Paramedic Care:

Principles & Practice

Fifth Edition

Volume 1
Introduction to Paramedicine

BRYAN E. BLEDSOE, do, facep, faaem, emt-p

Professor of Emergency Medicine
University of Nevada, Las Vegas School of Medicine
University of Nevada, Reno School of Medicine
Attending Emergency Physician
University Medical Center of Southern Nevada
Medical Director, MedicWest Ambulance
Las Vegas, Nevada

RICHARD A. CHERRY, ms, emt-p

Training Consultant
Northern Onondaga Volunteer Ambulance
Liverpool, New York

Legacy Author

ROBERT S. PORTER

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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-
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Cataloging-in-Publication data is on file with the Library of Congress.

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

Introduction 14 Returning to Service 49

History of EMS 14 Additional Responsibilities 49
Early Development 15 Administration 49
The Twentieth Century 17 Community Involvement 49
The Twenty-First Century 21 Support for Primary Care 50
Today’s EMS Systems 22 Citizen Involvement in EMS 50
Chain of Survival 23 Personal and Professional Development 50
Essential Components for Continuum of Care 23 Professionalism 50
Health Care System Integration 23 Professional Ethics 51
Levels of Licensure/Certification 24 Professional Attitudes 51
Quality of Education 24 Professional Attributes 52
Oversight by Local- and State-Level Agencies 24 Continuing Education 55

v
vi Contents

Quantitative and Qualitative Statistics 95

Other Types of Data 95
Format of a Research Paper 97
How a Research Paper Is Published 97
Accessing the Scientific Literature 98

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

8  Ethics in Paramedicine 145 Medical 185

Administrative 185
Introduction 146 Research 186
Overview of Ethics 146 Legal 186
Relationship of Ethics to Law and Religion 147 General Considerations 186
Making Ethical Decisions 147 Medical Terminology 186
Codes of Ethics 148 Abbreviations and Acronyms 188
Impact of Ethics on Individual Practice 148 Times 188
The Fundamental Questions 148 Communications 188
Fundamental Principles 149 Pertinent Negatives 193
Resolving Ethical Conflicts 149 Oral Statements 194
Ethical Issues in Contemporary Paramedic Practice 152 Additional Resources 194
Resuscitation Attempts 152 Elements of Good Documentation 194
Confidentiality 153 Completeness and Accuracy 194
Consent 154 Legibility 196
Allocation of Resources 155 Timeliness 196
Obligation to Provide Care 155 Absence of Alterations 196
Teaching 156 Professionalism 197
Professional Relations 156 Narrative Writing 197
Research 157 Narrative Sections 197
General Formats 199
Special Considerations 201
Patient Refusals 201
Services Not Needed 201
Multiple Casualty Incidents 202
Consequences of Inappropriate Documentation 203

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

10  Documentation 183

Adolescence 216
Physiologic Development 216
Introduction 184 Psychosocial Development 217
Uses for Documentation 185 Early Adulthood 218
viii Contents

Middle Adulthood 218 PART 6: The Body’s Defenses Against Disease

Late Adulthood 219 and Injury 314
Physiologic Development 219 Self-Defense Mechanisms 314
Psychosocial Development 220 Infectious Agents 314
Three Lines of Defense 316
The Immune Response 317
12  Pathophysiology 224 How the Immune Response Works: An Overview 317
Characteristics of the Immune Response and Immunity 317
Introduction 229
Induction of the Immune Response 318
Hierarchical Structure of the Body 229 Humoral Immune Response 321
PART 1: Disease 230 Cell-Mediated Immune Response 324
Predisposing Factors to Disease 230 Cellular Interactions in Immune Response 324
Risk Analysis 231 Fetal and Neonatal Immune Function 326
Disease 231 Aging and the Immune Response 326
Classifications of Disease 232 Inflammation 326
PART 2: Disease at the Chemical Level 234 Inflammation Contrasted to the Immune Response 326
The Chemical Basis of Life 235 How Inflammation Works: An Overview 327
Chemical Bonding 237 Acute Inflammatory Response 328
Inorganic and Organic Chemicals 239 Mast Cells 328
Classes of Biological Chemicals 239 Plasma Protein Systems 330
Acids and Bases 249 Cellular Components of Inflammation 332
Acid–Base Disorders 252 Cellular Products 333
PART 3: Disease at the Cellular Level 254 Systemic Responses of Acute Inflammation 333
The Cell 254 Chronic Inflammatory Responses 334
The Plasma Membrane and Cytoplasm 254 Local Inflammatory Responses 334
Plasma Membrane Functions 256 Resolution and Repair 334
The Cellular Environment: Fluids and Electrolytes 260 Age and the Mechanisms of Self-Defense 336
Water 261 Variances in Immunity and Inflammation 336
Electrolytes 263 Hypersensitivity: Allergy, Autoimmunity, and
Isoimmunity 336
Intravenous Therapy 268
Deficiencies in Immunity and Inflammation 340
The Internal Cell 271
Organelles and Their Functions 271 Stress and Disease 341
The Cytoskeleton and Other Internal Cell Structures 275 Concepts of Stress 341
Stress Responses 343
Cellular Respiration and Energy Production 276
Stress, Coping, and Illness Interrelationships 346
Cellular Respiration 276
Fermentation 278

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

Patient Care Using Medications 359 General Principles 443

Six Rights of Medication Administration 359 Medical Direction 444
Special Considerations 360 Standard Precautions 444
Pharmacology 362 Medical Asepsis 445
Pharmacokinetics 362 Medication Administration and Documentation 446
Pharmacodynamics 367 Percutaneous Medication Administration 447
PART 2: Drug Classifications 372 Transdermal Administration 447
Classifying Drugs 372 Mucous Membranes 448
Drugs Used to Affect the Nervous System 372 Pulmonary Medication Administration 450
Central Nervous System Medications 372 Nebulizer 450
Autonomic Nervous System Medications 387 Metered Dose Inhaler 451
Drugs Used to Affect the Cardiovascular Endotracheal Tube 452
System 400 Enteral Medication Administration 452
Cardiovascular Physiology Review 400 Oral Administration 453
Classes of Cardiovascular Drugs 403 Gastric Tube Administration 454
Drugs Used to Affect the Respiratory System 416 Rectal Administration 456
Antiasthmatic Medications 416 Parenteral Medication Administration 457
Drugs Used for Rhinitis and Cough 417 Syringes and Needles 457
Drugs Used to Affect the Gastrointestinal System 419 Medication Packaging 458
Drugs Used to Treat Peptic Ulcer Disease 419 Parenteral Routes 463
Drugs Used to Treat Constipation 420 PART 2: Intravenous Access, Blood Sampling,
Drugs Used to Treat Diarrhea 420 and Intraosseous Infusion 469
Drugs Used to Treat Emesis 420 Intravenous Access 469
Drugs Used to Aid Digestion 421 Types of Intravenous Access 469
Drugs Used to Affect the Eyes 421 Equipment and Supplies for Venous Access 470
Drugs Used to Affect the Ears 423 Intravenous Access in the Hand, Arm, and Leg 476
Drugs Used to Affect the Endocrine System 423 Intravenous Access in the External Jugular Vein 478
Drugs Affecting the Pituitary Gland 423 Intravenous Access with a Measured Volume
Administration Set 480
Drugs Affecting the Parathyroid and Thyroid Glands 424
Complications of Peripheral Intravenous Access 482
Drugs Affecting the Adrenal Cortex 424
Changing an IV Bag or Bottle 483
Drugs Affecting the Pancreas 425
Intravenous Medication Administration 483
Drugs Affecting the Female Reproductive System 427
Venous Blood Sampling 492
Drugs Affecting the Male Reproductive System 428
Removing a Peripheral IV 494
Drugs Affecting Sexual Behavior 428
Drugs Used to Treat Cancer Intraosseous Infusion 494
428
Access Site 495
Drugs Used to Treat Infectious Diseases
and Inflammation 430 Equipment for Intraosseous Access 496
Placing an Intraosseous Infusion 497
Drugs Used to Affect the Skin 433
Intraosseous Access Complications and Precautions 499
Drugs Used to Supplement the Diet 433
Contraindications to Intraosseous Placement 500
Vitamins and Minerals 433
PART 3: Medical Mathematics 500
Fluids and Electrolytes 433
Metric System 500
Drugs Used to Treat Poisoning and Overdoses 433
Conversion between Prefixes 501
Household and Apothecary Systems of Measure 502
Weight Conversion 502
Temperature 502

