced by both lymphocytes and macrophages.
most important phagocytes involved in inflammation are Interleukin-1 is a lymphocyte-stimulating factor. As noted
the neutrophils and the macrophages. earlier, during the immune response macrophages that
Neutrophils are the first phagocytes to reach the ingest antigens release IL-1, which assists helper T cells to
inflamed site. They ingest bacteria, dead cells, and cell respond to the antigens. It also enhances production of IL-2
debris, and then they die. Neutrophils can begin phagocyto- by the helper T cells, which encourages antibody produc-
sis quickly because they are already mature cells. Macro- tion. As part of the inflammatory process, IL-1 produced
phages come along later, because they first have to go through by macrophages induces neutrophilia, the proliferation of
the process of maturing from their parent monocytes. neutrophils.
Eosinophils, basophils, and platelets also migrate to Lymphokines are produced by T cells as a result of anti-
the site to join the inflammatory response. These cells func- gen stimulation during the immune response. In turn, these
tion with assistance from plasma proteins of the comple- lymphokines stimulate monocytes to develop into macro-
ment, coagulation, and kinin systems, acting to kill phages, a critical phase of the inflammatory response. Dif-
microorganisms, remove the dead cells and debris, and ferent kinds of lymphokines have different effects. One
prepare the site for healing. type, called migration-inhibitory factor (MIF), inhibits macro-
Eosinophils are the primary defense against parasites. phages from migrating away from the site of inflammation.
They contain large numbers of lysosomes. The eosinophils Another type, called macrophage-activating factor (MAF),
attach themselves to parasites and degranulate, depositing enhances the phagocytic activities of macrophages.
the caustic lysosomes, and killing the parasites by damag- Interferon is a cytokine that is critical in the body’s
ing their surfaces. Eosinophils also release chemicals that defense against viral infection. It is a small, low-molecular-
control the vascular effects of serotonin and histamine. weight protein produced and released by cells that have
Additionally, eosinophils help to control the inflammatory been invaded by viruses. It doesn’t kill viruses, nor does it
response, preventing it from spreading beyond the area have any effect on a cell that is already infected by a virus.
where it is needed by degrading vasoactive amines, However, interferon prevents viruses from migrating to
thereby limiting their effects. and infecting healthy cells.
Basophils are thought to function in the same way
within the blood as mast cells do outside the blood, releas- Systemic Responses
ing histamines and other chemicals that control constric-
tion and dilation of vessels.
of Acute Inflammation
Platelets, another cellular component of the inflamma- The three chief manifestations of acute inflammation are
tory response, are fragments of cytoplasm that circulate in fever, leukocytosis (proliferation of circulating white cells),
the blood. When cellular injury occurs, platelets act with and an increase in circulating plasma proteins.
components of the coagulation cascade to promote blood Endogenous pyrogen is a fever-causing chemical that is
clotting. Platelets also release serotonin, a substance with identical to IL-1 and is released by neutrophils and macro-
effects similar to those of histamine. phages. It is released after the cell engages in phagocytosis
or is exposed to a bacterial endotoxin or to an antigen-
antibody complex. Fever can have both beneficial and
Cellular Products harmful effects. On one hand, an increase in temperature
As mentioned earlier, cytokines are proteins produced by can create an environment that is inhospitable to some
white blood cells that act as “messengers” between cells. invading microorganisms. On the other hand, fever may
They are important in mediating both immune and inflam- increase susceptibility of the infected person to the effects
334 Chapter 12
of endotoxins associated with some Gram-negative bacte- leprosy and tuberculosis, which are caused by mycobacte-
rial infections. ria, bacteria that resist destruction by phagocytes.
In some infections, the number of circulating leuko- Tissue repair and possible scar formation are the final
cytes, especially neutrophils, increases. Several compo- stages of inflammation and will be discussed in more detail
nents of the inflammatory response stimulate production later.
of neutrophils, including a component of the complement
system. Phagocytes produce a factor that induces produc-
tion of granulocytes, including neutrophils, eosinophils,
Local Inflammatory Responses
and basophils. All the manifestations observed at the local inflammation
Plasma proteins called acute phase reactants, produced site result from (1) vascular changes and (2) exudation.
mostly in the liver, increase during inflammation. Their Redness and heat result from vascular dilation and
synthesis is stimulated by interleukins. Many of these act increased blood flow to the area. Swelling and pain result
to inhibit and control the inflammatory response. from the vascular permeability that permits infiltration of
exudate into the tissues.
Exudate has three functions:
Chronic Inflammatory Responses • To dilute toxins released by bacteria and the toxic
Defined simply, chronic inflammation is any inflammation products of dying cells
that lasts longer than two weeks. It may be caused by a
• To bring plasma proteins and leukocytes to the site to
foreign object or substance that persists in the wound—for
attack the invaders
example, a splinter, glass, or dirt—or it may accompany a
persistent bacterial infection. This can occur because some • To carry away the products of inflammation (e.g., tox-
microorganisms have cell walls with a high lipid or wax ins, dead cells, pus)
content that resist phagocytosis. Other microorganisms can The composition of exudate varies with the stage of
survive inside a macrophage. Still others produce toxins inflammation and the type of injury or infection. Early exu-
that persist even after the bacterium is dead, continuing to date (serous exudate) is watery with few plasma proteins or
incite inflammatory responses. Inflammation can also be leukocytes, as in a blister. In a severe or advanced inflam-
prolonged by the presence of chemicals and other irritants. mation, the exudate may be thick and clotted (fibrinous
During chronic inflammation, large numbers of neu- exudate), as in lobar pneumonia. In persistent bacterial
trophils—the phagocytes that were first on the scene dur- infections, the exudate contains pus (purulent, or suppura-
ing acute inflammation—degranulate and die. Now, the tive, exudate), as with cysts and abscesses. If bleeding is
neutrophils are replaced by components that have taken present, the exudate contains blood (hemorrhagic exudate).
longer to develop, and there is a large infiltration of lym- The lesions (infected areas or wounds) that result from
phocytes from the immune response and of macrophages inflammation vary, depending on the organ affected. In
that have matured from monocytes. In addition to attack- myocardial infarction, cellular death results in the replace-
ing foreign invaders, macrophages produce a factor that ment of dead tissue by scar tissue. An infarction of brain
stimulates fibroblasts, cells that secrete collagen, a critical tissue may result in liquefactive necrosis, in which the
factor in wound healing. dead cells liquefy and are contained in walled cysts. In the
As neutrophils, lymphocytes, and macrophages die, liver, destroyed cells result in the regeneration of liver cells.
they infiltrate the tissues, sometimes forming a cavity that Keep in mind that inflammation can only occur in vas-
contains these dead cells, bits of dead tissue, and tissue cularized tissues (tissues to which blood can flow). When
fluid, a mixture called pus. Enzymes present in pus even- perfusion is cut off, as in a gangrenous limb or a limb distal
tually cause it to self-digest, and it is removed through the to a tourniquet, inflammation cannot take place—and
epithelium or the lymphatic system. without inflammation, healing cannot take place.
Occasionally, when macrophages are unable to destroy
the foreign invader, a granuloma will form to wall off the
infection from the rest of the body. The granuloma is Resolution and Repair
formed as large numbers of macrophages, other white Healing begins during acute inflammation and may con-
cells, and fibroblasts are drawn to the site and surround it. tinue for as long as two years. The best outcome is resolu-
Cells decay within the granuloma, and the released acids tion, the complete restoration of normal structure and
and lysosomes break the cellular debris down to basic function. This can happen if the damage was minor, there
components and fluid. The fluid eventually diffuses out of are no complications, and the tissues are capable of regen-
the granuloma, leaving a hollow, hard-walled structure eration through the proliferation of the remaining cells. If
buried in the tissues. Some granulomas persist for the life resolution is not possible, then repair takes place, with
of the individual. Granuloma formation is common in scarring being the end result. This happens if the wound is
Pathophysiology 335
large, an abscess or granu- and an unidentified factor that stimulates epithelial factors
CONTENT REVIEW
loma has formed, or fibrin to grow over the wound.
➤➤ Outcomes of Healing
remains in the damaged
• Resolution (complete EPITHELIALIZATION While granulation is taking
tissues.
restoration of normal place and the original clot, or scab, is being dissolved, epi-
Both resolution and
structure) thelialization takes place. Epithelial cells move in under
• Repair (scar formation) repair begin in the same
the scab, separating it from the wound surface, and provid-
way, with debridement
ing a protective covering for the healing wound.
(“cleaning up”) of the site of inflammation. Debridement
involves the phagocytosis of dead cells and debris and the CONTRACTION Six to twelve days after the injury, con-
dissolution of fibrin cells (scabs). After debridement, there traction begins as the wound edges begin to move inward.
is a draining away of exudate, toxins, and particles from Contraction is caused by myofibroblasts in the granulation
the site, and vascular dilation and permeability are tissues. These are similar to the collagen-secreting fibro-
reversed. At this point, either regeneration and resolution blasts, but myofibroblasts contain parallel fiber bundles
or repair and scar formation will take place. in their cytoplasm similar to those in smooth muscle cells.
Minor wounds with little tissue loss, like paper cuts, They exert a contractile force as they connect to neighbor-
close and heal easily. They are said to heal by primary ing cells, slowly bringing the wound edges together.
intention. More extensive wounds require more complex
processes of sealing the wound, filling the wound, and Maturation
contracting the wound and are said to heal by secondary At the end of the reconstructive phase, collagen deposi-
intention. tion, tissue regeneration, and wound contraction are sel-
Both resolution and repair proceed in two overlapping dom completed. These processes may continue into the
phases: reconstruction and maturation. Reconstruction maturation phase, possibly for years. During maturation,
begins three or four days after injury or infection and takes scar tissue is remodeled; blood vessels disappear, leaving
about two weeks. Maturation begins several days after an avascular scar; and the scar tissue becomes stronger.
injury or infection and can take up to two years. Only epithelial, hepatic (liver), and bone marrow
cells are capable of the total regeneration by mitosis
Reconstruction known as hyperplasia (discussed earlier in the chapter).
Reconstruction of a wound proceeds through four steps: In most wounds, healing produces new tissues that are
initial wound response, granulation, epithelialization, and not structured exactly like the original tissues. Typically,
contraction. repaired tissues regain about 80 percent of their original
INITIAL RESPONSE The first step of healing is the seal- strength.
ing off of the wound by a clot (scab) that contains a mesh
of fibrin and trapped red and white blood cells. The fibrin Dysfunctional Wound Healing
mesh is formed as a result of activation of the coagulation Dysfunctional healing can result in an insufficient repair,
cascade. The fibrin traps platelets, which enhance the seal. an excessive repair, or a new infection. Causes of dysfunc-
The fibrin seal creates a barrier to bacterial invasion and a tional healing vary; they include disease states such as dia-
framework for collagen to fill the wound. betes, hypoxemia, nutritional deficiencies, and the use of
Eventually the fibrin clot is dissolved by enzymes and certain drugs. Dysfunctional healing can occur during the
cleared away through debridement by macrophages and inflammatory response or during reconstruction.
any remaining neutrophils. The clot will then be replaced
DYSFUNCTIONAL HEALING DURING INFLAMMA-
by normal tissue (in the case of resolution) or by scar tissue
TION During inflammation, several factors can disrupt
(in the case of repair).
healing. If bleeding hasn’t stopped, healing can be delayed
GRANULATION Repair begins with granulation. Gran- by clotting that takes up space and inhibits granulation
ulation tissues grow inward from the healthy connective and by blood-cell debridement from the site. Blood is also a
tissues surrounding the wound. The granulation tissues hospitable medium for infection, which in turn exacerbates
are filled with capillaries. Some capillaries differentiate inflammation and delays healing.
into venules and arterioles. Similarly, new lymph channels If there is excess fibrin in the wound, this, too, must be
develop in the granulation tissues. cleared away so as not to delay healing. Sometimes excess
The granulation tissues are surrounded by macro- fibrin causes adhesions, fibrous bands that bind organs
phages. The macrophages secrete fibroblast-activating fac- together and pose a significant problem if they occur in the
tor, which stimulates fibroblasts to enter the tissues and abdominal, pleural, or pericardial cavities.
secrete collagen. The macrophages also secrete angiogene- Other problems that can arise during inflammation
sis factor, which causes formation of the capillary buds, include hypovolemia, which inhibits inflammation
336 Chapter 12
(remember that perfusion is necessary to inflammation), in the wound bed, inhibiting inflammation and healing.
and anti-inflammatory steroid drugs that inhibit macro- Unfortunately, the elderly are also more prone to wound-
phage and fibroblast migration. ing as the protective fat layer diminishes and skin loses its
elasticity and becomes more vulnerable to tearing. Dimin-
DYSFUNCTIONAL HEALING DURING RECONSTRUC- ished sensitivity, mobility, and balance also lead to falls
TION A number of factors can disrupt the phases of and wounds.
reconstruction. For example, various nutritional deficien-
cies can inhibit collagen synthesis. Collagen synthesis can
also become excessive, causing the formation of raised
scars. Steroid drugs can suppress epithelialization.
Variances in Immunity
Wounds can also be disrupted by pulling apart. Surgi-
cal wounds are sometimes disrupted as a result of strain or
and Inflammation
Sometimes the immune and inflammatory systems work
obesity. In some cases—frequently with burns—wound
“too well” and sometimes not well enough. Hypersensi-
contraction is excessive, resulting in a deformity called con-
tivity reactions are an example of the former, and immune
tracture. Internal contractures may occur in cirrhosis of the
deficiency diseases are an example of the latter.
liver, duodenal strictures caused by improper healing of an
ulcer, or esophageal strictures from lye burns.
Positioning, exercises, surgery, and administration of Hypersensitivity: Allergy,
drugs can sometimes help to prevent or correct the results Autoimmunity, and Isoimmunity
of dysfunctional wound healing.
Immune responses are normally protective and helpful.
Hypersensitivity, however, is an exaggerated and harm-
Age and the Mechanisms ful immune response. The word hypersensitivity is often
of Self-Defense used as a synonym for allergy. However, hypersensitivity is
also used as an umbrella term for allergy and two other
Newborns and the elderly are particularly susceptible to
categories of harmful immune response, which are defined
problems of insufficient immune and inflammatory
as follows:
responses.
As noted earlier in the chapter, neonates generally go Three Types of Hypersensitivity
through a phase at about 5 or 6 months of age when • Allergy—an exaggerated immune response to an
immune system protection received from their mother is environmental antigen, such as pollen or bee venom.
depleted and their own immune system is still immature, • Autoimmunity—a disturbance in the body’s normal
making them particularly susceptible to respiratory tract tolerance for self-antigens, as in hyperthyroidism or
infections. Inflammatory responses are similarly imma- rheumatic fever.
ture in the neonate. For example, neutrophils and mono-
• Isoimmunity (also called alloimmunity)—an immune
cytes may not be capable of chemotaxis, the release of
reaction between members of the same species, com-
chemical factors that attract other white cells to the site of
monly of one person against the antigens of another
infection. This makes newborns prone to infections such
person, as in the reaction of a mother to her infant’s Rh
as cutaneous abscesses and cutaneous candidiasis. As
negative factor or in transplant rejections.
another example, the deficiency of a component of the
complement cascade in infants can cause a severe, over- The exact cause of such pathological immune responses
whelming sepsis or meningitis when infants are infected is not known, but at least three factors seem to be involved:
by bacteria for which they do not have transferred mater- (1) the original insult (exposure to the antigen); (2) the per-
nal antibody. son’s genetic makeup, which determines susceptibility to
The elderly also have difficulties with both the the insult; and (3) an immunologic process that boosts the
immune and the inflammatory responses. As discussed response beyond normal bounds.
earlier in the chapter, B cell and especially T cell functions Hypersensitivity reactions are classified as immediate
of the immune system decrease markedly after age 60. The hypersensitivity reactions or delayed hypersensitivity
elderly are also prone to impaired wound healing. This is reactions, depending on how long it takes the secondary
thought not to be due to the normal processes of aging but reaction to appear after reexposure to an antigen. The
rather to the higher incidence of chronic diseases such as swiftest immediate hypersensitivity reaction is anaphylaxis,
diabetes and cardiovascular disease in the elderly. Also, a severe allergic response that usually develops within
many elderly persons take prescribed anti-inflammatory minutes of reexposure. (Review the section on anaphylac-
steroids for conditions such as arthritis, and these inhibit tic shock earlier in this chapter. Also see the Medical Emer-
inflammation. Decreased perfusion contributes to hypoxia gencies chapter titled “Immunology.”)
Pathophysiology 337
The harmful effects of the immune complex result Graft rejection and
Content Review
from the activation of the complement system. Some com- contact allergic reactions
➤➤ Three Hypersensitivity
plement fragments are chemotactic for (attract) neutro- such as poison ivy are
Targets
phils. The neutrophils attempt to ingest the immune examples of Type IV reac-
• Environmental antigens
complexes but frequently fail because the complexes are tions. There may also be
(targeted by allergic
bound to the tissues. During this attempt, the neutrophils Type IV components to responses)
release large quantities of damaging lysosomal enzymes autoimmune diseases such • Self-antigens (targeted
into the tissues. as rheumatoid arthritis, in by autoimmune
The nature and course of immune complex diseases which the self-antigen is a responses)
vary tremendously. This results from the fact that immune protein present in joint tis- • Other person’s
complex formation is dynamic and constantly changing. sues, and insulin-depen- antigens (targeted by
There can be variations in the quantity and quality of circu- dent diabetes, in which the isoimmune responses)
lating antigen and the antigen-antibody ratio. Also, many self-antigen is a protein on
immune complexes bind complement components effec- the cell of the pancreas that produces insulin.
tively, which causes complement levels in the blood to fluc-
tuate. In some cases, the interaction between complement
and the immune complexes results in dissolving the com-
Targets of Hypersensitivity
Antigens, the proteins or “markers” on the surface of
plex and mitigating its effects. As a result of these factors,
cells, are the targets of the immune response and of the
immune complex diseases are characterized by tremen-
exaggerated immune response called hypersensitivity.
dous variability in symptoms and periods of alternating
As noted earlier, cells bearing these antigens can come
remission and exacerbation.
from one of three sources: the environment, the person’s
Some immune complex diseases are systemic and
own body, or another person. The source of the target
some are localized. Systemic immune complex diseases are
antigen is what defines the type of hypersensitivity, as
called serum sickness. They typically present with fever,
follows:
enlarged lymph nodes, rash, and pain, commonly affecting
the blood vessels, joints, and kidneys. Raynaud’s phenome- Type of Hypersensitivity Targeted Antigen
non is a form of serum sickness in which temperature gov-
Allergy Environmental antigens
erns deposition of immune complexes in the peripheral
circulation. Typical presentations include numbness in the Autoimmunity Self-antigens
fingers and toes, followed by cyanosis and gangrene or Isoimmunity Other person’s antigens
redness and pain.
Arthus reaction is an example of a localized immune In Allergy The antigens that are the targets of allergic
complex disease. It results from the interaction of an reaction are called allergens. Allergens typically occur on
environmental antigen with preformed antibody lodged cells from such environmental sources as ragweed, molds,
in the walls of blood vessels. A typical inflammatory certain foods such as shellfish or peanuts, animal sources
response follows, resulting in edema, hemorrhage, clot- such as cat dander, cigarette smoke, and components of
ting, and tissue damage. The antigen can enter the body house dust. Often, an allergen is contained in a capsule
through injection, ingestion, or inhalation. Examples of that is too large to be phagocytosed or is surrounded by a
arthus reactions are skin reactions following inocula- nonallergenic coating. The actual allergen is not released
tions, gastrointestinal reactions to ingestion of wheat until the capsule or coating is broken down by enzymes.
products, or hemorrhagic inflammation of the alveoli Most allergens are low-molecular-weight immunogens or
following inhalation of fungus from a source such as haptens (which are too small to cause an immune response
moldy hay. unless they bind with larger molecules).
In some situations, an allergen combines with compo-
Type IV—Cell-Mediated Tissue Reactions nents of the host tissue (tissues of the person’s body) to
Types I, II, and III hypersensitivity reactions are medi- form a new substance, called a neoantigen, which, in turn,
ated by antibody. Type IV reactions are activated directly induces an allergic response. For example, a drug such as
by T cells and do not involve antibody. There are two penicillin, which causes an allergic reaction in some peo-
cell-mediated mechanisms. One involves lymphokine- ple, is a hapten. It does not cause an allergic reaction until
producing T cells (Td cells). The other involves cytotoxic it binds to proteins on the plasma membranes of host cells.
T cells (Tc cells). The lymphokine produced by Td cells The immune system attacks the neoantigen and destroys
activates other cells such as macrophages. The Tc cells the cell it is bound to as well. In the case of penicillin, which
attack antigen-bearing cells directly and destroy them with attaches to red blood cells, the immune response kills the
the toxins they produce. red cells and causes anemia.
Pathophysiology 339
IN AUTOIMMUNITY The immune system normally as in Rh negative sensitivity. The other type is encountered
recognizes the person’s own tissues as self and tolerates in the rejection of grafts or transplants from one person to
the self-antigens presented by the body’s own cells. If the another.
body generated an immune response to its own tissues, it
would destroy itself. Autoimmunity is a form of exactly Autoimmune and Isoimmune Diseases
this undesirable situation: There is a breakdown in the A number of diseases are recognized or suspected to have
body’s tolerance for self-antigens, and the immune system an autoimmune or isoimmune basis. The following are
begins to attack the body’s own cells. some examples:
Tolerance for self-antigens begins in the embryo when
any lymphocytes that react to self-antigens are eliminated • Graves’ disease is thought to be caused by an antibody
or suppressed. Several causes of a later breakdown in toler- that stimulates overproduction of thyroid hormone.
ance have been identified. People with Graves’ disease have the symptoms of
For example, some cells are sequestered (hidden) from hyperthyroidism (e.g., elevated heart rate and blood
the immune system by existing in areas of the body that are pressure, increased appetite, increased activity level)
not drained by lymph (for example, the cornea and the tes- plus a visibly enlarged thyroid gland (goiter), bulging
ticles). If these cells become exposed to the immune system eyes, and sometimes raised areas of skin over the
(e.g., during trauma), the body may recognize them as for- shins. A pregnant woman with Graves’ disease can
eign and initiate an autoimmune response. pass the antibody and the disease along to the new-
A neoantigen can trigger an immune response to the born.
cells it is bound to. Infectious diseases can also trigger • Rheumatoid arthritis is a disease that causes inflamma-
autoimmune responses in one of two ways. A foreign infec- tion of the joints and eventual destruction of the inte-
tious antigen, in binding with an antibody, can form an rior of the joint. Its exact cause is not known, but it is
immune complex that lodges in host tissues and causes an recognized as an autoimmune disorder, probably
autoimmune response to the cells of those tissues. Addi- involving antibody reactions to self-antigen in the col-
tionally, a foreign antigen may resemble a self-antigen to lagen of the joints.
such a degree that the antibody to the foreign antigen also • Myasthenia gravis is a disease caused by antibody
attacks the self-antigen. response to self-antigens on acetylcholine receptors
Suppressor T cell dysfunction is another cause of auto- and the striations of skeletal and cardiac muscle. It is
immune disorders. In normal immune function, some T characterized by abnormal function of the neuromus-
cells develop clones that attack self-antigens. Suppressor T cular junction, resulting in episodes of muscular weak-
cells are thought to have the function of suppressing these ness. Like Graves’ disease, the mother’s antibody can
autoimmune responses. However, if the suppressor T cells bind with receptors on the infant’s muscle cells, caus-
dysfunction, the autoimmune response caused by T cell ing neonatal muscle weakness.
clones is able to develop.
• Immune thrombocytopenic purpura (ITP) presents with
The original insult that causes the autoimmune
pinhead-sized red spots on the skin, unexplained
response is usually easy to identify—for instance, an
bruises, and bleeding from the gums and nose and
administered drug causing autoimmune anemia or a recent
into the stool. It is characterized by a low platelet
infection such as rubella causing autoimmune encephalitis.
count. The exact cause is not known, but an autoim-
In other cases, the causative insult cannot be identified. In
mune disorder in which antibodies destroy the per-
these cases, the autoimmune disease is thought to have
son’s own platelets appears to be involved. Maternal
resulted from a prior infection that is no longer traceable.
antibodies can also destroy platelets in the neonate.
Genetic causes are actually easier to identify than
pathological causes. Most autoimmune diseases are famil- • Isoimmune neutropenia occurs when a mother has
ial. All affected family members may not have the same developed antibodies that attack and severely reduce
disorder, but each may have a different autoimmune disor- the level of neutrophils in her blood. The antibody in
der or a disorder characterized by hypersensitivity the maternal blood can also attack and destroy neutro-
responses. phils in the blood of the neonate.
• Systemic lupus erythematosus (SLE), also called simply
IN ISOIMMUNITY In isoimmunity, one member of a lupus, is an autoimmune disease in which a variety of
species has an immune reaction to cells from another mem- antibodies to self-antigens are developed that then
ber of the same species. In humans, two types of isoimmune attack nucleic acids, red blood cells, coagulation pro-
disorders are most common, as discussed earlier in this teins, lymphocytes, platelets, and many other targets
chapter. One type consists of transient neonatal diseases, within the person’s own body. The disease causes
in which the mother becomes sensitized to fetal antigens, episodal inflammations of joints, tendons, and other
340 Chapter 12
HIV is a retrovirus; that is, it carries its genetic infor- helped to greatly reduce the number of new cases reported
mation in RNA rather than DNA molecules. As a retrovi- in the United States. In some parts of the world, however,
rus, HIV infects target cells by binding to receptors on their including Africa and Asia, HIV/AIDS is still spreading at
surfaces, then inserting the HIV RNA into the cell. There, an extremely alarming rate, with seriously inadequate
the RNA is converted into DNA and becomes part of the reporting, prevention, and treatment.
infected cell’s genetic material. HIV can remain dormant
inside the host cell for years; however, once the cell is acti- Replacement Therapies
vated (and the mechanism by which this occurs is not fully for Immune Deficiencies
understood), HIV proliferates, kills the host cell, and can Advances have been made in the treatment of immune
then infect other cells. The result is a pervasive breakdown deficiencies through the use of replacement therapies, such
of the immune defenses, making the body vulnerable to a as those listed below.
wide variety of infections and disorders.
HIV can infect anyone, male or female, homosexual or Replacement Therapies
heterosexual, mostly through the exchange of body fluids Gamma globulin therapy. Gamma globulin is adminis-
during sexual intercourse or through injection. In the tered to individuals with B cell deficiencies that cause
United States, most cases to date have involved homosex- immunoglobulin (antibody) deficiencies.
ual men and intravenous drug users. However, preventive Transplantation and transfusion. HLA-matched bone
measures (safe sex practices—including use of condoms— marrow is transplanted into patients suffering severe
and clean-needle programs) have reduced the incidence of combined immune deficiencies (SCID), which is caused
HIV/AIDS among homosexual populations and drug by a lack of the stem cells from which T cells and B
users. An increasing proportion of new patients are women cells develop. In patients who lack a thymus or have
who have acquired the infection during heterosexual inter- a defective thymus, fetal thymus tissue may be
course. In other parts of the world, HIV/AIDS occurs transplanted. Enzyme deficiencies that cause SCID
equally among men and women. have been treated with transfusions of red blood
The possibility of acquiring HIV/AIDS by contact cells that contain the needed enzyme. Other sub-
with patients or accidental needle sticks fostered some- stances have been transfused into individuals to
thing of a panic among health care workers when AIDS help restore T cell function and reactivity against
first spread so alarmingly in the United States in the 1970s. certain antigens.
Following recommendations by OSHA, universal precau-
Gene therapy. Therapies involving identification of defec-
tions (Standard Precautions) have been widely adopted—
tive genes that are responsible for immune disorders,
including the use of disposable gloves, protective eyewear,
and replacement of these defective genes with cloned
masks, and gowns, as appropriate, to avoid contact with
normal genes, are in the early stages of development
any body fluids, along with improved techniques for han-
and use.
dling needles and other sharps. These measures have
proved effective in reducing the fear of HIV/AIDS infec-
tion and in making such infections very rare among health
care workers. Stress and Disease
Until recently, more than 90 percent of those with AIDS
Stress is a word that is used a lot in modern life. You might
have died within five years of the development of severe
have a stressful job, or feel stressed out by too many
symptoms. This picture has improved somewhat in devel-
demands on your job, or be going through a lot of emo-
oped nations with the initiation of treatments involving
tional stress in connection with a personal relationship. In
multiple chemotherapies (treatment “cocktails”) that have
some situations, you may be acutely aware of some of the
shown success in prolonging life, greatly improving feel-
physiologic components of stress—for example, sweaty
ings of health and well-being, and suppressing measurable
palms and a pounding heart just before you have to get up
blood levels of HIV.
and give a speech. If so, you already have a basic under-
It is not yet known if such treatments can eradicate
standing of stress that can help you grasp the physiologic
HIV and cure AIDS. One fear is that the treatments sup-
and medical concepts of stress and how stress is related to
press, but do not totally destroy, the HIV virus, which
disease.
“hides” somewhere in the body, waiting to proliferate at
some later date. Another fear is that HIV will develop
strains that are resistant to the treatments that appear to be Concepts of Stress
successful in the short term. Nevertheless, the success of Today, it is commonly understood that mind and body
these treatments has caused the first feelings of optimism interact. It was not always so. In fact, the concept that
since AIDS was identified. Preventive measures have also psychological states influence physiologic states—and,
342 Chapter 12
all the changes is the dynamic (always changing), yet system. This chain of events
CONTENT REVIEW
steady (tending always toward normal balance) state. is outlined in Figure 12-104
➤➤ Hormones Released in
Stressors cause a series of reactions that alter the and described in the next
Response to Stress
dynamic steady state. Usually, there is a return to normal, sections.
• Catecholamines
which may be rapid or slow. If a disturbance in the dynamic
(norepinephrine and
steady state—for example, a high blood glucose level—is Neuroendocrine epinephrine)
prolonged and a causative stressor is no longer present, it Regulation • Cortisol
is considered a sign of disease. As previously mentioned, • Beta endorphins
when a person encounters • Growth hormone
• Prolactin
Stress Responses a stressor and has a psy-
chological response to the
Alteration of the immune system is the ultimate outcome
stressor, the sympathetic nervous system is stimulated by
of a stress response that resists quick and successful adap-
corticotropin-releasing factor (CRF). In turn, this stimulates
tation. The interactions of psychological, neurologic/
release of catecholamines, cortisol, and other hormones.
endocrine, and immunologic factors that lead to this out-
come are known as psychoneuroimmunologic regulation. CATECHOLAMINES Sympathetic nervous system
The stress response is initiated by a stressor. The input stimulation results in the release of norepinephrine (nor-
of the stressor into the central nervous system, as mediated adrenalin) and epinephrine (adrenalin), which constitute
by the person’s psychological response, leads to production the category of hormones called catecholamines. The nerves
of corticotropin-releasing factor (CRF) from the hypothala- of the sympathetic nervous system exit the spine at the
mus, which, in turn, stimulates responses by the sympa- thoracic and lumbar levels, and norepinephrine is released
thetic nervous system and the endocrine system into the synaptic spaces (the spaces between the presynap-
(neuroendocrine regulation), which then affect the immune tic ganglia and the postsynaptic nerves).
STRESSOR
HYPOTHALAMUS RELEASES
CORTICOTROPIN-RELEASING FACTOR (CRF)
IMMUNE SYSTEM
Some effects enhance the immune response.
Some effects suppress the immune response.
FIGURE 12-104 The stress response: effects on the sympathetic nervous, endocrine, and immune systems.
344 Chapter 12
The immunosuppressive actions of cortisol seem noted to increase after stressful experiences such as electro-
clearly harmful, yet its production in response to stress shock, cardiac catheterization, and surgery. However, the
indicates that it is beneficial in protecting against stress. Its levels of GH become depressed with prolonged stress.
beneficial effects in stress, however, are not well under- Prolactin is released by the anterior pituitary gland and is
stood. It has been suggested that its promotion of gluco- necessary for breast development and lactation. Levels of
neogenesis helps ensure an adequate source of glucose as prolactin have been noted to rise after a variety of stressful
energy for body tissues, especially nerve tissues. Pooled stimuli. Testosterone is a hormone produced in the testicles
amino acids from protein breakdown may promote protein and also by the adrenal cortex in both males and females. It
synthesis in some cells. Its depressive influence on inflam- is necessary for development of male sexual characteristics
matory responses may play a role in decreasing peripheral and also affects many metabolic activities. Many stressful
blood flow and redirecting blood to critical organs or sites activities lead to a decrease in testosterone, which is
of injury. Suppression of immune function may also help thought to be a result of increased cortisol levels. Some
prevent tissue damage that results from prolonged immune competitive sports activities, however, appear to increase
responses. The physiologic effects of cortisol are summa- testosterone levels.
rized in Table 12-20.
Role of the Immune System in Stress
OTHER HORMONES In addition to the catecholamines During a stress response, as noted earlier, there is a com-
and cortisol, other hormones are associated with stress plex interaction among the nervous and endocrine sys-
response. For example, beta-endorphins (endogenous opi- tems and the immune system. As a consequence, a
ates) are released into the blood from the pituitary gland, variety of immune-related disorders are associated with
or possibly the central nervous system, in response to CRF stress.
stimulation. They may play a part in regulating ACTH The specific mechanisms by which stress leads to
secretion and inhibiting CRF secretion, which means that immune-related disorders is the subject of ongoing
beta-endorphins may exercise a control over the stress research but is not yet well understood. However, research
response. The beta-endorphins also are associated with points to the substances that serve as communicators
decreased pain sensitivity and increased feelings of well- between the cells of the nervous system, the endocrine sys-
being, which may help to moderate the psychological tem, and the immune system—including hormones, neu-
response to a stressor. rotransmitters, neuropeptides, and cytokines—as the
Growth hormone (GH) is released by the anterior pitu- pathways of cause and effect.
itary gland. GH affects protein, lipid, and carbohydrate The pathway is not a straight line. The directional
metabolism and immune function. Its levels have been arrows of cause and effect move forward, backward, and
Protein metabolism Increases protein synthesis in liver; depresses protein synthesis in other tissues; depresses immunoglobulin
production
Inflammatory effects Decreases blood levels of lymphocytes, macrophages, eosinophils; decreases leukocytes at inflammation site;
delays healing/promotes wound infection
Immune reserves Decreases lymphoid tissue mass; decreases circulation white cells; inhibits production of interleukin-1 and
interleukin-2; blocks cell-mediated immunity and generation of fever
Muscle function Maintains normal contractility and work output for skeletal and cardiac muscle
Cardiovascular function Maintains normal blood pressure; assists arteriole constriction; supports myocardial function
Central nervous system function Modulates perceptual/emotional functioning and daytime arousal
346 Chapter 12
in circles. Many components of the immune system can be adrenal gland to secrete cortisol, which suppresses the
affected by the factors produced by the neuroendocrine development of macrophages, T cells, B cells, and nat-
system. Conversely, immune system products can affect ural killer (NK) cells, a lymphocyte specially adapted
components of the neuroendocrine system. Here are two to recognize and kill virally infected cells and malig-
examples (Figure 12-105): nant cells.
• Pathway 1: Central nervous system to immune sys- • Pathway 2: Immune system to central nervous system.
tem. The central nervous system stimulates the hypo- During immune system response, macrophages
thalamus to produce CRF, which stimulates the secrete cytokines which stimulate the hypothalamus to
pituitary gland to produce ACTH, which stimulates the secrete CRF (which begins Pathway 1 again).
Summary
The cell is the basic unit of life. It contains all the components needed to turn nutrients into energy,
remove waste products, reproduce, and carry on other essential life functions. The body’s cells
interact via electrochemical substances including hormones, neurotransmitters, neuropeptides,
and cytokines. The cells exist in an environment of fluids and electrolytes. When something inter-
feres with normal cell function, the normal cell environment, or normal cell intercommunication,
disease can begin or advance.
Groups of cells that perform similar functions form tissues. A group of tissues functioning
together is an organ. A group of organs that work together is an organ system.
Perfusion of the tissues is necessary to provide essential nutrients to the cells (especially
oxygen and glucose) and to remove wastes. Inadequate perfusion, called hypoperfusion or
shock, can be caused by a problem in any of the three parts of the cardiovascular system (the
348 Chapter 12
heart, the blood vessels, or the blood), sometimes abetted by problems with the respiratory or
gastrointestinal system in which the normal intake and transfer of oxygen and glucose may be
interrupted. If not corrected, positive feedback mechanisms can enhance the process of shock,
creating a downward spiral toward irreversible shock, possible multiple organ dysfunction syn-
drome (MODS), and death.
Cells can be injured in a variety of ways, including hypoxia, chemicals, infectious agents,
immunologic/inflammatory injuries, and others. Diseases can be caused by genetic factors,
environmental factors, or a combination of factors (multifactorial diseases).
The body responds to cellular injury in a variety of ways to restore homeostasis, the body’s
normal dynamic steady state. Cells can adapt through atrophy, hypertrophy, hyperplasia, meta-
plasia, and dysplasia. Negative feedback mechanisms work to correct, or compensate for, shock—
if shock has not progressed too far.
The body’s chief means of self defense is the immune system and the immune and inflam-
matory responses, which work to attack and destroy infectious agents and other unwanted
invaders. Occasionally, the immune response system works “too well,” as in hypersensitivity
reactions, or not well enough, as in immune deficiency disorders. Stress can also contribute to
disease through the interactions of the nervous, endocrine, and immune systems.
Keep in mind that an understanding of the cell is essential to an understanding of all of
these physiologic and pathophysiologic systems and processes. The more you understand
what is happening at the cellular level, the better you will be able to understand the disease/
injury process. This will help you make better decisions for treatment and transport of your
patient.
Review Questions
1. The clear liquid portion of the cytoplasm in a cell is 2. The ___________ are the energy factories, sometimes
called ___________ called the “powerhouses,” of the cells.
a. cytosol. a. lysosomes
b. plasma. b. mitochondria
c. synovial fluid. c. Golgi apparatuses
d. aqueous humor. d. endoplasmic reticula
Pathophysiology 349
3. Which property of nerve cells results in the ability 12. The mechanism(s) that most commonly result in
to transmit an electrical impulse in response to a accumulation of water in the interstitial space
stimulus> include is/are ______________________
a. Excitability c. Conductivity a. lymphatic obstruction.
b. Automaticity d. Contractility b. an increase in hydrostatic pressure.
4. ___________ tissue has the capability of contraction c. increased permeability of the capillary
membrane.
when stimulated.
d. all of the above.
a. Nerve c. Connective
b. Muscle d. Epithelial 13. ___________ are proteins secreted by plasma cells in
response to an antigen.
5. What is the term for the body’s natural tendency to
a. Clonal antigens
keep the internal environment and metabolism
steady and normal? b. Antibodies
a. Positive responsiveness c. Antibiotics
b. Positive feedback system d. Haptens
c. Metabolism 14. Progressive impairment of two or more organ sys-
d. Homeostasis tems resulting from an uncontrolled inflammatory
response to a severe illness or injury is called
6. ___________ is the study of disease and its causes.
____________
a. Pathology
a. ALS. c. ARDS.
b. Physiologic disruption
b. MODS. d. AODS.
c. Physiology
15. An advanced stage of shock in which the body’s com-
d. Pathophysiology
pensatory mechanisms are no longer able to maintain
7. ___________ is an increase in the number of cells normal perfusion is called ________________
through cell division, resulting from an increased a. reversible shock.
workload.
b. compensated shock.
a. Multiplasia
c. homeostatic shock.
b. Metaplasia
d. decompensated shock.
c. Hypertrophy
16. Which of the following is not a commonly used pre-
d. Hyperplasia
hospital IV fluid?
8. What is the “force” or pressure that helps to push a. D5W
plasma out from a capillary bed>
b. Normal saline
a. Osmotic c. Oncotic
c. Lactated Ringer’s
b. Hydrostatic d. Filtration
d. Chloride solution.
9. Water accounts for approximately ___________ per- 17. The human somatic cell nucleus contains
cent of the total body weight. ___________ chromosomes.
a. 40 c. 60 a. 48 c. 24
b. 50 d. 70 b. 46 d. 23
10. The fluid found outside cells and within the circula- 18. The amount of blood ejected by the heart in one con-
tory system is the ___________ fluid. traction is referred to as the___________________
a. synovial a. preload.
b. interstitial b. afterload.
c. intravascular c. stroke volume.
d. extracellular d. cardiac force.
11. The most frequently occurring anions include all of 19. The energy that is produced during glucose break-
the following except ______________________ down is in the form of the chemical ______________
a. chloride. c. phosphate. a. ATP. c. TAP.
b. calcium. d. bicarbonate. b. APT. d. PTA.
350 Chapter 12
20. Obstructive shock is caused by an obstruction of 23. People with type___________ blood are known as
blood through the heart, and can be caused by universal donors, because this type of blood has no
___________________ antigens that will trigger an immune response in
a. cardiac tamponade. any other group.
b. pulmonary embolism. a. A c. O
c. tension pneumothorax. b. B d. AB
d. all of the above. 24. ___________ cells are the chief activators of the
21. What is the best description of shock? inflammatory response.
References
1. Behar, D. M., E. Metspala, T. Kivisild, et al. “The Matrilineal 4. Williams, D. “Radiation Carcinogenesis: Lessons from Cher-
Ancestry of Ashkenazi Jewry: Portrait of a Recent Founder nobyl.” Oncogene 27 (Suppl 2) (2008): S9–S18.
Event.” Am J Hum Genet 78 (2006): 487–497. 5. Harman, D. “Aging: A Theory Based upon Free Radical and
2. Lotti, M., L. Bergamo, and B. Murer. “Occupational Toxicology Radiation Chemistry.” J Gerontol 11 (1956): 298–300.
of Asbestos-Related Malignancies.” Clin Toxicol (Phla) 48 (2010):
485–496.
3. Hendricks, K. A., J. S. Simpson, and R. D. Larsen. “Neural Tube
Defects along the Texas-Mexico Border, 1993–1995.” Am J Epide-
miol 15 (1999): 1119–1127.
Further Reading
Bledsoe, B. E. and R.W. Benner. Critical Care Paramedic. Upper Saddle Page, J. O. Simple Advice. Carlsbad, CA: JEMS Publishing, 2002.
River, NJ: Brady/Pearson/Prentice-Hall, 2006. Page, J. O. The Magic of 3 A.M.: Essays on the Art and Science of Emer-
Bledsoe, B. E. “EMS Needs a Few More Cowboys.” Journal of Emer- gency medical Services. Carlsbad, CA: JEMS Publishing, 2002.
gency Medical Services (JEMS) 28(12) (2003): 112–113. Page, J. O. The Paramedics. Morristown, NJ: Backdraft Publications,
Bledsoe, B. E. “Where Are the Wise Men?” Emergency Medical Services 1979.
(EMS) 31(10) (2002): 172. Perry, M. Population 485: Meeting Your Neighbors One Siren at a Time.
Grayson, S. En Route: A Paramedic’s Stories of Life, Death, and Every- New York, NY: Harper-Collins, 2002.
thing in Between. New York: Kaplan Publishing, 2009.
Chapter 13
Emergency Pharmacology
Bryan Bledsoe, DO, FACEP, FAAEM
Standard
Pharmacology (Principles of Pharmacology; Emergency Medications)
Competency
Integrates comprehensive knowledge of pharmacology to formulate a treatment plan intended to mitigate emergencies
and improve the overall health of the patient.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to apply concepts of pharmacology to the
assessment and management of patients.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this chapter. 7. Explain the responsibilities with respect to
administering medications, including
2. Explain the chemical, generic, brand, and
medication delivery to special patient
official names of drugs, and the four main
populations.
sources of material from which drugs are
created. 8. Explain key principles of pharmacokinetics.
3. Identify reliable reference materials for drug 9. Describe each of the routes of drug
information. administration.
4. Describe each of the components of a drug 10. Describe the various forms of drugs and
profile. any storage considerations they may have.
5. Explain how key drug legislation applies 11. Explain key principles of
to the paramedic’s role in administering pharmacodynamics.
drugs.
12. Describe unintended adverse effects of drug
6. Discuss the processes of drug research and administration and how various factors, such
development for marketing, and the FDA as age, body mass, concurrent medications,
classification of newly approved drugs. and others, can alter drug responses.
351
352 Chapter 13
13. Describe the characteristics of drugs used to 19. Describe the characteristics of drugs used to
affect the central nervous system. affect the endocrine system.
14. Describe the characteristics of drugs used to 20. Describe the characteristics of drugs used
affect the autonomic nervous system. to affect the male and female reproductive
system and those that affect sexual
15. Describe the characteristics of drugs used to
behavior.
affect the cardiovascular system.
21. Describe the characteristics of drugs used
16. Describe the characteristics of drugs used to
to treat cancer, infection and inflammation,
affect the respiratory system.
the skin.
17. Describe the characteristics of drugs used to
22. Describe the characteristics of drugs used to
affect the gastrointestinal system.
supplement the diet, and those used for
18. Describe the characteristics of drugs used to poisoning and overdoses.
affect the eyes and ears.
Key Terms
active transport, p. 362 bioequivalence, p. 357 immunity, p. 431
adjunct medication, p. 373 biologic half-life, p. 370 insulin, p. 425
adrenergic, p. 388 biotransformation, p. 365 ionize, p. 364
affinity, p. 368 blood–brain barrier, p. 365 irreversible antagonism, p. 369
agonist, p. 368 carrier-mediated diffusion, p. 362 laxative, p. 420
agonist–antagonist, p. 368 cholinergic, p. 388 leukotrienes, p. 417
analgesia, p. 373 competitive antagonism, p. 369 medications, p. 354
analgesic, p. 373 diffusion, p. 363 metabolism, p. 365
anesthesia, p. 373 diuretic, p. 408 minimum effective
anesthetic, p. 375 dose packaging, p. 360 concentration, p. 370
antacid, p. 420 down-regulation, p. 368 mucolytic, p. 419
antagonist, p. 368 drug-response relationship, p. 370 neuroeffector junction, p. 387
antiarrhythmic, p. 403 drugs, p. 354 neuroleptanesthesia, p. 375
antibiotic, p. 430 duration of action, p. 370 neuroleptic, p. 382
anticoagulant, p. 414 efficacy, p. 368 neuron, p. 388
antiemetic, p. 421 enteral route, p. 366 neurotransmitter, p. 387
antifibrinolytic, p. 415 expectorant, p. 419 noncompetitive antagonism, p. 369
antihistamine, p. 418 extrapyramidal symptoms, p. 382 onset of action, p. 370
antihyperlipidemic, p. 415 facilitated diffusion, p. 362 organic nitrates, p. 413
antihypertensive, p. 408 fibrinolytic, p. 415 osmosis, p. 363
antineoplastic agent, p. 428 filtration, p. 363 oxidation, p. 365
antiplatelet, p. 414 first-pass effect, p. 365 parasympatholytic, p. 390
antitussive, p. 419 free drug availability, p. 361 parasympathomimetic, p. 390
assay, p. 357 glucagon, p. 425 parenteral route, p. 366
autonomic ganglia, p. 387 hemostasis, p. 414 partial agonist, p. 368
autonomic nervous system, p. 387 histamine, p. 418 passive transport, p. 363
bioassay, p. 357 hydrolyze, p. 365 pathogen, p. 431
bioavailability, p. 364 hypnosis, p. 378 pharmacodynamics, p. 362
Emergency Pharmacology 353
Case Study
Paramedics Jo Henderson and her partner, Scott Parker, him to hold still while she runs a 12-lead ECG, and then
are dispatched to a rural residence just outside of town she moves him to the ambulance for transport to the
on a “chest pain” call. The response time is approxi- nearest cardiac center.
mately 8 minutes. Emergency Medical Responders from Jo anticipates an approximately 75-minute trans-
the Alamo Fire Department are already on the scene. As port time to Our Lady of the Sea Hospital. The local
they pull up to the well-kept brick home, a woman community hospital closed several years ago due to
waves to them from the front porch. She tells them that financial reasons, forcing patients to drive 60 miles to a
she is the patient’s wife and shows them through the neighboring town for their health care needs. Because of
house to the den, where her husband is seated in an this, EMS has become even more important to the small
overstuffed recliner. The patient is Reverend Charles community. Jo reassesses her patient and finds that he is
Allen, a 54-year-old Methodist minister, who is well still having chest discomfort, but he now rates it as a 6
known to the paramedics. He is conscious and alert, but out of 10. She administers another 2 milligrams of mor-
in obvious distress. He is breathing at a rate of 24 breaths phine sulfate intravenously. She notices that the ECG
per minute with some difficulty. His skin is pale and shows ST elevation in leads V2 through V6, indicating
diaphoretic. While Jo gets a brief history from him, she an anterolateral injury. Jo confirms the key findings of
checks his radial pulse and finds that it is strong and the history to determine whether her patient is a candi-
regular at a rate of 84 beats per minute. Scott is busy date for prehospital fibrinolytic therapy. Finding no
attaching ECG electrodes and a pulse oximeter. The contraindications for fibrinolytic therapy, she contacts
Emergency Medical Responders have already started the hospital to notify the staff. The medical direction
oxygen administration with a nonrebreather mask. physician reviews the patient’s risk factors and confirms
They inform Jo and Scott that the patient’s blood pres- that there are no contraindications to fibrinolytic ther-
sure is 150/90 mmHg. apy. Jo faxes him a copy of the 12-lead. He agrees with
Reverend Allen tells Jo he is experiencing a “heavi- the paramedics’ assessment of anterolateral myocardial
ness” in his chest, which is making it difficult for him to ischemia and authorizes Jo to administer recombinant
breathe. He says it feels as though “an elephant is sitting tissue plasminogen activator (rtPA) via a standardized
on it.” He rates the discomfort as an 8 out of 10 and says protocol. The protocol includes an initial 15-mg bolus
it began about 15 minutes earlier, while he was watch- over 1 to 2 minutes followed by a timed infusion over
ing television. He denies any other complaints and has the next 90 minutes. Following the bolus, Jo prepares
no relevant medical history, takes no medications, and and starts the infusion using a programmed IV pump.
has no allergies. Per system standing orders, Jo adminis- Jo carefully documents the time at which the rtPA bolus
ters 325 milligrams of chewable aspirin to her patient was administered. In addition, they are to continue
while she listens to his lungs. He has clear breath sounds titrating the morphine sulfate, with the goal of eliminat-
in all fields. Jo asks Scott to place a saline lock while she ing all discomfort.
administers 0.4 milligram (1/150 grain) of nitroglycerin Jo continues to administer morphine incrementally
(NitroStat) sublingually. The patient’s pain has decreased until Reverend Allen reports that he is free of discom-
somewhat, but he is still very uncomfortable and is now fort. She carefully monitors his blood pressure and
complaining of nausea. Jo has him place another nitro- pulse rate throughout transport. On arrival at the hospi-
glycerin under his tongue while she administers 4 milli- tal, the patient is moved to the chest pain unit of the
grams of ondansetron (Zofran) intravenously. She asks emergency department. Initial laboratory studies and a
354 Chapter 13
chest X-ray are obtained. The patient is placed on a coronary intervention (PCI). The patient is referred to
12-lead ECG monitor. The paramedics note marked cardiovascular surgery. The next day, he undergoes
improvement in the ST segment elevation seen earlier in four-vessel coronary artery bypass grafting (CABG). He
leads V2 through V6. The patient remains pain free. does well in surgery and afterward. Thanks to the efforts
Shortly thereafter, he is taken to the intensive care unit of the paramedics, he has no permanent myocardial
and has an uneventful night. injury from the heart attack.
The next morning, he undergoes cardiac catheter- Reverend Allen is discharged from the hospital four
ization and coronary angiography. Unfortunately, Rev- days later and begins an aggressive cardiac rehabilita-
erend Allen has rather severe coronary artery disease, tion program. Six weeks later, he is able to resume his
with several high-grade blockages. The cardiologists usual activities and returns to the pulpit, much to the
determine that he has too much disease for percutaneous satisfaction of his parishioners.
Table 13-1 Schedules of Drugs According to the Controlled Substances Act of 1970
Schedule Description Examples
Schedule I High abuse potential; may lead to severe dependence; no accepted Heroin, LSD, mescaline
medical indications; used for research, analysis, or instruction only
Schedule II High abuse potential; may lead to severe dependence; accepted Opium, cocaine, morphine, codeine, oxycodone, hydrocodone,
medical indications methadone, secobarbital
Schedule III Less abuse potential than Schedule I and II; may lead to moderate Limited opioid amounts or combined with noncontrolled
or low physical dependence or high psychological dependence; substances; acetaminophen with codeine, buprenorphine
accepted medical indications
Schedule IV Low abuse potential compared to Schedule III; limited psychological Diazepam, lorazepam, phenobarbital
and/or physical dependence; accepted medical indications
Schedule V Lower abuse potential compared to Schedule IV; may lead to limited Limited amounts of opioids; often for cough or diarrhea
physical or psychological dependence; accepted medical indications
Federal drug laws require that certain substances be of drugs is a necessity. Despite FDA standards, drugs sold
appropriately secured, distributed, and accounted for. or distributed by various manufacturers may have bio-
Because of the complexity of this issue and the large vari- logical or therapeutic differences. An assay determines
ability of drugs used in EMS systems across the country, the amount and purity of a given chemical in a prepara-
specific answers to these concerns are not practical here. tion in the laboratory (in vitro). Although two generically
Consult your local protocols, laws, and most importantly, equivalent preparations may contain the same amount of
your medical director for guidance in this area. a given chemical (drug), they may have different thera-
peutic effects. This relative therapeutic effectiveness of
State chemically equivalent drugs is their bioequivalence. Bio-
equivalence is determined by a bioassay, which attempts
State laws vary widely. Some states have legislated which
to ascertain the drug’s availability in a biological model
medications are appropriate for paramedics to give,
(in vivo). Again, the USP is the official standard for the
whereas others have left those decisions to local control.
United States.
Local control varies as well. In some areas, regional EMS
authorities set the local standards; in others, the individual
medical directors and department directors do. In all cases,
however, the physician medical director can delegate to Drug Research and
paramedics the authority to administer medications, either
by written, verbal, or standing order. You must know the Bringing a Drug to Market
laws of the state where you practice. The pharmaceutical industry is highly motivated to bring
profitable new drugs to market. Proving the safety and
Local reliability of these new drugs, however, requires extensive
research. Even though better understanding of biology is
In each community, local leaders are responsible for
shortening the time needed to bring a new drug to market,
ensuring public safety. Local EMS agencies have the
the process still takes many years. To ensure the safety of
responsibility to create local policies and procedures to
new medications, the FDA has developed a process for
ensure the public well-being. An excellent example of a
evaluating their safety and efficacy. This process, illus-
local procedure protecting the patient (and thereby the
trated in Figure 13-1, adds even more time to the develop-
individual EMS provider and agency) would be a require-
ment cycle. Initial drug testing begins with the study of
ment to use a pulse oximeter whenever a patient is
both male and female mammals. After testing a drug’s
sedated or paralyzed. Even though this requirement
toxicity, researchers evaluate its pharmacokinetics—how
would not have the force of law, it would locally help to
it is absorbed, distributed, metabolized (biotransformed),
ensure that local EMS providers do not overlook hypoxia
and excreted—in animals. These animal studies also help
in these patients.
determine the drug’s therapeutic index (the ratio of its
lethal dose to its effective dose). If the results of animal
Standards testing are satisfactory, the FDA designates the drug as an
Because some generic drugs affect patients differently investigational new drug (IND), and researchers can then
than their brand name counterparts do, standardization test it in humans.
358 Chapter 13
Pre-Clinical
Testing,
Research and Clinical Research and Post-Marketing
Development Development NDA Review Surveillance
Phase 2
Surveys/
Sampling/
Testing
Animal
Testing Phase 3
Short-Term
Inspections
Long-Term
Phases of Human Studies data needed for these goals requires a large patient popula-
tion. Phase 3 studies are usually double-blind. That is, neither
Human studies take place in four phases.
the patient nor the researcher knows whether the patient
is receiving a placebo or the drug until after the study has
Phase 1 The primary purposes of phase 1 testing are to
been completed. This keeps personal biases from affecting
determine the drug’s pharmacokinetics, toxicity, and safe
the reporting of results. Some phase 3 studies are controlled
dose in humans. These studies are usually carried out on
studies, which are like placebo studies except that, instead of
limited populations of healthy human volunteers; some
a placebo, the patient receives a treatment that is known to be
drugs with a high risk of untoward effects will not be tested
effective. Occasionally, a double-blind study will be ended
on healthy individuals.
sooner than planned if the early results are convincing.
Phase 2 When phase 1 studies prove that the drug is Once phase 3 studies are completed, the manufacturer
safe, it is tested on a limited population of patients who have files a new drug application (NDA) with the Food and
the disease it is intended to treat. The primary purposes of Drug Administration, which then evaluates the data col-
phase 2 studies are to find the therapeutic drug level and lected in the investigation’s first three phases. At this point,
watch carefully for toxic and side effects. the FDA decides whether to conditionally approve manu-
facturing and marketing the drug in the United States. The
Phase 3 The main purposes of phase 3 testing are to FDA’s abbreviated new drug application (ANDA) process
refine the usual therapeutic dose and to collect relevant may significantly shorten this process for generic equiva-
data on side effects. Gathering the significant amounts of lents of currently approved drugs.
Emergency Pharmacology 359
Phase 4 Phase 4 testing involves postmarketing analysis and effective administration of medications. The following
during conditional approval. Once a drug is being used in guidelines will help you to meet that responsibility:
the general population, the FDA requires the drug’s maker
• Know the precautions and contraindications for all
to monitor its performance. Many drugs have been discon-
medications you administer.
tinued after marketing when previously unknown effects
became apparent. One example would be the antiemetic • Practice proper techniques.
thalidomide. Because children and pregnant women are • Know how to observe and document drug effects.
generally excluded from the first three phases of testing, the • Maintain a current knowledge of pharmacology.
premarket testing did not reveal that thalidomide caused • Establish and maintain professional relationships with
birth defects in the children of pregnant women who took it. other health care providers.
• Understand the pharmacokinetics and pharmacody-
FDA Classification of Newly namics.
Approved Drugs • Have current medication references available.
The FDA has developed a method for immediately classi- • Take careful drug histories, including:
fying new drugs. This method of drug classification uses a • Name, strength, and daily dose of prescribed drugs
number and a letter for each new drug in the IND phase or • Over-the-counter drugs
on NDA review by the FDA. The manufacturer has a right
• Vitamins
to contest this classification and have it changed before the
final classification is established. • Herbal medications
• Folk medicine or folk remedies
Numerical Classification (Chemical)
• Allergies
1. A new molecular drug
• Evaluate the compliance, dosage, and adverse reactions.
2. A new salt of a marketed drug
• Consult with medical direction when appropriate.
3. A new formulation or dosage form not previously
marketed
Six Rights of Medication
4. A new combination not previously marketed
5. A drug that is already on the market, a generic duplication
Administration
No pharmacology chapter would be complete without
6. A product already marketed by the same company
discussing the six rights of medication administration.
(This designation is used for new indications for a
They include the right medication, the right dose, the
marketed drug.)
right time, the right route, the right patient, and the right
7. A drug product on the market without an approved documentation.
NDA (drug was marketed prior to 1938)
Right Medication When following a physician’s
Letter Classification (Treatment or Therapeutic Potential)
verbal medication order, repeat the order back to him to
A. Drug offers an important therapeutic gain (P-priority) confirm that you both intend the same thing for the patient.
B. Drug that is similar to drugs already on the market Inspect the label on the drug at least three times before
(S-similar) giving the medication to the patient: first, as you remove
the medication from the drug box or cabinet; second, as
Other Classifications
you draw the medication into the syringe or dole the tablet
A. Drugs indicated for AIDS and HIV-related disease into a cup; and third, immediately before you administer
B. Drugs developed to treat life-threatening or severely the medication. Failure to confirm the medication name
debilitating illness is one of the most com-
C. An orphan drug mon medication adminis-
tration errors. If you have Content Review
any question about a drug, ➤➤ Six Rights of Medication
do not administer it with- Administration
Patient Care Using out confirmation. Showing • Right medication
• Right dose
Medications the medication container to
your partner and asking for • Right time
Paramedics are responsible for the standard of care for confirmation is an easy way • Right route
• Right patient
patients in their charge. They are, therefore, personally to further ensure that you
• Right documentation
responsible—legally, morally, and ethically—for the safe are giving the right drug.
360 Chapter 13
Right Dose To reduce medication errors, many drugs you must understand that
Content Review
come in unit dose packaging. That is, the package con- many drugs that affect the
➤➤ Special Considerations
tains a single dose for a single patient. Dosages of many mother also affect the fetus.
• Pregnant patients
emergency drugs, however, are based on patient weight, A drug’s possible benefits
• Pediatric patients
so a prefilled syringe may not contain the exact amount a to the mother must clearly
• Geriatric patients
patient needs. You will have to calculate the correct dose. outweigh its potential risks
One good practice for identifying potential medication to the fetus. For example, some situations such as cardiac
errors is to consider the number of unit dose packages arrest justify giving the mother medications that may harm
needed for a single dose. If your calculations tell you to the fetus because the drug’s possible harm to the fetus
open 10 vials for one dose of medication, for example, pru- is clearly outweighed by the fetus’s certain death if the
dence requires you to check the calculation and dose care- mother dies.
fully. The package may contain a unit dose of the wrong
medication, or you may have miscalculated. Patho Pearls
Right Time Even though paramedics usually give Medications That Cross the Placenta. Some medications
medications in urgent and emergent situations rather than cross the placenta and affect the fetus. Because of this, it is pru-
dent to ask whether a female patient might be pregnant before
on a schedule, timing can still be very important. Giving
administering a medication. In addition, some medications
nitroglycerin tablets too soon may precipitate hypotension;
cross into the breast milk and can potentially affect a breast-
if epinephrine is not repeated on time during cardiac arrest,
feeding baby.
it may not help to lower the threshold for defibrillation.
Take care to give medications punctually and to document
Pregnancy presents two particular pharmacological
their administration promptly.
problems: changes in the mother’s anatomy and physiol-
ogy, and the potential for drugs to harm the fetus. Because
Right Route Often, you will have to choose among
the mother is supporting the fetus entirely, her heart rate,
several treatments for a particular problem. In these cases,
cardiac output, and blood volume will increase. This
knowing the principles of pharmacokinetics can help greatly
altered maternal physiology can affect the onset and dura-
in giving your patient the medication via the right route.
tion of action of many medications. During the first trimes-
For example, your knowledge that you should administer
ter of pregnancy, the ingestion of some drugs (teratogenic
epinephrine intravenously rather than subcutaneously to
drugs) may potentially deform, injure, or kill the fetus.
the patient in anaphylactic shock because knowing that his
During the last trimester, drugs administered to the mother
blood is being shunted away from the skin will guide you
may pass through the placenta to the fetus. Some of these
to the proper administration route.
drugs will have unwanted effects on the fetus. Others may
Right Patient As the paramedic’s role in health care not be metabolized and/or excreted, possibly resulting in
expands, you will find yourself caring for more people than toxic accumulations. Additionally, a breast-feeding moth-
just “the patient in the back of the truck.” You will deal with er’s milk may pass some drugs to her infant.
multiple patients, and the potential for giving medication Under some conditions, of course, the health and
to the wrong patient will be real. You will have to identify safety of mother and fetus demand the use of drugs during
patients by name before administering medications. the pregnancy. Examples include pregnancy-induced dia-
betes, hypertension, and seizure disorders. To help health
Right Documentation The drugs you administer care providers determine when drugs are needed during
in the field do not stop affecting your patients when they pregnancy, the FDA has developed the classification sys-
enter the hospital. As a result, you must completely docu- tem shown in Table 13-2. Always consult medical direction
ment all your care, especially any drugs you have admin- for any questions about drug safety in pregnancy.
istered, so that long after you have gone on to your next
Pediatric Patients Several physiologic factors
call, other providers will know what drugs your patient
affect pharmacokinetics in newborns and young children.
has taken.
These patients’ absorption of oral medications is less than
an adult’s because of various differences in gastric pH, gas-
Special Considerations tric emptying time, and low enzyme levels. A newborn’s
Pregnant Patients Whenever you administer drugs skin is thinner than an older patient’s and is therefore more
to a woman of childbearing years, you must consider the permeable to topically administered drugs. This can result
possibility that she is pregnant. Treating pregnant patients in unexpected toxicity. Older children still have less gastric
clearly means treating two patients. Although emphasis acid than adults do, but their gastric emptying times reach
appropriately seems to center on the mother during care, an adult’s around the sixth to eighth month of life. Because
Emergency Pharmacology 361
P K+
Pharmacokinetics
P K+
Strictly defined, pharmacokinetics is
the study of the basic processes that (d) (e) (f)
determine the duration and intensity
Figure 13-3 Primary active transport by the Na+/K+ pump. The pump possesses three
of a drug’s effect. These four pro-
sodium-binding sites and two potassium-binding sites. ATP is used to power the pump,
cesses are absorption, distribution, which transports sodium ions outside the cell and potassium ions into the cell against their
biotransformation, and elimination. electrochemical gradients. (a) Intracellular Na+ ions bind to the pump protein. (b) The binding
of three Na+ ions triggers phosphorylation of the pump by ATP. (c) Phosphorylation induces
Review of Physiology a conformational change in the protein that allows the release of Na+ in the extracellular
fluid. (d) Extracellular K+ ions bind to the pump protein and trigger release of the phosphate
of Transport group. (e) Loss of the phosphate group allows the protein to return to its original conforma-
Pharmacokinetics is dependent on tion. (f) K+ ions are released to the inside of the cell, and the Na+ sites become again available
the body’s various physiologic for binding.
mechanisms that move substances
across the body’s compartments. These mechanisms can be Large molecules, such as glucose and most of the
broken down into two broad categories based on their amino acids, do not readily pass through the cell mem-
energy requirements and then further classified. A mecha- brane because of their size. These molecules are moved
nism is referred to as active transport if it requires the use across the cell membrane with the help of special “carrier”
of energy to move a substance. This energy is achieved by proteins found on the surface of the target cells. These large
the breakdown of high-energy chemical bonds found in molecules are “carried” across the cell membrane in a spe-
chemicals such as ATP (adenosine triphosphate). ATP is cial transport process called carrier-mediated diffusion or
broken down into ADP (adenosine diphosphate), liberating facilitated diffusion. These mechanisms typically do not
a considerable amount of biochemical energy. A common require the expenditure of energy. Once the molecule to be
example of an active transport mechanism is the sodium– transported binds with the carrier protein, the configura-
potassium (Na+–K+) pump. This is a protein pump that tion of the cell membrane changes, allowing the large mol-
actively moves potassium ions into the cell and sodium ions ecule to enter the target cell. Insulin, an important hormone
out of the cell. Because this movement goes against the ions’ secreted by the endocrine pancreas, can increase the rate of
concentration gradients, it must use energy (Figure 13-3). carrier-mediated glucose transport from 10- to 20-fold.
Emergency Pharmacology 363
Absorption
When a drug is administered to a patient it must find
its way to the site of action. If a drug is given orally or
injected into any place except the bloodstream,
versely, processes such as fever and hyperthermia increase Figure 13-6 Transport of ions across a cell membrane through a
peripheral blood flow and speed absorption. channel protein.
Drugs given orally (enterally) must first survive the
digestive processes before being absorbed across the
mucosa of the gastrointestinal system. If a drug is not solu- a rich vascular system with many capillaries that perfuse
ble in water, it will have difficulty being absorbed. Time- its absorbing surfaces, allowing nutrients (and drugs) to
released medications take advantage of this with an enteric diffuse into the bloodstream.
coating that releases the medication slowly. Some drugs Finally, the drug’s concentration affects its absorption.
have an enteric coating that will not dissolve in the more Because drugs diffuse in the body, the higher their concen-
acidic environment of the stomach, but will dissolve in the tration, the more rapidly the body will absorb them. This
alkaline environment of the duodenum. This allows a drug principle is frequently used when giving a “loading dose”
that would irritate the stomach or be destroyed by stomach of a drug and following it with a “maintenance infusion.”
acid to be passed through the stomach into the duodenum The loading dose is typically a larger dose of the same con-
and absorbed there. Besides being able to survive stomach centration of the drug. On occasion, a more concentrated
acid, a drug must also be somewhat lipid (fat) soluble to solution of the drug is used as the loading dose. Regard-
cross the cells’ lipid two-layered (bilayered) membranes. less, the desired effect is to rapidly raise the amount of the
Many drugs ionize, or become electrically charged or drug in the system to a therapeutic level. This is typically
polar, following administration. Generally, ionized drugs followed by a continuous infusion of the drug at a lower
do not absorb across the membranes of cells (lipid bilay- concentration, or slower administration rate, to keep it at
ers), but fortunately, most drugs do not fully ionize. In the therapeutic level.
addition, ions can be transported across the cell membrane Bioavailability is the measure of the amount of a
through the use of carrier proteins (Figure 13-6). In other drug that is still active after it reaches its target tissue.
instances, they reach an equilibrium between their ionized This is the bottom line as far as absorption is concerned.
and nonionized forms, and the nonionized form can be The goal of administering a drug is to ensure sufficient
absorbed. A drug’s pH also affects the extent to which it bioavailability of the drug at the target tissue in order to
ionizes. A drug that is a weak acid will ionize much more produce the desired effect, after considering all the
substantially in an alkaline environment than in an acidic absorption factors.
environment; conversely, an alkaline drug will ionize more
readily in an acidic environment than in an alkaline envi- Distribution
ronment. For example, aspirin (an acidic drug) does not Once a drug has entered the bloodstream, it must be dis-
dissociate well in the stomach (an acidic environment) and tributed throughout the body. Most drugs will pass easily
is therefore readily absorbed there. from the bloodstream, through the interstitial spaces, into
The nature of the absorbing surface and the blood flow the target cells. Some drugs, however, will bind to proteins
to the administration site also affect drug absorption. The found in the blood—most commonly, albumin—and
rate of absorption is directly related to the amount of sur- remain in the body for a prolonged time. They thus have a
face area available for absorption. The greater the area, the sustained release from the bloodstream and a prolonged
faster the absorption. Much of the gastrointestinal system period of action. The therapeutic effects of a drug are pri-
has multiple invaginations, or folds, that increase its sur- marily due to the unbound portion of the drug in the
face area. Also, the greater the blood flow is to an area, the blood. A drug that is bound to plasma proteins cannot
faster will be the rate of absorption. Again, the GI tract has cross membranes and reach the target cells. Thus, only the
Emergency Pharmacology 365
unbound drug is in equilibrium with the target cells and Because blood flow is lower in fatty areas than in muscu-
can cross the cell membranes. lar areas, fatty tissue is a relatively stable depot; it can nei-
Changing the bloodstream’s pH can affect the pro- ther absorb nor release a large amount of drug in a short
tein-binding action of a drug. Tricyclic antidepressants time. Similarly, bones and teeth can accumulate high
(TCAs), for instance, are strongly bound to plasma pro- amounts of drugs that bind to calcium, especially tetracy-
teins. Making the blood more alkaline increases protein cline antibiotics.
binding of the TCA molecules. Therefore, in addition to
supportive therapy, serious overdoses of TCAs are treated Biotransformation
by administering sodium bicarbonate. Sodium bicarbon- Like other chemicals that enter the body, drugs are metabo-
ate makes the blood more alkaline (raises the pH), caus- lized, or broken down into different chemicals (metabo-
ing increased binding of the TCA to serum proteins. lites). The special name given to the metabolism of drugs
Cumulatively, this decreases the amount of free drug in is biotransformation. Biotransformation has one of two
the blood, thus decreasing the adverse effects. Sodium effects on most drugs: (1) It can transform the drug into a
bicarbonate administration also facilitates elimination of more or less active metabolite, or (2) it can make the drug
the drug through the urine. more water soluble (or less lipid soluble) to facilitate elimi-
The presence of other serum protein-binding drugs nation. Some drugs, such as lidocaine, are totally metabo-
can also affect drug–protein binding. For example, the lized before elimination, others only partially, and still
drug warfarin (Coumadin) is highly protein bound (99 per- others not at all. The body will transform some molecules
cent). Its therapeutic effects are due to the 1 percent of the of most drugs and eliminate others without transforma-
drug that is unbound and circulating in the bloodstream. tion. Protein-bound drugs are not available for biotransfor-
Aspirin molecules bind to the same binding site on the mation. Some so-called prodrugs (or parent drugs) are not
serum proteins as do warfarin molecules. Thus, when aspi- active when administered, but biotransformation converts
rin is administered to a patient on warfarin, it displaces them into active metabolites.
some of the protein-bound warfarin, increasing the amount Many biotransformation processes occur in the liver.
of free (unbound) warfarin in the blood. Even if it displaces The endoplasmic reticula of hepatocytes (liver cells) con-
only 1 percent of the total warfarin, it effectively doubles tain microsomal enzymes that perform much of the metab-
the available warfarin. This can lead to unwanted side olizing. (Smaller quantities of these enzymes are also found
effects, such as hemorrhage. in the kidney, lung, and GI tract.) Because the blood supply
Albumin is one of the chief proteins in the blood that is from the GI tract passes through the liver via the portal
available for binding with drugs. When albumin levels are vein, all drugs absorbed in the GI tract pass through the
low (hypoalbuminemia), as occurs in malnutrition, drugs liver before moving on through the systemic circulation.
that are normally protein bound rise to much greater blood The first pass through the liver may partially or completely
levels than anticipated. For example, consider a patient inactivate many drugs. This first-pass effect is why some
who has been taking warfarin without difficulty. If he drugs cannot be given orally but instead must be given
develops hypoalbuminemia, his normal dose of warfarin intravenously to bypass the GI tract and prevent first-pass
will result in much more of the drug being available in the hepatic metabolism. It is also why drugs that can be given
body, possibly leading to dangerous bleeding. either orally or intravenously may require a much higher
Certain organs exclude some drugs from distribution. oral dose than IV dose. Because we can observe the extent
For example, the tight junctions of the capillary endothelial of first-pass metabolism, we can predict how much to
cells in the central nervous system (CNS) vasculature form increase a dose of an oral medication to deliver an effective
a blood–brain barrier. These cells are packed together so amount of the drug into the general circulation.
tightly that only non–protein-bound, highly lipid-soluble The liver’s microsomal enzymes react with drugs in
drugs can cross into the CNS. The so-called placental two ways: phase I, or nonsynthetic reactions; and phase II,
barrier can likewise prevent drugs from reaching a fetus, or synthetic reactions. Phase I reactions most often oxidize
although it is not the solid barrier that its name implies. the parent drug, although they may reduce it or hydrolyze
The fetus is exposed to almost every drug that the mother it. These nonsynthetic reactions make the drug more water
takes. However, because any drug must traverse the mater- soluble to ease excretion. A number of drugs and chemicals
nal blood supply and cross the capillary membranes into increase the activity of, or induce, the microsomal enzyme
the placental (fetal) circulation, delivering drugs to a fetus that causes phase I reactions. This means that more enzyme
requires them to be lipid soluble, nonionized, and non– is produced, and drugs will be metabolized more rapidly.
protein-bound. This may slow some drugs or reduce their Because the microsomal enzymes are nonspecific, they can
placental transfer to benign levels. be induced by one drug or chemical and then biotransform
Other drugs are deposited in specific tissues. Fatty tis- other drugs or chemicals. Phase II reactions, which are also
sue, for example, can serve as a drug depot, or reservoir. called conjugation reactions, combine the prodrug or its
366 Chapter 13
as an alternative to IV administration in pediatric emer- • Suspensions. Preparations in which the solid does not
gencies, it also sees limited use in adults. dissolve in the solvent; if left alone, the solid portion
• Umbilical. Both the umbilical vein and umbilical will precipitate out.
artery can provide an alternative to IV administration • Emulsions. Suspensions with an oily substance in the
in newborns.3 solvent; even when well mixed, globules of oil sepa-
• Intramuscular (IM). The intramuscular route allows a rate out of the solution.
slower absorption than IV administration, as the drug • Spirits. Solution of a volatile drug in alcohol.
passes into the capillaries. • Elixirs. Alcohol and water solvent, often with flavor-
• Subcutaneous (SC, SQ, SubQ). This route is slower ings added to improve the taste.
than the IM route, because the subcutaneous tissue is • Syrups. Sugar, water, and drug solutions.
less vascular than the muscular tissue.
Some drugs come in a gaseous form. The most common
• Inhaled/nebulized. This route, which offers very rapid
drug supplied this way is oxygen. Paramedics may also
absorption, is especially useful for delivering drugs
find nitrous oxide (N2O) used as an inhaled analgesic in
whose target tissues are in the lungs.
ambulances and emergency departments.
• Topical. Topical administration delivers drugs directly
to the skin. Drug Storage
• Transdermal. For drugs that can be absorbed through Certain guidelines should dictate the manner in which
the skin, the transdermal route allows slow, continu- drugs are stored; their properties may be altered by the
ous release. environment in which they are stored. Some EMS units are
• Nasal. Useful for delivering drugs directly to the nasal parked in heated stations, but others are kept outdoors and
mucosa, the nasal route has an expanding role in deliv- exposed to the elements. EMS systems must consider the
ering systemically acting drugs. storage requirements of all drugs and diluents when decid-
ing operational issues such as vehicle design and posting
• Instillation. Instillation is similar to topical adminis-
policies (as occur in system status management). This rap-
tration, but places the drug directly into a wound or
idly becomes a clinical issue because the actual potency of
an eye.
most medications is altered if they are not stored in proper
• Intradermal. For allergy testing, intradermal adminis- conditions. Examples of variables to consider when deter-
tration delivers a drug or biological agent between the mining the proper method of drug storage include temper-
dermal layers. ature, light, moisture, and shelf life.
receptor. When multiple other times, they are either reactivated or remanufac-
Content Review
drugs stimulate the same tured by the protein-manufacturing mechanism of the
➤➤ Types of Drug Actions
receptor, standard practice cell. Binding of a drug (or hormone) to a target cell recep-
• Binding to a receptor
is to use the generic name. tor causes the number of available receptors to decrease.
site
The force of attraction This process is known as down-regulation of the recep-
• Changing the physical
properties of cells between a drug and a tors. It results in a decreased responsiveness of the target
• Chemically combining receptor is their affinity. cell to the drug or hormone as the number of available
with other chemicals The greater the affinity, the active receptors decreases. In other cases, but less com-
• Altering a normal stronger the bond. Differ- monly, a drug (or hormone) can cause the formation of
metabolic pathway ent drugs may bind to the more receptors than normal. This process, up-regulation,
same type of receptor site, increases the target tissue’s sensitivity to the particular
but the strength of their bond may vary. The binding site’s drug or hormone.
shape determines its receptivity to other chemicals, Chemicals that stimulate a receptor site generally fall
whether they are drugs or endogenous substances. These into two broad categories—agonists and antagonists.
binding sites are relatively specific—a nonopiate drug gen- Agonists bind to the receptor and cause it to initiate the
erally will not affect an opiate binding site, although occa- expected response. Antagonists bind to a site but do not
sionally a drug with a similar receptor binding site will cause the receptor to initiate the expected response. Some
unexpectedly cross react. Receptors can also have sub- drugs, agonist–antagonists (also called partial agonists),
types. At least five subtypes of adrenergic receptors, for may do both. Nalbuphine (Nubain), for instance, stimu-
example, are important to paramedic practice. lates some of the opioid agonists’ analgesic properties but
A drug’s pharmacodynamics also involves its ability partially blocks others such as respiratory depression
to cause the expected response, or efficacy. Just as different (Figure 13-7).
drugs may have different affinities for a site, they may also
have different efficacies; that is, drug A may cause a stron-
ger response than drug B. Affinity and efficacy are not
Neuro-
directly related. Drug A may cause a stronger response transmitter
than drug B, even though drug B binds to the receptor site
more strongly than drug A.
When a drug binds with its specific type of receptor, a Gives
pharmacological
chemical change occurs that ultimately leads to the drug’s
response
effect. In most cases, drugs will either stimulate or inhibit Receptor site
the cell’s normal biochemical actions. In fact, a drug can-
not impart a new function to a cell. Some drugs may
interact with a receptor and directly result in the desired Agonist
effect. Other drugs, however, may interact with a receptor
and cause the release or production of a second com-
Gives
pound. This secondary compound, or second messenger, pharmacological
includes such compounds as calcium or cyclic adenosine response
Receptor site
monophosphate (cAMP). Cyclic AMP is the most com-
mon second messenger. It has a multitude of effects inside
the cell. These secondary messengers are particularly
Antagonist
important in the endocrine system, as they occur princi-
pally in endocrine glands. Once cAMP is formed inside
the cell, it activates still other enzymes, usually in a cas-
cading action. That is, the first enzyme activates another Gives NO
pharmacological
enzyme, which activates a third enzyme, and so forth.
response
This is important in that it amplifies the action so that Receptor site
even a small amount of a drug (or hormone) acting on the
cell surface can initiate a powerful, cascading, activating
force for the entire cell. Figure 13-7 Receptor site interactions. (top) Naturally occurring
neurotransmitter binds to receptor site and creates a physiologic
The number of receptors on a target cell usually does
response. (middle) Administered drug (agonist) binds to the receptor
not remain constant on a daily basis, or even from min- site and creates a physiologic response. (bottom) A drug (antagonist)
ute to minute. This is because the receptor proteins are binds to the receptor site but does not cause a physiologic response
often destroyed during the course of their function. At and prevents agonists from binding to the receptor site.
Emergency Pharmacology 369
Receptor-mediated drug actions work like a lock (the triggers the normal regulatory systems to decrease water
receptor) and key (the agonist). If you put the key in the reabsorption in the renal tubules, thereby reducing the total
lock and turn it, the lock will open. An antagonist is like a amount of water in the body.
key that fits into the lock but will not turn and cannot open
the lock. Target tissues generally have many receptors, so Drugs That Act by Chemically Combining
to take the analogy another step, imagine that to get maxi- with Other Substances Drugs that participate
mal effect a single key (agonist) must move around and in chemical reactions that change the chemical nature of
open many doors (trigger many biochemical responses). their substrates (the chemical or substance on which a drug
An agonist–antagonist would be a key that unlocks and acts) play a large role in paramedic practice. For example,
opens a door but gets stuck in the lock. That is, the drug isopropyl alcohol, which is often used to disinfect skin
will cause the expected effect, but that drug will also block before percutaneous needle insertion for phlebotomy or IV
another drug from triggering the same receptor. This com- cannulation, denatures the proteins on the surface of bacte-
petitive antagonism is considered surmountable because a rial cells. This ruptures the cells, destroying the bacteria.
sufficiently large dose of the agonist can overcome the The antacids are another example. They act by chemically
antagonism. neutralizing the hydrochloric acid in the stomach. Sodium
Noncompetitive antagonism can also occur. Continu- bicarbonate given intravenously chemically neutralizes
ing the lock, key, and door analogy, imagine that the door some of the acids in the bloodstream, effectively making
is barred. This antagonism would be insurmountable; no the blood more alkalotic.
amount of agonist could overcome it. Noncompetitive
Drugs That Act by Altering a Normal Meta-
antagonism occurs because the binding of the antagonist at
bolic Pathway Some anticancer and antiviral drugs
a different site causes a deformity of the binding site that
are chemical analogs of normal metabolic substrates. In a
actually prevents the agonist from fitting and binding.
process that has been dubbed a counterfeit incorporation
Irreversible antagonism may also occur when a competi-
mechanism, these drugs can be incorporated into the prod-
tive antagonist permanently binds with a receptor site.
ucts of metabolism of cancer cells. Because these drugs are
When this occurs, no amount of agonist will stimulate the
not really the expected substrate, the anticipated product
receptor. For the effects of such an antagonist to wear off,
either will not form or, if formed, will be substantially or
the body must create new receptors.
completely inactive.
Two drugs may appear to be antagonists while actu-
ally acting independently. This physiologic antagonism Responses to Drug Administration
can occur when one drug’s effects counteract another’s. When a drug is administered, a response is obviously
Although neither agent chemically affects the other, their anticipated. The actual response may be the one desired, or
net effect is antagonistic. An example of a receptor, agonist, it may be an unintended side effect. Most, if not all, drugs
antagonist, and agonist–antagonist can be described using have at least some minor side effects. Because our knowl-
an opiate receptor. These receptors occur naturally in the edge of pharmacology and physiology has not yet arrived
brain and respond to natural endorphins. Morphine sulfate at the point at which we can engineer the perfect drug, we
acts as an agonist. It binds to the opiate receptor and causes must weigh the need for the desired response against the
the expected response of pain relief. Naloxone (Narcan) dangers of side effects. In essence, every time we give a
acts as an antagonist. It will bind to the opiate receptor, but medication, we must carefully weigh the risks against the
will not initiate the pain relief. It will prevent morphine benefits. Although undesirable, side effects are predictable.
sulfate from binding to the site and thus effectively blocks Iatrogenic responses, however, are not predicted. In gen-
the morphine and its response. If the patient is given nal- eral, the term iatrogenic refers to a disease or response
buphine (Nubain), an agonist–antagonist, it will bind to induced by the actions of a care provider. Derived from the
the opiate receptor and relieve pain, but it is less efficacious Greek iatros (physician) and gennan (to produce), it literally
than morphine. The nalbuphine blocks morphine from the means physician produced. Negligence is not the only cause
receptor like an antagonist but stimulates the receptor on of iatrogenic responses. Some common unintended adverse
its own like an agonist, although to a lesser extent. responses to drugs include:
Drugs That Act by Changing Physical Prop- • Allergic reaction. Also known as hypersensitivity; this
erties Some drugs change the physical properties of effect occurs as the drug is antigenic and activates the
a part of the body. Drugs that change the osmotic bal- immune system, causing effects that are normally
ance across membranes are good examples of this type of more profound than seen in the general population.
drug action. The osmotic diuretic mannitol (Osmotrol), for • Idiosyncrasy. A drug effect that is unique to the indi-
instance, increases urine output by increasing the blood’s vidual; different than seen or expected in the popula-
osmolarity, or osmotic “pull.” This increased osmolarity tion in general.
370 Chapter 13
be 10 minutes. After another 10 minutes, 125 mcg/dL may cause nausea if taken on an empty stomach and
would remain. must therefore be taken only after eating.
• Pathological state. Several disease states alter the
Factors Altering Drug Response drug-response relationship. Most notable are renal
Different individuals may have different responses to the and hepatic dysfunctions, both of which may lead to
same drug given. Factors that alter the standard drug- excess accumulation of a drug in the body. Renal fail-
response relationship include the following: ure is likely to decrease elimination of drugs, whereas
hepatic failure may decrease or inhibit their metabo-
• Age. The liver and kidney functions of infants are not
lism, prolonging their duration of action. Acid–base
yet fully developed, so the response to drugs may be
disturbances may alter a drug’s solubility or the
altered. Likewise, as we age, the functions of these
extent to which it ionizes, thus changing its absorp-
organs begin to deteriorate. As a result, infants and the
tion rate.
elderly are most susceptible to having an altered
• Genetic factors. Genetic traits such as the lack of spe-
response to a drug.
cific enzymes or lowered basal metabolic rate alter
• Body mass. The more body mass a person has, the drug absorption or biotransformation and thus modify
more fluid is potentially available to dilute a drug. A the patient’s response.
given amount of drug will cause a higher concentra-
• Psychological factors. A patient’s mental state can
tion in a person with little body mass than in a much
also affect his response to a drug. The best-known
larger person. Thus, most drug dosages are stated in
example of this is the placebo effect. Essentially, if a
terms of body mass. For example, the standard dose of
patient believes that a drug will have a given effect,
fentanyl for a patient in pain is 1.0 mcg/kg. A 100-kg
then he is much more likely to perceive that the effect
patient will receive 100 mcg of fentanyl, whereas a
has occurred.
50-kg patient will receive only 50 mcg.