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

Endotracheal Intubation 556

Oral Endotracheal Intubation Indications—Non–
Medication-Assisted 557
15 Airway Equipment 557
Management and Complications of Endotracheal Intubation 561
Ventilation 512 Orotracheal Intubation Technique 564
Verification of Proper Tube Placement 566
Introduction 515 Retrograde Intubation 568
PART 1: Respiratory Anatomy, Physiology, Optical Laryngoscopes 568
and Assessment 516 Video Laryngoscopy 568
Anatomy of the Respiratory System 516 Improving Endotracheal Intubation Success 569
Upper Airway Anatomy 516 Blind Nasotracheal Intubation 571
Lower Airway Anatomy 518 Blind Nasotracheal Intubation Technique 572
Physiology of the Respiratory System 521 Digital Intubation 573
Respiration and Ventilation 521 Special Intubation Considerations 575
Measuring Oxygen and Carbon Dioxide Levels 522 Trauma Patient Intubation 575
Regulation of Respiration 524 Foreign Body Removal under Direct Laryngoscopy 577
Respiratory Problems 526 Pediatric Intubation 577
Airway Obstruction 527 Monitoring Cuff Pressure 580
Inadequate Ventilation 528 Post-Intubation Agitation and Field Extubation 581
Respiratory System Assessment 528 Cricothyrotomy 581
Primary Assessment 528 Needle Cricothyrotomy 582
Secondary Assessment 529 Open Cricothyrotomy 584
Noninvasive Respiratory Monitoring 532 Minimally Invasive Percutaneous Cricothyrotomy 587
PART 2: Basic Airway Management and Ventilation 540 Medication-Assisted Intubation 587
Proper Positioning 540 Rapid Sequence Intubation 587
Sniffing Position 541 Rapid Sequence Airway 592
Ramped Position 541 The Difficult Airway 592
Oxygenation 542 Predictors of a Difficult Airway or Ventilation 593
Oxygen Supply and Regulation 542 Effects of Obesity 596
Oxygen Delivery Devices 543 Predicting Difficulty: An Imperfect Science 596
Manual Airway Maneuvers 544 PART 4: Additional Airway and Ventilation Issues 597
Head-Tilt/Chin-Lift 544 Managing Patients with Stoma Sites 597
Jaw-Thrust Maneuver without Head Extension 544 Suctioning 598
Basic Airway Adjuncts 545 Suctioning Equipment 598
Nasopharyngeal Airway 545 Suctioning Techniques 599
Oropharyngeal Airway 546 Tracheobronchial Suctioning 599
Ventilation 547 Gastric Distention and Decompression 599
Mouth-to-Mouth/Mouth-to-Nose Ventilation 547 Transport Ventilators 601
Mouth-to-Mask Ventilation 548 Documentation 602
Bag-Valve-Mask Ventilation 548
Demand-Valve Device 550 Precautions on Bloodborne Pathogens and
PART 3: Advanced Airway Management and Ventilation 550 Infectious Diseases 608
Extraglottic Airway Devices 550 Suggested Responses to “You Make the Call” 610
Retroglottic Airway Devices: Dual Lumen 551 Answers to Review Questions 617
Retroglottic Airway Devices: Single Lumen 554 Glossary 619
Supraglottic Airway Devices 554 Index 644
Preface to Volume 1

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-

Overview of the ents important coping strategies.

New in the 5th Edition: Notes on diseases intro-
Chapters . . . and What’s duced by international travel. A new section Ebola
virus disease, how it is carried, and how to protect
New in the 5th Edition? against an exposure. A new section on post-traumatic
stress disorder.
CHAPTER 1  Introduction to Paramedicine introduces
the paramedic student to the world of paramedicine. CHAPTER 5  EMS Research discusses the importance of
It summarizes the importance of professionalism and research and evidence-based practices in EMS. It
the expanding roles of the paramedic. emphasizes ethical considerations in human research.
New in the 5th Edition: An introduction to Additionally, it explains how to read, evaluate, and
Mobile Integrated Health Care and Community participate in research.
Paramedicine, both concepts relating to paramedicine New in the 5th Edition: Updated American Heart
expanding beyond emergency response and transport Association Levels of Evidence.
to community health initiatives.
CHAPTER 6  Public Health discusses the increasingly
CHAPTER 2  EMS Systems reviews the history of EMS important role of EMS in public health, public educa-
and provides an overview of EMS today. It details the tion, and prevention of illness and injury—stopping
aspects of EMS system design and operation. It injuries and illnesses before they happen.

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

BEB, RAC Sean P. Haaverson, AA, NR/CCEMT-P

EMS Faculty
Central New Mexico Community College
Instructor Reviewers Albuquerque, NM
The reviewers of this edition of Paramedic Care: Principles L. Kelly Kirk, III, AAS, BS, EMT-P
& Practice have provided many excellent suggestions and Director of Distance Education
ideas for improving the text. The quality of the reviews has Randolph Community College
been outstanding, and the reviews have been a major aid in Asheboro, NC
xiii
xiv Acknowledgments

Paul Salway, CCEMT-P, NREMT-P Allen Walls

Firefi ghter/EMT-P Department of Fire & EMS
South Portland Fire Department Colerain Township, OH
South Portland, ME Brian J. Wilson, BA, NREMT-P
R. Thomy Windham, BS Education Director
Director Texas Tech School of Medicine
Pee Dee Regional Community Training El Paso, TX
Center
Florence, SC

We also wish to express appreciation to the following EMS Photo Acknowledgments

professionals who reviewed the third edition of Paramedic All photographs not credited adjacent to the photograph
Care: Principles & Practice. Their suggestions and or in the photo credit section below were photographed on
perspectives helped to make this program a successful assignment for Brady/Pearson Education.
teaching tool.

Mike Dymes, NREMT-P Organizations

EMS Program Director We wish to thank the following organizations for their
Durham Technical Community College valuable assistance in creating the photo program for this
Durham, NC edition:
Wes Hamilton, RN, BSN, CCRN, CFRN,
Canandaigua Emergency Squad
CTRN, NREMT-P, FP-C
Canandaigua, NY
Clinical Educator
Clinical Care Services Division Flower Mound Fire Department
Air-Evac Lifeteam Flower Mound, TX
West Plains, MO Children’s Hospital St. Louis/BJC Health Care
Sean Kivlehan, EMT-P St. Louis, MO
St. Vincent’s Hospital, Manhattan Christian Hospital/BJC Health Care
New York, NY St. Charles, MO
Darren P. Lacroix, AAS, EMT-P MedicWest Ambulance
Del Mar College Las Vegas, NV
Emergency Medical Service Professions Tyco Health Care/Nellcor Puritan Bennet
Corpus Christi, TX Pleasanton, CA
Mike McEvoy, PhD, REMT-P, Wolfe Tory Medical
RN, CCRN Salt Lake City, UT
EMS Coordinator
Saratoga County, NY
Models
Greg Mullen, MS, NREMT-P
Thanks to the following people from the Flower Mound
National EMS Academy
Fire Department, Flower Mound, Texas, who provided
Lafayette, LA
locations and/or portrayed patients and EMS providers in
Deborah L. Petty, BS, EMT-P I/C
our photographs.
Training Offi cer
St. Charles County Ambulance District FAO/Paramedic Wade Woody
St. Peter’s, MO FF/Paramedic Tim Mackling
B. Jeanine Riner, MHSA, BS, RRT, NREMT-P FF/Paramedic Matthew Daniel
GA Offi ce of EMS and Trauma FF/Paramedic Jon Rea
Atlanta, GA
FF/Paramedic Waylon Palmer
Michael D. Smith, LP
FF/EMT Jesse Palmer
Kilgore College
Longview, TX Captain/EMT Billy McWhorter
About the Authors
BRYAN E. BLEDSOE, DO, RICHARD A. CHERRY,
FACEP, FAAEM, EMT-P MS, EMT-P
Dr. Bryan Bledsoe is an emer- Richard Cherry is a Training
gency physician, researcher, Consultant for Northern Onon-
and EMS author. Presently he daga Volunteer Ambulance
is Professor of Emergency (NOVA) in Liverpool, New
Medicine at the University of York, a suburb of Syracuse. He
Nevada School of Medicine is also a program reviewer for
and an Attending Emergency The Continuing Education
Physician at the University Coordinating Board for Emer-
Medical Center of Southern gency Medical Services
Nevada in Las Vegas. He is (CECBEMS). He formerly held
board-certified in emergency positions in the Department of
medicine and emergency Emergency Medicine at
medical services. Prior to attending medical school, Dr. Upstate Medical University as Director of Paramedic Train-
Bledsoe worked as an EMT, a paramedic, and a para- ing, Assistant Emergency Medicine Residency Director, Clini-
medic instructor. He completed EMT training in 1974 cal Assistant Professor of Emergency Medicine, and Technical
and paramedic training in 1976 and worked for six years Director for Medical Simulation. His experience includes
as a field paramedic in Fort Worth, Texas. In 1979, he years of classroom teaching and emergency fieldwork. A
joined the faculty of the University of North Texas Health native of Buffalo, Mr. Cherry earned his bachelor’s degree at
Sciences Center and served as coordinator of EMT and nearby St. Bonaventure University in 1972. He taught high
paramedic education programs at the university. school for the next ten years while he earned his master’s
Dr. Bledsoe is active in emergency medicine and degree in education from Oswego State University in 1977.
EMS research. He is a popular speaker at state, national, He holds a permanent teaching license in New York State.
and international seminars and writes regularly for Mr. Cherry entered the emergency medical services
numerous EMS journals. He is active in educational field in 1974 with the DeWitt Volunteer Fire Department,
endeavors with the United States Special Operations where he served his community as a firefighter and EMS
Command (USSOCOM) and the University of Nevada provider for more than 15 years. He took his first EMT
at Las Vegas. Dr. Bledsoe is the author of numerous EMS course in 1977 and became an ALS provider two years later.
textbooks and has in excess of 1 million books in print. He earned his paramedic certificate in 1985 as a member of
Dr. Bledsoe was named a “Hero of Emergency Medi- the area’s first paramedic class. He then worked both as a
cine” in 2008 by the American College of Emergency paid and volunteer paramedic for the next 15 years.
Physicians as a part of their 40th anniversary celebration Mr. Cherry has authored several books for Brady. Most
and was named a “Hero of Health and Fitness” by Men’s notable are Paramedic Care: Principles & Practice, Essentials of
Health magazine as part of their 20th anniversary edi- Paramedic Care, Intermediate Emergency Care: Principles & Prac-
tion in November of 2008. He is frequently interviewed tice, and EMT Teaching: A Common Sense Approach. He has
in the national media. Dr. Bledsoe is married and divides made presentations at many state, national, and international
his time between his residences in Midlothian, TX, and EMS conferences on a variety of EMS clinical and teaching
Las Vegas, NV. topics. He and his wife, Sue, reside in Sun City West, Arizona.
In addition to riding horses, hiking, and playing softball, they
volunteer their time at Banner Del Webb Medical Center. Mr.
Cherry also plays lead guitar in a Christian band.
xv
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 A GUIDE TO
KEY FEATURES
Emphasizing Principles M01_BLED2031_05_SE_C01.indd Page 1 2/29/16 9:08 PM s-w-149 /203/PH02049/9780134572031_BLEDSOE_V1/BLEDSOE_V1_PRINCIPLES_AND_PRACTICE5_SE_9780 ...

Chapter 1

LEARNING OBJECTIVES
Introduction to
Paramedicine
Terminal Performance Objectives Bryan Bledsoe, DO, FACEP, FAAEM

and a separate set of

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/203/PH02049/9780134572031_BLEDSOE_V1/BLEDSOE_V1_PRINCIPLES_AND_PRACTICE5_SE_9780 ...

provided for each chapter. Preparatory (EMS Systems)

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

Table 11-1 Normal Vital Signs

Pulse (Beats Respiration Blood Pressure
per Minute) (Breaths per Minute) (Average mmHg) Temperature
infancy: TABLES
At birth: 100–180 30–60 60–90 systolic 98–100°F 36.7–37.8°C

At 1 year: 100–160 30–60 87–105 systolic 98–100°F 36.7–37.8°C

toddler (12 to 36 months) 80–110 24–40 95–105 systolic 96.8–99.6°F 36.0–37.5°C

A wealth of tables offers
Preschool age (3 to 5 years) 70–110 22–34 95–110 systolic 96.8–99.6°F 36.0–37.5°C the opportunity to highlight,
School-age (6 to 12 years) 65–110 18–30 97–112 systolic 98.6°F 37°C

Adolescence (13 to 18 years) 60–90 12–26 112–128 systolic 98.6°F 37°C

summarize, and compare
early adulthood (19 to 40 years) 60–100 12–20 120/80 98.6°F 37°C information.
Middle adulthood (41 to 60 years) 60–100 12–20 120/80 98.6°F 37°C

Late adulthood (61 years and older) * * * 98.6°F 37°C

*Depends on the individual’s physical health status.

 the risk-to-benefit ratio may not actually favor cricoid pres- components of the rule of
M s-w-149 /203/PH02049/9780134572031_BLEDSOE_V1/BLEDSOE_V1_PRINCIPLES_AND_PRACTICE5_SE_9780 ... 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 fingers
Airway Management and Ventilation 549 • Three providers. one
sphincter tone (actually working against the intended aspi- • Three airways
provider on the mask,
ally favor cricoid pres-
oid pressure applied
components of the rule of
threes. Whenever BVM
Content Review CONTENT REVIEW ration-sparing effect). However, cricoid pressure during
BVM ventilation is likely to have a more favorable risk-to-
one on the bag, and one
for cricoid pressure.
• Three PSI
• Three PEEP
➤ The Rule of Threes for benefit ratio and, as already noted, is recommended dur-
us often obscures the ventilation is difficult, ing optimal BVM ventilation if sufficient assistance is • Three inches. a reminder to place the patient in the
Optimal BVM Ventilation
onally, the esophagus however, the rule of threes available.12 sniffing position (elevate the head three inches) if not
e cricoid ring, and the should be employed.
• Three providers
• Three inches
Content review boxes set off from the text are interspersed
contraindicated.
to locate the cricoid cartilage, palpate the thyroid car-
e in lower-esophageal • Three fingers tilage (adam’s apple) and feel the depression just below it • Three fingers. three fingers on the cricoid cartilage to
nst the intended aspi-
• Three providers. one
provider on the mask, • Three airways throughout the chapter. They summarize key points and serve as pressure.
perform cricoid
(cricothyroid membrane). the prominence just inferior to
coid pressure during • Three PSI
more favorable risk-to-
one on the bag, and one
• Three PEEP a helpful study guide—in an easy format for quick review.
this depression is the ring of cricoid cartilage, which may
• Three airways. In a worst-case scenario, the airway
be difficult to identify in female and obese patients. to per-
for cricoid pressure. can be maintained, if necessary, with an orophrayngeal
s recommended dur- form cricoid pressure, apply firm downward pressure to
• Three inches. a reminder to place the patient in the airway and two nasopharyngeal airways (one in each
fficient assistance is the anterolateral aspect of the cartilage, using the thumb,
sniffing position (elevate the head three inches) if not nostril).
index, and middle finger of one hand. If a lesser-trained
lpate the thyroid car- contraindicated. • Three PSI. a gentle reminder to use the lowest pres-
provider is performing the maneuver, you should confirm
pression just below it • Three fingers. three fingers on the cricoid cartilage to sure necessary to see the chest rise.
that they are in the correct position (Figure 15-47).
inence just inferior to perform cricoid pressure. • Three seconds. a reminder to ventilate slowly and
Use caution not to apply so much pressure as to
cartilage, which may • Three airways. In a worst-case scenario, the airway allow time for adequate exhalation.
deform and possibly obstruct the trachea; this is a particu-
obese patients. to per- can be maintained, if necessary, with an orophrayngeal lar danger in infants. the necessary pressure has been esti- • Three PEEP. or up to 15 cm/H2o positive-end expira-
ownward pressure to airway and two nasopharyngeal airways (one in each mated as the amount of force that will compress a capped tory pressure (peep) as needed to improve oxygen
ge, using the thumb, nostril). 50-mL syringe from 50 mL to the 30 mL marking. In the saturations.
nd. If a lesser-trained event that the patient actively vomits, it is imperative to
• Three PSI. a gentle reminder to use the lowest pres-
r, you should confirm
sure necessary to see the chest rise. release the pressure to avoid esophageal rupture. Similarly, Bag-Valve Ventilation
PHOTOS AND
Figure 15-47). if cricoid pressure is being performed during intubation, of the pediatric patient
• Three seconds. a reminder to ventilate slowly and
much pressure as to reduce or release the pressure if the intubator is having dif- the differences in the pediatric patient’s anatomy require
allow time for adequate exhalation.
chea; this is a particu- ficulty visualizing the vocal cords. some variation in ventilation technique. First, the child’s
pressure has been esti-
ll compress a capped ILLUSTRATIONS
• Three PEEP. or up to 15 cm/H2o positive-end expira-
tory pressure (peep) as needed to improve oxygen optimal BVM Ventilation
relatively flat nasal bridge makes achieving a mask seal
more difficult. pressing the mask against the child’s face to
0 mL marking. In the saturations.
Using the rule of threes improve the seal can actually obstruct the airway, which is
ts, it is imperative to the rule of threes was developed to help providers recall the more compressible than an adult’s. you can best achieve
Bag-Valve Ventilation
eal rupture. Similarly,
ed during intubation, of the pediatric patient
Carefully selected photos and 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.
ntubator is having dif- a unique art program reinforce
the differences in the pediatric patient’s anatomy require For BVM ventilation, the
some variation in ventilation technique. First, the child’s bag size depends on the
relatively flat nasal bridge makes achieving a mask seal content coverage and add child’s age. Full-term neonates
more difficult. pressing the mask against the child’s face to and infants will require a
improve the seal can actually obstruct the airway, which is to text explanations. Thyroid cartilage
(Adam's apple)
pediatric BVM with a capacity
lp providers recall the more compressible than an adult’s. you can best achieve of at least 450 mL. For children
ation. Many patients the mask seal with the two-person BVM technique, using a up to 8 years of age, the pediat-
ted without using all jaw-thrust to maintain an open airway. ric BVM is preferred, although
For BVM ventilation, the for patients in the upper por-
bag size depends on the Cricothyroid tion of that age range you can
child’s age. Full-term neonates membrane
use an adult BVM with a capac-
and infants will require a ity of 1,500 mL if you do not
Thyroid cartilage Trachea
pediatric BVM with a capacity maximally inflate it. Children
(Adam's apple)
of at least 450 mL. For children Cricoid cartilage Esophagus
older than 8 years require an
occluding esophagus
M01_BLED9956_05_SE_C01.indd Page 17up to 8 years
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8:38 PM age, the pediat- /205/PH02050/9780134569956_BLEDSOE/BLEDSOE_PARAMEDIC_CARE_PRINCIPLES_AND_PRACTICE ... adult BVM to achieve adequate
ric BVM is preferred, although FiguRe 15-47 Cricoid pressure. tidal volumes. additionally, be
for patients in the upper por-
Cricothyroid tion of that age range you can
membrane
use an adult BVM with a capac-
Trachea
ity of 1,500 mL if you do not
maximally inflate it. Children
Cricoid cartilage Esophagus
older than 8 years require an
occluding esophagus