• Sex. Most differences in drug response due to sex
Drug–Drug Interactions
result from the relative body masses of men and
Drug–drug interactions occur whenever two or more
women. The different distribution and amounts of
drugs are available in the same patient. The interaction can
body fat also affect the amounts of drug available at
increase, decrease, or have no effect on their combined
any given time.
actions. Any number of variables may cause these drug–
• Environmental milieu. Various stimuli in a patient’s drug interactions, including the following:
environment affect his response to a given drug. This
is most clearly seen with drugs affecting mood or • One drug could alter the rate of intestinal absorption.
behavior. The same dose of an antianxiety medication • The two drugs could compete for plasma protein
such as diazepam (Valium) will have different effects, binding, resulting in one’s accumulation at the other’s
depending on the patient’s mood or surroundings. For expense.
example, if the patient were afraid of heights, his usual • One drug could alter the other’s metabolism, thus
dose of diazepam would not be likely to help him increasing or decreasing either’s bioavailability.
remain calm while rappelling from the top of a tall • One drug’s action at a receptor site may be antagonis-
building. Surrounding conditions may also affect the tic or synergistic to another’s.
distribution or elimination of a drug. Heat, for exam-
• One drug could alter the other’s rate of excretion
ple, causes vasodilation and increases perspiration,
through the kidneys.
both of which may alter
the rate at which the • One drug could alter the balance of electrolytes neces-
Content Review
body distributes and sary for the other drug’s expected result.
➤➤ Factors Affecting Drug-
eliminates a drug. In addition to drug-drug interactions, other types of
Response Relationship
• Age • Time of administration. interactions are possible. They include a drug’s effects on
• Body mass If a patient takes a drug the rate of absorption of food and nutrients, alteration of
• Sex immediately after eat- enzymes, and food-initiated alteration of drug excretion.
• Environment ing, its absorption will Alcohol consumption and smoking may also cause interac-
• Time of administration be different than if he tions with drugs. Finally, some drugs are incompatible
• Pathology took the same drug with each other. As an example, catecholamines such as
• Genetics epinephrine will precipitate in an alkaline solution such as
before breakfast in the
• Psychology
morning. Some drugs sodium bicarbonate.
372 Chapter 13
Part 2: Drug Classifications cord; all nerves that originate and terminate within either
the brain or the spinal cord are considered central. The
derivatives and nonopioid derivatives. Opioid antago- kappa k Analgesia, sedation, and miosis,
nists, which we also discuss in this section, reverse the respiratory depression, and
dysphoria
effects of opioid analgesics; adjunct medications enhance
the effects of other analgesics. sigma s Psychotomimetic (i.e., hallucina
tions), dysphoria, and possibly
dilation of the pupils
Opioid Agonists An opioid is chemically similar
to opium, which is extracted from the poppy plant and epsilon ´ Effects uncertain
has been used for centuries for its analgesic and halluci-
natory effects. Opium and all its derivatives effectively
treat pain because of their similarity to natural pain- sedation, and miosis (pupil constriction). It also decreases
reducing peptides called endorphins. Endorphins and, by cardiac preload and afterload, which makes it useful in
extension, opioid drugs work through opiate receptors treating myocardial infarction and pulmonary edema. At
and decrease by decreasing the sensory neurons’ ability higher doses, it may cause respiratory depression and
to propagate pain impulses to the spinal cord and brain. hypotension (Figure 13-9). Table 13-4 details common opi-
At least five types of opiate receptors have been identified oids used in EMS.4–10
(Table 13-3).
The prototype opioid drug is morphine. Several of Nonopioid Analgesics Three broad types of non-
morphine’s effects make it useful for clinical practice. At opioid medications also have analgesic properties, several
therapeutic doses, morphine causes analgesia, euphoria, of which also share antipyretic (fever-fighting) properties.
Opiate Receptors
–
–
Figure 13-9 The effects of opiates on opiate receptors. Opiates modify the action of dopamine in selected areas of the brain, which form part
of the brain’s “reward pathway.” After crossing the blood–brain barrier, opiates act on the various opioid receptors. This binding inhibits the
release of GABA from the nerve terminal, reducing the inhibitory effect of GABA on dopaminergic neurons. The increased activation of dopami-
nergic neurons and the release of dopamine into the synaptic cleft results in activation of the postsynaptic membrane. Continued activation of
the dopaminergic reward pathway leads to the feelings of euphoria and the “high” associated with opiate use. Morphine is a powerful agonist
at the opioid mu receptor subtype, and activation of these receptors has a strong activating effect on the dopaminergic reward pathway.
Table 13-4 Common Opioids
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Morphine Narcotic (opioid) Analgesia and • Moderate– • Hypotension 2–10 mg IV, IO, • Hypotension • Use appropriate
Duramorph sedation through severe pain • Hypersensitivity IM, SQ, • Syncope monitors
binding to opiate to the drug PO • Tachycardia • Naloxone is an
receptors • Bradycardia antagonist
• Apnea
• Nausea
• Vomiting
• Respiratory
depression
Hydromorphone Narcotic (opioid) Analgesia and • Moderate– • Hypersensitivity 0.5–2.0 mg IV, IO, • Nausea • Use appropriate
Dilaudid sedation through severe pain to the drug IM, SQ, • Vomiting monitors
binding to opiate PO • Cramps • Naloxone is an
receptors • Respiratory antagonist
depression
Fentanyl Narcotic (opioid) Analgesia through • Moderate– • Hypersensitivity 50–100 mcg IV, IO, • Nausea • Use appropriate
Sublimaze binding to opiate severe pain to the drug IM, SQ, • Vomiting monitors
receptors • Anesthetic IN • Cramps • Naloxone is an
• Chest wall antagonist
rigidity
• Respiratory
depression
Meperidine Narcotic (opioid) Analgesia through • Moderate– • Hypersensitivity 25–100 mg IV, IO, • Nausea • Use appropriate
Demerol binding to opiate severe pain to the drug IM, SQ, • Vomiting monitors
receptors • Patients receiving PO • Euphoria • Naloxone is an
monamine oxidase • Dysphoria antagonist
inhibitors (MAOIs) • Respiratory
depression
374
Emergency Pharmacology 375
These are salicylates, such as aspirin; nonsteroidal anti-inflam- are rarely used singly; rather, several different agents are
matory drugs (NSAIDs), such as ibuprofen and ketorolac; typically given together to achieve a balanced anesthetic
and para-aminophenol derivatives, such as acetaminophen. result. For example, intubating a conscious patient requires
The drugs in each of these classes affect the production of his natural gag reflex to be inhibited. Neuromuscular
prostaglandins and cyclooxygenase, important neurotrans- blocking agents such as succinylcholine are used to induce
mitters involved in the pain response. Table 13-5 details paralysis. Because this would be a terribly frightening and
common nonopioid analgesics. potentially painful procedure, antianxiety, amnesic, and
analgesic agents are also given to produce the desired
Opioid Antagonists Opioid antagonists are useful anesthetic effect.
in reversing the effects of opioid drugs. Typically, this is Anesthetics are given either by inhalation or injec-
necessary to treat respiratory depression. Naloxone (Nar- tion. The gaseous anesthetics given by inhalation include
can) is the prototype opioid antagonist. It competitively halothane, enflurane, and nitrous oxide. The first clini-
binds with opioid receptors but without causing the effects cally useful anesthetic was ether, a gas. Its discovery
of opioid bonding. It is commonly used to treat overdoses marked a new generation in surgical care, but it is very
of heroin and other opioid derivatives; however, it has a flammable. The modern gaseous anesthetics are much
shorter half-life than most opioid drugs, so repeated doses less volatile, but still decrease consciousness and sensa-
may be necessary to prevent its unwanted side effects. tion as required. These drugs, by some as-yet-unidenti-
Table 13-6 details common opiate antagonists.11–13 fied mechanism, hyperpolarize neural membranes,
making depolarization more difficult. This decreases the
Adjunct Medications Adjunct medications are firing rates of neural impulses and, therefore, the propa-
given concurrently with other drugs to enhance their effects. gation of action potentials through the nervous system,
Although they may have only limited or no analgesic prop- thus reducing sensation. These effects appear to depend
erties by themselves, combined with a true analgesic they on the gases’ solubility. The rate of onset of anesthesia
either prolong or intensify its effect. Examples of adjunct further depends on several additional factors, including
medications are benzodiazepines (diazepam [Valium], cardiac output, inhaled concentration of gas, pulmonary
lorazepam [Ativan], midazolam [Versed]), antihistamines minute volume, and end organ perfusion. Because these
(promethazine [Phenergan]), and caffeine. We will discuss gases clear mostly through the lungs, respiratory rate and
many of these agents in separate sections. depth affect the duration of their effect. Although halo-
thane is the prototype of inhaled anesthetics, nitrous
Opioid Agonist–Antagonists An opioid ago- oxide is the only medication in this class with which you
nist–antagonist displays both agonistic and antagonistic are likely to have much involvement.
properties. Pentazocine (Talwin) is the prototype for this Most anesthetics used outside the operating room are
class. Nalbuphine (Nubain) was commonly used in field given intravenously. This gives them a considerably faster
care. It is an agonist because, like opioids, it decreases onset and shorter duration, making them much more use-
pain response, and it is an antagonist because it has fewer ful in emergency care. Paramedics use these agents primar-
respiratory depressant and addictive side effects. Butor- ily to assist with intubation in rapid-sequence intubation.
phanol (Stadol) is another common opioid agonist–antago- They include several pharmacological classes, such as
nist. Although rarely used in modern EMS, these drugs are ultra-short-acting barbiturates (thiopental [Pentothal] and
detailed in Table 13-7. methohexital [Brevital]), benzodiazepines (diazepam
[Valium] and midazolam [Versed]), and opioids (fentanyl
Anesthetics [Sublimaze] and remifentanil [Ultiva]). We discuss barbitu-
Unlike analgesics, an anesthetic induces a state of anesthe- rates’ and benzodiazepines’ mechanisms of action in the
sia, or loss of sensation to touch or pain. Anesthetics are section on antianxiety and sedative–hypnotics.14–15
useful during unpleasant procedures such as surgery or Anesthetics are also given locally to block sensation
electrical cardioversion. At low levels of anesthesia, for procedures such as suturing and most dentistry. These
patients may have a decreased sensation of pain but remain agents are injected into the skin around the nerves that
conscious. Neuroleptanesthesia, a type of anesthesia that innervate the area of the procedure. They decrease the
combines this effect with amnesia, is useful in procedures nerve’s ability to depolarize and propagate the impulse
that require the patient to remain alert and responsive. from this area to the brain. Cocaine’s first clinical use was
Anesthetics as a group tend to cause respiratory, cen- as a topical anesthetic of the eye in 1884. The current proto-
tral nervous system (CNS), and cardiovascular depression. type of this class is lidocaine (Xylocaine). It is frequently
Different agents affect these systems to different degrees mixed with epinephrine. The epinephrine causes local
and are typically chosen for their ability to produce the vasoconstriction, decreasing bleeding and systemic absorp-
desired effect with minimal side effects. Anesthetic agents tion of the drug.
Table 13-5 Common Nonopioid Analgesics
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Acetaminophen Nonnarcotic Exact mechanism • Mild–moderate • Hypersensitivity 325–650 mg PO, IV • Rare • Can be liver
Tylenol, OFIRMEV analgesic, uncertain, but felt pain to the drug toxic—use
(injectable) antipyretic to inhibit • Fever • Alcoholism minimal dose
(para-aminophenol cyclooxygenase • Chronic liver disease necessary
derivative)
376
Table 13-6 Common Opioid Antagonists
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Naloxone Opiate Opioid antagonist • Partial • Hypersensitivity 0.4–2.0 mg IV, IO, SQ, • Fever • Administer
Narcan antagonist without opiate reversal of to the drug IN, nebulizer • Chills enough to reverse
agonist properties opiate drug • Nausea respiratory
(it has no activity effects • Vomiting depression and
when given in the • Opiate • Diarrhea avoid full narcotic
absence of an overdose • Opiate withdrawal
opiate agonist) withdrawal syndrome
Nalmefene Opiate Opioid antagonist • Partial • Hypersensitivity 0.5–1.0 mg IV, IM, SQ, IO • Fever • Duration of effect
Revex antagonist without opiate reversal of to the drug • Chills much longer than
agonist properties opiate drug • Nausea naloxone
(it has no activity effects • Vomiting
when given in the • Opiate • Diarrhea
absence of an overdose • Opiate
opiate agonist) withdrawal
Butorphanol Opiate agonist– Analgesia and • Moderate– • Hypersensitivity 1–4 mg IV, IM, SQ, • Sedation • Use with caution
Stadol antagonist sedation through severe pain to the drug IO, IN • Dizziness in patients with
binding to opiate • Opiate • Nausea liver and renal
receptors. It also dependence • Vomiting disease
has some opiate • Respiratory • Opiate
receptor antagonistic depression withdrawal
properties.
377
378 Chapter 13
• Moderate sedation, also called conscious seda- Figure 13-10 The effects of benzodiazepines on GABA A receptors. Their binding
tion, is characterized by purposeful response causes a conformational change in the receptor that results in an increase in GABA
to verbal and/or tactile stimulation. A receptor activity. BDZs do not substitute for GABA, which bind at the alpha
subunit, but increase the frequency of channel-opening events, which leads to an
• Deep sedation is characterized by purposeful increase in chloride ion conductance and inhibition of the action potential.
response to repeated or painful stimulation.
• General anesthesia is characterized by unarousable
Both benzodiazepines and barbiturates hyperpolar-
unresponsiveness, even with painful stimulation.
ize the membrane of central nervous system neurons,
Hypnosis in this context refers to the instigation of which decreases their response to stimuli. Gamma-ami-
sleep. Sleep may be categorized as either rapid-eye- nobutyric acid (GABA) is the chief inhibitory neu-
movement (REM) or non-rapid-eye-movement (non- rotransmitter in the central nervous system. GABA
REM). REM sleep is characterized by rapid eye movements receptors are dispersed widely throughout the CNS on
and lack of motor control. Most dreaming is thought to proteins that make up chloride ion channels in the cell
occur during REM sleep. Insomnia, or difficulty sleeping, membrane. When GABA combines with these receptors,
typically presents with increased latency (the period of the channel “opens” and chloride, which is more preva-
time between lying down and going to sleep) or awaken- lent outside the cell, diffuses through the channel. As
ing during sleep. chloride is an anion, or negative ion, it makes the inside
The two main pharmacological classes within this of the cell more negative than the outside. This hyperpo-
functional class are benzodiazepines and barbiturates. larizes the membrane and makes it more difficult to
Alcohol is also in this functional class. Benzodiazepines depolarize. Depolarization therefore requires a larger
and barbiturates work in similar ways. Benzodiazepines stimulus to cause the cell to fire. Both benzodiazepines
are frequently prescribed for oral use and are relatively and barbiturates increase the GABA receptor–chloride
safe and effective for treating general anxiety and insom- ion channel complexes’ potential for binding with
nia. Barbiturates, which have broader general depressant GABA, and both are dose dependent (Figure 13-10). At
activities and a higher potential for abuse, are used much low doses, they decrease anxiety and cause sedation
less frequently than benzodiazepines. Before the release of (See Tables 13-8 and 13-9.) As the dose increases, they
benzodiazepines in the 1960s, however, barbiturates were induce sleep (hypnosis) and, at higher doses, anesthesia.
the drug of choice for treating anxiety and insomnia. Because benzodiazepines only increase the effectiveness
Airway Unaffected No intervention required Intervention may be required Intervention often required
Diazepam Benzodiazepine Binds to Type A • Anxiety • History of 2–10 mg IV, IM, • Hypotension • Incompatible with other
Valium GABA receptors, • Seizures hypersensitivity IO, PO, • Sedation medications because it is
causing sedation • Sedation to the drug rectal • Amnesia not water soluble.
• Muscle • Respiratory depression • Can cause irritation with
relaxation • Nausea injection.
• Vomiting • Flumazenil is an antagonist.
Midazolam Benzodiazepine Binds to Type A • Anxiety • History of 1–5 mg IV, IM, • Hypotension • Flumazenil is an antagonist.
Versed GABA receptors, • Sedation hypersensitivity IO, • Sedation
causing sedation • Seizures to the drug • Amnesia
• Respiratory depression
• Nausea
• Vomiting
Lorazepam Benzodiazepine Binds to Type A • Anxiety • History of 1–4 mg IV, IM, • Hypotension • Flumazenil is an antagonist.
Ativan GABA receptors, • Sedation hypersensitivity IO, PO, • Sedation
causing sedation • Seizures to the drug rectal • Amnesia
• Respiratory depression
• Nausea
• Vomiting
Dissociative Agents
Ketamine Dissociative Causes dissociation • Sedation • History of 0.5–1.0 mg/kg IV, IM • Hallucinations • All monitors should be in place.
Ketalar anesthetic between the cortical • Analgesia hypersensitivity (IV); 2–4 mg/kg • Resuscitative equipment should be
and limbic system to the drug (IM) immediately available.
• Hypertension
Miscellaneous Agents
Nitrous Sedative/anesthetic CNS depressant • Pain • COPD Self- Inhalation • Dizziness • Should not be used in any patient
Oxide gas • Sedation • Pneumothorax administered • Hallucinations who cannot comprehend verbal
• Bowel • Nausea instructions or who is intoxicated
obstruction • Vomiting with alcohol or other medications.
• Altered mental status
Propofol Nonbarbiturate, Uncertain, but • Sedation • History of 25–75 mcg/ IV • Pain on induction • All monitors should be in place.
Diprivan nonbenzodiazepine appears to hypersensitivity kg/min • Nausea • Resuscitative equipment should be
sedative potentiate GABA to the drug • Vomiting immediately available.
receptors • Hypersensitivity • Respiratory depression
of soy or egg
products
Etomidate Nonbarbiturate, Appears to modulate • Sedation • History of 0.1–0.3 mg/kg IV • Myoclonic jerks • Does not have analgesic properties.
Amidate nonbenzodiazepine GABA receptors hypersensitivity • Respiratory depression • Calcium-channel blockers can
sedative to the drug • Laryngospasm prolong respiratory depression.
• Can cause increased cortisol levels.
• All monitors should be in place.
• Resuscitative equipment should be
immediately available.
380
Emergency Pharmacology 381
will use other treatments such as psychotherapy and elec- medications, frequently in
Content Review
troconvulsive therapy in conjunction with pharmaceuti- conjunction with medica-
➤➤ Major Classes of Antipsy-
cal interventions. tions from other classes
chotic Medications
Although we do not completely understand these dis- such as antianxiety drugs or
• Phenothiazines
eases’ specific pathologies, they seem to involve the mono- antidepressants. Extrapyra-
• Butyrophenones
amine neurotransmitters in the central nervous system. midal symptoms (EPS), a • Atypicals
These neurotransmitters (norepinephrine, dopamine, sero- common side effect of anti-
tonin) have been implicated in the control and regulation psychotic medications,
of emotions. Imbalances in these neurotransmitters, espe- include muscle tremors and parkinsonism-like effects. As a
cially dopamine, appear to be at least involved with, if not result, antipsychotic medications are also known as neuro-
responsible for, most mental disease. Regulating these and leptic (literally, affecting the nerves) drugs.
other excitatory and inhibitory neurotransmitters forms The two chief pharmaceutical classes of antipsychotics
the basis for psychopharmaceutical therapy. Schizophrenia and neuroleptics are phenothiazines and butyrophenones.
appears to be related to an increased release of dopamine, Both have been mainstays of psychiatry since the mid-
so treatment is aimed at blocking dopamine receptors. 1950s and are considered traditional antipsychotic drugs.
Depression seems to be related to inadequate amounts of Medications in this group block dopamine, muscarinic ace-
these neurotransmitters, so treatment is aimed at increas- tylcholine, histamine, and alpha1 adrenergic receptors in
ing their release or duration. the central nervous system. These medications’ therapeutic
The major diseases treated with psychotherapeutic med- effects appear to come from blocking the dopamine recep-
ications are schizophrenia, depression, and bipolar disorder. tors; their side effects are fairly well understood to origi-
The Diagnostic and Statistical Manual of Mental Disorders, fifth nate in blocking the other receptors. The phenothiazines’
edition (DSM-5), published by the American Psychiatric and butyrophenones’ mechanisms of action are the same;
Association, gives schizophrenia’s chief characteristics as a they differ only in potency and pharmacokinetics. The dis-
lack of contact with reality and disorganized thinking. Its tinction between potency and strength is important.
many different manifesta- Strength refers to the drug’s concentration, whereas
tions include delusions, hal- potency is the amount of drug necessary to produce the
Content Review lucinations (auditory more desired effect. Although the phenothiazines are considered
➤➤ Major Diseases Treated frequently than visual), dis- low-potency and the butyrophenones are considered high-
with Psychotherapeutic organized and incoherent potency, they both produce the same effect. The differences
Medications speech, and grossly disorga- in potency and pharmacokinetics determine which class of
• Schizophrenia nized or catatonic behavior. medication will be prescribed. Chlorpromazine (Thora-
• Depression
Schizophrenia is typically zine) is the prototype phenothiazine; haloperidol (Haldol)
• Bipolar disorder
treated with antipsychotic is the prototype of the butyrophenones (Figure 13-12).
Neuroleptic Actions
5 HT Nerve Nerve
Noradrenaline terminal terminal
Dopamine
Histamine
Haloperidol
(typical)
Figure 13-12 The mechanism of action of haloperidol. Haloperidol is an older “typical,” or “first-generation” drug. It is nonselective and
binds to a broad range of receptors. It can bind to dopamine, histamine, and a2 adrenergic receptors in the brain.
Emergency Pharmacology 383
Ziprasidone Unclassified Inhibits uptake • Psychosis • Hypersensitivity 50–100 mcg IM, PO • Extrapyramidal • Carbamazepine
Geodon antipsychotic of serotonin and • Tourette’s to the drug reactions (Tegretol) can
dopamine syndrome • Insomnia decrease ziprasidone
• Restlessness levels.
• Dry mouth
• Hypotension
• Tachycardia
384
Emergency Pharmacology 385
Drugs Used to Treat Parkinson’s Disease brain barrier. Levodopa is absorbed by the dopamine-
Parkinson’s disease is a nervous disorder caused by the releasing neuron terminals, where the enzyme
destruction of dopamine-releasing neurons in the substan- decarboxylase metabolizes it into dopamine, thus increas-
tia nigra, a part of the basal ganglia, which is a specialized ing the amount of dopamine available for release. Levodopa
area of the brain involved in controlling fine movements. is very effective and reduces symptoms in the vast majority
Dysfunction of parts of the basal ganglia causes the extra- of patients. As previously mentioned, however, symptoms
pyramidal symptoms (EPS) often seen as a side effect of will return within a period of years as the disease pro-
antipsychotic medications. gresses. Levodopa’s side effects include nausea, vomiting,
Parkinson’s disease is characterized by dyskinesia and ironically, for unknown reasons, dyskinesias. Because it
(dysfunctional movements) such as involuntary tremors, is converted to dopamine, levodopa may also have cardio-
unsteady gait, and postural instability. Severe cases also vascular effects, including tachycardias and hypertension.
involve bradykinesia (slow movements) and akinesia (the When given alone, levodopa is metabolized primarily
absence of movement). In the later stages, patients fre- outside the brain, where it is ineffective. To prevent this,
quently present with psychological impairment, including Sinemet, the most popular anti-Parkinson preparation
dementia, depression, and impaired memory. Parkinson’s available, combines levodopa with an inactive ingredient,
is a progressive disease that usually begins in middle age carbidopa. Although carbidopa by itself produces no
with subtle signs and progresses to a state of incapacitation. effects, it prevents levodopa’s conversion into dopamine in
Although no treatments can cure Parkinson’s or even slow the periphery. Because carbidopa does not cross the blood–
its progression, treating the symptoms can return some brain barrier, however, levodopa can still be metabolized
function to the patient. The goal in treating these patients is in the CNS. This decreases the incidence of cardiovascular
to restore their ability to function without causing unac- side effects and enables lower doses of levodopa to be
ceptable side effects. Some remarkably effective drugs are effective. Sinemet’s side effects are essentially those of
available. Unfortunately, they usually are effective for only levodopa by itself. Nausea and vomiting, stimulated from
several years. After that, signs and symptoms return and within the CNS, remain problematic.
often are more severe than before treatment began. Another dopaminergic medication, amantadine (Sym-
The medications that are effective in treating Parkin- metrel), promotes the release of dopamine from the dopa-
son’s disease are also effective in treating the EPS of anti- mine-releasing neurons that remain unaffected by the
psychotics. This is because fine motor control is based in disease. It has a rapid onset but generally becomes ineffec-
part on a balance between inhibitory and excitatory neu- tive in less than a year. Although it can be effective alone, it
rotransmitters. In the basal ganglia, dopamine, an inhibi- is usually given in conjunction with Sinemet or levodopa.
tory transmitter, opposes acetylcholine, an excitatory Several other medications, such as bromocriptine, directly
neurotransmitter. Parkinson’s disease and the medications stimulate the dopamine receptors instead of attempting to
that cause EPS both decrease the number of presynaptic increase the amount of dopamine released.
terminals that release dopamine in the basal ganglia. This One additional dopaminergic approach is to decrease
allows the excitatory stimulus of acetylcholine to domi- the breakdown of dopamine after it has been released. The
nate, ultimately impeding fine motor control. enzyme responsible for breaking down monoamines such
Pharmacological therapy for Parkinson’s disease seeks as norepinephrine, dopamine, and serotonin is monoamine
to restore the balance of dopamine and acetylcholine. This oxidase. (We have previously described monoamine oxi-
may be done either by increasing the stimulation of dopa- dase inhibitors in our discussion of their role in depres-
mine receptors or by decreasing the stimulation of acetylcho- sion.) One monoamine oxidase inhibitor, selegiline
line receptors. Drugs can do this either through dopaminergic (Carbex), is specific for monoamine oxidase type B. This
effects or through anticholinergic effects. Dopaminergic MAO-B enzyme is involved only in the breakdown of
effects increase the release of dopamine from the neuron, dopamine. (MAO-A is responsible for breaking down nor-
directly stimulate the dopamine receptors, or decrease the epinephrine and serotonin.) By selectively inhibiting the
breakdown of however much dopamine is being released. breakdown of dopamine, selegiline increases the amount
Anticholinergic effects prevent acetylcholine’s effects either available for binding with dopamine receptors, thus pro-
by reducing the amount of the neurotransmitter released or moting the dopamine–acetylcholine balance. This selective
by directly blocking the acetylcholine receptors. blockage avoids increased norepinephrine levels that can
Dopamine cannot be given directly to Parkinson’s dis- lead to undesired tachycardia and hypertension.
ease patients because it cannot cross the blood–brain barrier As opposed to dopaminergic medications, which act
and consequently would be ineffective in treating the dis- on the dopamine side of the dopamine–acetylcholine bal-
ease, while still causing many side effects. The drug of ance, anticholinergic medications act on the acetylcholine
choice in treating Parkinson’s disease, therefore, is side to block the acetylcholine receptors. The prototype
levodopa, an inactive drug that readily crosses the blood– anticholinergic, atropine, was initially used in this context
Emergency Pharmacology 387
with success, but it also had the typical peripheral anticho- parasympathetic nervous system are located close to the
linergic side effects of blurred vision, dry mouth, and uri- target organs (Figure 13-16).
nary hesitancy. More recently developed medications affect No actual physical connection exists between two
the CNS more than they do the peripheral nervous system. nerve cells or between a nerve cell and the organ it inner-
The prototype centrally acting anticholinergic medication vates. Instead, there is a space, or synapse, between nerve
is benztropine (Cogentin). Another example is diphen- cells. The space between a nerve cell and the target organ is
hydramine (Benadryl), which is more frequently adminis- a neuroeffector junction. Specialized chemicals called
tered for its antihistaminic properties. neurotransmitters conduct the nervous impulse between
nerve cells or between a nerve cell and its target organ.
Autonomic Nervous System
Medications
#WVQPQOKE
The autonomic nervous system is the part of the nervous PGTXQWUU[UVGO
system that controls involuntary (automatic) actions. Many
medications used in out-of-hospital care directly affect the
autonomic nervous system. It is essential that you have a
EQPUKUVUQHVYQFKXKUKQPU
good understanding of this aspect of the nervous system
and the ways in which emergency medications affect it.
The two functional divisions of the autonomic nervous
system are the sympathetic nervous system and the para-
sympathetic nervous system. The sympathetic nervous 5[ORCVJGVKE 2CTCU[ORCVJGVKE
6JQTCEQNWODCT
%TCPKQUCETCN
system allows the body to function under stress. It is often
&KXKUKQP &KXKUKQP
referred to as the fight-or-flight aspect of the nervous sys-
tem. The parasympathetic nervous system, however, pri-
marily controls vegetative functions such as digestion of
food. It is often referred to as the feed-or-breed or the rest-
2TGICPINKQPKE
ƂTUVQTFGT
and-repose aspect of the nervous system. The parasympa- 2TGICPINKQPKE
ƂTUVQTFGT
PGWTQPUKPNCVGTCNITC[ PGWTQPUKPDTCKPCPFUCETCN
thetic nervous system and the sympathetic nervous system JQTPUQHURKPCNUGIOGPVU URKPCNEQTF
5s5
work in constant opposition to control organ responses. 6s.
Content Review
Neurotransmitters are Drugs Used to Affect the
released from presynaptic Parasympathetic Nervous System
➤➤ Cranial Nerves Carrying
neurons and subsequently The parasympathetic nervous system arises from the
Parasympathetic Fibers
act on postsynaptic neurons brainstem and the sacral segments of the spinal cord. The
• III
or on the designated target preganglionic neurons of the parasympathetic nervous
• VII
• IX organ. When released by system are typically much longer than those of the sympa-
• X the nerve ending, the neu- thetic nervous system, because the ganglia are located
rotransmitter travels across close to the target tissues. Parasympathetic nerve fibers
the synapse and activates membrane receptors on the adjoin- that leave the brainstem travel within four of the cranial
ing nerve or target tissue. The neurotransmitter is then either nerves: the oculomotor nerve (III), the facial nerve (VII),
deactivated or taken back up into the presynaptic neuron. the glossopharyngeal nerve (IX), and the vagus nerve (X).
The two neurotransmitters of the autonomic nervous These fibers synapse in the parasympathetic ganglia with
system are acetylcholine (ACh) and norepinephrine. Acetyl- short postganglionic fibers that then continue to their tar-
choline is used in the preganglionic nerves of the sympa- get tissues. Postsynaptic fibers innervate much of the
thetic nervous system and in both the preganglionic and body, including the intrinsic eye muscles, the salivary
postganglionic nerves of the parasympathetic nervous sys- glands, the heart, the lungs, and most of the organs of the
tem. Norepinephrine is the postganglionic neurotransmitter abdominal cavity. The sacral segment of the parasympa-
of the sympathetic nervous system. Synapses that use ace- thetic nervous system forms distinct pelvic nerves that
tylcholine as the neurotransmitter are cholinergic synapses. innervate ganglia in the kidneys, bladder, sex organs, and
Synapses that use norepinephrine as the neurotransmitter the terminal portions of the large intestine (Figure 13-17).
are adrenergic synapses.
)CPINKQPKE
UGEQPFQTFGTPGWTQPU 6CTIGVQTICPU
0+++ +PVTKPUKEG[GOWUENGU
%KNKCT[ICPINKQP
RWRKNCPFNGPUUJCRG
0+:
1VKEICPINKQP 2CTQVKFUCNKXCT[INCPF
2CTCU[ORCVJGVKE
FKXKUKQP
QH#05 8KUEGTCNQTICPUQH
0: JGCFPGEMVJQTCEKE
+PVTCOWTCNICPINKC ECXKV[CPFOQUVQH
CDFQOKPQRGNXKEECXKV[
2TGICPINKQPKE 2GNXKE
ƂTUVQTFGTPGWTQPU PGTXGU 8KUEGTCNQTICPUKP
KPURKPCNEQTF +PVTCOWTCNICPINKC NQYGTCDFQOKPQRGNXKE
UGIOGPVU55 ECXKV[
Figure 13-17 Organization of the parasympathetic division of the autonomic nervous system.
Emergency Pharmacology 389
Stimulation of the parasympathetic nervous system results present in the neuromuscular junction. ACh is very short-
in the following conditions: lived. Within a fraction of a second after its release, it is
deactivated by another chemical, acetylcholinesterase.
• Pupillary constriction
Acetic acid and choline, which are produced when ACh is
• Secretion by digestive glands deactivated, are taken back up by the presynaptic neuron
• Reduction in heart rate and cardiac contractile force (Figure 13-19).
• Bronchoconstriction The parasympathetic system has two main types of
ACh receptors, nicotinic and muscarinic. Knowing these
• Increased smooth muscle activity along the digestive
receptors’ locations and functions will greatly simplify
tract
learning the functions of drugs in this class (Table 13-13).
These and other functions facilitate the processing of NicotinicN (neuron) receptors are found in all autonomic
food, energy absorption, relaxation, and reproduction ganglia, where acetylcholine serves as the presynaptic
(Figure 13-18). neurotransmitter of both the parasympathetic and sym-
All preganglionic and postganglionic parasympathetic pathetic nervous systems. NicotinicM (muscle) receptors
nerve fibers use acetylcholine as a neurotransmitter. ACh, are found at the neuromuscular junction and initiate
when released by presynaptic neurons, crosses the synap- muscular contraction as part of the somatic nervous sys-
tic cleft and activates receptors on the postsynaptic neu- tem. Muscarinic receptors are found in many organs
rons or on the neuroeffector junction. ACh is also the throughout the body and are primarily responsible for
neurotransmitter for the somatic nervous system and is promoting the parasympathetic response. Table 13-14
5RJGPQRCNCVKPGICPINKQP
0NNN .CETKOCNINCPF
'[G
%KNKCT[ICPINKQP
08NN
5WDOCPFKDWNCT 5CNKXCT[
ICPINKQP INCPFU
0N:
1VKEICPINKQP
8CIWU
0: *GCTV
%CTFKCE
RNGZWU
.WPI
%GNKCE
RNGZWU
.KXGTCPF
ICNNDNCFFGT
5VQOCEJ
*[RQICUVTKE
2CPETGCU
RNGZWU
5RNGGP
2GNXKE .CTIGKPVGUVKPG
PGTXGU
5OCNNKPVGUVKPG
4GEVWO
-KFPG[
5RKPCN
EQTF
1XCT[ $NCFFGT
Postsynaptic
terminal
Synaptic Synaptic
vesicles cleft
Choline
Acetic
ATP acid
Presynaptic
terminal Acetyl-
Pi + ADP cholinesterase
Diffusion of ACh
transmitter
Action potential
ACh
Figure 13-19 Physiology of a cholinergic synapse. Acetylcholine is released from the presynaptic nerve and stimulates receptors on the
postsynaptic nerve. Subsequently, acetylcholinesterase breaks down the acetylcholine and the presynaptic nerve fiber takes up the products.
summarizes the locations and actions of the muscarinic ing in hypotension, and excessive salivation, urination, defe-
receptors. cation, and sweating. Vomiting and abdominal cramps may
Because both nicotinic and muscarinic receptors are also occur. The acronym SLUDGE (salivation, lacrimation,
specialized for acetylcholine, they are termed cholinergic urination, defecation, gastric motility, emesis) is helpful for
receptors. Medications that stimulate them are known as remembering these effects.
cholinergics (parasympathomimetics), and those that The prototype direct-acting cholinergic is bethanechol
block them are known as anticholinergics or cholinergic (Urecholine). Its pharmacokinetics make it a good clinical
blockers (parasympatholytics). substitute for ACh. It is not broken down by cholinesterase,
the enzyme responsible for destroying ACh, and therefore
Cholinergics Cholinergic drugs act either directly or
indirectly. Direct-acting cholinergics (also called cholinergic
esters) simulate the effects of ACh by directly binding with Table 13-14 Location and Effect of Muscarinic Receptors
the cholinergic receptors.
Content Review Drugs in this class generally Organ Functions Location
➤➤ Sludge Effects of Cholin- produce the same effects Heart Decreased heart rate Sinoatrial node
ergic Medications as cholinergic stimula- Decreased conduction rate Atrioventricular node
• Salivation tion, focused mostly on the Arterioles Dilation Coronary
• Lacrimation muscarinic receptors. Their Dilation Skin and mucosa
• Urination adverse effects are related Dilation Cerebral
• Defecation primarily to decreased heart
• Gastric motility GI tract Relaxed Sphincters
rate, decreased peripheral
• Emesis Increased motility
vascular resistance result- Increased salivation Salivary glands
Increased secretion Exocrine glands
it has a longer duration of action. Most of its effects are on Irreversible cholinesterase inhibitors have only one
muscarinic receptors in the urinary bladder and gastroin- clinical function—the treatment of glaucoma—and only
testinal tract. It may be given orally or subcutaneously. one drug, echothiophate (Phospholine Iodide), has been
Thus, it is used primarily to increase micturition (urination) approved for that purpose. Cholinesterase inhibitors, how-
and peristalsis. Adverse effects are rare but related to its ever, are very useful as insecticides (organophosphates),
parasympathomimetic effects. Another direct-acting cho- and, unfortunately, their mechanism of action is also very
linergic medication, pilocarpine, is used as a topical treat- attractive for makers of chemical weapons. They are the
ment for glaucoma. chief component in nerve gases such as VX and sarin. They
Indirect-acting cholinergic drugs affect acetylcholines- cause extensive stimulation of cholinergic receptors, ulti-
terase. By inhibiting its actions in degrading acetylcholine, mately resulting in the SLUDGE response. Toxic levels
they prolong the cholinergic response. These drugs affect may also affect nicotinicM receptors, leading to paralysis.
both muscarinic and nicotinic receptors and therefore have Treatment for such toxic exposures involves drugs such as
little specificity. Their uses are limited primarily to treating high doses of atropine or pralidoxime (Protopam, 2-PAM)
myasthenia gravis, some types of poisoning, and glau- to block the effects of the accumulating ACh. Pralidoxime
coma, as well as for reversing nondepolarizing neuromus- can encourage irreversible cholinesterase inhibitors to
cular blockade. release cholinesterase.
The two basic types of indirect-acting cholinergic
Anticholinergics Anticholinergic agents oppose
drugs are reversible inhibitors and irreversible inhibitors.
the parasympathetic (cholinergic) nervous system. Just as
Both types bind with cholinesterase (ChE), acting as a sub-
there are multiple types of cholinergic receptors, there are
stitute for ACh. In doing so, they prevent ChE from
multiple classes of cholinergic receptor antagonists. We
destroying ACh. The difference between the reversible and
will discuss agents that selectively block muscarinic and
irreversible inhibitors is how long they remain bound with
nicotinic receptors, as well as nonselective blockers (gan-
cholinesterase. The reversible inhibitors remain bound
glionic blockers). A special subclass of nicotinic receptor
with cholinesterase much longer than ACh but eventually
blocking agents is neuromuscular blocking drugs.
release it. The irreversible inhibitors, too, will eventually
release cholinesterase, but they remain bound for so long Muscarinic Cholinergic Antagonists Cholinergic antag-
that, from a practical standpoint, they can be considered onists block the effects of acetylcholine almost exclusively at
irreversible. the muscarinic receptors. They are often called anticholin-
Neostigmine (Prostigmin) is the prototype reversible ergics or parasympatholytics. They work by competitively
cholinesterase inhibitor. It is used to treat myasthenia gra- binding with muscarinic receptors without stimulating them.
vis, an illness characterized by muscle weakness and pro- As a result, these receptors cannot bind with ACh.
gressive fatigue. This illness is an autoimmune disease that The prototype anticholinergic drug is atropine, which
destroys the nicotinicM receptors at the neuromuscular is widely used to block muscarinic receptors and is com-
junction. With fewer of these receptors, muscles cannot be monly administered in the field. Found in the plant Atropa
stimulated as well and weakness occurs. Neostigmine belladonna, atropine is one of several drugs classified as bel-
treats the symptoms of myasthenia gravis by blocking the ladonna alkaloids (scopolamine is also in this classifica-
degradation of ACh, thereby prolonging its effects and tion). Readily absorbed through both enteral and parenteral
increasing motor strength. Its primary side effects are due routes, it has therapeutic effects at dose-dependent levels
to the stimulation of muscarinic receptors and include the at most sites with muscarinic receptors. At low doses, atro-
SLUDGE responses. Fortunately, these responses may be pine decreases secretion from salivary and bronchial
treated effectively with a cholinergic blocker. Neostigmine glands as well as from the sympathetically innervated
can also reverse a nondepolarizing neuromuscular block- sweat glands. At moderate doses, it increases heart rate
ade. This use is fairly uncommon, however, because such and causes mydriasis (dilated pupils) and blurry vision. At
blockades typically are administered only intentionally as higher doses, it decreases gastric motility and stomach acid
part of anesthesia or before intubation. secretion. Atropine is also useful in reversing overdoses of
Physostigmine (Antilirium) is another reversible cho- muscarinic agonists (cho-
linesterase inhibitor. Its mechanism is similar to neostig- linergics or cholinesterase
mine’s, with their primary difference being in their inhibitors). Its side effects, Content Review
pharmacokinetics. Whereas neostigmine is poorly which are predictable, ➤➤ Types of Parasympathetic
absorbed across the cell membrane, physostigmine crosses include dry mouth, blurred Acetylcholine Receptors
rapidly and therefore has a shorter onset and may be given vision and photophobia, • Muscarinic
in lower doses. Physostigmine’s chief use is for reversing urinary retention, increased • Nicotinic
• NicotinicN (neuron)
overdoses of atropine, an anticholinergic drug that blocks intraocular pressure, tachy-
• NicotinicM (muscle)
muscarinic receptors. cardia, constipation, and
392 Chapter 13
anhidrosis (decreased fully conscious and aware but completely paralyzed, unable
Content Review
sweating), which may to move or breathe. Neuromuscular blockade is caused by
➤➤ Effects of Atropine
cause hyperthermia. A competitive antagonism of nicotinicM receptors at the neu-
Overdose
helpful mnemonic for romuscular junction. This is useful during surgery as part of
• Hot as hell
remembering the effects of anesthesia and during electroconvulsive therapy for depres-
• Blind as a bat
• Dry as a bone atropine overdose is “hot sion. These agents are most often used in the field to facilitate
• Red as a beet as hell, blind as a bat, dry intubation.
• Mad as a hatter as a bone, red as a beet, Neuromuscular blocking agents are either depolar-
mad as a hatter.” izing or nondepolarizing, depending on their mechanism
Scopolamine is another belladonna anticholinergic. Its of action. Most are nondepolarizing; only one depolariz-
actions are similar to atropine’s, but unlike atropine, sco- ing drug, succinylcholine (Anectine), is commonly used
polamine causes sedation and antiemesis. Thus, its pri- in the clinical setting. Tubocurarine, though not fre-
mary purpose is to prevent motion sickness. It is available quently used clinically, is the oldest neuromuscular
as a transdermal patch. blocker and the prototype nondepolarizing agent. It
Several synthetic medications mimic the effects of the produces neuromuscular blockade by binding with the
belladonna alkaloids while minimizing their side effects. nicotinicM receptor sites without causing muscle depo-
Ipratropium bromide (Atrovent), an inhaled anticholiner- larization. Succinylcholine acts in the same manner, but
gic, is effective in treating asthma because it relaxes the like acetylcholine, it does cause muscle depolarization
bronchial smooth muscle and causes bronchodilation. It is when it binds with the nicotinicM receptor. It is useful as
frequently administered along with an inhaled beta-adren- a neuromuscular blocker because, in contrast to ACh,
ergic agonist. Because it is inhaled and has little systemic which rapidly separates from the receptor, it remains
effect, ipratropium bromide avoids many of atropine’s side bound, preventing the muscle’s repolarization. Several
effects (Table 13-15). nondepolarizing agents are available; the specific agent
Other anticholinergic drugs include dicyclomine (Ben- chosen depends on its rate of onset and duration of
tyl) and benztropine (Cogentin). action. Succinylcholine has the shortest onset and dura-
tion of action because it has a naturally occurring
Nicotinic Cholinergic Antagonists Nicotinic cholin- enzyme, pseudocholinesterase, which degrades it. 16,17
ergic antagonists block acetylcholine only at nicotinic sites. See Table 13-16.
They include ganglionic blocking agents that block the
nicotinicN receptors in the autonomic ganglia and neuro- Ganglionic Stimulating Agents NicotinicN
muscular blocking agents that block nicotinicM receptors at receptors reside at the ganglia of both the parasympathetic
the neuromuscular junction. and sympathetic nervous systems. The alkaloid nicotine
stimulates these receptors. Nicotine is found in tobacco
Ganglionic Blocking Agents Ganglionic and, although it has no therapeutic uses, is of interest for
blockade is produced by competitive antagonism with two reasons. Historically, nicotine, along with muscarine,
acetylcholine at the nicotinicN receptors in the autonomic led to a much better understanding of the autonomic ner-
ganglia. This can, in effect, turn off the entire autonomic vous system’s specific receptors. Also, it is one of the most
nervous system. The two drugs in this class are trimeth- abused drugs in the world.
aphan (Arfonad) and mecamylamine (Inversine). Both are Nicotine may cause a variety of responses, most of
used to treat hypertension. The adverse effects of gangli- which are dose related. At low doses, like those from smok-
onic blockade include signs associated with antimuscarinic ing, nicotine causes excitation at the autonomic ganglia.
drugs like atropine—dry mouth, blurred vision, urinary This affects both the parasympathetic and sympathetic
retention, and tachycardia. Other adverse effects arising nervous systems. The parasympathetic response causes
from the vasodilation and decreased preload caused by increased salivation, peristalsis, and secretion of gastric
sympathetic blockage include profound hypotension, with acid. The sympathetic response causes the release of nor-
orthostatic hypotension even more evident. Trimethaphan epinephrine and epinephrine. These lead to increases in
is administered primarily for hypertensive crisis when heart rate, myocardial contractility, vasoconstriction, and
other treatments are ineffective. These agents are almost blood pressure, all of which increase the heart’s workload.
never used anymore because they are not selective and Sympathetic stimulation also increases awareness and sup-
many superior agents are available. presses fatigue and appetite.
Nicotine administration devices such as gum and
Neuromuscular Blocking Agents Neuromus- transdermal patches are available for use in smoking cessa-
cular blockade produces a state of paralysis without affect- tion. Their actions are similar to the actions of nicotine
ing consciousness. Imagine how terrifying it would be to be inhaled in smoke.
Table 13-15 Parasympatholytic Medications
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Atropine Muscarinic Selectively blocks • Bradycardia • Hypersensitivity 0.5–2.0 mg IV, IO • Blurred vision • Organophosphate
anticholinergic muscarinic receptors • Antidote for to the drug • Dry Mouth poisonings
(parasympatholytic) inhibiting organophosphate • Dilated pupils may require
parasympathetic poisoning • Confusion a significantly
stimulation • Premedication higher dose
for RSI
Ipratropium Muscarinic Selectively blocks • Bronchospasm • Hypersensitivity 500 mcg Inhaled • Blurred vision • Typically
Atrovent anticholinergic muscarinic associated with to the drug • Dry Mouth administered with
(parasympatholytic) receptors inhibiting obstructive lung • Dilated pupils a beta agonist
parasympathetic disease (asthma, • Cough (although not as
stimulation COPD) • Confusion frequently)
Vecuronium Nondepolarizing Binds to ACh receptors • Rapid sequence • Hypersensitivity to 0.1–0.15 mg/kg IV, IO • Skeletal muscle • These agents should
Norcuron neuromuscular at the neuromuscular intubation (RSI) the drug weakness be used only by
blocker junction, causing • Malignant persons skilled in their
paralysis hyperthermia use, competent at
• Apnea complicated airway
management, and
with all necessary
resuscitative equipment
available.
Rocuronium Nondepolarizing Binds to ACh receptors • Rapid sequence • Hypersensitivity to 1 mg/kg IV, IO • Hypertension • These agents should
Zemuron neuromuscular at the neuromuscular intubation (RSI) the drug • Hypotension be used only by
blocker junction, causing • Skeletal muscle persons skilled in their
paralysis weakness use, competent at
• Malignant complicated airway
hyperthermia management, and
• Apnea with all necessary
resuscitative equipment
available.
393
394 Chapter 13
• Stimulation of secretion by sweat glands Sympathetic nervous system stimulation also results in
direct stimulation of the adrenal medulla, the inner portion
• Constriction of blood vessels in the skin
of the adrenal gland (Figure 13-21). The adrenal medulla, in
• Increase in blood flow to skeletal muscles turn, releases the hormones norepinephrine (noradrenalin)
• Increase in the heart rate and force of cardiac contractions and epinephrine (adrenalin) into the circulatory system.
.CETKOCNINCPF
'[G
2105
5CNKXCT[
INCPFU
%CTFKCECPF
RWNOQPCT[RNGZWUGU
2QUVICPINKQPKE
ƂDGTUVQ *GCTV
URKPCNPGTXGU
KPPGTXCVKPIUMKP
DNQQFXGUUGNU
5WRGTKQT
CFKRQUGVKUUWG
OGUGPVGTKE
ICPINKQP %GNKCEICPINKQP .WPI
.KXGTCPF
ICNNDNCFFGT
5VQOCEJ
2CPETGCU
5RNGGP
.CTIGKPVGUVKPG
5OCNNKPVGUVKPG
+PHGTKQT
OGUGPVGTKE
ICPINKQP #FTGPCNOGFWNNC
5[ORCVJGVKE -KFPG[
EJCKPICPINKC
5RKPCN
EQTF
$NCFFGT
Via post-
Ganglionic ganglionic
(second-order) fibers
neurons Target Organs
Preganglionic
Sympathetic Visceral effectors
(first-order) neurons Collateral ganglia
Division in abdominopelvic
in spinal segments (unpaired)
of ANS cavity
T1– L2
Via release of
neurotransmitters
into circulation
Figure 13-21 Organization of the sympathetic division of the autonomic nervous system.
Approximately 80 percent of the hormones released by the In addition, both epinephrine and norepinephrine interact
adrenal medulla are epinephrine, and norepinephrine con- with specialized adrenergic receptors on the membranes of
stitutes the remaining 20 percent. Once released, these hor- the target organs. These receptors are located throughout
mones are carried throughout the body, where they cause the body. Once stimulated by the appropriate hormone,
their intended effects by acting on hormone receptors. The they cause a response in the organ or organs they control.
release of norepinephrine and epinephrine by the adrenal The two known types of sympathetic receptors are the
medulla stimulates tissues that are not innervated by sym- adrenergic receptors and the dopaminergic receptors. The
pathetic nerves. In addition, it prolongs the effects of direct adrenergic receptors are generally divided into four types.
sympathetic stimulation. All these effects serve to prepare These five receptors are designated alpha 1 (a1), alpha 2
the body to deal with stressful and potentially dangerous (a2), beta 1 (b1), beta 2 (b2), and beta 3 (b3). The a1 receptors
situations. cause peripheral vasoconstriction, mild bronchoconstric-
tion, and stimulation of metabolism. The a2 receptors are
Adrenergic Receptors Sympathetic stimulation found on the presynaptic
ultimately results in the release of the hormone norepi- surfaces of sympathetic Content Review
nephrine from postganglionic nerves. The norepinephrine neuroeffector junctions. ➤➤ Types of Sympathetic
subsequently crosses the synaptic cleft and interacts with Stimulation of a2 receptors Receptors
adrenergic receptors on the postsynaptic nerves. Shortly is inhibitory. These recep- • Adrenergic
thereafter, the norepinephrine is either taken up by the tors serve to prevent over- • alpha1 (a1)
presynaptic neuron for reuse or broken down by enzymes release of norepinephrine • alpha2 (a2)
present within the synapse (Figure 13-22). Sympathetic in the synapse. When the • beta1 (b1)
• beta2 (b2)
stimulation also results in the release of the hormones epi- level of norepinephrine in
• Dopaminergic
nephrine and norepinephrine from the adrenal medulla. the synapse gets high
396 Chapter 13
NE
NE
NE
MAO or
Action potential COMT
Metabolites
(inactive)
Figure 13-22 Physiology of an adrenergic synapse. Norepinephrine is released from the presynaptic nerve and stimulates receptors on the
postsynaptic nerve. Subsequently, the norepinephrine is either taken up by the presynaptic nerve or deactivated by enzymes in the synapse.
enough, the a2 receptors are stimulated, and norepineph- increase systolic and diastolic blood pressure and represent
rine release is inhibited. Stimulation of b1 receptors causes the chief therapeutic indication for alpha1 agonists. Stimu-
increases in heart rate, cardiac contractile force, and cardiac lation of a1 receptors locally may be useful in combination
automaticity and conduction. Stimulation of b2 receptors with local anesthetics. The main reason to add the a1 ago-
causes vasodilation and bronchodilation. Stimulation of b3 nist in this context is to cause local vasoconstriction so the
receptors promotes the breakdown of lipids for energy pro- systemic absorption of the anesthetic will decrease, and its
duction. It has long been thought that dopaminergic recep- duration will increase. Alpha1 agonists are also useful topi-
tors cause some degree of dilation of the renal, coronary, cally to decrease nasal congestion caused by dilation and
and cerebral arteries. However, recent studies have ques- engorgement of nasal blood vessels. The primary adverse
tioned whether such an effect exists. Several studies have responses to a1 agonist agents are hypertension and local
demonstrated that low-dose dopamine infusions actually tissue necrosis. If a medication with significant a1 proper-
worsen renal function instead of improving it. Other stud- ties infiltrates the surrounding tissue or distal body parts
ies have not been able to demonstrate improved bowel per-
fusion with dopamine administration.
Medications that stimulate the sympathetic nervous
Table 13-17 Location of Adrenergic Receptors and
Effects of Stimulation
system are sympathomimetics. Medications that inhibit
the sympathetic nervous system are called sympatholytics. Receptor Response to Stimulation Location
Some medications are pure alpha agonists, whereas others Constriction Arterioles
Alpha 1 (a1)
are pure alpha antagonists. Some medications are pure Constriction Veins
beta agonists, whereas others are pure beta antagonists. Mydriasis Eye
Medications such as epinephrine stimulate both alpha and Ejaculation Penis
beta receptors. Other medications, such as the bronchodila-
Alpha 2 (a2) Presynaptic terminal inhibition*
tors, are termed beta selective, as they act more on b2 recep-
tors than on b1 receptors. Beta 1 (b1) Increased heart rate Heart
the term adren-ergic.) There are two main types of adrenergic Dilation Arterioles
Inhibition of contractions Uterus
receptors, each with two subtypes. These receptors’ effects
Tremors Skeletal muscle
depend primarily on their locations. Table 13-17 describes
the chief locations and primary actions of each receptor. Beta 3 (b3) Lipolysis Adipose tissue
The primary clinical purpose for medications that stim- Dopaminergic Vasodilation (increased blood flow) Kidney
ulate a1 receptors is peripheral vasoconstriction. Constric-
*Stimulation of a2 adrenergic receptors inhibits the continued release of norepi-
tion of the arterioles increases afterload, whereas
nephrine from the presynaptic terminal. It is a feedback mechanism that limits the
constriction of venules increases preload (decreasing adrenergic response at that synapse. These receptors have no other identified
venous capacitance or “pooling”). Both these effects peripheral effects.
Emergency Pharmacology 397
Epinephrine Sympathetic a and b • Cardiac arrest • Few in the 0.3–1.0 mg IV, IO, IM, • Palpitations • Two preparations are
agonist adrenergic agonist • Symptomatic emergency SQ, ET, • Anxiety commonly available:
(b effects more bradycardia setting inhaled • Tremulousness • 1:1,000 (1 mg/mL)
pronounced although • Normovolemic • Headache • 1:10,000
dose-related) hypotension • Dizziness (1 mg/10 mL)
• Allergies/ • Hypertension
anaphylaxis • Can worsen
• Severe cardiac ischemia
bronchospasm
Norepinephrine Sympathetic a and b • Normovolemic • Should not 0.1–0.5 mcg/kg/min IV • Palpitations • Extravasation can
Levophed agonist adrenergic agonist hypotension be used in (titrate to effect) • Anxiety cause localized tissue
(a effects more • Septic shock hypovolemia • Tremulousness damage.
pronounced) • Cardiogenic until volume • Headache • Best administered
shock replacement • Dizziness through a central line.
has occurred • Hypertension
• Can worsen
cardiac ischemia
• Reflex bradycardia
Dopamine Sympathetic a and b • Normovolemic • Should not 2–20 mcg/kg/min IV • Palpitations • Extravasation can
Intropin agonist adrenergic agonist hypotension be used in (titrated to effect) • Anxiety cause localized tissue
• Symptomatic hypovolemia • Tremulousness damage.
bradycardia until volume • Headache • Best administered
• Septic shock replacement has • Dizziness through a central line.
• Cardiogenic occurred • Hypertension • Proposed renal benefit
shock • Can worsen has been disproven.
cardiac ischemia
• Reflex bradycardia
Dobutamine Synthetic a and b • Congestive • Should not 2–20 mcg/kg/min IV • Palpitations • Extravasation can
Dobutrex sympathetic adrenergic agonist heart be used in (titrate to effect • Anxiety cause localized tissue
agonist (inotropic properties failure hypovolemia • Tremulousness damage.
more pronounced until volume • Headache • Best administered
than chronotropic replacement has • Dizziness through a central line.
properties) occurred • Hypertension • Other agents preferred
• Can worsen in cardiogenic shock.
cardiac ischemia
• Reflex bradycardia
398
Phenylephrine Sympathetic Almost a pure • Normovolemic • Avoid in 100–180 mcg/min IV • Palpitations • Can be applied
Neo-Synephrine agonist a agonist causing hypotension cardiogenic (0.5-2.0 mcg/kg/min • Anxiety topically to nasal
vasoconstriction • Septic shock shock and titrate to effect) • Tremulousness mucosa to shrink
• Spinal shock • Headache tissues prior to nasal
• Dizziness procedures.
• Can worsen
cardiac ischemia
• Reflex bradycardia
Bronchodilators
Albuterol b agonist b agonist with • Bronchospasm • Known 2.5 mg (SVN); Inhalation • Palpitations • The patient’s heart
Ventolin, Proventil preference for • Allergies/ hypersensitivity 90 mcg (MDI) • Anxiety rate and SpO2 should
b2 adrenergic anaphylaxis to the medication • Tremulousness be monitored during
receptors • Hyperkalemia • Headache treatment.
• Dizziness
• Tachycardia
Levalbuterol b agonist b agonist with • Bronchospasm • Known 0.63 mc (SVN) Inhalation • Palpitations • The patient’s heart
Xopenex preference for b2 • Allergies/ hypersensitivity • Anxiety rate and SpO2 should
adrenergic receptors. anaphylaxis to the medication • Tremulousness be monitored during
It is a racemic isomer • Hyperkalemia • Headache treatment.
of albuterol. • Dizziness
• Tachycardia
Metaproterenol b agonist b agonist with • Bronchospasm • Known 0.2–0.3 mL of solution Inhalation • Palpitations • The patient’s heart
Alupent preference for b2 • Allergies/ hypersensitivity to containing 15 mg/mL • Anxiety rate and SpO2 should
adrenergic receptors anaphylaxis the medication (SVN); 0.65 mg (MDI) • Tremulousness be monitored during
• Hyperkalemia • Headache treatment.
• Dizziness
• Tachycardia
Terbutaline b agonist Relatively nonselective • Bronchospasm • Known 0.25 mg Inhalation • Palpitations • The patient’s heart
Brethine b agonist • Allergies/ hypersensitivity to SQ • Anxiety rate and SpO2 should
anaphylaxis the medication • Tremulousness be monitored during
• Hyperkalemia • Headache treatment.
• Preterm labor • Dizziness
• Tachycardia
Racemic Sympathetic Relatively nonselective • Croup • Known 0.25–0.75 mL of a Inhalation • Palpitations • The patient’s heart
Epinephrine agonist b agonist. It is a mix of hypersensitivity to 2.5% solution • Anxiety rate and SpO2 should
S2 both racemic isomers the medication • Tremulousness be monitored during
of epinephrine. • Headache treatment.
• Dizziness
• Tachycardia
399
400 Chapter 13
The heart is essentially a two-sided pump. The right ensure that the chambers contract in proper sequence. The
side is a low-pressure pump responsible for pulmonary cir- sinoatrial (SA) node is the heart’s dominant pacemaker. It
culation, and the left side is a high-pressure pump respon- spontaneously generates electrical impulses (action poten-
sible for systemic circulation. The human heart has four tials) that are propagated through intraatrial pathways to
chambers: two atria and two ventricles. The atria receive the atrioventricular (AV) node, where conduction is
blood from the pulmonary and
systemic circulation and pass it Superior
vena cava
on to the ventricles, where most
of the pumping pressure origi-
nates (Figure 13-23). Because the Pulmonary
left side of the heart must gener- trunk
ate substantially higher pressures
Left pulmonary
than the right, the left ventricle’s
arteries
muscular wall is much larger
than those of the other chambers.
Left pulmonary
The atria accept blood and allow
veins
it to pour passively into the ven-
tricles. Just before the ventricles
contract, the atria contract to “top
off” the volume of blood in the
ventricles. After this atrial “kick”
Right atrium Left ventricle
fills the ventricles, they contract,
forcing blood out of the heart.
The myocardial muscle contrac-
tion depends on three factors: Right ventricle
(1) electrical stimulation from the
conduction system, (2) adequate
amounts of ATP (energy), and
(3) adequate amounts of the cal-
cium ion. ATP and calcium are
both needed for the thin and thick
filaments to combine and shorten
the muscle. To pump blood effec- Inferior
tively, the entire heart must con- vena cava
tract in a precise sequence. Both
Figure 13-23 Blood flow through the heart.
atria contract at the same time
from the top down (toward the
AV valves). A slight delay allows
the ventricles to fill completely
with blood, and then both ventri-
SA node
cles contract simultaneously from atrial pathways
the bottom up (toward the semi-
lunar valves). This entire cycle AV junction
must repeat itself continually. AV node
Bundle of His
delayed momentarily. This delay gives the ventricles time side the cell than inside, resulting in a slight negative
to fill completely. The impulse then travels from the AV charge on the inside. The primary ions involved are sodium
node throughout the ventricles via the bundle of His and (Na+) on the outside of the cell and potassium (K+) on the
the Purkinje network. inside. Calcium (Ca++), which is responsible for muscle con-
All myocardial tissue, both contractile and conductive, traction, is present in storage vesicles surrounding the cell.
has the ability to self-generate electrical impulses (automa- These vesicles are called the sarcoplasmic reticulum. The cell
ticity) and to propagate those impulses to surrounding tis- membrane is said to depolarize when this charge is elimi-
sue. It does this through the movement of ions across the nated or reversed. When an impulse is generated and con-
cell membrane. At rest (when not stimulated), the cell ducted to the muscle cells, the process of depolarization and
membrane is polarized with a slight electrical charge. This repolarization begins. Figure 13-25 depicts the sequence of
charge is present because there are more positive ions out- ion movements in the depolarization and repolarization of
(#56216'06+#.5 (QWPFKPO[QECTFKCN
EQPVTCEVKNGVKUUWG
%C
0C 0C
1WVUKFG
/GODTCPG #62
+PUKFG
-
-
#EVKQPRQVGPVKCNQHECTFKCEEQPVTCEVKNG
OWUENGVKUUWGFGRGPFUWRQPCEVKXCVKQPQHHCUVUQFKWOEJCPPGNU
QRGPKPIVJGICVGU
XKCUVKOWNWUHTQORCEKPIEGNNU
5.19216'06+#.5 (QWPFKP5#
CPF#8PQFGU
%C
0C
1WVUKFG
/GODTCPG
+PUKFG
-
#EVKQPRQVGPVKCNQHECTFKCERCEKPIEGNNUUNQYUKPƃWZQH%C
NGCMKPICPFVQCNGUUGTGZVGPV0C
KUTGURQPUKDNGHQT
CWVQOCVKEKV[QTURQPVCPGQWUFGRQNCTK\CVKQP%NCUU+8CPVKCTTJ[VJOKEUKPJKDKVVJGUGECNEKWOEJCPPGNUCPFFGETGCUG
JGCTVTCVG
Figure 13-25 Ion movements in the depolarization and repolarization of slow and fast potentials.
Emergency Pharmacology 403
both slow and fast potentials. Fast potentials occur in car- As mentioned earlier, fast-potential means of depolar-
diac muscle tissue, as well as in the ventricular conduction ization dominate most of the heart, including the muscle
system; slow potentials occur in the pacemaker cells of the cells and the ventricular conduction system. This process
SA and AV nodes. normally does not include a phase 4 depolarization; rather,
Cyclic activity in the fast potentials has five phases. depolarization most often happens in response to an
Phase 0, which represents depolarization, results from a impulse generated in the SA node and propagated to the
rapid influx of Na+ ions into the cell. This makes the inside cell. In pathological conditions such as ischemia, myocar-
of the cell more positive than the outside and is normally dial infarction, and excessive sympathetic stimulation,
caused by the arrival of an impulse generated elsewhere in these tissues will develop phase 4 depolarization and gen-
the heart, such as the SA node. Sodium stops entering the erate an impulse abnormally. This abnormal impulse will
cell once the inside has become positive. Phases 1 through 3 then be propagated throughout the heart. These are con-
represent repolarization. In phase 1, K+ begins to leave the sidered ectopic foci, meaning the focus for the electrical
cell, slowly returning the cell to its normal negative charge. impulse generation originated somewhere other than
Phase 2 interrupts with an influx of Ca++ into the cell. where it normally should.
Remember, the muscles are using calcium inside the cell for Another cause of both abnormal beats and abnormal
contraction. This plateau phase delays repolarization and is rhythms is abnormal conduction. Figure 13-26 shows how
important for medications that affect the strength of contrac- an irregularity in the conduction system can generate
tion. Phase 3 is marked by a cessation of calcium influx and arrhythmias. The inverted Y in that diagram represents the
the rapid efflux of potassium. Phase 4 is normally a flat stage Purkinje network attaching to a single muscle fiber (repre-
representing the resting membrane potential. However, in sented by the horizontal bar under the Y). Impulses nor-
pathological states, phase 4 may include a slow influx of mally travel down both legs of the Y and begin depolarizing
sodium that will gradually make the inside of the cell more the muscle tissue. The muscle tissue depolarizes in both
positive. When the interior of the cell reaches a point called directions and meets in the middle of the Y, where it ends
its threshold potential, the cell will depolarize without waiting because the tissue is now refractory in both directions. In
for an impulse. Many antiarrhythmics have their mecha- pathological conditions, a section of one of the Purkinje
nism of action during this phase 4 depolarization. fibers has what amounts to a one-way valve that allows
The slow potentials, though similar to the fast ones, impulses to travel in only one direction. The impulse trav-
have several important distinctions. First, they are located els down the good leg and depolarizes the muscle fiber,
in the dominant pacemakers of the heart. Second, they which then propagates the impulse in both directions,
depolarize differently. Notice in Figure 13-25 how phase 4 unhindered by a refractory period in the opposing direc-
normally exhibits a gradually increasing slope toward the tion. Then the impulse will travel up the other leg of the Y,
threshold potential. Whereas sodium causes depolariza- through the one-way valve. If the tissue of the other leg is
tion (phase 0) of the fast potentials, a gradual influx of cal- no longer in the absolute refractory phase, the impulse will
cium causes it in the slow potentials. The slow potentials continue back down the first leg. This can create either an
normally undergo a gradual, phase 4 depolarization. early beat or, if circumstances are just right, a very rapid
Although we do not know the exact mechanism, this grad- reentrant rhythm (a so-called circus rhythm).
ual depolarization clearly is responsible for the spontane-
ous generation of impulses in the SA and AV nodes.
Although the AV node also has these slow potentials, the
Classes of Cardiovascular Drugs
SA node’s rate of depolarization is faster, making it the The drugs used to treat car- Content Review
heart’s dominant pacemaker. diovascular disease gener-
➤➤ Antiarrhythmics
ally fall into the two broad
Antiarrhythmics are routinely
Arrhythmia Generation functional classifications of
classified in the Vaughn-
Arrhythmias are generated at various places in the heart antiarrhythmics, also called
Williams and Singh Classifi-
through either abnormal impulse formation (automaticity) antidysrhythmics, and anti-
cation System.
or abnormal conductivity. The most prevalent types of hypertensives. • I: Na+ channel blockers
arrhythmias are tachycardia (too fast) and bradycardia (too • 1A
slow). An imbalance between the sympathetic and para- Antiarrhythmics • 1B
sympathetic nervous systems most often causes these Antiarrhythmic drugs are • 1C
arrhythmias. Typically, excessive parasympathetic stimula- used to treat and prevent • II: Beta-blockers
tion through muscarinic receptors causes bradycardias, abnormal cardiac rhythms. • III: K+ channel blockers
which are treated with anticholinergic medications. Tachy- Table 13-20 describes the • IV: Miscellaneous Ca++
channel blockers
cardias, however, have a variety of causes and are treated pharmacological classes of
• V: Miscellaneous
with the antiarrhythmics we discuss in this section. antiarrhythmics. Although
404 Chapter 13
Purkinje (a)
fiber
Right Left
Normal pathway branch branch
Ventricular muscle
Right branch
Left branch
(b)
Unilateral block
Purkinje fiber
Ventricular
muscle
(c)
Bidirectional block
Bundle
of His
Purkinje fiber
(d)
Abolishment of
unidirectional block
these medications are useful in treating arrhythmias, they considered the prototype for this class, we will use pro-
can also cause them or deterioration in existing rhythms cainamide here because it is administered more frequently
when used inappropriately (Table 13-21). in emergency medicine. Procainamide is indicated in the
treatment of atrial fibrillation with rapid ventricular
Sodium Channel Blockers (Class I) All the response and ventricular arrhythmias. Quinidine has a
medications in this general class affect the sodium influx in similar mechanism of action, but it also has anticholiner-
phases 0 and 4 of fast potentials. This slows the propaga- gic properties that may induce unintended tachycardias.
tion of impulses down the specialized conduction system Class IB drugs include lidocaine (Xylocaine), phenyt-
of the atria and ventricles, although it does not affect the oin (Dilantin), tocainide (Tonocard), and mexiletine (Mex-
SA or AV node. itil). Unlike Class IA drugs, Class IB drugs increase the rate
Class IA drugs include quinidine (Quinidex), procain- of repolarization. They also reduce automaticity in ventric-
amide (Pronestyl), and disopyramide (Norpace). In addi- ular cells, which makes them effective in treating rhythms
tion to slowing conduction, these drugs also decrease the originating from ectopic ventricular foci. Several of the
repolarization rate. This widens the QRS complex and drugs in this class are also used for other purposes. Lido-
prolongs the QT interval. Although quinidine is usually caine, the prototype, is frequently used with epinephrine
* Prototype.
Table 13-21 Antiarrhythmics
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Amiodarone Class III Prolongs action potential May be considered for: • Breastfeeding 150–300 mg IV • Hypotension • Constant ECG
Cordarone antiarrhythmic and duration in cardiac • Ventricular • Bradycardia • Bradycardia monitoring
tissues through sodium, tachycardia • High-grade heart • Prolonged PR, • Now first-line agent in
potassium, and calcium • Ventricular fibrillation block QRS, and QT ventricular fibrillation
channels; blocks a and that is unresponsive • Hypersensitivity to and tachycardia
b adrenergic receptors. to CPR, defibrillation, the drug
and vasopressor
therapy
Lidocaine Class Ib Amide-type local May be considered for: • Should not be 1.0–1.5 mg/kg IV • Drowsiness • Use with caution
Xylocaine antiarrhythmic; anesthetic; slows • Ventricular administered to • Slurred speech when administered
local anesthetic depolarization and tachycardia patients receiving • Confusion with other
automaticity • Ventricular fibrillation IV calcium channel • Seizures antiarrhythmics
that is unresponsive blockers • Hypotension
to CPR, defibrillation,
and vasopressor
therapy
• Local anesthetic
Procainamide Class Ia Ester-type local • Ventricular • Should not be 20–50 mg/min IV • Drowsiness • Carefully monitor
Pronestyl antiarrhythmic; anesthetic; reduces tachycardia with administered to • Slurred speech ECG (QRS duration)
local anesthetic automaticity and AV pulse patients receiving • Confusion during administration
conduction • Pre-excited atrial IV calcium channel • Seizures
fibrillation blockers • Hypotension
Phenytoin Class Ib Depresses automaticity • Life-threatening • Bradycardia 15–18 mg/kg IV • Drowsiness • Fosphenytoin is
Dilantin antiarrhythmic; and AV conduction; arrhythmias from • High-grade heart • Dizziness preferred for seizure
anticonvulsant reduces voltage and digitalis toxicity block • Headache management
spread of electrical • Seizures • Hypersensitivity to the • Hypotension
discharges in motor drug • Arrhythmias
cortex • Nausea
• Vomiting
Adenosine Nucleoside Slows AV conduction; • Supraventricular • Atrial fibrillation 6 mg IV • Facial flushing • Should be given by
Adenocard short half-life tachyarrhythmias • Torsades des • Headache rapid IV push followed
pointes • Chest pain by saline bolus
• Atrial fibrillation • Nausea • Arrhythmias
common following
administration
(Continued)
405
Table 13-21 Antiarrhythmics (Continued)
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Esmolol Class II Slows heart rate through • Tachycardia • Asthma 50–100 mcg/ IV • Bradycardia • Hypotension is
Brevibloc antiarrhythmic; selective blockade of b1 • Heart block kg/min • Hypotension common but dose
beta blocker receptors; short half-life • Bradycardia • Congestive related
• Cardiogenic heart failure • Should not be
shock • Lethargy administered to
patients receiving
IV calcium channel
blockers
Labetalol Class II Lowers blood pressure • Hypertensive • Asthma 10–20 mg IV, PO • Bradycardia • Should not be
Trandate, antiarrhythmic; through nonselective emergency • Heart block • Hypotension administered to
Normodyne beta blocker blockade of b receptors • Bradycardia • Congestive patients receiving
(and limited blockade of • Cardiogenic heart failure IV calcium channel
a2 receptors) shock • Lethargy blockers
Diltiazem Class IV Lowers blood pressure • Rapid ventricular rate • Hypotension 15–20 mg IV • Nausea • Can be given as IV
Cardizem antiarrhythmic; by relaxing vascular associated with atrial • Congestive heart • Vomiting bolus or IV infusion
calcium channel smooth muscle; slows fibrillation failure • Dizziness • Calcium chloride can
blocker AV conduction • Stable narrow- • Cardiogenic shock • Headache reverse some of the
complex • Wide-complex • Hypotension untoward effects
tachyarrhythmias ventricular
tachycardia
Magnesium Mineral/ Physiologic calcium- • Torsades des pointes • High-degree heart 1–2 g IV • Flushing • Can cause cardiac
Sulfate electrolyte channel blocker; • Asthma blocks • Sweating conduction problems
bronchodilator • Hypertensive • Shock • Bradycardia in conjunction with
disorders of • Dialysis • Respiratory digitalis
pregnancy • Hypocalcemia depression
• Ventricular fibrillation/ • Hypothermia
pulseless ventricular
tachycardia in adult
patients
406
Emergency Pharmacology 407
as a local anesthetic, and phenytoin (Dilantin) is most com- sympathetic terminals. They include bretylium (Bretylol)
monly used as an antiseizure medication. Lidocaine was and amiodarone (Cordarone); bretylium is the prototype.
once the drug of choice for treating ventricular tachycardia Their mechanism of action is on the potassium channels
and ventricular fibrillation. Prophylactic administration of in the fast potentials. By blocking the efflux of potassium,
lidocaine was once thought to benefit patients with myo- bretylium prolongs repolarization and the effective refrac-
cardial infarction. Recent studies, however, have shown it tory period. It was indicated in the treatment of ventricular
to be relatively ineffective. When given in overdose, lido- fibrillation and refractory ventricular tachycardia. It causes
caine has significant CNS side effects, including tinnitus, an initial release of norepinephrine at the sympathetic end
confusion, and convulsions. terminals, followed by an inhibition of that neurotransmit-
Class IC drugs include flecainide (Tambocor) and ter’s release. This delayed repolarization prolongs the QT
propafenone (Rythmol). They decrease conduction veloc- interval; consequently, bretylium’s primary and frequent
ity through the atria and ventricles, as well as through the side effect is hypotension. It is now rarely used.22
bundle of His and the Purkinje network. Like the Class IA
drugs, they delay ventricular repolarization. Both these Calcium Channel Blockers (Class IV) Cal-
medications, which are administered orally, are given to cium channel blockers’ effect on the heart is almost iden-
prevent recurrence of ventricular arrhythmias, but both tical to that of beta-blockers. They decrease SA and AV
also have proarrhythmic properties; that is, they are likely node automaticity, but most of their usefulness arises from
to cause arrhythmias as well as treat them. They also decreasing conductivity through the AV node. They effec-
depress myocardial contractility and are therefore reserved tively slow the ventricular conduction of atrial fibrillation
for potentially lethal ventricular arrhythmias that do not and flutter, and they can terminate supraventricular tachy-
respond to any other conventional therapy. cardias originating from a reentrant circuit. Verapamil
Moricizine (Ethmozine) is similar to the other Class I (Calan) and diltiazem (Cardizem) are the only two calcium
drugs but has additional properties that exclude it from the channel blockers that affect the heart. Verapamil is the
other subclasses. Like the other drugs in this class, it blocks prototype. Their chief side effect is hypotension and brady-
sodium influx during fast potential depolarization, thereby cardia. The section on antihypertensives discusses calcium
decreasing conduction velocity, but it can also depress channel blockers in more detail.
myocardial contractility. Like the Class IC drugs, it is
reserved for the treatment of ventricular arrhythmias Miscellaneous Antiarrhythmics Adenosine
refractory to other conventional therapy. (Adenocard) and digoxin (Lanoxin) are both effective anti-
arrhythmics. Magnesium is the drug of choice in torsades de
Beta-Blockers (Class II) The drugs in this class, pointes, a type of polymorphic ventricular tachycardia. We
propranolol (Inderal), acebutolol (Sectral), and esmolol briefly discuss each here.
(Brevibloc), are all beta adrenergic antagonists. Proprano- Adenosine does not fit any of the previous categories.
lol is nonselective, whereas acebutolol and esmolol are both It is an endogenous nucleoside with a very short half-life
selective for the b1 receptors in the heart. (The mechanism (about 10 seconds). It acts on both potassium and calcium
of action at the b1 receptor is described in the section on channels, increasing potassium efflux and inhibiting cal-
adrenergic antagonists.) Of the many beta-blockers, these cium influx. This results in a hyperpolarization that effec-
are the only ones approved for the treatment of arrhyth- tively slows the conduction of slow potentials, such as
mias. They are indicated in the treatment of tachycardias those found in the SA and AV nodes. It has little effect on
resulting from excessive sympathetic stimulation. The b1 the fast potentials in the ventricles and is not particularly
receptor in the heart is attached to the calcium channels. effective on ventricular tachycardias or atrial fibrillation or
Blocking the b1 receptors thus blocks the calcium channel flutter. Because of its short half-life, its side effects are short
and prevents the gradual influx of calcium in phase 0 of lived, but they can be alarming. They include facial flush-
the slow potential. As a result, the effects of beta-blocker ing, shortness of breath, chest pain, and marked bradycar-
therapy on arrhythmias are almost identical to those of cal- dias. Adenosine must be given as a rapid IV push, as the
cium channel blockers. Propranolol is the prototype Class II drug is metabolized rapidly. Doses should be increased in
drug. Because it is nonselective, it also blocks the effect of b2 patients taking adenosine blockers such as aminophylline
receptors, which leads to many of its side effects. Other side or caffeine. They should be decreased in patients taking
effects are consistent with those discussed in the section on adenosine uptake inhibitors such as dipyridamole (Persan-
drugs that affect the sympathetic nervous system. tine) and carbamazepine (Tegretol).
Digoxin (Lanoxin) is a paradoxical drug. Its many
Potassium Channel Blockers (Class III) Potas- effects on the heart make it both an effective antiarrhyth-
sium channel-blocking drugs are also known as antiad mic and a potent proarrhythmic (generator of arrhyth-
renergic medications because of their complex actions on mias). Although we do not clearly understand its specific
408 Chapter 13
prototype of this class. Furosemide blocks sodium reab- this, they use an osmotically large sugar molecule that is
sorption in the thick portion of the ascending loop of Henle freely filtered through the glomerulus and pulls water after
(hence, the name loop diuretic). In doing so, it decreases the it. Mannitol (Osmitrol), the prototype osmotic diuretic, is
pull of water from the tubule and into the capillary bed, used to treat increased intracranial and intraocular pressure.
thus decreasing fluid volume. Furosemide’s main side
effects are hyponatremia, hypovolemia, hypokalemia, and Adrenergic Inhibiting Agents Inhibiting the
dehydration. Because the decrease in volume is most effects of adrenergic stimulation can also control hyper-
noticeable as decreased preload, orthostatic hypotension is tension. Several broad mechanisms accomplish this: beta
a problem. Reflex tachycardia may also occur as the baro- adrenergic antagonism, centrally acting alpha adrenergic
receptors detect a decreased blood pressure and attempt to antagonism, adrenergic neuron blockade, a1 blockade, and
compensate by increasing heart rate. This happens in indi- alpha/beta blockade.
viduals with hypertension because the homeostatic “ther-
Beta Adrenergic Antagonists From Table 13-17 in our
mostat” has been set too high. In other words, the body
earlier discussion of b1 blockers, you will recall that most
believes that what is actually hypertension is normal and
b1 receptors are in the heart but some also exist in the
tries to maintain a higher blood pressure than is healthy.
juxtaglomerular cells of the kidney. Selective b1 blockade
This reflex tachycardia is frequently treated with concur-
is useful in treating hypertension for several reasons. It
rent administration of a loop diuretic with a b1 blocker.
decreases contractility, thereby directly decreasing cardiac
Hypokalemia is frequently treated by increasing dietary
output. It also reduces reflex tachycardia by inhibiting sym-
potassium intake (bananas are rich in potassium) or by
pathetically induced compensatory increases in heart rate.
prescribing potassium supplements. An unexplained side
Finally, it represses renin release from the kidneys, which,
effect of loop diuretics is ototoxicity (tinnitus and deaf-
in turn, inhibits the vasoconstriction activated by the renin–
ness). Administering loop diuretics slowly can decrease
angiotensin–aldosterone system. The prototype selective b1
ototoxicity.
blocker is metoprolol (Lopressor); the prototype nonselec-
Thiazides have a mechanism similar to loop diuretics.
tive beta-blocker is propranolol (Inderal). The section on b1
The main difference is that the thiazides’ mechanism affects
blockers discussed these agents’ side effects.
the early part of the distal convoluted tubules and there-
fore cannot block as much sodium from reabsorption. Thi- Centrally Acting Adrenergic Inhibitors Centrally act-
azides are often the drugs of choice in hypertension ing adrenergic inhibitors reduce hypertension by inhibiting
treatment because they can decrease fluid volume suffi- CNS stimulation of adrenergic receptors. In effect, they are
ciently to prevent hypertension but not so much that they CNS a2 agonists. Recall that a2 receptors are located on
promote hypotension. The prototype thiazide is hydro- the presynaptic end terminals in the sympathetic nervous
chlorothiazide (HydroDIURIL). This class has essentially system. When stimulated, they inhibit the release of nor-
the same side effects as loop diuretics. One important dis- epinephrine to counterbalance sympathetic stimulation. By
tinction is that thiazides depend on the glomerular filtra- increasing the stimulation of a2 receptors in the section of
tion rate, whereas loop diuretics do not. Thus, loop the CNS responsible for cardiovascular regulation, cen-
diuretics may be preferred for patients with renal disease. trally acting adrenergic inhibitors decrease the sympathetic
Potassium-sparing diuretics have a slightly different stimulation of both a1 and b2 receptors. The net effect is to
mechanism from other diuretics. Although they still affect decrease heart rate and contractility by decreasing release of
sodium absorption, they do so by inhibiting either the norepinephrine at b1 receptors and to promote vasodilation
effects of aldosterone on the distal tubules (as does spi- by decreasing norepinephrine release at a1 receptors at vas-
ronolactone) or the specific sodium–potassium exchange cular smooth muscle. The prototype drug in this category
mechanism (as does triamterene). Acting so late in the is clonidine (Catapres). Although it does have some side
nephritic loop, these agents are not very potent diuretics. effects—notably, drowsiness and dry mouth—clonidine is
In fact, they are rarely used alone but instead are typically a relatively safe and frequently prescribed antihypertensive
administered in conjunction with either a loop diuretic or a agent. Methyldopa (Aldomet) is another centrally acting
thiazide diuretic. They are useful as adjuncts to other antihypertensive with a mechanism similar to clonidine.
diuretics because they not only decrease sodium reabsorp-
tion (although in small volumes) but also increase potas- Peripheral Adrenergic Neuron Blocking Agents Like
sium reabsorption. This helps to limit the other diuretics’ the centrally acting adrenergic inhibitors, peripheral adren-
hypokalemic effects. Spironolactone (Aldactone) is the pro- ergic neuron blocking agents work indirectly to decrease
totype potassium-sparing diuretic. stimulation of adrenergic receptors. They do this by
Though not used in the treatment of hypertension, decreasing the amount of norepinephrine released from
osmotic diuretics are important because they alter the reab- sympathetic presynaptic terminals. These agents are no
sorption of water in the proximal convoluted tubule. To do longer commonly used.
410 Chapter 13
The prototype of this class is reserpine (Serpalan). The juxtaglomerular apparatus in the kidneys releases
Reserpine has two actions that decrease the amount of nor- renin in response to decreases in blood volume, sodium
epinephrine released. First, it decreases the synthesis of concentration, and blood pressure. Renin acts as an enzyme
norepinephrine. Second, it exposes norepinephrine in the to convert the inactive protein angiotensinogen into angio-
terminal vesicles to monoamine oxidase, an enzyme that tensin I. Neither angiotensinogen nor angiotensin I has
destroys it. This decreases stimulation of a1 receptors, much pharmaceutical effect, but angiotensin-converting
resulting in peripheral vasodilation, and of b1 receptors, enzyme (ACE) almost immediately converts angiotensin I
resulting in decreased heart rate and contractility. The in the blood into angiotensin II. (ACE is found in the lumen
decreased peripheral vascular resistance and cardiac out- of almost all vessels and is found in the lungs in very high
put in turn lower blood pressure. concentrations.) Angiotensin II causes both systemic and
Reserpine also decreases synthesis of several CNS local vasoconstriction, with more pronounced effects on
neurotransmitters (serotonin and other catecholamines). arterioles than on venules. It also lessens water loss by
This causes reserpine’s primary adverse effect, depression. decreasing renal filtration secondary to renal vasoconstric-
Reserpine, therefore, is not frequently used as an antihy- tion. Finally, angiotensin II also increases the release of
pertensive. Additional side effects include gastrointestinal aldosterone, a corticosteroid produced in the adrenal cor-
cramps and increased stomach acid production. Other tex. Aldosterone, in turn, increases sodium and water reab-
drugs with similar actions include guanethidine (Ismeline) sorption in the distal convoluted tubule of the nephrons
and guanadrel (Hylorel). (Figure 13-27).
ACE inhibitors are very effective in treating hyper-
Alpha1 Antagonists This chapter’s section on drugs tension and have also seen success in managing heart
affecting the sympathetic nervous system discusses the a1 failure and renal failure. ACE inhibitors block the con-
receptor antagonists in detail. Only their specific action will version of angiotensin I to angiotensin II, thereby provid-
be repeated here. The prototype selective a1 antagonist is ing a host of beneficial effects for patients with
prazosin (Minipress). It decreases blood pressure by com- hypertension. These include a rapid decrease in arterio-
petitively blocking the alpha1 receptors, thereby inhibiting lar constriction, which lowers peripheral vascular resis-
the sympathetically mediated increases in peripheral vas- tance and afterload. Although it does cause some dilation
cular resistance. By causing the arterioles to dilate, prazo- of the venules, this effect is limited. Because of the lim-
sin directly decreases afterload. By causing the venules to ited decrease in preload, orthostatic hypotension, com-
dilate, it promotes venous pooling, which decreases pre- mon in other antihypertensives, is not a significant
load. The decreased afterload and preload help to lower concern with ACE inhibitors. These agents also appear to
blood pressure. Terazosin (Hytrin) is another drug with be effective in preventing some of the untoward struc-
similar properties. tural changes in the heart and blood vessels that angio-
tensin II causes over time.
Combined Alpha/Beta Antagonists Labetalol (Nor-
The prototype ACE inhibitor is captopril (Capoten).
modyne) and carvedilol (Coreg) competitively bind with
Captopril acts like all ACE inhibitors to prevent hyperten-
both a1 and b1 receptors, increasing their antihypertensive
sion. Its main advantage is the absence of side effects
actions. Hypertension is treated by decreasing b1-mediated
common to other antihypertensives. It does not interfere
vasoconstriction, which, again, decreases both preload and
with beta receptors, so it does not decrease the ability to
afterload. Beta1 blockade decreases heart rate, contractility,
exercise or respond to hemorrhage. It does not cause
and renin release from kidneys. By blocking the release of
potassium loss like many diuretics, and it does not cause
renin, which promotes vasoconstriction, these agents
depression or drowsiness. Because it has no effect on sex-
decrease peripheral vascular resistance even further. Labet-
ual desire or performance, it is much more attractive to
alol is commonly used to treat hypertensive crisis and is
many patients who might not comply with other medica-
rapidly replacing the use of sublingual nifedipine (Procar-
tions. Other common ACE inhibitors include enalapril
dia) for this purpose.
(Vasotec), benazepril (Lotensin), and lisinopril (Zestril).
Angiotensin-Converting Enzyme (ACE) These medications are all taken orally. For intravenous
Inhibitors Agents in this class interrupt the renin– use in hypertensive crisis, enalaprilat (Vasotec I.V.) is
angiotensin–aldosterone system (RAAS) by preventing the available.
conversion of angiotensin I to angiotensin II. Angiotensin The most dangerous side effect of ACE inhibitors is
II is one of the most potent vasoconstrictors yet discov- pronounced hypotension after the first dose. This can be
ered. By decreasing the amount of circulating angiotensin minimized by reducing initial doses, and it does not reoc-
II, peripheral vascular resistance can be decreased, which cur. The main adverse effects of continual use are a persis-
leads to a decrease in blood pressure. tent cough and angioedema.
Emergency Pharmacology 411
4GPKP#PIKQVGPUKP#NFQUVGTQPG5[UVGO
.GIGPF
5GETGVKQPHTQO
CPQTICP
5[ORCVJGVKE
5VKOWNCVQT[
CEVKXKV[
UKIPCN
s +PJKDKVQT[
0C UKIPCN
.WPI -KFPG[ -
4GCEVKQP
5WTHCEGQHRWNOQPCT[ 6WDWNCT0C
%Ns
%Ns #EVKXG
CPFTGPCNGPFQVJGNKWO TGCDUQTRVKQPCPF-
*1 VTCPURQTV
#PIKQVGPUKP%QPXGTVKPI GZETGVKQP*1
'P\[OG
#%'
TGVGPVKQP 2CUUKXG
VTCPURQTV
#FTGPCNINCPF 9CVGTCPFUCNV
EQTVGZ TGVGPVKQP'HHGEVKXG
#PIKQVGPUKP+ #PIKQVGPUKP++ #NFQUVGTQPG EKTEWNCVKPIXQNWOG
UGETGVKQP KPETGCUGU2GTHWUKQP
QHVJGLWZVCINQOGTWNCT
#PIKQVGPUKPQIGP
CRRCTCVWUKPETGCUGU
#TVGTKQNCT #TVGTKQNG
XCUQEQPUVTKEVKQP
4GPKP +PETGCUGKPDNQQF
RTGUUWTG
.KXGT
#&*UGETGVKQP
s 2KVWKVCT[INCPF
&GETGCUGKP
RQUVGTKQTNQDG
*1
TGPCNRGTHWUKQP
LWZVCINQOGTWNCT -KFPG[
CRRCTCVWU %QNNGEVKPIFWEV
*1CDUQTRVKQP
Angiotensin II Receptor Antagonists This released from the sarcoplasmic reticulum on activation by
recently developed classification of antihypertensive an action potential. When it enters the muscle cell through
drugs also acts on the renin–angiotensin–aldosterone sys- calcium channels, muscle contraction ensues. Blocking the
tem. Angiotensin II receptor antagonists achieve the same calcium channels prevents the arterioles’ smooth muscle
effects as the ACE inhibitors without the side effects of from contracting and therefore dilates these vessels. When
cough or angioedema. The prototype of this new class is this occurs, peripheral vascular resistance decreases, and
losartan (Cozaar). blood pressure falls as a result of lower afterload. Because
nifedipine has little effect on veins, it does not cause a
Calcium Channel Blocking Agents We have corresponding drop in preload and consequently avoids
already discussed two calcium channel blockers, vera- orthostatic hypotension. Although nifedipine does not
pamil and diltiazem, in the section on antiarrhythmics. affect the cardiac electrical conduction system, it is effec-
Another structural subclass of calcium channel blockers is tive in dilating the coronary arteries and arterioles and
the dihydropyridines. The prototype dihydropyridine is thereby helps to increase coronary perfusion. The primary
nifedipine (Procardia, Adalat). Nifedipine, as well as the indications for nifedipine are angina pectoris and chronic
other members of the dihydropyridines, differs from vera- treatment of hypertension. Its primary side effects include
pamil and diltiazem in that it does not affect the calcium reflex tachycardia (responding to baroreceptor response to
channels of the heart at therapeutic doses. Rather, it acts decreased blood pressure), facial flushing, dizziness, head-
only on the vascular smooth muscle of the arterioles. These ache, and peripheral edema. It has been used commonly
agents act by blocking the calcium channels in the arteri- for the emergent reduction of blood pressure in the field;
oles. Calcium, which is required for muscle contraction, is however, labetalol and nicardipine are replacing it.
412 Chapter 13
Direct Vasodilators We have already discussed turns off the entire autonomic nervous system, which is obvi-
several drugs that cause vasodilation. Two specific classes ously not a very selective approach. When this happens, the
of vasodilators are those that dilate arterioles and those that effects on each organ system are determined by the predomi-
dilate both arterioles and veins. All these drugs are used to nant autonomic tone (the division of the ANS that normally
decrease blood pressure. has the greater influence on that organ). Because the arteries
Selective dilation of arterioles causes a decrease in and veins have predominant sympathetic control, they dilate
peripheral vascular resistance or afterload. This is the resis- in response to trimethaphan administration. This reduces
tance that the heart must overcome to eject blood. Decreas- both preload and afterload, and blood pressure drops. Tri-
ing peripheral vascular resistance lowers blood pressure, methaphan also directly affects vascular smooth muscle,
increases cardiac output, and reduces cardiac workload. causing dilation and the release of histamine, which is also
However, dilating the veins increases capacitance and a vasodilator. Mecamylamine (Inversine) is the other gangli-
decreases preload, the amount of blood in the heart prior to onic blocking drug available in the United States, although it
contraction. Starling’s law tells us that as preload increases, is not commonly used anymore.
so do stroke volume and cardiac output (up to a point). By
decreasing preload, venodilators decrease both blood pres- Cardiac Glycosides The cardiac glycosides occur
sure and cardiac output. naturally in the foxglove plant. The two drugs in the
Hydralazine (Apresoline) is the prototype for the class, digoxin (Lanoxin) and digitoxin (Crystodigin), are
selective arteriole dilators. It is effective in decreasing chemically related. These drugs are also known as digi-
peripheral vascular resistance and afterload and thus low- talis glycosides. Digoxin is the prototype. One of the ten
ering blood pressure. Its primary side effects are reflex most frequently prescribed medications in the country, it
tachycardia and increased blood volume. Both occur as a is indicated for heart failure and some types of arrhyth-
compensatory mechanism to lowered blood pressure, and mias. Digoxin’s mechanism of action is complex. It blocks
both have the effect of increasing cardiac workload. As a the effects of Na+K+ATPase, an enzyme responsible for
result, hydralazine is almost always prescribed in conjunc- returning ion flow to normal levels after muscle depolar-
tion with a beta-blocker and a diuretic. It is frequently used ization. By interfering with this sodium–potassium pump,
in the treatment of pregnancy-induced hypertension. digoxin increases the intracellular levels of sodium. Because
Minoxidil (Loniten) is another selective arteriole dila- sodium is also involved in a reciprocal exchange with cal-
tor with properties similar to those of hydralazine. One cium, a buildup of intracellular sodium leads to a similar
side effect deserves comment. It produces hypertrichosis buildup of intracellular calcium. These elevated levels of
(excessive hair growth) in about 80 percent of those taking intracellular calcium increase the strength of muscle con-
it. Although this is particularly irritating when it occurs all traction and are the basis for digoxin’s primary indication.
over a patient’s body, it can become a therapeutic effect Digoxin reduces the symptoms of congestive heart failure
when the drug is applied as a topical ointment. Minoxidil by increasing myocardial contractility and cardiac output.
is marketed in this form as Rogaine for promoting hair This diminishes the dilation of the heart’s chambers fre-
growth in men. quently seen in left heart failure because it enables the heart
Unlike hydralazine, sodium nitroprusside (Nipride) to effectively pump blood out of its ventricles, thus decreas-
acts on both arterioles and veins. It is the fastest acting anti- ing the engorgement typical of this condition. Increasing
hypertensive available and is the drug of choice in hyper- cardiac output decreases the sympathetic discharge medi-
tensive emergencies. It is very potent and is given via ated by baroreceptor reflexes, resulting in reduced afterload.
controlled IV infusion. Its effects are almost immediate and Furthermore, digoxin indirectly lessens preload by increas-
end within minutes of drug cessation; therefore, blood ing renal blood flow, which results in higher glomerular
pressure must be carefully and continuously monitored filtration and decreased blood volume. Digoxin also has
during infusion, preferably in the ICU. Sodium nitroprus- antiarrhythmic effects, which we discuss more thoroughly
side has several significant side effects. Obviously, hypo- in the section on antiarrhythmic medications.
tension can be a problem when this medication is not Although digoxin effectively treats the symptoms of
administered carefully. Because cyanide and thiocyanate heart failure, it also is potentially dangerous. Its therapeu-
are byproducts of nitroprusside metabolism, other adverse tic index is very small, and the individual variability is
effects include cyanide poisoning and thiocyanate toxicity. large. This leads to toxicity in some individuals even
though they have normal digoxin levels. Digoxin’s chief
Ganglionic Blocking Agents Ganglionic blocking adverse effects are arrhythmias. In fact, digoxin frequently
agents are nicotinicN antagonists. The prototype is trimeth- induces some of the same arrhythmias it is used to treat.
aphan (Arfonad). Because nicotinicN receptors exist at the Other side effects include fatigue, anorexia, nausea and
ganglia of both the sympathetic and the parasympathetic vomiting, and blurred vision with a yellowish haze and
nervous systems, competitive antagonism of these receptors halos around dark objects.
Emergency Pharmacology 413
Other Vasodilators and Antianginals The drugs dis- Verapamil and diltiazem also reduce SA and AV node con-
cussed in this section have vasodilatory properties that are ductivity, which can decrease reflex tachycardia and
useful in reducing blood pressure, but they are most com- arrhythmias. Nifedipine has relatively few effects on the
monly used to treat angina. The three basic types of angina heart and, thus, has limited antiarrhythmic properties. The
pectoris (chest pain) are stable (exertional) angina; unsta- calcium channel blockers are effective in all forms of angina.
ble angina; and variant, or Prinzmetal’s, angina. Stable and A primary side effect of these agents is hypotension.
unstable angina have the same pathophysiology and dif- Organic nitrates are potent vasodilators used to treat
fer only by causation: Stable angina occurs after exercise as all forms of angina. First used clinically in 1879, nitroglyc-
a result of increased myocardial oxygen demand; unstable erin (Nitrostat) is the oldest of these drugs and is the cate-
angina occurs without exertion. Both result from an imbal- gory’s prototype. Other agents include isosorbide (Isordil,
ance between myocardial supply and demand. A buildup of Sorbitrate) and amyl nitrite. Nitroglycerin acts on vascular
plaque (atherosclerosis) along the walls of coronary arteries smooth muscle via a complex series of events to decrease
decreases these vessels’ diameter and, as a result, the amount intracellular calcium, thus causing vasodilation. Nitroglyc-
of blood flow to the heart. The same imbalance causes erin primarily dilates veins rather than arterioles. This
Prinzmetal’s angina but it results from vasospasm instead of decreases preload and thus decreases myocardial work-
plaque buildup. The medications discussed in this section all load, which is its primary antianginal effect. In Prinzmet-
either increase oxygen supply or decrease oxygen demand. al’s angina, nitroglycerin reverses coronary artery spasm
In addition to their previously discussed use as antihy- and increases oxygen supply.
pertensives and antiarrhythmics, calcium channel blockers Nitroglycerin is very lipid soluble, which allows it to
have a role in the treatment of angina. The three calcium cross membranes easily. Because of this, it is readily absorbed
channel blockers most frequently used for this purpose are and can be administered via sublingual, buccal, and transder-
verapamil (Calan, Isoptin), diltiazem (Cardizem), and nife- mal routes. The primary concern with nitroglycerin is ortho-
dipine (Procardia). Recall that calcium is an integral part of static hypotension, a side effect more common in the presence
both depolarization and muscle contraction. The effects of of right ventricular failure. Other common side effects include
blocking its entry into the cells are twofold. All these agents headache and reflex tachycardia. Headache is frequently used
directly affect vascular smooth muscle, leading to dilation as an indicator of the effectiveness of nitroglycerin, which
of the arterioles and, to a lesser degree, of the venules. This rapidly loses its potency when exposed to light. Although
arterial dilation decreases peripheral vascular resistance orthostatic hypotension is a serious concern with the adminis-
and, as a result, afterload, which in turn directly decreases tration of nitroglycerin, this condition typically responds well
the workload of the heart and myocardial oxygen demand. to fluid infusions.24 Table 13-22 details common nitrates.
Nitroglycerin Nitrate Relaxes • Chest pain • Hypotension 0.5–1.0 inch Transdermal • Headache • Do not get
paste vascular • Congestive • Increased • Dizziness paste on
smooth heart failure intracranial • Weakness your finger,
muscle pressure • Tachycardia as this may
causing • Hypotension cause
vasodilation, a headache.
decreased • Monitor BP
cardiac closely.
work, and
improved
coronary
blood flow.
414 Chapter 13
The prototype oral anticoagulant is warfarin (Couma- used to prevent excessive bleeding and have an evolving
din). Warfarin’s history serves as a useful reminder of its role in the management of trauma.
primary side effect. Warfarin was first developed as a rat The most commonly used antifibrinolytic is tranexamic
poison that killed through uncontrolled bleeding. After acid (TXA). It has been shown to limit bleeding and decrease
noticing that a patient who attempted suicide by ingesting the need for transfusion in trauma patients. TXA is rela-
warfarin did not, in fact, die, its clinical use was investi- tively inexpensive and easy to administer. It has a good
gated. Needless to say, this drug’s primary side effect is safety profile and is being used in several EMS systems—
bleeding. especially those with long transport times.27
Warfarin prevents coagulation by antagonizing the
effects of vitamin K, which is needed for the synthesis of Antihyperlipidemic Agents
multiple factors involved in the clotting cascade. It is pre- Elevated levels of low-density lipoproteins (LDLs) have
scribed for chronic use to prevent thrombi in high-risk been clearly indicated as a causative factor in coronary
patients such as those who have hip replacements or artifi- artery disease. Lipoproteins are essentially transport mech-
cial heart valves or those who are in atrial fibrillation. anisms for lipids (triglycerides and cholesterol). Because
Because warfarin easily crosses the placental barrier and lipids are insoluble in plasma, the body coats them in a
has dangerous teratogenic (capable of causing malforma- plasma-soluble shell in order to transport them to their tar-
tions) properties, it is contraindicated in pregnant patients. get destinations. Lipoproteins are categorized as very-low-
It also interacts adversely with many other medications. density (VLDL), low-density (LDL), intermediate-density
Like heparin, warfarin may lead to bleeding. In cases of (IDL), and high-density (HDL). Low-density lipoproteins
overdose, you may give vitamin K as an antidote. contain most of the cholesterol in the blood and are
required for transporting cholesterol from the liver to the
Fibrinolytics Fibrinolytics (also called thrombolyt- peripheral tissues. Conversely, high-density lipoproteins
ics) act directly on thrombi to break them up. The sev- (HDLs) carry cholesterol from the peripheral tissues to the
eral available fibrinolytics share a similar mechanism of liver, where it is broken down.
action. Through a chemical conversion, these drugs acti- HDLs have been described as “good” cholesterol
vate enzymes that dissolve thrombi or clots. The prototype because they lower blood cholesterol levels and decrease
drug of this class is streptokinase (Streptase). Other fibrino- the risk of coronary artery disease (CAD). LDLs are known
lytics include alteplase (rtPA), tenecteplase (TNKase), and as “bad” cholesterol because they increase blood choles-
anistreplase (Eminase). These medications all dissolve clots terol levels and the risk of CAD. As blood cholesterol levels
effectively; they differ primarily in their administration and increase, fatty plaque is deposited under the arteries’ endo-
risk of bleeding side effects. thelial tissues. Atherosclerosis then develops, and coronary
Streptokinase, which is derived from the streptococci arteries decrease in diameter. Coronary vasoconstriction,
bacterium, is the oldest available fibrinolytic. Its mecha- in turn, reduces blood flow to the heart and, in times of
nism of action is to promote plasminogen’s conversion to increased myocardial oxygen demand, may lead to angina.
plasmin. Because plasmin dissolves the fibrin mesh of Also, newly deposited plaque is often unstable. Typically,
clots, it can directly treat the cause of most myocardial the plaque is under the endothelial tissues, which cap the
infarctions and some strokes, as opposed to antiplatelet plaque deposits. As the deposits age, the cap usually
agents and anticoagulants, which can only prevent poten- becomes fairly stable. In some cases, however, the cap
tial future thrombi. Streptokinase also breaks down fibrin- breaks open and exposes the plaque to the blood. When
ogen, the precursor to fibrin. Although this action does not this happens, platelet aggregation and coagulation begin.
serve a clinical purpose (the problematic clot has already If the developing clot breaks free of the vessel, it becomes a
been formed), it does play an important role in streptoki- thrombus and may completely occlude a coronary artery,
nase’s chief side effect, bleeding. Other side effects include leading to myocardial infarction.
allergic reaction, hypotension, and fever. The goal in lowering LDL levels is to prevent athero-
Alteplase (Activase) is produced by recombinant DNA sclerosis and subsequent CAD. While raising HDL levels
technology that is identical to the naturally occurring tis- would help accomplish this, no pharmaceutical means of
sue plasminogen activator (hence its common name, rtPA). doing so currently exists. By far, the best way to lower
The window of opportunity for fibrinolytic therapy is lim- LDL levels remains dietary modification. If this is not
ited. Because of this, some EMS systems administer fibri- sufficient, several classifications of antihyperlipidemic
nolytics in the prehospital setting.26 medications may be used. The most common are drugs
that inhibit hydroxymethylglutaryl coenzyme A (HMG
Antifibrinolytics Antifibrinolytics inhibit the CoA) reductase. The liver must have HMG CoA to syn-
activation of plasminogen to plasmin, prevent the breakup thesize cholesterol. By inhibiting this enzyme, HMG CoA
of fibrin (fibrinolysis) and maintain clot stability. They are agents lower LDL levels; however, they also increase the
416 Chapter 13
number of LDL receptors in the liver, causing a further allergens that might not normally produce dyspnea may
uptake of LDL. lead to an acute attack.
Five HMG CoA reductase inhibitors are available. Drug treatment of asthma aims to relieve broncho-
Because the names of all five end in statin, these agents are spasm and decrease inflammation. Specific approaches
also known as statins. They include lovastatin (Mevacor) are categorized as beta2 selective sympathomimetics, non-
and simvastatin (Zocor). Lovastatin is the HMG CoA selective sympathomimetics, methylxanthines, anticholin-
reductase inhibitors’ prototype. Overall, these drugs are ergics, glucocorticoids, and leukotriene antagonists.
well tolerated. Their chief side effects are headache, rash, Cromolyn (Intal), a frequently used anti-inflammatory
and flushing. In rare cases, they may cause hepatotoxicity agent, does not fit neatly into any of those categories.
and lead to liver failure. Table 13-23 summarizes these agents.
Bile acid-binding resins can also reduce LDL levels.
Inert substances that have no direct biological activity, Beta2 Specific Agents Drugs that are selective for
these agents pass straight through the GI system without b2 receptors are the mainstay in treating asthma-induced
being absorbed and are excreted in feces. They are useful, shortness of breath. Albuterol (Proventil, Ventolin) is the
however, in that they indirectly increase the number of prototype of this class. In general, these agents relax bron-
LDL receptors in the liver by binding with bile acids, thus chial smooth muscle, which results in bronchodilation and
decreasing their availability. Because the liver needs cho- relief from bronchospasm. Agents from this class are first-
lesterol to synthesize bile acids, it must have more choles- line therapy for acute shortness of breath and may also
terol to compensate for the decrease in bile acids. The be used daily for prophylaxis. Most are administered via
body therefore increases the LDL receptors on the liver. As metered dose inhaler or nebulizer. Albuterol and terbu-
more LDLs remain in the liver, their levels in the blood taline may both be taken orally, and terbutaline may be
drop. Because the body does not absorb bile acid-binding given by injection. These medications’ b2 specificity is not
agents, they have no systemic effects. Their chief untow- absolute; some patients may experience b1 effects such as
ard effect is constipation. Cholestyramine (Questran) is tachycardia or arrhythmias. Patients may also experience
the prototype.
Drugs that affect the respiratory system are useful for sev- Nonspecific agonists Epinephrine
eral purposes. The most obvious is the treatment of asthma, Ephedrine
but this class also includes cough suppressants, nasal Beta2 specific agonists
decongestants, and antihistamines. Inhaled (short-acting) Albuterol (Ventolin, Proventil),
Metaproterenol (Alupent), Terbutaline
(Brethine), Bitolterol (Tornalate)
Antiasthmatic Medications Inhaled (long-acting) Salmeterol (Serevent)
Asthma is a common disease that decreases pulmonary Methylxanthines Theophylline (Theo-Dur, Slo-Bid),
function and may limit daily activities. It typically presents Aminophylline
with shortness of breath, wheezing, and coughing. Its basic Anticholinergics Atropine
pathophysiology has two components: bronchoconstriction Ipratropium (Atrovent)
and inflammation. Typically, a response to some sort of
Anti-inflammatory agents
allergen sets both of these processes in motion. Common
culprits include pet dander, mold, and dust. Cold air, Glucocorticoids
tobacco smoke, or other pollutants may bring on acute epi- Inhaled Beclomethasone (Beclovent),
Flucticasone (Flovent),
sodes of shortness of breath in patients with existing asthma. Triamcinolone (Azmacort)
The response to asthma typically begins with an aller- Oral Prednisone (Deltasone)
gen’s binding to an antibody on mast cells. This causes the Injected Methylprednisolone (Solu-Medrol)
mast cell membrane to rupture and release its contents, Dexamethasone (Decadron)
including histamine, leukotrienes, and prostaglandins. Leukotriene antagonists Zafirlukast (Accolate)
These cause immediate bronchoconstriction, followed by a Zileuton (Zyflo)
slower inflammatory response that can lead to mucus Montelukast (Singulair)
plugs and a further decrease in airway size. The inflamma-
Mast-cell membrane stabilizer Cromolyn (Intal)
tion may, in turn, cause a hyperreactivity to stimuli, and
Emergency Pharmacology 417
tremors resulting from the stimulation of b2 receptors in can decrease them. Likewise, side effects from the intrave-
smooth muscles. Overall, these agents are very safe. nous administrations of methylprednisolone in emergencies
are not likely. When given orally or intravenously over long
Nonselective Sympathomimetics Medications periods, however, glucocorticoids may have profound side
that stimulate both b1 and b2 receptors, as well as a recep- effects, including adrenal suppression and hyperglycemia.
tors, are rarely used to treat asthma because they have the Another anti-inflammatory agent used to prevent
undesired effects of increased peripheral vascular resistance asthma attacks is cromolyn (Intal), an inhaled powder.
and increased risks for tachycardias and other arrhythmias. Although it is not a glucocorticoid, its actions are similar.
Nonselective drugs include epinephrine, ephedrine, and The inhaled glucocorticoids are relatively safe, but cromo-
isoproterenol. Epinephrine is the only nonselective sym- lyn is even safer. In fact, it is the safest of all antiasthma
pathomimetic in common use today, because of the avail- agents. Its only side effects are coughing or wheezing due
ability of selective agents. It may be given subcutaneously to local irritation caused by the powder. Cromolyn is often
for patients who have severe bronchospasm that does not used for preventing asthma in adults and children. It is
respond to other treatments. also a useful prophylaxis before activities known to cause
shortness of breath, such as exercise or mowing grass.
Methylxanthines The methylxanthines are CNS
stimulants that have additional bronchodilatory properties. Leukotriene Antagonists Leukotrienes are
They were once first-line therapy for asthma, but now they mediators released from mast cells on contact with aller-
are used only when other drugs such as b2 specific agents gens. They contribute powerfully to both inflammation and
are ineffective. We do not know the methylxanthines’ spe- bronchoconstriction. Consequently, agents that block their
cific action, but they may block adenosine receptors. The effects are useful in treating asthma. Leukotriene antago-
prototype methylxanthine, theophylline, is taken orally. nists can either block the synthesis of leukotrienes or block
Aminophylline, an IV medication, is rapidly metabolized their receptors. Zileuton (Zyflo) is the prototype of those
into theophylline and, therefore, has identical effects. These that block the synthesis of leukotrienes. Zafirlukast (Acco-
agents’ chief side effects are nausea, vomiting, insomnia, rest- late) is the prototype of those that block their receptors.
lessness, and arrhythmias. Aminophylline is still used occa-
sionally in the emergency treatment of acute asthma attacks.
Drugs Used for Rhinitis and Cough
Anticholinergics Ipratropium (Atrovent) is an Rhinitis (inflammation of the nasal lining) comprises a
atropine derivative given by nebulizer. Because stimulat- group of symptoms including nasal congestion, itching,
ing the muscarinic receptors in the lungs results in constric- redness, sneezing, and rhinorrhea (runny nose). Either
tion of bronchial smooth muscle, ipratropium, a muscarinic allergic reactions or viral infections such as the common
antagonist, causes bronchodilation. Ipratropium is inhaled cold may cause it. Drugs that treat the symptoms of rhinitis
and, therefore, has no systemic effects. Ipratropium and and cold are commonly found in over-the-counter reme-
b2 agonists like albuterol act along different pathways, dies. In addition, nasal decongestants, antihistamines, and
so their concurrent administration has an additive effect. cough suppressants are available in prescription medica-
Ipratropium’s most common side effect is dry mouth. This tions. Although manufacturers of cold medications often
results from the local effects of the drug that remains in the combine several drugs in one product intended to treat
oropharynx after administration. multiple symptoms, we discuss each class separately.
unpleasant stopping becomes. While pseudoephedrine is antihistamines are at best only a secondary drug for treat-
an over-the-counter (OTC) medication, it is often placed ing anaphylaxis. (Epinephrine is the drug of choice.)
behind the pharmacy counter because pseudoephedrine is Just as there are H1 and H2 histamine receptors, there
one of the ingredients used in the clandestine manufactur- are H1 and H2 histamine receptor antagonists. When most
ing of methamphetamine. people refer to antihistamines, they are thinking of H 1
receptor antagonists. These agents were in popular use
Antihistamines Antihistamines arrest the effects of long before the discovery of the H2 receptors. (We discuss
histamine by blocking its receptors. Histamine is an endog- H2 receptor antagonists in the section on drugs used to
enous substance that affects a wide variety of organ systems. treat peptic ulcer disease.) The chief side effect of antihista-
It is noted for its role in allergic reaction. In the vasculature, mines is sedation, which the early antihistamines all caused
histamine binds with H1 receptors to cause vasodilation and to some degree. Now a second generation of antihista-
increased capillary permeability. In the lungs, H1 receptors mines that do not cause sedation is available.
cause bronchoconstriction. In the gut, H2 receptors cause an The first-generation antihistamines comprise several
increase in gastric acid release. Histamine also acts as a neu- chemical subclasses. Examples include alkylamines (chlor-
rotransmitter in the central nervous system. Histamine is pheniramine [Chlor-Trimeton]), ethanolamines (diphen-
synthesized and stored in two types of granulocytes: tissue- hydramine [Benadryl] and clemastine [Tavist]), and
bound mast cells and plasma-bound basophils. Both types phenothiazines (promethazine [Phenergan]). The different
are full of secretory granules, which are vesicles containing classes of agents have the same actions, but they differ in
inflammatory mediators such as histamine, leukotrienes, the degree of sedation they cause and in their ability to
and prostaglandins, among others. When these cells are block other, nonhistamine receptors. Several antihista-
exposed to allergens, they develop antibodies on their sur- mines also have significant anticholinergic properties. In
faces. On subsequent exposures, the antibodies bind with fact, some are used specifically for their anticholinergic
their specific allergen. The secretory granules then migrate effects, notably promethazine and dimenhydrinate (Dra-
toward the cell’s exterior and fuse with the cell membrane. mamine), which are used to reduce motion sickness. Other
This causes them to release their contents. Although some than the sedation that first-generation antihistamines
available medications stabilize this membrane to prevent cause, these agents’ primary side effects are constipation
the release of these substances, the traditional antihista- and the effects of muscarinic blockade, such as dry mouth.
mines work by antagonizing the histamine receptors. Because they can thicken bronchial secretions, antihista-
Although they are commonly thought of as a nuisance, mines should not be used in patients with asthma.
histamines are useful in our immune systems. Only when The second-generation antihistamines include lorata-
our immune systems overreact do allergies such as hay dine (Claritin), cetirizine (Zyrtec), and fexofenadine
fever or cedar fever send us running for the antihistamines. (Allegra). These agents’ actions are similar to the first gen-
The typical symptoms of allergic reaction include most of eration’s, with the notable exception that they do not cross
those associated with rhinitis. Severe allergic reactions the blood–brain barrier and therefore do not cause seda-
(anaphylaxis) may cause hypotension. Although hista- tion. In addition, their H1 receptor antagonism is more pro-
mines play a major role in mild and moderate allergic reac- nounced, and their anticholinergic actions are greatly
tions, their part in anaphylaxis is minimal; therefore, diminished. See Table 13-24 for common antihistamines.
Cimetidine Antihistamine Selectively • Duodenal/ • Hypersensitivity to 300 mg IV, IM, • Diarrhea • Can be
Tagamet blocks H2 peptic ulcer the drug PO • Drowsiness used as
histamine • Anaphylaxis • Dizziness an adjunct
receptors for severe
allergic
reactions
and
anaphylaxis
Emergency Pharmacology 419
Drugs Used to Affect pylori infection is eliminated, the signs of PUD resolve, and
recurrence is low. Typically, three antibiotics will be used to
the vomiting center in the medulla and the chemoreceptor used to treat chemotherapy-induced nausea and vomiting.
trigger zone (CTZ). The vomiting center stimulates vomit- The two available agents are dronabinol (Marinol) and
ing directly, whereas the CTZ does so indirectly. nabilone (Cesamet). Because both agents are essentially
The vomiting center is stimulated by H1 and ACh the same as THC (the active ingredient in marijuana), their
receptors in the pathway between itself and the inner ear, side effects include euphoria similar to that of marijuana.
by sensory input from the eyes and nose (unpleasant or While those effects may be desirable for some, they may be
disturbing sights and smells), and by other parts of the intensely unpleasant for others.
brain in response to anxiety or fear. The CTZ stimulates the
vomiting center in response to stimuli from serotonin
receptors in the stomach and bloodborne substances such Drugs Used to Aid Digestion
as opioids and ipecac. Several drugs are available to aid the digestion of carbohy-
Stimulating emesis is rarely desired, but it can be use- drates and fats. These agents are similar to endogenous
ful in treating certain types of overdoses or poisonings. digestive enzymes released into the duodenum in response
Ipecac is the drug of choice when stimulating emesis is to vagal stimulation. Occasionally, supplemental enzymes
indicated. It stimulates the CTZ which, in turn, stimulates are necessary for patients whose vagal stimulus has been
the vomiting center. surgically severed or whose duodenum has been bypassed.
Two of these drugs are pancreatin (Entozyme) and pancre-
Antiemetics Unlike causing emesis, preventing eme- lipase (Viokase). Their chief side effects are nausea, vomit-
sis is frequently desirable. Antiemetics are indicated in ing, and abdominal cramping.
conjunction with chemotherapy, which may cause violent
nausea and vomiting. Antiemetics are also indicated in the
prophylactic treatment of motion sickness.
Multiple transmitters are involved in the vomiting Drugs Used
reflex. They include serotonin, dopamine, acetylcholine,
and histamine. Drugs that interfere with any of these trans- to Affect the Eyes
mitters can decrease or prevent nausea and vomiting. This Ophthalmic drugs are used to treat conditions involving
functional class includes several pharmacological sub- the eyes, primarily glaucoma and trauma. In addition,
classes: serotonin antagonists, dopamine antagonists, anti- some ophthalmic agents are used in diagnosing and exam-
cholinergics, and cannabinoids. ining the eyes.
Glaucoma is a degenerative disease that affects the
Serotonin Antagonists The prototype serotonin
optic nerve. Its causative factors are not clear; however,
antagonist is ondansetron (Zofran). It blocks the serotonin
correlations are known between it and several risk factors,
receptors in the CTZ, the stomach, and the small intestine.
including intraocular pressure, race (its rate is three times
It is very effective in the treatment of nausea and vomiting
higher among African Americans than among whites), and
associated with chemotherapy, and, unlike the dopamine
age. The medications used to treat glaucoma are all aimed
antagonists, it does not cause extrapyramidal effects such
at reducing intraocular pressure (IOP). Beta-blockers and
as dystonia and ataxia. Its most common side effects are
cholinergics are the most common. Beta-blockade decreases
headache and diarrhea.
IOP by an unknown mechanism. Timolol (Timoptic) and
Dopamine Antagonists Both phenothiazines and betaxolol (Betoptic) are examples of this class. Pilocarpine
butyrophenones effectively block dopamine receptors in (Isopto Carpine) is the prototype cholinergic drug for treat-
the CTZ. (This chapter’s section on psychotherapeutic med- ing glaucoma. It stimulates muscarinic receptors in the eye
ications discusses both of these medications at length.) The to cause miosis (pupil constriction) and ciliary muscle con-
phenothiazines include prochlorperazine (Compazine) and traction, which indirectly lowers IOP. Drugs from these
promethazine (Phenergan), whereas the butyrophenones classes are given topically. Beta-blockers have few side
include haloperidol (Haldol) and droperidol (Inapsine). effects, whereas pilocarpine causes blurred vision and local
Agents from both classes cause side effects of extrapyra- irritation.
midal effects and sedation. Another dopamine antagonist, Some diagnostic procedures call for causing mydriasis
metoclopramide (Reglan), is neither a phenothiazine nor a (pupil dilation) and cycloplegia (paralysis of the ciliary
butyrophenone. It is unique in that it blocks both serotonin muscles used to focus vision). The two pharmacological
and dopamine receptors in the CTZ. Table 13-25 details approaches to doing this involve anticholinergics or adren-
common antiemetics. ergic agonists. In this functional class, atropine solutions
(such as Atropisol) and scopolamine solutions (such as
Cannabinoids The cannabinoids are derivatives of Isopto Hyoscine) are typical anticholinergics; phenyleph-
tetrahydrocannabinol (THC) and are effective antiemetics rine solution (AK-Dilate) is the class’s principal adrenergic
Table 13-25 Antiemetics
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Prochlorperazine Phenothiazine Suppresses • Nausea • Hypersensitivity 5–10 mg IV, IM, • Drowsiness • Can potentiate
Compazine the CTZ; has • Vomiting to the drug or the IO, PO • Dizziness CNS
antihistaminic • Anxiety phenothiazine • Sedation depressants
effects • Psychosis class • Dry mouth (e.g., alcohol).
• Small children • Extrapyramidal
• Pregnancy symptoms
Promethazine Phenothiazine Suppresses • Nausea • Hypersensitivity 12.5–25 mg IV, IM, • Drowsiness • Can potentiate
Phenergan the CTZ; has • Vomiting to the drug PO • Dizziness CNS
antihistaminic • Sedation depressants
effects • Dry mouth (e.g., alcohol).
• Extrapyramidal • Extravasation
symptoms can cause
local tissue
injury.
• Rarely used.
Droperidol Antidopaminergic Blocks dopamine • Nausea • Hypersensitivity 1.25–2.50 mg IV, IM, • QTc • Has “black
Inapsine receptors (D2) • Vomiting to the drug prolongation box warning”
• Psychosis • Prolonged QTc • Hypotension due to
on ECG • Tachycardia possible QT
prolongation.
Ondansetron Serotonin Selectively blocks • Nausea • Hypersensitivity 4–8 mg IV, IM, • Dizziness • Commonly
Zofran antagonist 5-HT3 serotonin • Vomiting to the drug PO, SL • Lightheaded used in
receptors, emergency
including those medicine
in the CTZ and because of
vagus nerve good safety
terminals profile.
422
Emergency Pharmacology 423
to Affect the Ears lobes), pineal, thyroid, parathyroid, thymus, adrenal, pan-
creas, ovaries, and testes. (Table 13-26 lists the specific hor-
Most drugs used to treat conditions involving the ear are mones that each gland releases.) Of these, the pituitary is
aimed at eliminating underlying bacterial or fungal infec- commonly referred to as the master gland because of its
tions or at breaking up impacted earwax. Chloramphenicol role in controlling the other endocrine glands. (The hypo-
(Chloromycetin Otic) and gentamicin sulfate otic solution thalamus, in turn, controls many of the pituitary’s func-
(Garamycin) are common antibiotics; carbamide peroxide tions.) Once in the bloodstream, the hormones from these
(Auro Ear Drops) and carbamide peroxide and glycerin glands circulate widely throughout the body. To be effec-
(Ear Wax Removal System) are both used to treat earwax. tive, however, they must bind with very specific receptors.
Finally, several drugs are available to treat swimmer’s ear, This discussion focuses on the pharmacological actions of
an inflammation/irritation of the external ear. They include drugs that affect the various endocrine glands.
isopropyl alcohol (Auro-Dri Ear Drops) and boric acid and
isopropyl alcohol (Aurocaine 2).
Some drugs used for other purposes have ototoxic Drugs Affecting the Pituitary Gland
(harmful to the organs or nerves that produce hearing or The pituitary gland is made up of a posterior lobe and an
balance) properties if taken in overdose or administered anterior lobe. It sits in the sella turcica, a depression of the
too quickly. The most common ototoxic symptom is tinni- sphenoid bone, and is physically connected to the hypo-
tus, or ringing in the ears. Drugs with ototoxic properties thalamus. The posterior pituitary hormones are actually
include aspirin and other NSAIDs, some antibiotics synthesized in the hypothalamus and then migrate into the
(including erythromycin and vancomycin), and the diuretic posterior pituitary, where they are released on hypotha-
furosemide (Lasix). lamic stimulation. In contrast, the hormones of the anterior
pituitary are synthesized in that lobe. The hypothalamus therefore, is through calcium and vitamin D supplements.
secretes releasing hormones into a portal system that car- Hyperparathyroidism leads to high levels of calcium.
ries them into the anterior pituitary, where they stimulate Because it usually results from tumors, the treatment of
the release of the anterior pituitary hormones. There are six choice is surgical removal of all or part of the parathyroid
main anterior pituitary hormones. glands.
The thyroid gland produces thyroid hormones, which
Anterior Pituitary Drugs The only conditions play a vital role in regulating growth, maturation, and
treated with anterior pituitary-like drugs are those associ- metabolism. Hypothyroidism can occur in children or
ated with abnormal growth, specifically dwarfism, acromeg- adults. When it develops in children, it is known as cretin-
aly, and gigantism. Dwarfism is caused by a deficiency of ism and manifests itself as dwarfism and mental retarda-
growth hormone, and therapy is aimed at hormone replace- tion with characteristic features. Because most growth and
ment. Somatrem (Protropin) and somatropin (Humatrope) maturation in adults is complete, adult onset of hypothy-
are both essentially the same as the endogenous growth hor- roidism appears as decreased metabolic rate, weight gain,
mone, acting indirectly to increase skeletal growth as well fatigue, and bradycardia. In some cases, myxedema (facial
as cell numbers by stimulating another hormone, insulinlike puffiness) may be present. Treatment is aimed at thyroid
growth factor 1 (IGF-1), to cause its effects. These drugs’ pri- hormone replacement. The prototype drug, levothyroxine
mary side effects are pain and redness at the injection site. (Synthroid), is also the most commonly used. A synthetic
Some cases of inadvertent gigantism have been reported, analog of T4 (thyroxine), one of the thyroid hormones,
but this can be avoided with careful observation. levothyroxine generally has no significant side effects
Acromegaly and gigantism are caused by excesses of when taken in therapeutic doses. Overdose may lead to
growth hormone, usually resulting from a tumor. The thyrotoxicosis or thyroid storm. Thyrotoxicosis is a condi-
treatment of choice is surgical removal of the tumor, but tion in which hyperthyroidism causes an increase in thy-
octreotide (Sandostatin) is available for pharmacological roid hormones. Thyroid storm is a severe form of
intervention. Octreotide is a synthetic drug with actions thyrotoxicosis in which the manifestations of the disease
similar to somatostatin, the endogenous growth hormone increase to life-threatening proportions. Thyroid storm is
inhibiting hormone. Its main action inhibits the release of characterized by tachycardic arrhythmias, angina, hyper-
growth hormone. Octreotide’s many side effects include tension, and hyperthermia.
bradycardia, diarrhea, and stomach distress. Goiters are enlargements of the thyroid gland. They
are typically caused by insufficient dietary iodine. In devel-
Posterior Pituitary Drugs The two posterior
oped countries, goiter is much rarer than in undeveloped
pituitary hormones are oxytocin and antidiuretic hormone.
countries and is most commonly caused by Hashimoto’s
Oxytocin is discussed in the section on drugs affecting labor
disease, a chronic autoimmune disease. Treatment of goi-
and delivery. Antidiuretic hormone (ADH) increases water
ters is aimed at supplementing the inadequate iodine.
reabsorption in the renal collecting tubules, thus promoting
Hyperthyroidism is caused by excessive release of thy-
the retention of water and a more concentrated urine. Physi-
roid hormones, typically as a result of tumors. The most
ologically, ADH is a key component in regulating blood
common cause of hyperthyroidism in the United States is
volume, blood pressure, and electrolyte balance. Clinically,
Graves’ disease. It presents with tachycardia, hyperten-
ADH analogs are used to treat diabetes insipidus and noc-
sion, hyperthermia, nervousness, insomnia, increased met-
turnal enuresis (bedwetting). Diabetes insipidus, unlike dia-
abolic rate, and weight loss. In severe cases, exophthalmos
betes mellitus, is caused by inadequate amounts of centrally
(protrusion of the eyeballs) may occur. Treatment is typi-
acting ADH. This causes a profound polyuria and polydip-
cally surgical removal of all or part of the thyroid gland.
sia. At higher doses, ADH can cause vasoconstriction and
Radioactive iodine (131I) may also be given for radiation
increased blood pressure—hence its other name, vasopres-
therapy. Propylthiouracil (PTU) may be given alone or as
sin. Vasopressin (Pitressin), desmopressin (Stimate), and
adjunct therapy to surgery or radiation in treating hyper-
lypressin (Diapid) are all available to reverse this ADH
thyroidism.
deficiency. Desmopressin is also available for administra-
tion via intranasal spray for nocturnal enuresis.29
Drugs Affecting the Adrenal Cortex
Drugs Affecting the Parathyroid The adrenal cortex synthesizes and secretes three classes of
hormones: glucocorticoids, mineralocorticoids, and andro-
and Thyroid Glands gens. The glucocorticoids and mineralocorticoids are
The parathyroid glands are primarily responsible for regu- referred to collectively as corticosteroids, adrenocorticoids,
lating calcium levels. Hypoparathyroidism leads to or corticoids. As their name implies, glucocorticoids increase
decreased levels of calcium and vitamin D. Treatment, the production of glucose by enhancing carbohydrate
Emergency Pharmacology 425
metabolism, promoting gluconeogenesis, and reducing begins later in life (after age 40) and almost always occurs
peripheral glucose utilization. The most important gluco- in patients with obesity. Because they have functioning
corticoid is cortisol. The mineralocorticoids regulate salt beta cells that release insulin, type 2 diabetics usually do
and water balance. The primary mineralocorticoid is aldo- not depend on insulin replacement. Gestational diabetes, a
sterone. The androgens are important hormones in regulat- third type, occurs transitionally during pregnancy. Gesta-
ing sexual maturation and development. tional diabetes is a form of stress-induced diabetes in
Two diseases typify the disorders associated with the which the mother cannot effectively manage her blood glu-
adrenal cortex: Cushing’s disease and Addison’s disease. cose levels during pregnancy without medical interven-
Cushing’s disease is characterized by hypersecretion of tion. Gestational diabetes resolves itself within hours to
adrenocorticotropic hormone, an anterior pituitary tropic days after delivery.
hormone that increases the synthesis of corticoids, leading The two main substances involved with regulating
to excessive glucocorticoid secretion. Common signs and blood glucose are insulin and glucagon. Both are secreted
symptoms include hyperglycemia, obesity, hypertension, from the pancreas and both are used to manage diabetes.
and electrolyte imbalances. Addison’s disease is character- Secreted from the beta cells of the pancreatic islets of Lang-
ized by hyposecretion of corticoids as a result of damage to erhans in response to increased blood glucose levels, insu-
the adrenal gland. Common signs and symptoms include lin increases cellular transport of glucose, potassium, and
hypoglycemia, emaciation, hypotension, hyperkalemia, amino acids. It also converts glucose into glycogen for stor-
and hyponatremia. age in the liver and in skeletal muscle. Finally, insulin pro-
Treatment of Cushing’s disease is typically surgical. motes cell growth and division.
Symptomatic pharmacological intervention with an anti- Glucagon, too, is secreted from the pancreatic islets,
hypertensive (potassium-sparing diuretics such as spi- but by alpha cells rather than by the insulin-producing beta
ronolactone [Aldactone] or ACE inhibitors such as cells. Glucagon’s actions are the direct opposite of insulin’s;
captopril [Capoten]) may be necessary. Drugs that may it increases both glycogenolysis (glycogen breakdown into
inhibit the synthesis of corticosteroids (antiadrenals) may glucose) and gluconeogenesis (the synthesis of glucose
also be used as an adjunct to surgery or radiation. In high from glycerol and amino acids). Thus, while insulin
doses, the antifungal agent ketoconazole (Nizoral) is an decreases blood glucose levels, glucagon increases them.
effective temporary antiadrenal drug. At such doses, how- Patients with either type 1 or type 2 diabetes may
ever, it may cause liver dysfunction. experience both hyperglycemia and hypoglycemia. Hyper-
Treatment of Addison’s disease is aimed at replace- glycemia more often results from the disease, but hypogly-
ment therapy. Cortisone (Cortistan) and hydrocortisone cemia is a common side effect of treatment. The main
(Solu-Cortef) are the drugs of choice. Occasionally, a spe- intervention for patients with type 1 diabetes is insulin
cific mineralocorticoid is necessary. Fludrocortisone (Flori- replacement therapy. Several insulin preparations are
nef Acetate) is the only mineralocorticoid available.28 available. The most effective therapy for patients with type
2 diabetes is usually weight loss through diet modification
and exercise. When this is not effective, oral hypoglycemic
Drugs Affecting the Pancreas agents (e.g., metformin [Glucophage]) and, occasionally,
Diabetes mellitus is the most important disease involving insulin are used. Finally, glucagon and diazoxide (both can
the pancreas. Diabetes mellitus (as opposed to diabetes be considered hyperglycemic agents) are occasionally used
insipidus, which involves inadequate ADH secretion) for treating emergency hypoglycemia.
involves inappropriate carbohydrate metabolism. Tradi-
tionally, the term diabetes used alone refers to diabetes mel- Insulin Preparations Insulin comes from one of
litus, of which the two main types are, logically, type 1 and three sources. Initially, it came from either beef or pork
type 2. Type 1 diabetes is also known as insulin-dependent intestines. Now, recombinant DNA technology has made
diabetes mellitus, or IDDM. It results from an inadequate human insulin available (that is, insulin synthesized with a
release of insulin from the beta cells of the pancreatic islets. human RNA template, not harvested directly from humans).
Patients with type 1 diabetes rely on insulin replacement Insulin preparations differ primarily in their onset and
therapy to survive. Because IDDM typically manifests duration of action and in their incidence of allergic reaction.
itself at an early age (usually before 30 years), it is also Insulin preparations may be short acting, intermediate act-
commonly called juvenile onset diabetes. Most diabetics ing, or long acting, depending on their onset and duration
have type 2 diabetes, which is also referred to as non– of action. (Table 13-27 lists insulin preparations.)
insulin-dependent diabetes mellitus (NIDDM) or adult Insulin is also classified as natural (regular) or modi-
onset diabetes. It results from a decreased responsiveness fied. As their name suggests, the natural insulins are used
to insulin and a lack of synchronization between insulin as they occur in nature. The other insulin preparations
release and blood glucose levels. Type 2 diabetes typically have been modified to increase their duration of action and
426 Chapter 13
thus decrease the frequency of their administration. All Oral Hypoglycemic Agents Oral hypoglycemic
insulin preparations are given subcutaneously, with the agents are used to stimulate insulin secretion from the
exception of regular insulin, which may also be given pancreas in patients with NIDDM. These agents are ineffec-
intravenously. Insulin is not available as an oral medica- tive in people with type 1 diabetes because those patients
tion because the digestive enzymes would rapidly render cannot secrete insulin. This functional class comprises
it inactive; therefore, IDDM patients must take multiple four pharmacological classes: sulfonylureas, biguanides,
injections every day of their lives. This may discourage alpha-glucosidase inhibitors, and thiazolidinediones. The
compliance in some patients. sulfonylureas were the first class of oral hypoglycemics
The modified insulin preparations include NPH (neu- available and as such are also known as first-generation
tral protamine Hagedorn) insulin, which is regular insulin or second-generation oral hypoglycemics, depending on
attached to a large protein designed to delay absorption, when they were released. Drugs in this class include tol-
and the Lente series, which is attached to zinc. Two prepa- butamide (Orinase), chlorpropamide (Diabinese), glipi-
rations of Lente insulin are available by themselves, Lente zide (Glucotrol), and glyburide (Micronase). They work
and Ultralente. A third, Semilente insulin, is available only by increasing insulin secretion from the pancreas and may
in a combination product with other insulins. also increase tissue response to insulin. Their major side
Insulin preparations are used for lifelong replacement effect is hypoglycemia.
therapy in IDDM and for emergency treatment of hyper- The only agent in the biguanide class is metformin
glycemia and hyperkalemia in nondiabetics. (Recall that (Glucophage). It decreases glucose synthesis and increases
insulin also increases potassium uptake by cells and is glucose uptake. It does not stimulate the release of insulin
therefore useful in lowering potassium levels.) These prep- from the pancreas and therefore does not cause hypoglyce-
arations’ primary side effect is unintended hypoglycemia. mia. Its primary side effects are nausea, vomiting, and
Because b2 adrenergic blockers can hide the effects of decreased appetite.
hypoglycemia, patients may not recognize this condition’s Alpha-glucosidase inhibitors include acarbose (Precose)
signs until they cannot care for themselves. Also, beta- and miglitol (Glyset). They work by delaying carbohydrate
blockers decrease the release of glucagon, so these patients’ metabolism, which moderates the increase in blood glucose
hypoglycemia may be even worse. Insulin preparations that occurs after meals. These agents’ primary side effects
derived from beef or pork, as well as the Lentes, may lead are flatulence, cramps, diarrhea, and abdominal distention
to allergic reactions. The natural human insulin prepara- resulting from colonic bacteria feeding on the increased
tions do not have this effect. number of carbohydrates remaining in fecal matter.
Emergency Pharmacology 427
Thiazolidinediones are a new class of oral hypoglyce- therapy. Estrogen is also administered in cases of delayed
mic agents unrelated to the others. The only drug in this puberty in girls as a result of hypogonadism.
class is troglitazone (Rezulin). It works by promoting tis- The progestins’ principal noncontraceptive use is to
sue response to insulin and thus making the available insu- counteract the untoward effects of estrogen on the endo-
lin more effective. Troglitazone has no major side effects. metrium in hormone replacement therapy for postmeno-
pausal women. They are also used to treat amenorrhea,
Hyperglycemic Agents Two hyperglycemic agents, endometriosis, and dysfunctional uterine bleeding.
glucagon and diazoxide (Proglycem), act to increase blood
glucose levels. Glucagon is indicated for the emergency Oral Contraceptives Oral contraception is an
treatment of patients with hypoglycemia. It will frequently effective means of preventing pregnancy. All oral contra-
be given intramuscularly to hypoglycemic patients in ceptives’ primary mechanism of action is the prevention
whom an IV line is unobtainable. Occasional side effects of ovulation, which makes the endometrium less favorable
are nausea and vomiting and, rarely, allergic reactions. for implantation and promotes the development of a thick
Diazoxide (Proglycem) inhibits insulin release and is typi- mucus plug that blocks access to sperm through the cervix.
cally used only for patients with hyperinsulin secretion These contraceptives are either a combination of estrogen
resulting from pancreatic tumors; it is more commonly and progestin or, in the case of “mini-pills,” progestin only.
used for hypertension. It is not indicated for treating diabe- They may also be classified based on their administration
tes-induced hypoglycemia. cycle as monophasic, biphasic, or triphasic. These classes
D50W (50 percent dextrose in water) is a sugar solution differ in how they alter the dose of estrogen or progestin
given intravenously for acute hypoglycemia. Its primary throughout the menstrual cycle. Many different prepara-
side effect is local tissue necrosis if infiltration occurs. tions are available, although they all work in similar fash-
Many EMS systems have transitioned from D50W to D10W ion. In general, these drugs are well tolerated and have
(10 percent dextrose in water). D10W is less expensive and few side effects. The oral contraceptives’ chief side effects
equally effective. Furthermore, it causes less persistent are unintended pregnancy (in less than 3 percent of users),
hyperglycemia following administration. It is less hyper- thromboembolism (this risk is much lower with the newer
tonic than D50W and that decreases the likelihood of tissue low-estrogen dose preparations), hypertension, and abnor-
damage if the solution extravasates. mal uterine bleeding. They are in wide use and are one
of the most widely prescribed drug classes. They are the
Drugs Affecting the Female second most popular means of birth control after surgical
sterilization (male and female combined).
Reproductive System
The main groups of drugs affecting the female reproduc- Uterine Stimulants and Relaxants Drugs
tive system are estrogens, progestins, oral contraceptives, that increase uterine contraction (uterine stimulants) are
drugs affecting uterine contraction, and those used to treat oxytocics (oxytocin means rapid birth). Drugs that relax the
infertility. uterus or inhibit uterine contraction are tocolytics.
The primary indications for administration of an oxy-
Estrogens and Progestins Estrogens are pro- tocic are to induce labor and to treat severe postpartum
duced in females by the ovaries and the ovarian follicles, hemorrhage. Oxytocin is available commercially as Pitocin
and in pregnancy, the placenta. Outside of pregnancy, the and Syntocinon. The uterus becomes increasingly sensitive
ovaries are the principal source of estrogens. The principal to oxytocin throughout gestation, progressing from rela-
ovarian estrogen is estradiol, of which there are many com- tively insensitive before pregnancy to very sensitive
mercial preparations. The principal indication for estrogen around the time of labor. Oxytocin’s chief side effect, water
is replacement therapy in postmenopausal women. After retention, is rarely significant and only so if large volumes
menopause, estrogen levels drop significantly and have of fluid have been administered without careful ongoing
been indicated as the cause of menopausal symptoms such assessment. Ergonovine (Ergotrate), a derivative of a rye
as hot flashes and vaginal dryness and as an increased fungus, is a powerful uterine stimulant. It increases both
risk factor for osteoporosis. Hormone replacement therapy the force and duration of contraction. Because of this
(HRT) with estrogen has been shown to alleviate meno- increased duration, ergonovine is only used in the treat-
pausal symptoms and reverse the increased risk for osteo- ment of postpartum hemorrhage.
porosis; however, it is not without its own risks. Recent The tocolytics relax uterine smooth muscle by stimu-
studies have shown increased chances of breast cancer and lating the b2 receptors in the uterus. The two b2 agonists
stroke associated with hormone replacement therapy. Side commonly used for this purpose are terbutaline (Brethine)
effects include nausea, fluid retention, and breast tender- and ritodrine (Yutopar). Terbutaline’s primary use is to
ness. The nausea usually diminishes after several months of treat asthma, but it is commonly used to delay labor even
428 Chapter 13
though the FDA does not currently approve it for that pur- belief, no evidence indicates that cantharis actually
pose. Both agents decrease both the force and frequency of increases sexual appetite. Indeed, it can produce some very
contraction. Their chief side effects are the same as those of dangerous side effects. Hallucinogens such as LSD and
the other beta2 agonists used to treat asthma: tremors and marijuana, as well as alcohol, are also commonly believed
tachycardia. Occasionally, hyperglycemia may result from to heighten sexuality. Any such effect from these agents is
glycogenolysis in the liver. likely an indirect result of decreased inhibitions or anxiety.
These drugs all have very different effects, depending on
Infertility Agents A number of conditions may each individual’s unique physiology, expectations before
cause infertility, which is the inability to become pregnant, use, and surrounding circumstances. They have no proven
and medications can treat only some of them. Most infertil- direct physiologic effect on sexual gratification.
ity drugs are developed for women and promote maturation Levodopa (L-dopa), an anti-Parkinson’s drug, has
of ovarian follicles. Clomiphene (Clomid), urofollitropin demonstrated increased libido and improved erectile abil-
(Metrodin), and menotropins (Pergonal) are all within this ity as a side effect of treatment. Whether this results directly
class, although each of them acts by a different mechanism. from increased autonomic stimulation or indirectly from
These agents’ side effects include ovarian enlargement or improved self-esteem achieved in therapy, any improve-
cysts, abdominal pain, and menstrual irregularities. ment seems to be only temporary. Several drugs have been
developed that aid in erectile dysfunction. Erectile dys-
Drugs Affecting the Male function becomes more frequent with age or with certain
Reproductive System diseases such as diabetes or cardiovascular disease. Drugs
that aid in erectile dysfunction increase blood supply to the
Drugs that affect the male reproductive system include
penis. These include sildenafil (Viagra), vardenafil (Levi-
those that treat testosterone deficiency and benign prostatic
tra), and tadalafil (Cialis). These drugs act by relaxing vas-
hyperplasia. Testosterone replacement therapy may be
cular smooth muscle, which increases blood flow to the
indicated in testosterone deficiency caused by cryptorchi-
corpus cavernosum, the spongelike tissue on the sides of
dism (failure of one or both of the testes to descend during
the penis responsible for erection. These drugs are unique
puberty), orchitis (testicular inflammation), or orchidec-
in that they have no effect in the absence of sexual stimula-
tomy (testicular removal). It is also used in delayed puberty.
tion. Other drugs used to treat impotence have caused pro-
Preparations include testosterone enanthate, methyltestos-
longed and painful erections (priapism). The chief side
terone (Metandren), and fluoxymesterone (Halotestin).
effect of sildenafil is seen when it is used in combination
Benign prostatic hyperplasia is an enlarged prostate.
with nitrates. The combined effect of relaxing vascular
This is a common but problematic age-related disease. By
smooth muscle may lead to a dangerously decreased pre-
the age of 70, close to 75 percent of men will have symp-
load, which may lower blood pressure and lead to myocar-
toms severe enough to seek therapy. These symptoms may
dial infarction. Prehospital personnel should be aware of
include urinary hesitancy and retention. Treatment has tra-
this important interaction.
ditionally been surgery, but several drugs are available,
If you are called on to treat a patient with chest pain
including finasteride (Proscar), which interferes with the
who has taken sildenafil, vardenafil, or tadalafil recently, do
production of an enzyme involved with prostate growth.
not give him nitroglycerin or any other nitrate. Table 13-28
Side effects may include rash, breast tenderness, headache,
details hormones and related agents.
impotence, and decreased libido.
Oxytocin Hormone Oxytocic; • Postpartum • Anything other 10–20 units IV, IM • Anaphylaxis • Ensure placenta
Pitocin (oxytocin) causes uterine vaginal than postpartum in 500 mL IV; • Arrhythmias (and possible
contractions bleeding bleeding (in 3–10 units (IM) additional
and lactations • Induction/ the prehospital baby) has
augmentation setting) delivered before
of labor administering.
Glucagon Hormone Elevates blood • Hypoglycemia • Hypersensitivity to 0.25–0.5 units (IV); IV, IM, IO • Few in the • Less effective
(glucagon) glucose levels • Beta-blocker the drug 1.0 mg IM emergency in patients with
through conversion overdose setting decreased
of glycogen to glycogen stores
glucose and other (e.g., alcoholics).
factors
Insulin Hormone Causes glucose • Diabetes • Hypoglycemia Varies IV, SQ • Few in the • Dosages of the
Humulin, NovoLog, (insulin) uptake by the • Hyperglycemia • Normoglycemia emergency various insulin
Novolin cells thus lowering • Diabetic setting types vary
blood glucose ketoacidosis significantly.
levels
Dextrose, 50% Carbohydrate Substrate for • Hypoglycemia • None in the 12.5–25.0 g IV, PO • Local venous • Less concentrated
carbohydrate emergency setting irritation solutions (e.g.,
metabolism common 10%) equally
• Tissue injury effective with
fewer side effects.
Dextrose, 10% Carbohydrate Substrate for • Hypoglycemia • None in the 100 mL IV, IO • Local venous • Preferred over
carbohydrate emergency setting irritation D50W due to
metabolism common improved safety
• Tissue injury profile and cost.
Methylprednisolone Hormone Anti-inflammatory; • Asthma • Hypersensitivity to 125–250 mg IV, IO • GI bleeding • Effects are
(analog of suppresses • COPD the drug • Increases blood delayed and not
corticosteroid) immune response • Anaphylaxis glucose levels typically seen in
the prehospital
setting.
429
430 Chapter 13
with surgery is not possible, as there is nothing for the macrolide, aminoglycoside, and tetracycline antibiotics
surgeon to remove. inhibit protein synthesis, preventing the bacterial cell from
Chemotherapy is not nearly as safe or devoid of side replicating and thus spreading infection. These agents are
effects as antibiotic therapy; however, scientists have yet to usually bacteriostatic but can be bactericidal at high doses.
identify any unique characteristics of cancer cells that Typical side effects from antibiotics include gastrointestinal
would allow them to develop drugs specific to those cells. dysfunction, which commonly results from a decrease in
Because cancer is the abnormal growth of normal cells, the natural gastrointestinal bacteria that inhabit the colon.
drugs that kill cancerous cells therefore also kill noncancer-
ous cells. Chemotherapy is thus largely a balancing act
Patho Pearls
aimed at maximizing the kill rate of cancer cells while min-
imizing the death of normal tissue. The one characteristic Antibiotic Resistance. The misuse and overuse of antibiotics
that most cancer cells share is rapid cell division and repli- have contributed to a phenomenon known as antibiotic resis-
cation. Consequently, most antineoplastic agents have their tance. This resistance develops when potentially harmful bacte-
greatest effect on cancer cells during mitosis and on young, ria change in a way that reduces or eliminates the effectiveness
of antibiotics. Stated another way, the bacteria are “resistant”
small cancers that are undergoing rapid growth.
and continue to multiply in the presence of therapeutic levels of
The agents used to kill cancer cells are grouped accord-
an antibiotic. It is estimated that each year at least two million
ing to their mechanism of action. Antimetabolite drugs
people in the United States become infected with bacteria that
mimic some of the enzymes and proteins needed for DNA are resistant to antibiotics and at least 23,000 people die each
replication but do not have the same effects; therefore, they year as a direct result of these infections. Antibiotics are effective
prevent cells from reproducing. Their prototype is fluoro- only in the treatment of bacterial infections. Most common
uracil (Adrucil). Alkylating agents that interfere with DNA infections are viral and antibiotics are of no benefit. Patients and
splitting include cyclophosphamide (Cytoxan) and mech- health care professionals alike can play an important role in
lorethamine (Mustargen). Mitotic inhibitors also interfere combating antibiotic resistance. Patients should not demand
with cell division; they include vinblastine (Velban) and antibiotics when a health care professional says the drugs are
vincristine (Oncovin). not needed. Health care professionals should prescribe antibiot-
Chemotherapy’s primary side effects include nausea, ics only for infections they believe to be caused by bacteria.
vomiting, and other gastrointestinal disturbances, as well
as hair loss and weakness. Almost all antineoplastic agents Antifungal and Antiviral Agents Fungi are
cause severe side effects and are given in conjunction with parasitic microorganisms that cannot synthesize their own
antiemetics. food. Fungal infections (mycoses) may be treated with sev-
eral drugs. The azole antifungals inhibit fungal growth.
Their prototype is ketoconazole (Nizoral). Drugs used to
Drugs Used to Treat treat viruses work by a variety of mechanisms and include
acyclovir (Zovirax) and zidovudine (Retrovir), which is
Infectious Diseases commonly known as AZT. Protease inhibitors are one of the
more promising classes of drugs for treating viruses such as
and Inflammation HIV. Indinavir (Crixivan) is the prototype of this class.
Infectious diseases are typically caused by bacteria, viruses,
or funguses and may be treated with antimicrobial drugs Other Antimicrobial and Antiparasitic
developed to fight those particular invaders. We discuss Agents Although most diseases treated with the
each broad class here. medications discussed in this section are uncommon in
developed countries, they are leading causes of death in
Antibiotics An antibiotic agent may either kill the third-world countries. They include malaria, tuberculo-
offending bacteria (bactericidal agents) or so decrease the sis, leprosy, amebiasis, and helminthiasis. Tuberculosis is
bacteria’s growth that the patient’s immune system can increasingly appearing in the United States in patients with
effectively fight the infection (bacteriostatic agents). In compromised immune systems.
general, all these agents share one of several mechanisms. Malaria is a parasitic infection common in the tropics.
Drugs in the penicillin and cephalosporin classes, as well as It is transmitted by certain types of mosquitoes or, less
vancomycin (Vancocin), are bactericidal and act by inhibit- commonly, by blood transfusion. Drugs used to treat
ing cell wall synthesis. Unlike animal cells, bacteria have malaria are called schizonticides. They include chloroquine
hypertonic cell cytoplasm and depend on the rigid and rel- (Aralen), mefloquine (Lariam), and quinine. Treatment is
atively impermeable cell wall to maintain integrity. When aimed at either preventing infestation (prophylactic treat-
cell wall synthesis is inhibited, osmotic pressure pulls water ment for individuals traveling to high-risk areas) or killing
into the cell, and the cell ruptures, killing the bacteria. The the parasites in infected patients.
Emergency Pharmacology 431
Tuberculosis is caused by bacteria that are transmitted may lead to crystal deposits in various parts of the body
through airborne droplets from the coughing and sneezing that can cause kidney stones, nephritis, and atherosclerosis.
of infected patients. The bacteria can grow only in well- Drugs used to treat gout include colchicine and allopurinol
oxygenated areas. Because of the route of infection and the (Zyloprim).
need for oxygen, most patients with tuberculosis have
infestations in the lungs. Once in the lungs, the bacteria are Serums, Vaccines, and Other Immunizing
typically “walled off,” or enclosed in tubercules, and Agents The human body has a complex series of sys-
become dormant and noninfective. If the patient’s immune tems that help prevent disease. The most important of these
system is compromised, the bacteria may become active are the anatomic barriers such as the skin and mucous mem-
again and begin to cause symptoms. Drugs commonly branes that block the entrance of pathogens (disease-causing
used to treat tuberculosis include isoniazid (Nydrazid, organisms, including viruses and bacteria). If pathogens get
INH) and rifampin (Rifadin). past these protective barriers, our immune system comes into
Amebiasis is a parasitic infection of the intestines com- play. This system consists of the spleen, lymph nodes, thy-
mon in tropical areas. Transmission most frequently occurs mus, leukocytes, and proteins called antibodies in plasma.
via the oral–fecal route from eating poorly cooked food The ability to respond to pathogens is called immunity.
contaminated by cooks who wash their hands inade- Immunity may be acquired passively or actively. It is
quately. Drugs used to treat amebiasis include paromomy- passively acquired when antibodies pass directly into a
cin (Humatin) and metronidazole (Flagyl). person, either through artificial routes such as injection or
Helminthiasis is caused by parasitic worms (hel- through natural routes such as the placenta or breast milk.
minths), including flatworms and roundworms. These Immunity may also be actively acquired in response to the
worms usually invade the host’s intestinal tract and attach presence of a pathogen.
themselves to the lumen wall with hooks or suckers. They Actively acquired immunity occurs when T lympho-
cause symptoms by depriving the host of nutrients (espe- cytes (a type of leukocyte that becomes specialized in the
cially in children); by obstructing the intestinal lumen, thymus gland) comes in contact with a new pathogen. The
which leads to bowel obstruction; and by producing toxins. body produces an infinite variety of T cell configurations.
Treatment is aimed at either killing the organism outright When the pathogen comes into contact with a T cell that is
or destroying its ability to latch onto the intestinal wall so it specific to it, that T cell begins to reproduce rapidly. Some of
passes with the patient’s feces. These drugs include meben- these cells become involved in the immune response to the
dazole (Vermox) and niclosamide (Niclocide). pathogen, whereas others act as “memory” cells. The cells
Leprosy, also known as Hansen’s disease, is caused involved in the immune response either directly attack the
by bacteria. It leads to characteristic lesions, foot drop pathogen (cell-mediated immunity) or activate the comple-
(plantar flexion), and plantar ulceration. Drugs used to ment system, a complex cascade of events that leads to the
treat it include dapsone (DDS, Avlosulfon) and clofazi- immune response. The memory cells remain in the body in
mine (Lamprene). higher numbers so the next time this specific pathogen
enters the body, a much faster response is possible. At the
Nonsteroidal Anti-Inflammatory Drugs same time, B cells (lymphocytes that differentiate or become
NSAIDs (nonsteroidal anti-inflammatory drugs) are com- more specialized in the body, as opposed to the thymus)
monly used as analgesics and antipyretics (fever reducers). that are specific for the invading pathogen begin to produce
Many, including acetaminophen and ibuprofen, are avail- antibodies for that antigen. This process is called humoral
able over the counter. As a group, these agents interfere with immunity or antibody immunity. When an antibody con-
the production of prostaglandins, thereby interrupting the tacts its specific antigen, it forms a complex that triggers the
inflammatory process. NSAIDs are indicated for the relief complement system, leading to the immune response.
of pain, fever, and inflammation associated with common Serums and vaccines may augment the immune sys-
headache, arthritis, dysmenorrhea, and orthopedic injuries. tem. A serum is a solution containing whole antibodies for
They are also commonly prescribed to relieve pain follow- a specific pathogen. The antibodies give the recipient tem-
ing trauma and surgery. Other NSAIDs include ketorolac porary, passive immunity. A vaccine contains a modified
(Toradol), piroxicam (Feldene), and naproxen (Naprosyn). pathogen that does not actually cause disease but still stim-
ulates the development of antibodies specific to it. These
Uricosuric Drugs Uricosuric drugs are used to pathogens may be either dead or attenuated (having a
treat and prevent acute episodes of gout. Gout is an inflam- decreased disease-causing ability).
matory disease caused by an altered metabolism of uric The best age for vaccination against disease is within
acid and marked by hyperuricemia (high levels of uric acid the first two years of life, as the immune system is fairly
in the blood). It may present with acute episodes character- immature. Table 13-29 summarize the recommended
ized by pain and swelling of joints. Left untreated, gout schedule for immunization.
Table 13-29 Recommended Childhood (0–18 Years) Immunization Schedule United States, 2015
Figure 1. Recommended immunization schedule for persons aged 0 through 18 years – United States, 2015.
(FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]).
These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in Figure 1.
To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are shaded.
19–23
Vaccine Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 mos 18 mos 2-3 yrs 4-6 yrs 7-10 yrs 11-12 yrs 13–15 yrs 16–18 yrs
mos
Pneumococcal conjugate6
1st dose 2nd dose 3rd dose 4th dose
(PCV13)
Pneumococcal polysaccharide6
(PPSV23)
Inactivated poliovirus7
1st dose 2nd dose 3rd dose 4th dose
(IPV: <18 yrs)
Influenza8 (IIV; LAIV) 2 doses for Annual vaccination (LAIV or Annual vaccination (LAIV or IIV)
Annual vaccination (IIV only) 1 or 2 doses IIV) 1 or 2 doses 1 dose only
some: See footnote 8
Measles, mumps, rubella9 (MMR) See footnote 9 1st dose 2nd dose
MenACWY-CRM ≥ 2 mos)
Range of recommended Range of recommended ages Range of recommended ages for Range of recommended ages during Not routinely
ages for all children for catch-up immunization certain high-risk groups which catch-up is encouraged and for recommended
certain high-risk groups
This schedule includes recommendations in effect as of January 1, 2015. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and
feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee
on Immunization Practices (ACIP) statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Clinically significant adverse events that follow
vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967). Suspected cases of vaccine-preventable
diseases should be reported to the state or local health department. Additional information, including precautions and contraindications for vaccination, is available from CDC online
(http://www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm) or by telephone (800-CDC-INFO [800-232-4636]).
This schedule is approved by the Advisory Committee on Immunization Practices (http//www.cdc.gov/vaccines/acip), the American Academy of Pediatrics (http://www.aap.org), the American Academy of
Family Physicians (http://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org).
NOTE: The above recommendations must be read along with the footnotes of this schedule.
Note: This schedule plus the catch-up schedule for those who fall behind or start late and the accompanying footnotes can be found at http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf
432
Emergency Pharmacology 433
Immune Suppressing and Enhancing Agents alcoholics, and the malnourished. Additionally, people on
Available drugs can either suppress the immune system a strict vegetarian or vegan diet may need supplemental
(immunosuppressants) or enhance it (immunomodula- vitamins. Vitamins are either fat soluble or water soluble.
tors). Suppressing the immune system is indicated to pre- The liver stores the fat-soluble vitamins (A, D, E, and K), so
vent the rejection of transplanted organs and grafted skin. the patient will become deficient only after long periods of
Azathioprine (Imuran) is a commonly used immunosup- inadequate vitamin intake. Vitamin D is unique in that the
pressant that acts by decreasing cell-mediated reactions skin produces it with exposure to sunlight. The water-solu-
and suppressing antibody production. ble vitamins (C and those in the B complex) must be rou-
Immunomodulating agents enhance the natural tinely ingested, as the body does not store them. After
immune reaction in immunosuppressed patients such as short periods of deprivation, patients may begin to experi-
those with HIV. Zidovudine (Retrovir), commonly known ence vitamin deficiency. The B complex vitamins are
as AZT, and several protease inhibitors such as ritonavir grouped only because they occur together in foods; other-
(Norvir) and saquinavir (Invirase) are examples of these wise, they share no significant characteristics. The individ-
agents. ual B vitamins are named for the order in which they were
discovered (B1, B2, B3, and so forth). These vitamins also
have specific names. For example, B1 is also known as thia-
Supplement the Diet total body weight. The specific composition and amounts of
this fluid are vital to a patient’s well-being. The specific
Many disease processes affect the production, distribu- amounts of electrolytes such as calcium, potassium, sodium,
tion, and utilization of essential dietary nutrients. Addi- and chlorine are similarly important. The chapter “Patho-
tionally, the body’s intricate balance of fluid (including physiology” reviews the physiology of fluids and electro-
specific amounts of electrolytes) is a vital component of lytes and discusses acid–base balance.The indications and
maintaining homeostasis. Dietary supplements can help contraindications for administering fluids and electrolytes,
to maintain needed levels of these essential nutrients as well as these medications’ interactions, are covered in the
and fluids. chapters titled “Intravenous Access and Medication Admin-
istration” and “Hemorrhage and Shock.”
Vitamins and Minerals
Vitamins are organic compounds necessary for many dif-
ferent physiologic processes, including metabolism, Drugs Used to Treat
growth, development, and tissue repair. The body absorbs
most vitamins through the gastrointestinal tract following Poisoning and Overdoses
dietary ingestion. Vitamins must be obtained from the diet, The treatment for poisoning and overdose depends greatly
as the body cannot manufacture them. In developed coun- on the substance involved. In general, therapy aims at
tries, healthy adults usually receive adequate amounts of eliminating the substance by emptying the gastric con-
vitamins and do not need supplements. Vitamin supple- tents, by increasing gastric motility to decrease the time
ments may, however, be indicated for special populations, available for absorption, by alkalinizing the urine with
including pregnant and nursing women, patients with sodium bicarbonate (for tricyclic antidepressant and salic-
absorption disorders, the chronically ill, surgery patients, ylate overdose), or by filtering the substance from the
434 Chapter 13
A Night blindness, skin lesions Butter, yellow fruit, green leafy vegetables, milk
D Bone and muscle pain, weakness, softening of bones Fish, fortified milk, exposure to sunlight
Water Soluble
B1 (thiamine) Peripheral neuritis, depression, anorexia, poor memory Whole grain, beef, pork, peas, beans, nuts
B2 (riboflavin) Sore throat, stomatitis, painful or swollen tongue, anemia Milk, eggs, cheese, green leafy vegetables
B3 (niacin) Skin eruptions, diarrhea, enteritis, headache, dizziness, insomnia Meat, eggs, milk
B6 (pyridoxine) Skin lesions, seizures, peripheral neuritis Liver, meats, eggs, vegetables
B12 (cyanocobalamin) Irreversible nervous system damage, pernicious anemia Fish, egg yolk, milk
blood with dialysis. Activated charcoal may be used as a and symptoms of this overstimulation may be remem-
gastric absorbent.31 bered by the acronym SLUDGE (salivation, lacrimation,
Actual antidotes are few; however, some medications urination, defecation, gastric motility, and emesis). Other
are effective in treating certain overdoses or poisonings. signs include bradycardia, hypotension, bronchospasm,
General mechanisms for antidote action include receptor muscle fasciculations, miosis (pupil constriction), and
site antagonism, blocking enzyme actions involved with respiratory arrest. The antidotes for organophosphate poi-
metabolism of the substance, and chelation (binding the soning are atropine and pralidoxime (2-PAM, Protopam).
substance with a stable compound such as iron so it Atropine antagonizes ACh, whereas pralidoxime breaks
becomes inactive). Specific antidotes include acetylcysteine the organophosphate–acetylcholinesterase bond, freeing
(Mucomyst) for acetaminophen overdose and deferox- AChE to break down the excess ACh. Hydroxocobalamin
amine for iron chelation. Organophosphates are a common is now available as an antidote for cyanide poisoning.
ingredient in insecticides and herbicides as well as chemi- Hydroxocobalamin is a precursor to cyanocobalamin (vita-
cal weapons. They are aggressive acetylcholinesterase min B12). When administered, it chelates the cyanide mol-
(AChE) inhibitors that prevent the breakdown of acetyl- ecule from cytochrome oxidase, thus restoring normal
choline, leading to overstimulation of the parasympathetic energy production. It has largely replaced the old cyanide
nervous system as well as neuromuscular junctions. Signs antidote kit.32 See Table 13-31 for common antidotes.
Table 13-31 Common Antidotes
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Naloxone Opiate antagonist Opioid antagonist without • Partial reversal of • Hypersensitivity to 0.4–2.0 mg IV, IO, • Fever • Administer enough to reverse
Narcan opiate agonist properties (it opiate drug effects the drug SQ, IN, • Chills respiratory depression and avoid
has no activity when given • Opiate overdose nebulizer • Nausea full narcotic withdrawal syndrome.
in the absence of an opiate • Vomiting
agonist) • Diarrhea
• Opiate withdrawal
Flumazenil Benzodiazepine Competitively blocks • Benzodiazepine • Hypersensitivity to 0.2 mg IV • Fatigue • Administer with caution in patients
Romazicon antagonist benzodiazepines at the overdose the drug • Headache dependent on benzodiazepines,
GABA/benzodiazepine • Nervousness as life-threatening withdrawal
receptor complex • Dizziness (including seizures) can occur.
Hydroxocobalamin Cyanide antidote Chelates cyanide from • Cyanide or • None in the 5–10 g IV • Chromaturia • Be prepared to continue full
Cyanokit cytochrome oxidase suspected cyanide emergency setting • Red skin resuscitative measures following
forming cyanocobalamin poisoning • Rash administration.
(vitamin B12) • Hypertension
• Nausea
• Headache
Amyl nitrite Cyanide antidote Vasodilator; oxidizes • Cyanide poisoning • None in the 1–2 inhalants Inhaled • Headache • Headache and hypotension
hemoglobin to emergency setting • Weakness common.
methemoglobin which • Dizziness • Can worsen hypoxia in the setting
reacts with cyanide ion to • Flushing of carbon monoxide poisoning.
form cyanomethemoglobin, • Tachycardia
that is enzymatically • Orthostatic
degraded hypotension
Sodium nitrite Cyanide antidote Vasodilator; oxidizes • Cyanide poisoning • Should not be 150–300 mg IV • Headache • Headache and hypotension
hemoglobin to administered to • Weakness common.
methemoglobin which asymptomatic • Dizziness • Can worsen hypoxia in the setting
reacts with cyanide ion to patients • Flushing of carbon monoxide poisoning.
form cyanomethemoglobin, • Tachycardia
which is enzymatically • Orthostatic
degraded hypotension
Sodium thiosulfate Cyanide antidote Converts cyanide to • Cyanide poisoning • None in the 12.5 g IV • Nausea • Should be administered as part of
thiocyanate, which is emergency setting • Vomiting the standard (Pasadena) cyanide
removed by the kidneys • Joint pain kit.
• Psychosis
Pralidoxime Organophosphate Reactivates cholinesterase; • Organophosphate • Poisonings 1–2 g over IV • Excitement • Always protect rescue personnel
2-PAM, Protpam antidote deactivates certain poisoning other than 30 minutes • Manic behavior from the poison.
organophosphates organophosphates • Laryngospasm • 2-PAM administration should
• Tachycardia always follow atropinization.
435
Summary
Pharmacology is a cornerstone of paramedic practice. Paramedics must have a solid understand-
ing of its foundations (legal issues, terminology, drug forms, and routes), pharmacokinetics, and
pharmacodynamics if they are to practice their profession safely. Additionally, paramedics must
understand not only the medications they personally administer, but also the medications that
their patients are taking on an ongoing basis. You are personally, ethically, and legally responsible
for every medication you administer. If medical direction orders you to give a medication or a
dosage that is potentially dangerous, it is your responsibility to question and even refuse to
administer a harmful medication or dosage.
Even though you are not likely to remember everything in this chapter after your first read-
ing, with diligent study and practice you can master this information. This chapter has barely
broken the surface of pharmacology. To continue your education, you should take the time to
understand the mechanisms and interactions of the medications your patients are taking. If you
do not already know them (you will not, in the majority of cases, as you begin your career), look
them up. Many very useful drug references are available today. Most are small and can be easily
carried with you on a smart phone, on your unit, or in your station.
Pharmacology is a dynamic field with new discoveries being made every day. Emergency
treatments are constantly changing, based on the latest results of pharmacological studies. If you
take your responsibilities as a paramedic seriously and practice lifelong learning, remaining cur-
rent on the latest changes in this field, you can be confident in your ability to give your patients
the care they deserve.
Review Questions
1. The study of drugs and their interactions with the 9. The proprietary name of a drug, such as Valium, is
body is called _______________ the same as the ________________
a. physiology. a. official name.
b. toxicology. b. chemical name.
c. pharmacology. c. generic name.
d. pharmacopeia. d. trade name.
2. A drug or other substance that blocks the actions of 10. Drug legislation was instituted in 1906 by the
the sympathetic nervous system is called ________________________
__________________________ a. Narcotics Act.
a. adrenergic. b. Cosmetics Act.
b. sympatholytic. c. Pure Food and Drug Act.
c. sympathomimetic. d. Pharmacology Act.
d. anticholinergic.
11. ___________ drugs may be similar to those existing
3. Which drug is frequently used in the treatment of in nature, or they may be entirely new medications
pregnancy-induced hypertension? not found in nature.
a. Coreg c. Captopril a. Plant c. Synthetic
b. Apresoline d. Nifedipine b. Animal d. Mineral
4. Because they can thicken bronchial secretions, you 12. The six rights of medication administration include
should not use ___________ in patients with asthma. the right ____________________
a. mucolytics a. dose.
b. antitussives b. time.
c. antihistamines c. route.
d. antiarrrhythmics
d. all of the above.
5. The following describes a Schedule ___________
13. In which type of medication route is the drug subject
drug: High abuse potential; may lead to severe
to the “first-pass effect”?
dependence; accepted medical indications.
a. Oral c. Subcutaneous
a. I c. III
b. Intramuscular d. Intravenous
b. II d. IV
14. Drugs manufactured in gelatin containers are called
6. ______________is an example of an anticholinergic
____________________
drug used in the treatment of asthma
a. pills. c. capsules.
a. Prednisone c. Proventil
b. tablets. d. extracts.
b. Atrovent d. Beclovent
7. The drug name found in the United States Pharmaco- 15. A drug’s pharmacodynamics involves its ability to
peia (USP) is its ___________________ cause the expected response, or __________________
8. The drug name that is derived from a drug’s basic 16. A type of anesthesia that combines decreased sensa-
molecular structure is referred to as its tion of pain with amnesia, while the patient remains
_____________________________ conscious, is a(n) _________________________
a. official name. a. opioid.
b. chemical name. b. nonopioid.
c. generic name. c. anesthetic.
d. trade name. d. neuroleptanesthesia.
438 Chapter 13
17. ___________ agents block the parasympathetic ner- 19. One of aspirin’s primary side effects is ______________
vous system. a. stasis.
a. Cholinergic b. bleeding.
b. Adrenergic c. headache.
c. Antiadrenergic d. seizures.
d. Anticholinergic
20. ___________ are mediators released from mast cells
18. In antiarrhythmic classifications, Class IA drugs on contact with allergens, and contribute to the
include all of the following except inflammation response of the immune system.
_______________________ a. BNP modulators
a. quinidine. b. Leukotrienes
b. lidocaine. c. Glucocorticoids
c. procainamide. d. Methylxanthines
d. disopyramide. See Answers to Review Questions at the end of this book.
References
1. Olasveengen, T. M., K. Sunde, C. Brunborg, J. Thowsen, P. A. 13. Robertson, T. M., G. W. Hendey, G. Stroh, and M. Shalit. “Intrana-
Steen, and L. Wik. “Intravenous Drug Administration during sal Naloxone Is a Viable Alternative to Intravenous Naloxone for
Out-of-Hospital Cardiac Arrest: A Randomized Trial.” JAMA Prehospital Narcotic Overdose.” Prehosp Emerg Care 13 (2009):
302 (2009): 2222–2229. 512–515.
2. Niemann, J. T., S. J. Stratton, B. Cruz, and R. J. Lewis. “Endotra- 14. Holsti, M., B. L. Sill, S. D. Firth, F. M. Filloux, S. M. Joyce, and R.
cheal Drug Administration during Out-of-Hospital Resuscita- A. Furnival. “Prehospital Intranasal Midazolam for the Treat-
tion: Where Are the Survivors?” Resuscitation 53 (2002): 153–157. ment of Pediatric Seizures.” Pediatr Emerg Care 23 (2007): 148–153.
3. Fowler, R., J. V. Gallagher, S. M. Isaacs, E. Ossman, P. Pepe, and 15. Kress, J. P. and Hall J. B. “Sedation in the Mechanically Ventilated
M. Wayne. “The Role of Intraosseous Vascular Access in the Out- Patient.” Crit Care Med 34 (2006): 2541–2546.
of-Hospital Environment (Resource Document to NAEMSP Posi- 16. Bulger, E. M., M. K. Copass, D. R. Sabath, R. V. Maier, and G. J.
tion Statement).” Prehosp Emerg Care 11 (2007): 63–66. Jurkovich. “The Use of Neuromuscular Blocking Agents to Facili-
4. Thomas, S. H., O. Rago, T. Harrison, P. D. Biddinger, and S. K. tate Prehospital Intubation Does Not Impair Outcome after Trau-
Wedel. “Fentanyl Trauma Analgesia Use in Air Medical Scene matic Brain Injury.” J Trauma 58 (2005): 718–723; discussion
Transports.” J Emerg Med 29 (2005): 179–187. 723–724.
5. Galinski, M., F. Dolveck, S. W. Borron et al. “A Randomized, 17. Wyer, P. C., P. Perera, Z. Jin et al. “Vasopressin or Epinephrine for
Double-Blind Study Comparing Morphine with Fentanyl in Out-of-Hospital Cardiac Arrest.” Ann Emerg Med 48 (2006): 86–97.