Summary adult BVM to achieve adequate

tidal volumes. additionally, be
The scene size-up is the initial step in the patient care process. Sizing up the scene and situation
begins at your initial dispatch and does not end until you are clear of the call. As the call unfolds,
you should be making constant observations and adjustments to your plan of action. remember
M15_BLED2031_05_SE_C15.indd
that your safety and the safety of your partner are paramount—it is hard to effectively treat both
SUMMARY
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yourself and others.

Scene size-up should be practiced so much that it becomes second nature to you. It is like
noticing veins on people in public after you begin starting IVs. (you have all done it—looked
across the room at the back of someone’s hand and noticed what nice veins they had.) Sizing up
This end-of-chapter feature provides a
a scene is no different. After a while, you begin to notice mechanisms of injury and other impor-
tant details almost subconsciously. But be careful and do not get complacent! Always make it a
concise review of chapter information.
point to pause for just a few seconds and consciously look around the scene before proceeding
into any situation. Summary
Scene size-up is not a step-by-step process, but a series of decisions you make when con- airway assessment and maintenance is the most critical step in managing any patient. If you do
fronted with a variety of circumstances that are often beyond your control. It is a way to not promptly establish a definitive airway and provide proper ventilation, the patient’s outcome
make order out of chaos, keep yourself and your crew safe, and ensure that all necessary will be poor. Frequently reassessing the airway is mandatory to ensure that the patient has not
resources are focused on patient care and outcomes. With time and experience, you will decompensated, requiring additional airway procedures. Successful management of all airways
learn to perform a scene size-up quickly and focus on important issues. your careful size-up requires the paramedic to follow the proper management sequence.
lays the foundation for an organized and timely approach toward patient care and scene Basic airway and management skills can make the difference between a successful outcome
management. And always remember that scene size-up is not a one-time occurrence. It is an and a poor patient prognosis. once you have mastered these basic skills and made them a part of
ongoing process. airway management in every patient, you should learn and use advanced skills such as intuba-
tion, rSI, and cricothyrotomy. you must maintain proficiency in all airway skills, especially the
more advanced techniques, through ongoing continuing education, physician medical direction,
you make the Call and testing with each eMS service. If you cannot do this, it is in the patient’s best interest to focus
on less sophisticated airway skills. If you anticipate that every airway will be complicated, apply

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.
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68 Chapter 4

REVIEW QUESTIONS Review Questions

1. When you couple the physical assessment findings 4. your patient has smoked 2 packs of cigarettes each
with the patient’s medical history, you are able to day for the past 35 years. He is a ______________

These questions ask students to review and derive a list of ______________

a. clinical diagnostics.
pack/year smoker.
a. 35 c. 730

recall key information they have just learned. b. field prognoses

c. chief complaints
b. 70 d. 25,550
5. The CAGE questionnaire is used as an evaluation
d. differential field diagnoses. tool to assess a patient with what type of history?
2. The pain, discomfort, or dysfunction that caused a. Alcoholism c. Allergies
your patient to request help is known as the b. Lung disease d. Pregnancy
______________
6. What interviewing mnemonic should be used for
a. primary problem. each presenting problem a patient has?
M09_BLED2031_05_SE_C09.indd Page 182 2/29/16 9:05 PM s-w-149 /203/PH02049/9780134572031_BLEDSOE_V1/BLEDSOE_V1_PRINCIPLES_AND_PRACTICE5_SE_9780 ... b. nature of the illness. a. SAmPLE
c. differential diagnosis. b. DCAP–BTLS
d. chief complaint. c. OPQRST–ASPN
3. you are assessing a patient who complains of car- d. AEIOU–TIPS
182 Chapter 9 diac-type chest pain that is felt in the jaw and down
7. The mnemonic GPAL is used to evaluate a patient’s
the left arm. This pattern of pain is known as
______________
6. Which radio frequencies may be used by cities and 9. a communications system that uses a different ______________
a. alcoholism.
municipalities for their ability to better transmit transmit and receive frequency allowing for simulta- a. sympathetic pain.
through concrete and steel? neous communications between two parties is called b. allergies.
b. tenderness.
a. UHF c. 800-mHz _________________ c. pregnancy history.
c. referred pain.
b. VHF d. none of the above a. multiplex. d. endocrine dysfunction.
d. associated pain.
b. duplex.
7. Which frequency band is typically used by county
c. simplex. match the following elements of the present illness of the patient with a chief complaint of chest pain with their respective
and suburban agencies due to its ability to transmit
examples:
over various terrains and longer distances? d. complex.
1. O a. Pain is 6 on a scale of 1–10
a. UHF c. 800-mHz 10. _________________ communications systems are
2. P b. Patient also complains of shortness of breath and nausea
b. VHF d. none of the above capable of transmitting both voice and electronic
3. Q c. Pain had a sudden onset
patient data simultaneously.
8. What is the name of the basic communications sys- 4. R d. Pain began 2 hours ago
tem that uses the same frequency to both transmit a. Multiplex c. Simplex
5. S e. Pain worsens while lying down
and receive? b. duplex d. Complex
6. T f. Patient denies dizziness
a. Multiplex c. Simplex See answers to Review Questions at the back of this book.
7. AS g. Pain goes through to the back
b. duplex d. Complex
8. PN h. Pain is heavy and vise-like
See Answers to Review Questions at the back of this book.
references
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-

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.

the Emergency department.” Ann Emerg Med 55 (2010): 171–180.

material providing the basis of
5. association of Public-Safety Communications officials (aPCo).
[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://
www.its.dot.gov/ng911/.)
Acad Emerg Med 11 (2004): 1229–1236.
13. drEaMS ambulance Project. (See article at: https://www.ems1. updated data and research used in the
7. Centers for disease Control and Prevention. recommendations com/ems-products/technology/articles/1183110-drEaMS-
from the Expert Panel: advanced automatic Collision notifica-
tion and triage of the Injured Patient. (See nHtSa summary at
revolutionizes-communication-between-Er-and-ambulance/.)
14. Haskins, P. a., d. G. Ellis, and J. Mayrose. “Predicted Utilization
preparation of each chapter.
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-
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 ...