Prehospital Analgesia.” American Journal of Emergency Medicine
18. Ong, M. E., E. H. Tan, F. S. Ng et al. “Survival Outcomes with
23 (2005): 114–119.
the Introduction of Intravenous Epinephrine in the Manage-
6. Green, R., B. Bulloch, A. Kabani, B. J. Hancock, and M. Tenenbein. ment of Out-of-Hospital Cardiac Arrest.” Ann Emerg Med 50
“Early Analgesia for Children with Acute Abdominal Pain.” Pedi- (2007): 635–642.
atrics 116 (2005): 978–983.
19. De Backer, D., P. Biston, J. Devriendt et al. “Comparison of Dopa-
7. Kanowitz, A., T. M. Dunn, E. M. Kanowitz, W. W. Dunn, and K. mine and Norepinephrine in the Treatment of Shock.” N Engl J
Vanbuskirk. “Safety and Effectiveness of Fentanyl Administra- Med 362 (2010): 779–789.
tion for Prehospital Pain Management.” Prehosp Emerg Care 10
(2006): 1–7. 20. Delbridge, T., R. Domeier, and C. B. Key. “Prehospital Asthma
Management.” Prehosp Emerg Care 7 (2003): 42–47.
8. Meine, T. J., M. T. Roe, A. Y. Chen et al. “Association of Intrave-
nous Morphine Use and Outcomes in Acute Coronary Syn- 21. Christianson, G., A. Woolf, and K. R. Olson. “b-Blocker Ingestion:
dromes: Results from the CRUSADE Quality Improvement An Evidence-Based Consensus Guideline for Out-of-Hospital
Initiative.” Am Heart J 149 (2005): 1043–1049. Management.” Clinical Toxicology 43 (2005): 131–146.
9. Rickard, C., P. O’Meara, M. McGrail, D. Garner, A. McLean, and 22. Marill, K. A., I. S. deSouza, D. K. Nishijima, T. O. Stair, G. S. Set-
P. Le Lievre. “A Randomized Controlled Trial of Intranasal Fen- nik, and J. N. Ruskin. “Amiodarone Is Poorly Effective for the
tanyl vs. Intravenous Morphine for Analgesia in the Prehospital Acute Termination of Ventricular Tachycardia.” Ann Emerg Med
Setting.” Am J Emerg Med 25 (2007): 911–917. 47 (2006): 217–224.
10. Pace, S. and T. F. Burke. “Intravenous Morphine for Early Pain 23. Kessler, C. S. and Y. Joudeh. “Evaluation and Treatment of
Relief in Patients with Acute Abdominal Pain.” Acad Emerg Med 3 Severe Asymptomatic Hypertension.” Am Fam Physician 81
(1996): 1086–1092. (2010): 470–476.
11. Barton, E. D., C. B. Colwell, T. Wolfe et al. “Efficacy of Intranasal 24. Tang, W. H. “Pharmacological Therapy for Acute Heart Failure.”
Naloxone as a Needleless Alternative for Treatment of Opioid Cardiol Clin 25 (2007): 539–551; vi.
Overdose in the Prehospital Setting.” J Emerg Med 29 (2005): 25. Anderson, J. L., C. D. Adams, E. M. Antman et al. “ACC/AHA
265–271. 2007 Guidelines for the Management of Patients with Unstable
12. Kelly, A. M., D. Kerr, P. Dietze, I. Patrick, T. Walker, and Z. Kout- Angina/Non ST-Elevation Myocardial Infarction: A Report of
sogiannis. “Randomised Trial of Intranasal versus Intramuscular the American College of Cardiology/American Heart Associa-
Naloxone in Prehospital Treatment for Suspected Opioid Over- tion Task Force on Practice Guidelines (Writing Committee to
dose.” Med J Aust 182 (2005): 24–27. Revise the 2002 Guidelines for the Management of Patients with
Emergency Pharmacology 439
Unstable Angina/Non ST-Elevation Myocardial Infarction): 29. Knapp, B. and C. Wood. “The Prehospital Administration of
Developed in Collaboration with the American College of Emer- Intravenous Methylprednisolone Lowers Hospital Admission
gency Physicians, the Society for Cardiovascular Angiography Rates for Moderate to Severe Asthma.” Prehosp Emerg Care 7
and Interventions, and the Society of Thoracic Surgeons: (2003): 423–426.
Endorsed by the American Association of Cardiovascular and 30. Donnino, M. W., J. Vega, J. Miller, and M. Walsh. “Myths and
Pulmonary Rehabilitation and the Society for Academic Emer- Misconceptions of Wernicke’s Encephalopathy: What Every
gency Medicine.” Circulation 116 (2007): e148–e304. Emergency Physician Should Know.” Ann Emerg Med 50 (2007):
26. Pedley, D. K., K. Bissett, E. M. Connolly et al. “Prospective Obser- 715–721.
vational Cohort Study of Time Saved by Prehospital Thromboly- 31. Manoguerra, A. S. and D. J. Cobaugh. “Guidelines for the Man-
sis for ST Elevation Myocardial Infarction Delivered by agement of Poisoning Consensus Panel. Guideline on the Use of
Paramedics.” BMJ 327 (2003): 22–26. Ipecac Syrup in the Out-of-Hospital Management of Ingested
27. Ausset, S, Glassberg E, Nadler R, et al. “Tranexamic Acid as Part Poisons.” Clin Toxicol (Phila) 43 (2005): 1–10.
of Remote Damage-Control Resuscitation in the Prehospital Set- 32. Borron, S. W., F. J. Baud, P. Barriot, M. Imbert, and C. Bismuth.
ting: A Critical Appraisal of the Medical Literature and Available “Prospective Study of Hydroxocobalamin for Acute Cyanide
Alternatives.” J Trauma Acute Care Surg 2015;78:S70–S75. Poisoning in Smoke Inhalation.” Ann Emerg Med 49 (2007):
28. Gueugniaud, P. Y., J. S. David, E. Chanzy et al. “Vasopressin and 794–801, 801.e1–e2.
Epinephrine vs. Epinephrine Alone in Cardiopulmonary Resus-
citation.” N Engl J Med 359 (2008): 21–30.
Further Reading
Bledsoe, Bryan E. and Dwayne E. Clayden. Prehospital Emergency Shannon, Margaret T., Billie Ann Wilson, and Carolyn L. Stang.
Pharmacology. 7th ed. Upper Saddle River, NJ: Pearson/Prentice Prentice Hall’s Health Professionals Drug Guide 2009–2010. Upper
Hall, 2011. Saddle River, NJ: Pearson/Prentice Hall, 2010.
Katzung, Bertram G. Basic and Clinical Pharmacology. 11th ed. Phila-
delphia: McGraw-Hill Medical, 2009.
Chapter 14
Intravenous Access and
Medication Administration Bryan Bledsoe, DO, FACEP, FAAEM
STANDARD
Pharmacology (Medication Administration)
COMPETENCY
Integrates comprehensive knowledge of pharmacology to formulate a treatment plan intended to mitigate emergencies
and improve the overall health of the patient.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to apply concepts of pharmacology to the
assessment and management of patients.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
11. Discuss individual components of an IV saline locks, heparin locks, and venous
administration set along with the different access devices.
types of administration sets and their
17. Explain the advantages, disadvantages, and
appropriate indications for use.
use of electromechanical infusion devices in
12. Identify the common intravenous cannulas the out-of-hospital environment.
used in the out-of-hospital environment and
18. Discuss the emerging role of ultrasound-
individual indications for use.
guided intravenous access.
13. List common location for intravenous
19. Identify the indications, equipment,
cannulation by the paramedic, and describe
procedure, and complications of obtaining
the basic steps necessary to initiate a patent
a blood sample from a patient.
IV line in each location.
20. Identify the indications, contraindications,
14. Name the common factors affecting the
equipment, procedure, and complications
IV flow rates, and list the complications
of intraosseous infusion initiation.
of IV access.
21. Given the variety of medication dosages,
15. Describe the steps needed to access the IV
drug packaging, and patient factors,
line for bolus and infusion of medications,
precisely calculate intravenous infusion
and how to change the intravenous bag
rates and drug dosages.
when empty.
16. Discuss the alternatives to intravenous line
initiation for medication therapy, such as
KEY TERMS
administration tubing, p. 472 desired dose, p. 503 hypertonic, p. 471
air embolism, p. 483 disinfectant, p. 446 hypodermic needle, p. 458
ampule, p. 458 dosage on hand, p. 503 hypotonic, p. 471
anticoagulant, p. 483 drip chamber, p. 472 induced therapeutic
antiseptic, p. 446 drip rate, p. 472 hypothermia (ITH), p. 471
Case Study
It is early in February, and clouds heavy with snow The patient is responsive but exhibits lethargy and
loom not far in the distance. Paramedic Susan Adams fatigue from the increased work of breathing and
watches the sky and hopes she will get off work on time, hypoxia. Inspection of her oral cavity reveals no foreign
before the storm hits. Suddenly the tones drop, alerting bodies or other obstructions. Susan deems the patient
her and her partner, Advanced EMT Todd Michaels, of a able to maintain her airway and forgoes a nasopharyn-
28-year-old female patient with shortness of breath. geal airway adjunct.
After acknowledging the call and confirming the loca- The patient is tachypneic at 36 breaths per minute.
tion with their GPS device, Susan and Todd get under Tidal and minute volumes are shallow. Todd obtains a
way. In preparation, Susan dons gloves and eye protec- pulse oximetry reading (SpO2) of 86 percent on room
tion. Additionally, she reviews the likely causes of short- air. Exhaled carbon dioxide (EtCO2) is 55 mmHg. A
ness of breath in a 28-year-old patient. quick two-point auscultation reveals expiratory wheez-
As Susan and Todd pull up to the residence, they ing in the upper lobes of both the right and left lungs.
observe a well-kept house. A woman frantically waves Because the patient will not tolerate the assistance
them inside, shouting that her daughter cannot breathe. of ventilations with a bag-valve mask, Susan applies
Quickly, they grab the airway kit, cardiac monitor, and 100 percent oxygen.
medication bag, then cautiously enter the residence. Without missing a beat, Susan proceeds to evaluate
Once inside, Susan and Todd begin to size up the the circulatory system. The patient’s radial pulse is
scene. Immediately to their left, they find the female weak and rapid, with accompanying cool, diaphoretic
patient seated on a chair in the tripod position. Quick skin. Again, Susan notes cyanosis.
observation reveals her to be in considerable respiratory Realizing that the situation is critical, Susan turns to
distress and exhibiting cyanosis around the lips and in the patient’s mother while Todd applies the cardiac
the extremities. Even without a stethoscope, Susan monitor and obtains vital signs. When Susan asks about
detects expiratory wheezing. a history of asthma, the mother confirms it and adds
Susan promptly introduces herself and Todd to the that this particular episode has been occurring over the
patient and asks what is wrong. Because the patient can past day and a half. Her daughter ’s metered-dose
barely talk, Susan cannot obtain a specific chief com- inhaler of albuterol has not provided any relief as it has
plaint. Recognizing a life-threatening situation, she in the past. Aside from the asthma, the patient has no
gains consent for treatment and turns her attention to other medical history. She has no allergies and has not
the primary assessment. eaten or drunk anything today.
Intravenous Access and Medication Administration 443
Confident that she is dealing with an asthmatic minimal improvement with the nebulizer treatment.
patient, Susan performs a detailed secondary assess- Susan places a continuous positive airway pressure
ment. She accordingly notes bilateral distention of the (CPAP) mask and begins CPAP with 100 percent oxy-
jugular veins and retractions at the suprasternal notch gen. The patient quickly starts to pink up. The albuterol
and intercostal spaces, along with nasal flaring and is placed in an in-line delivery system so the patient
pursed lips. Quickly she auscultates breath sounds from receives the medication through the CPAP device.
the posterior thorax in a six-point pattern. She observes En route to the hospital, Susan performs reassess-
bilateral expiratory wheezing in the apices of the lungs ment by evaluating the components of the primary
with no net air movement in the bases. assessment and the effects of all interventions. The
Todd informs Susan of the patient’s vital signs: patient now is more alert and breathes easier. Her pulse
pulse, 116 beats per minute; respirations, 56 per minute; oximetry reads 92 percent, and her expiratory wheezing
and blood pressure, 152/94 mmHg. With the primary has subsided significantly. Her EtCO2 has dropped to 50
assessment and history obtained, Susan begins emer- mmHg. Susan now notes air movement in the bases of
gency interventions. The cardiac monitor displays sinus the lungs. Additionally, the cyanosis and diaphoresis
tachycardia with no ectopy. have almost subsided, and vital signs have returned to
As Todd obtains a venous blood sample and estab- normal limits. Because the pulse oximeter reading is still
lishes an IV line, Susan assembles a nebulizer and adds low and some residual wheezing persists, Susan gives
a solution of 2.5 mg of albuterol and 500 mcg of ipratro- another nebulized treatment of 2.5 mg of albuterol
pium (diluted in 3 mL of normal saline) to the chamber. (without ipratropium). She alerts the receiving hospital.
She gives the nebulizer, complete with medication, to Once at the hospital, Susan and Todd turn over care
the patient for self-administration. Susan proceeds to to the emergency department staff. Later they find out
administer 125 mg of methylprednisolone (Solu- that the woman was admitted for overnight observation
Medrol) intravenously. Todd prepares the cot and loads with the diagnosis of acute exacerbation of asthma. She is
the patient for transport. The patient is exhibiting doing fine and is expected to be released in the morning.
side effects, dosages, and to be administered slow IV push.” By echoing, you confirm
CONTENT REVIEW
routes of administration is your reception and understanding of the order. If medical
➤➤ Six Rights of Drug
crucial to effective patient direction has issued an inappropriate medication or dos-
Administration
care. (See the “Emergency age, echoing may bring it to light and elicit an immediate
• Right person
Pharmacology” chapter.) correction. If you still find the order questionable after
• Right drug
• Right dose You can attain effective echoing, diplomatically request clarification or ask about
• Right time pharmacological therapy the intent.
• Right route and eliminate medication Pharmacological therapy permits you to function as an
• Right documentation errors by following the extension of the physician. No room exists for medication
“six rights” of medication errors, as once a medication is given it is difficult, if not
administration: impossible, to retrieve. In addition, withholding a needed
medication can have catastrophic consequences. Concen-
Right person. Ensure that the patient receiving the medica-
tration and knowledge are the keys to this component of
tion is the right person. Generally, you will provide
paramedic care.
one-on-one attention. In a clinical setting, however,
keeping track of multiple patients proves more chal-
lenging. Medical Direction
Right medication. Ensure that you administer the proper Paramedics do not practice autonomously. You will oper-
medication. Many medications are contained in simi- ate under the license of a medical director who is respon-
lar appearing packages. To avoid inadvertently deliv- sible for all of your actions. This responsibility extends to
ering the incorrect medication, read the label! the administration of medications.
Administering the incorrect medication can have The medical director (or the EMS system) determines
disastrous consequences. which medications you will use and the routes by which
Right dose. Be certain that you administer the exact dosage you will deliver them. Some states have a “state medica-
of any medication. The correct dose may be standard- tion list” whereby the medications a service carries are dic-
ized or require calculation. Never underdose or over- tated by law or a legislative or regulatory agency. Although
dose a patient. some medications can be administered via off-line medical
Right time. Timing their administration is important for direction (written standing orders), you may need specific
many medications. Typically, in the emergent setting, authorization for others after consulting on-line or direct
you will quickly administer the necessary emergency medical direction. You must strictly abide by all of your
medications. During transfers and critical care trans- medical director’s guidelines.
ports, you may have to administer other medications Knowing all medication administration protocols is
at preestablished intervals. essential, especially which medications to administer
Right route. Specific medications require specific delivery under standing orders and which to deliver only after get-
routes. You must be familiar not only with the proper- ting authorization from medical direction. You can ill
ties of individual medications, but also with their dif- afford to waste valuable time looking up procedures and
ferent routes of administration. directives for the critical patient who requires immediate
medication therapy. Furthermore, because inappropriate
Right documentation. Documenting medication adminis-
medication delivery can have serious consequences, you
tration is of paramount importance. You must record
may face severe legal ramifications even if your patient
all appropriate information about every medication
suffers no harm.1, 2
you administer. Pertinent information includes, but is
not limited to, medication name(s), dose, route of
delivery, person administering, time administered, Standard Precautions
and patient response to the medication—both good
Establishing routes for medication delivery presents the
and bad.
constant potential for exposure to blood and other body
In the field, you will be responsible for the safe and fluids. Formerly called body substance isolation (BSI), the
appropriate delivery of medications. If you ever doubt the strategy is now called Standard Precautions. In 1996 (and
use or dosage of a medication, contact medical direction updated in 2011), the Centers for Disease Control and Pre-
immediately. You must repeat back, or echo, all medication vention (CDC) established a single set of guidelines called
orders issued by on-line medical direction. For example, if Standard Precautions. These guidelines are measures to
medical direction ordered you to administer 25 mg of decrease your risk of exposure. The purpose of Standard
diphenhydramine (Benadryl), you would echo, “Medic 101 Precautions is to ensure that you take the same precautions
copies the medication order for 25 mg of diphenhydramine for every patient (Table 14-1).
Intravenous Access and Medication Administration 445
Personal protective equipment (PPE) Gloves For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes
and nonintact skin.
Gown During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids,
secretions, and excretions is anticipated.
Mask, eye protection (goggles), face shield* During procedures and patient-care activities likely to generate splashes
or sprays of blood, body fluids, or secretions, especially suctioning or endotracheal intubation
Soiled patient-care equipment Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly
contaminated; perform hand hygiene.
Environmental control Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently
touched surfaces in patient-care areas.
Textiles and laundry Handle in a manner that prevents transfer of microorganisms to others and to the environment.
Needles and other sharps Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed scoop
technique only; use safety features when available; place used sharps in puncture-resistant container.
Patient resuscitation Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions.
Patient placement Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment,
does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome
following infection.
Respiratory hygiene/cough etiquette Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch
receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated
or maintain spatial separation, >3 feet if possible.
*During aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols (e.g., SARS), wear a fit-tested N95 or higher
respirator in addition to gloves, gown, and face/eye protection.
During most patient care, you will wear gloves and one of the most effective ways to decrease your exposure
eye protection (Figure 14-1). A mask is often required for to infectious material. The chapter “Workforce Wellness
procedures and patient care conditions when there is an and Safety” includes a thorough discussion of Standard
increased likelihood that splashes or sprays of blood, body Precautions.
fluids, or secretions may occur. This is especially impor-
tant during suctioning, endotracheal intubation, and other
airway procedures. Remarkably, the simplest standard Medical Asepsis
precaution is often the most neglected: handwashing. Medical asepsis (a-, without; sepsis, infection) describes a
Washing your hands before and after patient contact is medical environment free of pathogens. Many paramedic
procedures, especially those related to medication admin-
istration, place the patient at increased risk for infection.
The external environment is full of microorganisms, many
of them pathogenic. Techniques such as intravenous access
or endotracheal intubation can allow pathogens to enter
the patient’s body, where they may cause local or systemic
complications. Medical asepsis practices, including the use
of sterilization, disinfectants, and antiseptics, guard against
this hazard.
Sterilization
A truly aseptic environment is a sterile one. A sterile envi-
ronment is free of all forms of life. Generally, environments
are sterilized with extensive heat or chemicals. A sterile
FIGURE 14-1 Standard Precautions should be followed on each environment is difficult to attain in the out-of-hospital set-
possible patient encounter. ting. Consequently, you must practice medically clean
446 Chapter 14
techniques to minimize your patient’s risk of infection. minimize or eliminate the risk of an accidental needle stick,
Medically clean techniques involve the careful handling of take these precautions:
sterile equipment to prevent contamination. For example,
• Minimize the tasks you perform in a moving ambu-
much of the equipment used for medication administra-
lance. Use needles as sparingly as possible in the back
tion is packaged sterilely. Once you open the package, you
of a moving ambulance. When appropriate, perform all
must use a medically clean technique to keep the equip-
interventions involving needles on scene. If en route, it
ment clean and uncontaminated until you use it. If you
may occasionally be necessary to have the driver pull
drop a piece of equipment on a dirty surface, you should
the ambulance to the side of the road and stop briefly.
discard it and obtain a new piece. Other medically clean
Most paramedics become quite proficient at complet-
techniques, including hand washing, glove changing, and
ing these procedures in a moving ambulance.
discarding equipment that is in opened packages, help to
prevent equipment and patient contamination. Remember, • Immediately dispose of used sharps in a sharps con-
too, that many patients have lowered immunity levels or tainer. A sharps container is a rigid, puncture-resistant
carry infectious diseases. Thus, keeping the ambulance container clearly marked as biohazardous. You can
and equipment clean is another essential medically clean deposit whole needles and prefilled syringes in it, thus
procedure. eliminating the need for bending or cutting. Some sharps
containers have adapters that permit the easy removal of
needles from blood draw equipment and syringes. You
Disinfectants and Antiseptics should also dispose of items such as used ampules in the
When administering medications, you must use disinfec- sharps container. Avoid dropping sharps onto the floor
tants and antiseptics to ensure local cleanliness. Do not con- for later disposal. In the heat of the moment, you may
fuse disinfectants and antiseptics; the distinction between forget the sharp or mentally misplace it.
them is important. Disinfectants are toxic to living tissue.
• Recap needles only as a last resort. If you absolutely
You will therefore use them only on nonliving surfaces or
must recap a needle, never use two hands to do so.
objects such as the inside of an ambulance or laryngoscope
Instead, use the “one-handed scoop” method. First,
blades after use. Never use disinfectants on living tissue.
place the cap on the bench top and hold the syringe in
Antiseptics are not toxic to living tissue. They destroy or
one hand. Keep the other hand by your side. Next, slip
inhibit pathogenic microorganisms that already exist on liv-
the needle into the cap. Finally, lift it up and snap it on
ing surfaces and are generally used to cleanse the local area
securely using only one hand and dispose of it prop-
before a needle puncture. Common antiseptics include
erly (Figure 14-2).
alcohol and iodine preparations, used either alone or
together. Frequently, antiseptics are diluted disinfectants. By law, every medical organization must have a biological
hazard exposure plan. Be familiar with yours. If you are
exposed to blood or other body substances, follow the plan
Disposal of Contaminated
and immediately notify the appropriate resources. Remem-
Equipment and Sharps ber that prevention is the best medicine.3
Blood and body fluid can harbor infectious material that
endangers the health care provider, family, bystanders, or
the patient himself. Many times, the patient is infected Medication Administration
with pathogenic organisms long before signs and symp- and Documentation
toms appear. Therefore, you must treat all blood and body
When administering medications, proper and thorough
fluids as potentially infectious.
documentation is extremely important. You must record all
Medication administration commonly involves nee-
information concerning the patient and the medication,
dles in direct contact with the patient’s blood and body
including:
fluid. Once used, a needle presents a significant risk. Inad-
vertent needle sticks, the • Indication for medication administration
CONTENT REVIEW most common accident in • Dosage and route delivered
➤➤ Needle Handling health care, can transmit
• Patient response to the medication—both positive and
Precautions diseases between the
negative
• Minimize tasks in a patient and paramedic.
moving ambulance. Properly handling needles You must also document the patient’s condition and vital
• Properly dispose of all and other sharps before signs before medication administration, as well as after. In
sharps. and after patient use can addition to communicating all information to those to
• Recap needles only as
prevent many of these acci- whom you transfer care, you must record it on a copy of the
a last resort.
dental needle sticks. To patient care report.
Intravenous Access and Medication Administration 447
FIGURE 14-2 The “one-hand scoop” is the safest way to recap a needle when it must be recapped.
CONTENT REVIEW
In emergent and none- Transdermal Administration
mergent situations alike,
➤➤ Routes of Drug Medications given by the transdermal (trans-, across;
you will administer a vari-
Administration dermal, skin) route promote slow, steady absorption.
ety of medications through
• Percutaneous Nitroglycerin, hormones, and analgesics are commonly
a variety of delivery routes.
• Pulmonary administered transdermally. Transdermal delivery can
• Enteral The routes of medication
also produce localized effects, as with anti-inflammatories
• Parenteral administration fall into
and other bacteriostatic and softening agents. Applying
four basic categories: per-
medication locally avoids passing larger quantities of the
cutaneous, pulmonary, enteral, and parenteral. Technically,
medication through the entire body, where it is not needed.
medications delivered through the rectum and pulmonary
Transdermal medications include lotions, ointments,
system are topical medications; however, accepted practice
creams, foams, wet dressings, adhesive-backed applica-
classifies these routes separately. Which route you use will
tions, and suppositories.
depend on the medication you are administering and your
To administer a transdermal medication, use the fol-
patient’s status.
lowing technique:
Mucous Membranes
The mucous membranes absorb medications at a moderate
to rapid rate. Similar to transdermal administration, medi-
cation delivery through the mucous membranes avoids the FIGURE 14-3 Sublingual medication administration. Place the pill
or direct spray between the underside of the tongue and the floor of
digestive tract and complications associated with that
the oral cavity.
route. You can deliver medications through the mucous
membranes at several sites (sublingual, buccal, ocular,
nasal, and aural). However, specific medications are made
Buccal
The buccal region lies in the oral cavity between the cheek
for specific sites and generally are not interchangeable.
and gums. Buccal medications are generally tablets. Hor-
monal and enzyme preparations are typically given buccally.
Sublingual To administer a medication buccally, follow these steps
Sublingual medications are absorbed through the mucous
(Figure 14-4):
membranes beneath the tongue (sub-, below; lingual,
tongue). The sublingual region is extremely vascular and 1. Use Standard Precautions.
permits rapid absorption with systemic delivery. These 2. Confirm the indication, medication, dose, buccal route,
medications are generally dissolvable tablets or sprays. and expiration date.
One commonly administered sublingual medication is
nitroglycerin.
To administer a medication via the sublingual route,
follow these steps (Figure 14-3):
3. Place the medication between the patient’s cheek and Ocular medications may also be packaged as ointments.
gum. Instruct the patient to allow the pill or other To apply an ointment, follow the same procedure as
preparation to dissolve. Ensure that the patient does above, but carefully squeeze the ointment onto the con-
not swallow the medication. junctival sac. If you administer too much medication,
4. Monitor the patient for desirable or adverse effects. carefully blot away the excess drops or ointment with
sterile gauze. The ointment will melt as it warms to body
Ocular temperature and will spread smoothly across the surface
Ocular medications are topical medications that are of the eye.
administered through the mucous membranes of the eye.
These are typically local medications for alleviating eye Nasal
pain, treating infection, decreasing intraocular pressure, or The mucous membranes of the nose are another port for
lubricating the eyelid. Medications delivered by way of the topical medication delivery. Given through the nares (nos-
eye are labeled for ophthalmic use and packaged as drops trils), these nasal medications are usually drops or sprays
or ointments. intended for local effect. A commercial device called the
If medication is to be administered only to one eye, be mucosal atomization device (MAD) is commonly used.
sure to medicate the correct eye. The following abbreviations Often, these medications are aerosolized to provide better
were formerly used to designate right, left, or both eyes: distribution to the nasal mucosa. The intranasal route can
be used for analgesia (particularly in children), sedation,
o.d. right eye (oculus dexter) epistaxis, and to reduce nasal congestion from nasotra-
o.s. left eye (oculus sinister) cheal intubation.4,5,6,7
o.u. both right and left eyes (oculus uterque) To administer a medication via the nose, use the fol-
lowing technique (Figure 14-6):
However, to avoid confusion, it is preferred to simply write
“left eye,” “right eye” or “both eyes.” 1. Use Standard Precautions, including face mask.
To administer a medication via eye drops, use the fol- 2. Have the patient blow his nose and tilt his head back-
lowing technique (Figure 14-5): ward.
1. Use Standard Precautions. 3. Use a medicine dropper or squeezable nebulizer
to administer the medication into the appropriate
2. Have your patient lie supine or lay his head back and
nare(s) according to the manufacturer’s instructions
look toward the ceiling.
(Figure 14-7).
3. Pull the lower eyelid downward to expose the conjunc-
4. Hold the naris or nares shut and/or tilt the head for-
tival sac. Never touch the eye.
ward to distribute the medication.
4. Use a medicine dropper to place the prescribed dosage
5. Monitor the patient for desirable and undesirable
on the conjunctival sac. Never administer medications
effects.
directly on the eye unless specifically instructed.
5. Instruct the patient to hold his eye(s) shut for 1 to
Aural
2 minutes.
Some medications are delivered to the mucous membranes
of the ear and ear canal through drops or medicated gauze.
Pulmonary Medication
FIGURE 14-7 Mucosal atomization device (MAD) for intranasal
Administration
administration of emergency medications. Special medications can be administered into the pulmo-
nary system via inhalation or injection. Generally in the
form of gases, powders, fine mists, or liquids, these medi-
These aural medications primarily treat local infections cations include those that promote bronchodilation for
and ear pain. Use the following technique to administer respiratory emergencies. Other inhaled medications are
medicated drops (Figure 14-8): mucolytics, antibiotics, and topical steroids. Inhalation can
1. Use Standard Precautions. also be used for humidification and pulmonary deconges-
tion.
2. Confirm the indication, medication, dose, and expira-
tion date.
3. Determine the correct ear for administration. Nebulizer
4. Have the patient lie in the lateral recumbent position Typically, medications administered by inhalation are
with the affected ear upward. delivered with the aid of a small volume nebulizer (SVN)
or handheld nebulizer (HHN). A nebulizer uses pressur-
5. Manually open the ear canal: For adult patients, pull
ized oxygen or air to disperse a liquid into a fine aerosol
the ear up and back; for pediatric patients, pull it down
spray or mist. Inhalation carries the aerosol into the lungs.
and back.
Figure 14-9 illustrates a typical nebulizer. The specific
6. Administer the appropriate dose of medication with a design depends on the manufacturer, but they all work on
medicine dropper. the same principle and typically have the same parts:
7. Have the patient continue to lie with his ear up for 10
• Mouthpiece
minutes.
• Medication reservoir
8. Monitor the patient for desirable and undesirable
effects. • Oxygen port
• Relief valve
Using medicated gauze or cotton is generally reserved
for the hospital setting. If your local protocols permit you • Oxygen tubing
to administer these medications, follow the procedure • Oxygen source
Nebulizers also come preattached to an oxygen face mask FIGURE 14-12 In-line administration of nebulized medication in an
intubated patient.
in both pediatric and adult sizes (Figure 14-10). Use nebuli-
zation face masks for pediatric or adult patients who can-
not hold the nebulizer. Nebulizers can also be used with For a nebulizer to be effective, the patient must have
CPAP devices when indicated (Figure 14-11).8 They can an adequate tidal volume and respiratory rate. If the tidal
also be used in patients who are intubated and receiving volume is shallow or respiratory rate low, the medication
mechanical ventilation (Figure 14-12). will not move from the nebulizer into the lungs. For
patients with a poor tidal and/or respiratory rate who can-
not pull the medication into their lungs, you can connect
the nebulizer to a bag-valve mask, a CPAP device, and/or
an endotracheal tube.
Oral Administration
Oral medication administration denotes any medica-
Mouth tion taken by mouth (oral) and swallowed into the
gastrointestinal (GI) tract. From the GI tract, the
medication is absorbed and distributed throughout
the body. When administering a medication by the
oral route, you must be sure that the patient has an
adequate level of consciousness to support his air-
way. Administering an oral medication to a patient
Esophagus
who cannot support his airway may result in an
airway occlusion or aspiration into the lungs. If
aspiration into the lungs occurs, aspiration pneu-
monia and its deadly consequences may occur.
Stomach Medications for oral delivery come in a vari-
ety of forms, either solid or liquid.
Large intestine • Capsules. Capsules contain liquid, dry, or
beaded medication in a soluble casing. For
Small intestine maximum effectiveness, the patient must
swallow them whole.
• Tablets. Tablets comprise medicated powder
compressed into a small, solid disk. Typically,
tablets may be scored to permit breaking in
Rectum
half or quarters when lower dosages are
Anus required.
• Enteric coated/time-release capsules and tab-
FIGURE 14-14 Gastrointestinal tract. lets. These forms of medication release the
medication gradually as layers of the capsule
the mouth to the stomach and on through the intestines to or tablet slowly erode. Time-release capsules or tablets
the rectum (Figure 14-14). You can administer enteral medi- must be swallowed whole.
cations orally, through a gastric tube, or rectally. • Elixirs. Elixirs are liquid medications combined with
Several advantages make the gastrointestinal tract alcohol or placed in a sweetened fluid.
the most common route for medication delivery. Aside
• Emulsions. Emulsions are medications combined with
from sheer convenience, it is the least expensive route,
a fat or oil emulsifier.
and its use requires little equipment and minimal train-
ing. In some instances, after you have delivered a medica- • Lozenges. Lozenges are solid forms of medication that
tion you may be able to retrieve it by inducing vomiting, slowly dissolve in the mouth, thus permitting gradual
by removing it from the rectum, or simply by having the swallowing.
patient spit it out. • Suspensions. A suspension is a liquid that contains
Conversely, enteral medication administration poses small particles of solid medication.
several disadvantages. Physical activity, emotions, or food • Syrups. A syrup is a concentrated solution of sugar in
can significantly alter the gastrointestinal tract’s chemical water or another liquid to which a medication is added.
and physical environment, making absorption unreliable.
In addition, as all blood from the stomach and small intes-
tine must pass through the hepatic circulatory system (por-
Equipment for Oral Administration
Administering oral medications is simple and easy. The
tal circulation), the liver ’s condition can reduce the
basic equipment that you may need depends on the medi-
medication’s effectiveness. A dysfunctional liver can sig-
cation and the patient’s status:
nificantly alter medication distribution and, in extreme
cases, metabolize therapeutic medications into inert or • Soufflé cup. A soufflé cup is a paper or plastic cup.
harmful substances. Furthermore, a patient resistant to or Placing a solid medication in a soufflé cup makes it
454 Chapter 14
easy to see and minimizes contact with the provider’s and psychiatric patients, you may have to visually con-
hands. firm that the patient has swallowed the medication by
• Medicine cup. A medicine cup is a plastic or glass cup inspecting the oral cavity.
with volumetric measurements on the side. It facili-
tates giving specific amounts of liquid medication. Gastric Tube Administration
When you pour medication into the cup, the liquid
For patients who have difficulty swallowing or whose
does not form a flat surface but clings to the sides at a
nutritional status is poor, you may place a gastric tube to
higher level, forming a meniscus. To compensate for
support or completely supplement nutritional require-
the meniscus, measure the medication toward the cen-
ments. Gastric tubes are also used in instances of medica-
ter, at its lowest level.
tion overdose, trauma, and upper gastrointestinal bleeding.
• Medicine dropper. A medicine dropper has markings
They may be surgically inserted directly into the stomach
for measuring liquid volumes. You will use it for spe-
through the abdomen or indirectly through the nose (naso-
cial medications and to administer medications to chil-
gastric tube) or mouth (orogastric tube). Placing a gastric
dren or patients who cannot tolerate other forms of
tube through the abdominal wall is reserved for the hospi-
oral medication.
tal setting. Before administering any medication through a gas-
• Teaspoon. You will use these accurately sized measur- tric tube or other enteral tube, ensure that it is indeed an enteral
ing spoons to administer liquid medications. A tea- tube and not a similar-looking device such as a chronic ambula-
spoon normally holds 5 mL of fluid; however, the tory peritoneal dialysis (CAPD) catheter. In some EMS sys-
volume of household teaspoons varies significantly. To tems, paramedics insert orogastric or nasogastric tubes in
ensure accurate medication administration, use a mea- the field for emergencies. A properly placed gastric tube
sured teaspoon or syringe. allows enteral medication delivery. Few emergency medi-
• Oral syringe. Oral syringes are calibrated plastic cations are administered via a nasogastric or orogastric
syringes without a hypodermic needle. They are con- tube. Other medications, many used in the nonacute set-
sidered the most accurate oral means of administering ting, also are administered via the gastric tube. With modi-
liquid-based medications. When administering a med- fication, most oral medications can be administered this
ication with the oral syringe, place the end of the way. However, you should avoid administering time-
syringe in the patient’s mouth and deliver only as release capsules and enteric-coated tablets through a gas-
much medication as the patient can safely swallow. tric tube, as crushing them for delivery destroys their
Several administrations may be necessary to deliver a slow-release mechanism. Also, ensure that the medication
complete dose. has been sufficiently crushed so as not to become trapped
• Nipple. For the neonate or infant, liquid medication and occlude the gastric tube.
can be delivered with a plastic nipple. To administer a medication via a gastric tube, use the
following technique (Procedure 14-1):
General Principles of Oral Administration 1. Use Standard Precautions.
To administer medications orally, use the following
2. Confirm proper tube placement. Disconnect the tube
technique:
from the drainage or suction unit or clamping device.
1. Use Standard Precautions. Clamp the tube from the drainage or suction unit to
2. Note whether to administer the medication with food prevent gastric contents spilling from either device.
or on an empty stomach. Attach a cone-tipped syringe to the proximal end of
3. Gather any necessary equipment such as a soufflé cup the gastric tube. Gently inject air while auscultat-
or teaspoon; mix liquids or suspensions, or otherwise ing over the stomach. Following this, withdraw the
prepare medications as needed. plunger while observing for the presence of gastric
fluid or contents, which indicates appropriate place-
4. Have your patient sit upright (when not contraindi-
ment. Leave the tube disconnected from the drainage
cated).
or suction unit.
5. Place the medication into your patient’s mouth. Allow
3. Irrigate the gastric tube. To irrigate the gastric tube,
self-administration when possible; assist when needed.
draw up 50 to 100 mL of normal saline into a cone-
6. Follow administration with 4 to 8 ounces of water or tipped syringe. Insert the syringe into the open end
other liquid. Swallowing a liquid pushes the medica- of the gastric tube. With the syringe tip pointed at
tion into the stomach. the floor, gently inject the saline into the tube. If the
7. Ensure that the patient has swallowed the medication saline encounters resistance, look for problems such as
and it is not hidden in his mouth. For some pediatric tube kinking. Have the patient lie on his left side and
Intravenous Access and Medication Administration 455
14-1A Confirm proper tube placement. 14-1B Withdraw the plunger while observing for the presence
of gastric fluid or contents.
14-1C Instill medication into the gastric tube. 14-1D Gently inject the saline.
Legal Considerations
Accidental Needlesticks. Administering medications in
an emergency setting increases the chances of accidental
needle stick injuries for all involved. It is paramount that
paramedics anticipate potential dangers and avoid them.
For example, a natural reaction to pain (such as occurs with
a medication injection) is to withdraw. This sudden move-
ment can cause an accidental needle stick injury. Similarly,
FIGURE 14-17 Prepackaged enema container.
the combative or agitated patient poses a significant risk.
Always make sure that medication administration is safe. If
Additionally, the rectal route may prove beneficial for a it is not, defer administration until additional resources or
personnel are available. Your safety and the safety of your
pediatric patient who resists oral administration or for
partner come first.
whom IV access proves impractical.
Suppositories are medications packaged in a soft, pli-
able form. Generally refrigerated until they are used, they delivery; however, additional, specific criteria apply to
begin to melt at body temperature in the rectum. Some are parenteral administration. Typically, the parenteral route
lubricated to ease insertion. Suppositories can be lubricated involves the use of needles as medications are injected into
by running a small amount of lukewarm tap water over the the circulatory system or tissues. Consequently, some
suppository prior to insertion. To administer a suppository, forms of parenteral medication delivery afford the most
manually insert it into the rectum. Hold the buttocks shut rapid medication delivery and absorption.
for 5 to 10 minutes to allow for retention and absorption.
An enema is typically a liquid bolus of medication
that is injected into the rectum. Medications given via this
Syringes and Needles
route are typically referred to as small-volume enemas. Frequently, giving medications via the parenteral route
They are typically prepackaged in a squeezable container requires a syringe and hypodermic needle.
with a rectal tip (Figure 14-17).
To administer a medicated small-volume enema, use Syringe
the following technique: A syringe is a plastic tube with which liquid medications
can be drawn up, stored, and injected. Syringes range in size
1. Use Standard Precautions and confirm the need for
from 1 to 100 mL and greater. Remember that although med-
administration via a small volume enema.
ication dosages are generally given by weight (g/mg/mcg),
2. Place the patient on his left side. Flex his right leg to syringes represent volume. Therefore, you must be prepared
expose the anus. to mathematically convert these measurements.
3. Insert the prelubricated rectal tip into the anus and A syringe’s two major components are a barrel and a
advance 3 to 4 inches. plunger (Figure 14-18). The tube-like barrel, or body, func-
4. Gently squeeze the medicated solution of the bottle tions as a reservoir for medication. Markings on its side
into the rectum and colon. calibrate its overall volume. Smaller syringes are calibrated
in 0.10-mL intervals, larger syringes in 1.0-mL intervals.
5. Hold the buttocks together to enhance absorption into
The plunger is a device that fits into the barrel. At
the rectal and intestinal tissue.
one end it has a handle for pulling or pushing. At the
Only medications with specific guidelines for rectal opposite end, a rubber stopper fits snugly into the barrel.
administration should be delivered through this route. Do Pulling on the plunger draws material into the barrel;
not administer rectal medications in the presence of diar- pushing on it expels material from the barrel. The rubber
rhea, rectal bleeding, hemorrhoids, or any other situation
involving severe anal irritation.
Parenteral Medication
Administration
Parenteral route denotes the administration of medication
outside the gastrointestinal tract. Broadly, this encom-
passes pulmonary and some topical forms of medication FIGURE 14-18 Syringe.
458 Chapter 14
Hypodermic Needle
The hypodermic needle is a hollow metal tube used with the FIGURE 14-20 Safety needles help to minimize the possibility of
syringe to administer medications. It is sharp enough to eas- needle stick injuries.
ily puncture tissues, blood vessels, or IV medication ports.
The hypodermic needle’s primary components include Medication Packaging
a hilt and shaft. The hilt is a threaded plastic tube that
All medications delivered by the parenteral route are liq-
screws securely onto the syringe’s distal adapter. The shaft
uids. They are packaged in a variety of containers with
is a thin metal tube through which medications can flow
which you must be familiar, as obtaining medication from
from the syringe into the delivery site. A bevel at the shaft’s
each type requires a different procedure. The kinds of par-
distal end accounts for its sharpness (Figure 14-19).
enteral medication containers include the following:
Hypodermic needles come in a variety of gauges and
lengths. A needle’s gauge describes its diameter. Generally, • Glass ampules
hypodermic needle gauges range from 18 to 27. The gauge • Single and multidose vials
and actual diameter are inversely related: the higher the
• Nonconstituted medication vials
gauge, the smaller the diameter. Thus, a 25-gauge needle’s
diameter is smaller than an 18-gauge needle’s. Conversely, • Nebulizer vials
a 20-gauge needle’s diameter is larger than a 22-gauge nee- • Prefilled syringes
dle’s. Hypodermic needle lengths generally range from • Intravenous medication fluids
⅜ to 1½ inches. The package label lists the size of the syringe
and the gauge and length of the hypodermic needle. You must also be thoroughly familiar with the information
Because syringes and hypodermic needles frequently included on the labels of all medication containers:
involve invasive procedures, they are packaged sterile. • Name of medication. The label lists both the generic
Never use either a syringe or a hypodermic needle from and trade name of the medication. Always ensure that
a package that has been opened or tampered with. Used you have selected the right medication.
hypodermic needles are sharp and present a biohazard.
• Expiration date. All medications have an expiration
Dispose of them immediately after you complete any
date after which they cannot be used. Never use an
task involving their use. Many modern needles are
expired medication.
designed for safe needle disposal without recapping the
• Total dose and concentration. The total dose of medica-
needle (Figure 14-20). These decrease the possibility of
tion is the total weight (g/mg/mcg) of medication in the
accidental needle stick injuries and are preferred in the
container. The concentration represents the weight of the
emergency setting.
medication per volume of fluid. For example, if 10 mg of
a medication were packaged in 10 mL of fluid, the total
dose would be 10 mg, and the concentration would be 10
mg/10 mL or 1 mg/mL. Beware—identical medications
can be packaged in different dosages and concentrations.
Glass Ampules
An ampule, or amp, is a breakable glass vessel containing
FIGURE 14-19 Hypodermic needle. liquid medication. It has a cone-shaped top, thin neck,
Intravenous Access and Medication Administration 459
14-2A Hold the ampule upright and tap its top to dislodge 14-2B Place gauze around the thin neck . . .
any trapped solution.
14-2C . . . and snap it off with your thumb. 14-2D Draw up the medication.
460 Chapter 14
14-3A Confirm the vial label. 14-3B Prepare the syringe and hypodermic needle.
14-3C Cleanse the vial’s rubber top. 14-3D Insert the hypodermic needle into the rubber
top and inject the air from the syringe into the vial.
Intravenous Access and Medication Administration 461
3. Determine the volume of medication to be administered. 5. Gently agitate or shake the vial to ensure complete
4. Prepare the syringe and hypodermic needle. Because mixture.
the vial is vacuum packed, you will have to replace the 6. Determine the volume of newly constituted medica-
volume of medication removed with air to maintain tion to be administered.
equilibrium in the vial. Withdraw the plunger to draw 7. Prepare the syringe and hypodermic needle. Because
a volume of air into the syringe equal to the volume of the vial is vacuum packed, you will have to replace the
medication to be administered. This technique permits volume of medication removed with air to retain equi-
easy medication retrieval from the vial. librium in the vial. By withdrawing the plunger, place
5. Cleanse the vial’s rubber top with an antiseptic alcohol into the syringe a volume of air equal to the volume of
preparation. medication that will be removed. This technique per-
mits easy medication retrieval from the vial.
6. Insert the hypodermic needle into the rubber top and
inject the air from the syringe into the vial. Then with- 8. Cleanse the medication vial’s rubber top with an anti-
draw the appropriate volume of medication. septic alcohol preparation.
9. Insert the hypodermic needle into the rubber top and
7. Reconfirm the indication, medication, dose, and route
withdraw the appropriate volume of medication.
of administration.
10. Reconfirm the indication, medication, dose, and route
8. Administer appropriately via the indicated route.
of administration.
9. Properly dispose of the needle, syringe, and vial. 11. Administer appropriately via the indicated route.
12. Monitor the patient for the desired effects.
Nonconstituted Medication Vial
13. Properly dispose of the needle and syringe.
The nonconstituted medication vial extends the viability
and storage time of medications that have a short shelf life
or are unstable in liquid form. The nonconstituted medica- Prefilled or Preloaded Syringes
tion vial actually consists of two vials, one containing a Prefilled or preloaded syringes are packaged in tamper-
powdered medication and one containing a liquid mixing proof containers with the medication already in the syringe.
solution (Figure 14-23). To prepare the medication you must Because the syringe is prefilled, you do not need to draw the
mix it, or reconstitute it, by withdrawing the liquid solution medication from another source. Generally, prefilled
from its vial and placing it in the powdered medication’s syringes contain standard dosages, thus decreasing the
vial. In a Mix-o-Vial system, the two vials are joined and chance of dosage error.
you must squeeze them together to break the seal and mix. The prefilled syringe consists of two parts, a syringe
To prepare a medication from a nonconstituted medi- and a glass tube prefilled with liquid medication. The plastic
cation vial, use the following technique (Procedure 14-4): syringe is similar to those described earlier; however, it does
not have a plunger. Rather, you screw the prefilled glass
1. Confirm medication indications and patient allergies. tube into the syringe barrel and secure it (Figure 14-24).
2. Confirm the vial’s label (name, dose, expiration date). Pushing the glass container into the syringe barrel expels the
3. Remove all solution from the vial containing the mix- medication through the attached hypodermic needle.
ing solution, using the same procedure as you would to Follow these steps to administer a medication from a
withdraw medication from a single or multidose vial. prefilled syringe:
4. With an alcohol preparation, cleanse the top of the vial 1. Confirm medication indications and patient allergies.
containing the powdered medication and inject the 2. Confirm the prefilled syringe label (name, dose, and
mixing solution. expiration date).
14-4A Inspect the medication. Check 14-4B Compress the plunger to mix 14-4C Shake the vial to adequately
the label and the expiration date. the solution and the solvent. mix the solution.
14-4D Remove the protective cover- 14-4E Uncap the syringe and prepare 14-4F Insert the needle through the
ing to expose the diaphragm. to withdraw the medication. diaphragm.
14-4G Withdraw the 14-4H Expel any air from the 14-4I Administer the
medication from the vial. syringe. medication and properly
dispose of the needle.
Intravenous Access and Medication Administration 463
14-5A Assemble and prepare the needed 14-5B Check the medication. 14-5C Draw up the medication.
equipment.
14-5D Prepare the administration site. 14-5E Pull the patient’s skin taut. 14-5F Insert the needle, bevel up, at a 10°
to 15° angle.
14-5G Remove the needle and cover the 14-5H Monitor the patient.
puncture site with an adhesive bandage.
6. Insert the needle, bevel up, just under the skin, at a 10° Do not rub or massage the injection site. This promotes
to 15° angle. systemic absorption and nullifies the advantage of local-
7. Slowly inject the medication; look for a small bump or ized effect.
wheal to form as medication is deposited and collects
in the intradermal tissue.
Subcutaneous Injection
8. Remove the needle and dispose of it in the sharps Subcutaneous injections place medication into the subcu-
container. taneous tissue (sub-, below; cutaneous, skin). The subcuta-
9. Place the adhesive bandage over the site; use the gauze neous layer consists of loose connective tissue between the
for hemorrhage control if needed. skin and muscle (Figure 14-26). The subcutaneous tissue
Intravenous Access and Medication Administration 465
Epidermis
45°
Dermis
Subcutaneous Muscle
tissue
14-6D Prep the site. 14-6E Insert the needle at a 45° angle. 14-6F Remove the needle and cover the
puncture site.
Vertical line
Preferred Preferred
site Deltoid
site muscle
Gluteal artery
Horizontal line
Hip
Fold separating
the buttocks
Sciatic nerve
• Syringe (1 to 5 mL, depending on dosage) 6. Insert the needle just into the skin at a 90° angle with
• 21- to 23-gauge hypodermic needle, ⅜ to 1 inch long the bevel up.
• Sterile gauze and adhesive bandage 7. Pull back the plunger to aspirate tissue fluid.
• If blood appears, the hypodermic needle is in a
Follow these steps to administer an intramuscular
blood vessel, and absorption of the medication will
injection (Procedure 14-7):
be too rapid. Start the procedure over with a new
1. Assemble and prepare the needed equipment. syringe.
2. Use Standard Precautions and confirm the medica- • If no blood appears proceed with step 8.
tion, indication, dosage, and need for intramuscular 8. Slowly inject the medication.
injection. 9. Remove the needle and dispose of it in the sharps
3. Draw up medication as appropriate. container.
4. Prepare the site with antiseptic solution. 10. Place an adhesive bandage over the site; use gauze for
5. Stretch the skin taut over the injection site with your hemorrhage control if needed.
nondominant hand. 11. Monitor the patient.
14-7D Prepare the site. 14-7E Insert the needle at a 90° angle. 14-7F Remove the needle and cover the
puncture site.
After administration, gently rubbing or massaging the • Obtaining venous blood specimens for laboratory
site helps to initiate systemic absorption. Do not massage analysis
the site, however, if you have administered heparin or
Because veins are easier to locate and penetrate, venous
another anticoagulant. Again, some authorities recom-
access is preferable to arterial access. Additionally, venous
mend a 0.1-mL air plug as described under subcutaneous
circulation pressure is lower than arterial pressure and
injection.
presents fewer hemorrhage control complications.
Basilic
vein Dorsal
venous
network
Cephalic
vein
Dorsal venous
arch
External jugular
vein
FIGURE 14-30 Peripheral IV access sites: veins of the arm, hand, neck, and foot.
470 Chapter 14
and one-half times the colloidal osmotic pressure of calories needed for cellular metabolism. While D5W
albumin. Anaphylactic reaction is a possible side effect. initially increases circulatory volume, glucose mole-
• Hetastarch (Hespan). Like dextran, hetastarch is a cules rapidly diffuse across the vascular membrane
sugar molecule with osmotic properties similar to and increase the free water.
those of protein. Hetastarch does not appear to share Both lactated Ringer ’s and normal saline solution are
dextran’s side effects. used for fluid replacement because of their immediate
Although colloids help maintain vascular volume, using ability to expand the circulating volume. However,
them in the field is not practical. Their high cost, short shelf owing to the movement of electrolytes and water, two-
life, and specific storage requirements suit them better to thirds of either solution will be lost to the extravascular
the hospital setting. However, the paramedic who works in space within 1 hour. Crystalloids such as normal saline
an emergency department, critical care transport, or at a mixed with D5W or half-strength normal saline (0.45 per-
mass-casualty incident may have to administer colloidal cent) are combinations or modifications of the previous
solutions. solutions.
Occasionally, you will have to warm or cool the IV
CRYSTALLOIDS Crystalloids are the primary out-of- fluid. A hypothermic patient may benefit from having a
hospital IV solutions. Crystalloids contain electrolytes and crystalloid warmed before and during fluid administra-
water but lack colloids’ larger proteins and larger mol- tion. Warm fluids assist in elevating the patient’s core tem-
ecules. The many preparations of crystalloid solutions are perature. Conversely, cool fluids may benefit the patient
classified by their tonicity (number of particles per unit with an increased core temperature. With the introduction
volume) relative to that of body plasma: of induced therapeutic hypothermia (ITH), out-of-hospital
providers now commonly administer cold IV fluids to car-
• Isotonic solutions. Isotonic solutions have a tonicity
diac arrest victims to minimize subsequent secondary
equal to that of blood plasma. In a normally hydrated
injury. You can cool or warm fluids by storing them in a
patient, they will not cause a significant fluid or elec-
special temperature-controlled compartment or by using
trolyte shift.
the heater or air conditioner in the ambulance, helicopter,
• Hypertonic solutions. Hypertonic solutions have a or mobile intensive care unit. Commercial fluid heaters are
higher solute concentration than do the cells. When available. Their use is detailed later in this chapter. Some
administered to the normally hydrated patient, they fluids, such as blood and some colloids, require constant
cause fluid to shift out of the intracellular compart- storage in a cool environment.
ment and into the extracellular compartment. Later,
solute will diffuse in the opposite direction. BLOOD The most desirable fluid for replacement is
whole blood. Unlike colloids and crystalloids, the hemo-
• Hypotonic solutions. Hypotonic solutions have a
globin in blood carries oxygen. Blood, however, is a pre-
lower solute concentration than do the cells. When
cious commodity and must be conserved so that it can be
administered to a normally hydrated patient, they
of benefit to the most people. Its use in the field is generally
cause fluid to move from the extracellular compart-
limited to aeromedical services or mass-casualty incidents.
ment and into the intracellular compartment. Later,
O-negative blood’s universal compatibility makes it ideal
the solutes will move in the opposite direction.
for administration in the field. The “Hematology” chapter
The particular type of IV solution you select depends on discusses blood in detail.
your patient’s needs. The following are the three most
PACKAGING OF INTRAVENOUS FLUIDS Most intra-
commonly used IV fluids in out-of-hospital care:
venous fluids and blood are packaged in soft plastic or
• Lactated Ringer’s. Lactated Ringer’s solution, also vinyl bags of various sizes (50, 100, 250, 500, 1,000, 2,000,
called Hartman’s solution, is an isotonic electrolyte and 3,000 mL) (Figure 14-32). Some contain medication that
solution. It contains sodium chloride, potassium chlo- is incompatible with plastic or vinyl and must be packaged
ride, calcium chloride, and sodium lactate in water. in glass bottles.
• Normal saline solution. Normal saline is an isotonic The IV-fluid container provides important information.
electrolyte solution containing 0.9 percent sodium • Label. A label on every IV bottle or bag lists the fluid
chloride in water. type and expiration date. Like any other medication,
CONTENT REVIEW
• 5 percent dextrose in intravenous solutions have a shelf life; do not use them
➤➤ Crystalloid Classes water (D5W). D5W is a after their expiration date. Discard any fluid that
• Isotonic hypotonic glucose solu- appears cloudy, discolored, or laced with particulate.
• Hypertonic
tion used to keep a vein In addition, avoid using any fluid whose sealed pack-
• Hypotonic
patent and to supply aging has been opened or tampered with.
472 Chapter 14
Flow regulator
Port for
drug
infusion
it will lodge and effectively block all blood flow distal to the
point of occlusion.
Many aeromedical and facility-based paramedics
administer blood and must be familiar with blood tubing.
Although most ambulances do not carry blood, paramed-
FIGURE 14-36 Measured volume administration set. ics may initiate normal saline with blood tubing in antici-
pation that whole blood or blood products will be required
(Figure 14-36). The burette chamber holds between 120 immediately in the emergency department (Figure 14-37).
and 150 mL of fluid. The components of the measured Blood tubing comes in two configurations, straight
volume administration set include the following: and Y. Y tubing has two administration ports: one for
blood and one for IV normal saline solution. Typically,
• Flanged spike
blood is administered with normal saline. Fluids like lac-
• Clamp tated Ringer’s increase the potential for blood coagula-
• Airway handle tion. The two-port design permits immediate access to
• Medication injection port normal saline if the blood supply is exhausted or must be
shut down, as for a transfusion reaction. When you use Y
• Burette chamber
blood tubing, establish a traditional IV by connecting a
• Float valve bag of normal saline to the tubing. Attach the blood to the
• Drip chamber second port when needed, while maintaining strict medi-
• Flow regulator cal asepsis. Using the flow regulator, discontinue the nor-
mal saline while opening the clamp regulating the flow of
• Medication injection port
blood. Straight blood tubing has only one reservoir.
• Needle adapter
Therefore, only blood is attached to the tubing. A medica-
When opened, the airway handle on top of the burette tion administration port close to the needle adapter
chamber permits air to be displaced or replaced as fluid allows you to piggyback a secondary line of normal saline
enters or exits the chamber. If a medication must be mixed into the tubing.
in a specific amount of IV solution, you can add it through
MISCELLANEOUS ADMINISTRATION SETS Some
the medication administration port after correctly filling
tubing now has a manual dial that can set drops per min-
the chamber.
ute or specific flow rates. Some manufacturers have created
BLOOD TUBING Administering whole blood or blood a single drip chamber that can create either microdrips or
components requires blood tubing, which contains a fil- macrodrips, depending on the patient’s need.
ter that prevents clots and other debris from entering the
patient. Without exception, all blood must be filtered. In-Line Intravenous Fluid Heaters
Blood that is stored or delivered over an extended period Technology now makes it possible to heat IV fluids to near
is prone to form fibrin clots or to accumulate other debris. body temperature in the field. Most EMS units store their
If these clots or debris enter the circulatory system, they IV fluids in the unit. These fluids, when opened, are at the
can travel in the form of an embolus. Remember, once an same temperature as the ambient air. Thus, the tempera-
embolus encounters a blood vessel too small for its passage, ture of IV fluids can vary significantly depending on where
Intravenous Access and Medication Administration 475
in the country (or world) you work. Many patients are very • Metal stylet (needle). The metal stylet permits easy
prone to the development of hypothermia following fluid puncturing of the skin and blood vessel. Blood from
administration. These include the elderly, children, the the vein flows through the hollow stylet to the flash-
frail, and those suffering from fever or similar conditions. back chamber.
When indicated, it is prudent to use an in-line IV fluid • Flashback chamber. The clear plastic flashback cham-
heater to warm the IV fluid to body temperature. These ber allows you to see the blood after the metal stylet
devices are designed to shut down if the IV fluid tempera- has punctured the vein. Blood in the flashback cham-
ture exceeds body temperature. Likewise, different devices ber confirms placement of the stylet in the vein.
are available to meet the various flow requirements of, for • Teflon catheter. The Teflon catheter slides over the
example, trauma patients, pediatrics, or geriatrics. metal stylet into a successfully punctured vein.
Always use Standard Precautions. Open the unit and
• Hub. Located on the back of the Teflon catheter, the
test the battery. Attach the in-line intravenous fluid heater
hub receives the needle adapter of the administration
between the end of the IV tubing and the extension tubing
tubing once removed from the metal stylet.
supplied with the unit. Turn the device on and monitor the
indicator lights. The unit should remain with the patient For peripheral venous access, the over-the-needle catheter
on arrival at the hospital and throughout his hospital stay. is preferred because it is easy to place and anchor and per-
It is switched to a direct current (DC) adapter on the mits freer movement of the patient. Most of these needles
patient’s arrival at the floor. now have a needlestick protection mechanism that covers
the exposed needle (Figure 14-39).
Intravenous Cannulas
The intravenous cannula permits actual puncture and HOLLOW-NEEDLE CATHETER For pediatric patients
access into a patient’s vein. The distal portion of the admin- or other patients with tiny, delicate veins, use hollow-
istration tubing connects to the IV cannula, thus complet- needle catheters (Figure 14-40). These catheters do not
ing the bridge between the solution bag and patient. The have a Teflon tube; rather, the metal stylet itself is inserted
three basic types of IV cannulas are: into the vein and secured there. Because the sharp metal
stylet can easily damage the vein, you must insert it very
• Over-the-needle catheter
carefully. Some hollow-needle catheters have wings for
• Hollow-needle catheter guidance and securing into a vein. These hollow-needle
• Plastic catheter inserted through a hollow needle catheters are referred to as winged catheters or butterfly
catheters.
Needle
Plastic cap
14-8A Place the constricting band. 14-8B Cleanse the venipuncture site. 14-8C Insert the intravenous cannula into
the vein.
14-8D Withdraw any blood samples 14-8E Connect the IV tubing. 14-8F Turn on the IV and check the flow.
needed.
14-8G Secure the site. 14-8H Label the intravenous solution bag.
3. Select the venipuncture site. Acceptable sites have 5. Cleanse the venipuncture site. You must cleanse the
clearly visible veins and are free of bruising or scarring. intended site of pathogens to decrease the likelihood
Straight veins are easier to cannulate than crooked ones. of infection. Alcohol and similar antiseptic solutions
4. Place the constricting band proximal to the intended are the most commonly used. Start at the site itself
site of puncture. Tighten it enough to impede venous and work outward in an expanding circle. This pushes
blood flow without restricting arterial blood passage. pathogens away from the puncture site.
Never leave the constricting band in place for more 6. Insert the intravenous cannula into the vein. With
than 2 minutes, as intrinsic changes will occur in the your nondominant hand, pull all local skin taut to
slowed venous blood. stabilize the vein and prevent it from rolling. With the
478 Chapter 14
distal bevel of the metal stylet up, insert the cannula patient requires immediate fluid administration. This is an
into the vein at a 10° to 30° angle. Continue until you extremely painful site to access, so you typically will
feel the cannula “pop” into the vein or see blood in reserve its use for patients with a decreased or total loss of
the flashback chamber. The metal stylet is now in the consciousness.
vein; however, the Teflon catheter is not. To place the Cannulating the external jugular vein requires essen-
catheter into the vein, carefully advance the cannula tially the same equipment as other forms of peripheral IV
approximately 0.5 cm further. (If you are using a but- access, plus a 10-mL syringe. You will not need a constrict-
terfly cannula, it has no Teflon catheter, and you must ing band. To access the external jugular, use the following
carefully advance the needle itself.) technique (Procedure 14-9):
7. Holding the metal stylet stationary, slide the Teflon 1. Prepare all equipment as for peripheral IV access in an
catheter over the needle into the vein. Place a finger arm, hand, or leg. In addition, fill the 10-mL syringe
over the vein at the catheter tip and tamponade (press with 3 to 5 mL of sterile saline. Attach the distal part
gently downward to occlude the vein), thus prevent- of the syringe to the flashback chamber of a large bore,
ing blood from flowing from the catheter and/or air over-the-needle catheter. Use Standard Precautions.
from entraining into the circulatory system. Care-
2. Place the patient supine and/or in the Trendelenburg
fully remove the metal stylet, retract the needle, and
position. This position will increase blood flow to the
promptly dispose of it in the sharps container. Remove
chest and neck, thus distending the vein and making
the venous constricting band.
it easier to see. In addition, the supine-Trendelenburg
8. Obtain venous blood samples, as discussed in the sec- position decreases the chance of air entering the circu-
tion on venous blood sampling. latory system during cannulation.
9. Attach the administration tubing to the cannula.
3. Turn the patient’s head to the side opposite of access.
Remove the protective cap from the needle adapter
This maneuver makes the site easier to see and reach;
and tightly secure the needle adapter into the cannula
do not perform it if the patient has traumatic head
hub. Open the flow regulator and allow the fluid to run
and/or neck injuries.
freely for several seconds. Adjust the flow rate. Do not
let go of the cannula and administration tubing until 4. Cleanse the site with antiseptic solution. Start at the
you have secured them, as explained in step 10. site of intended puncture and work outward 1 to 2
inches (2.4–5.0 cm) in ever-increasing circles.
10. Cover the catheter and puncture site with an adhesive
bandage or other commercial device. Loop the distal 5. Occlude venous return by placing a finger on the exter-
tubing and secure with tape. This makes the medica- nal jugular just above the clavicle. This should distend
tion administration port more accessible and attaches the vein, again allowing greater visualization and ease
the device to the patient more securely. Continue by of puncture. Never apply a venous constricting band
taping the administration tubing to the patient, proxi- around the patient’s neck.
mal to the venipuncture site. 6. Position the intravenous cannula parallel with the vein,
11. Label the intravenous solution bag with the following midway between the angle of the jaw and the clavicle.
information: Point the catheter at the medial third of the clavicle and
insert it, bevel up, at a 10° to 30° angle.
• Date and time initiated
7. Enter the external jugular while withdrawing on the
• Person initiating the intravenous access
plunger of the attached syringe. You will see blood
12. Continually monitor the patient and flow rate. in the syringe or feel a pop as the cannula enters the
vein. Once inside the vein, advance the entire cathe-
Intravenous Access ter another 0.5 cm so the tip of the Teflon catheter lies
within the lumen of the vein. Then slide the Teflon
in the External Jugular Vein catheter into the vein and remove the metal stylet, as
The external jugular vein is a large peripheral blood vessel previously described, and retract the needle. Immedi-
in the neck, between the angle of the jaw and the middle ately dispose of the metal stylet.
third of the clavicle. It connects into the central circula-
8. Obtain venous blood samples, as discussed in the sec-
tion’s subclavian vein. Because it lies so close to the central
tion on venous blood sampling.
circulation, cannulation here offers many of the same ben-
efits afforded by central venous access. Fluids and medica- 9. Attach the administration tubing to the IV catheter.
tions rapidly reach the core of the body from this site. Allow the intravenous solution to run freely for several
Consider accessing the external jugular only after you seconds. Set the flow rate and secure as appropriate.
have exhausted other means of peripheral access or when a 10. Monitor the patient for complications.
Intravenous Access and Medication Administration 479
14-9A Place the patient supine or in the Trendelenburg 14-9B Turn the patient’s head to the side opposite of access
position. and cleanse the site.
14-9C Occlude venous return by placing a finger on the exter- 14-9D Point the catheter at the medial third of the clavicle
nal jugular just above the clavicle. and insert it, bevel up, at a 10° to 30° angle.
Although using the external jugular vein has advan- To refill the burette chamber, open the uppermost
tages, it also has distinct drawbacks. You may inadver- clamp until you have delivered the desired volume; then
tently puncture the airway or damage the nearby arterial repeat step 4.
vessels. Additionally, this is a painful entry site for the con- You can also use measured volume administration sets
scious patient. To minimize risks, perform the procedure for continuous fluid administration. Fill the burette cham-
very carefully. ber with at least 30 mL of solution and close the airway
handle. Leave the uppermost clamp open and adjust the
Intravenous Access with a Measured rate with the lower flow regulator.
1. Prepare the tubing by closing all clamps, and insert the 1. Prepare the tubing by closing all clamps, and insert the
flanged spike into the IV solution bag’s spike port. flanged spike into the spike port of the blood and/or
normal saline solution (Y-configured tubing).
2. Open the airway handle. Open the uppermost clamp
and fill the burette chamber with approximately 20 2. Squeeze the drip chamber until it is one-third full and
mL of fluid. Squeeze the drip chamber until the fluid blood covers the filter. Repeat for the normal saline if
reaches the fill line. Open the bottom flow regulator to you are using Y tubing.
purge air through the tubing. When all air is purged, 3. If you are using straight tubing, piggyback a second-
close the bottom flow regulator. ary line of normal saline into the blood tubing, unless
3. Continue to fill the burette chamber with the desig- you plan to piggyback the straight blood tubing into a
nated amount of solution. large-bore primary line.
4. Close the uppermost clamp and open the flow regu- 4. Flush all tubing with normal saline and blood as
lator until you reach the desired drip rate. Leave the appropriate.
airway handle open, so that air replaces the displaced 5. Attach blood tubing to the intravenous cannula or into
fluid. a previously established IV line.
14-10A Spike the solution bag. 14-10B Open the uppermost clamp and 14-10C Close the uppermost clamp and
fill the burette chamber with the desired open the flow regulator.
volume of fluid.
Intravenous Access and Medication Administration 481
14-11A Insert the flanged spike into the spike port of the 14-11B Squeeze the drip chamber until it is one-third full and
blood and/or normal saline solution. blood covers the filter.
14-11C Attach blood tubing to the intravenous cannula or 14-11D Open the clamp(s) and/or flow regulator(s) and
into a previously established IV line. adjust the flow rate.
6. Ensure patency by infusing a small amount of normal mistake both in and out of the hospital. Additionally,
saline. Shut down when you have confirmed patency. ensure that the patient is not wearing restrictive cloth-
7. Open the clamp(s) and/or flow regulator(s) that allows ing that interferes with venous blood flow.
blood to move from the bag to the patient. Adjust the • Edema at the puncture site. Swelling at the IV site indi-
flow rate accordingly. cates fluid collection caused by infiltration. This extrav-
8. When blood therapy is complete or must be discontin- asation occurs if you accidentally puncture the vein
ued, shut down the flow regulator from the blood supply more than once, thus allowing IV solution and blood to
and open the regulator(s) for the normal saline solution. escape from the second puncture and accumulate in the
surrounding tissue. An infiltrated IV site is not usable.
Factors Affecting Intravenous Flow Rates • Cannula abutting the vein wall or valve. If the distal
If an IV does not flow properly, check for the following
tip of the cannula butts against a wall or valve, care-
problems and correct them as appropriate.
fully reposition it. You may have to untape and retape
• Constricting band. Has the venous constricting band the cannula once you have achieved an adequate flow
been removed? This is probably the most common rate. Additionally, you may need to use an arm board
482 Chapter 14
to keep the patient’s extremity straight, as flexion may or IV solution can cause a
CONTENT REVIEW
kink the vein at the site and impede the solution’s flow. pyrogenic reaction. The
➤➤ IV Troubleshooting
• Administration set control valves. Ensure that the abrupt onset of fever (100°F
• Constricting band still
flow regulator is open. Be sure to check the flow regu- to 106°F), chills, backache,
in place?
lator and clamps of both the primary and any second- headache, nausea, and
• Edema at puncture
ary or extension tubing. vomiting characterize these site?
reactions. Cardiovascular • Cannula abutting vein
• IV bag height. When you move the patient, you may
collapse may also result. wall or valve?
raise the cannulation site above the IV solution bag.
Typically, a pyrogenic • Administration set
This interrupts the solution’s gravitational flow from
reaction will occur within control valves closed?
the bag into the patient.
one-half to one hour after • IV bag too low?
• Completely filled drip chamber. Is the drip chamber you initiate an IV. If you • Completely filled drip
completely filled? You can easily correct this by invert- suspect a pyrogenic reac- chamber?
ing the bag and squeezing the fluid from the drip tion, immediately terminate • Catheter patent?
chamber back into the bag. ➤➤ IV Access Complications
the IV and reestablish access
• Pain
• Catheter patency. A blood clot at the end of the Teflon in the opposite side with
• Local infection
catheter or needle may obstruct the flow of solution new equipment and fluid.
• Pyrogenic reaction
from the IV solution bag into the body. If the flow Typically, pyrogenic • Allergic reaction
slows, increase the IV drip rate to keep the catheter or reactions occur secondary • Catheter shear
needle clear. If the flow stops completely, cleanse the to the use of intravenous • Inadvertent arterial
medication administration port closest to the IV entry solutions that have been puncture
site with alcohol preparations and insert a syringe and contaminated with a micro- • Circulatory overload
hypodermic needle. Gently aspirate back on the organism or other foreign • Thrombophlebitis
syringe until the blood clot is pulled into the syringe. matter. Pyrogenic reactions • Thrombus formation
Never flush an IV that has stopped running because of underscore the need to dis- • Air embolism
a clot. Flushing will force the clot into the circulatory card any fluid that is cloudy • Necrosis
system and can cause occlusions in the heart or lungs. • Anticoagulants
or any equipment that has
been opened.
If flow remains inadequate after you have eliminated all
these possible causes, lower the IV bag below the insertion ALLERGIC REACTION A patient receiving IV therapy
site. If blood flows into the IV administration tubing, the may develop an allergic reaction. Most often, allergic reac-
site is patent and the problem lies elsewhere. If the prob- tions accompany the administration of blood or colloidal
lem persists, remove the IV and reestablish it on another (protein-containing) solutions. In addition, some patients
extremity, using all new equipment. If you do not observe may react to the latex in some types of IV administration
blood return, the site is inoperable. tubing.
The sudden onset of hives (urticaria), itching (pruri-
Complications of Peripheral tus), localized or systemic edema, or shortness of breath
Intravenous Access may signify an allergic reaction. If you suspect an allergic
reaction, stop the IV infusion and remove the IV catheter.
Even though it is a routine procedure, intravenous access is
Treat the patient as discussed in the “Immunology” chapter.
not trouble free. It can cause a number of complications.
CATHETER SHEAR A catheter shear can occur if you pull
PAIN Pain at the puncture site occurs during needle pen-
the Teflon catheter through or over the needle after you have
etration or with extravasation. To minimize pain, use a
advanced it into the vein. The soft plastic catheter will eas-
smaller-gauge catheter or use a 1 percent lidocaine solution
ily snag on the metal stylet’s sharp point and shear off, thus
(without epinephrine) to anesthetize the overlying skin
forming a plastic embolus. Therefore, never draw the Teflon
before insertion.
catheter over the metal stylet after you have advanced it.
LOCAL INFECTION Local infection occurs if you do
not properly cleanse the site and thus introduce pathogens INADVERTENT ARTERIAL PUNCTURE Because arter-
through the puncture. This complication does not become ies may lie close to veins, accidental arterial puncture may
apparent until after the IV has been established for several occur. Arterial blood is bright red and characteristically
hours. spurts with each contraction of the heart. When an arterial
puncture occurs, immediately remove the catheter and apply
PYROGENIC REACTION Pyrogens (foreign proteins direct pressure to the site for at least 5 minutes. Do not release
capable of producing fever) in the administration tubing the pressure until the hemorrhage has stopped.
Intravenous Access and Medication Administration 483
CIRCULATORY OVERLOAD Circulatory overload 2. Occlude the flow of solution from the depleted bag or
occurs if you administer too much fluid for the patient’s bottle by moving the roller clamp on the IV adminis-
condition. You must monitor flow rates carefully, especially tration tubing.
for patients with medical conditions such as kidney failure 3. Remove the spike from the depleted IV bag or bottle. Be
or heart failure who are intolerant of excessive fluid. Contin- careful not to drop or contaminate the spike in any way.
ually examine the patient for signs of circulatory overload
4. Insert the spike into the new IV bag or bottle. Ensure
(crackles, tachypnea, dyspnea, and jugular venous disten-
that the drip chamber is filled appropriately.
tion, as discussed in the chapter “Secondary Assessment”).
If you encounter circulatory overload, adjust the flow rate. 5. Open the roller clamp to the appropriate flow rate.
THROMBOPHLEBITIS Thrombophlebitis, or inflam- If air becomes entrained within the administration tubing
mation of the vein, is particularly common in long-term during this process, cleanse the medication administration
intravenous therapy. Redness and edema at the puncture port below the trapped air and insert a hypodermic needle
site are typical signs of thrombophlebitis. This complica- and syringe. Pull the plunger back to aspirate the trapped
tion may also present as pain along the course of the vein, air into the syringe. After you have removed the air, adjust
sometimes accompanied by inflammation and tenderness. the IV flow rate as needed.
Typically, thrombophlebitis does not occur until several
hours after IV initiation. When you suspect thrombophlebi- Intravenous Medication
tis, terminate the IV and apply a warm compress to the site.
Administration
THROMBUS FORMATION A thrombus, or blood clot, Medications can be delivered through an existing IV line. As
can form if IV access injures the vessel wall. A thrombus may the IV line is seated directly into a vein, the blood rapidly
form around the catheter and occlude the movement of fluid absorbs these medications and distributes them throughout
between the IV and the blood vessel. If you suspect a throm- the body. Intravenous administration avoids many of the bar-
bus, restart the IV using new equipment. Do not attempt to riers to medication absorption in other routes. For example,
dislodge the clot with a fluid bolus, as this may create an medications given via the gastrointestinal tract face enzymes
embolus that causes neurologic or pulmonary complications. and other chemicals that may deactivate, exacerbate, or in
AIR EMBOLISM Air embolism occurs when air enters some other way alter the medication being administered.
the vein. Air embolism is most likely to occur during cen- Likewise, local tissues can absorb medications administered
tral venous access or when administration tubing has not via the subcutaneous or intramuscular routes, thus prevent-
been properly flushed. Failure to tamponade larger veins ing the total dosage from reaching the bloodstream for deliv-
during cannulation may allow air into the vein. ery. The two methods for administering medications through
an IV line are intravenous bolus and intravenous infusion.
NECROSIS Necrosis, or the sloughing off of dead tissue,
occurs later in IV therapy as medication (e.g., norepineph- Intravenous Bolus
rine, epinephrine, dopamine, dobutamine) has extrava- An intravenous bolus involves injecting the circulatory
sated into the interstitial space. system with a concentrated dose of medication through the
medication administration port of an established IV. This
ANTICOAGULANTS Anticoagulant medications such
procedure requires the following equipment:
as aspirin, platelet aggregate inhibitors, warfarin (Couma-
din), or heparin increase the chance of bleeding and impede • Personal protective equipment
hemorrhage control during IV establishment. They drasti- • Antiseptic solution
cally increase the complications of hematoma or infiltration. • Packaged medication
• Syringe (size depends on the volume of medication
Changing an IV Bag or Bottle you will administer)
You may sometimes have to change an IV bag or bottle. This • 18- to 20-gauge hypodermic needle, 1 to 1.5 inches long
generally occurs when only 50 mL of solution remain and • Existing intravenous line with medication port
you must continue therapy after those 50 mL are depleted.
Changing the solution bag or bottle is a sterile process. If the To administer an intravenous medication bolus, use the
equipment becomes contaminated you should dispose of it. following technique (Procedure 14-12):
To change the IV solution bag or bottle, use the follow- 1. Ensure that the primary IV line is patent.
ing technique:
2. Confirm the medication, indication, dosage, and need
1. Prepare the new IV solution bag or bottle by removing for an IV bolus. Confirm that the medication is com-
the protective cover from the IV tubing port. patible with the solution being infused.
484 Chapter 14
14-12A Prepare the equipment. 14-12B Prepare the medication. 14-12C Check the label.
14-12D Select and clean an 14-12E Pinch the line. 14-12F Administer the medication.
administration port.
3. Draw up the medication or prepare a prefilled syringe Use the following technique to administer a medica-
as appropriate. tion as an IV infusion (Procedure 14-13):
4. Cleanse the medication port nearest the IV site with an 1. Establish a primary IV line and ensure patency.
antiseptic preparation.
2. Confirm administration indications and patient allergies.
5. Insert a hypodermic needle through the port membrane.
3. Prepare the infusion bag or bottle. (If the infusion is
6. Pinch the IV line above the medication port. This pre- premixed, continue to step 4.)
vents the medication from traveling toward the fluids
a. Draw up the appropriate quantity of medication from
bag, forcing it instead toward the patient.
its source with a syringe.
7. Inject the medication, as appropriate.
b. Cleanse the IV bag or bottle’s medication port with
8. Remove the hypodermic needle and syringe and an antiseptic wipe.
release the tubing.
c. Insert the hypodermic needle into the medication
9. Open the flow regulator to allow a 20-mL fluid flush. port and inject the medication.
The fluid will push the medication into the patient’s
d. Gently agitate the bag or bottle to mix its contents.
circulatory system.
e. Label the bag or bottle.
10. Dispose of the hypodermic needle and syringe as
appropriate. Monitor the patient for desired or unde- 4. Connect administration tubing to the medication bag or
sired effects. bottle and fill the drip chamber to the fluid line. Most
infusions require microdrip tubing. If you use a mechan-
Intravenous Medication Infusion ical infusion pump, you may need to use special tubing.
Many cardiac medications and antibiotics are given as 5. Place the hypodermic needle on the administration tub-
intravenous infusions (IV piggybacks). Intravenous medi- ing’s needle adapter and flush the tubing with solution.
cation infusions deliver a steady, continual dose of medica- (The needle adapter typically accepts a 20-gauge needle.)
tion through an existing IV line. You may give them either 6. Cleanse the medication administration port on the pri-
as an initial dosage or to maintain medication levels after mary line with alcohol and insert the secondary line’s
delivering an initial bolus. hypodermic needle. Secure the hypodermic needle
Piggybacking IV infusions through an existing intra- and the secondary administration line with tape or
venous line gives you greater control over medication another securing device.
delivery and allows you to easily discontinue the infusion 7. Reconfirm the indication, medication, dose, and route
when therapy is complete or must be stopped. Never of administration.
administer intravenous infusions as a primary IV line.
8. Shut down the primary line so no fluid will flow from
IV infusions are contained in bags or bottles of intrave-
the primary solution bag.
nous solution. If the IV infusion is premixed, read the label
on the bag for the following information: 9. Adjust the secondary line to the desired drip rate. If you
are using a mechanical infusion pump, set it accordingly.
• Name of medication
10. Properly dispose of the needle and syringe.
• Total dosage in weight mixed in bag
• Concentration (weight per
single mL)
• Expiration date
14-13A Select the drug. 14-13B Draw up the drug. 14-13C Select IV fluid for dilution.
14-13D Clean the medication addition port. 14-13E Inject the drug into the fluid. 14-13F Mix the solution.
When the infusion is complete, shut down the secondary use, a saline lock may be used. Sterile saline is injected
line with the flow regulator or a clamp. Open the primary following the medication. Saline remains in the lock to
line and adjust it to the indicated drip rate. Remove the keep it open. For long-term use, a heparin lock is pre-
hypodermic needle from the medication administration ferred. Although it functions the same as a saline lock, a
port and properly dispose of all contents. If required by heparin lock is filled with a low-concentration solution of
your local protocols, retain the medication bag to verify heparin, which aids in keeping any blood that gets into
administration and for quality assurance. the device from clotting. Typically, a medication will be
You can also use measured volume administration administered through the heparin lock. This is followed
tubing to administer medicated infusions. First, fill the by a saline flush to ensure that no medication remains in
burette chamber of a measured volume administration the lock or hub. Then, the lock and hub are filled with a
device with a specific volume of fluid. Then you can inject heparin solution. This aids in keeping the IV site open for
the medication through the medication injection site on top a long period of time.
of the burette chamber. You must adjust the flow rate to Initiating a heparin or saline lock requires the follow-
deliver the precise amount of medication required. In addi- ing equipment:
tion, you can mix the medication within the IV bag or bot-
• IV cannula
tles as previously described and use the measured volume
administration tubing solely for administering the infusion • Heparin or saline lock
rather than for mixing it. • Syringe with 3 to 5 mL sterile saline or commercial
saline injection device
Heparin Lock and Saline Lock • Tape or commercial securing device
When a patient requires occasional IV medication drips or • Venous blood drawing equipment
boluses but does not need continuous fluid, heparin locks
• Venous constricting band
are used. A heparin lock is a peripheral IV port that does
• Antiseptic solution
not use a bag of fluid. Like a typical IV start, it places an IV
cannula into a peripheral vein; however, instead of IV • Heparin for flush solution (if using heparin lock)—
administration tubing, it has attached short tubing with a typically 10 or 100 units/mL
clamp and a distal medication port (Figure 14-43). A hepa- To place a heparin lock, follow these steps:
rin lock decreases the risk of accidental fluid overload and
electrolyte derangement. You also may withdraw blood 1. Select the venipuncture site.
samples from the lock if it is in a suitable vein. For short-term 2. Place the constricting band proximal to the puncture site.
3. Cleanse the venipuncture site with antiseptic solution.
4. Insert the intravenous cannula into the vein.
5. Slide the Teflon catheter into the vein.
6. Carefully remove the metal stylet, retract or protect the
stylet, and promptly dispose of it into the sharps con-
tainer. Remove the venous constricting band.
7. Obtain venous blood samples, as explained under
“Venous Blood Sampling.”
8. Attach the heparin lock tubing to the catheter hub.
9. Cleanse the medication port and inject 3 to 5 mL of ster-
ile saline into the lock. Easy flow of the saline without
edema at the puncture site indicates patency. If you
encounter resistance or if edema forms, restart the pro-
cedure with new equipment. If a heparin lock is desired,
fill the port with the designated heparin flush solution.
10. Apply an adhesive bandage or other commercial
device. Secure the tubing to the patient.
• Packaged medication
• Syringe (the size depends on the volume being admin-
istered)
• 18- to 20-gauge hypodermic needle 1 to 1½ inches long
• Tunnel. Catheters can be inserted by tunneling under Figure 14-45 Example of a medication port venous access device.
the skin either into the subclavian vein or into the (Source: St Bartholomew’s Hospital/Science Source)
Intravenous Access and Medication Administration 489
Legal Considerations
Drawing Blood for Law Enforcement. In some regions,
paramedics may be asked to draw blood for law enforce-
ment. If this is the case in your system, make sure that you
have established protocols and medical director permis-
sion before performing the task. Be advised that you may
well be called to court to testify about what you saw or
FIGURE 14-47 Modern infusion pump.
what you did.10
(© Edward T. Dickinson, MD)
Intravenous Access and Medication Administration 491
Ultrasound-Guided Intravenous Access FIGURE 14-49 The use of medical ultrasound can help in placement
The use of portable ultrasound to aid in placement of of peripheral venous catheters.
peripheral intravenous lines is now common in hospital (© Edward T. Dickinson, MD)
emergency departments. With the advent of newer porta-
ble ultrasound machines it is also being used in the out-of- Once a vein is identified, hold the probe in your non-
hospital setting.11 dominant hand or have an assistant hold the probe in posi-
Medical ultrasound is a diagnostic imaging technique tion (Figure 14-50).
based on the application of ultrasound. Ultrasound uses Prep the skin and choose a catheter of adequate length
sound or other vibrations having an ultrasonic frequency to enter the vein. Insert the needle through the skin. Once
to image specific body structures. An ultrasound trans- through the skin, the needle should be visible as a shadow
ducer probe emits and receives ultrasound waves. These on the ultrasound image. Direct the needle toward the tar-
waves are converted into an electrical signal (image) that get vein. As you approach the wall of the vein, the needle
can be displayed on a computer or similar screen. This will compress or tent the vein. Advance the needle into the
gives a real-time image of the structures being observed. lumen of the vein. You will often feel a subtle “pop” when
Blood vessels are filled with fluid (blood) and are usually this occurs (Figure 14-51).
easy to identify using ultrasound imaging. This technique You should notice a flash in the catheter indicating
is beneficial in patients with veins that are deep or difficult entry into the vein. Advance the catheter into the vein
to palpate. It is also useful in shock and hypotension, when while withdrawing the needle. Verify placement by observ-
the veins are less distended. ing the needle within the lumen of the vein on ultrasound
Generally, the medium footprint linear array probe and by the ability to withdraw a small amount of blood.
is the preferred ultrasound probe for peripheral IV inser- Secure the catheter in a common fashion and begin fluid or
tions. A tourniquet is not required but can be used as medication administration as indicated. Remove, clean,
desired. Place conductive gel on the probe and place the and secure the ultrasound probe.
probe over the planned IV site. Start by placing the
transducer over the antecubital fossa in a transverse ori-
entation (Figure 14-49). The probe indicator should point
to the patient’s right side (operator’s left side). Survey
the venous anatomy. Apply pressure to compress the
vessels seen. Veins will compress readily, whereas arter-
ies will not. Arteries can be distinguished from veins as
follows:
FIGURE 14-51 Ultrasound identification of needle within the lumen MISCELLANEOUS EQUIPMENT Depending on the
of the vein. technique you use to obtain venous blood, you will also
(© Edward T. Dickinson, MD) need syringes, hypodermic needles, and commercially
manufactured plastic sleeves called vacutainers.