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):
283–285.
Security), Volume 3, 2005.
McGinnis, K. K. Rural and Frontier Emergency Medical Services
This list features recommendations Workforce Safety and Wellness 59
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.
for books and journal articles that go
Key termS
beyond chapter coverage.
anchor time, p. 76 incubation period, p. 65 post-traumatic stress
burnout, p. 76 infectious disease, p. 65 disorder, p. 77

circadian rhythms, p. 76 isometric exercise, p. 61 Standard Precautions, p. 66

cleaning, p. 70 isotonic exercise, p. 61 sterilization, p. 70

Code Green Campaign, p. 78 pathogens, p. 65 stress, p. 74

disinfection, p. 70 personal protective equipment stressor, p. 74

exposure, p. 70 (PPe), p. 66 tema Conter memorial trust, p. 78

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 ...

Patient Assessment in the Field 241

PROCEDURE SCANS
Procedure 7-4 reassessment

Visual skill summaries provide

step-by-step support in skill instruction.

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-
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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

Preliminary Data penetrating wound to the chest” or “a fall from 25 feet.”

For documentation, always record the date and time of the

physical exam. Determine your patient’s age, sex, race,
Patho Pearls Offer a snapshot of pathological
The renowned Canadian physician Sir William Osler said, “Lis-
birthplace, and occupation. This provides a starting point
for the interview and establishes you as the interviewer.
ten to the patient, and he will tell you what is wrong.” This
advice is as true today as it was 100 years ago. A great deal of
considerations students will
Who is the source of the information you receive about information can be determined from a skillful history taking.
your patient? Is it the competent patient himself, his spouse,
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a friend, or a bystander? Are you receiving a report from a
As you listen to a patient’s medical history, try to understand encounter in the field.
/205/PH02050/9780134569956_BLEDSOE/BLEDSOE_PARAMEDIC_CARE_PRINCIPLES_AND_PRACTICE
the underlying pathophysiologic processes that might cause the ...

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?

ASSESSMENT PEARLS Assessment Pearls

Chest pain is a common reason that people summon EmS.
However, the causes of chest pain are numerous. In emergency
Ask him to explain how the symptom feels, and listen care-
fully to his answer. Does your patient call his pain crush-
ing, tearing, oppressive, gnawing, crampy, sharp, dull, or
medicine or EmS, we often look to exclude the most serious otherwise? Quote his exact descriptors in your report.
causes before determining whether chest pain is of a benign
origin. Internal organs do not have as many pain fibers as do
Region/Radiation
Offer tips, guidance, and information such structures as the skin and other areas. Pain arising from an
internal organ tends to be dull and vague. This is because Where is the symptom? Does it move anywhere else? Iden-
nerves from various spinal levels innervate the organ in ques- tify the exact location and area of pain, discomfort, or dys-
to aid in patient assessment. tion. The heart, for example, is innervated by several thoracic
spinal nerve segments. Thus, cardiac pain tends to be dull and
function. Does your patient complain of pain “here,” while
holding a clenched fist over the sternum, or does he grasp
is sometimes described as pressure. It also tends to cause
the entire abdomen with both hands and moan? If your
referred pain (i.e., pain in an area somewhat distant to the
patient has not done so, ask him to point to the painful
organ), such as pain in the left arm and jaw. Dull pain that is
area. Identify the specific location, or the boundary of the
hard to localize (or to reproduce with palpation) may be due to
cardiac disease. One sign often seen with patients suffering car- pain if it is regional.
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diac disease is Levine’s sign. With Levine’s sign, the patient Determine whether the pain is truly pain (occurring
will subconsciously clench his fist when describing the chest independently) or tenderness (pain on palpation). Also
pain. Levine’s sign is associated with pain of a cardiac origin determine whether the pain moves or radiates. Localized
(e.g., angina or acute coronary syndrome). pain occurs in one specific area, whereas radiating pain
Secondary Assessment 85

the result of a head injury, hypothermia, severe hypoxia, or pediatric pearls

drug overdose. Bradycardia is a common finding in the In infants and small children, use the brachial artery or auscul-
well-conditioned athlete, but it may be found in almost tate for an apical pulse. remember that auscultating an apical
anyone. Treat bradycardia only if it compromises your pulse does not provide information about your patient’s hemo-
patient’s cardiac output and general circulatory status. dynamic status. To locate the brachial artery, feel just medial to
Tachycardia usually indicates an increase in sympa- the biceps tendon. Auscultate the apical pulse just below the

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-
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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

Shows how extending extra kindness and

many factors may influence your patient’s see how things are going. Why don’t we? Before you leave
ately performing advanced procedures such as administra-
blood pressure. Anxiety, for example, may cause it your patient and the family, why not ask them for permission tion of drugs, defibrillation, synchronized cardioversion,
102 Chapter 5 Femoral – just below inguinal ligament
to rise. His position (sitting, lying, standing) also to call the next day or in a few days to see how they’re doing? needle decompression of the chest, or endotracheal intuba-

First, darken the room to the Popliteal

extent– possible. compassion can make an important difference to
just behindBecause
knee may affect the measurement. If your patient has
from about 6 to 15 inches away and aim your light about 15
If they say no or are hesitant to give permission, drop it. If
they give permission, call them and see if there is anything
tion will depend on your assessment and correct field diag-
nosis. If your assessment does not reveal your patient’s true
recently been smoking, exercising, or eating, you
you will not likely be dilating the patient’s pupils, select to 25 degrees nasally. At this distance, you should note a
patients and families coping with an emergency.
must wait at least 5 to 10 minutes to allow his blood you can do for them. problem, the consequences can be devastating.
the narrowest beam of light possible. Dim the light of the red “reflex” while looking through the pupil. The red reflex The follow-up has many benefits. you get to reconnect
pressure to return to a resting level before you mea- As always, common sense dictates how you proceed
ophthalmoscope to minimize pupillaryDorsalis pedis – top of foot
constriction. Begin is simply a reflection of the retina back through the pupil. with the people in your community. It is great for public rela- in the field. When you assess the responsive medical
sure it. Because of these many intangibles, you
the exam with the lens disk at zero diopters. Keep your Absence of the red reflex is commonly secondary to cata- tions. It is educational because you can see whether your
should never use blood pressure as the single indi- patient, the history reveals the most important diagnostic
index finger on the lens disk so Posterior
you cantibial – behind
adjust medial
the disk asmalleolus
racts. Less commonly, it may indicate a detached retina, an diagnosis was accurate. It’s a winner from every angle. When
cator of your patient’s condition. Always correlate it information and takes priority over the physical exam. For
necessary to focus on the various structures during the artificial eye, or, in children, a retinoblastoma. they hang up, they’ll be thinking, “Wow!”
with his other clinical signs of end-organ perfusion, the trauma patient and the unresponsive medical patient,
exam. Use the same eye as the eye you are examining (i.e., place your non-examining hand on the patient’s shoul-
such as level of response, skin color, temperature, the reverse is true. However, trauma may cause a medical
use your right eye to examine the patient’s right eye and der or on the patient’s forehead to gain a sense of proprio-
Figure 5-12 Know each pulse location. and condition, as well as peripheral pulses. emergency, and, conversely, a medical emergency may
use your left eye to examine the patient’s left eye). Ask ception so you can tell how far away you are from the cause trauma. only by performing a thorough patient
your patient to focus on a stationary object straight ahead patient. If your hand is on the patient’s forehead, you may
and slightly above his neutral plane of vision. assist the patient in keeping his eyelid open by holding the Introduction assessment can you discover the true cause of your
patient’s problems. This chapter provides problem-ori-
examine the eye in the following manner: Standing lid up with your thumb near the eyelashes. While keeping Patient assessment means conducting a problem-oriented ented patient assessment examples based on the informa-
laterally and slightly above your patient, look at the eye the red reflex in view, slowly move toward your patient’s evaluation of your patient and establishing priorities of tion and techniques presented in the previous six chapters.
eye while the patient continues to fix his gaze on an object care based on existing and potential threats to human life. you will need to refer to those chapters for the details of
in the distance. Adjust the lens disk as needed to focus on In the previous six chapters, you studied all the techniques taking a history and conducting a physical exam.
In the Field the retina. Farsighted patients will require more “plus” of assessing the scene, conducting a primary assessment, Let’s review the basic components of a patient assess-
The Tools of Your Trade: The Ophthalmoscope diopters (black or green numbers), whereas nearsighted taking a comprehensive patient history and physical exam, ment in the field.
An ophthalmoscope (Figure 5-27) is a medical instrument patients will require more “minus” diopters (red numbers) and using modern technology to monitor your patient’s
used to examine the internal eye structures, especially the to keep the retina in focus.