Venous Blood Sampling
The laboratory analysis of blood can provide valuable
Obtaining Venous Blood
Obtaining venous blood is a simple process; however, if
information about the sick and/or injured patient. The
the blood is to remain usable, you must pay strict attention
concentrations of electrolytes, gases, hormones, or other
to detail. You can obtain blood either from an IV catheter or
chemicals in blood can often shed light on the underlying
directly from the vein. Which technique you use will
causes of vague complaints such as dizziness or general-
depend on the situation. In either case, venous blood sam-
ized weakness. Additionally, blood evaluation can confirm
ples are best obtained from sturdy veins such as the
suspected conditions. For example, elevated cardiac
cephalic, basilic, or median. Smaller veins such as those on
enzymes in a patient’s blood can confirm a suspected myo-
the back of the hand are more likely to collapse during
cardial infarction.
retrieval, making the procedure difficult to complete.
In the field, you often will be the first to assess and
treat an ill or injured patient. Many of your interventions OBTAINING VENOUS BLOOD FROM AN IV CATH-
can alter the blood’s composition and erase important ETER The most convenient way to obtain venous blood
information. If you obtain venous blood samples before is through an IV catheter at the time of peripheral vascular
performing those interventions, they will enable the physi-
cian to evaluate the patient’s original status.
Venous blood is commonly obtained via venipuncture.
Thus, paramedics, who routinely initiate intravenous
access, can simultaneously obtain blood samples. Doing so
saves considerable hospital time and avoids multiple nee-
dle sticks.
You should obtain venous blood in the following situ-
ations:
access. In addition to blood tubes, you will need a tube agitate the tubes to mix the anticoagulant evenly with
holder (Figure 14-53). The tube holder is commonly referred the blood.
to as a vacutainer. A special adapter needle called a multi- 6. Tamponade the vein and remove the vacutainer and
draw needle fits into the tube holder. The multidraw needle multidraw needle. Attach the IV and ensure patency.
has a rubber-covered needle used to puncture the self-
7. Properly dispose of all sharps.
sealing top of the blood tube. The remaining portion of the
multidraw needle protrudes from the tube holder and fits 8. Label all blood tubes with the following information:
snugly into the hub of the IV catheter. • Patient’s first and last name
To obtain blood directly from the IV catheter, use the • Patient’s age and gender
following procedure:
• Date and time drawn
1. Assemble and prepare all equipment. Inspect the • Name of the person drawing the blood
blood tubes for expiration or damage and insert the
If commercial equipment is not available, use a 20-mL
multidraw needle into the vacutainer.
syringe (Figure 14-54). Attach the syringe’s needle adapter
Note: Never place blood tubes into the assembled vac-
to the IV catheter hub and gently pull back the plunger.
utainer and multidraw needle until you are ready to
Blood will fill the syringe. When the syringe is full, remove
draw blood. This will destroy the vacuum and render
it from the IV catheter and place the IV line into the IV
the blood tube useless.
catheter. Carefully attach a hypodermic needle to the
2. Establish IV access with the IV catheter. Do not connect syringe to puncture the tops of the blood tubes. In the
IV administration tubing. appropriate order, place the collected blood into the blood
3. Attach the end of the multidraw needle adapter to the tubes and agitate gently. When finished, properly dispose
hub of the cannula. of all sharps and label the blood tubes.
4. In correct order, insert the blood tubes so that the rub-
ber-covered needle punctures the self-sealing rubber OBTAINING BLOOD DIRECTLY FROM A VEIN When
top. Blood should be pulled into the blood tube. IV access is difficult or unobtainable, you may draw blood
5. Fill all blood tubes completely, as the amount of anti- directly from the vein with a hypodermic needle. This tech-
coagulant is proportional to the tube’s volume. Gently nique is useful for routine sampling that will not require
(a) (b)
(c) (d)
FIGURE 14-56 Intraosseous needle placement sites depend on the device being used and include (a) the proximal tibia, (b) the medial malleo-
lus of the distal tibia, (c) the humeral head, and (d) the sternum.
496 Chapter 14
Condyles Adjustable
Epiphyseal plastic disk
Cannula
plates
Trocar
Epiphysis
Tibal tuberosity
Handle
(a)
FIGURE 14-61 The EZ-IO™, which uses a small drill to place the
needle into the bone, is approved for both adults and children.
(Vidacare.com)
14-14A Select the medication and prepare equipment. 14-14B Palpate the puncture site and prep with an antiseptic
solution.
After establishing intraosseous access, you must periodi- administration tubing with the techniques as described under
cally flush the intraosseous needle to keep it patent. Failure “Intravenous Medication Administration” (“Intravenous
to do so may allow the needle to become occluded, hinder- Medication Bolus and Intravenous Medication Infusion”).
ing medication administration. If an intraosseous infusion is complete or must be dis-
Because the intraosseous needle is connected to the pri- continued because of an adverse reaction, shut down the
mary IV administration set and fluid, the intraosseous route secondary line with the flow regulator or a clamp. Open
can also deliver any solution or medication that can be the primary line and adjust it to the indicated drip rate.
administered by IV bolus or continuous infusion. To admin- Remove the hypodermic needle from the medication
ister medications or solutions through the intraosseous administration port and properly dispose of all contents if
route, use the medicinal administration port on the primary the infusion has been exhausted.
Intravenous Access and Medication Administration 499
14-14E Connect the IV fluid tubing. 14-14F Secure the needle appropriately.
• Multiplication
• Division
• Fractions
• Decimal fractions
• Proportions
• Percentages
If you are deficient in one or more of these areas, refer to any text on basic and intermediate
math.13
CONTENT REVIEW
➤➤ Fundamental Metric Units
• Grams—mass Metric System
• Meters—distance
Medication doses are most often expressed and measured in metric units. Accepted world-
• Liters—volume
wide, the metric system is pharmacology’s principal system of measurement. Once you
become familiar with it, the metric system is easy to use.
Cultural Considerations The metric system’s three fundamental units are grams
(mass), meters (distance), and liters (volume). In pharma-
The Metric System. Although the United States has been
cology, you will frequently encounter dosages greater or
slow to adopt the metric system, it is widely used in science
less than these fundamental units. To avoid long numbers
and medicine. As a paramedic, you must be familiar with the
metric system and be able to make calculations using it.
with repetitive zeros when measurements are substantially
less than or greater than the fundamental unit, the metric
Intravenous Access and Medication Administration 501
To convert a measurement to a larger unit, divide the original measurement by the numer-
ical equivalent of the smaller measurement’s prefix.
When converting a measurement to or from a prefix that is not the fundamental unit, first
convert the existing measurement to the fundamental measurement. Then convert the fun-
damental measurement to the desired unit.
For the beginner, this technique prevents confusion. The more experienced provider will
be able to make a direct conversion from milligrams to micrograms.
502 Chapter 14
Weight Conversion
Some medications’ dosages are calculated according to kilograms of body weight. To con-
vert pounds to kilograms, use the following formula:
kilograms = pounds>2.2
Temperature
The international thermometric scale measures temperature in degrees Celsius. Although
degrees Celsius is often cited interchangeably with degrees centigrade, the two scales are
slightly different. For practical purposes, however, you can think of them both as dividing
the interval between the freezing and boiling points of water into 100 equal parts, with 0°
being the freezing point and 100° being the boiling point. The household measurement
system, in contrast, divides the interval between the freezing and boiling points of water
into 180 equal parts, with 32° being the freezing point and 212° being the boiling point.
When taking a body temperature, use the following formulas to convert between degrees
Fahrenheit and degrees Celsius:
°F = 9>5 °C + 32
°C = 5>9 (°F - 32)
°F = 9>5 (28.4) + 32
°F = 51.12 + 32
°F = 83.1
28.4 °C = 83.1 °F
Converting between the different prefixes and between different systems of measure-
ment is crucial in calculating medication dosages. You should continually practice all con-
versions, not only during your formal education but also throughout your career in the
emergency medical services.
Intravenous Access and Medication Administration 503
Units
Some medications are measured in units. Penicillin, heparin, and insulin are administered
in units. Units, in pharmacology, are a measure of biological activity, not of weight, mass, or
volume. Thus, units do not convert among the metric, household, and apothecary systems.
Medical Calculations
Frequently, you will have to apply basic mathematical principles to calculate specific quan-
tities before administering medications and fluids. In out-of-hospital care, the following
forms of medications often require calculation:
• Oral medications
• Liquid parenteral medications
• Intravenous fluid administration
• Intravenous medication infusions
Most medications are provided in stock solution. Therefore, you must calculate the exact
amount of medication to remove from the stock for administration. To calculate basic med-
ication dosage, you will need three facts:
• Desired dose
• Dosage on hand
• Volume on hand
DESIRED DOSE The desired dose is the specific quantity of medication needed. Most
dosages are expressed as a weight (grams, milligrams, or micrograms). Dosages may be
standard or calculated according to body weight or age.
DOSAGE AND VOLUME ON HAND All liquid medications are packaged as concen-
trations. Concentration refers to weight per volume. A liquid medication’s concentration is
the medication’s weight (grams, milligrams, or micrograms) per volume of liquid (mL) in
which it is dissolved. For example, 50 percent dextrose (D50) is packaged as a concentration
of 25 grams (weight) dextrose in 50 mL (volume) of water. From the concentration, you can
determine the dosage on hand (weight) and the volume on hand. For 50 percent dextrose,
the dosage on hand is 25 grams and the volume on hand is 50 mL. Concentrations are iden-
tified on all medication packaging and labels.
Because you cannot see the desired dose dissolved in liquid, you must convert its
weight to volume, a readily visible measurement, using the following formula:
volume to be administered = volume on hand (desired dose)
dosage on hand
To use this formula, you must express all weight and volume measurements with the same
metric prefix. For example, if the desired dose is expressed in milligrams, the dosage on
hand must also be expressed in milligrams, volume on hand in milliliters.
MATH SUMMARY 1 Because you cannot see the 90 mg of acetaminophen, you must convert this weight to
a volume. To do so you need these facts:
x = 8 mL * 90 mg
x = 8 mL * 90 mg desired dose = 90 mg
720 mL mg dosage on hand = 500 mg
x =
500 mg volume on hand = 8 mL
x = 1.44 mL
Use the formula to calculate the dosage’s volume:
volume to be administered = volume on hand (8 mL) * desired dose (90 mg)
dosage on hand (500 mg)
8 mL x
*
500 mg 90 mg
720 mL mg
x =
500 mg
x = 1.44 mL
Converting Prefixes
The following example shows how to calculate the volume to be administered when the
desired dose, the dosage on hand, and the volume on hand are not all expressed in metric
units with the same prefix.
EXAMPLE 2. A physician orders you to give 250 mg of a medication via IV bolus. The
multidose vial contains 2 grams of the medication in 10 mL of solution. How much of the
medication should you administer?
Because the desired dose is expressed as milligrams, the dosage on hand must be con-
verted from grams to milligrams. In the metric system, 2 grams equal 2,000 milligrams. You
now know:
desired dose = 250 mg
dosage on hand = 2,000 mg
volume on hand = 10 mL
Now you can use the formula to calculate the volume to be administered:
MATH SUMMARY 3 volume on hand (10 mL) * desired dose (250 mg)
volume to be administered =
10 mL * 250 mg dosage on hand (2,000 mg)
x =
2,000 mg volume to be administered = (10 mL * 250 mg)/2,000 mg
2,500 mL mg volume to be administered = 2,500 mL mg)/2,000 mg
x =
2,000 mg
volume to be administered = 1.25 mL
x = 1.25 mL
Administer 1.25 mL of solution to deliver 250 mg of medication.
Intravenous Access and Medication Administration 505
You can also solve this problem using the ratio proportion, as follows: MATH SUMMARY 4
10 mL>2,000 mg = x>250 mg 10 mL x
=
2,500 mL mg = 2,000 mg x 2,000 mg 250 mg
desired dose = 5 mg
dosage on hand = 10 mg MATH SUMMARY 5
volume on hand = 2 mL 2 mL x
=
volume on hand (2 mL) * desired dose(5 mg) 10 mg 5 mg
volume to be administered =
dosage on hand (10 mg) 10 mL mg
x =
volume to be administered = (2 mL * 5 mg)>10 mg 10 mg
volume to be administered = 10 mL mg>10 mg x = 1.0 mL
volume to be administered = 1.0 mL
Using the ratio and proportion method, the problem is solved as follows:
2 mL>10 mg = x>5 mg
10 mL mg>10 mg = x
1.0 mL = x
EXAMPLE 4. You must administer 1.5 mg/kg of lidocaine via IV bolus to a patient in sta-
ble ventricular tachycardia. The concentration of lidocaine is 100 mg in a prefilled syringe
containing 10 mL of solution. The patient weighs 158 lb.
Start by converting the patient’s weight to kilograms:
kilograms = pounds>2.2
kilograms = 158 lb>2.2
kilograms = 71.82
MATH SUMMARY 7 Use the same formula as before to calculate the volume to be administered:
Medicated Infusions
To calculate the correct IV infusion rate, use the following formula:
volume on hand * drip factor * desired dose
drops>minute =
dosage on hand
• Volume to be administered
• Drip factor of the administration set (drops/mL)
• Total time of infusion (minutes)
Intravenous Access and Medication Administration 507
EXAMPLE 6. A physician tells you to administer 500 milliliters of normal saline solution
to a patient over 1 hour (60 minutes). The administration tubing is a macrodrip set with a
drip factor of 10 drops/mL. At what drip rate would you run this infusion?
MATH SUMMARY 9
volume to be administered = 500 mL
500 mL * 10 drops>mL
administration set drip factor = 10 drops>mL x =
60 minutes
total time of infusion = 60 minutes
5,000 mL 10 drops mL
x =
Calculate the infusion rate: 60 min
x = 83.3 drops>min
drops>minute = (500 * 10)>60
drops>minute = 5,000>60
drops>minute = 83.3
Set the flow rate at approximately 83 drops per minute to infuse 500 milliliters of normal
saline in almost exactly 60 minutes.
You can use the same formula to determine how long it will take to use all the fluid in
a container.
EXAMPLE 7. You are transporting a patient with an IV antibiotic. The infusion rate is
45 drops/minute and the administration tubing is a microdrip set (60 drops/mL). In the
500 milliliter bag of D5W, 150 milliliters remain. How long will it take the antibiotic to
complete infusion?
Use the same formula as in example 6; however, in this instance you will find time in
minutes.
45 drops>minute = (150 mL)(60 drops>mL)
x
MATH SUMMARY 10
45 drops>minute = 9,000 mL drops mL
x = 9,000 mL
x
drops/mL
9,000 mL drops mL
x = 45 drops>min
45 drops>minutes
x = 200 min
x = 200 minutes
The antibiotic will complete infusion in 200 minutes, or 3 hours and 20 minutes.
508
Intravenous Access and Medication Administration 509
Review Questions
1. The simplest and often the most neglected form of 9. The abbreviation _________________ designates the
Standard Precautions is _________________ right eye.
a. handwashing. a. o.u. c. o.d.
b. donning a gown. b. o.p. d. o.s.
c. wearing gloves. 10. In an acute respiratory emergency involving a
d. wearing eye goggles. patient with a prescribed metered dose inhaler
2. A cleansing agent that is toxic to living tissue (MDI), always use a(n) _________________ instead
is_________________ of the MDI.
3. A drug administered through the mucous mem- 11. When using an endotracheal tube, you must increase
branes of the ear and ear canal is a(n) conventional IV dosages from _________________ to
_________________ _________________ times.
a. buccal medication. a. 1, 2 c. 2, 2½
18. Advantages of saline and heparin locks include all 25. The metric prefix hecto- means_________________
of the following except_________________ a. 1. c. 100.
a. provides a peripheral IV port. b. 10. d. 1,000.
b. does not need continuous fluid infusion.
26. What is the metric unit for volume measurement?
c. blood samples cannot be withdrawn from the
a. Liter c. Gram
lock.
b. Meter d. Milli
d. decreases the risk of accidental electrolyte
derangement. 27. Medical control orders you to administer Valium,
2.0 mg. The medication is in a prefilled syringe
19. Causes of hemolysis include_________________
labeled 10 mg in 2 mL. You draw up the correct
a. using too small a needle for retrieval.
dose, which is_________________
b. vigorously shaking the blood tubes after they are
a. 0.20 mL. d. 4.0 mL.
filled.
b. 2.0 mL. e. none of the above.
c. too forcefully aspirating blood into or out of a
syringe. c. 0.4 mL.
d. all of the above. 28. To administer 35 mg of Benadryl from a syringe
labeled 50 mg/mL, you would give:
20. Which of the following is not considered a complica-
tion of intraosseous access? a. 1.5 mL. d. 0.7 mg.
a. Local infection b. 0.8 mL. e. none of the above.
b. Air embolism c. 0.7 mL.
c. Fat embolism 29. 0.75 liters converted to milliliters
d. Thrombophlebitis is_________________
a. 1,075 mL. d. 750 mL.
21. The bone most commonly used for intraosseous
access is the_________________ b. 1.075 mL. e. none of the above.
a. tibia. c. fibula. c. 75 mL.
b. femur. d. humerus. 30. Two grams is equal to_________________
22. The three fundamental units of the metric system a. 1,000 mg. c. 3,000 mg.
are: b. 2,000 mg. d. 2,000 mcg.
a. meters, liters, grains. 31. 2.5 grams is equal to_________________
b. grams, meters, liters. a. 150 mg. d. 2,000 mcg.
c. inches, pints, pounds. b. 1,500 mg. e. none of the above.
d. grams, liters, ounces. c. 2,500 mcg.
23. 1,000 milligrams equals_________________ 32. 1 kilogram is equal to_________________
a. 1 kilogram. c. 0.001 gram. a. 2.0 pounds.
b. 1 gram. d. 10 grams. b. 2.2 pounds.
24. A patient weighs 90 kg. What is his weight in c. 0.2 pounds.
pounds? d. 2.2 kilograms.
a. 180 c. 75 e. none of the above.
b. 41 d. 198 See Answers to Review Questions at the back of this book.
References
1. Hobgood, C., J. B. Bowen, J. H. Brice, B. Overby, and J. H. Compliance with Universal Precautions.” Am J Infect Control 38
Tamayo-Sarver. “Do EMS Personnel Identify, Report, and Dis- (2010): 86–94.
close Medical Errors?” Prehosp Emerg Care 10 (2006): 21–27. 4. Rickard, C., P. O’Meara, M. McGrail, D. Garner, A. McLean, and
2. Vilke, G. M., S. V. Tornabene, B. Stepanski, et al. “Paramedic P. Le Lievre. “A Randomized Controlled Trial of Intranasal Fen-
Self-Reported Medication Errors.” Prehosp Emerg Care 11 tanyl vs. Intravenous Morphine for Analgesia in the Prehospital
(2007): 80–84. Setting.” Am J Emerg Med 25 (2007): 911–917.
3. Harris, S. A. and L. A. Nicolai. “Occupational Exposures in 5. Barton, E. D., C. B. Colwell, T. Wolfe et al. “Efficacy of Intranasal
Emergency Medical Service Providers and Knowledge of and Naloxone as a Needleless Alternative for Treatment of Opioid
Intravenous Access and Medication Administration 511
Overdose in the Prehospital Setting.” J Emerg Med 29 (2005): 11. Schoenfield, E., Boniface, K., Shokoohi, H. “ED Technicians Can
265–271. Successfully Place Ultrasound-Guided Intravenous Catheters in
6. Holsti, M., B. L. Sill, S. D. Firth, F. M. Filloux, S. M. Joyce, and R. Patients with Poor Vascular Access.” Am J Emerg Med 29
A. Furnival. “Prehospital Intranasal Midazolam for the Treat- (2011):496–501.
ment of Pediatric Seizures.” Pediatr Emerg Care 23 (2007): 148–153. 12. Fowler, R., J. V. Gallagher, S. M. Isaacs, E. Ossman, P. Pepe, and
7. Kelly, A. M., D. Kerr, P. Dietze, I. Patrick, T. Walker, and Z. Kout- M. Wayne. “The Role of Intraosseous Vascular Access in the Out-
sogiannis. “Randomised Trial of Intranasal versus Intramuscular of-Hospital Environment (resource document to NAEMSP posi-
Naloxone in Prehospital Treatment for Suspected Opioid Over- tion statement).” Prehosp Emerg Care 11 (2007): 63–66.
dose.” Med J Aust 182 (2005): 24–27. 13. Leidel, B. A., C. Kirchhoff, V. Braunstein, V. Bogner, P. Biberthaler,
8. Warner, G. S. “Evaluation of the Effect of Prehospital Application and K. G. Kanz. “Comparison of Two Intraosseous Access
of Continuous Positive Airway Pressure Therapy in Acute Respi- Devices in Adult Patients under Resuscitation in the Emergency
ratory Distress.” Prehosp Disaster Med 25 (2010): 87–91. Department: A Prospective, Randomized Study.” Resuscitation 81
(2010): 994–999.
9. Niemann, J. T., S. J. Stratton, B. Cruz, and R. J. Lewis. “Endotra-
cheal Drug Administration during Out-of-Hospital Resuscita- 14. Eastwood, K. J., M. J. Boyle, and B. Williams. “Paramedics’ Abil-
tion: Where Are the Survivors?” Resuscitation 53 (2002): 153–157. ity to Perform Drug Calculations.” West J Emerg Med 10 (2009):
240–243.
10. Harrison, G., K. G. Speroni, L. Dugan, and M. G. Daniel. “A
Comparison of the Quality of Blood Specimens Drawn in the 15. Bernius, M., B. Thibodeau, A. Jones, B. Clothier, and M. Witting.
Field by EMS versus Specimens Obtained in the Emergency “Prevention of Pediatric Drug Calculation Errors by Prehospital
Department.” J Emerg Nurs 36 (2010): 16–20. Care Providers.” Prehosp Emerg Care 12 (2008): 486–494.
Further Reading
Bledsoe, Bryan E. and Dwayne Clayden. Prehospital Emergency Pharma- Martini, Frederic. Fundamentals of Anatomy and Physiology. 8th ed. San
cology. 7th ed. Upper Saddle River, NJ: Pearson/Prentice Hall, 2012. Francisco: Benjamin Cummings, 2008.
Campbell, John Emory and the Alabama Chapter of the American McKenry, Leda M., et al. Pharmacology in Nursing. 21st ed. St. Louis:
College of Emergency Physicians. International Trauma Life Sup- Mosby, 2003.
port for Prehospital Providers. 6th ed. Upper Saddle River, NJ: Pear- McSwain, Norman E. and Scott Frame. Prehospital Trauma Life Sup-
son/Prentice Hall, 2012. port. 7th ed. St. Louis: Mosby, 2010.
Kee, Joyce L. and Evelyn R. Hayes. Pharmacology: A Nursing Process Mikolaj, Alan A. Drug Dosage Calculations for the Emergency Care
Approach. 6th ed. Philadelphia: W. B. Saunders Company, 2009. Provider. 2nd ed. Upper Saddle River, NJ: Pearson/Prentice
Lesmeister, Michele B. Math Basics for the Health Professional. 3rd ed. Hall, 2003.
Upper Saddle River, NJ: Pearson/Prentice Hall, 2009.
Chapter 15
Airway Management
and Ventilation Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P
W. E. Gandy, JD, NREMTP
Darren Braude, MD, MPH, FACEP
STANDARD
Airway Management, Respiration, and Artificial Ventilation
COMPETENCY
Integrates comprehensive knowledge of anatomy, physiology, and pathophysiology into the assessment to develop and
implement a treatment plan with the goal of ensuring a patent airway, adequate mechanical ventilation, and respiration for
patients of all ages.
Learning Objectives
Terminal Performance Objective: After reading this chapter, you should be able to apply principles of airway manage-
ment and ventilation to the assessment and management of patients.
Enabling Objectives: To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this chapter. 6. Demonstrate techniques of basic airway
management, including positioning,
2. Review the basic anatomy and physiology
administering supplemental oxygen by a
of the upper and lower airway, the
variety of devices, manual airway
respiratory cycle, oxygen and carbon
maneuvers, and inserting basic airway
dioxide transport, and clinical differences in
adjuncts.
the pediatric airway.
7. Discuss the “Rule of Threes” as it pertains
3. Describe findings consistent with upper
to optimal bag-valve mask ventilations.
airway obstruction and abnormal upper
airway sounds. 8. Explain the importance of nonlinear
thinking and action in assessment and
4. Discuss the steps of the primary survey as it
management of problems with the airway
relates to the assessment of airway patency
and ventilation.
and ventilatory adequacy.
9. Identify the types, indications,
5. Describe the function, procedure for use,
contraindications, procedure for use, and
and benefits of noninvasive respiratory gas
limitations of the various extraglottic airway
monitoring in identifying oxygenation and
devices.
ventilation sufficiency.
512
Airway Management and Ventilation 513
10. Describe the indications, contraindications, intubation, and the process (or order) by
advantages, disadvantages, complications, which rapid sequence intubation is
equipment, and techniques for endotracheal performed.
intubation.
18. Recognize predictors of a difficult airway
11. Discuss the role and use of optical and and ventilation, and discuss techniques
video laryngoscopy devices during patient that can increase first-attempt intubation
intubation. success rates.
12. Identify multiple ways to confirm that the 19. Discuss the assessment and management of
patient is being adequately ventilated the airway and ventilation in a patient with
regardless of what type of airway and a stoma.
ventilation device(s) are being used.
20. Identify and discuss the equipment needed
13. Identify alternative approaches to traditional for effective suctioning of the nasopharynx,
endotracheal intubation to include nasal oropharynx, and the trachea in the intubated
intubation, retrograde intubation, digital patient.
intubation, and lighted stylet intubation.
21. Describe the benefits of gastric decompression
14. Discuss special considerations of anatomy, in the ventilated patient, to include the
equipment, and procedure when intubating equipment needed and procedure for proper
and ventilating pediatric patients. placement.
15. Discuss management of post-intubation 22. Identify the role and basic function of
agitation and field extubation. transport ventilators in the prehospital
16. Describe the indications, contraindications, environment.
advantages, disadvantages, complications,
23. Given scenarios of patients requiring airway
and equipment for performing
or ventilatory management, including
cricothyrotomy techniques.
patients with a difficult airway, discuss how
17. Describe the pharmacology of medications to employ techniques to achieve adequate
commonly used in medication-assisted oxygenation.
KEY TERMS
ABCs, p. 528 capnography, p. 534 endotracheal tube introducer, p. 560
alveoli, p. 519 carbon dioxide, p. 516 eustachian tube, p. 517
anoxia, p. 530 compliance, p. 531 extraglottic airway (EGA)
apnea, p. 526 continuous positive airway devices, p. 550
Case Study
Ellis County Unit 947, along with a fire engine, is dis- personal protective equipment, Kathy assesses the
patched to a motor vehicle collision on rural County patient. She finds him to be unresponsive. William,
Road 664, approximately eight miles from town. This Sharon, and the firefighters help her logroll the patient
particular stretch of road is well known to paramedics to a supine position while keeping the cervical spine in
because of a number of serious crashes over the last sev- a neutral position. Sharon maintains the neck in a neu-
eral months. The road contains numerous sharp curves tral position while Kathy opens the airway with the
and is under construction in several locations. Today, modified jaw-thrust technique.
Unit 947 is staffed by paramedic Kathy Mulligan and The patient exhibits agonal respirations. In addi-
AEMT William Benson. In addition, paramedic student tion, gurgling noises are heard with each breath. After
Sharon Rodriguez is assigned to the unit for her para- suctioning bloody secretions from his mouth, Kathy
medic field internship. There are three volunteer fire- attempts to insert an oropharyngeal airway. However,
fighter/EMTs on the engine. the patient’s teeth are tightly clenched, and the airway
On arrival at the scene, they find one vehicle that will not pass. Sharon places a nasal airway, and then the
has apparently run off the road and struck a telephone entire team provides three-person ventilatory support
pole. Witnesses to the crash estimate that the vehicle with a bag-valve-mask (BVM) unit and 100 percent oxy-
was traveling at approximately 45 miles per hour gen. The Glasgow Coma Score is 5.
before striking the pole. The lone 24-year-old male They load the patient into Unit 947 and initiate
occupant was ejected from the vehicle and lies face Code 3 transport to the closest Level 1 trauma center, 31
down in a ditch approximately 50 feet from the car. minutes away. En route, they obtain a full set of vital
After ensuring scene safety and donning the appropriate signs, keep the patient warm, and start a large-bore IV.
Airway Management and Ventilation 515
The patient’s blood pressure is 167/92 mmHg, heart rebounds, and they decompress the stomach with a gas-
rate is 110, and oxygen saturation is only 88 percent, tric tube inserted through the dedicated channel on the
despite optimal BVM ventilation. Kathy radios to have device. They connect the LMA Supreme™ to the trans-
another paramedic meet them en route so they can per- port ventilator, and monitor capnography and other
form rapid sequence intubation (RSI), as their protocols vitals. They adjust the ventilator to maintain a normal
require that two medics be present for this procedure. exhaled CO2 and administer fentanyl and midazolam to
When they meet up with the second paramedic 23 keep the patient comfortable. They arrive at the trauma
minutes from the hospital, they are still having trouble center 16 minutes later. The patient’s blood pressure is
maintaining adequate oxygenation, and there is no indi- 147/84 mmHg, heart rate is 98, oxygen saturation is 93
cation of tension pneumothorax or other treatable etiol- percent, and exhaled CO2 is 35.
ogy. The two medics agree that RSI is indicated. One of The trauma team leaves the LMA Supreme™ in place
the firefighters maintains cervical stabilization. They to obtain initial radiographs and CT scans, which reveal a
give the 100-kg patient 30 mg of etomidate and 200 mg pulmonary contusion and a large subdural hematoma
of succinylcholine. Forty-five seconds after succinylcho- that requires emergent surgical drainage. In the operating
line was administered, the fasciculations (muscle room, the patient is intubated through the LMA
twitches) have passed from head to toe, and the patient Supreme™, using fiber-optic guidance. Following sur-
is flaccid. gery, the patient begins to regain consciousness but
Kathy attempts bimanual laryngoscopy, but is requires continued intubation for 72 hours because of
unable to visualize the glottis or posterior cartilages. oxygenation and ventilation issues. On day four, he is suc-
She makes one attempt with an endotracheal tube intro- cessfully extubated and moved to a regular hospital room.
ducer under the epiglottis, which is unsuccessful, and Kathy and her Unit 947 team stop at the hospital to
the patient’s oxygen saturations are noted to be falling. visit after the patient is extubated. He has no recall of
The two medics then elect to place an LMA Supreme™ the crash at all. The last thing he remembers is looking
airway. They inflate the cuff and begin ventilations with on the floor of his car for a CD that he dropped. One
high-concentration supplemental oxygen, using a self- week after the crash, he is discharged to rehabilitation
inflating bag. The patient’s oxygen saturation quickly with minimal neurologic deficits.
PART 1: Respiratory stances entering the nasal cavity. Because of this, they can
become infected. Fractures of the upper sinuses (sphe-
Anatomy, Physiology, noids) can occasionally cause cerebrospinal fluid (CSF) to
leak from the cranial cavity into the nasal cavity. Clinically,
and Assessment this presents with clear fluid draining from the nose (rhi-
norrhea) and can provide a direct route for the transmis-
Anatomy of the sion of pathogens to the brain and associated structures.
Respiratory System
The respiratory system provides a passage
for oxygen, a gas necessary for energy pro-
duction, to enter the body and for carbon NASAL CAVITY
LARYNGOPHARYNX
Upper Airway Anatomy (HYPOPHARYNX)
Vallecula
The upper airway extends from the mouth
Epiglottis
and nose to the larynx (Figure 15-1). It
Glottic opening
includes the nasal cavity, oral cavity, and LARYNX
Vocal cords
pharynx. The larynx joins the upper and Esophagus
lower airways. Thyroid cartilage
Trachea
Cricothyroid membrane
The Nasal Cavity Cricoid cartilage
The nasal cavity is the most superior part
Thyroid gland
of the airway. The maxillary, frontal, nasal,
ethmoid, and sphenoid bones comprise FIGURE 15-1 Anatomy of the upper airway.
Airway Management and Ventilation 517
The eustachian tubes, or auditory tubes, connect the ear system. It contains several openings, including the internal
with the nasal cavity and allow for equalization of pressure nares, the mouth, the larynx, and the esophagus.
on each side of the tympanic membrane. Swallowing can The pharynx is divided into three regions: the naso-
assist in equalizing this pressure. The nasolacrimal ducts pharynx, the oropharynx, and the laryngopharynx (hypo-
drain tears and debris from the eyes into the nasal cavity. pharynx). The nasopharynx is the uppermost region,
This can cause the nose to run when someone cries. extending from the back of the nasal opening to the plane
Air enters the nasal cavity through the external nares of the soft palate. The oropharynx extends from the plane
(nostrils). Nasal hairs just inside the external nares initially of the soft palate to the hyoid bone. The adenoids, lym-
filter the incoming air. The air then proceeds into the nasal phatic tissue in the mouth and nose, filter bacteria. Either
cavity, where it strikes three bony projections: the superior, hypertrophy or swelling of the adenoids from infection
middle, and inferior turbinates, or conchae. These shelflike may make them large enough to obscure your view of the
structures, which are parallel to the nasal floor, serve as posterior pharynx. The laryngopharynx extends posteri-
conduits into the sinuses, increase the surface area of the orly from the hyoid bone to the esophagus and anteriorly
nasal cavity, and cause turbulent airflow. This turbulence to the larynx. The laryngopharynx is especially important
helps to filter the air by depositing airborne particles on the in airway management.
mucous membrane lining the nasal cavity. Hairlike fibers Because the mouth and pharynx serve dual purposes
called cilia propel those trapped particles to the back of the for respiration and digestion, a number of mechanisms
pharynx, where they are swallowed. Because the mucous help prevent accidental blockage. To prevent foreign mate-
membrane is covered with mucus and has a rich blood sup- rial from entering the trachea and lungs, sensitive nerves
ply, it also immediately warms and humidifies the air enter- activate the body’s cough and swallowing mechanisms as
ing the nose. By the time the air reaches the lower airway, it well as the gag reflex.
is at body temperature (37°C), 100 percent humidified, and Located anteriorly in the hypopharynx is the epiglot-
virtually free of airborne particles. Air proceeds from the tis, a leaf-shaped cartilage that prevents food from entering
nasal cavity through internal nares into the nasopharynx. the respiratory tract during swallowing. Just anterior and
The tissue of the nasal cavity is extremely delicate and superior to the epiglottis is the vallecula, a fold formed by
vascular. Because of this, it is susceptible to trauma. Always the base of the tongue and the epiglottis. It is an important
remember that improper or overly aggressive placement of landmark for endotracheal intubation. A series of liga-
tubes or mechanical airways can cause significant bleeding ments and muscles connect the epiglottis to the hyoid bone
that direct pressure might not control. and mandible. Immediately behind the hypopharynx are
the fourth and fifth cervical vertebral bodies.
The Oral Cavity
The cheeks, the hard and soft palates, and the tongue form The Larynx
the mouth, or oral cavity. The lips that surround the mouth’s The larynx is the complex structure that joins the pharynx
opening are fleshy folds of skin. Behind the lips lie the gums with the trachea (Figure 15-2). Lying midline in the neck, it
and teeth, normally numbering 32 in the adult. Significant is attached to and lies just inferior to the hyoid bone and
force is required to avulse (dislodge) or fracture the teeth. anterior to the esophagus. It consists of the thyroid and cri-
Broken or dislodged teeth can potentially obstruct the airway. coid cartilage (both considered tracheal cartilage), glottic
The hard palate anteriorly and the soft palate posteriorly opening, vocal cords, arytenoid cartilage, pyriform fossae,
form the top of the oral cavity and separate it from the nasal and cricothyroid membrane.
cavity. The tongue, a large muscle on the bottom of the oral The main laryngeal cartilage is the shield-shaped thy-
cavity, is the most common airway obstruction. It attaches to roid cartilage. Larger in males than in females, the thyroid
the mandible and the hyoid bone through a series of muscles cartilage forms the anterior prominence called the Adam’s
and ligaments. The U-shaped hyoid bone is located just apple. The arytenoid cartilage, which forms a pyramid-
beneath the chin. The hyoid bone is unique: It is the only bone shaped attachment for the vocal cords posteriorly, is an
in the axial skeleton that does not articulate with any other important landmark for endotracheal intubation. Posteri-
bone. Instead, it is suspended by ligaments from the styloid orly, smooth muscle closes a gap in the thyroid cartilage.
process of the temporal bone and serves to anchor the tongue Directly behind the Adam’s apple, the thyroid cartilage
and larynx, as well as to support the trachea. houses the glottic opening, the narrowest part of the adult
trachea, which is bordered by the vocal cords. The patency
The Pharynx of the glottic opening, or glottis, depends heavily on mus-
The pharynx is a muscular tube that extends vertically from cle tone. On either side of the glottic opening are the pyri-
the back of the soft palate to the superior aspect of the form fossae, recesses that form the lateral borders of the
esophagus. It allows the air to flow into and out of the respi- larynx. The thyrohyoid membrane attaches the upper end
ratory tract and food and liquids to pass into the digestive of the thyroid cartilage to the hyoid bone.
518 Chapter 15
Epiglottis
Lesser cornu
Hyoid bone
Extrinsic ligament
Vestibular fold
Vocal cords
Larynx Thyroid cartilage
Arytenoid cartilage
(Anterior) (Posterior)
Within the laryngeal cavity lie the true vocal cords, rocedures are the thyroid gland, carotid arteries, and jug-
p
white bands of cartilage that regulate the passage of air ular veins. The thyroid gland is a “bow-tie” shaped endo-
through the larynx and produce voice by contraction of crine gland located in the neck. It is highly vascular and
the laryngeal muscles. The vocal cords can also close lies inferior to the cricoid cartilage. It contains two lobes,
together to prevent foreign bodies from entering the air- one on each side of the trachea. These lobes are joined in
way. The passage of an endotracheal tube between the the middle by the isthmus that extends across the trachea.
vocal cords interferes not only with the creation of sound, The carotid arteries run closely along the trachea. Several
but also with the protective function of coughing. Beneath branches of the carotid arteries cross the trachea. Likewise,
the thyroid cartilage is the cricoid cartilage, which forms the jugular veins lie very close to the trachea. Several
the inferior border of the larynx. Often it is considered the branches of the jugular veins, such as the superior thyroid
first tracheal ring. Unlike the thyroid and other tracheal vein, cross the trachea.
cartilages, whose posterior surfaces are open and not
fused, the cricoid cartilage forms a complete ring. In chil-
dren, the cricoid cartilage is the narrowest part of the
Lower Airway Anatomy
laryngeal airway. The fibrous cricothyroid membrane The lower airway extends from below the larynx to the alve-
connects the inferior border of the thyroid cartilage with oli (Figure 15-3). This is where the respiratory exchange of
the superior aspect of the cricoid cartilage. It is the site for oxygen and carbon dioxide occurs. Helpful landmarks are
surgical airway techniques. the fourth cervical vertebra at the posterior superior bor-
A mucous membrane lines most of the larynx. Rich der, and the xiphoid process anterior inferiorly, although
with nerve endings from the vagus nerve, it is so sensitive the posterior lung extends beyond this inferiorly.
that any irritation sparks a cough, or forceful exhalation of
a large volume of air. First, air is drawn into the respira- The Trachea
tory passageways. Next, the glottic opening shuts tightly, As air enters the lower airway from the upper airway, it
trapping the air within the lungs. Then the abdominal and first enters and then passes through the trachea. The tra-
thoracic muscles contract, pushing against the diaphragm chea is a 10- to 12-centimeter-long tube that connects the
and increasing intrathoracic pressure. The vocal cords larynx to the two mainstem bronchi. It contains cartilagi-
suddenly open, and a burst of air forces foreign particles nous, C-shaped, open rings
out of the lungs. The laryngeal mucous membrane is so that form a frame to keep it Content Review
sensitive that its stimulation by a laryngoscope or endo- open. The trachea is lined ➤➤ Lower Airway Components
tracheal tube can cause bradycardia (slow pulse rate), with respiratory epithe- • Trachea
hypotension (low blood pressure), and decreased respira- lium containing cilia and • Bronchi
tory rate. mucus-producing cells. • Alveoli
• Lung parenchyma
Other structures proximate to the larynx and of The mucus traps particles
• Pleura
particular interest when you perform surgical airway that the upper airway did
Airway Management and Ventilation 519
Hyoid
Smooth muscle
Larynx
Tracheal cartilage
Mucous cartilage
Trachea
Respiratory
epithelium
Respiratory
Lamina mucosa
propria
Primary Left
bronchi mainstem
bronchus
Right
mainstem
bronchus
Lung
tissue
Carina
not filter. The cilia then move the trapped particulate mat- bronchoconstriction can inhibit the movement of air
ter up into the mouth, where it is swallowed or expelled. through the bronchiole.
After approximately 22 divisions, the bronchioles turn
The Bronchi into the respiratory bronchioles. These structures contain
At the carina, the trachea divides, or bifurcates, into the only muscular connective tissue and have a limited capac-
right and left mainstem bronchi. The right mainstem ity for gas exchange. The respiratory bronchioles terminate
bronchus is almost straight, whereas the left mainstem at the alveoli.
bronchus angles more acutely to the left. Because of this,
the right mainstem is often the site of aspirated foreign The Alveoli
bodies. In addition, when an endotracheal tube is inserted The respiratory bronchioles divide into the alveolar ducts,
too far, it tends to enter the right mainstem bronchus, thus which terminate in balloonlike clusters of alveoli called
ventilating only the right lung. Mainstem bronchi enter alveolar sacs (Figure 15-4). The alveoli contain an alveolar
the lung tissue at the hilum and then divide into the sec- membrane that is only one or two cell layers thick. Because
ondary and tertiary bronchi. The secondary and tertiary of this, the alveoli comprise the key functional unit of the
bronchi ultimately branch into the bronchioles, or small respiratory system. Most oxygen and carbon dioxide gas
airways. exchanges take place here, although limited gas exchange
The bronchioles are encircled with smooth muscle that may occur in the alveolar ducts and respiratory bronchi-
contains beta-2 (β2) adrenergic receptors. When stimu- oles. The alveoli become thinner as they expand. This facil-
lated, these β2 receptors relax the bronchial smooth muscle, itates diffusion of oxygen and carbon dioxide. The alveoli’s
thus increasing the airway’s diameter. This bronchodila- surface area is massive, totaling more than 40 square
tion can increase the amount of air transported through the meters—enough to cover half a tennis court. These hollow
bronchiole. Conversely, parasympathetic receptors, when structures resist collapse largely because of the presence of
stimulated, cause the bronchial smooth muscles to con- surfactant, a chemical that decreases their surface tension
tract, thus reducing the diameter of the bronchiole. This and makes it easier for them to expand. Alveolar collapse
520 Chapter 15
Smooth muscle relative size and position of some components. The airway
is smaller in all aspects, particularly the diameters of the
openings and passageways.
In the pediatric pharynx, the jaw is smaller and the
Elastin fibers tongue relatively larger, resulting in greater potential air-
way encroachment (Figure 15-5). The epiglottis is much
floppier and rounder (“omega” shaped). The dental (alve-
olar) ridge and teeth are softer and more fragile than an
adult’s and potentially more subject to damage from air-
way maneuvers.
Alveoli The larynx lies more superior and anterior in children
and is funnel-shaped because the cricoid cartilage is unde-
veloped. Before the age of 10, the cricoid cartilage is the
narrowest part of the airway. Most significantly, even a
small foreign body or a limited degree of swelling in the
Capillaries
pediatric airway can be life threatening. Because of this,
young children tend to suffer more problems related to the
FIGURE 15-4 Anatomy of the alveoli. trachea than do older children. A common example is
croup (laryngotracheobronchitis), a viral infection that
causes the soft tissues below the glottis to swell. This can
(atelectasis) can occur if surfactant is insufficient or if the reduce the diameter of the airway, potentially causing seri-
alveoli are not inflated. No gas exchange takes place in ous problems.
atelectatic alveoli. The ribs and the cartilage of the pediatric thoracic
cage are softer and more pliable. This lack of rigidity less-
The Lung Parenchyma ens the thoracic wall’s and accessory muscles’ ability to
The alveoli are the terminal ends of the respiratory tree and assist lung expansion during inspiration. As a result,
the functional units of the lungs. As such, they are the core
of the lung parenchyma. The lung parenchyma is
arranged in two pulmonary lobules that form the
anatomic division of the lungs. These lobules are fur-
ther organized into lobes. The right lung has three
lobes: the upper lobe, the middle lobe, and the lower
lobe. The left lung, which shares thoracic space with
the heart, has only two lobes: the upper lobe and the
lower lobe.
The Pleura
Membranous connective tissue, called pleura, covers
the lungs. The pleura consists of two layers: visceral
and parietal. The visceral pleura envelops the lungs
and does not contain nerve fibers. In contrast, the
parietal pleura lines the thoracic cavity and does con- Relatively greater
tain nerve fibers. The potential space between these proportion of
soft tissue
two layers, called the pleural space, usually holds a
small amount of fluid that reduces friction between Larynx more superior
the pleural layers during respiration. Occasionally, and anterior
the pleura can become inflamed, causing significant Epiglottis rounder
and floppier
pain with respiration. This condition, called pleurisy,
is a common cause of chest pain, particularly in ciga- Smaller jaw
rette smokers. Loosely attached
Cricoid cartilage – mucous membranes
narrowest part of
The Pediatric Airway the pediatric airway
The pediatric airway is fundamentally the same as an
adult’s, but you will need to know the differences in FIGURE 15-5 Anatomy of the pediatric airway.
Airway Management and Ventilation 521
infants and children tend to rely more on their diaphragms system, the central nervous system, and the musculoskel-
for breathing. Always pay close attention to these differ- etal system.
ences when treating pediatric patients, especially those The thoracic cavity is a closed space, opening to the
with respiratory complaints. external environment only through the trachea. The dia-
phragm separates the thoracic cavity from the abdomen.
When the diaphragm contracts, it draws downward, away
Physiology of the from the thoracic cavity, thus enlarging it. Likewise, when
the muscles between the ribs, or intercostal muscles, con-
Respiratory System tract, they draw the rib cage upward and outward, away
Just as successful airway management requires a firm from the thoracic cavity, further increasing its volume.
understanding of airway anatomy, a good outcome for The respiratory cycle begins when the lungs have
these patients requires a working knowledge of the mechan- achieved a normal expiration and the pressure inside the
ics of oxygenation and ventilation. Your knowledge of nor- thoracic cavity equals the atmospheric pressure. At this
mal respiratory physiology will lay the groundwork for point, respiratory centers in the brain communicate with
your comprehension of important pathophysiology and the diaphragm by way of the phrenic nerve, signaling it to
will help you to determine which actions will ensure opti- contract and thus initiate the respiratory cycle. As the size
mal patient care. of the thorax increases in relation to the volume of air it
holds, pressure within the thorax decreases, becoming
lower than atmospheric pressure. This negative intratho-
Respiration and Ventilation racic pressure invites air into the thorax through the air-
Respiration, as noted earlier, is the exchange of gases way. Because the visceral and parietal pleura remain in
between a living organism and its envi-
ronment. Pulmonary, or external, respi-
ration occurs in the lungs when the
respiratory gases are exchanged +PSWKGVDTGCVJKPI 'ZRKTGFCKT
between the alveoli and the red blood
O. %QPVCKPU 1Z[IGP
cells in the pulmonary capillaries QHKPURKTGFCKT 0KVTQIGP
through the capillary membranes (Fig- %CTDQPFKQZKFG
ure 15-6). Cellular, or internal, respira-
tion, however, occurs in the peripheral %QPVCKPU 1Z[IGP
0KVTQIGP
capillaries. It is the exchange of the %CTDQPFKQZKFG
respiratory gases between the red
blood cells and the various body tis- O.
sues. Cellular respiration in the periph- QEEWRKGUVJG
eral tissue produces carbon dioxide EQPFWEVKPIRCVJYC[U
pFGCFURCEGq
(CO2). The blood picks up this waste
product in the capillaries and trans-
O.
VQIGVJGT
ports it as bicarbonate ions through the YKVJO.QHCKT
venous system to the lungs. Whereas RTGXKQWUN[EQPVCKPGF
respiration describes the process of gas KPEQPFWEVKPIRCVJYC[U
TGCEJVJGCNXGQNK
exchange in the lungs and peripheral
tissues, ventilation is the mechanical
process that moves air into and out of
the lungs. Ventilation is necessary for
respiration to occur.
contact with each other under normal circumstances, the exchange carbon dioxide for oxygen. The pulmonary capil-
highly elastic lungs immediately assume the thoracic cavi- laries recombine into larger veins, eventually terminating
ty’s internal contour. These combined factors move air into in the pulmonary vein. The pulmonary vein empties the
the lungs (inspiration). At the same time, the alveoli inflate oxygenated blood into the left atrium of the heart. Finally,
with the lungs. They become thinner as they expand, the heart transports the oxygenated blood through the left
allowing oxygen and carbon dioxide to diffuse across their ventricle and into the systemic arterial system via the aorta
membranes. and its tributaries.
When the pressure in the thoracic cavity again The lungs themselves receive little of their blood sup-
reaches that of the atmosphere, the alveoli are maximally ply from the pulmonary arteries or veins. Instead, bron-
inflated. Pulmonary expansion stimulates microscopic chial arteries that branch from the aorta supply most of
stretch receptors in the bronchi and bronchioles. These their blood. Bronchial veins return this blood from the
receptors signal the respiratory center by way of the lungs to the superior vena cava.
vagus nerve to inhibit inspiration, and the air influx stops.
This process is primarily protective, as it prevents overin-
flation of the lungs. Measuring Oxygen and Carbon
At the end of inspiration, the respiratory muscles now Dioxide Levels
relax, thus decreasing the size of the chest cavity, and in You can determine the amount of oxygen and carbon diox-
turn increasing the intrathoracic pressure. The naturally ide in the blood by measuring their partial pressures. Par-
elastic lungs recoil, forcing air out through the airway tial pressure is the pressure exerted by each component of
(expiration) until intrathoracic and atmospheric pressure a gas mixture. In other words, the partial pressure of a gas
are equal once again. Normal expiration is a passive pro- is its percentage of the mixture’s total pressure. The partial
cess, whereas inspiration is an active process, using energy. pressure of oxygen at normal atmospheric pressure, for
In respiratory inadequacy, when this process fails to pro- example, is the percentage of oxygen in atmospheric air (21
vide satisfactory gas exchange, the patient may use acces- percent) multiplied by the atmospheric pressure at sea
sory respiratory muscles, such as the strap muscles of his level (760 torr, or 14.7 pounds per square inch):
neck and his abdominal muscles, to augment his efforts to
expand the thoracic cavity. 0.21 * 760 torr = 159.6 torr
Pulmonary Circulation
Respiration also requires an intact
circulatory system. In fact, during
each cardiac cycle, the heart
pumps as much blood to the
lungs as it pumps to the periph- Superior
vena cava Pulmonary
eral tissues. In the capillaries, artery
these cells take oxygen from red
blood cells coming from the arte- Aorta
rial system and give up carbon
dioxide to blood returning to the
venous system. The venous sys-
tem carries this deoxygenated Pulmonary vein
blood to the right side of the
heart, and the right ventricle
pumps it into the pulmonary
artery (Figure 15-7). The pulmo-
nary artery immediately branches
into the right and the left pulmo-
nary arteries, each supplying its
respective lung. In turn, both
branches quickly fan into smaller Inferior vena cava
arteries that end in the pulmo-
nary capillaries. These capillaries
are spread over the surfaces of the
alveoli, where the red blood cells FIGURE 15-7 Pulmonary circulation.
Airway Management and Ventilation 523
the space between the alveolar membrane and the pul- • Causes of increased CO2 production include:
monary capillary membrane, as in pneumonia, chronic • Fever
obstructive pulmonary disease (COPD), or pulmonary
• Muscle exertion
edema (swelling)
• Shivering
• Ventilation/perfusion mismatch occurs when a por-
tion of the alveoli collapses, as in atelectasis. Blood • Metabolic processes resulting in the formation of
travels past these collapsed alveoli without oxygen- metabolic acids
ation (shunting), without carbon dioxide transfer, and • Decreased CO2 elimination (increased CO2 levels in
without oxygen uptake. This can result from hypoven- the blood) results from decreased alveolar ventilation.
tilation, which can occur secondary to pain or inability Common causes include hypoventilation due to:
to inspire (traumatic asphyxia). When the lung col- • Respiratory depression by drugs
lapses, as in pneumothorax, hemothorax, or a combi-
• Airway obstruction
nation of the two, less surface area is available for gas
• Impairment of the respiratory muscles
exchange. Alternately, a ventilation/perfusion mis-
match can occur when blood is prevented from reach- • Obstructive diseases such as asthma and emphysema
ing the alveolar capillary membranes but alveolar Increased CO2 levels (hypercarbia) are usually treated by
ventilation remains adequate. This occurs when a increasing the rate and/or volume of ventilation and by
blood clot travels to or is formed in the pulmonary correcting the underlying cause.
arterial system, a condition known as pulmonary throm-
boembolism.
Regulation of Respiration
You can correct oxygen derangements by increasing
Voluntary and Involuntary
ventilation, administering supplemental oxygen, using
intermittent positive-pressure ventilation (IPPV), or
Respiratory Controls
The number of times a person breathes in 1 minute, the
administering medications to correct underlying prob-
respiratory rate, is unique in that both voluntary and
lems such as pulmonary edema, asthma, or pulmonary
involuntary nervous system mechanisms control it. We do
embolism. The emergency being treated determines the
not ordinarily need to make a conscious effort to breathe;
desired fractional concentration of oxygen (FiO2) to be
our brains automatically regulate this function. However,
delivered. It is crucial to remember not to withhold oxy-
we can voluntarily override our involuntary respirations
gen from any patient whose clinical condition indicates
until physical and chemical mechanisms signal the ner-
its need.
vous system’s respiratory centers to provide involuntary
impulses and correct any breathing irregularities.
Carbon Dioxide Concentrations
in the Blood
Alveolar Respiratory
The blood transports carbon dioxide mainly air membrane Capillary blood
in the form of bicarbonate ion (HCO3–). It
carries approximately 70 percent as bicar- 7%
CO Dissolved CO gas
bonate and approximately 23 percent com-
bined with hemoglobin. Less than 7 percent
is dissolved in the plasma. Unlike oxygen, CO + plasma protein Carbamino compounds
23%
when carbon dioxide binds with hemoglo- CO CO + Hb HbCO
bin, it binds to an amino acid and not to the
iron-containing heme binding site where Reverse chloride shift Cl
oxygen binds (Figure 15-8). Several factors 70%
CO CO + H O HC HCO + H
influence carbon dioxide’s concentration in
the blood, including increased CO2 produc-
tion and/or decreased CO2 elimination: 98.5%
O O + HHb HbCO + H
• Hyperventilation lowers CO2 levels
and can be the result of an increased
respiratory rate or deeper respiration, 1.5%
Dissolved O gas
O
both of which increase the minute vol-
ume. (We discuss minute volume more
completely later in this chapter.) FIGURE 15-8 Respiratory gas exchange and transport at the alveolar/capillary membrane.
Airway Management and Ventilation 525
NERVOUS IMPULSES FROM THE RESPIRATORY Conversely, low PaCO2 levels will raise CSF pH, in turn
CENTER The main respiratory center lies in the medulla, decreasing chemoreceptor stimulation and slowing respi-
located in the brainstem. Various neurons within the ratory activity. Because PaCO2 is inversely related to CSF
medulla initiate impulses that result in respiration. A rise pH, PaCO2 is seen as the normal neuroregulatory control
in the frequency of these impulses increases the respiratory of respirations. Additionally, any increase in the arterial
rate. Conversely, a decrease in their frequency decreases PCO2 stimulates the peripheral chemoreceptors to signal
the respiratory rate. The medulla is connected to the respi- the brainstem to increase respiration, thus speeding CO2
ratory muscles primarily via the vagus nerve. This is an elimination from the body.
involuntary pathway. If the medulla fails to initiate respi-
ration, an additional control center in the pons, called the HYPOXIC DRIVE The body also constantly monitors the
apneustic center, assumes respiratory control to ensure the PaO2 and the pH. In fact, hypoxemia (decreased partial
continuation of respirations. A third center, the pneumotaxic pressure of oxygen in the blood) is a profound stimulus
center, also in the pons, controls expiration (Figure 15-9). of respiration in a normal individual. People with chronic
respiratory disease such as emphysema and chronic bron-
STRETCH RECEPTORS During inspiration, the lungs chitis tend to retain CO2 and, therefore, have a chroni-
become distended, activating stretch receptors. As the cally elevated PaCO2. Chemoreceptors in the periphery
degree of stretch increases, these receptors fire more fre- eventually become accustomed to this chronic condition,
quently. The impulses they send to the brainstem inhibit and the central nervous system stops using PaCO2 to
the medullary cells, decreas-
ing the inspiratory stimulus. Nervous Control & Respiration
Thus, the respiratory muscles
relax, allowing the elastic lungs Stimulation
regulate respiration. This activates a default mechanism includes the trachea and bronchi. Obstructions or dis-
called hypoxic drive, which increases respiratory stimula- eases such as chronic obstructive pulmonary disease or
tion when PaO2 falls and inhibits respiratory stimulation atelectasis can cause physiologic dead space.
when PaO2 climbs. High-volume oxygen administration • Alveolar volume (VA). The alveolar volume is the
to people with this condition can cause respiratory arrest. amount of gas in the tidal volume that reaches the
Because high-concentration oxygen can quickly double or alveoli for gas exchange. It is the difference between
even triple the PaO2, peripheral chemoreceptors stop stim- tidal volume and dead-space volume (approximately
ulating the respiratory centers, causing apnea (cessation of 350 mL in the adult male):
breathing). Although this is a potential threat, it is never
appropriate to withhold oxygen from a patient for whom VA = VT - VD
oxygen therapy is indicated. However, you must be pre- • Minute volume (Vmin). The minute volume is the
pared to assist with ventilations if the patient’s respiratory amount of gas moved in and out of the respiratory
effort becomes inadequate. tract in 1 minute:
CONTENT REVIEW Airway may block the airway at the larynx. This at least diminishes
airflow into the respiratory system, and the patient’s breath-
➤➤ Causes of Airway Obstruction ing efforts may inadvertently suck the base of his tongue
Obstruction
Blockage of the airway is into an obstructing position. The patient’s tongue can block
• Tongue
an immediate threat to the his airway whether he is lateral, supine, or prone; however,
• Foreign bodies
patient’s life and a true the blockage depends on the position of the patient’s head
• Trauma
• Laryngeal spasm and emergency. Upper airway and jaw, so simple airway maneuvers such as the jaw-thrust
edema obstruction may be defined can usually open his airway.
• Aspiration as an interference with air
➤➤ Blockage of the airway is movement through the FOREIGN BODIES Large, poorly chewed pieces of food
an immediate threat to the upper airway. can obstruct the upper airway by becoming lodged in the
patient’s life and a true Airway obstruction hypopharynx. These cases often involve alcohol consump-
emergency. may be either partial or tion and denture dislodgement. Because they frequently
complete. Partial obstruc- occur in restaurants and are mistaken for heart attacks, they
tion allows either adequate or poor air exchange. Patients are commonly called “café coronaries.” The patient may
with adequate air exchange can cough effectively; those clutch his neck between the thumb and fingers, a universal
with poor air exchange cannot. They often emit a high- distress signal. Children, especially toddlers, often aspirate
pitched noise while inhaling (stridor), and their skin may foreign objects, as they have the tendency to put objects into
have a bluish appearance (cyanosis). They also may have their mouths.
increased breathing difficulty, which can manifest as chok-
TRAUMA In trauma, particularly when the patient
ing, gagging, dyspnea, or dysphonia (difficulty speaking).
is unresponsive, loose teeth, facial bone fractures, and
When you cannot feel or hear airflow from the nose and
avulsed or swollen tissue may obstruct the airway. Secre-
mouth, or when the patient cannot speak (aphonia),
tions such as blood, saliva, and vomitus may compromise
breathe, or cough, his airway is completely obstructed. He
the airway and risk aspiration. Additionally, penetrating
will quickly become unconscious and die if you do not
or blunt trauma may obstruct the airway by fracturing or
relieve the obstruction. In the absence of breathing, diffi-
displacing the larynx, allowing the vocal cords to collapse
culty ventilating the patient will indicate complete airway
into the tracheal lumen (channel).
obstruction.
LARYNGEAL SPASM AND EDEMA Because the glottis
Causes of Airway Obstruction is the narrowest part of an adult’s airway, edema (swelling)
The tongue, foreign bodies, teeth, spasm or edema, vomi- or spasm (spasmotic closure) of the vocal cords is poten-
tus, and blood can all obstruct the upper airway. tially lethal. Even moderate edema can severely obstruct
airflow and cause asphyxia (the inability to move air into
THE TONGUE The tongue is the most common cause of
and out of the respiratory system). Just beneath the mucous
airway obstruction (Figure 15-10). Normally, the subman-
membrane that covers the vocal cords is a layer of loose tis-
dibular muscles directly support the tongue and indirectly
sue where blood or other fluids can accumulate. This tissue
support the epiglottis. However, without sufficient muscle
may swell following injury, and the swelling will be slow
tone, the relaxed tongue falls back against the posterior
to subside. Causes of laryngeal spasm and edema include
pharynx, thus occluding the airway. This may produce snor-
trauma, anaphylaxis, epiglottitis, and inhalation of super-
ing respiratory noises. At the same time, the epiglottis also
heated air, smoke, or toxic substances. The most common
cause of spasm is overly aggressive intubation. In addition,
it often occurs immediately on extubation, especially when
the patient is semiconscious. Some authors propose that
laryngeal spasm can sometimes be partially overcome by
strengthening ventilatory effort, forceful upward pull of
the jaw, or the use of muscle relaxants, although the success
of these maneuvers is quite variable.
also significantly increase patient mortality. Vomitus con- “Primary Assessment, “History Taking,” “Secondary
sists of food particles, protein-dissolving enzymes, hydro- Assessment,” “Patient Monitoring Technology,” and
chloric acid, and gastrointestinal bacteria that have been “Patient Assesssment in the Field” discuss in detail the
regurgitated from the stomach into the hypopharynx and steps of patient assessment that are summarized next.)
oropharynx. If this mixture enters the lungs, it can result
in increased interstitial fluid and pulmonary edema. The Primary Assessment
consequent marked increase in alveolar/capillary distance
The purpose of the primary assessment is to identify any
seriously impairs gas exchange, thus causing hypoxemia
immediate threats to the patient’s life, specifically airway,
and hypercarbia. Aspirated materials can also severely
breathing, and circulation problems (ABCs). For patients
damage the delicate bronchiolar tissue and alveoli. Gastro-
in cardiac arrest, compressions come before airway and
intestinal bacteria can produce overwhelming infections.
breathing (CAB). However, as discussed in the introduc-
These complications occur in 50 to 80 percent of patients
tion, airway assessment, management, and ventilation
who aspirate foreign matter.
should be considered and can occur together.
First, assess the airway to ensure that it is patent. Snor-
Inadequate Ventilation ing or gurgling may indicate potential airway problems.
Insufficient minute volume respirations can compromise Next, determine the adequacy of breathing. If the patient is
adequate oxygen intake and carbon dioxide removal. comfortable, with a normal respiratory rate, alert, and
Additionally, oxygenation may be insufficient when condi- speaking without difficulty, you may generally assume
tions increase metabolic oxygen demand or decrease avail- that his airway is patent and breathing is adequate.
able oxygen. A reduction of either the rate or the volume of Patients with altered mental status warrant further
inhalation leads to a reduction in minute volume. In some evaluation. Feel for air movement with your hand or
cases, the respiratory rate may be rapid but so shallow that cheek (Figure 15-11). Look for the chest to rise and fall
little air exchange takes place. Among the causes of such normally with each respiratory cycle (Figure 15-12). Lis-
decreased ventilation are depressed respiratory function as ten for air movement and equal bilateral breath sounds
from impairment of respiratory muscles or nervous sys- (Figure 15-13). The absence of breath sounds on one side
tem, bronchospasm from intrinsic disease, fractured ribs, may indicate a pneumothorax or hemothorax in the
pneumothorax, hemothorax, drug overdose, renal failure, trauma patient. In an adult patient, the respiratory rate
spinal or brainstem injury, or head injury. In some condi- generally ranges between 12 and 20 breaths per minute.
tions, such as sepsis, the body’s metabolic demand for oxy- Breathing should be spontaneous, effortless, and regular.
gen can exceed the patient’s ability to supply it. Irregular breathing suggests a significant problem and
Additionally, the environment may contain a decreased usually requires ventilatory support. Observe the chest
amount of oxygen, as in high-altitude conditions or a wall for any asymmetrical movement. This condition,
house fire, which also produces toxic gases such as cyanide known as paradoxical breathing, may suggest a flail
and carbon monoxide. These situations of inadequate ven- chest. Patients showing increased respiratory effort;
tilation can lead to hypercarbia and hypoxia. insisting on upright, sniffing, or semi-Fowler’s position-
ing; or refusing to lie supine should be considered to be in
significant respiratory distress.
Respiratory System
Assessment
Vigilance is the key to airway management in every
patient. The trauma patient whose airway and breathing
initially looked fine on exam may become symptomatic
with the pneumothorax that was not initially evident. The
asthma patient who initially responded to nebulizer treat-
ment may have a sudden bronchospasm and worsen
acutely. Minute-by-minute reassessment of the adequacy
of every patient’s airway and breathing is essential. The
changes may be subtle increases in rate, worsening or onset
of irregularity, or increased difficulty speaking. Assess-
ment of the respiratory system begins with the primary
assessment and should continue through the secondary
assessment and the reassessment. (The chapters titled FIGURE 15-11 Feel.
Airway Management and Ventilation 529
History
The time when the patient and his family noted the onset
of symptoms is important information, as is whether the
acute event occurred suddenly or gradually. Identifying
possible triggers such as allergens or heat also can help the
patient avoid them in the future. Additionally, the symp-
toms’ course of development since onset will help direct
diagnosis and treatment. Have they been progressively
worsening, recurrent, or continuous? Associated symp-
toms will further help to assess the cause of the patient’s
problem. Has he had fever or chills, productive cough,
chest pain, nausea or vomiting, or diaphoresis? Does he
FIGURE 15-13 Listen. think his voice sounds normal?
The patient’s past medical history will put his present
complaints into perspective and help to identify the risk
If the patient is not breathing, or if you suspect airway
factors for a variety of likely diagnoses. Determine whether
problems, open the airway using the head-tilt/chin-lift or
the present episode is similar to any past episodes of short-
jaw-thrust maneuver, as described later in this chapter. If
ness of breath, what medical evaluations have been done,
trauma is possible, use the jaw-thrust maneuver while stabi-
and what they have found. Has the patient ever been
lizing the cervical spine in the n
eutral position. Once the air-
admitted to the hospital for his complaints? Has he ever
way is open, reevaluate the breathing status. If breathing is
been intubated?
adequate, provide supplemental oxygen and assess circula-
The recent history leading to the onset of symptoms is
tion. Consider the use of airway adjuncts, as discussed later. If
also important. Did the patient run out of medication?
breathing is inadequate or absent, begin artificial ventilation
Has he been noncompliant with (not taken) his medica-
(Figure 15-14). When assisting a patient’s breathing with a
tions? Did he drink too much fluid or alcohol? Did he have
ventilatory device (bag-valve mask or other positive-pressure
a seizure or vomit? Did he eat something that might
device), or after placing an airway adjunct (nasopharyngeal
induce an allergic reaction? Did he receive any trauma? If
airway or oropharyngeal airway), or endotracheally intubat-
an injury is involved, evaluate the mechanism of injury.
ing, monitor the chest’s rise and fall to determine correct
Keep in mind that blunt trauma to the neck may have
usage and placement. (We discuss these ventilatory devices
injured the larynx. Anything that makes the patient’s con-
and mechanical airways in detail later in this chapter.)
dition better (ameliorates) or worse (exacerbates, aggra-
vates) is also significant.
Secondary Assessment
After you complete the primary assessment and correct any Physical Examination
immediate life threats, conduct the secondary assessment Your physical examination of a patient with respiratory
while continuously monitoring the patient’s airway, breath- problems should continue the evaluation of his airway,
ing, and circulation. breathing, and circulation begun during your primary
530 Chapter 15
assessment. Now you will use the physical examination • Sighing—slow, deep, involuntary inspiration followed
techniques of inspection, auscultation, and palpation to by a prolonged expiration. It hyperinflates the lungs
evaluate his injury or illness in more detail and determine and reexpands atelectatic alveoli. This normally occurs
your plan of action. (The chapter “Primary Assessment” about once a minute.
explains these techniques in detail.) • Grunting—a forceful expiration that occurs against a
partially closed epiglottis. It is usually an indication of
INSPECTION Begin the physical assessment by inspect- respiratory distress.
ing the patient. Evaluate the adequacy of his breathing.
Note any obvious signs of trauma. Always remember to Note any decrease or increase in the respiratory rate,
assess skin color as an indicator of oxygenation status. one of the earliest indicators of respiratory distress.
Early in respiratory compromise, the sympathetic ner- Also, look for use of the accessory respiratory muscles—
vous system will be stimulated to help offset the lack of intercostal, suprasternal, supraclavicular, and subcostal
oxygen. When this happens, the skin will often appear retractions—and the abdominal muscles to assist breath-
pale and diaphoretic. Cyanosis (bluish discoloration) is ing. This indicates increased respiratory effort second-
another sign of respiratory distress. When oxygen binds ary to respiratory distress. In infants and children, nasal
with the hemoglobin, the blood appears bright red. Deox- flaring and grunting indicate respiratory distress. COPD
ygenated hemoglobin, however, is blue and gives the patients having difficulty breathing will purse their lips
skin a bluish tint. This is not a reliable indicator, however, during exhalation. Monitor the patient’s blood pressure,
as severe tissue hypoxia is possible without cyanosis. including any differences noted during expiration
In fact, cyanosis is considered a late sign of respiratory versus inspiration. Patients with severe chronic obstruc-
compromise. When it does appear, it usually affects the tive pulmonary disease may sustain a drop in blood
lips, fingernails, and skin. A red skin rash, especially if pressure during inspiration. This drop is due to increased
accompanied by hives, may indicate an allergic reaction. pressure within the thoracic cavity that impairs the abil-
A cherry-red skin discoloration may, on rare occasions, ity of the ventricles to fill. Thus, decreased ventricular
be associated with carbon monoxide poisoning, as can filling leads to decreased blood pressure. A drop in
bullae (large blisters). blood pressure of greater than 10 torr is termed pulsus
Observe the patient’s position. Tripod positioning paradoxus and may be indicative of severe obstructive
(seated, leaning forward, with one arm forward to stabilize lung disease.
the body) may indicate COPD or asthma exacerbation; Determine whether the pattern of respirations is
orthopnea (increased difficulty breathing while lying abnormal—deep or shallow in combination with a fast or
down) may indicate congestive heart failure, or asthma. slow rate. Some common abnormal respiratory patterns
Next, inspecting for dyspnea—an abnormality of include:
breathing rate, pattern, or effort—is essential. Dyspnea
• Kussmaul’s respirations—deep, slow or rapid, gasping
may cause or be caused by hypoxia. Prolonged dyspnea
breathing, commonly found in diabetic ketoacidosis
without successful intervention can lead to anoxia (the
absence or near-absence of oxygen), which without inter- • Cheyne–Stokes respirations—progressively deeper,
vention is a premorbid (occurring just before death) event, faster breathing alternating gradually with shallow,
as the brain can survive only 4 to 6 minutes in this state. slower breathing, indicating brainstem injury
Remember that all interventions are useless if you do not • Biot’s respirations—irregular pattern of rate and depth
establish a patent airway. with sudden, periodic episodes of apnea, indicating
Also observe for the following modified forms of increased intracranial pressure
respiration: • Central neurogenic hyperventilation—deep, rapid respi-
rations, indicating increased intracranial pressure
• Coughing—forceful exhalation of a large volume of air
from the lungs. This performs a protective function in • Agonal respirations—shallow, slow, or infrequent
expelling foreign material from the lungs. breathing, indicating brain anoxia
• Sneezing—sudden, forceful exhalation from the nose. It Finally, observing altered mentation may be key in
is usually caused by nasal irritation. determining whether breathing is adequate or if significant
• Hiccoughing (hiccups)—sudden inspiration caused by hypoxia may be present. If the patient’s mental status is
spasmodic contraction of the diaphragm with spastic not normal, you must determine his usual baseline mental
closure of the glottis. It serves no known physiologic status before you can make this assessment.
purpose. It has, occasionally, been associated with
acute myocardial infarctions on the inferior (diaphrag- AUSCULTATION Following inspection, listen at the
matic) surface of the heart. mouth and nose for adequate air movement. Then listen
Airway Management and Ventilation 531
to the chest with a stethoscope (auscultate) (Figure 15-15). Sounds that may indicate compromise of gas exchange
In a prehospital setting, you should auscultate the right include:
and left apex (just beneath the clavicle), the right and left
• Crackles (rales)—a fine, bubbling sound heard on inspi-
base (eighth or ninth intercostal space, midclavicular line),
ration, associated with fluid in the smaller bronchioles
and the right and left lower thoracic back or right and left
midaxillary line (fourth or fifth intercostal space, on the lat- • Rhonchi—a coarse, rattling noise heard on inspiration,
eral aspect of the chest). When the patient’s condition per- associated with inflammation, mucus, or fluid in the
mits, you can monitor six locations on the posterior chest, bronchioles
three right and three left. The posterior surface is preferable
When you assess the effectiveness of ventilatory sup-
because heart sounds do not interfere with auscultation at
port or the correct placement of an airway adjunct, remem-
this location. However, because patients are usually supine
ber that air movement into the epigastrium may sometimes
during airway management, the anterior and lateral posi-
mimic breath sounds. Thus, listening to the chest should
tions usually prove more accessible. Breath sounds should
be only one of several means that you use to assess air
be equal bilaterally. Sounds that point to airflow compro-
movement. Another method of checking correct place-
mise include:
ment of an airway adjunct is to auscultate over the epigas-
• Snoring—results from partial obstruction of the upper trium; it should be silent during ventilation. When you
airway by the tongue provide ventilatory support, watch for signs of gastric dis-
• Gurgling—results from the accumulation of blood, tention. They suggest inadequate hyperextension of the
vomitus, or other secretions in the upper airway neck, undue pressure generated by the ventilatory device,
or improper placement of airway adjuncts.
• Stridor—a harsh, high-pitched sound heard on inhala-
tion, associated with laryngeal edema or constriction
Palpation Finally, palpate. First, using the back of
• Wheezing—a musical, squeaking, or whistling sound your hand or your cheek, feel for air movement at the
heard in inspiration and/or expiration, associated mouth and nose. (If an endotracheal tube is in place, you
with bronchiolar constriction can check for air movement at the tube’s adapter.) Next,
• Quiet—diminished or absent breath sounds are an palpate the chest for rise and fall. In addition, palpate the
ominous finding and indi- chest wall for tenderness, symmetry, abnormal motion,
cate a serious problem crepitus, and subcutaneous emphysema.
Content Review
with the airway, breathing, When ventilating with a bag-valve device, gauge air-
➤➤ Beware of the quiet chest.
or both flow into the lungs by noting compliance. Compliance
532 Chapter 15
Speed of information provided • Reflects changes in oxygenation <5 minutes • Reflects changes in ventilation <10 seconds
• Delayed detection of hypoventilation or apnea • Immediate detection of hypoventilation and apnea
Compatibility Should be used with capnography Should be used with pulse oximetry
refers to the stiffness or flexibility of the lung tissue, and it measurements used most commonly in prehospital care are
is indicated by how easily air flows into the lungs. When pulse oximetry, CO oximetry, and capnography. Peak expi-
compliance is good, airflow meets minimal resistance. ratory flow testing can also be useful in the prehospital set-
When compliance is poor, ventilation is harder to achieve. ting for some respiratory diseases, although it is not widely
Compliance is often poor in diseased lungs and in patients employed. These measurements use various devices and
suffering from chest wall injuries or tension pneumotho- methodologies that, when used alone, have their limita-
rax. If a patient shows poor compliance during ventilatory tions. However, when used together, they can provide a
support, look for potential causes. Upper airway obstruc- fairly comprehensive and reliable picture of the patient’s
tions, which cause difficulty with mechanical ventilation, respiratory status. Table 15-2 details some of the advantages
can mimic poor compliance. If ventilating the patient is ini- and limitations of pulse oximetry and capnography.
tially easy but then becomes progressively more difficult,
repeat the primary assessment and look for the develop- Pulse Oximetry
ment of a new problem, possibly related to the mechanical Pulse oximetry is widely used in prehospital emergency
airway maneuvers. The following questions will aid this care and often referred to as the “fifth vital sign.” A pulse
assessment: oximeter measures hemoglobin oxygen saturation in
peripheral tissues (Figure 15-16). It is noninvasive (does
• Is the airway open?
not require entering the body), rapidly applied, and easy to
• Is the head properly positioned in extension (non-
operate. Pulse oximetry readings are generally accurate
trauma patients)?
measures of arterial oxygen saturation and continually
• Is the patient developing tension pneumothorax? reflect any changes in peripheral oxygen delivery. In fact,
• Is the endotracheal tube occluded (a mucus plug or pulse oximetry often detects problems with oxygenation
aspirated material)?
• Has the endotracheal tube been inadvertently pushed
into the right or left mainstem bronchus?
• Has the endotracheal tube been displaced into the
esophagus?
• Is the mechanical ventilatory equipment functioning
properly?
hemoglobin; the other emits infrared light, a wavelength <85 Severe Increase FiO2 to increase
specific for deoxygenated hemoglobin. Each hemoglobin hypoxemia saturation. Increase ventilation.
Capnography
Exhaled carbon dioxide (CO2) monitoring, also called
end-tidal carbon dioxide (ETCO2) monitoring, or capnom-
etry, is a noninvasive method of measuring the levels of
carbon dioxide (CO2) in the exhaled breath. Capnography
FIGURE 15-17 Pulse CO oximetry. is a recording or display of the exhaled carbon dioxide
(© Dr. Bryan E. Bledsoe) levels measured by capnometry. When first introduced
Airway Management and Ventilation 535
Advantages
Disadvantages
FIGURE 15-24 Some CO2 detectors can display both a waveform +++
&
%CTDQPFKQZKFG
OO*I
and a number. %
sponds to the late phase of inspiration and the early +PURKTCVKQP 'ZRKTCVKQP
6KOG
part of expiration (in which dead-space gases without
CO2 are released). FIGURE 15-25 Normal capnogram. AB = Phase I: late inspiration,
early expiration (no CO2). BC = Phase II: appearance of CO2 in
• Phase II. Phase II (BC in Figure 15-25) is the respira- exhaled gas. CD = Phase III: plateau (constant CO2). D = highest
tory upstroke. This reflects the appearance of CO2 in point (ETCO2). DE = Phase IV: rapid descent during inspiration.
the alveoli. EA = respiratory pause.
538 Chapter 15
%CTDQPFKQZKFG
OO*I
for tube misplacement. Continuous waveform capnogra-
phy may also be used to ensure proper exhaled CO2 levels
for head trauma and stroke patients. Continuous waveform
capnography adds the ability to help troubleshoot hypox-
emia and difficult ventilation and assess for bronchospasm,
pulmonary embolus, and so on. Continuous waveform
capnography also has utility in monitoring nonintubated
patients. By following trends in the capnogram, prehospital
personnel can continuously monitor the patient’s condition,
detect trends, and document the response to medications.
Several medical conditions and mechanical ventilation +PURKTCVKQP 'ZRKTCVKQP
problems can be readily detected by capnography when 6KOG
compared to the normal capnogram (Figure 15-26). These FIGURE 15-27 Capnogram pattern showing classic “shark fin”
include: waveform consistent with obstructive pulmonary disease (asthma
and COPD).
• Obstructive disease. Obstructive pulmonary diseases,
such as asthma and chronic obstructive pulmonary
disease (COPD), obstruct air entry and alter the shape
of the capnogram. These diseases give the typical
“shark fin” shape to the capnogram (Figure 15-27).
to hyperventilation or to problems in the breathing cir-
cuit (Figure 15-28).
+PURKTCVKQP 'ZRKTCVKQP
6KOG
FIGURE 15-28 An elevation in the baseline indicates rebreathing of
%CTDQPFKQZKFG
OO*I
%CTDQPFKQZKFG
OO*I
%CTDQPFKQZKFG
OO*I
+PURKTCVKQP 'ZRKTCVKQP
6KOG
+PURKTCVKQP 'ZRKTCVKQP FIGURE 15-31 Waveform variations seen with leakage in the
6KOG
endotracheal tube cuff or in the breathing circuit.
FIGURE 15-29 So-called curare notch or curare cleft seen in mechan-
ically ventilated patients as neuromuscular blocker levels fall.
%CTDQPFKQZKFG
OO*I
%CTDQPFKQZKFG
OO*I
+PURKTCVKQP 'ZRKTCVKQP
6KOG
FIGURE 15-32 Persistently low ETCO2 levels consistent with significant
dead space ventilation (V/Q mismatch) as seen in pulmonary embolism.
+PURKTCVKQP 'ZRKTCVKQP
6KOG
• Hyperventilation. Hyperventilation leads to elimina-
tion of CO2 and a progressively lower exhaled CO2 level
(Figure 15-34).
• Hypoventilation. Hypoventilation results in CO2 reten-
tion and a progressive elevation in exhaled CO2 levels
(Figure 15-35).
cheal tube placement.
Airway Management
and Ventilation
Basic airway management and ventilation includes most
%CTDQPFKQZKFG
OO*I
airway maneuvers that have been shown to be lifesaving,
including proper positioning, suctioning, oxygen adminis-
tration, and bag-valve-mask (BVM) ventilation. Paramedics
must continue to focus on these basic skills, despite their
advanced training and techniques. It is easy to get tunnel
vision when considering endotracheal intubation and other
advanced procedures, yet these techniques are rarely life-
saving and are often worthless if not preceded by good
basic management. As the senior member of most EMS
teams, it is the responsibility of the paramedic to ensure
6KOG that other providers on scene are performing optimal basic
airway management. Lead by example whenever possible!
FIGURE 15-35 Progressive increase in ETCO2 levels consistent with
hypoventilation.
output, coronary perfusion pressure, and even with the Proper Positioning
effectiveness of CPR compressions. Trauma patients are often confined to the supine position
Continuous waveform capnography is rapidly becom- as a result of spinal immobilization. However, some cir-
ing a standard of care in EMS (Figure 15-36). Misplaced cumstances may warrant flexibility, if permitted by local
endotracheal tubes represent a significant area of liability protocols. For example, the patient with facial and airway
trauma who is able to maintain his airway as long as he is
sitting up may be placed in a cervical collar in a seated
position rather than restricted to a supine position.
Conscious medical patients should be maintained in
their position of comfort if they are not placed in cervical
immobilization. Unconscious medical patients who do not
require other interventions, such as BVM ventilation,
should be placed on their side with the head elevated (if
not contraindicated) to minimize the risk of aspiration.
Unconscious patients who do require airway and ven-
tilation interventions, such as BVM ventilation or intuba-
tion, are usually best maintained in an ear-to-sternal-notch
position, in which the supine patient’s head is elevated to
the point where the ear and the sternal notch are horizon-
FIGURE 15-36 Most modern patient monitors allow the constant tally aligned (Figure 15-37). This position is often referred
monitoring of numerous physiologic parameters. to as the sniffing position in non-obese patients and the
Airway Management and Ventilation 541
(a)
D
FIGURE 15-37 Airway management and ventilation is improved when the ear-to-sternal notch axis is aligned: (a) child, (b) adult.
CONTENT REVIEW
ramped position in obese Sniffing Position
patients. With both the
➤➤ Unconscious patients To place non-obese patients in the sniffing position, first
sniffing and ramped posi-
who require airway and achieve an ear-to-sternal notch horizontal alignment by
tions, the ear-to-sternal
ventilation interventions slightly flexing the patient’s neck and extending the head
notch alignment is main-
are usually best (assuming no cervical spine injury is suspected). This can
maintained in an ear-to- tained. This positioning
be maintained by placing a towel or small pillow under the
sternal-notch position maximizes upper airway
head (Figure 15-38).
(ear and sternal notch patency allowing for effec-
horizontally aligned). tive ventilation and, if
➤➤ Ear-to-Sternal-Notch required, endotracheal Ramped Position
Positions intubation. It also improves The strategy for positioning obese patients is different. It is
• Sniffing position (if the mechanics of ventila- often difficult or impossible to place them into the sniffing
patient is not obese) tion, both with spontane- position by elevating just the head. Instead, you must ele-
• Ramped position (if ous breathing and with vate the entire upper portion of the body. This can be
patient is obese)
BVM ventilation. achieved with blankets, towels, and pillows or with a
FIGURE 15-38 The “sniffing position” provides adequate ear-to-sternal notch alignment in non-obese adults.
(© Edward T. Dickinson, MD)
542 Chapter 15
FIGURE 15-39 (a) In the supine obese patient, the line from ear to sternal notch is not horizontal. (b) The “ramped position” with the upper
body raised achieves horizontal ear-to-sternal notch alignment in obese patients.
commercial wedge pillow (Figure 15-39). When considering levels of carbon dioxide). In these patients there is a theo-
airway management in an obese patient, prepare a proper retical risk of depressing respirations as the body senses
ramp (head and shoulder support) before transferring the plentiful oxygen. This is rarely a clinical issue during all
patient. Lifting obese patients during airway management but the longest EMS transports. Thus, you should feel com-
is often difficult.11 fortable giving as much oxygen as necessary to maintain
adequate oxygen saturations. Remember, however, that
you do not necessarily need to return these patients to nor-
mal oxygen saturations, as their bodies are generally used
Oxygenation to lower oxygen levels. Of course, you should monitor
Oxygen is an important drug, and you must thoroughly your patient closely for evidence of respiratory depression.
understand its indications and precautions. Providing sup- You may also use capnography to assess for early signs of
plemental oxygen to patients who are frankly hypoxemic worsening hypercarbia.
will diminish the hypoxia’s secondary effects on organs As discussed earlier in this chapter, there is now evi-
such as the brain and the heart and lessen subjective respi- dence that high oxygen levels (hyperoxia) may be as dan-
ratory distress. gerous as low levels (hypoxia) because of the possible
In some circumstances, oxygen administration is also formation of oxygen free radicals. This has been demon-
indicated even though the patient’s oxygen saturation may strated in post-cardiac arrest patients, stroke patients, neo-
be normal. Keep in mind that oxygen may be carried both nates, and head trauma patients. Therefore, oxygen
on hemoglobin and dissolved in the blood. Under normal saturation should always be maintained in the normal
circumstances, the dissolved portion of oxygen is relatively range, using the lowest necessary oxygen flow.
insignificant. When supplemental oxygen is administered,
the dissolved portion of oxygen may increase many-fold. Oxygen Supply and Regulation
This relatively small amount of extra oxygen may be
Oxygen is supplied either as a compressed gas or a liquid.
important to patients with tissue hypoxemia from any
Compressed gaseous oxygen is stored in an aluminum or
cause such as septic shock, myocardial infarction, cardio-
steel tank in 400-liter (D), 660-liter (E), or 3,450-liter (M)
genic shock, or severe trauma. Oxygen administration is
volumes. To calculate how long the oxygen will last, use
also very important prior to intubation, regardless of the
the appropriate formula below—the same formula but
oxygen saturation. Finally, ill or injured pregnant patients
with a different constant for each type of cylinder: 0.16 for a
may benefit from supplemental oxygen administration,
D cylinder, 0.28 for an E cylinder, and 1.56 for an M cylinder:
regardless of their oxygen saturation, to enhance oxygen
delivery to the fetus. D cylinder tank life in minutes = (tank pressure in psi * 0.16)
Never withhold oxygen from any patient for whom it , liters per minute
is indicated. Caution is advised in patients with COPD,
E cylinder tank life in minutes = (tank pressure in psi * 0.28)
who may have developed a hypoxic drive to breathe (in
, liters per minute
which reduced oxygen levels trigger breathing), as
opposed to a normal hypercarbic drive to breathe (in which M cylinder tank life in minutes = (tank pressure in psi * 1.56)
breathing is triggered by chronic hypercarbia, or elevated , liters per minute
Airway Management and Ventilation 543
Liquid oxygen is cooled to aqueous form and warmed Simple Face Mask
back to its gaseous state for delivery. Although liquid oxy- The simple face mask is indicated for patients requiring
gen requires less storage space than an equal amount of moderate oxygen concentrations. Side ports allow room air
compressed oxygen, you must keep it upright and accom- to enter the mask and dilute the oxygen concentration dur-
modate other special requirements for its storage and ing inspiration. Flow rates generally range from about 6 to 10
transfer. L/min, providing 40 to 60 percent oxygen at the maximum
A regulator for an oxygen tank is either a high-pressure rate, depending on the patient’s respiratory rate and depth.
regulator, which is used to transfer oxygen at high pres- Delivery of volumes beyond 10 L/min does not enhance
sures from tank to tank, or a therapy regulator, which is oxygen concentration. These devices are rarely carried by
used for delivering oxygen to patients. The default pres- EMS providers but will be encountered during transfers.
sure for therapy regulators is 50 psi, which is controlled
within the regulator to allow for adjustable low-flow oxy-
Partial Rebreather Mask
gen delivery.
The partial rebreather mask is indicated for patients requir-
ing moderate-to-high oxygen concentrations when satis-
Oxygen Delivery Devices factory clinical results are not obtained with the simple
face mask. One-way disks that cover the partial rebreather
Oxygen delivery to patients is measured in liters of flow
mask’s side ports prevent the inspiration of room air. Mini-
per minute (L/min). A number of delivery devices are
mal dilution occurs with inspiration of residual expired air
available; the patient’s condition will dictate which method
along with the supplemental oxygen. Maximal flow rate is
you use. You must continually reassess the patient who
10 L/min.
requires oxygen therapy to be certain that the method of
delivery and flow rate are adequate. Some patients may
require positive pressure ventilation rather than a passive Nonrebreather Mask
delivery device. The nonrebreather mask has one-way side ports as well,
but also has an attached reservoir bag to hold oxygen ready
Nasal Cannula to inhale. It provides the highest oxygen concentration of
The nasal cannula is a catheter placed at the nares. It pro- all oxygen delivery devices available, or about 80 percent
vides an optimal oxygen supplementation of up to 40 per- when set at 15 L/min of oxygen and the mask is fit tightly
cent when set at 6 L/min flow. At flow rates above 6 L/min, to the face. These masks are commonly used by EMS for
the nasal mucous membranes become very dry and easily initial management of patients with high oxygen require-
break down. Patients generally tolerate the nasal cannula ments. Any patient who requires a nonrebreather should
well. It is indicated for low-to-moderate oxygen require- be closely monitored for refractory hypoxemia that requires
ments and long-term oxygen therapy. invasive or noninvasive positive pressure ventilation.
Positive Airway Pressure patients with cervical spine injuries. To perform the head-
Positive airway pressure (PAP) is delivered via a face tilt/chin-lift:
mask to maintain a constant level of pressure within the 1. Place the patient supine and position yourself at the
airway, which assists a patient in breathing by preventing side of the patient’s head.
collapse of the airway during inhalation. Continuous pos-
2. Place one hand on the patient’s forehead and, using
itive airway pressure (CPAP) maintains a steady level of
firm downward pressure with your palm, tilt the head
pressure during both inhalation and exhalation. Bilevel
back.
positive airway pressure (BiPAP) maintains a higher level
of pressure during inhalation and a lower level of pressure 3. Put two fingers of the other hand under the bony
during exhalation. CPAP and BiPAP devices can be used part of the chin and lift the jaw anteriorly to open
to administer oxygen in conjunction with increased air- the airway.
way pressures. Caution: Avoid compressing the soft tissues of the neck
and chin, which could cause airway obstruction.
FIGURE 15-40 Head-tilt/chin-lift maneuver. FIGURE 15-41 Modified jaw-thrust without head extension in trauma.
Airway Management and Ventilation 545
Nasopharyngeal Airway
• It may kink and clog, obstructing the airway.
The nasopharyngeal airway (NPA), or “nasal trumpet,” is
an uncuffed tube made of soft rubber or plastic. The naso- • Inserting it is difficult if nasal damage (old or new) is
pharyngeal airway follows the natural curvature of the present.
nasopharynx, passing through the nose and extending • You may not use it if the patient has or is suspected to
from the nostril to the posterior pharynx just below the have a basilar skull fracture, as the tube could inadver-
base of the tongue. It varies from 17 to 20 cm in length, and tently pass into the cranium.
its diameter ranges from 20 to 36 Fr (French). A funnel-
The properly sized nasopharyngeal tube is slightly
shaped projection at its proximal end helps prevent the
smaller in diameter than the patient’s nostril, and in adults
tube from slipping inside a patient’s nose and becoming
it is equal to or slightly longer than the distance from the
lost or aspirated. The distal end is beveled to facilitate pas-
patient’s nose to his earlobe. Selecting the appropriate size
sage. Nasopharyngeal airways are generally underutilized.
is important. Too small a tube will not extend past the
They are well tolerated in most patients and are very effec-
tongue; too long a tube may pass into the esophagus and
tive at maintaining the airway. Specific indications for the
result in hypoventilation of the lungs and distention of the
use of the nasopharyngeal airway include obtunded
stomach when positive pressure is applied (Figures 15-42
patients (those with reduced mental acuity, with or with-
and 15-43).
out a suppressed gag reflex) and unconscious patients. If
the patient does not tolerate the nasopharyngeal airway, Inserting the Nasopharyngeal Airway
you should remove it.
To insert a nasopharyngeal airway:
Advantages of the Nasopharyngeal Airway
1. Ensure or maintain effective ventilation with supple-
• It can be rapidly inserted and safely placed blindly. mental oxygen.
• It bypasses the tongue, providing a patent airway.
• You may use it in the presence of a gag reflex.
• You may use it when the patient has suffered injury to
his oral cavity.
• You may suction through it.
• You may use it when the patient’s teeth are clenched.
2. Lubricate the exterior of the tube with a water-soluble airway, then his gag reflex is intact and an oral airway is
gel to decrease trauma during insertion. Lidocaine gel not indicated.
may be used to increase tolerance of the device after Oropharyngeal airways are available in sizes ranging
insertion. from #0 (for neonates) to #6 (for large adults). Selecting
3. Select the naris that appears largest. Push gently up on the proper size is important. If the airway is too long, it
the tip of the nose and pass the tube gently into the can press the epiglottis against the entrance of the larynx,
nostril with the bevel oriented toward the septum and resulting in airway obstruction. If it is too small, it will
the airway directed straight back along the nasal floor, not adequately hold the tongue forward. To measure for
parallel to the mouth. Avoid pushing against any resis- the appropriate oropharyngeal airway, place the flange
tance, because this may cause tissue trauma and air- beside the patient’s cheek, parallel to the front of the teeth
way kinking. (Figure 15-44). A properly sized airway will extend from
the patient’s mouth to the angle of his jaw (Figure 15-45).
4. Verify the appropriate position of the airway. Resolution
of noisy breathing and improved compliance during Inserting the Oropharyngeal Airway
BVM ventilation support correct positioning. Also, feel
at the airway’s proximal end for airflow on expiration. To insert the oropharyngeal airway:
5. Provide supplemental oxygen and/or ventilate the 1. Open the mouth and remove any visible obstructions.
patient as indicated. 2. Ensure or maintain effective ventilation with supple-
mental oxygen.
Oropharyngeal Airway 3. Grasp the patient’s jaw and lift anteriorly.
The oropharyngeal airway (OPA) is a noninvasive semi- 4. With your other hand, hold the airway device at its
circular plastic or rubber device designed to follow the proximal end and insert it into the patient’s mouth.
palate’s curvature. It holds the base of the tongue away Make sure the curve is reversed, with the tip pointing
from the posterior oropharynx, thus preventing it from toward the roof of the mouth.
obstructing the glottis. Its use is indicated in patients with 5. Once the tip reaches the level of the soft palate, gently
no gag reflex. rotate the airway 180° until it comes to rest over the
tongue.
Advantages of the Oropharyngeal Airway
Many of your cases in the field will call for ventilatory sup-
port. These situations range from apneic (nonbreathing)
Mouth-to-Mouth/
patients to less obvious instances when patients are experi- Mouth-to-Nose Ventilation
encing depressed respiratory function. Remember that an Mouth-to-mouth and mouth-to-nose ventilation are the
unconscious patient’s respiratory center may not function most basic methods of rescue ventilation, but their use is
adequately. A significant decrease in the patient’s rate or limited by exposure to body fluids and by limited oxy-
depth of breathing will gen delivery, as expired air contains only 17 percent oxy-
Content Review lead to decreased respira- gen. These methods are indicated only in the presence of
➤➤ Remember that an tory minute volume with apnea when no other ventilation devices are available.
unconscious patient’s subsequent hypercarbia When using one of these methods, take care not to
respiratory center may not
and respiratory acidosis. hyperinflate the patient’s lungs nor to hyperventilate
function adequately.
This will result in further yourself.
548 Chapter 15
Mouth-to-Mask Ventilation
The pocket mask is a clear plastic device with a one-way
valve that you place over an apneic patient’s mouth and
nose. It prevents direct contact between you and your
patient’s mouth and expired air, thus reducing the risk of
contamination and subsequent infection. A pocket mask
also has an inlet for supplemental oxygen. Mouth-to-mask
ventilation combined with an oxygen flow rate of 10 L/min
can deliver an inspired oxygen concentration of approxi-
mately 50 percent. However, pocket masks are much less
effective than bag-valve-mask devices and are very tiring
for the rescuer.
To perform the mouth-to-mask technique, position the FIGURE 15-46 Bag-valve-mask unit.
head to open the airway by one of the previously discussed
methods (head-tilt/chin-lift or jaw-thrust), position the be adjusted to maintain appropriate volumes in the bag so
mask to obtain a good seal, and provide adequate ventila- the bag is neither overinflated nor subject to collapsing
tory volumes. As with mouth-to-mouth and mouth-to- entirely with each ventilation. Because they are more com-
nose methods, hyperinflation of the patient’s lungs, gastric plicated to use, flow-inflating-bag devices are rarely used
distention in the patient, and hyperventilation in the res- in EMS except in critical care transport of neonates and
cuer are potential complications. infants.
Any patient who requires assisted ventilation needs
Bag-Valve-Mask Ventilation supplemental oxygen, so high-flow oxygen (10 to 15 L/min)
The first technique employed for most patients who are not should always be used. Because of the attached reservoir, a
breathing or not breathing adequately is bag-valve-mask bag-valve device can deliver 90 to 95 percent oxygen with
(BVM) ventilation with a self-inflating bag and reservoir these flow rates and a tight mask seal.
attached to high-concentration oxygen. Many patients may One, two, or three rescuers may perform BVM ventila-
be entirely managed with BVM ventilation whereas, in tion. One-person BVM ventilation is the most difficult
other cases, it is a bridge to more invasive techniques. BVM method to master, because obtaining and maintaining the
ventilation is one of the most important and challenging mask seal while simultaneously delivering ventilations can
EMS skills and must be mastered. Even though the para- be challenging, especially if there are secretions, facial hair,
medic may need to delegate BVM ventilation to other pro- or the need for high airway pressures, and/or the rescuer
viders, the paramedic is still responsible for ensuring good has small hands. Therefore, BVM ventilation should gener-
technique. ally be performed with at least two providers, one to
The BVM consists of an oblong, self-inflating silicone squeeze the bag and one to open the airway and maintain
or rubber bag with two one-way valves (an air/oxygen- the mask seal.
inlet valve and a patient valve), a detachable transparent Observe the patient for chest rise, development of gas-
plastic face mask, and an oxygen reservoir. Both the bags tric distention, and changes in compliance of the bag with
and the masks come in variable sizes to fit patients from ventilation. Complications of BVM ventilation include
neonates to large adults. The valve must be open for oxy- inadequate volume delivery if there is a poor mask seal or
gen to flow to the patient. Some devices have a built-in improper technique, barotrauma from overinflation of the
colorimetric end-tidal CO2 detector (Figure 15-46) or posi- lungs, and gastric distention.
tive-pressure valves. Because of the risk of transmitting
infectious diseases, BVMs should be disposable. Do not Cricoid Pressure
reuse them. Posterior pressure on the cricoid cartilage is referred to as
Some BVM devices have a pop-off valve to limit the risk cricoid pressure. Because the cricoid ring is the only com-
of lung injury from overaggressive ventilation. However, plete ring in the trachea, posterior pressure on the front of
some patients with high airway resistance and/or poor lung the ring will be transmitted to the back of the ring and will
compliance require high pressures for ventilation, so a hopefully compress the esophagus between the back of the
mechanism to override the pop-off valve is essential. cricoid ring and the front of the spinal column.
Another variety of BVM bag is the anesthesia bag, This maneuver became popular with the advent of
more commonly called a flow-inflating bag, which does not rapid sequence intubation (RSI) as a means to limit regur-
self-inflate but instead relies on an adequate flow of oxy- gitation and subsequent aspiration. (RSI is discussed in
gen. Oxygen flow into the bag and flow out of the bag may detail later in this chapter.) Recent evidence suggests that
Airway Management and Ventilation 549
the risk-to-benefit ratio may not actually favor cricoid pres- components of the rule of
CONTENT REVIEW
sure during intubation, because cricoid pressure applied threes. Whenever BVM
➤➤ The Rule of Threes for
correctly to compress the esophagus often obscures the ventilation is difficult,
Optimal BVM Ventilation
intubator’s view of the larynx. Additionally, the esophagus however, the rule of threes
• Three providers
does not always lie directly behind the cricoid ring, and the should be employed.
• Three inches
pressure itself causes a reflex decrease in lower-esophageal • Three providers. One • Three fingers
sphincter tone (actually working against the intended aspi- provider on the mask, • Three airways
ration-sparing effect). one on the bag, and one • Three PSI
Cricoid pressure use during BVM ventilation specifi- for external laryngeal • Three PEEP
cally (and not as a technique to improve laryngoscopic manipulation.
view), may still be of some benefit according to clinical
• Three inches. A reminder to place the patient in the
research despite the skill falling into disfavor.12 Due to this
sniffing position (elevate the head three inches) if not
conflict on the efficacy of the skill, in any instance where
contraindicated.
cricoid pressure may attempted, the paramedic should
• Three fingers. Three fingers on the larynx to perform
ensure the skill is still approved by protocol, or at very
external laryngeal manipulation (Figure 15-47).
least, approved by online medical direction.
Since cricoid pressure may still be used by some pro- • Three airways. In a worst-case scenario, the airway
viders under specific criteria, the skill to do so properly can be maintained, if necessary, with an orophrayngeal
will now be discussed. To locate the cricoid cartilage, first airway and two nasopharyngeal airways (one in each
palpate the thyroid cartilage and feel the depression just nostril).
below it (cricothyroid membrane). The prominence infe- • Three PSI. A gentle reminder to use the lowest pres-
rior to this depression is the cricoid ring. Apply firm sure necessary to see the chest rise.
downward pressure to the anterolateral aspect of the • Three seconds. A reminder to ventilate slowly and
cartilage, using the thumb, index, and middle finger of allow time for adequate exhalation.
one hand. • Three PEEP. Or up to 15 cm/H2O positive-end expira-
Use caution not to apply so much pressure as to tory pressure (PEEP) as needed to improve oxygen
deform and possibly obstruct the trachea; this is a particu- saturations.
lar danger in infants. The necessary pressure has been esti-
mated as the amount of force that will compress a capped Bag-Valve Ventilation
50-mL syringe from 50 mL to the 30 mL marking. In the of the Pediatric Patient
event that the patient actively vomits, it is imperative to The differences in the pediatric patient’s anatomy require
release the pressure to avoid esophageal rupture. some variation in ventilation technique. First, the child’s
relatively flat nasal bridge makes achieving a mask seal
Optimal BVM Ventilation more difficult. Pressing the mask against the child’s face to
Using the Rule of Threes improve the seal can actually obstruct the airway, which is
The rule of threes was developed to help providers recall the more compressible than an adult’s. You can best achieve
components of optimal BVM ventilation. Many patients the mask seal with the two-person BVM technique, using a
can be easily oxygenated and ventilated without using all jaw-thrust to maintain an open airway.
For BVM ventilation, the
bag size depends on the
child’s age. Full-term neonates
and infants will require a
Thyroid cartilage pediatric BVM with a capacity
(Adam's apple)
of at least 450 mL. For children
up to 8 years of age, the pediat-
ric BVM is preferred, although
for patients in the upper por-
Cricothyroid tion of that age range you can
membrane use an adult BVM with a capac-
ity of 1,500 mL if you do not
Trachea
maximally inflate it. Children
Cricoid cartilage Esophagus older than 8 years require an
occluding esophagus
adult BVM to achieve adequate
FIGURE 15-47 External laryngeal manipulation. tidal volumes. Additionally, be
550 Chapter 15
CONTENT REVIEW
➤➤ Extraglottic Airways
• Retroglottic (dual-lumen)
• ETC
• PtL
• Retroglottic (single
lumen)
• King LT
• EGTA/EOA
• Supraglottic
• S.A.L.T.
• LMA; LMA Supreme;
LMA Fastrach
• air-Q
• Ambu Laryngeal Mask
➤➤ Because the majority of
literature has failed to
find a survival benefit to
prehospital endotracheal
FIGURE 15-48 Demand valve and mask.
intubation, and the
procedure is associated
with serious potential certain that the mask fits oxygen-powered ventilation device, will deliver 100 percent
complications, many
properly, from the bridge of oxygen to a patient at its highest flow rates (40 liters per
EMS systems are moving
the nose to the cleft of the minute maximum). Flow is restricted to 30 cm H2O or less to
entirely to extraglottic
chin. If a length-based diminish gastric distention that can occur with its use (Fig-
airways or employing
them earlier in the event resuscitation tape (Broselow ure 15-48). Demand-valve devices have fallen out of favor
of difficult intubation. tape) is available, you can because of the risks of gastric distension and barotrauma in
use it to help determine the unconscious patients.
proper mask size.
To achieve a proper mask seal, place the mask over the
patient’s mouth and nose. Avoid compressing the eyes.
Using one hand, place your thumb on the mask at the apex
PART 3: Advanced Airway
and your index finger on the mask at the chin (C-grip).
Apply gentle pressure downward on the mask to establish
Management and Ventilation
Advanced airway management has historically meant just
an adequate seal. Maintain the airway by lifting the bony
endotracheal intubation and surgical airways (which will
prominence of the chin with the remaining fingers forming
be discussed later in the chapter). Now, however, advanced
an E under the jaw. Avoid placing pressure on the soft area
airway management includes placement of other invasive
under the chin. You may use the one-rescuer technique,
airways that do not pass through the vocal cords, such as
although the two-rescuer technique will be more effective.
extraglottic airways.13–16
Ventilate according to current standards, obtaining
chest rise with each breath. Begin the ventilation and say,
“squeeze,” providing just enough volume to initiate chest
rise—being very careful not to overinflate the child’s lungs.
Allow adequate time for exhalation, saying, “release,
Extraglottic Airway Devices
Extraglottic airway (EGA) devices are inserted blindly
release.” Continue ventilations, maintaining the correct
into the airway to facilitate oxygenation and ventilation via
timing by saying, “squeeze, release, release.” Use three cri-
a self-inflating bag or transport ventilator, but do not enter
teria to assess adequacy of ventilations: (1) look for ade-
the glottis (the space between the vocal cords). Hence the
quate chest rise; (2) listen for lung sounds at the third
term extraglottic, meaning “outside the glottis.” Because
intercostal space, midaxillary line; and (3) assess for clini-
EGAs do not enter the glottis, these devices do not require
cal improvement (skin color and heart rate).
the use of a laryngoscope to visualize the glottic opening,
although some of them permit it. Their insertion without
Demand-Valve Device laryngoscopy is described as “blind.”
The demand-valve device, also called the manually trig- There are subcategories of EGAs, depending on where
gered, oxygen-powered ventilation device or flow-restricted, they actually “sit.” Some sit in the esophagus, which places
Airway Management and Ventilation 551
• In the esophageal position, gastric decompression is and advance it past the hypopharynx to the depth
possible through the #2 port. indicated by the markings on the tube. The black
• When intubating around the ETC, the proximal bal- rings on the tube should be between the patient’s
loon may be deflated and the distal balloon left inflated teeth.
to seal off the esophagus. 7. Inflate the pharyngeal cuff with 100 mL of air and the
Disadvantages of the ETC distal cuff with 10 to 15 mL of air.
8. Ventilate through the longer, blue, #1, proximal port
• Trauma, including esophageal perforation, has been
with a bag-valve device connected to 100 percent oxy-
reported.
gen, while auscultating over the chest and stomach.
• It cannot be placed in patients with an intact gag reflex. If you hear bilateral breath sounds over the chest and
• High cuff volumes may result in tissue ischemia. none over the stomach (indicating that the device is sit-
• It cannot be placed in patients under 4 feet tall. ting in and occluding the esophagus while directing
• Clinical assessment is necessary to ensure ventilation oxygen flow into the trachea), secure the tube and con-
through the correct port. tinue ventilating.
• It does not completely isolate the trachea in the esoph- 9. If you hear gastric sounds over the epigastrium and
ageal position. no breath sounds (indicating that the device is sitting
in and occluding the trachea while directing oxygen
• Placement is not 100 percent foolproof.
flow into the esophagus), change ports and ventilate
Inserting the ETC through the clear, shorter, #2, distal port to direct oxy-
To place the ETC: gen into the trachea. Confirm breath sounds over the
chest with absent gastric sounds.
1. Perform optimal BVM ventilation with high-concen-
10. Use multiple confirmation techniques. End-tidal CO2
tration oxygen.
is reliable with an ETC as long as the patient is produc-
2. Place the patient supine in a neutral position if possible. ing CO2. An esophageal detector device (EDD) may
3. Prepare and check equipment. Select a Regular size for be used on an ETC by attaching it to the #2 port that
patients 6 feet tall or taller. Select a Small-Adult size is open on the distal end. Note that failure to inflate
for patients less than 6 feet tall. Note that this sizing indicates appropriate esophageal positioning and you
instruction is evidence based but is different from the should continue ventilation through the #1 port. This
manufacturer’s instructions. is somewhat backward compared to using an EDD to
4. Stabilize the cervical spine if cervical injury is possible. confirm endotracheal intubation. (The EDD will be
5. Perform the Lipp maneuver (or modified Lipp maneu- explained in detail later.)
ver) to preshape the ETC (Figure 15-51). 11. Secure the tube and continue ventilating with 100 per-
6. Grab and lift the jaw or, if within your scope of prac- cent oxygen.
tice, use a laryngoscope to create a channel and visu- 12. Frequently reassess the airway and adequacy of
alize the esophagus. Insert the ETC gently in midline ventilation.
(a) (b)
FIGURE 15-51 Lipp maneuver. (a) The Lipp maneuver and (b) the modified Lipp maneuver will aid in ETC placement and will help to mini-
mize associated trauma to the airway.
Airway Management and Ventilation 553
If the patient regains consciousness or if the protective retroglottic airways, but both balloons are inflated through
airway reflexes return, remove the PtL. It is best to remove a single port with a single syringe. The King is able to gen-
the PtL before endotracheal intubation. erate significant airway pressures when needed and offers
Complications of PtL placement include the following: substantial aspiration reduction.
Laryngeal Airways
Laryngeal airways are supraglottic airways. They are avail-
able in a variety of specific types, including the original
LMA, the LMA Supreme™, the LMA Fastrach™, the
CookGas air-Q™, and the Ambu Laryngeal Mask.
Epiglottis
Aryepiglottic fold
Laryngeal
inlet
Pyriform
fossa Interarytenoid
notch
Mucous
membrane
Thyroid covering
gland cricoid
cartilage
Esophagus Upper
esophageal
sphincter
FIGURE 15-55 Laryngeal mask airway (LMA). FIGURE 15-57 LMA Fastrach intubating laryngeal mask airway (LMA).
556 Chapter 15
• It isolates the trachea and permits complete control of FIGURE 15-60 Airway roll and necessary airway management
the airway. equipment and supplies.
• It impedes gastric distention by channeling air directly
into the trachea. introducer (gum-elastic bougie) and backup airways should
• It eliminates the need to maintain a mask seal. also be available (Figure 15-60).
• It offers a direct route for suctioning of the respiratory
passages. Laryngoscope
The laryngoscope is an instrument for lifting the tongue and
• It permits administration of the medications lidocaine,
epiglottis out of the line of sight so that you can see the vocal
epinephrine, atropine, and naloxone via the endotra-
cords. You will typically use it to place an endotracheal tube,
cheal tube. (Use the mnemonic LEAN or NAVEL [if
but you may also use it in conjunction with Magill forceps to
vasopressin is added] to remember these medications.)
retrieve a foreign body obstructing the upper airway or to
Disadvantages of Endotracheal Intubation place retroglottic airways such as the ETC.
A laryngoscope consists of a handle and a blade. The
• The technique requires considerable training and
handle may be either reusable or disposable. It houses bat-
experience.
teries that power a light in the blade’s distal tip. This light
• It requires specialized equipment.
illuminates the airway, making it easier to see upper air-
• It requires direct visualization of the vocal cords. way structures. The point attaching the handle and the
• It bypasses the upper airway’s function of warming, blade is called the fitting; it locks the blade in place and
filtering, and humidifying the inhaled air. provides electrical contact between the batteries and the
• It is time consuming. bulb (Figure 15-61).
Equipment
The equipment needed for traditional oral endotracheal
intubation includes a functioning laryngoscope (handle and
blade), an appropriate-size
CONTENT REVIEW endotracheal tube with sty-
➤➤ Endotracheal Intubation let, a 10-mL syringe, a bag-
Indicators valve mask, a suction
• Respiratory arrest device, a bite block, Magill
• Cardiac arrest forceps, a means to confirm
• Airway swelling tube placement, and a
(anaphylaxis; airway
means to secure the tube in
burns)
place. An endotracheal tube FIGURE 15-61 Engaging the laryngoscope blade and handle.
558 Chapter 15
Elevate blade
FIGURE 15-64 Curved blades FIGURE 15-65 Straight blades
to a right angle
in a variety of sizes. in a variety of sizes.
combined with a bougie is often the “go-to technique” FIGURE 15-69 Endotrol ETT.
among experienced intubators for managing the difficult
airway, particularly when only the epiglottis can be visual-
ized. A straight blade is often better for endotracheal intu- 7.5 mm for average-sized females and 7.5 to 8.0 mm for
bation in infants, because it helps to lift the relatively large average-sized adult males. (We discuss endotracheal intu-
and floppy epiglottis, although a curved blade may be use- bation of children in detail later in this chapter.)
ful to control a large infant tongue. Adult tubes come with an inflatable cuff at the distal
end to provide a seal between the tube and the trachea.
Endotracheal Tubes Pediatric tubes are available with or without a cuff. His-
The endotracheal tube (ETT) is a flexible translucent tube torically, only uncuffed tubes were placed in pediatric
open at both ends and available in lengths ranging from patients, but now it is common practice to use a cuffed tube
12 to 32 cm, with centimeter markings along its length (Fig- in infants and older children. A thin inflation tube runs the
ure 15-68). The distal end has a beveled tip to facilitate length of the main tube from the distal cuff to a syringe. A
smooth movement through airway passages. The proximal one-way valve at the proximal end of the inflation tube
end has a standard 15-mm inside diameter and 22-mm out- permits the syringe to push air into the distal cuff or pull it
side diameter connector that attaches to the ventilatory out but prevents air from escaping the cuff when the
device, usually either a self-inflating bag or a mechanical syringe is removed. A pilot balloon at the inflation tube’s
ventilator. The ETT is available with internal tube diame- proximal end helps indicate whether the distal cuff is prop-
ters ranging from 2.5 to 9.0 mm, which is clearly marked erly inflated, although evidence has shown that this is
on the tube and packaging. The typical tube size is 7.0 to highly unreliable. Because overinflation may lead to tra-
cheal mucosal damage, it is suggested that a
Open end manometer be used to ensure proper pressures,
(top) especially during longer transports. Alterna-
15mm adaptor tively, paramedics should learn to listen for air
leakage and place only enough air in the cuff to
Inflation
valve inflate it without causing a leak. Always check
the distal cuff for leaks before insertion.
Pilot
balloon Suppliers typically prewrap an ETT in a
gently curved shape. This is because the trachea
lies anteriorly in the neck, and the tube must be
10cc directed upward to enter the glottic opening.
syringe Stylets may be used to make further shape
enhancements. Another variation is the Endotrol
ETT, which has a proximal O-shaped ring
Cuff
attached to a plastic wire that runs the length of
Open end the tube and terminates distally (Figure 15-69).
(bottom)
Pulling the ring bends the distal end of the tube
upward and directs it into the glottic opening.
This can facilitate placement of the tube without
the need for a stylet, primarily during nasotra-
FIGURE 15-68 ETT and syringe. cheal intubation.
560 Chapter 15
Magill Forceps
The Magill forceps are scissor-style clamps with circular
tips used primarily to remove foreign bodies in the airway
(Figure 15-74).
Lubricant
FIGURE 15-71 ETT, stylet, and syringe, assembled for intubation Water-soluble lubricants facilitate inserting the ETT. Do not
with “straight-to-cuff” configuration of stylet and tube. use petroleum-based lubricants, as they may damage the
(© Dr. Bryan E. Bledsoe) ETT and cause tracheal inflammation.
Airway Management and Ventilation 561
Legal Considerations
Negligence and Malpractice Suits. Although negligence
and malpractice lawsuits against EMS personnel are relatively
uncommon, many of those that do arise involve airway man-
agement. Airway issues may result in death or serious disabil-
ity, so paramedics must take great care to ensure that airway
management procedures are performed properly. In systems
not using medication-assisted intubation, the most common
source of airway-related claims is unrecognized esophageal
intubation. Systems performing medication-assisted intuba-
tion also expose themselves to claims related to inappropriate
intubation and failed intubations in patients who arguably
might have done better without intubation in the first place.
Your best line of defense is to be highly competent in these
procedures. This starts with your initial paramedic education
but must continue after school is completed. If you work in a
system where there is limited opportunity to use your airway
skills, then you should increase your in-service education and
arrange to spend some time in the operating suite if this is avail-
able. When there, do not overlook opportunities to place extra-
glottic airways and to practice bag-valve-mask ventilation.
FIGURE 15-73 Commercial ET tube holder.
Always make sure that all airway equipment is functioning
(© Dr. Bryan E. Bledsoe)
properly at the beginning of each shift and after each call. After
performing endotracheal intubation, it is essential to confirm
and document proper tube placement by at least three methods,
including at least one objective means such as an esophageal
detector device or capnography. Following intubation, periodi-
cally and obsessively check and confirm continued proper tube
placement, especially after any patient movement. If there is a
doubt in regard to tube placement, the tube should be checked or
removed and mechanical ventilation continued by other means.
You must have at least one extraglottic airway avail-
FIGURE 15-74 Magill forceps. able at all times as a backup and have a clear plan of when
to use it based on your experience, patient condition, ser-
vice or regional protocols, and local convention. Persisting
Suction Unit in attempts to intubate with resulting hypoxemia, airway
A suction unit helps to remove secretions and foreign trauma, and aspiration is a common source of EMS airway lit-
materials from the oropharynx during intubation attempts. igation. If you are using medication-assisted intubation, you
It is a vital element that you must never forget. (This will should carefully weigh the risks and benefits, including any
be discussed in more detail later in this chapter.) predicted difficulties in airway management, before proceed-
ing, and consider calling medical control in borderline cases.
End-Tidal CO2 Detector or Esophageal Finally, clear and accurate documentation is imperative.
Detector Device Be especially mindful of documenting your indication for air-
It is imperative that all tube placements be confirmed way management, other options considered, tube confirma-
tion, and any noted complications.
objectively using an end-tidal CO2 detector or an esopha-
geal detector device. It is not adequate to rely on subjective
measures such as direct visualization, misting, lung
Complications of
sounds, or an absence of epigastric sounds.
Endotracheal Intubation
Protective Equipment Intubation presents a number of potential complications.
Endotracheal intubation, like many airway procedures, Properly attending to detail and taking appropriate pre-
carries the risk of exposure to body substances. Because of cautions will help you to avoid many of these problems.
this, it is essential to employ Standard Precautions. These
include, but are not limited to, gloves, mask, protective Equipment Malfunction
eyewear, and possibly a gown. Remember, personal safety Equipment malfunctions consume valuable time when
comes first! Always use Standard Precautions. you are establishing an airway. Having a preassembled
562 Chapter 15
airway kit that is checked through the use of a neuromuscular blocking agent that
CONTENT REVIEW
regularly will lessen the eliminates the gag reflex and prevents active vomiting. Use
➤➤ Complications of
chances of this occurring. of a sedative alone to facilitate intubation without a neuro-
Endotracheal Intubation
Ideally, someone should muscular blocker potentially creates a high risk for aspira-
• Equipment malfunction
check the airway kit daily tion, as these drugs will depress the patient’s ability to
• Tooth breakage and
soft-tissue lacerations to be sure that all needed protect his airway without eliminating the gag reflex.
• Aspiration supplies are present and
• Elevated intracranial that the laryngoscope bulb, Elevated Intracranial Pressure
pressure batteries, and blade are in Intracranial pressure (ICP) can become elevated during
• Transport delays good working condition. intubation from the reflex response to stimulation of the
• Hypoxemia airway with a laryngoscope and endotracheal tube,
• Esophageal intubation whether or not the patient is sedated and/or paralyzed. In
• Endobronchial
Tooth Breakage
most patients, this elevation is of no clinical significance. In
intubation and Soft-Tissue a few rare patients with intracranial bleeding or masses
• Tension pneumothorax Laceration who are on the brink of brain herniation, however, this
➤➤ Use the laryngoscope as Endotracheal intubation increase can have significant repercussions. In such
an instrument, not a tool. can easily injure the lips patients, you can either avoid the procedure altogether, use
Avoid pressure on the and teeth, but you can elim-
teeth. medications to attempt to blunt the reflex response, and/or
inate this hazard by care- use a very gentle technique. The possibility of increasing
fully using the laryngoscope ICP is one of the reasons that nasotracheal intubation is
as an instrument, not a tool. Guide the blade gently into the relatively contraindicated in head injury and stroke.
mouth and avoid pressure on the teeth. When manipulating
the jaw anteriorly, keep your wrist straight while lifting with Transport Delays
your shoulder, using gentle traction upward and toward the Whenever an airway procedure is performed on scene rather
feet rather than rotating and flexing your wrist (i.e., lever- than en route, it will add to the total out-of-hospital time. In
ing). All levers require a fulcrum—and the only fulcrums some cases there may be no choice, but in other cases it may
available in your patient’s mouth will be his upper incisors. be possible to defer the intubation until transport or to per-
Having an assistant apply a jaw-thrust during laryngoscopy form a bridge procedure, such as placing an extraglottic air-
and paying attention to precise triggering of the hyoepiglot- way or providing BVM ventilation. The paramedic needs to
tic ligament in the vallecula when using a curved blade will look at the big picture and decide whether the underlying
also minimize trauma. problem can be treated adequately in the prehospital setting
If you use the laryngoscope too roughly, you can also by airway management or whether the patient requires an
traumatize the patient’s tongue, posterior pharynx, glottic emergency lifesaving procedure that is available only at the
structures, and trachea. This can also happen if you direct hospital, such as a catheterization or surgery.
the tube away from the midline into the pyriform sinuses,
allow the stylet to protrude from the distal end of the ETT, or Hypoxemia
merely apply too much pressure to a styletted tube. In some Delays in oxygenation from prolonged intubation attempts
cases, the trauma may be so substantial that the patient can can produce profound, life-threatening hypoxemia. If the
no longer be ventilated with an extraglottic airway device or patient has a measurable oxygen saturation, it is simple to
bag-valve mask. A gentle technique, attention to detail, and monitor and abort the attempt as soon as the saturation
moving early to alternative strategies in the event of diffi- reaches a predetermined cutoff level, usually 90 percent for
culty are the keys to avoiding these traumatic complications. patients with head trauma or stroke. For patients without a
detectable oxygen satura-
Aspiration tion, it is much more diffi- CONTENT REVIEW
Aspiration is the entry of stomach contents, blood, or secre- cult to know when to abort ➤➤ To avoid hypoxemia
tions into the lungs. A common cause of aspiration during the attempt, although it is during intubation, limit
non–medication-facilitated airway management is placing safe to assume that such each intubation attempt to
a laryngoscope (or tongue blade or oropharyngeal airway) patients have very little no more than 20 seconds
into the mouth of a patient who has just enough gag reflex reserve. One basic rule is to before reoxygenating the
to vomit but is too obtunded to fully protect his airway. limit each intubation patient.
Therefore, you need to be very gentle in placing anything attempt to no more than 20 ➤ ➤ Consider the use of
into the mouth when you are not sure whether the patient seconds before stopping to apneic oxygenation to
prevent hypoxia during
has an intact gag reflex. Rapid sequence intubation, dis- reoxygenate the patient. To
endotracheal intubation.
cussed later, is intended to minimize the risk of aspiration gauge this interval, some
Airway Management and Ventilation 563
paramedics were once taught to hold their breath from the • Gurgling sounds over the epigastrium with each
time they stop ventilating the patient until they start again; breath delivered
this is no longer recommended, as it is very difficult to per- • Distention of the abdomen
form a complex procedure while holding your breath.
• An absence of breath condensation in the endotracheal
A new strategy, called apneic oxygenation, supplies
tube
oxygen to the apneic (non-breathing) patient during endo-
tracheal intubation to minimize the likelihood of hypox- • A persistent air leak, despite inflation of the tube’s
emia occurring during intubation. To achieve apneic distal cuff
oxygenation in endotracheal intubation, place the patient’s • Cyanosis and progressive worsening of the patient’s
head in a reverse Trendelenburg position at a 20° to condition
30° angle. Then, insert a nasal oxygen cannula with the • Phonation (noise made by the vocal cords)
flow rate set at 5 liters per minute (or more). If possible, the
• No color change with colorimetric exhaled CO2 detector
patient should be pre-oxygenated with 3 minutes of nor-
• An absent waveform on capnography
mal tidal volume breathing or eight vital capacity breaths
(BVM-assisted ventilation). With mechanical ventilation, • A falling pulse oximetry reading
the nasal cannula can be placed under the BVM mask (Fig-
If you have any suspicion that the tube is in the esopha-
ure 15-75). This effectively pre-oxygenates the patient prior
gus, remove it immediately. Perform BVM ventilation
to intubation and increases the physiologic reserve of oxy-
with 100 percent oxygen and either initiate transport,
gen, thus mitigating the possible effects of hypoxia during
place an extraglottic airway, or repeat endotracheal intu-
intubation.
bation with another tube.34–35
If you cannot pass the tube through the vocal cords on
the first attempt, at least identify your landmarks and note
any unique or difficult features that may be modifiable. For Endobronchial Intubation
example, if you can identify only the epiglottis, this will If you pass the endotracheal tube successfully through
warrant use of a bougie, or a very anterior larynx will the vocal cords and advance it too far, it likely will enter
prompt use of external laryngeal manipulation or better either the right or left mainstem bronchus, although it is
positioning. The absence of any identifiable landmarks far more likely to pass into the right mainstem, which
should prompt placement of an extraglottic airway. angles away from the trachea less acutely than does the
left. In either case, the ETT then ventilates only one lung,
Esophageal Intubation and the result is hypoventilation and hypoxia from inad-
Misplacement of the ETT into the esophagus deprives the equate gas exchange. Also, when the bag-valve device
patient of oxygenation and ventilation. It is potentially lethal, insufflates enough air for two lungs into the smaller area
resulting in severe hypoxemia and brain death if you do not of only one lung, it can create enough pressure to cause
recognize it immediately. It also directs air into the stomach, barotrauma, such as a pneumothorax, worsening the
encouraging regurgitation, which can lead to aspiration. patient’s condition. Findings in endobronchial intubation
Indicators of esophageal intubation include the following: include breath sounds present on one side of the chest but
diminished or absent on the other, poor compliance (resis-
• An absence of chest rise and absence of breath sounds tance to ventilations with the bag-valve device), and evi-
with mechanical ventilation dence of hypoxemia.
You may avoid inserting the ETT too far by following
these guidelines:
To resolve the problem, loosen or remove any securing 7. Hold the laryngoscope in your left hand, whether you
devices and withdraw the ETT until breath sounds are are right- or left-handed. Insert the laryngoscope blade
present and equal bilaterally. Be certain to deflate the cuff gently into the right side of the patient’s mouth. If
when pulling back on the ETT. using a curved blade, gently sweep the tongue to the
left and work in the midline. If using a straight blade,
Tension Pneumothorax remain on the right side of the mouth. Your primary
Any tear in the lung parenchyma can cause a pneumotho- goal at this point is to visualize the epiglottis.
rax. This may occur from excessive pressure being applied 8. Advance the curved blade until the distal end is at
to a healthy lung or normal pressures applied to abnormal the base of the tongue in the vallecula (Figure 15-76a).
lungs such as occurs in COPD patients or patients who Advance the straight blade until the distal end is under
have suffered recent chest trauma. If this is allowed to the epiglottis (Figure 15-76b). Alternatively, with a
progress untreated, a tension pneumothorax may develop.
A tension pneumothorax will adversely affect the other
lung, the heart, and the structures of the mediastinum. Ten-
sion pneumothorax is marked by progressively worsening
compliance (more difficulty in ventilating), diminished
unilateral breath sounds, hypoxemia with hypotension,
and distended neck veins. If you suspect tension pneumo-
thorax, needle decompression of the chest is indicated, as
described in the chapter “Chest Trauma.”
15-1A Ventilate the patient. 15-1B Prepare the equipment. 15-1C Apply external laryngeal manipu-
lation to assist in vocal cord visualization.
15-1D Visualize the larynx and insert 15-1E Inflate the cuff, ventilate, and 15-1F Confirm placement with an ETCO2
the ETT. auscultate. detector.
straight blade, you may fully advance until the distal 10. Quickly but carefully visualize the airway structures
tip is in the esophagus and then visualize while slowly to assure you can visualize the vocal cords. If you
withdrawing the blade. If you cannot visualize the epi- still cannot visualize the posterior cartilages, perform
glottis, withdraw the blade, reposition the patient, and external laryngeal manipulation. You may not see the
repeat. entire glottis or even part of it, but you should at least
9. Keeping your left wrist straight, use your left shoulder clearly visualize the posterior cartilages and interary-
and arm to continue lifting the mandible and tongue to tenoid notch.36
a 45° angle to the ground (up and toward the feet) until 11. Hold the ETT in your right hand with your finger-
landmarks are exposed (Figure 15-77). Be careful not to tips as you would a dart or a pencil. This gives you
put pressure on the teeth. Consider having an assistant control to gently maneuver the ETT. Advance the
perform the jaw-thrust simultaneously. At this point, tube through the right corner of the patient’s mouth,
you may need to suction any large amounts of emesis, and direct it toward the midline. Pass the ETT gen-
blood, or secretions in the posterior pharynx. tly through the glottic opening until its distal cuff
566 Chapter 15
Subjective Techniques
Subjective methods of tube placement confirmation
(a)
include direct visualization, tube misting, and auscultation
for breath sounds. Well-performed EMS studies have dem-
onstrated that reliance on subjective means alone results in
a 10 to 20 percent rate of missed esophageal intubations.
Therefore, subjective observations, although they are
important, should not be relied on solely for confirmation
of correct tube placement.
• Direct visualization. Although seeing the tube pass
through the cords should be considered the gold stan-
dard, this method of tube confirmation has failed. There
(b)
are at least three possible explanations. First, in the
Figure 15-77 (a) The epiglottis. (b) Laryngoscope view of the emergency situation, visualization of the tube’s passage
glottis, closed during the act of swallowing. through the cords is often unsatisfactory as a result of
(Source (b): Gastrolab/Science Source) patient immobilization, positioning, or blood/vomitus
in the airway. Second, the tube itself often obscures
visualization. Third, even if the tube is observed to pass
disappears beyond the vocal cords; then advance it through the cords, it may become dislodged when the
another 1 to 2 cm. Hold the tube in place with your stylet is removed and/or if the end-tidal CO2 detector
hand to prevent its displacement. Do not let go under and BVM are attached before the tube has been secured.
any circumstance until it is taped or tied securely in For these reasons direct visualization alone cannot be
place. relied on to confirm tube placement.
12. Remove the stylet (if used) and attach a bag-valve • Tube misting. Observing mist or condensation in the
device to the 15/22-mm connector on the tube. tube, or a “vapor trail,” has long been held out as a
13. Objectively confirm tube placement with capnogra- means of confirming tracheal placement of the tube,
phy. In addition, check for equal breath sounds to be but it is not reliable.
sure the tube is not too deep. There have been many Content Review
14. Ventilate the patient with 100 percent oxygen. cases of a vapor trail ➤➤ Endotracheal placement
noted with an esopha- of the tube must be con-
15. Gently insert an oropharyngeal airway to serve
geal intubation as well firmed immediately after
as a bite block, and secure the ETT with umbilical
as cases when the placement and continu-
tape, adhesive tape, or a commercial tube-holding
vapor trail is missing ously thereafter. Do not
device.
with a correctly placed become overly reliant on
16. Place the patient on the transport ventilator and moni- tracheal tube. Never technology; the patient’s
tor the continuous capnography waveform. make any decisions clinical condition should
17. Reconfirm appropriate tube placement periodically, on tube placement be the deciding factor in
your patient management
especially after any major patient movement or if there based solely on tube
decisions.
is any deterioration of patient status. misting.
Airway Management and Ventilation 567
Retrograde Intubation
FIGURE 15-79 AirTraq.
Retrograde intubation is a technique in which a needle is
inserted into the airway through the cricoid membrane
from the outside, much like a needle cricothyrotomy, Video Laryngoscopy
except it is directed superiorly rather than inferiorly. Once Video laryngoscopes have a camera on the distal end of the
the needle is in the airway, a guidewire is passed through device that transmits a high-quality magnified image to a
the needle and hopefully retrieved in the oral cavity and video screen that is attached to the device either directly or
withdrawn through the mouth. An endotracheal tube is by a cable. The screen is held by an assistant, mounted in the
then passed over the wire into the airway. ambulance, or placed on the patient’s chest or bedside. The
One difficulty is that the guidewire must be with- technique is considered indirect in that the intubator looks at
drawn before the tube can be passed distal to the cricoid the screen while intubating, not directly in the patient’s
membrane, and that does not leave a lot of margin for mouth, much like a video game. Studies with this technology
error. Overall, the technique is not very rapid, so the demonstrate that it is superior to traditional direct laryngos-
patient must be quite stable. Although some EMS services copy unless the pharynx is completely full of blood, emesis,
have embraced this technique over the years and used it or secretions. A number of devices are now available with a
successfully, there are not many cases in which this would wide range of prices. None of these devices has been shown
be the only viable approach. Retrograde intubation will to be clearly superior to the others. This technology will
probably be replaced by newer technology and simpler likely replace traditional direct laryngoscopy in the years to
techniques, such as those making use of external laryngeal come as prices come down (Figures 15-80 and 15-81).37
manipulation (ELM) and the gum-elastic bougie, which
are discussed under “Improving Endotracheal Intubation
Success.”
Optical Laryngoscopes
Several devices allow visualization of the glottic opening
and associated anatomy using fiber-optic technology.
Among these is the AirTraqTM, a disposable device, avail-
able in a variety of adult and pediatric sizes, that transmits
the view from the end of the device to a small attached
screen via a prism mechanism (Figure 15-79). The endotra-
cheal tube is preloaded into a channel on the side of the
device. Once the cords are visualized on the screen, the tube
is advanced into the glottis through the channel. The tube
is directable by redirecting the entire device rather than
the tube itself. A video monitor that can be attached to proj-
ect the obtained view onto a screen is also available. Studies
and clinical experience have found the AirTraq to be very
successful, although the cost advantage of a disposable
device is offset somewhat by having multiple sizes to stock
with expiration dates and needing to use them regularly to FIGURE 15-80 McGrath® video laryngoscope.
maintain skills. (© Dr. Bryan E. Bledsoe)
Airway Management and Ventilation 569
Figure 15-82 Preshaping the bougie prior to use will improve Figure 15-83 External laryngeal manipulation (ELM) can assist
insertion. Note the coude tip. with better visualization of the glottis and airway structures.
(© Dr. Bryan E. Bledsoe). (© Dr. Bryan E. Bledsoe)
in all cases, tracheal positioning should also be confirmed external laryngeal manipulation (ELM) (Figure 15-83). A
by hold-up, the resistance felt when the introducer passes third option is to have the assistant apply backward, upward,
into the smaller airways. If hold-up does not occur by the rightward pressure on the larynx (the BURP maneuver) (Fig-
time the device has been inserted 40 cm beyond the teeth ure 15-84). ELM affords the intubator the opportunity to use
(introducers have a mark to indicate this distance), then it immediate hand-eye feedback to obtain the optimal view
is safe to assume that you are in the esophagus. and is now generally preferred over the BURP maneuver.
Once tracheal position is ensured, an endotracheal
tube may be passed over the introducer while the intuba- Optimal Positioning
tor maintains an open channel with the laryngoscope. The There is no substitute for a well-positioned patient. Unless
scope is not removed until the tube is passed. A gentle contraindicated or impossible for reasons such as patient
counterclockwise rotation of the tube over the introducer entrapment, all patients should be in a sniffing position or,
may be necessary to avoid its getting stuck on cartilages or if obese, in the ramped position.
cords. Once the tube is passed to the appropriate depth, the
introducer is removed and the tube placement confirmed Video Laryngoscopy
with the usual methods. This technology is clearly changing how we intubate.
Many programs have introducers at the patient’s side Except in patients with excessive oral secretions, video
during all intubations. Some EMS programs have even laryngoscopy is superior to traditional direct laryngoscopy.
adopted use of the introducer in place of a
stylet for all intubations instead of waiting to
use it only for difficult intubations. The intro-
ducer may also be used as a “place saver” if
the glottic opening is swollen or smaller than
anticipated, rather than withdrawing com- Rightward
pletely while preparing a smaller tube.
Other Technology
Other devices that may prove valuable in certain cir-
cumstances are specialized blades, lighted stylets, intu-
bating laryngeal airways, and fiber-optic stylets. Most of
these devices are much more affordable at this point FIGURE 15-86 TrachlightTM lighted stylet in use.
than video laryngoscopes and will probably see greater (© Dr. Bryan E. Bledsoe)
use in EMS.
A number of different blades are available, includ-
Most EMS services with a substantial budget are
ing different shapes, different lighting mechanisms (e.g.,
choosing video devices over fiber optics.
IntuBriteTM), articulating tips, and attached prisms (Fig-
ure 15-85).
Lighted stylets, such as the TrachlightTM, allow for Using Rapid Sequence Intubation
intubation with a high degree of success despite oral secre- Success rates with rapid sequence intubation (RSI) are rou-
tions and cervical precautions (Figure 15-86). The device is tinely higher than success rates without RSI, although this
placed blindly into the airway with an endotracheal tube may be offset by the increased potential for devastating
preloaded, and the intubator observes for a bright glow in complications. The balance of the literature to date has not
the midline of the anterior neck, indicating tracheal place- shown improved survival with prehospital RSI. RSI is dis-
ment. The tube is then slid over the device into the trachea. cussed in more detail later.
Unfortunately, this technique is more difficult in bright
ambient light, with obese patients, and patients with very
dark skin. Blind Nasotracheal
Intubating laryngeal airways allow for intubation with
a high degree of success despite oral secretions, cervical Intubation
precautions, and obesity. As previously noted, the oral route is usually preferred
Fiber-optic stylets combine the visualization common over the nasal route for prehospital intubation. The naso-
in flexible bronchoscopes seen in hospital operating suites tracheal route (through the nose and into the trachea) used
and intensive care units with a rigid delivery device to sim- to be very common in EMS, emergency medicine, and
plify placement. anesthesia but has generally fallen out of favor. In a few
circumstances, however, the nasal route may be the best or
only option, such as in the patient with trismus or with an
anticipated difficult laryngoscopy, so this remains an
important paramedic skill. When done by EMS, nasotra-
cheal intubation is a “blind” procedure performed without
direct visualization of the vocal cords; in the hospital set-
ting, it may be performed with direct visualization or fiber-
optic guidance. It is important to remember that blind
nasotracheal intubation (BNTI) requires a cooperative or
unresponsive spontaneously breathing patient.
Relative Contraindications
Absolute Contraindications
Disadvantages of Nasotracheal
Intubation
The following disadvantages of
nasotracheal intubation discourage
its use unless clearly indicated by
the patient’s condition:
The fact that there are so many contraindications and the procedure easier, if available. Attach an end-tidal
disadvantages means that many patients are not good can- CO2 detection device to the proximal end of the tube.
didates for this procedure. Alternatively, a device to enhance audible detection of
breath sounds, such as the beck Airway Airflow Moni-
Blind Nasotracheal tor (BAAM®) whistle or the Burden nasoscope, may be
used (Figures 15-88 and 15-89).
Intubation Technique
7. Lubricate the tube generously. Topical lidocaine may
To perform blind nasotracheal intubation (Figure 15-87):
be preferred for long-term comfort but probably does
1. Use Standard Precautions. not affect the initial attempt.
2. Using basic manual and adjunctive maneuvers, open 8. Insert the ETT into the nostril with the bevel along the
the airway and ventilate the patient with 100 percent floor of the nostril or facing the nasal septum, directed
oxygen. posteriorly. This will help avoid damage to the tur-
3. Prepare your equipment. binates. There is some tendency to direct the tube
upward, but recall that the nasopharynx runs directly
4. Place the patient in his position of comfort. If the
anterior to posterior.
patient is unconscious or if you suspect cervical spine
injury, place the patient supine and use manual in-
line stabilization as appropriate.
5. Inspect the nose and select the larger nostril as your
passageway.
6. Select the correct size endotracheal tube. Normally use
a tube one-half to one full size smaller than for oral
intubation. For an average adult male, a size 7 mm is
appropriate. For an average adult female, a size 6.5 mm Figure 15-88 Beck Airway Airflow Monitor (BAAM®) for blind
is appropriate. Tubes with a directable tip may make nasotracheal intubations.
Airway Management and Ventilation 573
15-2A Ventilate the patient and apply manual C-spine 15-2B Apply extra laryngeal manipulation to assist with
stabilization. glottic visualization.
15-2C Ventilate the patient and confirm placement. 15-2D Secure the ETT and place a cervical collar.
Foreign Body Removal under basis, by individual paramedics, in light of local protocols
and customs.
Direct Laryngoscopy A randomized controlled study in a large urban area
When confronted with a patient who has apparently comparing non–drug-facilitated intubation in children
choked, you should initially carry out basic maneuvers for with BVM ventilation of children showed no improvement
airway obstruction that are appropriate to the patient’s age in outcomes with intubation over outcomes with BVM
and mental status, such as abdominal thrusts or chest ventilation. Recent evidence also shows that extraglottic
thrusts. If these fail to alleviate the obstruction, direct visu- airway devices can be very effective in children. For now,
alization of the airway with a laryngoscope may enable the decision on whether pediatric intubation is part of the
you to remove an obstructing foreign body using Magill paramedic scope of practice, and for what circumstances,
forceps or a suction device (Figure 15-94). The procedure is determined locally.43
for visualizing the airway is identical to that used for Airway management in children is similar to that for
orotracheal intubation. adults, but there are a few important differences based on
pediatric anatomy and physiology:
pediatric endotracheal tubes should be 2 to 3 cm below stimulation with the laryngoscope, or from succinyl-
the vocal cords, as deeper insertion may result in choline. To prevent this complication, avoid long
mainstem intubation or injury to the carina. The intubation attempts and be as gentle as possible
uncuffed ETT has a black glottic marker at its distal during laryngoscopy. You must monitor heart rate
end that should be placed at the level of the vocal throughout the procedure and stop the procedure to
cords. The cuffed ETT should be placed so that the cuff provide 100 percent oxygen by BVM ventilation or
is just below the vocal cords. For detailed guidelines extraglottic airway device if the heart rate falls
regarding the depth of insertion for different age below 60 beats per minute in a child or below 80
groups, refer to Table 15-7. Alternatively, you can use beats per minute in an infant. You should also be
the formula described earlier. prepared to give atropine (0.02 mg/kg, 0.1 mg mini-
• The occiput is relatively large. Infants will often mum) by IV bolus, although this is never a substi-
require a towel roll behind the shoulders to maintain tute for oxygenation.
an open airway, much the same way that older chil- • Higher basal metabolism combined with less func-
dren and adults may require a towel roll behind the tional residual capacity (smaller volume of air present
head. in the lungs). Children are more prone to a decrease in
• The epiglottis is floppy and round (“omega” shaped). oxygen saturation during intubation attempts. Ensur-
A straight blade is usually preferred initially to control ing adequate preoxygenation, keeping intubation
the epiglottis. An introducer may be useful if the glot- attempts short, and moving early to an extraglottic
tis cannot be viewed. device are helpful precautions.
• The tongue is larger in relation to the oropharynx. A To perform endotracheal intubation on a pediatric
curved blade may be useful to control the tongue dur- patient (Procedure 15–3):
ing intubation.
1. Use Standard Precautions.
• The glottic opening is higher and more anterior in the 2. Continue BVM ventilation with 100 percent oxygen
neck. Thus, it is easy to place the blade and tube too while using a towel roll under the shoulders of an
deep. External laryngeal manipulation (ELM) is useful infant or towels under the head in older children (if
to bring the glottis into view. not in cervical spine precautions) to achieve a sniffing
• The narrowest part of the airway is the cricoid carti- position.
lage, not the glottic opening as in adults. Uncuffed 3. Prepare and check your equipment. As stated earlier, a
tubes were traditionally mandated on the theory that straight blade is usually preferred in infants and small
the narrow cricoid made the cuff unnecessary, children, but it is suggested to have an age-appropriate
although many current management protocols have curved blade available as well, in case tongue control
changed, and cuffed tubes are being used more com- becomes critical. With children younger than 8 years,
monly. For now, most EMS services are still using you will either use an uncuffed endotracheal tube or
uncuffed tubes for pediatric patients under the age of a cuffed tube that is a half size smaller than calculated
8 years. with standard formulas. Because of the short distance
• Greater vagal tone. Infants and children are much between the mouth and the trachea, you rarely need a
more prone to bradycardia with hypotension during stylet to position the tube properly. Remember to lubri-
airway management, caused by hypoxemia or direct cate the ETT with water-soluble gel.
Airway Management and Ventilation 579
15-3C Insert the laryngoscope. 15-3D Visualize the child’s larynx and insert the ETT.
15-3E Ventilate, inflate the ETT cuff (if it is a cuffed tube), and 15-3F Confirm placement with an ETCO2 detector or waveform
auscultate. capnography.
(Continued)
580 Chapter 15
4. In case of trauma, remove the front of the cervical col- Confirm correct placement of the ETT. Hold the
lar and have an assistant maintain manual in-line sta- tube in place with your left hand, attach an age-appro-
bilization of the cervical spine. priate bag-valve device to the 15/22-mm connector,
5. Hold the laryngoscope in your left hand and insert it and deliver several breaths with an end-tidal CO2
gently into the right side of the patient’s mouth. Do detector in-line. For additional confirmation, observe
not attempt to sweep the tongue with a straight blade. for symmetrical chest rise and fall with each ventila-
tion. Also auscultate for equal, bilateral breath sounds
6. Advance the straight blade on the right side of the
at the lateral chest wall, high in the axilla, and absent
tongue with the tip directed toward the midline until
breath sounds over the epigastrium. An esophageal
the distal end reaches the base of the tongue. Alterna-
detector device may also be used for patients over 10
tively, you may use the “hub technique” by initially
kg as long as you squeeze the bulb before attaching it
advancing the straight blade gently into the esophagus
to the tube.
as far as it will go without resistance, then withdraw-
ing while performing ELM. If using a curved blade, 10. If the tube has a distal cuff, do not inflate it unless
sweep the tongue from right to left and advance in the there is a detectable air leak. If a leak is audible,
midline. inflate the distal cuff with just enough air to stop the
leak.
7. Look for the tip of the epiglottis and gently lift with
the tip of the blade while simultaneously perform- 11. Secure the ETT with tape or a commercial device, being
ing ELM with an assistant’s hand until the glottis very careful not to compress the tube. Note placement
or posterior cartilages are visualized. Keep in mind of the distance marker at the teeth/gums, recheck
that a child—particularly an infant—has a shorter for proper placement, and continue ventilatory sup-
airway and a higher glottis than an adult. Because port. Periodically reassess ETT placement and watch
of this, you may see the cords much sooner than you the patient carefully for any clinical signs of difficulty.
expect. Continue ongoing waveform capnography monitoring
if possible.
8. If you cannot see the epiglottis, you are likely too deep.
Gently and slowly withdraw while continuing to visu- 12. Place a gastric tube if allowed by protocol.
alize until the vocal cords fall into view.
9. Grasp the endotracheal tube in your right hand and, Monitoring Cuff Pressure
under direct visualization of the vocal cords or pos- Several recent studies have shown that even experienced
terior cartilages, insert it through the right corner of paramedics are unable to judge the pressure in an endotra-
the patient’s mouth into the glottic opening. Pass it cheal tube cuff accurately by palpating the pilot balloon,
through until the vocal cord marking on the tube is and that cuff pressures may be way in excess of the recom-
at the level of the cords or until the distal cuff of the mended ranges. Similarly, we now know that excessive
ETT just disappears beyond the vocal cords. In some pressures can cause tracheal damage much sooner than
cases, advancing an endotracheal tube will be diffi- previously thought. Combining these two pieces of infor-
cult at the level of the cricoid. Do not force the ETT mation tells us that we must use extreme caution and vigi-
through this region, as it may cause laryngeal edema lance regarding cuff pressures, because even if the
and bleeding. prehospital transport time is short, it is unlikely that the
Airway Management and Ventilation 581
Needle Cricothyrotomy
Needle cricothyrotomy involves placing a large-bore needle
with plastic cannula, such as a 14-gauge intravenous cathe-
ter, through the cricothyroid membrane into the trachea.
Epiglottis
Oxygen must then be forced through this small-caliber Hyoid
bone
device, using a bag-valve device or a high-pressure oxygen
source. Ventilation by this route is called transtracheal jet Thyroid Cricothyroid
ventilation or transtracheal jet insufflation. (Insufflation is cartilage membrane
blowing something into the body.) Thyroid
Because very high pressures may insufflate large vol- Cricoid gland
cartilage
umes of oxygen, barotrauma, including pneumothorax, is
a potential complication. Exhalation is limited if it must Trachea
take place through the same small-diameter catheter,
which results in rising carbon dioxide levels. In some cases,
the anatomy that required the needle cricothyrotomy for FIGURE 15-95 Anatomic landmarks for cricothyrotomy.
oxygenation does not impede normal exhalation.
In general, needle cricothyrotomy is considered a tem-
porizing technique to be used for 30 minutes or less and you may fill the syringe with sterile water or saline to
restricted to pediatric patients in whom open cricothyrot- facilitate detection of air when aspirating.
omy is contraindicated. This technique has been removed 3. Place the patient supine and hyperextend the head and
from the paramedic scope of practice in some states neck. (Maintain neutral position if you suspect cervical
because it is rarely used and there are few, if any, reports of spine injury.) Position yourself at the patient’s side.
it saving a life. 4. Palpate the inferior portion of the thyroid cartilage
The potential complications of needle cricothyrotomy and the cricoid cartilage. The indention between the
with jet ventilation include: two is the cricothyroid membrane (Figures 15-95
• Barotrauma from overinflation if using transtracheal and 15-96).
jet insufflation 5. Prepare the anterior neck with antiseptic solution.
• Excessive bleeding due to improper catheter place- 6. Firmly grasp the laryngeal cartilages and reconfirm the
ment site of the cricothyroid membrane.
• Subcutaneous emphysema from improper placement 7. Carefully insert the needle into the cricothyroid mem-
into the subcutaneous tissue, excessive air leak around brane at midline, directed 45° caudally (toward the
the catheter, or laryngeal trauma feet) (Figure 15-97). Often you will feel a pop as the
• Bleeding needle penetrates the membrane.
• Hypoventilation and respiratory acidosis
• Aspiration, as the airway is unprotected
8. Advance the needle while aspirating with the syringe. FIGURE 15-98 Advance the catheter with the needle.
If air returns easily, the catheter is in the trachea. If
blood returns or you feel resistance to return, reevalu- 12. Open the release valve to introduce an oxygen jet into
ate needle placement. the trachea (Figure 15-100). Then adjust the pressure to
9. After you confirm proper placement, hold the needle allow adequate lung expansion (usually about 50 psi,
steady and advance the catheter. Then withdraw the compared with about 1 psi through a regulator).
needle (Figure 15-98). 13. Watch the chest carefully, turning off the release valve
10. Reconfirm placement by again withdrawing air from as soon as the chest rises. Exhalation then occurs pas-
the catheter with the syringe. Secure the catheter in sively through the glottis as a result of elastic recoil of
place (Figure 15-99). the lungs and chest wall. Deliver at least 20 breaths
11. Attach the jet-ventilation device to the catheter and a per minute, keeping the inflation-to-deflation time
50-psi oxygen supply. If this is unavailable, you may approximately 1:3. Keep in mind that you may need to
connect a bag-valve device to the catheter using the adjust this to the patient’s needs, particularly in COPD
inner adapter from a 7.5-mm endotracheal tube. The and asthma patients, who often require a longer expi-
bag-valve device must be connected to oxygen. ration time.
14. Continue ventilatory support, assessing for adequacy Open Cricothyrotomy Traditional Technique
of ventilations and looking for the development of any To perform open cricothyrotomy by the traditional tech-
potential complications. nique (Procedure 15–4):
15. You should be anticipating the need for an alternative
1. Use Standard Precautions, including face mask and
means of oxygenation and ventilation within approxi-
shield.
mately 30 minutes.
2. Use BVM ventilation and supplemental oxygen to
maintain oxygenation and ventilation as well as pos-
Open Cricothyrotomy sible while preparing supplies.
An open, or surgical, cricothyrotomy involves placing an 3. Locate the thyroid cartilage and the cricoid cartilage.
endotracheal or tracheostomy tube directly into the trachea Identify the cricothyroid membrane between these two
through a surgical incision at the cricothyroid membrane. cartilages.
Open cricothyrotomy is preferred to needle cricothyrotomy 4. Clean the area with antiseptic solution.
in older pediatric patients and adult patients, because it
5. Stabilize the cartilages with one hand, while using a
allows for enhanced oxygenation and ventilation and pro-
scalpel in the other hand to make a 2- to 4-cm vertical
tects the airway against aspiration. The greater potential
skin incision in the midline over the membrane.
complications of open cricothyrotomy mandate even more
training and skills monitoring than for the needle method. 6. Locate the cricothyroid membrane again, using blunt
Indications are the same as for needle cricothyrotomy. dissection if necessary.
Contraindications are the same as for needle cricothyrot- 7. Make a 1- to 2-cm incision in the horizontal plane
omy with the addition that open cricothyrotomy is contra- through the membrane.
indicated in children under the age of 8 because the 8. Insert a tracheal hook on the inferior portion of the thy-
cricothyroid membrane is small and underdeveloped. roid cartilage to help maintain the opening. This may
The potential complications of open cricothyrotomy also be improvised with an adult or pediatric stylet.
with jet ventilation include: 9. Insert curved hemostats into the membrane incision
• Incorrect tube placement into a false passage and spread it open.
• Cricoid and/or thyroid cartilage damage 10. Insert either a cuffed endotracheal tube or a tracheos-
tomy tube into the opening, directing the tube distally
• Thyroid gland damage
into the trachea. Ideally a 6-mm tube will fit, although
• Severe bleeding smaller patients may require a smaller size.
• Laryngeal nerve damage 11. Inflate the cuff and ventilate.
• Subcutaneous emphysema 12. Confirm placement with multiple methods as avail-
• Vocal cord damage able and appropriate.
• Infection 13. Secure the tube in place.
Airway Management and Ventilation 585
15-4A Locate the cricothyroid membrane. 15-4B Stabilize the larynx and make a 1- to 2-cm skin incision
over the cricothyroid membrane.
(Continued)
586 Chapter 15
15-4H Ventilate.
15-4I Secure the tube, reconfirm placement, and evaluate the patient.
Open Cricothyrotomy Technique This technique has been associated with more compli-
cations in some studies.
Variations
Variations on the traditional open cricothyrotomy tech- • Bougie-aided. An endotracheal tube introducer (bou-
nique include the rapid four-step technique and the bougie- gie) may be used with either the traditional or the
aided technique. rapid four-step technique to minimize the risk of
placement in a false passage, to allow the operator to
• Rapid four-step. In this technique, a single incision is let go without losing critical landmarks, and to ease
made horizontally through the skin and cricoid mem- threading of the tube. In the simplest version of this
brane, then a tracheal hook is held in the left hand and technique, an adult bougie is passed into the trachea
traction is applied against the cricoid membrane, through the incision in the cricothyroid membrane,
directed toward the feet, and the tube is inserted with directed distally, and intratracheal placement is con-
the right hand, mimicking endotracheal intubation. firmed with palpation of clicks as the bougie passes
Airway Management and Ventilation 587
over the cartilage rings and/or palpation of hold-up The current evidence has not found a survival benefit
within 20 cm. Note that the distance to hold-up is to prehospital RSI outside the air-medical setting, and in
much shorter than when using the introducer/bougie some cases survival rates are notably worse with RSI.
through the mouth. Once placement is confirmed, the Despite this literature, some EMS services have been able
endotracheal or tracheostomy tube is threaded over to employ these techniques safely and with apparent
the bougie into the trachea. advantage to their patients, but it takes a great deal of ini-
tial and ongoing training, active medical director involve-
ment, a thorough quality assurance program, and the
Minimally Invasive Percutaneous maturity to select patients carefully and move early to
Cricothyrotomy backup devices.
A number of hybrid techniques are available to perform a
cricothyrotomy using a needle but allowing for a much
larger diameter ventilation catheter. Some of these tech-
Rapid Sequence Intubation
niques involve devices that are placed blindly and that Your immediate concern with every patient you treat is
consist of the needle, a dilator, and a catheter, all in one. to maintain a patent airway and adequate oxygenation
Other methods are based on the Seldinger technique (the and ventilation (except for patients in cardiac arrest, in
same technique used for central line insertion), in which a whom chest compressions would come first). Clearly, if a
guidewire is placed through a needle, which is then patient is in cardiac arrest (once circulation has been
removed so that dilators and the ventilation tube may be attended to) or is in respiratory arrest, or is unconscious
placed into the trachea over the guidewire. or obtunded and not protecting his airway, airway man-
In general, there is no advantage to these needle tech- agement with BVM ventilation, an EGA, or intubation is
niques over the open techniques, and complications may indicated.
actually be higher, although there is substantial variation Occasionally, however, you may encounter an awake
among devices and techniques. Individual agencies should patient with an airway disorder who is hypoxemic
consult their medical director and evaluate each device despite high-concentration oxygen via a nonrebreather
and technique on a case-by-case basis. We cannot stress or CPAP and therapy directed at the underlying prob-
enough that you must continually practice this skill with lem. This patient is working hard to breathe but does not
the medical director’s involvement to maintain proficiency. have adequate gas exchange to support life. Subtle
altered mental status may indicate that some level of sig-
nificant hypoxemia is putting essential brain functions
at risk.
Medication-Assisted Assisting respirations with a BVM on such a patient is
and modified in emergency medicine and EMS to become draw on once a patient has been administered a paralytic
rapid sequence intubation. agent and ceases to breathe.
RSI involves a series of steps that includes administra- Patients with healthy lungs and adequate functional
tion of a neuromuscular blocking drug to a critically ill or residual capacity may develop enough reserve from pre-
injured patient, who is presumed to have a full stomach, to oxygenation to survive up to 8 minutes of medication-
facilitate oral intubation without aspiration or other com- induced apnea without desaturation (loss of blood oxygen
plications. The procedure is called “rapid” because the saturation). Thus, preoxygenation allows us to chemically
individual steps are performed in “rapid succession,” one paralyze a patient yet withhold positive pressure ventila-
right after the other, not because the entire procedure is tion, thereby limiting the risk of gastric insufflation and
fast. In fact, RSI can take quite a bit of time in some cases. subsequent aspiration, without the patient becoming
The entire RSI procedure is intended to minimize the hypoxemic.
risk of aspiration in a high-risk population. This requires Unfortunately, many critically ill or injured patients
preoxygenation and avoiding positive pressure ventilation cannot tolerate 8 minutes of apnea. Common clinical vari-
when possible. The risks of RSI are very substantial, since a ables that affect the amount of apnea time a patient can
patient undergoing the procedure is, by definition, breath- withstand before becoming hypoxic include age, obesity,
ing, yet you are giving the patient medications that will pregnancy, lung disease, baseline saturations, acute illness,
eliminate his respiratory drive and his ability to protect his and more (Table 15-8). Children, for instance, have shorter
own airway from aspiration. apnea times in large part because of their increased basal
Potential indications include those listed next. Note, metabolism. Some patients, such as those with fever, shock,
however, that the fact that a patient meets a stated indica- alcohol withdrawal, and cocaine/amphetamine intoxica-
tion for RSI does not mean that this is the best thing to do tion, have substantially increased oxygen demand and
for that individual patient. “chew through” their reserve very quickly. Obese and
pregnant patients have less reserve in large part because of
Indications
limited functional residual capacity.52
• Impending or actual respiratory failure from any cause In most cases, preoxygenation will be accomplished
• Impending or actual inability to protect the airway with a tight-fitting nonrebreather mask with 10–15 lpm
from any cause flow for at least 3 minutes. Such a system delivers 70 to 90
percent oxygen and is sufficient for most patients. A bag-
• Combativeness secondary to presumed head trauma
valve mask may be used without positive pressure to
• Hypoxemia despite maximal therapy deliver 100 percent oxygen if desired. If positive pressure
Relative Contraindications must be used due to patient hypoxia, concentrate on good
technique to minimize air entry into the stomach.
• Predicted difficult airway After preoxygenation, patients may be roughly catego-
• Short ETA to hospital or more experienced providers rized as having “adequate,” “limited,” or “no” reserve,
• Only one paramedic on scene which generally dictates the preoxygenation preparations
• Ability to manage the patient with less risky proce-
dures
Table 15-8 High-Risk Characteristics That Decrease
• When the only indication is airway protection
Oxygen Reserve
Absolute Contraindications
Characteristics That Decrease Oxygen Reserve
• Respiratory arrest Decreased Oxygen Storage Capacity
• Cardiac arrest
• Elderly
• Obesity
• Pregnancy
Preoxygenation • Lung disease: acute, chronic, acute-on-chronic
The air we are all breathing at this very moment is only • Chest trauma
• Baseline hypoxemia
21 percent oxygen, regardless of your location or alti-
tude; the remaining 79 percent is nearly all nitrogen. If all Increased Oxygen Consumption
the nitrogen in your lungs were replaced with oxygen, • Fever/sepsis
you would have nearly five times the oxygen present • Severe pain
now. This is what occurs with preoxygenation. Hence, • Alcohol withdrawal
• Cocaine/methamphetamine intoxication
preoxygenation is sometimes called “denitrogenation” or • Tachycardia
“nitrogen washout.” This fivefold increase in oxygen in • Shock
• Children
the lungs creates an oxygen reserve that the body can
Airway Management and Ventilation 589
There is evidence that lidocaine is useful in asthmatic patients. There used to be concern about using ket-
patients to avoid or lessen bronchospasm triggered by amine in patients with head trauma and stroke, but
airway manipulation.53 that has largely been disproved as long as the patient
is not hypertensive.
INDUCTION AGENTS The purpose of an induction
• Propofol. Propofol is commonly used in the hospital
agent is to render the patient unaware during the proce-
for induction, but its use is limited in EMS by poten-
dure. Some EMS RSI protocols call for the use of induction
tially profound hypotension.
agents only in awake patients. Because it is impossible to
know how aware an unconscious patient might be, we
NEUROMUSCULAR BLOCKING AGENTS (PARA-
recommend routine use for any patient who requires RSI
LYTICS) Paralytics, or neuromuscular blocking agents,
(Table 15-10). Common induction agents used in EMS
are drugs that temporarily stop skeletal muscle function
include the following:
without affecting cardiac or smooth muscle. The two pri-
• Etomidate. Etomidate is a great agent for induction mary categories are competitive and noncompetitive
because it rarely causes any rise or drop in blood pres- agents. The competitive agents have a dose response such
sure or pulse. It also works extremely fast, with a rela- that the higher the dose, the quicker the paralysis takes
tively consistent dose response. There has been place but the longer it lasts. Competitive agents are nonde-
concern about suppression of adrenal gland function polarizing; that is, they do not cause fasciculations (muscle
in septic patients, but thus far there is no evidence that twitches) and generally have fewer adverse effects and
this is a significant enough safety concern to cause contraindications. Noncompetitive agents have a much
EMS to avoid it. more limited dose response such that the onset time and
• Midazolam. Midazolam is a benzodiazepine seda- duration are somewhat fixed as long as a reasonable dose
tive/hypnotic. The major advantage of midazolam is is used. The noncompetitive agents are also called depolar-
amnesia. That is, the patient is unlikely to recall the izing agents because they cause fasciculations before the
procedure. The major disadvantage is that the dose onset of paralysis.54–56
required for induction is commonly associated with • Succinylcholine. Succinylcholine is the prototype non-
hypotension. It is also hard to predict the dose that will competitive depolarizing neuromuscular blocker.
make any particular patient unaware. Because of its fast onset (about 45 seconds) and short
• Ketamine. Ketamine is a dissociative agent that is duration (about 8 minutes), this is the preferred agent
being used more in emergency medicine and critical for most EMS services. Unfortunately, succinylcholine
care transport with some use in EMS as well. The has a host of potential adverse effects (Table 15-11) that
advantages of ketamine are that it has a predictable result in a number of contraindications that must be
dose response, does not cause hypotension, and pro- considered in all patients. Succinylcholine is not rou-
vides analgesia as well as sedation. The major disad- tinely recommended for maintaining paralysis, so a sec-
vantage is hypertension and tachycardia in some ond competitive agent must usually be carried as well.
Diazepam (Valium) 0.2–0.5 mg/kg 2–3 min 30–40 min Amnesia effects Hypotension, respiratory
depression
Etomidate (Amidate) 0.3 mg/kg 1–2 min 5 min Little effect on blood pressure, Suppresses cortisol, not good
decreases intracranial pressure (ICP) for head-injured patients
Ketamine (Ketalar) 1–2 mg/kg 1 min 10–20 min Decreases bronchospasm, little Increases ICP
hypotension, amnesia
Sodium thiopental 3–5 mg/kg 1 min 5 min Blunts ICP changes Significant hypotension,
bronchospasm
Propofol (Diprivan) 1–1.5 mg/kg 1 min 3–5 min Rapid onset, good sedative effects Significant hypotension
Fentanyl 3–5 mcg/kg 1–2 min 30–40 min Little effect on blood pressure; Can cause muscle rigidity in
blunts ICP changes chest wall
Airway Management and Ventilation 591
agent and paralytic. The induction agent should rou- Relative RSA Contraindications
tinely be given before the paralytic.
• Patient’s airway may be managed by other means
9. Pass the tube with direct or indirect visualization or an • Anticipated inability to ventilate by BVM
endotracheal tube introducer. Use all available adjunc-
• Anticipated need for very high airway pressures
tive techniques including external laryngeal manipula-
tion (ELM). Monitor oxygenation and be ready to abort • Very high aspiration risk
the attempt before the oxygen level reaches critical • Short ETA to hospital or arrival of help with more
point. In most cases, where the patient is adequately resources
preoxygenated and has a saturation of 100 percent • Only one paramedic on scene
beforehand, the attempt should be stopped when the
saturation reaches about 93 percent.
10. Post-intubation management begins with objective tube The Difficult Airway
confirmation, using capnography. Lung sounds should As a paramedic, you will be expected to be able to effec-
be used to help guide tube depth. A bite block should tively manage patients when establishing and maintaining
be inserted, and the tube should be secured in place an airway may be difficult. It has been estimated that 1 out
and the cervical collar replaced if indicated. The patient of 10 endotracheal intubations can be classified as “diffi-
should be placed on the transport ventilator including cult,” and intubation may be impossible in 1 out of 100
in-line continuous capnography. The patient should patients when conventional techniques (including straight-
then receive analgesia and sedation. Ongoing paralysis blade, ELM, and introducers) are attempted.57–58
should be administered only if absolutely necessary to It is important, however, to think globally in terms of
manage the patient on the ventilator and never with- the difficult airway rather than considering only difficult
out analgesia and sedation. Monitor oxygen saturation intubation. The concept of the difficult airway includes dif-
(SpO2), end-tidal CO2, blood pressure, clinical exam, ficult BVM ventilation, difficult extraglottic airway place-
and ventilator parameters. ment and ventilation, difficult intubation, and difficult
cricothyrotomy.
Rapid Sequence Airway • Difficult bag-valve-mask ventilation: a clinical situa-
Rapid sequence airway (RSA) is a new airway management tion in which a paramedic anticipates or experiences
technique in which the preparation and pharmacology of difficulty maintaining an adequate saturation (usually
RSI is paired with intentional placement of an extraglottic >90%) using high-concentration oxygen, basic airway
airway device, without prior attempt at direct laryngos- adjuncts, and two-person technique.
copy, in selected patients. The theoretical advantages to • Difficult extraglottic airway: a clinical situation in
RSA over RSI include less hypoxemia, less airway trauma, which a paramedic anticipates or experiences difficult
and no risk of tube misplacement. The major risks are aspi- inserting or ventilating with an extraglottic airway
ration and ineffective ventilation. The risk of aspiration is device.
offset by fewer airway attempts and new gastric-isolation
• Difficult intubation: a clinical situation in which a
EADs that achieve an excellent seal pressure and also allow
paramedic anticipates or experiences difficulty visual-
for gastric decompression. The risk of ineffective ventila-
izing the vocal cords or posterior cartilages within one
tion is offset through careful patient and device selection.
optimal attempt and without the patient developing
RSA Indications hypoxemia.
• Same as RSI • Difficult cricothyrotomy: a clinical situation in which
a paramedic anticipates or experiences difficulty
Absolute RSA Contraindications
obtaining a surgical airway in less than 60 seconds.
• Upper airway pathology known or suspected • Difficult airway: a clinical situation in which a para-
• Blunt or penetrating anterior neck trauma medic anticipates or experiences difficulty with any
• Inhalation injury critical portion of air-
way management, CONTENT REVIEW
• Angioedema
including BVM venti- ➤➤ Difficult Airway Factors
• Anaphylaxis
lation, extraglottic • Difficult BVM ventilation
• Upper airway tumor • Difficult extraglottic
airway placement,
• Obstructing upper airway infection—croup, epiglotti- endotracheal intuba- airway placement
tis, parapharyngeal abscess • Difficult intubation
tion, or surgical crico-
• Difficult cricothyrotomy
• Caustic ingestion thyrotomy.
Airway Management and Ventilation 593
Class I Class II Class III Class IV the percentage of the glottis that
can be visualized is scored. The
score ranges from 0 (none of the
glottis visualized) to 100 (vocal
cords fully visualized). This sys-
tem also helps to predict the dif-
ficulty of endotracheal intubation
(Figure 15-102).
As you may already have
figured out, airway classification
Grade I Grade II Grade III Grade IV systems such as Mallampati,
Cormack and LeHane, and
POGO, though very helpful in
more controlled or leisurely
environments, have little appli-
cation to emergency medicine.
FIGURE 15-101 Airway scoring systems. Mallampati classification system (top); Cormack and
LeHane classification system (bottom).
This is especially so in the case of
the austere prehospital environ-
ment. However, knowing the
Rarely will a paramedic have time to assess the Malla- features of these classification systems can help you to bet-
mpati class prior to intubation attempts. The Mallampati ter anticipate the difficult airway.
assessment is done with the patient awake and sitting up.
The patient opens his mouth and sticks his tongue out.
Recognizing that the Mallampati system is of little use in “LEMONS”
the unconscious patient, Cormack and LeHane adapted “LEMONS” is an acronym that can be used to remember
the system to classify the view one sees with a laryngo- assessments and findings associated with a difficult air-
scope. The Cormack and LeHane grading system is simi- way. Factors that have been assembled into the LEMONS
lar to Mallampati’s (see Figure 15-101). mnemonic can encompass the entire difficult airway
assessment, including difficult bag-valve-mask ventila-
Grade 1: Entire glottic opening and vocal cords may be seen. tion, EGA insertion and ventilation, endotracheal intuba-
Grade 2: Epiglottis and posterior portion of glottic opening tion, and cricothyrotomy (Table 15-13). Unfortunately,
may be seen with a partial view of vocal cords. most of these clinical assessments cannot be realistically
Grade 3: Only epiglottis and (sometimes) posterior carti- performed in the austere prehospital environment. For
lages seen. example, the Mallampati score, as already noted, relies on
having a cooperative patient sit up, open his mouth fully,
Grade 4: Neither epiglottis nor glottis seen.
and stick out his tongue so the hard palate, uvula, and
A similar system used in EMS is the percentage of glottic posterior pharynx can be visualized. The astute paramedic
opening (POGO) system. With the POGO scoring system, will still look into the mouth before committing to intuba-
tion in order to assess overall working room—a modified
Mallampati score.
LEMONS
100%
L Look externally
M Mallampati score
O Obstruction
N Neck mobility
Percentage of glottic opening (POGO) scale.
S Saturations
FIGURE 15-102 POGO scoring system.
Airway Management and Ventilation 595
The 3–3–2 Rule LOOK EXTERNALLY Look for factors that will make
BVM ventilation, EGA, intubation, or surgical airway dif-
ficult. This includes facial hair, secretions, massive obesity,
facial trauma, upper airway pathology, and gross face/
neck anatomic deformities.
NECK MOBILITY Neck mobility is most often limited may not generate enough airway pressure to lift a very
by cervical spine immobilization, although patients with heavy chest. Finally, obesity may make identification of
rheumatoid arthritis or spinal fusions, and elderly patients landmarks for a surgical airway very difficult.
with severe degenerative disease, may also have restricted
range of motion. This is another reminder that any patient Predicting Difficulty:
in spinal precautions should be considered to have a dif-
ficult airway. It is important in these cases that the front
An Imperfect Science
of the cervical collar be removed and manual stabilization Prediction of difficult intubation is an imperfect science
with a jaw-thrust applied during intubation to allow for- at best with limited applicability to most patients under-
ward movement of the chin. going emergency airway management (Figure 15-104).
Prediction of difficult BVM ventilation is somewhat
SATURATIONS One of the most critical elements in air- more reliable. Nonetheless, providers should look for
way management is the time allowed to successfully com- and heed obvious warning signs of a difficult intubation
plete the procedure. The primary determinant of time in or BVM ventilation and prepare accordingly. Do not,
these procedures is the oxy-
gen saturation and, in turn, Sometimes we are already into
your ability to preoxygen- RSI when we get into trouble!
Difficult airway
ate and create an oxygen
reserve. As noted earlier, a
patient whose oxygen satu- Recognized
airway Paralyze the
ration is near 100 percent Unrecognized patient
problem
following preoxygenation
has “adequate reserve,”
above 90 percent but less Time for Mask ventilation Intubation
proper NO! Remember to reposition Fail
than 100 percent has “lim- techniques
preparation? the patient
ited reserve,” and less than
90 percent despite appro- Succeed Fail
priate preoxygenation has NO
Yes Unable to
“no reserve.” Yes
Able to ventilate ventilate!
Nonemergency Emergency
Awake pathway pathway
Effects of Obesity intubation
choices
The airway effects of obe-
LMA
sity are complex but, over- Intubation
Succeed CombiTube
all, negative. Much of the techniques
TTJV
anatomic problem with
Sometimes, use of an Consider
intubation in the morbidly adjunct technique will that these
obese may be overcome Fail facilitate the intubation, techniques
Remember, but these take time, so are buying
with proper positioning—
we just don't we have to be able to time to get Fail
that is, the ramped posi- have a choice ventilate the patient. reorganized,
tion, which was described about canceling and intubate
earlier in the chapter. Obe- the case! the patient.