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

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Chapter 1
Introduction to
Paramedicine 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 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

critical care transport, p. 7 (EMT), p. 3 Paramedic, p. 3

Emergency Medical Responder mobile integrated health paramedicine, p. 4

(EMR), p. 3 care, p. 4

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.

Introduction The Emergency Medical Services (EMS) system has

made significant advances over the past 30 years. Under-
Congratulations on your decision to become a Paramedic. standably, the roles and responsibilities of the paramedic
Before you begin this long but rewarding endeavor, it is have advanced accordingly. Not that long ago, the ambu-
important to understand what the job of a paramedic in the lance was simply a vehicle that provided rapid, horizontal
twenty-first century entails. As a member of the allied transportation to the hospital. Today, equipped with the
health professions (ancillary health care professions, apart latest in equipment and technology, the modern ambu-
from physicians and nurses), the paramedic is highly lance is truly a mobile emergency room that brings sophis-
regarded by society (Figure 1-1). ticated emergency medical care to the patient. The
 Introduction to Paramedicine 3

• 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

Public Health Public Safety

Figure 1-3  The paramedic must always be an advocate for

the patient.

health resources in the community. In the future, there will

Figure 1-2  Modern EMS is a combination of public health, public be a continuing demand to control or cut health care costs.
safety, and health care. As a consequence, paramedics may find themselves in the
role of gatekeepers to the health care system. For example,
public health, and public safety. Any of these might come you may be charged with the responsibility of ensuring
into play on a given day. As EMS research evolves, it is that your patient gets to the appropriate health care facility
becoming clear that illness and injury prevention are just in a timely manner, even though the appropriate health
as important as acute health care and public safety care facility may not be a hospital emergency department.
responsibilities (Figure 1-2). The totality of these roles Paramedics must always strive toward maintaining
and responsibilities of paramedic practice is known as high-quality health care at a reasonable cost. Nevertheless,
paramedicine. you must always be an advocate for your patient and
The primary task of the paramedic is to provide emer- ensure that the patient receives the best possible care—
gency medical care in an out-of-hospital setting. As a para- without regard to the patient’s ability to pay or insurance
medic, you will use your advanced training and equipment status (Figure 1-3).
to extend the care of the emergency physician to the patient Paramedics of the twenty-first century will continue to
in the field. However, you must also be able to make accu- fill the well-defined and traditional role of 911 response, but
rate independent judgments. The ability to do this in a they will also find themselves taking on a wide variety of
timely manner is essential, as it can mean the difference additional responsibilities. The emerging roles and respon-
between life and death for the patient. sibilities of the paramedic include public education, health
To function as a paramedic—to practice the art and sci- promotion, and participation in injury and illness preven-
ence of out-of-hospital medicine in conjunction with physi- tion programs. One rapidly expanding role of paramedics
cian medical oversight—you must have fulfilled the is mobile integrated health care. Mobile integrated health
prescribed requirements of the appropriate licensing or care, also called community paramedicine, is a new and
credentialing body. Licensing or credentialing is typically evolving aspect of community-based health care in which
provided by a state or provincial agency. All paramedics paramedics function outside their customary emergency
must be licensed, registered, or otherwise credentialed by response and transport roles in ways that facilitate more
the appropriate agency in the area where they work. appropriate use of emergency care resources (Figure 1-4).
Paramedics may function only under the direction of Paramedics also serve to enhance access to primary care for
the EMS system’s medical director. Because of this, in addi- medically underserved populations and help to ensure that
tion to being appropriately licensed or credentialed, the all members of the community have access to some level of
system’s medical director must also approve and creden- health care.3 As the scope of paramedic service continues to
tial the paramedic before being permitted to practice expand, the paramedic will function as a facilitator of access
advanced prehospital care. Paramedics must possess to care, as well as an individual treatment provider.
knowledge, skills, and attitudes consistent with the expec- Paramedics are responsible and accountable to the sys-
tations of the public and the profession. tem medical director, their agency, the public, and their
As a paramedic, you must recognize that you are an peers. Although this may seem like a difficult standard to
essential component in the continuum of care. Further- meet, if you always act in the best interest of the patient,
more, paramedics often serve as a link between various you will seldom run into problems.
 Introduction to Paramedicine 5

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

behavior, whereas etiquette

Content Review
refers to good manners.
➤➤ Out-of-Hospital Paramedic
Both can apply to all human
Work Environments
relationships. However,
• Critical care transport
you will find that questions
• Helicopter air
of ethics most often arise in ambulance
relationships with patients • Tactical EMS
and the public, whereas eti- • Mobile integrated
quette more often relates to health care
behavior between health • Industrial medicine
professionals. • Sports medicine
The public must feel • Corrections
confident that, for the para- • Hospital emergency
(a)
medic, the patient’s and department
➤➤ Many aspects of out-
public’s interests are always
of-hospital care now
placed above personal, cor-
provide opportunities for
porate, or financial inter-
paramedics to work in
ests. You must never forget environments other than
that the emergency patient the typical 911 response
is your primary concern. vehicle.
Emergency patients are
vulnerable and in need. Always keep this in mind and serve
as their advocate until you turn patient care over to another
health care professional.

(b)

Figure 1-5  (a and b) Public education is an important part of the

paramedic’s job.
Expanded Scope of Practice
Paramedics have a very bright future. New technologies
and therapies can literally bring the emergency depart-
and physiology course is now a prerequisite to the para- ment to the patient. Paramedics must be willing to step up
medic course. The paramedic course itself requires a far to these expanding roles, or persons from other health care
more extensive foundation of medical knowledge to disciplines will fill them.6 There are many aspects of out-
underlie the required skills. In particular, the curriculum of-hospital care that can provide you with the opportunity
provides for an improved understanding of the patho- to work in an environment other than the typical 911
physiology of the various illness and injury processes response vehicle. These include:
paramedics encounter in their work. The materials pre- • Critical care transport
sented in the 2009 DOT EMS Instructional Guidelines are
• Helicopter air ambulance
the foundation for this textbook.
As a paramedic, you must actively participate in the • Tactical EMS
design, development, evaluation, and publication of • Primary care
research on topics relevant to your profession. For years, • Industrial medicine
paramedic practice was based on anecdotal data and tradi-
• Sports medicine
tion. Only during the past two decades did we truly begin
• Corrections
applying the scientific method to various aspects of prehos-
pital practice. Surprisingly, we found that there were little or • Hospital emergency departments
no scientific data to support many of our prehospital prac- Paramedics are now stepping into nontraditional roles
tices. As a result of research, many traditional EMS treat- such as these because of their unique education and ability
ments have been abandoned or refined. There are still many to think and work independently.
unanswered questions about paramedic practice, and these
can be answered only by sound scientific research.
An essential aspect of a health professional is accep- Critical Care Transport (CCT)
tance and adherence to a code of professional ethics and As a result of the specialization of health care facilities that
etiquette. Ethics are standards of right or honorable began to occur in the 1990s, an increasing number of
 Introduction to Paramedicine 7

Figure 1-6  The modern critical care transport vehicle provides

­virtually all the capabilities of the hospital intensive care unit.

patients are being moved from one health care facility to

another for specialized care. Many of these patients are
critically ill and require equipment and care more sophisti-
Figure 1-8  The helicopter has become an important part of the
cated than that available on standard ambulances. Because
modern EMS system.
of this, many EMS systems have developed specialized
(© REACH Air medical Services, LLC)
critical care transport vehicles to move these patients
between facilities.
These vehicles include specialized ground ambu- rural areas. Most helicopter air ambulance (HAA) programs
lances, fixed-wing aircraft, and helicopters. Many services staff the helicopter with two medical crew members and
have elected to use large vehicles mounted on truck chassis often include paramedics. The flight paramedic typically
to provide the added space needed for critical care trans- will respond to both scene calls and interfacility transfers.
port (Figure 1-6). To staff these vehicles, paramedics have The skills of the flight paramedic are very similar to those
been educated in various aspects of critical care medicine. of a critical care paramedic, but must include additional
These include advanced airway management, ventilator education in flight physiology, aircraft operations, flight
management, fluid and electrolyte therapy, advanced safety, and similar areas. (Figure 1-8).
pharmacology, specialized monitoring, operation of intra-
aortic balloon pumps, and other techniques usually found
in an intensive care setting. This provides a safe and effi- Tactical EMS
cient way to move critical patients between facilities with- Over the past decade or so there has been a trend to use
out compromising hospital staffing (Figure 1-7). EMS personnel in tactical situations. Tactical EMS is
designed to enhance the safety of special operations per-
sonnel and the public. In some situations, tactical para-
Helicopter Air Ambulance (HAA)
medics are cross trained as police officers and carry
Helicopters have been a part of the EMS system for more weapons. The role of the tactical paramedic is to provide
than 30 years and play an important role—especially in life-saving care, sometimes in dangerous environments,
until the patient can be safely evacuated to the general
EMS system. Many of the practices and techniques of tacti-
cal EMS were drawn from experience with the military—
particularly with special operations (Figure 1-9).