Intubation adjuncts
sity also limits the effects Surgical Stylet Surgical
airway Retrograde airway
of preoxygenation due to
Eschmann
reduced functional resid- Fiberoptics
ual capacity as well as
increased oxygen demand Succeed
so that time to perform the By the time we get
to surgical airway,
intubation before critical failure is not an option!
hypoxemia may be lim- Confirm
ited. Obesity definitely
makes BVM ventilation
more difficult, and some FIGURE 15-104 Difficult airway management algorithm.
extraglottic rescue devices (From Stewart, C. E. Advanced Airway Management, Upper Saddle River, NJ; Pearson/Prentice Hall, 2002)
Airway Management and Ventilation 597
Battery-operated Lightweight, portable, excellent suction power, simple Battery memory decreases with time; mechanically more
to operate and troubleshoot in the field complicated than hand-powered, some fluid contact
components are not disposable
Mounted Strong suction, adjustable vacuum power, disposable Not portable, cannot be serviced in the field, no substitute
fluid contact components power source
swelling. Begin by preoxygenating the patient with 100 per- should be gravity: Turning the patient or just his head to
cent oxygen and then inject 3 mL sterile saline down the the side (if not in cervical precautions) is faster and more
trachea through the stoma. Gently insert a sterile catheter effective than any suction device. However, suctioning
until resistance is met. While the patient coughs or exhales, equipment still must be readily available for all patients if
suction the airway during withdrawal of the catheter. repositioning is not possible or as an adjunct to rotation.
Supplemental oxygen may be delivered by placing an
oxygen mask over the stoma or tracheostomy tube. If this is Suctioning Equipment
insufficient or if the patient requires positive pressure venti-
Many kinds of suctioning devices are available. They
lation, it is very easy to attach a bag-valve device to the tra-
may be handheld, oxygen-powered, battery-operated, or
cheostomy tube. If the patient has a stoma but no
mounted (nonportable). Table 15-15 details the advan-
tracheostomy tube, then gently insert a lubricated endotra-
tages and disadvantages of each.
cheal or tracheostomy tube to perform ventilation.
To suit the prehospital environment, your equipment
should be lightweight, portable, and durable; generate a
Suctioning vacuum level of at least 300 mmHg when the distal end
is occluded; and allow a flow rate of at least 30 liters per
Anticipating and being prepared for complications when minute when the tube is open. In addition to a portable
managing airways is the key for successful outcomes. You device, the ambulance should have a mounted, vacuum-
must anticipate that a patient may vomit and be prepared powered suction device that can generate stronger suc-
to turn the patient and suction in order to remove blood, tion and that can be a backup device in case of equipment
mucus, and emesis. The first line of defense against aspiration failure (Figure 15-106).
Suctions larger volumes of fluid rapidly Cannot remove large volumes of fluid rapidly
Used in oropharyngeal airway only Can be placed in the oropharynx, nasopharynx, or down the endotracheal tube
Removes larger particles Suction tubing without catheter (facilitates suctioning of large debris)
The most commonly used suction catheters are hard/ In many cases, you will suction extremely viscous, or
rigid catheters (“Yankauer” or “tonsil tip”) and soft catheters thick, secretions that can obstruct the flow of fluid
(“whistle tip”). Table 15-16 summarizes their differences. through the tubing. To reduce this problem, suction water
Because suctioning also removes oxygen, and because through the tubing between suctioning attempts. This
you must interrupt oxygen delivery to suction, you should dilutes the secretions and facilitates flow to the suction
limit each suctioning attempt to 10 seconds. If possible, canister. Most suction units have small water canisters for
hyperventilate the patient with 100 percent oxygen before this purpose.
and after each effort. Do not apply suction while inserting
the catheter. Apply suction only as you withdraw the cath- Tracheobronchial Suctioning
eter after properly positioning it.
Suctioning is normally applied to the oropharynx. How-
Complications of suctioning are usually related to
ever, you may occasionally need to suction a patient
hypoxemia from prolonged suctioning attempts without
through an endotracheal tube or a tracheostomy tube to
proper ventilation. The decrease in myocardial oxygen
remove secretions or mucus plugs from the tracheobron-
supply can cause cardiac dysrhythmias. Suctioning can
chial airway that can cause respiratory distress. Tracheo-
also stimulate the vagus nerve, causing bradycardia and
bronchial suctioning risks hypoxemia, so ensuring
hypotension, or the anxiety of being suctioned can cause
adequate oxygenation before and after the procedure is
hypertension and tachycardia. Stimulation of the cough
essential. Sterile technique should be used to avoid con-
reflex will cause a patient to cough, causing an increase in
taminating the pulmonary system. Use only the soft-tip
intracranial pressure and reducing cerebral blood flow.
catheter intended for endotracheal use to avoid damaging
any structures, and be certain to lubricate well. Once you
Suctioning Techniques have preoxygenated the patient with 100 percent oxygen,
You must have suction equipment by any patient who has gently insert the lubricated tube, using sterile gloves, until
airway compromise and will need airway management. you feel resistance (Figure 15-107). Then apply suction for
Do not forget this basic and important skill. To suction a only about 10 seconds while withdrawing the catheter. You
patient: may need to inject 3 to 5 mL of sterile water or saline down
the endotracheal tube before suctioning to help loosen
1. Use Standard Precautions, including protective eye-
thick secretions.
wear, gloves, and face mask.
2. Preoxygenate the patient; this may require brief hyper-
ventilation.
3. Determine the depth of catheter insertion by measur- Gastric Distention
ing from the patient’s earlobe to his lips.
4. With the suction turned off, insert the catheter into
and Decompression
your patient’s pharynx to the predetermined depth. A common problem during BVM ventilation is the entry of
air into the stomach (gastric insufflation), which increases
5. Turn on the suction unit and place your thumb over
the risk of vomiting and regurgitation with subsequent
the suction control orifice; limit suction to 10 seconds.
aspiration. The enlarged stomach also pushes against the
6. Continue to suction while withdrawing the catheter. diaphragm, inhibiting the lungs’ expansion and increasing
When using a whistle-tip catheter, rotate it between resistance to ventilation. Pediatric patients are prone to
your fingertips. bradycardia from vagal stimulation that may result. Ide-
7. While maintaining ventilatory support, hyperventilate ally, gastric insufflation will be prevented rather than
the patient with 100 percent oxygen. treated, as it is much less likely to occur with optimal BVM
600 Chapter 15
ventilation technique, as discussed earlier in this chapter. unless they have undergone a banding or cautery proce-
Gastric insufflation is even less likely to occur with an dure within the past two weeks. However, gastric intuba-
extraglottic airway (EGA) device. tion should be avoided if esophageal obstruction or
Unfortunately, even with optimal BVM ventilation perforation is suspected.
technique, gastric insufflation is inevitable with prolonged All three routes—nasogastric, orogastric, and EGA—
ventilation, and poor BVM ventilation technique is still carry the risk of misplacement into the lungs, although this
rampant in prehospital care. Therefore, paramedics will is much less likely using an EGA. Both the oral and nasal
need to be able to treat this condition with gastric decom- routes put the patient at risk for vomiting and bleeding
pression, which involves the placement of a gastric tube during insertion. For this reason, gastric tubes should not
into the stomach via the mouth (orogastric) or the nose be placed in obtunded patients unless they are already
(nasogastric) or through an EGA. intubated or have an EGA in place.
Nasogastric tube placement is generally preferred in As for any other invasive procedure, you should
awake patients, as it is more comfortable than orogastric always wear protective eyewear, gloves, and a face shield
placement and does not interfere with speech. However, whenever you place a gastric tube. To place an orogastric
placement in an awake patient is rarely necessary in pre- tube in the unconscious patient:
hospital care, except during some air medical transports,
1. Take Standard Precautions.
and is not discussed here.
2. Place the patient’s head in a neutral position while
Orogastric tube placement is recommended in most
ventilating via the endotracheal tube or EGA.
unconscious patients to minimize the risk of epistaxis and
sinusitis. It is also recommended with facial fractures, to 3. Select the correct size gastric tube. Most adults take a
avoid placing the tube through a skull fracture into the 16 Fr when placed orally. Some EGAs will accommo-
brain, and in patients who are at increased risk for nasal date only larger or only smaller sizes, and this should
bleeding. If the patient has an EGA in place that has a be checked in advance.
dedicated channel for gastric tube insertion, this should 4. Determine the approximate length of tube insertion
be used. by measuring from the epigastrium to the angle of the
Contrary to popular belief, gastric tubes may be gently jaw, then to the mouth opening or to the proximal end
placed in patients who have gastric or esophageal varices of the EGA.
Airway Management and Ventilation 601
5. Generously lubricate the distal tip of the gastric tube transports of relatively uncomplicated adult and older
and gently insert it into the oral cavity at midline. pediatric patients. These devices generally allow for con-
6. Advance the tube gently to the length you determined trol of ventilatory rate and tidal volume only. Most of these
prior to insertion. units deliver controlled ventilation only (will breathe only
for patients who are not breathing on their own), whereas
7. Check that the tube has not curled in the mouth.
other units will function as intermittent mandatory venti-
8. Confirm placement by injecting 30 to 50 mL of air lators (assisting spontaneously breathing patients), which
while listening to the epigastric region for air entry revert to controlled mechanical ventilation in patients who
into the stomach. In addition, end-tidal CO2 detectors are not breathing.
are now available that will attach to a gastric tube. The inspired oxygen concentration is usually fixed at
In this case the detection of CO2 indicates incorrect 100 percent, but it may be adjustable. Oxygen consumption
placement in the lungs, rather than correct placement on longer transports may be substantial. Most of these
in the stomach. Coughing also suggests malposition devices do not provide CPAP. These devices also offer little
in the lungs, although this is unreliable in uncon- ability to monitor airway pressures or delivered volumes
scious patients. and usually do not have warning alarms, but instead have
9. Apply gentle suction to the tube to evacuate gastric a pop-off valve that prevents pressure-related injury. When
fluids and gas. airway pressure exceeds a preset level (typically 60 cm
10. Secure the tube in place. H2O), the valve opens, venting some of the tidal volume.
This safety feature may actually hinder ventilation in
11. Document the indication for gastric decompression,
patients who require greater positive pressure, such as
the size tube placed, the technique, means of con-
those with significant lung pathology (e.g., cardiogenic
firmation, any complications incurred, the type and
pulmonary edema, adult respiratory distress syndrome
volume of gastric contents evacuated, and the clinical
[ARDS], pulmonary contusion, and bronchospasm). Con-
response.
sider using a bag-valve device if this problem occurs.
Critical care transport ventilators, in contrast to the sim-
Transport Ventilators ple units just described, offer a host of features such as dif-
ferent ventilator modes, enhanced monitoring, alarms, and
Mechanical ventilation, as by a transport ventilator more (Figure 15-108). The increased adjustability allows for
mounted in the ambulance, is designed to assist or replace keeping the patient more comfortable with less sedation,
the patient’s own breathing. In a patient who is not breath- analgesia, and paralysis. Some of these devices can be used
ing spontaneously, the mechanical ventilator provides to provide mask CPAP as well. Inspired oxygen concentra-
“controlled” ventilations. Some mechanical ventilators are tion can usually be adjusted. These critical transport devices
designed to provide intermittent “mandatory” ventilation; can be used on most pediatric patients and some neonates.
that is, the ventilator will assist a patient’s own spontane- The trade-off for these features is much higher cost, and
ous breaths but will revert to controlled ventilations if the their greater complexity requires much more extensive
patient stops breathing. training. These advanced ventilators are worth considering
There is accumulating evidence that mechanical venti- if you have long transports, do a lot of interfacility trans-
lation is superior to manual ventilation except in the crash- ports, or have a large pediatric population.
ing patient, for whom assessment of compliance and
elimination of the ventilator as a source of the problem
becomes essential. Mechanical ventilation frees up provider
hands and, when used correctly, is less likely to cause
hemodynamic impairment or CO2 fluctuations that have
been associated with worse outcomes in head trauma
patients. It is recommended that all patients with an inva-
sive airway (ETT or EGA) be maintained on a ventilator all
the way to patient turnover in the hospital when a ventila-
tor is available and not contraindicated.
There are two general varieties of ventilators for pre-
hospital use: simple compact devices with a minimum of
options for general use and more complicated devices for
critical care transport.
The simple out-of-hospital ventilator devices are
designed for convenience and ease of use during short FIGURE 15-108 Transport ventilators.
602 Chapter 15
The documentation sample shown in Figure 15-109 is agree. Because patients who require prehospital airway
by no means the only way to document airway manage- management are at high risk for a bad outcome from the
ment. It is, however, provided as an example. One may be outset, and because airway management literally deter-
tempted to say that the example is “over-documentation.” mines whether the patient lives or dies, it stands to reason
However, few practitioners who have been called to tes- that the greatest emphasis should be placed on detailed
tify under oath about their airway management would documentation of these issues.
Review Questions
1. The depression between the epiglottis and the base c. respiratory rate.
of the tongue is called the _____________ d. total lung capacity.
a. naris. c. larynx.
3. A drop in blood pressure of greater than 10 torr dur-
b. glottis. d. vallecula. ing inspiration is called_____________
2. The average volume of gas inhaled or exhaled in one a. compliance.
respiratory cycle is the_____________ b. laryngeal spasm.
a. minute volume. c. pulsus paradoxus.
b. tidal volume. d. paradoxical breathing.
604
Airway Management and Ventilation 605
4. To avoid hypoxia during intubation, limit each 13. _____________ is often called the “fifth vital sign.”
intubation attempt to no more than _____________ a. Heart rate
seconds before reoxygenating the patient. b. Blood pressure
a. 10 c. 30 c. Pulse oximetry
b. 20 d. 40 d. Blood glucose level
5. Which medication is not a preferred neuromuscular 14. The visual representation of the expired CO2 wave-
blocking agent for emergency RSI? form is the_____________
a. Atracurium c. Pancuronium a. capnogram. c. capnometry.
b. Vecuronium d. Succinylcholine b. capnograph. d. capnography.
6. The_____________ is the most superior part of the 15. Which of the following is an advantage of the naso-
airway. pharyngeal airway?
a. pharynx c. oral cavity a. It isolates the trachea from aspiration.
b. larynx d. nasal cavity b. It is designed to be suctioned through.
7. The _____________ is the only bone in the axial skel- c. It can be used in a patient with a gag reflex.
eton that does not articulate with any other bone. d. It cannot cause any type of soft tissue trauma
a. femur c. stapes during insertion.
b. hyoid d. patella 16. Advantages of endotracheal intubation include
8. The _____________ comprise(s) the key functional which of the following?
unit of the respiratory system. a. It eliminates the need to maintain a mask seal.
a. hilum b. It isolates the trachea and permits complete
b. alveoli control of the airway.
c. bronchi c. It impedes gastric distention by channeling air
directly into the trachea.
d. respiratory bronchioles
d. All of the above.
9. The paramedic can correct oxygen derangements
17. Which medication is generally the second-line para-
by_____________
lytic when succinylcholine is contraindicated?
a. increasing the ventilatory rate in a spontaneously
breathing patient. a. Atracurium
b. administering supplemental oxygen. b. Fentanyl
c. using negative CPAP pressure. c. Rocuronium
d. all of the above. d. Pancuronium
10. The _____________ is the amount of gas in the tidal 18. Relative contraindications for blind nasotracheal
volume that remains in air passageways unavailable intubation include_____________
for gas exchange. a. suspected elevation of intracranial pressure.
a. base tidal volume c. dead-space volume b. suspected basilar skull fracture.
b. minute volume d. total lung capacity c. a combative patient.
d. all of the above.
11. “Difficulty speaking” defines_____________
a. aphagia. c. dysphonia. 19. Which airway can work properly regardless of the
b. aphonia. d. dysphagia. tip being in the esophagus or the trachea?
a. ET c. LMA
12. “An irregular pattern of rate and depth with
b. ETC d. PLA
sudden, periodic episodes of apnea, indicating
increased intracranial pressure” 20. Open cricothyrotomy is contraindicated in children
describes_____________ under the age of _____________ because the crico-
a. agonal respirations. thyroid membrane is small and underdeveloped.
b. Biot’s respirations. a. 8 c. 12
c. Kussmaul’s respirations. b. 10 d. 14
d. Cheyne-Stokes respirations. See Answers to Review Questions at the back of this book.
606 Chapter 15
References
1. Austin, M. A., K. E. Wills, L. Blizzard, E. H. Walters, and R. 19. Cady, C. E., M. D. Weaver, R. G. Pirrallo, and H. E. Wang. “Effect
Wood-Baker. “Effect of High Flow Oxygen on Mortality in of Emergency Medical Technician-Placed Combitubes on Out-
Chronic Obstructive Pulmonary Disease Patients in Prehospital comes after Out-of-Hospital Cardiopulmonary Arrest.” Prehosp
Setting: Randomised Controlled Trial.” BMJ 341 (2010): c5462. Emerg Care 13 (2009): 495–499.
2. Body, R. and K. Hogg. “Best Evidence Topic Reports. Oxygen in 20. Russi, C. S., L. Miller, and M. J. Hartley. “A Comparison of the
Acute Uncomplicated Myocardial Infarction.” Emerg Med J 21 King-LT to Endotracheal Intubation and Combitube in a Simu-
(2004): 75. lated Difficult Airway.” Prehosp Emerg Care 12 (2008): 35–41.
3. Moradkhan, R. and L. I. Sinoway. “Revisiting the Role of 21. Gaither, J. B., J. Matheson, A. Eberhardt, and C. B. Colwell.
Oxygen Therapy in Cardiac Patients.” J Am Coll Cardiol 56 “Tongue Engorgement Associated with Prolonged Use of the
(2010): 1013–1016. King-LT Laryngeal Tube Device.” Ann Emerg Med 55(4) (2010):
4. Barker, S. J., J. Curry, D. Redford, and S. Morgan. “Measurement 367–369.
of Carboxyhemoglobin and Methemoglobin by Pulse Oximetry: 22. Guyette, F. X., H. Wang, and J. S. Cole. “King Airway Use by Air
A Human Volunteer Study.” Anesthesiology 105 (2006): 892–897. Medical Providers.” Prehosp Emerg Care 11 (2007): 473–476.
5. Bledsoe, B. E., K. Nowicki, J. H. Creel, D. Carrison, and H. W. 23. Bledsoe, B. E., D. Slattery, R. Lauver, W. Forred, L. Johnson, and
Severance. “Use of Pulse CO-Oximetry as a Screening and Moni- G. Rigo. “Can Emergency Medical Services Personnel Effectively
toring Tool in Mass Carbon Monoxide Poisoning.” Prehosp Emerg Place and Use the S.A.L.T. Airway?” Prehosp Emerg Care 15 (2011):
Care 14 (2010): 131–133. 359–365.
6. Rucker, J., J. Tesler, L. Fedorko et al. “Normocapnia Improves 24. Murray, M. J., M. J. Vermeulen, L. J. Morrison, and T. Waite.
Cerebral Oxygen Delivery during Conventional Oxygen Therapy “Evaluation of Prehospital Insertion of the Laryngeal Mask Air-
in Carbon Monoxide-Exposed Research Subjects.” Ann Emerg way by Primary Care Paramedics with Only Classroom Manne-
Med 40 (2002): 611–618. quin Training.” CJEM 4 (2002): 338–343.
7. Camp, N. E. “Methemoglobinemia.” J Emerg Nurs 33 (2007): 25. Chen, L. and A. L. Hsiao. “Randomized Trial of Endotracheal
172–174. Tube versus Laryngeal Mask Airway in Simulated Prehospital
8. Abu-Laban, R. B., P. J. Zed, R. A. Purssell, and K. G. Evans. Pediatric Arrest.” Pediatrics 122 (2008): e294–e297.
“Severe Methemoglobinemia from Topical Anesthetic Spray: 26. Choyce, A., M. S. Avidan, C. Patel et al. “Comparison of Laryn-
Case Report, Discussion and Qualitative Systematic Review.” geal Mask and Intubating Laryngeal Mask Insertion by the Naïve
CJEM 3 (2001): 51–56. Intubator.” Br J Anaesth 84 (2000): 103–105.
9. Kupnik, D. and P. Skok. “Capnometry in the Prehospital Setting: 27. Davis, D. P. “Should Invasive Airway Management Be Done in
Are We Using Its Potential?” Emerg Med J 24 (2007): 614–617. the Field?” CMAJ 178 (2008): 1171–1173.
10. Silvestri, S., G. A. Ralls, B. Krauss et al. “The Effectiveness of 28. Bochicchio, G. V. and T. M. Scalea. “Is Field Intubation Useful?”
Out-of-Hospital Use of Continuous End-Tidal Carbon Dioxide Curr Opin Crit Care 9 (2003): 524–529.
Monitoring on the Rate of Unrecognized Misplaced Intubation 29. Wang H. E. and D. M. Yealy. “Out-of-Hospital Endotracheal Intu-
within a Regional Emergency Medical Services System.” Ann bation: Where Are We?” Ann Emerg Med 47 (2006): 532–541.
Emerg Med 45 (2005): 497–503. 30. Wang, H. E., G. K. Balasubramani, L. J. Cook, J. R. Lave, and
11. Collin, J. S., H. J. Lemmens, J. B. Brodsky et al., “Laryngoscopy D. M. Yealy. “Out-of-Hospital Endotracheal Intubation
and Morbid Obesity: A Comparison of the ‘Sniff’ and ‘Ramped’ Experience and Patient Outcomes.” Ann Emerg Med 55(6)
Position.” Obes Surg 14 (2004): 1171–1175. (2010): 527–537.e6.
12. Ellis, D. Y., T. Harris, and D. Zideman. “Cricoid Pressure in 31. Wang, H. E. and D. M. Yealy. “How Many Attempts Are
Emergency Department Rapid Sequence Tracheal Intubations: A Required to Accomplish Out-of-Hospital Endotracheal Intuba-
Risk-Benefit Analysis.” Ann Emerg Med 50 (2007): 653–665. tion?” Acad Emerg Med 13 (2006): 372–377.
13. Hubble, M. W., L. Brown, D. A. Wilfong, A. Hertelendy, R. W. 32. Warner, K. J., D. Carlbom, C. R. Cooke, E. M. Bulger, M. K.
Benner, and M. E. Richards. “A Meta-Analysis of Prehospital Copass, and S. R. Sharar. “Paramedic Training for Proficient
Airway Control Techniques Part I: Orotracheal and Nasotra- Prehospital Endotracheal Intubation.” Prehosp Emerg Care 14
cheal Intubation Success Rates.” Prehosp Emerg Care 14 (2010): (2010): 103–108.
377–401. 33. Wang, H. E., B. N. Abo, J. R. Lave, and D. M. Yealy. “How Would
14. Hubble, M. W., D. A. Wilfong, L. H. Brown, A. Hertelendy, and R. Minimum Experience Standards Affect the Distribution of Out-
W. Benner. “A Meta-Analysis of Prehospital Airway Control of-Hospital Endotracheal Intubations?” Ann Emerg Med 50 (2007):
Techniques Part II: Alternative Airway Devices and Cricothyrot- 246–252.
omy Success Rates.” Prehosp Emerg Care 14 (2010): 515–530. 34. Katz, S. H. and J. L. Falk. “Misplaced Endotracheal Tubes by
15. Colwell, C. B., K. E. McVaney, J. S. Haukoos, et al. “An Evalua- Paramedics in an Urban Emergency Medical Services System.”
tion of Out-of-Hospital Advanced Airway Management in an Ann Emerg Med 37 (2001): 32–37.
Urban Setting.” Acad Emerg Med 12 (2005): 417–422. 35. Jones, J. H., M. P. Murphy, R. L. Dickson, G. G. Somerville, and E.
16. Guyette, F. X., M. J. Greenwood, D. Neubecker, R. Roth, and H. E. J. Brizendine. “Emergency Physician-Verified Out-of-Hospital
Wang. “Alternate Airways in the Prehospital Setting (Resource Intubation: Miss Rates by Paramedics.” Acad Emerg Med 11
Document to NAEMSP Position Statement).” Prehosp Emerg Care (2004): 707–709.
11 (2007): 56–61. 36. Levitan, R. M., W. C. Kinkle, W. J. Levin, and W. W. Everett.
17. Bercker, S., W. Schmidbauer, T. Volk et al. “A Comparison of Seal “Laryngeal View during Laryngoscopy: A Randomized Trial
in Seven Supraglottic Airway Devices Using a Cadaver Model of Comparing Cricoid Pressure, Backward-Upward-Rightward
Elevated Esophageal Pressure.” Anesth Analg 106 (2008): 445–448, Pressure, and Bimanual Laryngoscopy.” Ann Emerg Med 47
Table of Contents. (2006): 548–555.
18. Cady, C. E. and R. G. Pirrallo. “The Effect of Combitube Use on 37. Wayne, M. A. and M. McDonnell. “Comparison of Traditional
Paramedic Experience in Endotracheal Intubation.” Am J Emerg versus Video Laryngoscopy in Out-of-Hospital Tracheal Intuba-
Med 23 (2005): 868–871. tion.” Prehosp Emerg Care 14 (2010): 278–282.
Airway Management and Ventilation 607
38. Cobas, M. A., M. A. De la Peña, R. Manning, K. Candiotti, and A. ortality in Attempted Prehospital Intubation.” J Emerg Med
M
J. Varon. “Prehospital Intubations and Mortality: A Level 1 38 (2010): 175–181.
Trauma Center Perspective.” Anesth Analg 109 (2009): 489–493. 49. Davis, D. P., J. V. Dunford, J. C. Poste et al. “The Impact of
39. Davis, D. P., J. Peay, M. J. Sise et al. “The Impact of Prehospital Hypoxia and Hyperventilation on Outcome after Paramedic
Endotracheal Intubation on Outcome in Moderate to Severe Rapid Sequence Intubation of Severely Head-Injured Patients.”
Traumatic Brain Injury.” J Trauma 58 (2005): 933–939. J Trauma 57 (2004): 1–8; discussion 8–10.
40. Shafi, S. and L. Gentilello. “Pre-Hospital Endotracheal Intubation 50. Davis, D. P., D. B. Hoyt, M. Ochs et al. “The Effect of Paramedic
and Positive Pressure Ventilation Is Associated with Hypoten- Rapid Sequence Intubation on Outcome in Patients with Severe
sion and Decreased Survival in Hypovolemic Trauma Patients: Traumatic Brain Injury.” J Trauma 54 (2003): 444–453.
An Analysis of the National Trauma Data Bank.” J Trauma 59 51. Davis, D. P., M. Ochs, D. B. Hoyt, D. Bailey, L. K. Marshall, and P.
(2005): 1140–1145; discussion 1145–1147. Rosen. “Paramedic-Administered Neuromuscular Blockade
41. Zink, B. J. and R. F. Maio. “Out-of-Hospital Endotracheal Intuba- Improves Prehospital Intubation Success in Severely Head-
tion in Traumatic Brain Injury: Outcomes Research Provides Us Injured Patients.” J Trauma 55 (2003): 713–719.
with an Unexpected Outcome.” Ann Emerg Med 44 (2004): 451–453. 52. Dunford, J. V., D. P. Davis, M. Ochs, M. Doney, and D. B. Hoyt.
42. Stockinger, Z. T. and N. E. McSwain. “Prehospital Endotracheal “Incidence of Transient Hypoxia and Pulse Rate Reactivity dur-
Intubation for Trauma Does Not Improve Survival over Bag- ing Paramedic Rapid Sequence Intubation.” Ann Emerg Med 42
Valve-Mask Ventilation.” J Trauma 56 (2004): 531–536. (2003): 721–728.
43. Gausche, M., R. J. Lewis, S. J. Stratton et al. “Effect of Out-of- 53. Butler, J. and R. Jackson. “Towards Evidence Based Emergency
Hospital Pediatric Endotracheal Intubation on Survival and Medicine: Best BETs from Manchester Royal Infirmary. Ligno-
Neurological Outcome: A Controlled Clinical Trial.” JAMA 283 caine Premedication before Rapid Sequence Induction in Head
(2000): 783–790. Injuries.” Emerg Med J 19 (2002): 554.
44. Henning, J., P. Sharley, and R. Young. “Pressures within Air- 54. Reid, C., L. Chan, and M. Tweeddale. “The Who, Where, and
Filled Tracheal Cuffs at Altitude—An In Vivo Study.” Anaesthesia What of Rapid Sequence Intubation: Prospective Observational
59 (2004): 252–254. Study of Emergency RSI outside the Operating Theatre.” Emerg
45. Mizelle, H. L., S. G. Rothrock, S. Silvestri, and J. Pagane. “Pre- Med J 21 (2004): 296–301.
ventable Morbidity and Mortality from Prehospital Paralytic 55. Walls, R. M., C. A. Brown, A. E. Bair, and D. J. Pallin, of the
Assisted Intubation: Can We Expect Outcomes Comparable to NEAR II Investigators. “Emergency Airway Management: A
Hospital-Based Practice?” Prehosp Emerg Care 6 (2002): 472–475. Multi-Center Report of 8937 Emergency Department Intuba-
46. Bernard, S. A., V. Nguyen, P. Cameron, et al. “Prehospital Rapid tions.” J Emerg Med 41(4) (2010): 347–354.
Sequence Intubation Improves Functional Outcome for Patients 56. Wang, H. E., D. P. Davis, M. A. Wayne, and T. Delbridge. “Pre-
with Severe Traumatic Brain Injury: A Randomized Controlled hospital Rapid-Sequence Intubation; What Does the Evidence
Trial.” Ann Surg 252 (2010): 959–965. Show?” Prehosp Emerg Care 8 (2004): 366–377.
47. Bulger, E. M., M. K. Copass, D. R. Sabath, R. V. Maier, and G. J. 57. Kheterpal, S., L. Martin, A. M. Shanks, and K. K. Tremper. “Pre-
Jurkovich. “The Use of Neuromuscular Blocking Agents to Facili- diction and Outcomes of Impossible Mask Ventilation: A Review
tate Prehospital Intubation Does Not Impair Outcome after Trau- of 50,000 Anesthetics.” Anesthesiology 110 (2009): 891–897.
matic Brain Injury.” J Trauma 58 (2005): 718–723; discussion 58. Vadeboncoeur, T. F., D. P. Davis, M. Ochs, J. C. Poste, D. B. Hoyt,
723–724. and G. M. Vilke. “The Ability of Paramedics to Predict Aspiration
48. Cudnik, M. T., C. D. Newgard, M. Daya, and J. Jui. “The in Patients Undergoing Prehospital Rapid Sequence Intubation.”
Impact of Rapid Sequence Intubation on Trauma Patient J Emerg Med 30 (2006): 131–136.
Further Reading
American College of Surgeons, Committee on Trauma. Advanced Braude, D. Rapid Sequence Intubation & Rapid Sequence Airway, 2nd ed.
Trauma Life Support Course: Student Manual. 8th ed. Chicago: Albuquerque, NM: University of New Mexico Press, 2009.
American College of Surgeons, 2008. Stewart, Charles E. Advanced Airway Management. Upper Saddle
Bledsoe, Bryan E. and Dwayne Clayden. Prehospital Emergency Pharma- River, NJ: Pearson/Prentice Hall, 2002.
cology. 7th ed. Upper Saddle River, NJ: Pearson/Prentice Hall, 2012.
Precautions on Bloodborne
Pathogens and Infectious
Diseases
Prehospital emergency personnel, like all health care work- diseases. This regulation requires employers to pro-
ers, are at risk for exposure to bloodborne pathogens and vide hepatitis B (HBV) vaccinations free of charge,
infectious diseases. In emergency situations it is often dif- maintain a written exposure control plan, and provide
ficult to take or enforce proper infection control measures. personal protective equipment. These requirements
However, as a paramedic, you must recognize your high- primarily apply to private employers. Applicability to
risk status. Study the following information on infection local and state governmental employees varies by
control carefully. locality. Many states have developed their own OSHA
Infection control is designed to protect emergency per- plans.
sonnel, their families, and their patients from unnecessary • National Fire Protection Association (NFPA) Guidelines.
exposure to communicable diseases. Laws, regulations, This is a national organization that has established spe-
and standards regarding infection control include: cific guidelines and requirements regarding infection
• Centers for Disease Control and Prevention (CDC) Guide- control for emergency response agencies, particularly
lines. The CDC has published extensive guidelines on fire departments and EMS services.
infection control. Proper equipment and techniques
that should be used by emergency response personnel
to prevent or minimize risk of exposure are defined. Standard Precautions
• The Ryan White Act. The Ryan White Act of 1990 allows
emergency personnel to find out if they were exposed and Personal Protective
to an infectious disease while rendering patient care.
Employers are required to name a “designated offi- Equipment
cer” to coordinate communications with the treating Emergency response personnel should practice Standard
hospital. Precautions by which ALL body substances are considered
• Americans with Disabilities Act. This act prohibits dis- to be potentially infectious. To practice Standard Precau-
crimination against individuals with disabilities, tions, all emergency personnel should utilize personal pro-
including those with contagious diseases. It guaran- tective equipment (PPE). Appropriate PPE should be
tees equal employment opportunities and job protec- available on every emergency vehicle. The minimum rec-
tion if the infected individual can perform essential job ommended PPE includes the following:
functions and does not pose a threat to the safety and • Gloves. Disposable gloves should be donned by all
health of patients and coworkers. emergency response personnel BEFORE initiating any
• Occupational Safety and Health Administration (OSHA) emergency care. When an emergency incident involves
Regulations. OSHA has enacted a regulation entitled more than one patient, you should attempt to change
Occupational Exposure to Bloodborne Pathogens that gloves between patients. When gloves have been con-
classifies emergency response personnel as being at the taminated, they should be removed as soon as possi-
greatest risk of occupational exposure to communicable ble. To properly remove contaminated gloves, grasp
608
Precautions on Bloodborne Pathogens and Infectious Diseases 609
one glove approximately 1 inch from the wrist. With- N-95 or a high-efficiency particulate air (HEPA) respi-
out touching the inside of the glove, pull the glove rator, as approved by the National Institute of Occupa-
halfway off and stop. With that half-gloved hand, pull tional Safety and Health (NIOSH). It should fit snugly
the glove on the opposite hand completely off. Place and be capable of filtering out the tuberculosis bacillus.
the removed glove in the palm of the other glove, with An N-95 or HEPA respirator should be worn when car-
the inside of the removed glove exposed. Pull the sec- ing for patients with confirmed or suspected TB. This
ond glove completely off with the ungloved hand, is especially true when performing “high-hazard” pro-
only touching the inside of the glove. Always wash cedures such as administration of nebulized medica-
hands after gloves are removed, even when the gloves tions, endotracheal intubation, or suctioning on such a
appear intact. patient.
• Masks and Protective Eyewear. Masks and protective • Gowns. Gowns protect clothing from blood splashes. If
eyewear should be present on all emergency vehicles large splashes of blood are expected, such as with
and used in accordance with the level of exposure childbirth, wear impervious gowns.
encountered. Masks and protective eyewear should be
• Resuscitation Equipment. Disposable resuscitation equip-
worn together whenever blood spatter is likely to
ment should be the primary means of artificial ventila-
occur, such as during arterial bleeding, childbirth,
tion in emergency care. Such items should be used
endotracheal intubation, invasive procedures, oral
once, then disposed of.
suctioning, and cleanup of equipment that requires
heavy scrubbing or brushing. Both you and the patient Remember, the proper use of personal protective
should wear masks whenever the potential for air- equipment ensures effective infection control and mini-
borne transmission of disease exists. mizes risk. Use ALL protective equipment recommended
• HEPA and N-95 Respirators. Due to the resurgence of for any particular situation to ensure maximum protection.
tuberculosis (TB), prehospital personnel should pro- Consider ALL body substances potentially infectious
tect themselves from TB infection through use of an and ALWAYS practice Standard Precautions.
Suggested Responses
to “You Make the Call”
The following are suggested responses to the “You Make the • Facilities—by designating special referral centers,
Call” scenarios presented in each chapter of Volume 1, Introduc- prehospital personnel can make transport decisions
tion to Advanced Prehospital Care. Each represents an acceptable to medical facilities based on specific patient’s needs.
response to the scenario but should not be interpreted as the only • Communications—without a single system of com-
correct response. munication, which allows all EMS personnel to
communicate with each other, efficiently managing
Chapter 1—Introduction this type of incident would be impossible.
to Paramedicine • Trauma systems—by having a system of specialized
care for trauma patients, patients involved in this
1. Discuss the vast differences between EMS and paramedic
incident can be assured of the appropriate care.
care in the United States, Canada, and other economi-
cally developed nations compared with those that exist in • Medical direction—an active physician medical direc-
some less-developed countries of the world. How should tor provided on-line guidance to EMS providers.
awareness of such differences affect your attitude about 2. For what possible reason was the top-priority patient sent so
your work? far from the scene?
While people in the United States, Canada, and other The top-priority patient was likely sent so far away
developed countries consider EMS a necessity and benefit because of the extent of injuries and/or need for specialty
from high standards of emergency care, people in some care. Local hospitals may not be the most effective facility
poorer or less-developed countries often do not expect to receive a patient when specialty care (burn care, trauma
anything more than a ride to the hospital. Rather than feel- care, stroke, cardiac, etc.) is required. Sometimes it is in the
ing smug about our “superiority,” however, North Ameri- patient’s best interest to bypass a local facility for another
can paramedics should feel both privileged and determined facility that is better prepared to handle the situation/care.
to work hard to live up to the high standards we enjoy. 3. How important was the role played by the emergency medi-
There is also an obligation to take part in any opportuni- cal dispatcher in this scenario? Explain.
ties to participate in programs in which information is
The role the 911 dispatcher played was extremely
exchanged between nations and EMS systems in the ongo-
important. He put the mass-casualty plan into effect and
ing effort to raise standards both in the United States and
sent the appropriate law enforcement and fire personnel.
around the world. From those to whom much is given,
That is, as a key member of a centralized communications
much is expected.
system, he directed the movement of resources within the
system, while maintaining enough available resources to
Chapter 2—EMS Systems provide for the rest of the community.
1. Which of the “ten system elements” identified by NHTSA 4. How might the EMS system benefit from an evaluation of
are mentioned in this scenario? this incident?
• Transportation—two modes of transportation were Even if this incident went smoothly, the QI process
used in this incident, air and ground. should review it. If nothing else, the review of the event
610
Suggested Responses to “You Make the Call” 611
will prove to be a good opportunity to provide continuing or confidence.* People will pick up on the slightest sig-
education on how such an event should be handled. It is nal that you are not confident, which in turn can possi-
unlikely that the event was handled so perfectly that there bly escalate the situation.
is nothing to learn from it. It could be something as simple 3. Did you and your partner act professionally? If so,
as a better staging location for the ambulances or landing explain how.
zone for the helicopter. Either way, by reviewing the event
Yes, the paramedics acted professionally. Initially,
in QI, the agency will be able to identify and improve
they had to respond to the patient, his wife, and his son.
areas that may have been overlooked during the heat of
Although the family was being difficult, that did not
the moment.
change the patient-care routine. They did not become
rude with the family, or take out their frustrations on the
Chapter 3—Roles and Responsibilities patient. They were self-confident, and showed inner
strength, self-control, excellent communication skills, and
of the Paramedic excellent decision-making skills.
1. What were your key responsibilities in the previously detailed
scenario?
Your primary responsibilities in this scenario, just like
Chapter 4—Workforce Safety
any other, are safety for you and your partner followed by and Wellness
patient care and safety of the patient and bystanders. After 1. Are your stress levels inappropriately high? What are the
ensuring that neither you nor your partner is in any dan- indications?
ger, assessment and treatment of the patient is your next
Yes, your stress levels are inappropriately high. This is
responsibility. This scenario is complicated by the family’s
evidenced by your irritability and sour stomach. Your stress
ignorance of the capabilities and roles of EMS within the
is compounded by a poor diet, financial and home troubles,
health care system. If possible, your partner can use this
and the death of a young person. Even worse, you knew
teaching moment to briefly educate the family to your
this person, and you will see the continued effects of the
capabilities. Maintaining a professional demeanor and
loss. In this situation, you are not handling the stress appro-
going out of the way to make sure the family is made
priately. Instead of spending your time off doing stress-
aware of the patient’s status are diplomacy skills used by a
relieving activities such as exercise, hobbies, sports, or other
true professional.
relaxation activities, you took on yet another overtime shift.
Additionally, you have the responsibility to trans-
2. Might it be a good idea for you to go to the funeral? Why or
port the patient to the most appropriate facility, notify
why not?
medical control of the situation, and ensure the continu-
ity of care by reporting and turning the patient over to The answer to this question depends on the individual.
someone of equal or higher training. Your final responsi- Some individuals need to have final closure and can only
bilities with continuity of care involve timely and accu- find this by attending the funeral or at least visiting the
rate documentation of your assessment and treatment for family at the funeral home. Other people choose to avoid
the patient and being sure the documentation has been the funeral home and services, claiming that the lack of clo-
submitted to the patient’s chart at the receiving hospital. sure is easier to deal with. In any event, you should be
Finally, you must ensure your unit has been placed back aware of which method works best to help you deal with
in service as quickly as possible and made available for stressful events and follow through with them.
any additional calls. 3. How can you improve stress management in the future?
2. How should you have prepared yourself mentally and physi- Methods to manage stress include following through
cally for this call? with a healthy diet, regular exercise (30+ minutes a day),
Preparing yourself for this call involves physical avoiding additional stress when possible, relaxation
and mental fitness preparation. A good exercise and exercises, and finding a hobby to relieve stress. Suggest
diet program helps to ensure good health which, in and attend discussion meetings following any critical
turn, helps you to deal with stressors of the job. Clearly, events such as the one mentioned in the scenario. Don’t
this situation is a stressful situation and one that is all hesitate to contact a mental health professional and make
too familiar. Mental preparation involves staying up an appointment.
to date with continuing education and familiarizing
yourself with your protocols. When you are confident *Confidence and arrogance (cockiness) are close cousins. It is imperative that you
learn to be confident without being arrogant. Arrogance breeds dissention
in your actions and care, stressors such as family or between you and coworkers, first responders, hospital personnel, and the public.
bystanders yelling at you will not sway your treatment On the other hand, self-confidence can be calming and build a sense of trust.
612 Suggested Responses to “You Make the Call”
3. How does justice come into play in this situation? Was the ambulance dispatched to the main coroner,
Justice refers to the paramedic’s obligation to treat all whose name is Spice?
patients fairly. If the paramedic were to use the emergency What is “PMD”?
lights and siren for Phil Cornock, he would be making an “Patient is nasty and abusive” is judgmental.
exception to a policy restriction. If he makes this exception, and
“Looks like a drug abuser” is judgmental.
there are other patients who might benefit by getting to the
hospital faster but do not because the paramedics are follow- “Abnoctious” should be spelled “obnoxious.”
ing the rules, then those patients are not being treated fairly. “Obnoxious” is judgmental.
4. How should paramedics in general respond when a patient What exactly are the injuries?
requests an intervention that is not medically indicated? Exactly what treatment, if any, was rendered?
In the absence of standards or protocols that fit the sit- Was EMS transport not needed because the patient was
uation, the paramedic needs to reason out the problem. He not hurt, or because the police transported him?
must first state the action in a universal form, then consider
Did the patient go to the hospital or to jail?
the implications or consequences of the action and, finally,
2. What will you do to make sure your documentation is better
compare them to relevant values.
than this?
Avoid using codes.
Chapter 9—EMS System
Practice spelling and use only words you can spell
Communications correctly.
1. Based on the information provided, organize and prepare
Do not use abbreviations that are unclear; spell out
your radio report to inform the receiving hospital of your
terms the first time you use them, followed by the
patient’s condition.
abbreviation in parentheses.
Rescue: Palermo Rescue to Davidson Medical Center.
Do not be judgmental.
Hospital: Davidson Medical, Doctor Stowe here, go
Describe the head-to-toe assessment completely.
ahead.
Be particularly careful and complete in no-transport
Rescue: Davidson Medical, this is Paramedic Kirk
situations.
inbound to your facility with a 69-year-old male
patient complaining of chest pain. How do you copy?
Hospital: I copy a 69-year-old male complaining of Chapter 11—Human Life Span
chest pain, go ahead. Development
Rescue: Doctor Stowe, this patient’s pain began about 1. Do you believe that this is normal behavior for a patient of
30 minutes ago while he was at rest. He describes it this age and in this particular situation?
as a substernal pressure-type pain radiating into his Yes, it is exactly the type of behavior that should be
arm and jaw. He has a history of heart disease and expected from a patient this age and in this situation.
two prior MIs with bypass surgery two years ago.
2. What is a likely reason for this behavior?
His current meds are Lanoxin, Lasix, Capoten, and
aspirin, and he is allergic to Mellaril. His blood Adolescents are very concerned with modesty and pri-
pressure is 210/110, pulse of 70, respirations of 20 vacy. The reason for her behavior is likely that her parents
mildly labored with a pulse oximetry of 93 percent and younger sister are in the room with her. Additionally,
with supplemental oxygen. He has become pro- the patient may have been hiding something from her par-
gressively more dyspneic in our presence. We have ents, such as sexual activity, drug or alcohol use, birth con-
an ETA to your facility of 10 minutes. Do you have trol pills, or another issue, that she does not want to reveal
any further orders at this time? to them or her sister.
3. What might you do to make this patient more cooperative?
Chapter 10—Documentation If possible, have a “same sex” provider perform the
1. What is wrong with this narrative? patient assessment. If this is possible, then you might ask the
parents and sister to leave the room. If there is no “same sex”
What is a “10-48”? Is this the same in every EMS system?
provider available, then have the mother stay in the room for
Was the ambulance dispatched to the corner of Main the protection of both the patient and the provider, but have
and Spice? her move to a point away from the bed so that answers to your
Was the ambulance dispatched to the coroner, at Main questions cannot be heard. If possible, palpate the abdomen
and Spice? through a thin sheet to further protect the patient’s modesty.
614 Suggested Responses to “You Make the Call”
airway can cause an airway occlusion and/or aspiration into Chapter 15—Airway Management
the lungs. If aspiration occurs, the patient is at risk for an
inflammatory response and deadly aspiration pneumonia.
and Ventilation
2. Of the following medications and routes of delivery, 1. What is your primary assessment and management of this
which will provide the fastest and most predictable rate child?
of absorption? Your initial assessment always begins with making sure
• aspirin—enteral tract the scene is safe and donning PPE. Your next step is to deter-
mine if there is any suspected trauma and assess the child’s
• nitroglycerin—sublingual
LOC by gently tapping and calling the child’s name. Quickly
• morphine sulfate—IV bolus follow this with opening the airway (head-tilt/chin-lift if no
The morphine sulfate delivered as an intravenous trauma is suspected and jaw-thrust if trauma is suspected)
bolus will provide the most predictable and fastest rate of and determine if the child is breathing. If the child is not
drug absorption. Any medication delivered directly into breathing, give positive pressure ventilations ([3]2) by either
the venous circulation will be carried by the blood and BVM, FROPVD, or pocket mask and begin chest compres-
quickly reach its target site. sions. (Remember, these are done in lieu of abdominal thrusts
Drug absorption in the enteral tract (aspirin given for pediatric patients.) If you are the only ALS person on
orally) can be affected adversely by physical activity, emo- scene, these BLS maneuvers should be performed by your
tion, and the presence of food. Absorption via the sublingual basic partner or another BLS-trained person while you pre-
route involves passage of the medication (nitroglycerin) pare your equipment. Approximately every 2 minutes, you
through the mucous membranes beneath the tongue. Once should stop the BLS compressions, assess the airway for a
it passes through these membranes, the drug can then be visible obstruction, and begin the compressions again.
circulated via the venous circulation throughout the body. Note: Even though the patient is not breathing, placing
Even though passage is relatively fast, overall absorption a nonrebreather mask over the patient’s mouth and nose
does not occur as quickly as when the medication is injected may help provide some oxygenation during the compres-
directly into the venous circulation. sions. (If the airway is completely obstructed, this is less
3. When administered sublingually, how is the nitroglycerin likely to help. However, if there is any air movement, no
absorbed into the body? matter how small, the increased oxygenation provided by
the NRB can do nothing but help.) Remember to remove
When administering nitroglycerin via the sublingual
the mask prior to attempting any type of ventilations.
route, the medication must be absorbed through the
If the airway obstruction is not relieved by BLS maneu-
mucous membranes beneath the tongue. The area beneath
vers within the first 2 minutes of your arrival, you should
the tongue is extremely rich with blood vessels. Once
begin advanced airway procedures including the use of an
through the mucous membranes, the nitroglycerin is car-
appropriately sized extraglottic airway, direct laryngos-
ried by the venous circulation and systemically distributed
copy, and retrieving the occlusion with Magill forceps or
throughout the body.
placing an endotracheal tube. If the obstruction is still unre-
4. You elect to administer 3 mg of morphine sulfate to the lieved, your last resort would be use of a surgical airway
patient. The medication is packaged as 10 mg in 5 mL of (cricothyrotomy) to create an airway until hospital doctors
solution in a multidose vial. How many milliliters must you can remove the obstruction.
administer to give the 3 mg of morphine?
2. What are your first actions?
Using the formula as discussed in the chapter, the drug
Your first actions are to gain control of the scene and call
dosage can be calculated as follows:
for any needed additional assistance, such as Emergency
5 ml (volume on hand) * 3 mg (desired dose) Medical Responders or other EMS units or law enforcement,
= 1.5 mL to help with maintaining order. Additionally, you will want
10 mg (dosage on hand)
to attempt to determine the extent of the child’s airway
To deliver 3 mg of morphine sulfate, you must admin- obstruction by opening the airway; listening, looking, and
ister 1.5 mL of the medication solution. feeling for air movement and chest rise; and giving positive
Using the ratio and proportion method, the amount of pressure ventilations with a BVM or pocket mask.
drug to administer is calculated as follows:
3. What are your options for managing the airway after the
5 mL>10 mg = x mL>3 mg obstruction is relieved?
15>10 = x Upon relieving the airway obstruction, your first pri-
x = 1.5 mL ority is to ventilate the patient and check for circulatory
616 Suggested Responses to “You Make the Call”
function or pulses. If pulses are present, you should pro- • Pediatric tongues are larger in proportion.
ceed with securing the airway with whatever means nec- • Nasal openings are smaller and adenoids are large
essary and available to maintain a secure, open airway. on pediatric patients.
Options for this will include (in order from least invasive
• The pediatric cricoid rings are pliable and may be
to most invasive):
compressed with overaggressive cricoid pressure.
• Oxygen delivery via nonrebreather mask
• Distance from the vocal cords to the carina is closer
• Nasopharyngeal airway in pediatrics, requiring the tube to be inserted only
• Oropharyngeal airway 2–3 cm below the cords.
• Blind insertion airway device • Large occiput in pediatrics makes positioning
• Endotracheal tube difficult.
In addition to the airway device just mentioned, the • The pediatric epiglottis is floppy and round (“omega”
patient should be placed on supplemental oxygen to shaped), making use of the straight (Miller) blades
maintain pulse oximetry levels of at least 90 percent. This more popular for pediatric intubation.
may include nasal cannula, nonrebreather mask, or bag- • The pediatric glottic opening is higher and more
valve mask. anterior in the neck, making it easier to insert the
4. What are the major anatomic differences between pediatric laryngoscope blade too deeply.
and adult patients in terms of airway management? • The narrowest part of the pediatric airway is the cri-
coid cartilage, not the glottic opening.
• Pediatric structures are smaller and more difficult to
• Children will desaturate (oxygen) faster than an adult.
navigate.
Answers to Review Questions
Below are answers to the Review Questions presented in each chapter of Volume 1.
617
618 Answers to Review Questions
8. c 17. b 9. c
9. b 18. c 10. c
10. a 19. a 11. b
20. d 12. d
Chapter 10— 21. d 13. c
22. c 14. a
Documentation 23. c 15. b
1. d 24. b 16. d
2. c 25. c 17. a
3. b 18. c
4. a 19. d
5. a Chapter 13— 20. d
6. a Emergency 21. a
7. d 22.
8. c
Pharmacology b
23. b
1. c 24. b
Chapter 11—Human 2. b 25. c
3. b
Life Span 4. c
26. a
27. c
Development 5. b 28. c
1. c 6. b 29. d
2. d 7. a 30. b
3. c 8. b 31. e
4. a 9. d 32. b
5. c 10. c
6. b 11. c
7. c 12. d Chapter 15—Airway
13.
8. c a
Management and
9. a 14. c
10. c 15. b Ventilation
16. d 1. d
Chapter 12— 17. d 2. b
18. b 3. c
Pathophysiology 19. b 4. c
1. a 20. b 5. c
2. b 6. d
3. c 7. b
4. b Chapter 14— 8. b
5. d Intravenous Access 9. b
6. d 10.
7. d
and Medication c
11. c
8. b Administration 12. d
9. c 1. a 13. c
10. c 2. c 14. a
11. b 3. c 15. c
12. d 4. b 16. d
13. b 5. b 17. c
14. b 6. b 18. d
15. d 7. d 19. b
16. d 8. c 20. a
Glossary
10-code radio communications system using codes that concentration, opposite to the normal direction of diffu-
begin with the word ten. sion; requires the use of energy to move a substance.
abandonment termination of the paramedic–patient actual damages compensable physical, psychological, or
relationship without assurance that an equal or greater financial harm.
level of care will continue. acute of sudden onset, as an acute disease.
ABCs airway, breathing, and circulation. ad hoc database database created each time a patient is
ABO blood groups four blood groups formed by the encountered to include information about that patient
presence or absence of two antigens known as A and B. such as vital signs, video, electronic health record, and
A person may have either (type A or type B), both (type voice-to-text medical findings that can be stored and
AB), or neither (type O). An immune response will be then accessed as needed by rescuers, helicopter crew,
activated whenever a person receives blood containing and hospital physicians.
A or B antigen if this antigen is not already present in addendum addition or supplement to the original
his own blood. report.
abstract a written summary of the key points, especially adenosine triphosphate (ATP) a high-energy com-
of a scientific paper; a report presented before publica- pound present in all cells, especially muscle cells;
tion of the entire paper. when split by enzyme action, it yields energy. Energy
accelerometers sensors in a vehicle that can measure a is stored in ATP.
change in total velocity, forces applied to the vehicle, adipocytes fat cells.
direction forces were applied, whether the vehicle adipose tissue fat.
rolled over, whether air bags were deployed, and the adjunct medication agent that enhances the effects of
vehicle’s final resting position. other medications.
accreditation a system ensuring that education pro- administration tubing flexible, clear plastic tubing that
grams for paramedics and other EMS personnel levels connects the solution bag to the IV cannula.
meet minimal guidelines for faculty, facilities, equip- administrative law law that is enacted by governmental
ment, medical oversight, clinical affiliations, and finan- agencies at either the federal or state level. Also called
cial stability. regulatory law.
acid–base reaction any chemical reaction that results in adrenergic pertaining to the neurotransmitter norepi-
the transfer of protons. nephrine.
acidosis a high concentration of hydrogen ions; a pH advance directive a document created to ensure that
below 7.35; an excess of acids in the body. certain treatment choices are honored when a patient is
acids substances that give up protons during chemical unconscious or otherwise unable to express his choice
reactions. of treatment.
acquired immunity protection from infection or disease advanced automatic crash notification (AACN) data
that is (1) developed by the body after exposure to an collection and transmission system that can automati-
antigen (active acquired immunity) or (2) transferred cally contact a national call center or local public safety
to the person from an outside source such as from the answering point and transmit detailed crash data, such
mother through the placenta or as a serum (passive as the type of vehicle, speed and direction of impact,
acquired immunity). and probable severity of injury to occupants. The
active transport movement of a substance through a cell AACN call center can simultaneously dispatch a vari-
membrane against the osmotic gradient; that is, from ety of responders, including rescue/extrication crews,
an area of lesser concentration to an area of greater fire service, and medical helicopter transport, and
619
620 Glossary
advise the most appropriate hospital or trauma center cytoplasm; the synthesis of steroid compounds by the
to prepare for arrival of patients. body.
Advanced Emergency Medical Technician (AEMT) the anaerobic metabolism the first stage of metabolism,
level of EMS practitioner who performs the responsibil- which does not require oxygen, in which the break-
ities of an EMT with the addition of limited advanced down of glucose (in a process called glycolysis)
emergency medical care. produces pyruvic acid and yields very little energy.
aerobic metabolism the second stage of metabolism, Anaerobic means “without oxygen.”
requiring the presence of oxygen, in which the break- analgesia the absence of the sensation of pain.
down of glucose (in a process called the Krebs or citric analgesic medication that relieves the sensation of pain.
acid cycle) yields a high amount of energy. Aerobic analysis of variance (ANOVA) parametric statistic used
means “with oxygen.” to ascertain the extent to which significant group differ-
affinity force of attraction between a medication and a ences can be inferred to the population.
receptor. anaphylaxis a life-threatening allergic reaction; also
afterload the resistance a contraction of the heart must called anaphylactic shock.
overcome in order to eject blood; in cardiac physiology, anchor time set of hours when a night-shift worker can
defined as the tension of cardiac muscle during systole reliably expect to rest without interruption.
(contraction). anesthesia the absence of all sensations.
against medical advice (AMA) your patient refuses anesthetic medication that induces a loss of sensation to
care even though you feel he needs it. touch or pain.
agonist medication that binds to a receptor and causes it anion an ion with a negative charge—so called because
to initiate the expected response. it will be attracted to an anode, or positive pole.
agonist–antagonist medication that binds to a receptor anoxia the absence or near-absence of oxygen in certain
and stimulates some of its effects but blocks others. tissues or in the body as a whole.
Also called partial agonist. antacid alkalotic compound used to increase the gastric
AIDS (acquired immunodeficiency syndrome) a group environment’s pH.
of signs, symptoms, and disorders that often develop antagonist medication that binds to a receptor but does
as a consequence of HIV infection. not cause it to initiate the expected response.
air embolism air in the vein. antiarrhythmic medication used to treat and prevent
albumin a protein commonly present in plant and ani- abnormal cardiac rhythms.
mal tissues. In the blood, albumin works to maintain antibiotic agent that kills or decreases the growth of
blood volume and blood pressure and provides colloid bacteria.
osmotic pressure, which prevents plasma loss from the antibody a substance produced by B lymphocytes in
capillaries. response to the presence of a foreign antigen that will
alkalosis a low concentration of hydrogen ions; a pH combine with and control or destroy the antigen, thus
above 7.45; an excess of base in the body. preventing infection.
allergy exaggerated immune response to an environ- anticoagulant medication that inhibits blood clotting.
mental antigen. antiemetic medication used to prevent vomiting.
allied health professions ancillary health care profes- antifibrinolytic medication that inhibits the activation of
sions apart from physicians and nurses, such as para- plasminogen to plasmin, prevents the breakup of fibrin
medics, respiratory therapists, and physical therapists. (fibrinolysis), and maintains clot stability.
alveoli microscopic air sacs where most oxygen and car- antigen a marker on the surface of a cell that identifies it
bon dioxide gas exchanges take place. as “self” or “non-self.”
amino acids molecules containing an amine group, a antigen–antibody complex the substance formed when
carboxylic acid group, and varying side chains; among an antibody combines with an antigen to deactivate or
other functions, amino acids are the building blocks of destroy it; also called immune complex.
proteins. antigen-presenting cells (APCs) cells, such as macro-
ampule breakable glass vessel containing liquid phages, that present (express onto their surfaces) por-
medication. tions of the antigens they have digested.
amylopectin a highly branched polymer of glucose; one antigen processing the recognition, ingestion, and
of two types of starch, the other being amylose. breakdown of a foreign antigen, culminating in produc-
amylose a linear, unbranched polymer of glucose; one of tion of an antibody to the antigen or in a direct cyto-
two types of starch, the other being amylopectin. toxic response to the antigen.
anabolism the constructive phase of metabolism in antihistamine medication that arrests the effects of
which cells convert nonliving substances into living histamine by blocking its receptors.
Glossary 621
antihyperlipidemic medication used to treat high blood autoimmunity an immune response to self-antigens,
cholesterol. which the body normally tolerates.
antihypertensive medication used to treat hypertension. automatic crash notification (ACN) data collection and
antineoplastic agent medication used to treat cancer. transmission system that can automatically contact a
antiplatelet medication that decreases the formation of national call center or local public safety answering
platelet plugs. point and transmit limited specific crash data, such as
antiseptic cleansing agent that is not toxic to living tissue. that a crash has taken place and where it is located.
antitussive medication that suppresses the stimulus to automatic location information (ALI) in computers at
cough in the central nervous system. enhanced 911 communication centers, the ability to dis-
anxious avoidant attachment a type of bonding that play the location of a caller’s phone.
occurs when an infant learns that his caregivers will automatic number identification (ANI) in computers
not be responsive or helpful when needed. at enhanced 911 communication centers, the ability to
anxious resistant attachment a type of bonding that display a caller’s telephone number.
occurs when an infant is uncertain about whether or autonomic ganglia groups of autonomic nerve cells
not his caregivers will be responsive or helpful when located outside the central nervous system.
needed. autonomic nervous system the part of the nervous sys-
apnea temporary stop in breathing. tem that controls involuntary actions.
apneic oxygenation a method of providing oxygen to autonomy a competent adult patient’s right to deter-
an apneic (non-breathing) patient during endotracheal mine what happens to his own body.
intubation to minimize the possibility of hypoxia devel- B lymphocytes the type of white blood cells that, in
oping during the procedure. response to the presence of an antigen, produce anti-
apoptosis response in which an injured cell releases bodies that attack the antigen, develop a memory for
enzymes that engulf and destroy it; one way the body the antigen, and confer long-term immunity to the
rids itself of damaged and dead cells. antigen.
arterial oxygen concentration (CaO2) a measure of oxy- bacteria (singular, bacterium) single-celled organisms
gen content in the arterial blood. with a cell membrane and cytoplasm but no organized
asepsis a condition free of pathogens. nucleus. They bind to the cells of a host organism to
aspiration inhaling foreign material such as vomitus obtain food and support.
into the lungs. bag-valve mask (BVM) ventilation device consisting
assault an act that unlawfully places a person in appre- of a self-inflating bag with two one-way valves and a
hension of immediate bodily harm without his consent. transparent plastic face mask.
assay test that determines the amount and purity of a bandwidth (1) the width of a range of frequencies, mea-
given chemical in a preparation in the laboratory. sured in hertz; (2) a rate of data transmission, measured
atelectasis alveolar collapse. in bits per second (bps).
atom the fundamental chemical unit, which contains barotrauma injury caused by pressure within an
subatomic particles, including electrons, protons, and enclosed space.
neutrons. basement membrane a thin sheet of fibers that underlies
atomic number the number of protons in the nucleus of the epithelia, the membranes that line or cover internal
an atom; an element is defined by its atomic number. and external body surfaces.
atrophy a decrease in cell size resulting from a decreased bases substances that acquire protons during chemical
workload. reactions.
aural medication medication administered through the basophils granular white blood cells that, similarly to
mucous membranes of the ear and ear canal. mast cells, release histamine and other chemicals that
authoritarian a parenting style that demands abso- control constriction and dilation of blood vessels dur-
lute obedience without regard to a child’s individual ing inflammation.
freedom. battery the unlawful touching of another individual
authoritative a parenting style that emphasizes a bal- without his consent.
ance between a respect for authority and individual bench research research done in a controlled laboratory
freedom. setting using nonhuman subjects.
autoimmune disease failure of the immune system beneficence the principle of doing good for the patient.
to recognize certain tissues normally present in the benign not cancerous; not able to spread to other tissues.
body resulting in an attack against those tissues by the See also malignant.
immune system; autoimmune disease includes rheu- bias potential unintended or unavoidable effect on
matic heart disease and rheumatoid arthritis. study outcomes.
622 Glossary
bilevel positive airway pressure (BiPAP) air or oxygen carbon dioxide waste product of the body’s metabolism.
delivered under pressure that is higher during inhala- carcinogenesis the process of developing a cancer.
tion and lower during exhalation. cardiac contractile force the strength of a contraction of
bioassay test to ascertain a medication’s availability in a the heart.
biologic model. cardiac output the amount of blood pumped by the
bioavailability amount of a medication that is still active heart in 1 minute (computed as stroke volume × heart
after it reaches its target tissue. rate).
bioequivalence relative therapeutic effectiveness of cardiogenic shock shock caused by insufficient cardiac
chemically equivalent medications. output; the inability of the heart to pump enough blood
biologic half-life time the body takes to clear one-half of to perfuse all parts of the body.
a medication. carrier proteins proteins involved in carrying solutes
biotransformation special name given to the metabo- (ions or molecules) across a biologic membrane.
lism of medications. carrier-mediated diffusion process in which carrier
blood tube glass container with color-coded, self-sealing proteins transport large molecules across the cell mem-
rubber top. brane. See facilitated diffusion.
blood tubing administration tubing that contains a fil- cartilage a type of connective tissue that provides struc-
ter to prevent clots or other debris from entering the ture and support to other tissues.
patient. cascade a series of actions triggered by a first action and
blood–brain barrier tight junctions of the capillary culminating in a final action—typical of the actions
endothelial cells in the central nervous system vascu- caused by plasma proteins involved in the comple-
lature through which only non–protein-bound, highly ment, coagulation, and kinin systems.
lipid-soluble medications can pass. case report a structured study of a single unit, subject,
bolus concentrated mass of medication. event, or patient.
bonding the formation of a close personal relationship case series observational study that tracks patients with
(as between mother and child), especially through fre- a known exposure or examines their medical records
quent or constant association. for exposure and outcome.
breach of duty an action or inaction that violates the catecholamines epinephrine and norepinephrine, hor-
standard of care expected from a paramedic. mones that strongly affect the nervous and cardiovas-
bronchi tubes from the trachea into the lungs. cular systems, metabolic rate, temperature, and smooth
bubble sheet scannable run sheet on which you fill in muscle.
boxes or “bubbles” to record assessment and care infor- catheter inserted through the needle/intracatheter Teflon
mation. catheter inserted through a large metal stylet.
buccal between the cheek and gums. cation an ion with a positive charge—so called because
buffer a substance that tends to preserve or restore a it will be attracted to a cathode, or negative pole.
normal acid-base balance by increasing or decreasing cell membrane also plasma membrane; the outer cover-
the concentration of hydrogen ions. ing of a cell.
burette chamber calibrated chamber of Berutrol IV cell the basic structural unit of all plants and animals.
administration tubing that enables precise measure- A membrane enclosing a thick fluid and a nucleus.
ment and delivery of fluids and medicated solutions. Cells are specialized to carry out all of the body’s basic
burnout when coping mechanisms no longer buffer job functions.
stressors, which can compromise personal health and cell-mediated immunity the short-term immunity to
well-being. an antigen provided by T lymphocytes, which directly
bystander a family member, friend, or stranger to the attack the antigen but do not produce antibodies or
patient who is present at the patient’s medical emer- memory for the antigen.
gency. cells regions into which a cell phone service is divided.
call routing the process of transferring an emergency cellular adaptation physiologic or structural changes to
call to the nearest 911 center; occasionally technical a cell in response to change or stress or a pathological
problems cause such a call to be routed out of the call condition.
area. cellular respiration metabolic processes with a cell that
cannula hollow needle used to puncture a vein. convert nutrients to energy in the form of adenosine
cannulation see intravenous (IV) access. triphosphate (ATP) and that subsequently release waste
CaO2 see arterial oxygen concentration. products from the cell.
capnography a recording or display of the measurement cellular telephone system A type of wireless communi-
of exhaled carbon dioxide concentrations over time. cation, called “cellular” because it is based on a complex
Glossary 623
of separate base stations, each covering one “cell” or civil law division of the legal system that deals with
geographic area. As a cell phone user travels, calls are noncriminal issues and conflicts between two or more
transferred from base station to base station. parties.
cellulose a polysaccharide polymer with glucose as its civil rights the rights of personal liberty guaranteed to
monomer that is the major structural material of plants. American citizens by the 13th and 14th amendments
central venous access surgical puncture of the internal to the United States Constitution and by certain acts of
jugular, subclavian, or femoral vein. Congress.
centrioles cylindrical structures within cells that play an cleaning washing an object with cleaners such as soap
important role in cell division. and water.
certification the process by which an agency or associa- clinical presentation the manifestation of a disease; the
tion grants recognition to an individual who has met its signs and symptoms of a disease.
qualifications. clinical protocols the policies and procedures estab-
chain of survival As defined by the American Heart lished by a medical director for all components of an
Association, the five most important factors affecting EMS system, such as medical treatment protocols.
survival of a cardiac arrest patient: (1) immediate rec- clonal diversity the development of receptors, by B lym-
ognition and activation of EMS; (2) early CPR; (3) rapid phocyte precursors in the bone marrow, for every pos-
defibrillation; (4) effective advanced life support; (5) sible type of antigen.
integrated post–cardiac arrest care. clonal selection the process by which a specific antigen
chemoreceptors sensory receptors that detect and act reacts with the appropriate receptors on the surface of
on chemical signals—for example, sensing a change immature B lymphocytes, thereby activating them and
in carbon dioxide levels in the blood and responding prompting them to proliferate, differentiate, and pro-
by causing an increase in respiratory rate to expel the duce antibodies to the activating antigen.
excess carbon dioxide from the body. coagulation system a plasma protein system that results
chemotactic factors chemicals that attract white cells to in formation of a protein called fibrin. Fibrin forms a
the site of inflammation, a process called chemotaxis. network that walls off an infection and forms a clot that
chemotaxis see chemotactic factors. stops bleeding and serves as a foundation for repair
chi square test nonparametric statistic used with nomi- and healing of a wound. Also called the clotting system.
nal data to test group differences. Code Green Campaign organization that works to raise
cholinergic pertaining to the neurotransmitter acetyl- awareness of mental health issues and care that can be
choline. provided for mental health challenges associated with
chromatin a combination of DNA and other proteins in the EMS service. See also Tema Conter Memorial Trust.
nucleus of a cell that condenses to form chromosomes. coenzymes nonprotein substances that bind to enzyme
chromosomes threadlike structures within the nuclei of proteins to assist them in biochemical transformations.
cells that carry genetic information. Also called cofactors.
chronic slow in onset, persisting over a long period of cofactors see coenzymes.
time, as in a chronic disease. cognitive radio a “smart” device that is able to search
cilia threadlike projections from the surface of cells that the airwaves it covers for strong signals with no com-
move back and forth and can sweep debris such as peting transmissions to provide the best possible chan-
mucus or dust away from the cell. nel of communication.
circadian rhythms physiologic phenomena that occur at cohort study study of a group of subjects initially identi-
approximately 24-hour intervals. fied as having one or more characteristics in common
circulatory overload an excess in intravascular fluid who are followed over time.
volume. collagen proteins that are the main component of con-
cisternae saclike structures within body cells that form nective tissue.
part of the structure of rough endoplasmic reticulum colloid intravenous solution containing large proteins
(RER) and of the Golgi apparatus and act as carrier that cannot pass through capillary membranes; also col-
vessels that transport proteins from the RER to the loid solution.
Golgi apparatus for further processing. common law law that is derived from society’s accep-
citric acid cycle a key phase of glucose metabolism, tance of customs and norms over time. Also called case
requiring the presence of oxygen, in which pyruvic acid law or judge-made law.
(a product of the breakdown of glucose) is oxidized, common operating picture (COP) a single display of
resulting in the release of energy in the form of ATP operational information, such as data about a traffic
and carbon dioxide as waste. Also called the Krebs cycle crash and emergency responses to it, that is simultane-
or the tricarboxylic acid (TCA) cycle. ously shared by all units involved in responding to the
624 Glossary
emergency so that all those involved are working with continuous positive airway pressure (CPAP) air or oxy-
the same information. gen delivered under pressure that is maintained at a
communication the process of exchanging information steady level during both inhalation and exhalation.
between individuals. contraction inward movement of wound edges dur-
communication protocols predetermined, written ing healing that eventually brings the wound edges
guidelines for the type of information you may com- together.
municate by various means of communication without control group an experimental study group that does
breaching patient confidentiality and privacy. not receive a treatment or intervention that is given to
community paramedicine health care performed by the experimental group.
paramedics apart from customary emergency response convenience sampling sampling in which the subjects
and transport, such as in physicians’ offices, outpatient or patients are selected, in part or in whole, at the con-
clinics, or as part of paramedic crews specially trained venience of the researcher.
to periodically assess and monitor high-risk patients conventional reasoning the stage of moral development
receiving home care or elsewhere in the community. during which children desire approval from individu-
Also called mobile integrated health care. als and society.
compensated shock early stage of shock during which Cormack and LeHane grading system a system for
the body’s compensatory mechanisms are able to evaluating and scoring airway difficulty based on the
maintain normal perfusion. portion of the glottic opening and vocal cords that may
competent able to make an informed decision about be seen.
medical care. cortisol a steroid hormone released by the adrenal cortex
competitive antagonism one medication binding to a that regulates the metabolism of fats, carbohydrates,
receptor and causing the expected effect while also sodium, potassium, and proteins and has an anti-
blocking another medication from triggering the same inflammatory effect.
receptor. covalent bond force holding atoms together that results
complement system a group of plasma proteins (the when atoms share electrons.
complement proteins) that are dormant in the blood cricoid pressure pressure applied in a posterior direction
until activated, as by antigen-antibody complex forma- to the anterior cricoid cartilage; occludes the esophagus.
tion, by products released by bacteria, or by compo- cricothyroid membrane membrane between the cricoid
nents of other plasma protein systems. When activated, and thyroid cartilages of the larynx.
the complement system is involved in most of the criminal law division of the legal system that deals with
events of inflammatory response. wrongs committed against society or its members.
compliance the stiffness or flexibility of the lung tissue. cristae folds within mitochondria that form shelves
complications abnormalities or conditions that result within the mitochondria.
from another, original disease or problem. Also called critical care transport the transport of critically ill or
sequelae. injured patients.
compound chemical union of two or more elements. cross-sectional study a study in which a statistically sig-
concentration weight per volume. nificant sample of a population is used to estimate the
concentration gradient the gradual change in con- relationship between an outcome of interest and popu-
centration of a solution over a distance within the lation variables as they exist at one particular time.
solution. crystalloid intravenous solution that contains electro-
confidence interval an expression of how closely the lytes but lacks the larger proteins associated with a col-
sample estimate matches the true value in the whole loid; also crystalloid solution.
population. cyanosis bluish discoloration.
confidentiality principle of law that prohibits the release cytokines proteins, produced by white blood cells, that
of medical or other personal information about a regulate immune responses by binding with and affect-
patient without the patient’s consent. ing the function of the cells that produced them or of
congenital metabolic diseases diseases affecting the other, nearby cells.
metabolism that are present from birth. cytoplasm the thick fluid, or protoplasm, that fills a cell.
connective tissue the most abundant body tissue; it pro- cytoskeleton system of filaments, microtubules, and
vides support, connection, and insulation. Examples intermediate filaments that are part of the internal
are bone, cartilage, fat, and blood. structure of a cell.
consent the patient’s granting of permission for cytotoxic toxic, or poisonous, to cells.
treatment. data dictionary a source of information about a specific set
constitutional law law based on the U.S. Constitution. of data that provides definitions of terms, explanations
Glossary 625
of interrelations among the separate data, and similar difficult child an infant who can be characterized by
information. irregularity of bodily functions, intense reactions, and
data dredging the inappropriate (sometimes deliberately withdrawal from new situations.
so) use of data mining to uncover relationships in data diffusion the movement of atoms or molecules from an
that may be misleading. area of higher concentration to an area of lower concen-
data mining the process of searching large amounts of tration. See also facilitated diffusion; osmosis.
data for patterns or relationships. digital communications data or sounds translated into
dead spot an area where transmission and reception of a a digital code for transmission, usually a binary code
radio or other signal is poor. consisting of 1 and 0, the numbers corresponding to
debridement the cleaning up or removal of debris, dead voltage values.
cells, and scabs from a wound, principally through disaccharides complex sugars, such as sucrose, lactose,
phagocytosis. and maltose.
decompensated shock advanced stages of shock when disease an abnormal structural or functional change
the body’s compensatory mechanisms are no longer within the body.
able to maintain normal perfusion; also called progres- disinfectant cleansing agent that is toxic to living
sive shock. tissue.
defamation an intentional false communication that disinfection cleaning with an agent that can kill some
injures another person’s reputation or good name. microorganisms on the surface of an object.
degranulation the emptying of granules from the inte- dissociate separate; break down. For example, sodium
rior of a mast cell into the extracellular environment. bicarbonate, when placed in water, dissociates into a
dehydration excessive loss of body fluid. sodium cation and a bicarbonate anion.
delayed hypersensitivity reaction a hypersensitivity dissociation reaction any reaction in which a compound
reaction that takes place after some time elapses fol- or a molecule breaks apart into separate components.
lowing reexposure to an antigen. Delayed hypersensi- diuretic an agent that increases urine secretion and
tivity reactions are usually less severe than immediate elimination of body water; medication used to reduce
reactions. circulating blood volume by increasing the amount of
demand-valve device a ventilation device that is manu- urine.
ally operated by a push button or lever. Do Not Resuscitate (DNR) order legal document, usu-
denaturation loss of a protein’s three-dimensional ally signed by the patient and his physician, that indi-
shape caused by factors such as heat, chemicals, cates to medical personnel which, if any, life-sustaining
or pH; the change in the appearance and structure measures should be taken when the patient’s heart and
of an egg white when it is cooked is an example of respiratory functions have ceased.
denaturation. dosage on hand the amount of medication available in a
deoxyribonucleic acid (DNA) double-stranded, heli- solution.
cal polymer chain within the nucleus of a cell that dose packaging medication packages that contain a
carries the genetic information that encodes proteins single dose for a single patient.
and enables the cell to reproduce and perform its double blind study study comparing two or more treat-
functions. ments in which neither the investigators nor the sub-
Department of Homeland Security (DHS) a depart- jects know which treatment group individual subjects
ment of the U.S. government charged with the protec- have been assigned to.
tion of the country from threats and attacks. down-regulation binding of a medication or hormone to
dependent variable variable assessed by the experi- a target cell receptor that causes the number of recep-
menter to determine whether there is a difference in it tors to decrease.
that is due to the independent variable. drip chamber clear plastic chamber that allows visual-
descriptive statistics statistics that summarize research ization of the drip rate.
data. drip rate pace at which the fluid moves from the bag
desired dose specific quantity of medication needed. into the patient.
diagnosis the process of identifying and assigning a drop (Latin guttae, drops [gutta, drop]); quantity of a
name to a disease in an individual patient or a group of solution that falls in one spherical mass.
patients with similar signs and symptoms. drop former device that regulates the size of drops.
diapedesis movement of white cells out of blood ves- drug-response relationship correlation of different
sels through gaps in the vessel walls that are created amounts of a medication to clinical response.
when inflammatory processes cause the vessel walls drugs foreign substances placed into the human body.
to constrict. See also medications.
626 Glossary
duplex communications system that allows simultane- embolus foreign particle in the blood.
ous two-way communications by using two frequen- Emergency Medical Dispatcher (EMD) the person who
cies for each channel. manages an EMS system’s response and readiness and
duration of action length of time the amount of medi- is responsible for assignment of emergency medical
cation remains above its minimum effective concen- resources to a medical emergency.
tration. Emergency Medical Responder (EMR) the level of EMS
duty to act a formal contractual or informal legal obliga- practitioner who is likely to be the first person on the
tion to provide care. scene with emergency care training and the ability to
dynamic steady state homeostasis; the tendency of the initiate immediate lifesaving care.
body to maintain a net constant composition even Emergency Medical Services (EMS) system a com-
though the components of the body’s internal environ- prehensive network of personnel, equipment, and
ment are always changing. resources established for the purpose of delivering aid
dysplasia a change in cell size, shape, or appearance and emergency medical care to the community.
caused by an external stressor. Emergency Medical Technician (EMT) the level of EMS
dysplastic having an abnormal appearance, as with a practitioner who provides basic emergency medical
cell seen under a microscope. care and transportation.
dyspnea an abnormality of breathing rate, pattern, or employment laws laws that address employee/
effort. employer relationships.
ear-to-sternal-notch position position in which a supine endocrine secretions secreted substances that are
patient’s head is elevated to the point where the ear released into the bloodstream or surrounding tissues
and the sternal notch are horizontally aligned. In the without the aid of ducts.
non-obese patient, this position may be called the sniff- endocytosis process by which substances can enter a cell
ing position. In the obese patient, this position may be when a section of the cell’s plasma membrane encircles
called the ramped position. the substance, then pinches off into a vesicle that is
easy child an infant who can be characterized by regu- released into the cell. See also exocytosis.
larity of bodily functions, low or moderate intensity of endoderm the innermost of three germ layers, primi-
reactions, and acceptance of new situations. tive cell types that develop in the embryo and that will
echo procedure immediately repeating each transmis- differentiate into the various tissues and organs of the
sion received during radio communications. body. See also ectoderm; germ layers; mesoderm.
ectoderm the outermost of three germ layers, primitive endoplasmic reticulum organelle within a cell that is a
cell types that develop in the embryo and that will dif- network of tubules, vesicles, and sacs that interconnect
ferentiate into the various tissues and organs of the with the plasma membrane, the nuclear envelope, and
body. See also endoderm; germ layers; mesoderm. many of the other organelles of the cell.
edema excess fluid in the interstitial space. endotoxins molecules in the walls of certain Gram-
efficacy a medication’s ability to cause the expected negative bacteria that are released when the bacterium
response. dies or is destroyed, causing toxic (poisonous) effects
electrolyte a substance that, in water, separates into elec- on the host body.
trically charged particles. endotracheal tube (ETT) a flexible plastic tube that is
electron negatively charged particle that orbits the inserted into the trachea, usually under laryngoscopy,
nucleus of an atom. for the purpose of ventilating the lungs.
electron shells levels of orbitals within which electrons endotracheal tube introducer a device designed to
rotate around the nucleus of an atom. See also orbital. facilitate the introduction of an endotracheal tube; com-
electron transport chain carriers embedded on the cris- monly called a gum-elastic bougie. It is a stylet that can
tae in the inner membrane of the mitochondria of cells be pushed into the glottis and is flexible enough so that
that transfer electrons from one molecule to another, the operator can feel the entry. When entry is achieved,
releasing energy in the process. the endotracheal tube can then be passed over the
element a substance that cannot be separated into sim- introducer and into the glottis.
pler substances. An element is defined by its atomic enema a liquid bolus of medication that is injected into
number, the number of protons in its nucleus. the rectum.
emancipated minor a person under 18 years of age who enteral route delivery of a medication through the
is married, pregnant, a parent, a member of the armed gastrointestinal tract.
forces, or financially independent and living away from enzymes substances that speed up chemical reactions
home. without themselves being consumed in the process.
Glossary 627
enzyme–substrate complex an enzyme and the sub- controlled interventions manipulated by the inves-
stance (substrate) it is bound to and working on. tigator according to a strict logic that allows causal
eosinophils granular white blood cells that attack inference about the effects of the interventions under
parasites and also help to control and limit the inflam- investigation.
matory response. exposure any occurrence of blood or body fluids coming
epidemiology the study of factors that influence the fre- in contact with nonintact skin, mucous membranes, or
quency, distribution, and causes of injury, disease, and parenteral contact (e.g., a needlestick).
other health-related events in a population. expressed consent verbal, nonverbal, or written com-
epithelial tissue the protective tissue that lines inter- munication by a patient that he wishes to receive
nal and external body tissues. Examples include skin, medical care.
mucous membranes, and the lining of the intestinal tract. extension tubing IV tubing used to extend a macrodrip
epithelialization growth of epithelial cells under a scab, or microdrip setup.
separating it from the wound and providing a protec- external validity the extent to which the findings of a
tive covering for the healing wound. study are relevant to subjects and settings beyond those
epithelium see epithelial tissue. in the study; a synonym for generalizability.
erythrocytes red blood cells, which contain hemoglobin, extracellular fluid (ECF) the fluid outside the body cells.
which transports oxygen to the cells. Extracellular fluid is composed of intravascular fluid
ethics the rules or standards that govern the conduct of and interstitial fluid.
members of a particular group or profession. extraglottic airway (EGA) device airway device that
etiology the study of disease causes; the occurrences, does not enter the glottis.
reasons, and variables of a disease. extrapyramidal symptoms (EPS) common side effects
eukaryotic cells cells that contain a nucleus and of antipsychotic medications, including muscle tremors
organelles. The cells of most multicellular organisms, and parkinsonism-like effects.
including humans, are eukaryotes. See also prokaryotic extravasation leakage of fluid or medication from the
cells. blood vessel that is commonly found with infiltration.
eustachian tube a tube that connects the ear with the extravascular outside the vein.
nasal cavity. extubation removing a tube from a body opening.
evidence-based medicine (EMB) the conscientious, exudate substances that penetrate vessel walls to move
explicit, and judicious use of scientific evidence of into the surrounding tissues.
effectiveness in decisions about the care of a patient or facilitated diffusion process in which carrier proteins
patients. transport large molecules across the cell membrane.
excited delirium syndrome (ExDS) a condition that Also called carrier-mediated diffusion.
may result from abuse of stimulant drugs, typically false imprisonment intentional and unjustifiable deten-
presenting as a triad of effects: delirium, psychomotor tion of a person without his consent or other legal
agitation, and physiologic excitation. authority.
exocrine secretions secreted substances that are depos- Federal Communications Commission (FCC) agency
ited on the surface of the skin or other epithelial surface that controls all nongovernmental communications in
through ducts. the United States.
exocytosis process by which substances can exit after fermentation the breakdown of glucose without oxygen.
being encircled by a membrane vesicle. See also endo- fibrinolytic medication that acts directly on thrombi to
cytosis. break them down; also called thrombolytic.
exotoxins toxic (poisonous) substances secreted by fibroblasts the most abundant cells in the connective
bacterial cells during their growth. tissue; cells that secrete collagen proteins that maintain
expectorant medication intended to increase the produc- a structural framework for many tissues and play an
tivity of cough. important role in wound healing.
experiment study in which the researcher has control Fick principle principle stating that the overall move-
over some of the conditions in which the study takes ment and utilization of oxygen in the body is depen-
place and control over some aspects of the independent dent on five conditions: adequate concentration of
variables being studied. inspired oxygen; appropriate movement of oxygen
experimental group the group in experimental design across the alveolar/capillary membrane into the arte-
that receives the experimental condition or treatment. rial bloodstream; adequate number of red blood cells to
experimental study study in which subjects are ran- carry the oxygen; proper tissue perfusion; and efficient
domly assigned to groups that experience carefully offloading of oxygen at the tissue level.
628 Glossary
field diagnosis what you believe to be your patient’s glycogen a glucose polymer that is primarily stored in
problem, based on the patient’s history and physical the liver and skeletal muscle that can be converted by
exam. the body into glucose. See also glycogenolysis.
filtration movement of water out of the plasma across glycogenolysis a process controlled by the hormones
the capillary membrane into the interstitial space; glucagon and epinephrine in which stores of glycogen
movement of molecules across a membrane from an are broken down into glucose to meet a bodily need for
area of higher pressure to an area of lower pressure. glucose. See also glycogen.
FiO2 concentration of oxygen in inspired air. glycolysis a series of reactions by which a molecule of
first-pass effect the liver’s partial or complete inactiva- glucose is converted into two molecules of pyruvic
tion of a medication before it reaches the systemic cir- acid, a process that begins the conversion of glucose
culation. into energy and that also produces free hydrogen ions
flagella threadlike structures whose undulating move- that determine the body’s pH.
ment provides motion to certain bacteria, protozoa, and Golgi apparatus organelle within a cell that processes
spermatozoa. proteins for the cell membrane and other organelles.
flail chest defect in the chest wall that allows a Good Samaritan laws laws that provide immunity to
segment to move freely, causing paradoxical chest certain people who assist at the scene of a medical
wall motion. emergency.
free drug availability proportion of a medication avail- granulation filling of a wound by the inward growth of
able in the body to cause either desired or undesired healthy tissues from the wound edges.
effects. granulocytes white cells with multiple nuclei that have
free radicals atoms or molecules with an unpaired elec- the appearance of a bag of granules; also called poly-
tron in the outer shell. Most free radicals are highly morphonuclear cells. Types of granulocytes are neutro-
reactive and cause cell damage, especially oxidative phils, eosinophils, and basophils.
damage. granuloma a tumor or growth that forms when foreign
free water water that is free of solute. bodies that cannot be destroyed by macrophages are
French unit of measurement approximately equal to surrounded and walled off.
one-third of a millimeter. half-life a unit of rate of decay of radioactive isotopes;
fructose a five-carbon monosaccharide sugar found in the time it takes for the decaying parent isotope to
many plants and vegetables as well as in honey. decrease by half.
gag reflex mechanism that stimulates retching, or striv- hand-off the process of transferring patient care to
ing to vomit, when the soft palate is touched. receiving facility staff; the verbal report given by an
galactose a six-carbon monosaccharide sugar found pri- EMT or paramedic to the receiving nurse or physician.
marily in dairy products. haptens molecules that do not trigger an immune
gauge the size of a needle’s diameter. response on their own but can become immunogenic
general adaptation syndrome (GAS) a sequence of when combined with larger molecules.
stress response stages: stage I, alarm; stage II, resistance Health Insurance Portability and Accountability Act
or adaptation; stage III, exhaustion. (HIPAA) law enacted by the United States Congress
geographic information system (GIS) an information in 1996 that includes provisions for protecting the secu-
system that stores and analyzes information about rity and privacy of a person’s health information.
or within a specific geographic area for the purpose helicopter air ambulances (HAA) emergency care pro-
of aiding decision making within an organization or vided by EMS personnel and helicopter flight crews
group for which the specific GIS has been developed. who are trained in the preparation of patients for and
germ layers the three primitive cell types (endoderm, the care of patients during helicopter transport.
ectoderm, mesoderm) that develop in the embryo hematocrit the percentage of the blood occupied by
and that will differentiate into the various tissues erythrocytes.
and organs of the body. See also ectoderm; endoderm; hemoconcentration elevated numbers of red and white
mesoderm. blood cells.
global positioning system (GPS) a global navigational hemoglobin an iron-based pigment present in red blood
satellite system in which satellites orbiting the earth cells that binds with oxygen and transports it to the
provide specific time and location information. cells.
glottis liplike opening between the vocal cords. hemoglobin-oxygen saturation (SaO2) the amount of
glucagon substance that increases blood glucose level. oxygen bound to one gram of hemoglobin.
glucose a six-carbon monosaccharide sugar that is the hemolysis the destruction of red blood cells.
principal energy source for the human body. hemostasis the stoppage of bleeding.
Glossary 629
hemothorax accumulation in the pleural cavity of blood hypercarbia excessive level of carbon dioxide in the blood.
or fluid containing blood. hyperoxia excessive level of oxygen in certain tissues or
heparin lock peripheral IV cannula with a distal medi- in the body as a whole.
cation port used for intermittent fluid or medication hyperplasia an increase in the number of cells resulting
infusions. Flushes of heparin solution, which inhibit from an increased workload.
blood coagulation, are used to maintain patency of the hypersensitivity an exaggerated and harmful immune
device. response; an umbrella term for allergy, autoimmunity,
hepatic alteration change in a medication’s chemical and isoimmunity.
composition that occurs in the liver. hypertonic state in which a solution has a higher sol-
Hgb the amount of hemoglobin present in arterial blood. ute concentration on one side of a semipermeable
high-pressure regulator regulator used to transfer oxy- membrane than on the other side; having a greater
gen at high pressures from tank to tank. concentration of solute molecules; one solution may be
histamine a substance released during the degranu- hypertonic to another.
lation of mast cells and also released by basophils hypertrophy an increase in cell size resulting from an
that, through constriction and dilation of blood ves- increased workload.
sels, increases blood flow to the injury site and also hyperventilation syndrome excessive CO2 elimination
increases the permeability of vessel walls. resulting in respiratory alkalosis, caused by hyper-
histology the study of tissues. ventilation.
histopathology the study of diseased or abnormal hyperventilation rapid or deep breathing in excess of
tissues. the body’s needs.
HIV (human immunodeficiency virus) a virus that hypnosis instigation of sleep.
breaks down the immune defenses, making the body hypocapnia a reduced level of plasma CO2.
vulnerable to a variety of infections and disorders. hypodermic needle hollow metal tube used with the
HLA antigens antigens the body recognizes as self or syringe to administer medications.
non-self; present on all body cells except the red blood hypoperfusion inadequate perfusion of the body tis-
cells. sues, resulting in an inadequate supply of oxygen and
hollow-needle catheter stylet that does not have a nutrients to the body tissues. Also called shock.
Teflon tube but is itself inserted into the vein and hypothesis testable statement that indicates what the
secured there. researcher expects to find, based on theory and knowl-
homeostasis the natural tendency of the body to main- edge of the literature.
tain a steady and normal internal environment. hypotonic state in which a solution has a lower solute
hotspot relating to Internet access that is provided over concentration on one side of a semipermeable mem-
a wireless local area network through a router to an brane than on the other side; having a lesser concentra-
Internet service provider. tion of solute molecules; one solution may be hypotonic
Huber needle needle that has an opening on the side of to another.
the shaft instead of the tip. hypoventilation reduced rate or depth of breathing that
humoral immunity the long-term immunity to an does not meet the body’s needs.
antigen provided by antibodies produced by B lym- hypovolemic shock shock caused by a loss of intravas-
phocytes. cular fluid volume.
hydrogen bond a weak bond formed by the attraction hypoxemia decreased partial pressure of oxygen in the
between a slightly positively charged hydrogen atom blood.
and a slightly negatively charged oxygen atom, as hypoxemia decreased partial pressure of oxygen in the
between H2O (water) molecules. blood.
hydrolysis the breakage of a chemical bond by adding hypoxia a general oxygen deficiency or oxygen defi-
water, or by incorporating a hydroxyl (OH−) group ciency to a particular tissue or organ.
into one fragment and a hydrogen ion (H+) into the hypoxic drive mechanism that increases respiratory
other. stimulation when PaO2 falls and inhibits respiratory
hydrophilic attracted to water. stimulation when PaO2 climbs.
hydrophobic repellent to water. iatrogenic disease a disease that results from a medical
hydrostatic pressure blood pressure or force against treatment given for another disease or condition.
vessel walls created by the heartbeat. Hydrostatic pres- idiopathic of unknown cause, in reference to a disease.
sure tends to force water out of the capillaries into the immediate hypersensitivity reaction a swiftly occur-
interstitial space. ring secondary hypersensitivity reaction (one that
hypercapnia an elevated level of plasma CO2. occurs after reexposure to an antigen). Immediate
630 Glossary
hypersensitivity reactions are usually more severe than injection placement of medication in or under the skin
delayed reactions. The swiftest and most severe such with a needle and syringe.
reaction is anaphylaxis. injury intentional or unintentional damage to a person
immune response the body’s reactions that inactivate or resulting from acute exposure to thermal, mechanical,
eliminate foreign antigens. electrical, or chemical energy or from the absence of
immunity exemption from legal liability; a long-term such essentials as heat and oxygen.
condition of protection from infection or disease; the injury risk a hazardous or potentially hazardous
body’s ability to respond to the presence of a pathogen. situation that puts people in danger of sustaining
immunogens antigens that are able to trigger an injury.
immune response. injury surveillance program the ongoing systematic
immunoglobulins antibodies; proteins, produced in collection, analysis, and interpretation of injury data
response to foreign antigens, that destroy or control the essential to the planning, implementation, and evalua-
antigens. tion of public health practice.
implied consent consent for treatment that is presumed inorganic chemicals chemicals that do not contain the
for a patient who is mentally, physically, or emotion- element carbon. See also organic chemicals.
ally unable to grant consent. Also called emergency insidious existing without symptoms or with mild
doctrine. symptoms, as a disease that does not seem as serious as
in vitro descriptive term for processes that are carried it is or as it may become.
out outside the living body, usually in the laboratory, as institutional review board (IRB) board of experts,
distinguished from in vivo processes. established at all research institutions, that oversees the
in vivo descriptive term for processes that are carried ethical conduct of research.
out within a living body. insufflate to blow into.
incubation period the time between contact with a dis- insulin substance that decreases blood glucose level.
ease organism and the appearance of first symptoms. intentional tort a civil wrong committed by one person
independent variable presumed cause of the dependent against another based on a willful act. See also tort law.
variable. internal validity ability of the research design to accu-
induced therapeutic hypothermia (ITH) the administra- rately answer the research question.
tion of cold IV fluids to cardiac arrest patients to mini- interoperability a feature of the emergency and public
mize subsequent secondary injury. safety communications infrastructure that allows per-
infectious disease any disease caused by the growth of sonnel from different jurisdictions and systems to com-
pathogenic microorganisms that may be spread from municate with one another effectively.
person to person. interstitial fluid the fluid in body tissues that is outside
inferential statistics statistics used to determine the cells and outside the vascular system.
whether changes in a dependent variable are caused by intervener physician a physician at the scene of an
an independent variable. emergency who is not affiliated with EMS or not affili-
inflammation the body’s response to cellular injury; ated with the EMS service that has been dispatched to
also called the inflammatory response. In contrast to the the scene.
immune response, inflammation develops swiftly, is intracatheter see catheter inserted through the needle.
nonspecific (attacks all unwanted substances in the intracellular fluid (ICF) the fluid inside the body cells.
same way), and is temporary, leading to healing. intradermal within the dermal layer of the skin.
information communications technology (ICT) infor- intramuscular within the muscle.
mation technology blended with communications tech- intraosseous within the bone.
nology to provide for dissemination of information. intravascular fluid the fluid within the circulatory system;
informed consent consent for treatment that is given blood plasma.
based on full disclosure of information. intravenous (IV) access surgical puncture of a vein to
infusion liquid medication delivered through a vein. deliver medication or withdraw blood. Also called
infusion controller gravity-flow device that regulates cannulation.
fluid’s passage through an electromechanical pump. intravenous fluid chemically prepared solution tailored
infusion pump device that delivers fluids and medica- to the body’s specific needs.
tions under positive pressure. intubation passing a tube into a body opening.
infusion rate speed at which a medication is delivered invasion of privacy violation by one person of another
intravenously. person’s personal life or personal information.
inhalation drawing of medication into the lungs along involuntary consent consent to treatment granted by the
with air during breathing. authority of a court order.
Glossary 631
ion a charged particle; an atom or group of atoms whose larynx the complex structure that joins the pharynx with
electrical charge has changed from neutral to positive the trachea.
or negative by losing or gaining one or more electrons. laxative medication used to decrease stool’s firmness
(In an atom’s normal, nonionized state, its positively and increase its water content.
charged protons and negatively charged electrons bal- legislative law law created by lawmaking bodies such
ance each other so that the atom’s charge is neutral.) as Congress and state assemblies. Also called statutory
ion channels hydrophilic pores through a membrane law.
that open and allow certain types of solutes, usually leukocytes white blood cells, which play a key role in
inorganic ions, to pass through. the immune system and inflammatory (infection-fight-
ionic bond a bond resulting from the attraction between ing) responses.
an atom or molecule with a negative charge and an leukotrienes also called slow-reacting substances of ana-
atom or molecule with a positive charge. phylaxis (SRS-A); substances synthesized by mast cells
ionize become electrically charged or polar. during the inflammatory response that cause vasodila-
irreversible antagonism a competitive antagonist per- tion, vascular permeability, and chemotaxis.
manently binds with a receptor site. liability legal responsibility.
irreversible shock shock that has progressed so far that libel the act of injuring a person’s character, name,
no medical intervention can reverse the condition and or reputation by false statements made in writing or
death is inevitable. through the mass media with malicious intent or reck-
ischemia a blockage in the delivery of oxygenated blood less disregard for the falsity of those statements.
to the cells. licensure the process by which a governmental agency
isoimmunity an immune response to antigens from grants permission to engage in a given trade or profes-
another member of the same species—for example, Rh sion to an applicant who has attained the degree of
reactions between a mother and infant or transplant competency required to ensure the public’s protection.
rejections; also called alloimmunity. life expectancy based on the year of birth, the average
isometric exercise active exercise performed against number of additional years of life expected for a mem-
stable resistance, where muscles are exercised in a ber of a population.
motionless manner. lipid bilayer plasma membrane consisting of two lay-
isotonic state in which solutions on opposite sides of a ers of phospholipids. Each phospholipid molecule has
semipermeable membrane are in equal concentration; a hydrophilic head (that attracts water) and a hydro-
equal in concentration of solute molecules. Solutions phobic tail (that repels water). In the outer layer, the
may be isotonic to each other. hydrophilic heads face outward, in contact with the
isotonic exercise active exercise during which muscles extracellular fluid (ECF). In the inner layer, the hydro-
are worked through their range of motion. philic heads face inward, in contact with the intracel-
isotopes variants of the same element, having the same lular fluid (ICF). The hydrophobic tails of both layers
number of protons but varying in the number of neu- face each other and hold the layers of the membrane
trons. See also element. together.
iterative process process for calculating a desired result lipids a broad group of chemicals, not soluble in water,
by means of a repeated cycle of operations that comes that includes triglycerides, phospholipids, and steroids.
closer and closer to the desired result. Lipp maneuver a procedure for manually preshaping an
IV catheter see over-the-needle catheter. Esophageal Tracheal Combitube (ETC).
jargon language used by a particular group or profes- living will a legal document that allows a person to
sion. specify the kinds of medical treatment he wishes to
justice the obligation to treat all patients fairly. receive should the need arise.
kinin system a plasma protein system that produces local limited to one area of the body.
bradykinin, a substance that works with prostaglan- logarithm a base number that is raised to a certain power.
dins to cause pain. It also has actions similar to those of A common example is 23 = 8, in which 2 is raised to
histamine (vasodilation and bronchospasm, increased the third power, meaning that 2 (the first power) is
permeability of the blood vessels, and chemotaxis) multiplied by itself (to the second power, which equals
but acts more slowly than histamine, thus being more 4), then multiplied by itself again (to the third power,
important during later stages of inflammation. which equals 8)—which may be expressed as 2 × 2 × 2
lactose the principal sugar in milk; a disaccharide, it is a = 8. In 23, 2 is the base number and 3 is the exponent.
combination of glucose and galactose. Luer sampling needle long, exposed needle that screws
laryngoscope instrument for lifting the tongue and epi- into the vacutainer and is inserted directly into the
glottis in order to see the vocal cords. vein.
632 Glossary
lumen the channel through a tube. median the middle score in a set of scores that have been
lymphocyte a type of leukocyte, or white blood cell, ordered from lowest to highest.
that attacks foreign substances as part of the body’s medical director a physician who is legally respon-
immune response. sible for all clinical and patient care aspects of an EMS
lymphokine a cytokine released by a lymphocyte. system.
lysosome organelle within a cell that degrades and medical oversight the medical policies, procedures, and
removes products of ingestion and worn out parts of practices established by the medical director of an EMS
the cell and converts complex nutritional molecules system.
into simple nutritional molecules; sometimes called the medically clean careful handling to prevent contamina-
cell’s “garbage disposal system.” tion.
macrodrip tubing administration tubing that delivers a medicated solution parenteral medication packaged in
relatively large amount of fluid. an IV bag and administered as an IV infusion.
macrophages large white blood cells (matured mono- medication injection port self-sealing membrane into
cytes) that will ingest and destroy, or partially destroy, which a hypodermic needle is inserted for medication
invading organisms. administration.
Magill forceps scissor-style clamps with circular tips. medications agents used in the diagnosis, treatment, or
major histocompatibility complex (MHC) a group of prevention of disease. See also drugs.
genes on chromosome 6 that provide the genetic code memory cells cells produced by mature B lymphocytes
for HLA antigens. that “remember” the activating antigen and will trigger
malfeasance a breach of duty by performance of a a stronger and swifter immune response if reexposure
wrongful or unlawful act. to the antigen occurs.
malignant cancerous; able to spread to other tissues. See mesoderm the middle of three germ layers, primitive
also benign. cell types that develop in the embryo and that will dif-
Mallampati classification system a system for evaluat- ferentiate into the various tissues and organs of the
ing and scoring airway difficulty by assessing the ton- body. See also ectoderm; endoderm; germ layers.
sillar pillars and uvula. meta-analysis the process or technique of synthesizing
maltose a breakdown product of starch; a disaccharide, research results by using various statistical methods
it is a combination of two glucose molecules. to retrieve, select, and combine results from previous
margination adherence of white cells to vessel walls in separate but related studies.
the early stages of inflammation. metabolic acid–base disorders metabolic acidosis and
mass number the total number of neutrons and protons metabolic alkalosis; disorders that result from changes
in an atom. in the production of acid or changes in bicarbonate lev-
mast cells large cells, resembling bags of granules, that els within the body.
reside near blood vessels. When stimulated by injury, metabolic acidosis acidity caused by an increase in acid,
chemicals, or allergic responses, they activate the inflam- often because of increased production of acids during
matory response by degranulation (emptying their gran- metabolism or from causes such as vomiting, diarrhea,
ules into the extracellular environment) and synthesis diabetes, or medication.
(construction of leukotrienes and prostaglandins). metabolic alkalosis alkalinity caused by an increase in
maturation continuing processes of wound reconstruc- plasma bicarbonate resulting from causes including
tion that may occur over a period of years after initial diuresis, vomiting, or ingestion of too much sodium
healing, as scar tissue is remodeled and strengthened. bicarbonate.
maximum life span the theoretical, species-specific, lon- metabolism the total changes that take place during
gest duration of life, excluding premature or “unnatu- physiologic processes; the body’s breaking down of
ral” death. chemicals into different chemicals.
mean average obtained by adding the objects or items metallic elements elements that tend to lose electrons.
and dividing the sum by the number of objects or items See also nonmetallic elements.
present. metaplasia replacement of one type of cell by another
measured volume administration set IV setup that type of cell that is not normal for that tissue.
delivers specific volumes of fluid. metastasis movement of cancer cells to other areas of the
measures of central tendency numerical information body from the original site.
regarding the most typical or representative scores in a metered dose inhaler handheld device that produces a
group. medicated spray for inhalation.
mechanism of injury (MOI) the force or forces that microdrip tubing administration tubing that delivers a
caused an injury. relatively small amount of fluid.
Glossary 633
minimum effective concentration minimum level of morals social, religious, or personal standards of right
medication needed to cause a given effect. and wrong.
minor depending on state law, this is usually a person morbidity the rate or incidence of a disease.
under the age of 18. Moro reflex a reflex that occurs when a newborn is
minute volume (Vmin) the amount of air (gas) inhaled startled; arms are thrown wide, fingers spread, and a
and exhaled in one minute. grabbing motion follows; also called startle reflex.
minute volume the amount of air (gas) inhaled and mortality the number of deaths in a given period.
exhaled in one minute. mucolytic medication intended to make mucus more
misfeasance a breach of duty by performance of a legal watery.
act in a manner that is harmful or injurious. mucous membrane lining in body cavities that handle
mission-critical communications information that must air transport; usually contains small, mucous-secreting
get through without fail because a patient’s well-being cells.
depends on it. mucus slippery secretion that lubricates and protects
mitochondria organelles within the cells that are the airway surfaces.
principal site of conversion of food to energy. multiband radio radio or radio system that combines a
mixed research a research design that contains both wide range of radio bands, allowing services that oper-
quantitative and qualitative properties. ate on separate bands—such as police, fire, and EMS—
Mix-o-Vial see nonconstituted medication vial. to communicate across the separate systems.
mobile data unit (MDU) vehicle-mounted computer multiple organ dysfunction syndrome (MODS) pro-
keyboard and display with broadband capacity via gressive impairment of two or more organ systems
radio or wireless connection, capable of sending ambu- resulting from an uncontrolled inflammatory response
lance status and patient information to the hospital or to a severe illness or injury.
ambulance quarters. multiplex duplex system that can transmit voice and
mobile integrated health care health care performed data simultaneously.
by paramedics apart from customary emergency muscle tissue tissue that is capable of contraction when
response and transport, such as in physicians’ stimulated. There are three types of muscle tissue: car-
offices, outpatient clinics, or as part of paramedic diac (myocardium, or heart muscle), smooth (within
crews specially trained to periodically assess and intestines, surrounding blood vessels), and skeletal, or
monitor high-risk patients receiving home care or striated (allows skeletal movement). Skeletal muscle is
elsewhere in the community. Also called community mostly under voluntary, or conscious, control; smooth
paramedicine. muscle is under involuntary, or unconscious, control;
mode value that occurs most frequently in a data set. cardiac muscle is capable of spontaneous, or self-
modeling a procedure whereby a subject observes a excited, contraction.
model perform some behavior and then attempts to nares (sing. naris) nostrils.
imitate that behavior. Many believe it is the funda- nasal cannula catheter placed at the nares.
mental learning process involved in socialization. nasal medication medication administered through the
molarity moles of solute per liter of solution. A mole mucous membranes of the nose.
is the measure of mass or weight used in chemistry, nasolacrimal ducts tubular vessels that drain tears and
sometimes defined as “molecular weight.” debris from the eyes into the nasal cavity.
mole see molarity. nasopharyngeal airway (NPA) uncuffed tube that fol-
molecule a substance made up of atoms held together lows the natural curvature of the nasopharynx, passing
by one or more covalent bonds. through the nose and extending from the nostril to the
monoclonal antibody an antibody that is very pure and posterior pharynx.
specific to a single antigen. nasotracheal route through the nose and into the trachea.
monocytes white cells with a single nucleus; the largest National Emergency Medical Services Education Standards:
normal blood cells. During inflammation, monocytes Paramedic Instructional Guidelines Guidelines devel-
mature and grow to several times their original size, oped and published in 2009 by the U.S. Department of
becoming macrophages. Transportation for the education of the various levels
monokine a cytokine released by a macrophage. of EMS practitioner—Emergency Medical Responders,
monomer an atom or a small molecule that may bind Emergency Medical Technicians, Advanced Emergency
chemically to other monomers to form a polymer. See Medical Technicians, and Paramedics.
also polymer. National EMS Information System (NEMSIS) national
monosaccharides simple sugars, such as glucose, fructose, repository formed to collect and store EMS data from
and galactose. every state in the United States, to create a national
634 Glossary
EMS database and to create a data dictionary that can negligence is often considered to be synonymous with
be accessed and used by individual EMS systems. malpractice. The four elements that must be present
National EMS Research Agenda document describ- to prove negligence in a court of law are duty to act,
ing the history and current status of EMS research and breach of duty to act, actual damages, and proximate
proposing a strategy to guide the research component cause. See also negligence per se.
of EMS into the future; commissioned by the National negligence per se negligence committed as a result of
Highway Traffic Safety Administration and the Mater- violating a statute with resultant injury; automatic neg-
nal and Child Health Bureau of the United States gov- ligence. See also negligence.
ernment; published in 2001. neoplasia abnormal or uncontrolled cell growth. See also
National Highway Traffic Safety Administration neoplasm.
(NHTSA) An agency of the U.S. government estab- neoplasm a tumor that results from neoplasia. See also
lished by the Highway Safety Act of 1970 to carry out neoplasia.
safety programs to improve motor vehicle and high- nerve tissue tissue that transmits electrical impulses
way safety, particularly to prevent vehicular crashes. throughout the body.
National Incident Management System (NIMS) a sys- net filtration the total loss of water from blood plasma
tem administered by the U.S. Secretary of Homeland across the capillary membrane into the interstitial
Security to provide a consistent approach to disaster space. Normally, hydrostatic pressure forcing water
management by all local, state, and federal employees out of the capillary is balanced by oncotic force pulling
who respond to such incidents. water into the capillary for a net filtration of zero.
National Transportation Safety Board (NTSB) an neuroeffector junction specialized synapse between a
independent U.S. government investigative agency nerve cell and the organ or tissue it innervates.
responsible for civil transportation accident investiga- neurogenic shock shock resulting from brain or spi-
tion, including investigation of aviation accidents and nal cord injury that causes an interruption of nerve
incidents, certain types of highway crashes, ship and impulses to the arteries with loss of arterial tone, dila-
marine accidents, pipeline incidents, and railroad acci- tion, and relative hypovolemia.
dents. neuroglia glial cells that support, insulate, and protect
natriuretic peptides (NPs) peptide hormones synthe- neurons.
sized by the heart, brain, and other organs with effects neuroleptanesthesia anesthesia that combines decreased
that include excretion of large amounts of sodium in sensation of pain with amnesia while the patient
the urine and dilation of the blood vessels. remains conscious.
natural immunity inborn protection against infection or neuroleptic antipsychotic (literally, affecting the nerves).
disease that is part of the person’s or species’ genetic neuron nerve cell; cell that transmits electrical impulses.
makeup. neurotransmitter chemical messenger that conducts a
nature of the illness (NOI) a patient’s general medical nervous impulse across a synapse.
condition or complaint. neutron electrically neutral particle within the nucleus
nebulizer inhalation aid that disperses liquid into aero- of an atom.
sol spray or mist. neutrophil a type of white blood cell; a phagocyte that
necrosis cell death; the sloughing off of dead tissue; a has the ability to ingest other cells and substances.
pathological cell change. Four types of necrotic cell nominal data categorical data in which the order of the
change are coagulative, liquefactive, caseous, and fatty. categories is arbitrary (e.g., 1 = male, 2 = female).
Gangrenous necrosis refers to tissue death over a wide noncompetitive antagonism the binding of an antago-
area. nist causes a deformity of the binding site that prevents
needle adapter rigid plastic device specifically con- an agonist from fitting and binding.
structed to fit into the hub of an intravenous cannula. nonconstituted medication vial/Mix-o-Vial vial with
needle cricothyrotomy surgical airway technique that two containers, one holding a powdered medication
inserts a 14-gauge needle into the trachea at the crico- and the other holding a liquid mixing solution.
thyroid membrane. nonfeasance a breach of duty by failure to perform a
negative feedback loop body mechanisms that work to required act or duty.
reverse, or compensate for, a pathophysiologic process nonmaleficence the obligation not to harm the patient.
(or to reverse any physiologic process, whether patho- nonmetallic elements elements that tend to gain elec-
logical or nonpathological). trons. See also metallic elements.
negligence deviation from accepted standards of care nonrandomized controlled trial research protocol in
recognized by law for the protection of others against which the subjects are assigned to the study groups by
the unreasonable risk of harm. In medical practice, a method other than randomization.
Glossary 635
normoxia normal level of oxygen in certain tissues or in into the trachea through a surgical incision at the crico-
the body as a whole. thyroid membrane.
nuclear envelope double membrane that encloses the orbital a specific region within which an electron rotates
nucleus of a cell. around the nucleus of an atom. Each orbital has a spe-
nuclear pores openings in the nuclear envelope. See also cific shape and can hold two or more electrons. See also
nuclear envelope. electron shells.
nucleolus a specialized region of DNA within the ordinal data a type of data containing limited categories
nucleus of a cell that is active in the production of ribo- with a ranking from the lowest to the highest (e.g.,
somal RNA. mild, moderate, severe).
nucleoplasm the materials on the inside of the nucleus organ system a group of organs that work together.
of a cell. Examples are the cardiovascular system, formed of the
nucleotides the fundamental building blocks of the heart, blood vessels, and blood; and the gastrointestinal
nucleic acids, DNA and RNA; nucleotides consist of system, comprising the mouth, salivary glands, esopha-
five-carbon sugar molecules bound to a nitrogen base gus, stomach, intestines, liver, pancreas, gallbladder,
and a phosphate group. rectum, and anus.
nucleus the organelle within a cell that contains the organ a group of tissues functioning together. Examples
DNA and RNA, or genetic material, proteins, and are heart, liver, brain, ovary, and eye.
other components; in the cells of higher organisms, the organelles structures that perform specific functions
nucleus is surrounded by a membrane. within a cell.
null hypothesis a hypothesis that predicts that an organic chemicals chemicals that contain the element
observed difference is due to chance alone and not to a carbon. See also inorganic chemicals.
systematic cause. organic nitrates potent vasodilators used to treat all
observational study study in which a phenomenon is forms of angina.
described but no attempt is made to analyze the effects organism the sum of all the cells, tissues, organs, and
of variables on the phenomenon; also called a descrip- organ systems of a living being. Examples include the
tive study. human organism and a bacterial organism.
ocular medication medication administered through the oropharyngeal airway (OPA) semicircular device that
mucous membranes of the eye. follows the curvature of the palate.
odds ratio a measure of association in a case-control osmolality the concentration of solute per kilogram of
study that quantifies the relationship between an expo- water. See also osmolarity.
sure and health outcome from a comparative study. osmolarity the concentration of solute per liter of water
off-line medical oversight medical policies, procedures, (often used synonymously with osmolality).
and practices established by a system medical director osmosis movement of solvent in a solution from an area
in advance of a call. of lower solute concentration to an area of higher solute
oncotic force a form of osmotic pressure exerted by the concentration.
large protein particles, or colloids, present in blood osmotic diuresis greatly increased urination and dehy-
plasma. In the capillaries, the plasma colloids tend to dration due to high levels of glucose that cannot be
pull water from the interstitial space across the capil- reabsorbed into the blood from the kidney tubules,
lary membrane into the capillary. Oncotic force is also causing a loss of water into the urine.
called colloid osmotic pressure. osmotic gradient the difference in concentration
on-line medical direction orders directly provided to a between solutions on opposite sides of a semiperme-
prehospital care provider by a qualified physician by able membrane.
either radio or telephone. osmotic pressure the pressure exerted by the concen-
onset of action the time from administration until a tration of solutes on one side of a membrane that, if
medication reaches its minimum effective concentra- hypertonic, tends to “pull” water (cause osmosis) from
tion. the other side of the membrane.
Ontario Prehospital Life Support Study (OPALS) a osteocytes cells that reside in the lacunae, or cavities,
study conducted in the province of Ontario, Canada, of within mature bone and are responsible for the turn-
prehospital practices and outcomes. over of mineral content of the surrounding bone.
open access journals scientific publications, typically outcomes-based research research designed to under-
Internet based, that allow unrestricted access to the stand the end results of particular health care practices
contents. and interventions.
open cricothyrotomy surgical airway technique that overhydration the presence or retention of an abnor-
places an endotracheal or tracheostomy tube directly mally high amount of body fluid.
636 Glossary
over-the-needle catheter/IV catheter semiflexible cath- pathology the study of disease and its causes.
eter enclosing a sharp metal stylet. pathophysiology the study of the functional changes
oxidation the loss of hydrogen atoms or the acceptance that occur within living cells and tissues that are associ-
of an oxygen atom. This increases the positive charge ated with or that result from disease or injury.
(or lessens the negative charge) of the molecule; the peer review a process of self-evaluation by a profession
loss of electrons from one atom to another. See also such as EMS in which qualified individuals within the
reduction. profession or service assess ongoing practices to main-
oxygen gas necessary for energy production. tain standards and improve performance.
oxygen saturation percentage (SpO2) the saturation of peptide a protein chain containing less than 10 amino
arterial blood with oxygen as measured by pulse oxim- acids. See also polypeptide.
etry expressed as a percentage. peptide bond the force that holds amino acids together;
P value the probability of obtaining by chance a result at the primary linkage of all protein structures.
least as extreme as that observed, even when the null perfusion the supplying of oxygen and nutrients to the
hypothesis is true and no real difference exists; if it is body tissues as a result of the constant passage of blood
≤0.05, the sample results are usually deemed statisti- through the capillaries.
cally significant and the null hypothesis is rejected. peripheral vascular resistance the resistance of the ves-
PA alveolar partial pressure. sels to the flow of blood: increased when the vessels
Pa arterial partial pressure. constrict, decreased when the vessels relax.
PaCO2 partial pressure of carbon dioxide in the blood. peripheral venous access surgical puncture of a vein in
palmar grasp a reflex in the newborn, which is elicited the arm, leg, or neck.
by placing a finger firmly in the infant’s palm. peripherally inserted central catheter (PICC) line
paradoxical breathing asymmetrical chest wall move- threaded into the central circulation via a peripheral site.
ment that lessens respiratory efficiency. permissive a parenting style that takes a tolerant,
Paramedic the level of EMS practitioner who pro- accepting view of a child’s behavior.
vides the highest level of prehospital care, including peroxisome organelle within a cell within which hydro-
advanced assessments and care, formation of a field gen peroxide is degraded.
impression, and invasive and drug interventions. personal protective equipment (PPE) equipment used
paramedicine the totality of the roles and responsibili- by EMS personnel to protect against injury and the
ties of paramedic practice involving health care, public spread of infectious disease.
health, and public safety; the highest level of Emer- pH scale pH is the abbreviation for potential of hydro-
gency Medical Systems practice. gen, a measure of relative acidity or alkalinity. The pH
parameter a value that specifies one of the members of a scale is inverse to the concentration of acidic hydrogen
family of probability distributions, such as the mean or ions; therefore, the lower the pH, the greater the acid-
the standard deviation. ity, and the higher the pH, the greater the alkalinity.
parasympatholytic medication or other substance that The pH scale ranges from 0 to 14. A normal pH range
blocks or inhibits the actions of the parasympathetic is 7.35 to 7.45.
nervous system (also called anticholinergic). phagocytes cells that have the ability to ingest other cells
parasympathomimetic medication or other substance and substances, such as bacteria and cell debris. All
that causes effects like those of the parasympathetic granulocytes and monocytes are phagocytes.
nervous system (also called cholinergic). phagocytosis the process whereby a cell engulfs large
parenchyma principal or essential parts of an organ. particles or bacteria.
parenteral route delivery of a medication outside the pharmacodynamics how a medication interacts with the
gastrointestinal tract, typically using needles to inject body to cause its effects.
medications into the circulatory system or tissues. pharmacokinetics how a medication is absorbed, dis-
partial agonist see agonist–antagonist. tributed, metabolized (biotransformed), and excreted;
partial pressure the pressure exerted by each compo- how medications are transported into and out of the
nent of a gas mixture. body.
passive transport movement of a substance without the pharmacology the study of medications and their inter-
use of energy. actions with the body.
pathogen a microorganism capable of producing infec- pharynx a muscular tube that extends vertically from
tion or disease, such as an atom or a virus. the back of the soft palate to the superior aspect of the
pathogenesis the sequence of events in the development esophagus.
of a disease. phospholipids class of lipids that form the membrane
pathologist a physician who specializes in pathology. that surrounds cells.
Glossary 637
physician orders for life-sustaining treatment polypeptide a protein chain containing more than 10
(POLST) a set of orders regarding care for a termi- amino acids. See also peptide.
nally ill patient, signed by a physician, to be honored polysaccharides a type of carbohydrate that includes
by health care providers who deal with the patient. starches, cellulose, and glycogen.
physiologic stress a chemical or physical disturbance population group of persons, elements, or both that
in the cells or tissue fluid produced by a change in the share common characteristics that are being studied by
external environment or within the body. the investigator.
pinocytosis the process whereby a cell engulfs droplets positional asphyxia lack of oxygen resulting in uncon-
of fluid. sciousness or death that occurs in a person who is
placebo a substance or intervention having no effect being restrained. Also called restraint asphyxia.
but administered or provided as a control in testing — post hoc taking place after the fact, as in a review of data
experimentally or clinically — the efficacy of a biologi- after the experiment has concluded.
cally active preparation. postconventional reasoning the stage of moral develop-
placental barrier biochemical barrier at the maternal– ment during which individuals make moral decisions
fetal interface that restricts certain molecules. according to an enlightened conscience.
plasma the liquid part of the blood. postganglionic nerves nerve fibers that extend from the
plasma membrane the membrane that surrounds a cell. autonomic ganglia to the target tissues.
See also cell membrane. post-traumatic stress disorder (PTSD) anxiety disorder
plasma protein systems complex sequences of actions that develops after exposure to traumatic events.
triggered by proteins present in the blood. For example, prearrival instruction instructions from a medically
immunoglobulins (antibodies) are plasma proteins. trained dispatcher to a person at the scene of an emer-
Three plasma protein systems involved in inflamma- gency on how to initiate lifesaving first aid with the
tion are the complement system, the coagulation sys- dispatcher’s help while waiting for the on-scene arrival
tem, and the kinin system. of emergency personnel.
plasma-level profile describes the lengths of onset, preconventional reasoning the stage of moral develop-
duration, and termination of action, as well as the ment during which children respond mainly to cultural
medication’s minimum effective concentration and control to avoid punishment and attain satisfaction.
toxic levels. predisposing factors factors that may lead to or increase
platelet aggregation inhibitor medication that decreases the chance of contracting a disease.
the formation of platelet plugs. prefilled/preloaded syringe syringe packaged in a tam-
platelets fragments of cytoplasm that circulate in the perproof container with the medication already in the
blood and work with components of the coagulation barrel.
system to promote blood clotting. Platelets also release preganglionic nerves nerve fibers that exit the central
serotonin, a vasoconstrictive substance. nervous system and terminate in the autonomic ganglia.
pleura membranous connective tissue covering the prehospital care report (PCR) the written record of an
lungs. EMS response.
pneumothorax accumulation of air or gas in the pleural preload the amount of blood delivered to the heart dur-
cavity. ing diastole (when the heart fills with blood between
POGO scoring system a system for evaluating and scor- contractions); in cardiac physiology, defined as the ten-
ing airway difficulty by the percentage of the glottis sion of cardiac muscle fiber at the end of diastole.
that can be visualized. primary care basic health care provided at the patient’s
pOH scale the number of hydroxide ions present in a first contact with the health care system.
solution. The pOH is the opposite of the pH. See also primary immune response the initial development of
pH scale. antibodies in response to the first exposure to an anti-
polar bond an unequal covalent bond; a bond in which gen in which the immune system becomes “primed”
the sharing of electrons is unequal. See also covalent to produce a faster, stronger response to any future
bond. exposures.
polar molecule a molecule formed with a polar bond, in primary intention simple healing of a minor wound
which different parts of the same molecule have a dif- without granulation or pus formation.
ferent and unequal charge. See also polar bond. primary prevention keeping an injury from ever
polymer a large organic molecule formed by combining occurring.
many smaller molecules (monomers). An example is principal investigator (PI) the scientist or scholar with
the polymer starch, which is largely made up of smaller primary responsibility for the design and conduct of a
glucose molecules. See also monomer. research project.
638 Glossary
priority dispatching system that uses medically public safety answering point (PSAP) any agency that
approved questions and predetermined guidelines to takes emergency calls from citizens in a given region
determine the appropriate level of response. and dispatches the emergency resources necessary to
prodrug (parent drug) medication that is not active respond to individual calls for help.
when administered, but whose biotransformation con- PubMed computerized database operated by the
verts it into active metabolites. National Libraries of Medicine that allows one to
profession a specialized body of knowledge or skills. search many of the world’s science resources.
professional boundaries ethical and societal limits to pulmonary embolism blood clot that travels to the
the interactions between members of a profession, such pulmonary circulation and hinders oxygenation of the
as doctors or paramedics, and the clients or patients blood.
they serve. pulse oximetry a measurement of hemoglobin oxygen
professionalism the conduct or qualities that optimally saturation in the peripheral tissues.
characterize a practitioner in a particular field or occu- pulsus paradoxus drop in blood pressure of greater than
pation. 10 torr during inspiration.
prognosis the expected outcome of a disease or injury. pus a liquid mixture of dead cells, bits of dead tissue, and
prokaryotic cells cells that do not contain a nucleus and tissue fluid that may accumulate in inflamed tissues.
do not contain organelles. Most prokaryotes are sur- pyrogen foreign protein capable of producing fever.
rounded by a rigid cell wall. The cells of most single- qualitative research research in which the researcher
celled organisms, such as bacteria, are prokaryotes. See explores relationships using textual, rather than quanti-
also eukaryotic cells. tative, data. Case study, observation, and ethnography
prospective medical oversight guidelines established by are forms of qualitative research.
a medical director in advance of emergency calls, such qualitative statistics the analysis of nonnumeric data.
as those regarding selection of personnel and supplies, quality improvement (QI) an evaluation program that
training and education, and protocol development. emphasizes service and uses customer satisfaction as
prospective study study designed to observe outcomes the ultimate indicator of system performance.
or events that will occur subsequent to the identifica- quality of life the general well-being of individuals and
tion of the group of subjects to be studied. society.
prostaglandins substances synthesized by mast cells quantitative research a study type that quantifies rela-
during the inflammatory response that cause vasodila- tionships between variables, using numeric terms.
tion, vascular permeability, and chemotaxis and also quantitative statistics statistics that involve analysis of
cause pain. numeric data and are used to make conclusions and
proteins nitrogen-based complex compounds that are future predictions.
the basic building blocks of cells and are essential for quasiexperimental study study that does not use ran-
the growth and repair of living tissues. dom assignments to place the subjects into the various
proton positively charged particle within the nucleus of study groups.
an atom. radio band a range of radio frequencies.
prototype medication that best demonstrates the class’s radio frequency the number of times per second a radio
common properties and illustrates its particular charac- wave oscillates.
teristics. radioactive decay the breakdown of the nucleus of an
proximate cause action or inaction of the paramedic that unstable atom, resulting in the emission of radiation.
immediately caused or worsened the damage suffered See also radioactive isotopes.
by the patient. radioactive isotopes atoms with unstable nuclei that
psychoneuroimmunological regulation the interactions break down and emit radiation, in a process called
of psychological, neurologic/endocrine, and immuno- radioactive decay.
logic factors that contribute to alteration of the immune ramped position the ear-to-sternal-notch position in an
system as an outcome of a stress response that is not obese patient. See also ear-to-sternal-notch position.
quickly resolved. random sampling sampling in which subjects are cho-
psychotherapeutic medication medication used to treat sen by random chance. See randomized controlled trial
mental dysfunction. (RCT).
public health the science and practice of protecting and randomized controlled trial (RCT) study in which sub-
improving the health of a community through the use jects are assigned to different treatments, interventions,
of preventive medicine, health education, control of or conditions according to chance, rather than with
communicable diseases, application of sanitary mea- reference to some aspect of their condition, history, or
sures, and monitoring of environmental hazards. prognosis.
Glossary 639
rapid sequence intubation (RSI) giving medications to retroglottic airways extraglottic airway devices that are
sedate (induce) and temporarily paralyze a patient and placed in the esophagus (behind the vocal cords).
then performing orotracheal intubation. retrospective medical oversight actions of a medical
reasonable force the minimal amount of force necessary director intended to evaluate ongoing calls or calls that
to ensure that an unruly or violent person does not have already taken place, such as auditing a call, direct-
cause injury to himself or others. ing peer review, conflict resolution, and other quality
recall bias an error caued by differences in the accuracy or assurance or improvement processes.
completeness of the recollections retrieved by study par- retrospective study research conducted by review-
ticipants regarding events or experiences from the past. ing records (e.g., birth and death certificates, medical
receptor specialized protein that combines with a medi- records, school or employment records) or informa-
cation resulting in a biochemical effect. tion about past events elicited through interviews with
reciprocity the process by which an agency grants auto- persons who have, and controls who do not have, the
matic certification or licensure to an individual who disease or condition, or another characteristic under
has comparable certification or licensure from another investigation.
agency. Rh blood group a group of antigens discovered on the
reduction the gain of atoms by one atom from another. red blood cells of rhesus monkeys that is also present to
See also oxidation. some extent in humans.
regeneration regrowth through cell proliferation. Rh factor an antigen in the Rh blood group that is
registration the process of entering one’s name and also known as antigen D. About 85 percent of North
essential information within a particular record, done Americans have the Rh factor (are Rh positive),
in EMS to verify the provider’s initial certification and whereas about 15 percent do not have the Rh factor
to monitor recertification. (are Rh negative). Rh positive and Rh negative blood
repair healing of a wound with scar formation. are incompatible; that is, a person who is Rh negative
repeaters electronic devices that receive a signal and can experience a severe immune response if Rh posi-
rebroadcast it at a higher power. tive blood is introduced, as through a transfusion or
res ipsa loquitur a legal doctrine invoked by plaintiffs during childbirth.
to support a claim of negligence; it is a Latin term that ribonucleic acid (RNA) a chemical similar to deoxyribo-
means “the thing speaks for itself.” nucleic acid (DNA) that serves as a template for protein
research a systematic investigation, including develop- synthesis.
ment of the research design, testing, and evaluation, ribosome organelle within a cell that synthesizes poly-
intended to develop or contribute to generalizable peptides and proteins.
knowledge. rooting reflex a reflex that occurs when an infant’s cheek
resolution the complete healing of a wound and return is touched by a hand or cloth; the hungry infant turns
of tissues to their normal structure and function; the his head to the right or left.
ending of inflammation with no scar formation. rough endoplasmic reticulum (RER) parts of the
respiration the exchange of gases between a living endoplasmic reticulum that contain ribosomes during
organism and its environment. protein synthesis. See also endoplasmic reticulum; ribo-
respiratory acid–base disorders respiratory acidosis some.
and respiratory alkalosis; disorders that result from an rules of evidence guidelines that must be followed for
inequality between carbon dioxide generation in the permitting a new medication, process, or procedure to
peripheral tissues and carbon dioxide elimination by be used in EMS.
the respiratory system. SafeCom a communications program of the U.S.
respiratory acidosis acidity caused by abnormal retention Department of Homeland Security that provides
of carbon dioxide resulting from impaired ventilation. research and guidance to emergency response agen-
respiratory alkalosis alkalinity caused by excessive cies regarding the development of interoperable com-
elimination of carbon dioxide resulting from increased munications systems.
respirations. saline lock peripheral IV cannula with a distal medica-
respiratory rate number of times a person breathes in tion port used for intermittent fluid or medication infu-
1 minute. sions. Saline is injected into the device to maintain its
response time time elapsed from when a unit is alerted patency.
until it arrives on the scene. sampling error difference between the values obtained
restraint asphyxia lack of oxygen resulting in uncon- from the sample and those that actually exist in the
sciousness or death that occurs in a person who is total population.
being restrained. Also called positional asphyxia. SaO2 see hemoglobin-oxygen saturation.
640 Glossary
saturated fatty acids a class of triglycerides that have a septum cartilage that separates the right and left nasal
single bond between carbon atoms, leaving room for cavities.
two hydrogen atoms. sequelae see complications.
scaffolding a teaching/learning technique in which one serotonin a substance released by platelets that, through
builds on what has already been learned. constriction and dilation of blood vessels, affects blood
science the systematic study of the nature and behav- flow to an injured or affected site.
ior of the material and physical universe, based on serum solution containing whole antibodies for a spe-
observation, experiment, and measurement, and the cific pathogen.
formulation of laws to describe these facts in general sharps container rigid, puncture-resistant container
terms. clearly marked as a biohazard.
scientific method a method of investigation in which shock see hypoperfusion.
a problem is first identified and observations, experi- side effect unintended response to a medication.
ments, or other relevant data are then used to construct sign objective finding that can be identified through
or test hypotheses that purport to solve it. physical examination.
scope of practice the range of duties and skills paramed- simple diffusion the passive movement of molecules
ics and other levels of EMS certification are allowed through a membrane from an area of greater concentra-
and expected to perform. tion to an area of lesser concentration. See also facili-
second messenger chemical that participates in complex tated diffusion; osmosis.
cascading reactions that eventually cause a medica- simplex communications system that transmits and
tion’s desired effect. receives on the same frequency.
secondary immune response the swift, strong response single blind study a study in which the investigator, but
of the immune system to repeated exposures to an not the subject, knows the treatment assignment.
antigen. sinus air cavity that conducts fluids from the Eustachian
secondary intention complex healing of a larger wound tubes and tear ducts to and from the nasopharynx.
involving sealing of the wound through scab forma- situational awareness (SA) perception of all aspects of a
tion, granulation or filling of the wound, and constric- scene or situation.
tion of the wound. slander act of injuring a person’s character, name, or
secondary prevention medical care after an injury or reputation by false or malicious statements spoken
illness that helps to prevent further problems from with malicious intent or reckless disregard for the fal-
occurring. sity of those statements.
secretory immune system lymphoid tissues beneath slow-to-warm-up child an infant who can be character-
the mucosal endothelium that secrete substances such ized by a low intensity of reactions and a somewhat
as sweat, tears, saliva, mucus, and breast milk; also negative mood.
called the external immune system or the mucosal immune smart phone devices that combine the voice capabil-
system. ity of a basic cell phone with the ability to perform a
secure attachment a type of bonding that occurs when variety of data messaging functions such as e-mail and
an infant learns that his caregivers will be responsive Internet connections as well as taking and sending pho-
and helpful when needed. tos and video.
sedation state of decreased anxiety and inhibitions. smooth endoplasmic reticulum (SER) portion of the
selection bias the selection of individuals, groups, or endoplasmic reticulum without ribosomes; it provides
data for analysis in such a way that proper random- surface area of the action or storage of key enzymes
ization is not achieved, thereby ensuring that the and their products. See also endoplasmic reticulum;
sample obtained is not representative of the population enzymes.
intended to be analyzed. sniffing position the ear-to-sternal-notch position
semantic related to the meaning of words. in a non-obese patient. See also ear-to-sternal-notch
semipermeable referring to a membrane that allows position.
unrestricted movement of some substances across the sodium–potassium pump an enzyme (Na+ -K+-ATPase);
membrane while restricting the movement of other a mechanism of active transport in the plasma mem-
substances. Also called selectively permeable. brane, powered by adenosine triphosphate (ATP), that
septic shock shock that develops as the result of infec- moves sodium ions out of a cell and potassium ions
tion carried by the bloodstream, eventually causing into the cell to help maintain cell potential and regular
dysfunction of multiple organ systems. cellular volume.
septicemia the systemic spread of toxins through the solute a substance dissolved in a solvent, forming a
bloodstream. Also called sepsis. solution. See also solvent.
Glossary 641
solvent a substance that dissolves other substances, sucrose common table sugar; a disaccharide, it is a com-
forming a solution. See also solute. bination of glucose and fructose.
spike sharp-pointed device inserted into the IV solution suction to remove with a vacuum-type device.
bag’s administration set port. sugars a class of carbohydrate that can be further classified
standard deviation (SD, σ) a statistic representing the as simple sugars (monosaccharides) or complex sugars
degree of dispersion of a set of scores around their (disaccharides). See also disaccharides; monosaccharides.
mean. suppository medication packaged in a soft, pliable form
standard of care the degree of care, skill, and judgment for insertion into the rectum.
that would be expected under like or similar circum- supraglottic airways extraglottic airway devices that are
stances by a similarly trained, reasonable paramedic in placed above the vocal cords (above the glottis).
the same community. surfactant substance that decreases surface tension.
Standard Precautions a strict form of infection control sympatholytic medication or other substance that blocks
that is based on the assumption that all blood and other the actions of the sympathetic nervous system (also
body fluids are infectious. called antiadrenergic).
standing orders treatment procedures preauthorized by sympathomimetic medication or other substance that
a medical director. causes effects like those of the sympathetic nervous
starches polymers of glucose; carbohydrates. system (also called adrenergic).
statistics mathematical techniques used to summarize symptom subjective complaint; what the patient is expe-
research data or to determine whether the data support riencing and, possibly, can describe.
the researcher’s hypothesis. synapse space between nerve cells.
statuatory law law created by lawmaking bodies syndrome a constellation of signs and symptoms com-
such as Congress and state assemblies. Also called monly found in association with a particular disease or
legislative law. condition.
stem cells undifferentiated cells in the bone marrow syringe plastic tube with which liquid medications can
from which all blood cells, including thrombocytes, be drawn up, stored, and injected.
erythrocytes, and various types of leukocytes, develop; systemic throughout the body.
stem cells are also called hemocytoblasts. systematic sampling statistical sampling technique in
stenosis narrowing or constriction. which there is order to the selection of samples for the
sterile free of all forms of life. study. The most common form is where every kth sam-
sterilization use of a chemical or physical method such ple is taken (e.g., every 10th name from the phone book).
as pressurized steam to kill all microorganisms on an T cell receptor (TCR) a molecule on the surface of a
object. helper T cell that responds to a specific antigen. There
steroids an organic compound, a class of lipid. The is a specific TCR for every antigen to which the human
dietary fat cholesterol and the sex hormones estradiol body may be exposed.
and testosterone are examples of steroids. T lymphocytes the type of white blood cell that does not
stock solution standard concentration of routinely used produce antibodies but, instead, attacks antigens directly.
medications. t test a statistical test used to determine if the scores of
stoma opening in the anterior neck that connects the tra- two groups differ on a single variable.
chea with ambient air. teachable moment a time shortly after an injury when
stress response changes within the body initiated by a the patient and observers remain acutely aware of what
stressor. has happened and may be especially receptive to teach-
stress a hardship or strain; a physical or emotional ing about how a similar injury or illness could be pre-
response to a stimulus. vented in the future.
stressor a stimulus that causes stress. Tema Conter Memorial Trust Canadian organization that
stroke volume the amount of blood ejected by the heart works to raise awareness of mental health issues and care
in one contraction. that can be provided for mental health challenges associ-
stylet plastic-covered metal wire used to bend the ETT ated with EMS service. See also Code Green Campaign.
into a J or hockey-stick shape. teratogenic drug medication that may deform or kill a
subcutaneous the layer of loose connective tissue fetus.
between the skin and muscle. teratogens external factors that can affect the develop-
sublingual beneath the tongue. ment of a fetus.
substrate a substance an enzyme acts on. terminal-drop hypothesis a theory that death is pre-
sucking reflex a reflex that occurs when an infant’s lips ceded by a five-year period of decreasing cognitive
are stroked. functioning.
642 Glossary
termination of action time from when the medication’s triglycerides lipids consisting of one molecule of glyc-
level drops below its minimum effective concentration erol and three fatty acid molecules that are a rich source
until it is eliminated from the body. of energy for the body.
terrestrial-based triangulation a system of location trocar a sharp, pointed instrument.
based on the use of three land-based points of observa- trunking communications system that pools all frequen-
tion, such as using the strengths of signals from three cies and routes transmissions to the next available fre-
cell phone towers to locate a given cell phone signal, or quency.
more traditional methods such as the use of sextants in trust vs. mistrust refers to a stage of psychosocial
surveying. development that lasts from birth to about 1½ years
tertiary prevention rehabilitation after an injury or of age.
illness that helps to prevent further problems from tumor a mass of uncontrolled cell growth. A tumor may
occurring. be benign (noncancerous) or malignant (cancerous).
therapeutic index ratio of a medication’s lethal dose for turgor normal tension in a cell; the resistance of the skin
50 percent of the population to its effective dose for 50 to deformation. (In a normally hydrated person, the
percent of the population. skin, when pinched, will quickly return to its normal
therapy regulator pressure regulator used for delivering formation. In a dehydrated person, the return to nor-
oxygen to patients. mal formation will be slower.)
thrombocytes platelets, which are important in blood turnover the continual synthesis and breakdown of
clotting. body substances that results in the dynamic steady
thrombophlebitis inflammation of the vein. state.
thrombus blood clot. ultrahigh frequency (UHF) radio frequency band from
tidal volume (TV) the average volume of gas inhaled or 300 to 3,000 megahertz.
exhaled in one respiratory cycle. ultrasound use of high frequency sound waves to pro-
tiered response multiple levels of emergency care per- duce images of internal body structures.
sonnel responding to the same incident. unit predetermined amount of medication or fluid.
time sampling statistical sampling technique in which unsaturated fatty acids a class of triglycerides that have
the samples are chosen by a given time interval or time a double bond between carbon atoms, leaving room for
span (e.g., what the subjects were thinking about at only one hydrogen atom.
intervals of three hours, or what they were doing dur- upper airway obstruction an interference with air move-
ing the same half-hour each day). ment through the upper airway.
tissue a group of cells that perform a similar function. up-regulation when a medication causes the formation
tonicity solute concentration or osmotic pressure rela- of more receptors than normal.
tive to the blood plasma or body cells. vaccine solution containing a modified pathogen that
topical medications material applied to and absorbed does not actually cause disease but still stimulates the
through the skin or mucous membranes. development of antibodies specific to it.
tort law division of the legal system that deals with civil vacuole organelle within a cell that provides temporary
wrongs committed by one individual against another. storage or transport of substances such as food sources.
See also intentional tort. vacutainer device that holds blood tubes.
total body water (TBW) the total amount of water in the valence electrons electrons found in the outermost shell
body at a given time. (valence shell) of an atom.
total lung capacity (TLC) maximum lung capacity. valence shell the outermost electron shell of an atom.
trachea 10- to 12-cm-long tube that connects the larynx See also electron shells.
to the mainstem bronchi. validity extent to which an investigator’s findings are
transdermal absorbed through the skin. accurate or reflect the underlying purpose of the study.
trauma center a medical facility that has the capability of vallecula depression between the epiglottis and the base
caring for the acutely injured patient. A trauma center of the tongue.
must meet strict criteria to use this designation. variance measure of variability indicating the average of
trauma a physical injury or wound caused by external the squared deviations from the mean.
force or violence. venous access device surgically implanted port that per-
treatment group the study group in an experimental mits repeated access to central venous circulation.
design that will receive the treatment or intervention venous constricting band flat rubber band used to
being studied. impede venous return and make veins easier to see.
triage tags tags containing vital information, which are ventilation the mechanical process that moves air into
affixed to the patient during a multiple-patient incident. and out of the lungs.
Glossary 643
Venturi mask high-concentration face mask that uses a invade and live inside the cells of the organisms they
Venturi system to deliver relatively precise oxygen con- infect.
centrations. voice over Internet protocol (VOIP) technology that
very high frequency (VHF) radio frequency band from provides voice communications through Internet access
30 to 300 megahertz. from a computer or mobile device.
vial plastic or glass container with a self-sealing rubber volume on hand the available amount of solution con-
top. taining a medication.
virus an organism much smaller than a bacterium, years of productive life a calculation made by subtract-
visible only under an electron microscope. Viruses ing the age at death from 65.
Index
644
Index 645
optical laryngoscopes and, 568 classes of, 287–288 professional relations, 156–157
oral (OETI), 557 defined, 286 research, 157
orotracheal technique, 564–566 functions of, 287 resuscitation attempts, 152–153
overview, 556 types and functions, 287–288 teaching, 156
on pediatric patients, 578–580 types and locations illustration, 286 Etiology, 231
positioning, 570 Epithelialization, 335 Etomidate, 590
protective equipment, 561 Epithelium, 286 ETT. See Endotracheal tube
retrograde intubation, 568 Equipment. See also specific equipment Eukaryotic cells, 254, 271
stylet, 560 cleaning, 70 Eustachian tubes, 517
suction unit, 561 decontamination of, 70 Evaluation, as epidemiology role, 109
syringe, 560 disinfection, 70 Evidence-based decision making,
tension pneumothorax and, 564 personal protective (PPE), 66–68 103–104
tooth breakage and, 562 sterilization, 70 Evidence-based medicine (EBM),
training, 569 Erythrocytes, 268 37–38
transport delays and, 562 Esophageal detector device (EDD), Excited delirium syndrome
tube-holding devices, 560 567 (ExDS), 128
verification of proper tube Esophageal Gastric Tube Airway Exocrine secretions, 287
placement, 566–568 (EGTA®), 554 Exocytosis, 260, 261
video laryngoscopes and, 568–569 Esophageal intubation, 538, 563 Exotoxins, 315
Endotracheal tube (ETT) Esophageal Obturator Airway Experimental design
defined, 559 (EOA®), 554 case report, 92
Endotrol, 559 Esophageal Tracheal Combitube case series, 92
illustrated, 559, 560 (ETC™), 551–553 cohort study, 91
inserting too far, avoiding, 563–564 Estrogens, 427 control group, 89
insertion (digital intubation), ETCO2, 535, 539, 540 cross-sectional study, 92
574, 575 Ethical conflicts double blind study, 90
leak detection, 538 impartiality test, 152 experimental group, 89
misplacement, 563 interpersonal justifiability test, 152 expert opinions, editorials, and
size for pediatric patents, 577, 578 quick approach to, 151 rational conjecture, 92–93
using, 452 reasoning out, 150 meta-analysis, 90
Endotracheal tube introducer, 560, resolving, 149–152 nonrandomized controlled
567, 569–570 universalizability test, 152 trials, 91
End-tidal CO2 monitoring, 534 Ethical decision-making, 147–148, 150 observational study, 89–90
Enema, 457 Ethical relativism, 147 quasiexperimental study, 89–90
Enteral medication administration Ethics randomized controlled trial (RCT),
gastric tube, 454–456 adolescent development of, 217 90–91
oral, 453–454 codes of, 148 single blind study, 90
overview of, 452–453 defined, 6, 35, 146–147 study types, 90–93
rectal, 456–457 EMT Code of Ethics, 52 study validity, 93
Enteral routes, 365, 452 fundamental principles, 149 treatment group, 89
Environment, disease and, 230–231 fundamental questions, Experimental group, 89
Enzymes, 243 148–149 Experimental study, 89
Enzyme-substrate complex, 243 impact on individual practice, 148 Experiments, 87–88
EOA® (Esophageal Obturator introduction to, 146 Expert opinions, editorials, and
Airway), 554 overview of, 146–152 rational conjecture, 92–93
Eosinophils, 333 in paramedicine, 145–148 Expiratory reserve volume
Epidemiology. See also Public health professional, 51 (ERV), 526
defined, 108 relationship to law and religion, 147 Exposure, 70–71
EMS public health strategies, in research, 93–94 Expressed consent, 130–131
110–111 Ethics issues Extension tubing, 473
injury risk and, 109 allocation of resources, 155 External jugular vein, peripheral
roles and responsibilities, 109 confidentiality, 153–154 venous access in, 478–480
years of productive life and, 109 consent, 154–155 External validity, 93
Epithelial tissues. See also Tissues obligation to provide care, 155–156 Extracellular fluid (ECF), 261
654 Index
Extraglottic airway (EGA) devices Field diagnosis, 198 Geographic information system
Ambu®, 556 Field extubation, 581 (GIS), 172
CookGas air-Q®, 556 Field pronouncements, 74 Geriatric patients
defined, 550 Filtration, 267, 363 drug administration, 361
difficult placement, 592, 593 Financing, EMS system, 38 intraosseous infusion, 497
dual lumen, 551–554 FiO2, 524 public health, 114–115
Esophageal Gastric Tube Airway First-pass effect, 365 Germ layers, 284, 285
(EGTA®), 554 Flagella, 276 Glass ampules, 458–460
Esophageal Obturator Airway Flail chest, 528 Global positioning systems (GPS), 168
(EOA®), 554 Fluids. See also Intravenous fluids Glottis, 517
Esophageal Tracheal Combitube administration of, 433 Gloves, 69
(ETC™), 551–553 replacement of, 269 Glucagon, 425
gastric distention and Folk remedies, 355 Glucocorticoids, 417
decompression and, 600 Fontanelles, 212 Glucose
King LT™ Airway, 554 Food and Drug Administration (FDA) breakdown, 304
Laryngeal Mask Airway classifications of newly approved defined, 240
(LMA™), 555 drugs, 359 facilitated diffusion, 266
LMA Fastrach™, 555–556 pregnancy categories, 361 impaired use of, 304–306
LMA Supreme™, 555 Forced expiratory volume (FEV), 526 Glycogen, 241
Pharyngeo-Tracheal Lumen Airway Foreign bodies Glycogenolysis, 241
(PtL™), 553–554 in airway obstruction, 527 Glycolysis, 276–277, 278, 303
retroglottic, 551–554 removal under direct Goiters, 424
single lumen, 554–555 laryngoscopy, 577 Golgi apparatus, 273
subcategories, 550–551 Free drug availability, 361 Good Samaritan laws, 124, 127, 128
supraglottic, 554–556 Free radicals, 243, 533 Gout, 298
Supraglottic Airway Free water, 257 Gowns, 67, 69
Laryngopharyngeal Tube™ Fructose, 240 Grading, of cancer cells, 295
(S.A.L.T.®), 554 Functional capacity volume (FRC), 526 Granulation, 335
Extrapyramidal symptoms (EPS), 382 Fundamental principles of Granulocytes, 332–333
Extravasation, 481 bioethics, 149 Granuloma, 334
Extravascular space, 490 Fungi, 315–316 Graves’ disease, 339
Extubation, 527, 581 Grief, 72–73
Exudate, 332 G Growth hormone (GH), 345
Eyes, drugs used to affect, 421–423 Gag reflex, 517
EZ-IO™, 496, 497 Galactose, 240 H
Gamma-aminobutyric acid (GABA), H2 receptor antagonists, 420
F 378–379 HAA. See Helicopter air ambulance
Facilitated diffusion, 258–259, 266, 362 Ganglionic blocking agents, 392, 412 Habits and addictions, 63
Fair Labor Standards Act, 141 Ganglionic stimulating agents, 392 Half-life, 235
False imprisonment, 135 Gastric distention and decompression, Hand-off
Family history, 296–297 599–601 defined, 170
Family Medical Leave Act, 141 Gastric tube administration, as high-risk area, 36
FAST1®, 496, 497 454–456 transfer communications in,
Federal Communications Commission Gastrointestinal disorders, 298–299 170–171
(FCC), 180 Gastrointestinal system, 219–220 Haptens, 319
Female reproductive system, drugs Gauge, needle, 458 Head elevation, preoxygenation, 589
affecting, 427–428 Gender Head-tilt/chin-lift, 544
Fentanyl, 589, 591 as altering drug response factor, 371 Head-to-toe narrative approach,
Fermentation, 278–280 disease and, 230 197–198
Fetal immune function, 325 Gene therapy, 341 Health care system integration, 23–24
Fibrin, 331 General adaptation syndrome Health Insurance Portability and
Fibrinolytics, 415 (GAS), 342 Accountability Act (HIPAA),
Fibroblasts, 289 Genetic diseases, 233 5, 129
Fick principle, 302 Genetics, 295–296 Health promotion, 110
Index 655
Heart. See also Cardiovascular system Human life span development Hypovolemic shock, 308–309
blood flow through, 401 adolescence, 216–217 Hypoxemia, 313, 525, 562–563
conductive system, 401 early adulthood, 218 Hypoxia, 282, 530
as pump, 300–301 infancy, 210–213 Hypoxic drive, 526
Helicopter air ambulance (HAA) introduction to, 209
development and use, 20 late adulthood, 219–221 I
overview, 7 middle adulthood, 218 Iatrogenic deficiencies, 340
recommended improvements, 22 school age, 215–216 Iatrogenic disease, 233–234
Helminthiasis, 431 toddler and preschool age, 213–215 ICT. See Information communications
Hematocrit, 269 Human papillomavirus (HPV), 284 technology
Hematologic disorders, 298 Humoral immunity, 317–318 IDDM (insulin-dependent diabetes
Hemochromatosis, 298 Huntington’s disease, 299 mellitus), 425
Hemoconcentration, 494 Hydrogen bonds, 238–239 Identity development, adolescent, 217
Hemoglobin, 268–269, 523 Hydrolysis, 365 Idiopathic disease, 231
Hemoglobin-oxygen saturation Hydrophilic, 259 Idiosyncrasy, 369
(SaO2), 523 Hydrophobic, 259 Idiotypic antigenic determinants, 323
Hemolysis, 494 Hydrostatic pressure, 267 Immediate hypersensitivity
Hemophilia, 298 Hypercapnia, 252 reactions, 336
Hemostasis, 414 Hypercarbia, 524 Immune response
Hemostatic agents, 414–415 Hyperoxia, 533 aging and, 326
Hemothorax, 524 Hyperplasia, 280 cell-mediated, 319, 324
Heparin, 414 Hypersensitivity cellular interactions in,
Heparin lock, 487–488 defined, 336 324–326
Hepatic alteration, 456 delayed reactions, 336 characteristics of, 316,
Hetastarch (Hespan), 471 immediate reactions, 336 317–318
Hgb, 523 mechanisms of, 337 development of, 316
Hierarchical structure of the body, targets of, 338–339 humoral, 321–324
229–230 Type I IgE reaction, 337 illustrated, 327
High-density lipoproteins (HDLs), 415 Type II tissue-specific reactions, 337 induction of, 318–321
High-efficiency particulate air (HEPA) Type III immune-complex-mediated inflammation contrasted with,
respirator, 67 reactions, 337–338 326–327
High-pressure regulator, 543 Type IV cell-mediated tissue overview of, 317
HIPAA (Health Insurance reactions, 338 primary, 317
Portability and Accountability Hypertension, 298 secondary, 317
Act), 5, 129 Hyperthyroidism, 424 Immune suppressing and enhancing
Histamines, 328, 418 Hypertonic solutions, 258, 265, agents, 433
Histology, 284 270, 471 Immune system
Histopathology, 284 Hypertrophy, 280–281 infancy, 211
History of EMS, 14–22 Hyperventilation, 253, 539 role in stress, 345–346
HIV (human immunodeficiency Hyperventilation syndrome, 253 secretory, 321
virus), 315, 340–341 Hypnosis, 378 systemic, 321
HLA antigens, 320 Hypocapnia, 253 toddler/preschool age
HMG CoA reductase inhibitors, Hypodermic needles, 458 children, 214
415–416 Hypoglycemic agents, 426–427 Immune thrombocytopenic purpura
Hollow-needle catheter, 475 Hypoperfusion. See Shock (ITP), 339
Homeostasis, 229, 265, 342–343 Hypothesis Immunity
Hormone actions, 423 constructing, 87 acquired, 317
Hormones, 429 defined, 87 cell-mediated, 318
Hospital emergency departments, 9 null, 101–102 characteristics of, 317–318
Hotspots, 175 revising, 88 deficiencies in, 340–341
Housing, late adulthood, 220–221 terminal-drop, 221 defined, 124
Huber needle, 489 testing, 87–88 governmental, 127
Human immunodeficiency virus Hypotonic solutions, 258, 270, 471 humoral, 317–318
(HIV), 315, 340–341 Hypoventilation, 252–253, 524, 539 natural, 317
656 Index
Legal-medical issues (continued ) Lower airway anatomy, 518–521 Mechanism of injury (MOI), 45
legal system and, 122 Luer sampling needle, 494 Median, 94
paramedic-patient relationship, Lumen, 527 Medical asepsis, 445–446
128–136 Lung cancer, 297 Medical calculations, 503
PCRs and, 186 Lung parenchyma, 520 Medical direction, 25, 127, 444
resuscitation issues, 136–139 Lymph, 290 Medical director
Legibility, documentation, 196 Lymph nodes, 318 communication with, 162
Legislative law, 122 Lymphocytes defined, 25
LEMONS acronym B, 317, 321 discussion with, 170
evaluate 3-3-2 rule, 595 defined, 317 liability concerns, 127
look externally, 595 T, 318, 324 Medical liability, 125–127
Mallampati score, 595 Lymphokines, 325, 333 Medical oversight
neck mobility, 596 Lysosomes, 274 off-line, 25–26
obstruction, 595 protocols, 26
overview, 594 M public health, 114–115
saturations, 596 Macrodrip tubing, 472–473 Medical quality video/imaging, 177
Leprosy, 431 Macrophage-activating factor Medical terminology, 186–188
Leukocytes, 268 (MAF), 333 Medically clean techniques, 446
Leukotrienes, 330, 417 Macrophages, 289 Medicated solutions, 463
Level I facility, 47 Magill forceps, 560, 561 Medication administration
Level II facility, 47 Magnesium, 265, 408 accidental needlesticks, 457
Level III facility, 47 Mainstream capnography, 536–537 charting abbreviations, 193
Level IV facility, 47 Major histocompatibility complex documentation, 446–447
Liability (MHC), 320 electromechanical devices, 490–491
claims, 125 Malaria, 430 enteral, 452–457
defined, 121 Male reproductive system, drugs gastric tube, 454–456
medical, 125–127 affecting, 428 heparin lock and saline lock,
Liability concerns Malfeasance, 126 487–488
airway issues, 128 Malignant neoplasms, 233 intradermal, 463–464
“borrowed servant” doctrine, Mallampati classification system, intramuscular injection, 465–469
127–128 593–594 intraosseous infusion, 494–500
civil rights, 128 Maltose, 240 intravenous, 483–492
medical direction, 127 Manual airway maneuvers, 544 intravenous bolus, 483–485
off-duty paramedics, 128 Margination, 332 intravenous medication infusion,
restraint issues, 128 Masks and protective eyewear, 67 485–487
Libel, 129, 197 Mass number, 235 mathematics, 500–507
Licensure, 29, 124 Mass-casualty preparation, 33 mucous membranes, 448–450
Lidocaine, 589–590 Mast cells, 289, 328–330 onset of action, 370
Life expectancy, 219 Mathematics oral, 453–454
Lifestyle, disease and, 230 dosage calculations for oral overview of, 446–447
Ligaments, 290 medications, 503–507 parenteral, 457–469
Lipid layer, 255 medical calculations, 503 percutaneous, 447–450
Lipids, 245, 246 metric system, 500–503 principles of, 443–447
Lipoproteins, 415 Maturation, 335 pulmonary, 450–452
Lipp maneuver, 552 Maximum life span, 219 rectal, 456–457
Living will, 136–137 MDU (mobile data unit), 175 responses to, 369–370
LMA Fastrach™, 555–556 Mean, 94 routes of, 447–469
LMA Supreme™, 555 Measured volume administration set “six rights” of, 359–360, 444
Local complications, 445 components of, 474 subcutaneous, 464–465, 466
Local inflammatory responses, 334 defined, 473 time of, 371
Logarithm, 249 illustrated, 474 transdermal, 447–448
Loop diuretic, 409 intravenous (IV) access with, venous access devices, 488–490
Loss, 72–73 480–482 Medication injection ports, 473
Low-density lipoproteins (LDLs), 415 Measures of central tendency, 94 Medication ports, 488
Index 659
Medication-assisted intubation (MAI) Minimum effective concentration, 370 Muscarinic cholinergic antagonists,
defined, 587 Minors, 131 391–392
overview, 587 Minute volume, 253, 524, 526 Muscarinic receptors, 390
rapid sequence airway (RSA), 592 Misfeasance, 126 Muscle tissues
rapid sequence intubation (RSI), Mission-critical communications, 175 defined, 286
587–592 Mitochondria, 275 diagram and chart of, 290
Medications. See also Drugs Mixed research, 89 types of, 291
adjunct, 373, 375 Mix-o-Vial, 461 Musculoskeletal system
aural, 449–450 Mobile data unit (MDU), 175 infancy, 212
buccal, 448–449 Mobile integrated health care toddler/preschool age children, 214
charting abbreviations, 190 community care, 7, 8 Mutual aid, 33
defined, 354, 443 defined, 4 Myasthenia gravis, 339
as high-risk area, 36 Mode, 95
nasal, 449 Modeling, 215 N
ocular, 449 MODS. See Multiple organ N-95 respirator, 67, 68, 69
patient care using, 359–361 dysfunction syndrome Napoleonic wars, 16
psychotherapeutic, 381–385 MOI (mechanism of injury), 45 Nares, 517
“six rights” of, 359–360, 444 Molarity, 249 Narrative
sublingual, 448 Molecules, 237 assessment/management plan,
topical, 447 Moles, 249 198–199
Mental health services, 78 Monoamine oxidase inhibitors body systems approach, 198
Mesoderm, 285 (MAOIs), 385 call incident format, 200
Meta-analysis, 90 Monoclonal antibodies, 323 CHART format, 199–200
Metabolic acid-base disorders, 252 Monokines, 325 head-to-toe approach, 197–198
Metabolic acidosis, 253–254 Monomers, 240 objective, 197–198
Metabolic alkalosis, 254 Monosaccharides, 240 patient management format, 200
Metabolic diseases, 232–233 Morals, 146 sections, 197–199
Metabolism Morbidity, 86 SOAP format, 199
aerobic, 303 Moro reflex, 211 subjective, 197
anaerobic, 303 Mortality, 86 writing, 197–200
defined, 232, 365 Motor vehicle collisions, 115 Nasal cannula, 543
Metallic elements, 238 Motor vehicle laws, 124 Nasal cavity, 516–517
Metaplasia, 281 Mourning, 72–73 Nasal decongestants, 417–418
Metastasis, 292 Mouth-to-mask ventilation, 548 Nasal medications, 449
Metered dose inhalers (MDIs), Mouth-to-mouth ventilation, 547 Nasogastric tube, 455
451–452 Mouth-to-nose ventilation, 547 Nasolacrimal ducts, 517
Methemoglobin, 534 Mucosal atomization device Nasopharyngeal airway (NPA),
Methylphenidates, 379, 381 (MAD), 449 545–546
Methylxanthines, 379, 381, 417 Mucous membranes, 448–450, 517 Nasotracheal intubation
Metric system Mucus, 517 defined, 571
conversion between prefixes, 501 Multiband radio, 177 disadvantages of, 572
equivalents, 502 Multidraw needle, 493 illustrated, 572
fundamental units, 500 Multifactorial disorders, 296 relative and absolute
prefixes, 501 Multiple casualty incidents, 202–203 contraindications, 571–572
temperature, 502 Multiple organ dysfunction technique, 572–573
units, 503 syndrome (MODS) National Emergency Medical Services
weight conversion, 502 causes of, 312–313 Education Standards: Paramedic
Microcirculation, 301 clinical presentation of, 313–314 Instructional Guidelines, 5
Microdrip tubing, 472–473 defined, 312 National Emergency Medical
Midazolam, 590 pathophysiology of, 313 Services Information System
Middle adulthood, 218 presentation over time, 314 (NEMSIS), 165
Migration-inhibitory factor (MIF), 333 Multiple sclerosis, 299 National EMS Core Content, 24
Minimally invasive percutaneous Multiplex, 174 National EMS Education Instructional
cricothyrotomy, 587 Multi-vital-signs monitoring, 178 Guidelines, 24, 28
660 Index
National EMS Education Standards, 24 Neoplasia, 233, 291–295 NPA (nasopharyngeal airway),
National EMS Research Agenda, 86 Neoplasms, 233 545–546
National EMS Scope of Practice Nervous system NTSB (National Transportation Safety
Model, 24 autonomic, 387–388 Board), 22
National Highway Traffic Safety drugs used to affect, 372–400 Nuclear envelope, 272
Administration (NHTSA), 20, functional organization of, 372 Nuclear pores, 272
32, 33 infancy, 211–212 Nucleolus, 272
National Incident Management late adulthood, 220 Nucleoplasm, 272
System (NIMS), 21 parasympathetic, 388–393 Nucleotides, 244
National Registry of Emergency sympathetic, 394–400 Nucleus, 254, 271–272
Medical Technicians (NREMT), 5, toddler/preschool age Null hypothesis, 101–102
19, 29 children, 214 Nutrition, 61–63
National Transportation Safety Board Nervous tissues, 286, 291 Nutritional deficiencies, 340
(NTSB), 22 Net filtration, 267 Nutritional diseases, 233
Natriuretic peptides (NPs), 301 Neuroeffector junction, 387
Natural immunity, 317 Neurogenic shock, 309–310 O
Nature of illness (NOI), 45 Neuroglia, 291, 292 Oath of Geneva, 51
Nebulizers, 450–451, 543 Neuroleptanesthesia, 375 Obesity, 61, 231, 299, 596
Neck mobility, 596 Neuroleptic drugs, 382 Objective narrative, 197–198
Necrosis, 281, 483 Neuromuscular blocking agents, 392, Obligation to provide care, 155–156
Needle adapter, 473 393, 590–591 Observational study, 89–90
Needle cricothyrotomy. See also Neuromuscular disorders, 299 Obstructive disease, 538
Cricothyrotomy Neurons, 291, 388 Occupational Safety and Health
barotrauma as complication, 582 Neurotransmitters, 387 Act, 141
defined, 581 Neutrons, 235 Ocular medications, 449
with jet ventilation technique, Neutrophils, 333 Odds ratio, 97
582–584 NHTSA (National Highway Traffic Off-duty paramedics, 128
positioning for cricothyroid Safety Administration), 20, Off-line medical oversight, 25–26
puncture, 583 32, 33 Oncogenesis, 294
potential complications, 582 Nicotinic cholinergic antagonists, Oncogenic viruses, 293
Needles 391–392 Oncotic force, 267
catheter inserted through, 476 Nicotinic receptors, 390 On-line medical direction, 25
gauge, 458 NIDDM (non-insulin-dependent Onset of action, 370
Huber, 489 diabetes mellitus), 425 Ontario Prehospital Advanced Life
hypodermic, 458 NIMS (National Incident Management Support (OPALS) study, 20
intraosseous, 496–497 System), 21 OPA (oropharyngeal airway),
Luer sampling, 494 Nineteenth century EMS, 17 546–547
multidraw, 493 Nitrates, 413 Open access journals, 98
in obtaining medication from Nitroglycerin, 413 Open cricothyrotomy
ampules, 459–460 NOI (nature of illness), 45 bougie-aided, 586–587
in obtaining medication from vials, Nominal data, 95 defined, 581
460–461 Noncompetitive antagonism, 369 illustrated, 585–586
Negative feedback loops, 300 Nonconstituted medication vials, indications warranting, 584
Negligence 461, 462 potential complications, 584
claim components, 125–126 Nonfeasance, 126 rapid four-step, 586
contributory or comparative, 127 Nonmaleficence, 149 technique variations, 586–587
defense to charges of, 127 Nonmetallic elements, 238 traditional technique, 584
defined, 125 Nonopioid analgesics, 373, 376 Opioids
per se, 126 Nonrandomized controlled trials, 91 agonist-antagonists, 375, 377
NEMSIS (National Emergency Nonrebreather mask, 543 agonists, 373
Medical Services Information Nonselective sympathomimetics, 417 antagonists, 375, 377
System), 165 Nonsteroidal anti-inflammatory drugs common, 374
Neoantigen, 338, 339 (NSAIDs), 375, 431 receptors, 373
Neonatal immune function, 325 Normoxia, 533 Optical laryngoscopes, 568
Index 661
Oral administration. See also Oxygen humidifier, 543 Parathyroid glands, 424
Medication administration Oxygen saturation percentage Parenchyma, 520
defined, 453 (SpO2), 533 Parenteral medication administration
equipment for, 453–454 Oxygenation, 542–544 ampules, 458–460
medication forms, 453 intraosseous infusion, 494–500
principles of, 454 P intravenous access, 469–494
Oral cavity, 517 P value, 100 medication packaging, 458–463
Oral contraceptives, 427 PA, 523 overview of, 457
Oral endotracheal intubation Pa, 523 parenteral routes, 457, 463–469
(OETI), 557 PaCO2, 251, 535 syringes and needles, 457–458
Oral statements, 194 Palmar grasp, 212 vials, 460–461
Orbitals, 236 Palpation, 531–532 Parenteral routes
Ordinal data, 95 Pancreas defined, 366, 457
Organ donation, 138–139 diabetes mellitus and, 425 intradermal injection, 463–464
Organ level, 295 drugs affecting, 425–427 intramuscular injection, 465–469
Organ systems, 295 Para-aminophenol derivatives, 375 list of, 366–367
Organelles, 254, 271–275 Paradoxical breathing, 528 overview of, 463
Organic chemicals, 239 Paramedicine subcutaneous injection,
Organic nitrates, 413 community, 4, 178 464–465, 466
Organisms, 295 defined, 4 types of, 463
Oropharyngeal airway (OPA), ethics in, 145–158 Parkinson’s disease
546–547 introduction to, 1–11 characteristics of, 386
Orotracheal intubation, 564–566 responsibility of, 43 defined, 386
Osmolality, 258, 266 Paramedic-patient relationship drugs used to treat, 386–387
Osmolarity, 258 confidentiality, 128–130 Partial agonists, 368
Osmosis, 257–258, 266, 363 consent, 130–135 Partial pressure, 522, 523
Osmotic diuresis, 308 patient transportation, 135–136 Partial rebreather mask, 543
Osmotic gradient, 257, 265, 266 Paramedics Passive transport, 363
Osmotic pressure, 258, 266 characteristics of, 5 Pathogenesis, 231
Osteocytes, 290 defined, 3 Pathogens, 65, 431
Outcomes-based research, 86 ethics, 6 Pathologist, 229
Overdoses, drugs used to treat, expanded scope of practice, 6–9 Pathology, 229
433–435 functioning as, 4 Pathophysiology. See also Disease
Overhydration, 263 hats worn by, 5 defined, 229
Oversight health care, 4 introduction to, 229
by local-/state-level agencies, 24 laws affecting, 123–125 knowledge requirement, 43
medical, 25 legal protection for, 123–125 Patient advocacy, 55
off-line medical, 25–26 mobile integrated health care, 4 Patient assessment, 45
prospective medical, 25 off-duty, 128 Patient care report, 140
retrospective medical, 25 as patient advocate, 4 Patient information, charting
Over-the-counter (OTC) drugs, 357 roles and responsibilities, 3–4 abbreviations, 189
Over-the-needle catheter, 475 scope of practice, 123–124 Patient management
Oxidation, 276, 365 as true health professional, 5–6 narrative format, 200
Oxidative stress, 282, 533 Parameters, 95 as primary responsibility, 46
Oxygen Parasites, 315–316 Patient refusals, 201
concentration in blood, 523–524 Parasympathetic nervous system Patient safety
defined, 516 ACh receptors, 389 causes of errors, 35
delivery devices, 543–544 defined, 388 high-risk areas, 36
impaired use of, 303–304 medications, 388–393 Patient transfer. See Transfer
liquid, 543 organization of, 388 Patient transportation. See
measurement of, 522–524 postganglionic fibers Transportation
partial pressure of, 302 distribution, 389 PCR. See Prehospital care report
supply and regulation, 542–543 Parasympatholytics, 390, 391–392 Peak expiratory flow testing, 540
transport, 302 Parasympathomimetics, 390–391 Pediatric airway, 520–521
662 Index
Scope of practice (continued ) at cellular level, 303–306 isotonic, 257, 265, 270, 471
defined, 24, 123 compensated, 306 medicated, 463
helicopter air ambulance (HAA), 7 decompensated, 306–307 saline, 471
hospital emergency departments, 9 defined, 299 stock, 503
industrial medicine, 8 hypovolemic, 308–309 Solvents, 248–249, 262
legal considerations, 123–124 impaired use of glucose and, Spike, 472
mobile integrated health care, 7, 8 304–306 SpO2 (oxygen saturation
sports medicine, 8, 9 impaired use of oxygen and, percentage), 533
tactical EMS, 7, 8 303–304 Sports medicine, 8, 9
Screening tests, 70 irreversible, 306 Standard charting abbreviations,
Second messenger, 368 neurogenic, 309–310 189–193
Secondary immune response, 317 pathogenesis of, 305 Standard deviation, 95, 96
Secondary intention, 335 septic, 311–312 Standard of care, 126
Secondary prevention, 109 types of, 307–312 Standard Precautions
Secretory immune system, 321, Shoe covers, 69 application areas, 66
323–324 Sibling relationships, toddler/ defined, 66, 444
Secure attachment, 212 preschool age children, 215 EMS providers, 112
Sedation Side effects, 369 personal protective equipment
common sedatives, 380 Sidestream capnography, 536–537 (PPE), 66–68
defined, 378 Signs, 232 summary of, 445
levels of, 378 Simple diffusion, 256–257, 265 use of, 68
Ramsey score, 379 Simple face mask, 543 Standing orders, 26
Selective IgA deficiency, 340 Simplex, 173 Standing posture, 64
Selective serotonin reuptake inhibitors Single blind study, 90 Stand-off vital-signs monitoring, 178
(SSRIs), 385 Sinuses, 516 Starches, 240
Self-confidence, 54 Sitting posture, 64 Statistics
Self-defense mechanisms Situational awareness (SA), 171 analysis of variance (ANOVA), 95
infectious agents, 314–316 Skeletal muscle, 291 chi square test, 95
lines of defense, 316–317 Skeletal muscle relaxants, 400 defined, 94
overview of, 314 Skill-based failures, 35 descriptive, 94–95
Self-motivation, 53 Skin, drugs used to affect, 432 inferential, 94, 95
Semantic, 180 Slander, 129–130, 197 nominal data, 95
Semipermeable membrane, 255 Sleep, infants, 212 odds ratio, 97
Senses Slow-to-warm-up child, 213 ordinal data, 95
late adulthood, 220 SLUDGE (salivation, lacrimation, overview of, 94–97
toddler/preschool age children, 214 urination, defecation, gastric qualitative, 95
Septic shock, 311–312 motility, emesis), 390, 391, 434 quantitative, 95
Septicemia, 315 Smart phones, 175 t test, 95
Septum, 516 Smooth endoplasmic reticulum (SER), Stem cells, 291
Sequelae, 232 272–273 Stenosis, 581
Serotonin, 328 Smooth muscle, 291 Sterile environment, 445–446
Serotonin antagonists, 421 Sniffing position, 540–541 Sterilization, 70
Serum sickness, 338 SOAP format, 199 Steroids, 247–248, 249
Serums, 431 Sodium, 264 Stimulants, CNS, 379–381
Service quality, 35 Sodium channel blockers (class I), Stock solution, 503
Severe combined immune deficiencies 404–407 Stoma, 597–598
(SCID), 341 Sodium-potassium pump, 259, Stress
Sexual behavior, drugs affecting, 428 260, 266 adapting to, 74–75
Sharps, disposal of, 446 Software-defined radio, 176–177 alarm phase, 75
Sharps containers, 446 Solute, 257 burnout and, 76
Shock Solutions cellular response to, 280–284
anaphylactic, 310–311 colloidal, 470–471 concepts of, 341–343
cardiogenic, 307–308 hypertonic, 258, 265, 270, 471 coping and illness interrelationships,
causes of, 303 hypotonic, 258, 270, 471 346–347
Index 667