Mobile Integrated Health Care

Today, many patients can receive primary care outside the
hospital at far less cost—for example, in physicians’ offices
and minor-care or outpatient clinics.7 Additionally, many
patients can be cared for at home. In certain cases, para-
medics, in close contact with medical direction, can pro-
vide care at the scene without transport to the hospital
(e.g., to treat simple lacerations or to change dressings or
Figure 1-7  Critical care transport provides for the safe transfer of gastrostomy tubes). Several EMS systems have designated
critically ill or injured patients between health care facilities. specialized crews to periodically assess and monitor high-
(© Edward T. Dickinson, MD) risk patients in their community (Figure 1-10).
8  Chapter 1

Figure 1-11  The industrial paramedic provides several important

services in addition to emergency care.

calls and minor medical care. Having paramedics on site

allows for increased employee safety and decreased time
lost from work (Figure 1-11).

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

Figure 1-13  Paramedics often accompany U.S. Border Patrol

agents and provide care to both officers and detainees.
(Photo used by permission. Courtesy of the Office of Border Patrol, Field
­Communications Branch)

medical and nursing staff with skills and responsibilities

within the scope of paramedicine. Many paramedics enjoy
the diversity and work experience of a busy emergency
department (Figure 1-14).

Figure 1-12  Injuries and medical emergencies are common at

sporting events, and many teams and facilities have paramedics
readily available.
(© Ray Kemp/Science Source)

Hospital Emergency Departments

Faced with a nursing shortage, many hospitals have found
paramedics to be very suitable providers for emergency
departments and minor care centers. The role of the para-
medic in these settings varies significantly from state to
state, based on local laws. In some situations, the para-
medic will function in a role comparable to nursing. In oth- Figure 1-14  Hospitals are increasingly turning to paramedics to
ers, they will work in a more technical role, assisting the help staff at busy emergency departments and trauma centers.

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.

You Make the Call

Finally, after two straight years of urban EMS work without a vacation, you and two of your best
paramedic friends, Eileen and Dee Dee, are taking the trip you’ve been planning for some time.
The small airplane grinds to a bumpy halt as you land on a tiny speck of land in the midst of a
bright turquoise sea. The ride from the mainland was rough, and Eileen has thrown up. To make
matters worse, two of your bags didn’t make it aboard the plane. You question the ticket agent
who says, “Maybe a plane come Monday. No plane Sunday.” Your dream vacation is quickly turn-
ing into a nightmare.
After standing in the sun for 45 minutes waiting for a taxi, a 1995 Kia shows up. The driver
tells you that your hotel is about 45 minutes away. He throws your bags into the trunk, ties the
trunk shut with a piece of rope, and takes off like a dragster from the starting line. You and your
friends hang on for dear life as the cab speeds through the winding streets. You try to remember
whether people on this island drive on the left side or the right. You certainly can’t tell based on
your driver’s actions. The driver seems to know everybody and honks accordingly. Loud island
music crackles through the small speakers in the cab. Dee Dee, the friend who managed not to
vomit on the plane, leans over to you and tells you that she thinks she needs to vomit now.
Suddenly, you see a plume of smoke billowing up on the road ahead. As the cab slows, you
spot what appears to be an accident. On closer inspection, you see that another cab has plowed
into a station wagon at an intersection. Several people are lying on the ground, and there is the
general appearance of pandemonium. Dee Dee throws up.
The three of you, experienced paramedics, get out of the cab to take a look. The scene appears
safe to approach. Unfortunately, the accident looks severe, with several persons suffering seri-
ous injuries. Bystanders begin to reach inside the station wagon and drag the occupants out to a
nearby shade tree. You try to offer some advice on providing cervical spine precautions, but they
aren’t paying any attention to you. You cringe as you see a patient’s head fall back and strike the
ground.
Before long, all six victims are spread out under a large magnolia tree. A woman is crying
loudly and reciting a prayer. A dog walks among the victims. One of the bystanders says that
the police should be there “pretty soon.” You ask if anyone has called the fire department. The
bystander responds with a confused look on his face. “Why do we call the fire department?” he
asks. “I do not see a fire.”
One victim is obviously dead of a massive head injury. The others are alive but with various
injuries. You and your friends try to provide what care you can with absolutely no medical equip-
ment available. Before long, you hear the shrill siren of an approaching police car. The police offi-
cers get out of their vehicle and take a significant amount of time putting their hats on. One officer
goes to the vehicles. The other goes to the magnolia tree, where he proceeds to get into a heated
argument with one of the bystanders. Nobody is paying much attention to the victims except you
and your friends.
Before long, there is some excitement as another vehicle pulls up. It seems to be some sort of
ambulance. It is an old delivery van painted white with a large orange cross on the side. There
are two attendants dressed in white smocks. They carry a canvas litter and, again with no spinal
precautions and in no particular order, they begin to load up the victims. You and your friends
try to relay the results of your assessment and care. The attendants continue with their tasks, both
disinterested and unimpressed with your work. From what you can tell, absolutely no medical
care is being provided.
When the last victim is loaded with the other five in the van, both attendants take their seats
in the front of the van and leave for the hospital. The shrill sound of the siren slowly fades into the
 Introduction to Paramedicine 11

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.

Introduction bystander—a family member, friend, or a stranger to the

patient—initiates contact with an emergency dispatch cen-
As discussed in the preceding chapter, the emergency ter. EMS dispatch is then responsible for collecting essen-
medical services (EMS) system is a comprehensive net- tial information and sending out the closest appropriately
work of personnel, equipment, and resources established staffed and equipped unit. In many EMS systems, the dis-
to deliver aid and emergency medical care to the commu- patcher also provides prearrival instructions (discussed
nity. To meet the needs of the community it serves, an EMS later in the chapter) to the patient or caller so that care may
system must function as a unified whole. In general, an begin immediately.
EMS system is composed of both out-of-hospital and in- Usually, the first EMS provider to respond to the scene
hospital components. The out-of-hospital component of an emergency is a police officer, firefighter, lifeguard,
includes: teacher, or other community member who has received
• Members of the community who are trained in first aid basic medical training in an approved Emergency Medical
and CPR Responder program. That person’s role is to stabilize the
patient until more advanced EMS personnel arrive.
• A communications system that allows public access to
The next EMS provider likely to arrive on scene
emergency services dispatch and allows EMS provid-
depends on the type of EMS system involved. In most
ers to communicate with one another
areas, the dispatcher will send an EMT-level or paramedic-
• EMS providers, including paramedics level ambulance. In other areas of the country, EMS uses a
• Fire/rescue and hazardous-materials services tiered response, sending multiple levels of emergency care
• Law enforcement officers personnel to the same incident.1 In still other areas of the
country, paramedic personnel may respond to every inci-
• Public utilities, such as power and gas companies
dent regardless of the level of care needed to treat a patient
• Resource centers, such as regional poison control centers (Figure 2-1).
The in-hospital component includes: Once emergency care has been initiated, EMS provid-
ers must quickly decide on the medical facility to which
• Emergency nurses the patient should be transported. This decision is based
• Advanced-practice providers (physicians’ assistants on the type of care needed, transport time, and local proto-
and advanced-practice nurses) cols. In a comprehensive EMS system in which specialty
• Emergency physicians and specialty physicians centers have been designated (such as pediatric, trauma,
• Ancillary services, such as radiology and respiratory and burn centers), it may be necessary to transport the
therapy patient to a facility other than the closest hospital.
On arrival at the receiving medical facility, where an
• Specialty physicians, such as trauma surgeons and car-
emergency nurse or physician assumes responsibility for
diologists
the patient, the patient is assigned a priority of care. If
• Social workers needed, a surgeon or other specialist will be summoned.
• Mental health providers
• Rehabilitation services

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

Basic life support (BLS) Advanced life support (ALS)

Alternative Response

Fire/rescue

Basic and advanced

life support

Figure 2-1  Some systems elect to use a tiered response whereby

EMT providers provide initial on-scene care while paramedic
care arrives later. Other systems send an paramedic provider to
each call.

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

Table 2-1  An EMS Timeline

1797 Napoleon’s chief physician implements a prehospital system designed to triage and transport the injured from the field to aid stations.

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.

1958 Dr. Peter Safar demonstrates the efficacy of mouth-to-mouth ventilation.

1960 Cardiopulmonary resuscitation (CPR) is shown to be efficacious.

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.

1967 Star of Life is patented by the American Medical Association.

1968 AT&T designates 911 as its new national emergency number.

1970 National Registry of EMTs is founded.

1970 Television show Emergency! debuts on NBC.

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.

1975 National Association of EMTs is organized.

1979 First automated external defibrillators (AEDs) become available.

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 Prehospital trauma life support (PHTLS) is developed.

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:

• Lack of uniform laws and standards for prehospital care

• Poorly equipped ambulances
• Poor-quality ambulances
• Lack of communications between the ambulance and
the hospital
• Inadequate training of ambulance personnel
Figure 2-2  Medical evacuation helicopters, colloquially called
“Dustoff,” saved many lives during the Vietnam War. • Inadequate physician and nursing staffing of hospital
(Dust off © Joe Kline Aviation Art) emergency departments
 EMS Systems 19

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:

• Regulation and policy. Each state must have laws, reg-

ulations, policies, and procedures that govern its EMS
system. It also is required to provide leadership to
local jurisdictions.
• Resources management. Each state must have central
control of EMS resources so all patients have equal
access to acceptable emergency care.
Figure 2-3  The television show Emergency! played a major role in
bringing the world of EMS into the public spotlight. • Human resources and training. Qualified instructors
(Larry Barbier/NBCU Photo Bank via AP Images) should teach a standardized EMS curriculum, and all
20  Chapter 2

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

• Medical direction In 2005, two devastating hurricanes (Katrina and Rita)

• Education systems hit several Gulf Coast states, causing massive damage and
loss of life. The emergency response, in some cases, was
• Public education
less than ideal. Additional changes were made to improve
• Prevention the Federal Emergency Management Agency (FEMA) and
• Public access other governmental agencies following these disasters. A
• Communication systems significant economic downturn in 2008 forced many cities
to cut back on EMS and fire operations. As in most times of
• Clinical care
economic distress, EMS and hospital emergency depart-
• Information systems
ments were faced with less funding and more patients.
• Evaluation In the 2010s, EMS began to fill nontraditional roles,
Although many of the recommendations proposed by including some primary care roles, through community
the EMS Agenda for the Future have been realized, many paramedicine and mobile integrated health care programs.
have not. Despite this, this document continues to serve as The driving forces for these endeavors vary. In some com-
a guide for EMS providers, health care organizations and munities, primary care is limited, so EMS providers have
institutions, governmental agencies, and policy makers stepped up and assumed part of the role. In other commu-
who must be committed to improving the health of their nities, building codes and fire prevention strategies have
communities and to ensuring that EMS efficiently contrib- significantly reduced the incidence of fires. Because of this,
utes to that goal. They must invest the resources necessary some fire departments have looked to expand their ser-
to provide the nation’s population with emergency health vices beyond traditional firefighting roles. Community
care that is reliably accessible, effective, subject to continu- paramedicine has seemed to be a natural fit.
ous evaluation, and integrated with the remainder of the
health care system.
EMS at the Crossroads
In 2006, the National Academies Institute of Medicine pub-
lished another evaluation of the status of emergency ser-
The Twenty-First Century vices in the United States. This document, titled Emergency
The United States has changed significantly following the Medical Services: At the Crossroads, was critical of many EMS
terrorist attacks of September 11, 2001 (Figure 2-4). Among practices. The study found that there were significant prob-
other things that occurred as a result of 9/11, review of the lems at the federal level. Despite the advances made in
public safety system found numerous flaws. President EMS, sizable challenges remained. At the federal policy
George W. Bush established the Department of Home- level, government leadership in emergency care was found
land Security to coordinate the various agencies respon- to be fragmented and inconsistent. As it is currently orga-
sible for protecting the country. With this came the nized, responsibility for prehospital and hospital-based
National Incident Management System (NIMS) and emergency and trauma care is scattered across multiple
other strategies to prepare the country for terrorist attacks agencies and departments. Similar divisions are evident at
and other threats.16 the state and local levels. In addition, the current delivery
system suffers in a number of key areas:

• Insufficient coordination. EMS care is highly frag-

mented, and often uncoordinated among providers.
Multiple EMS agencies serving within a single popula-
tion center do not operate cohesively. Agencies in adja-
cent jurisdictions often are unable to communicate
with one another. In many cases, EMS and other public
safety agencies cannot talk to one another because
they operate with incompatible communications
equipment or on different frequencies.
• Coordination of transport within regions is limited.
The management of the regional flow of patients is
poor, and patients may not be transported to facilities
that are optimal and ready to receive them. Communi-
Figure 2-4  The attacks on New York City and Washington on cations and hand-offs between EMS and hospital per-
­September 11, 2001, forever changed the face of EMS. sonnel are frequently ineffective and often omit
(© Reuters) important clinical information.
22  Chapter 2

• 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

oversight, the provision of EMS is still primarily a local • Transportation

government responsibility. Because of the differences • Emergency department care
among localities, there are significantly different
• Definitive care
approaches to the provision of EMS across the United
States. Government entities have elected to operate various • Rehabilitation
service types of EMS. These include: To achieve this continuum, several components of the EMS
• Fire-based system must be in place.

• 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

Medical Oversight advanced practice practi-

Content Review
tioner, or paramedic. In all
An EMS system must retain a medical director—a physi- ➤➤ Four “Ts” of Emergency
circumstances, ultimate on-
cian who is legally responsible for all clinical and patient- Care
line responsibility remains
care aspects of the system. The medical director serves as • Triage
with the medical director.
the de facto conscience of the EMS system and must first be • Treatment
On-line medical direc- • Transport
an advocate for quality patient care. Prehospital medical
tion offers several benefits • Transfer
care provided by nonphysicians is considered a delegated
to the patient. It gives the
practice of the system medical director; that is, prehospital
EMS provider direct and immediate access to medical con-
care providers are the medical director’s designated agents,
sultation for specific patient care. It also allows for the trans-
regardless of who their employers may be.
mission of essential data, such as 12-lead ECGs. The
The medical director’s roles in an EMS system are to:
transmission of physiologic data provides the on-line physi-
• Educate and train personnel cian with diagnostic information that can be used to make
• Participate in personnel and equipment selection critical decisions while the patient is still on scene or en route.
Most EMS systems have the equipment to record on-line
• Develop clinical protocols in cooperation with expert
consultations. Those recordings can then be used for peer
EMS personnel
review and other continuous quality improvement activities.
• Participate in quality improvement and problem reso- When at the scene of an emergency, the health care
lution provider with the most knowledge and experience in the
• Provide direct input into patient care delivery of prehospital emergency care should be in charge.
• Interface between the EMS system and other health When a nonaffiliated physician or intervener physician is
care agencies on scene and on-line medical direction may not exist, the
• Advocate within the medical community paramedic should relinquish responsibility to the physi-
cian. However, the intervener physician must first identify
• Serve as the “medical conscience” of the EMS system,
himself, demonstrate a willingness to accept responsibility,
including advocating for quality patient care
and document the intervention as required by the local
In addition to the responsibilities just listed, the medical EMS system. If the treatment differs from established pro-
director is the ultimate authority for all medical issues tocols, the intervener physician must accompany the
within the system. Traditionally, medical oversight has patient in the ambulance to the hospital.
been divided into an on-line (direct) component and an off- If an intervener physician is on scene and on-line med-
line (indirect) component. The trend has been to decrease ical direction does exist, the on-line physician is ultimately
on-line activities and to bolster the off-line component.23 responsible. In case of a disagreement, the paramedic must
take orders from the on-line physician.
On-Line Medical Direction
On-line medical direction occurs when a qualified physi-
cian gives direct orders to a prehospital care provider by
Off-Line Medical Oversight
Off-line medical oversight refers to medical policies, pro-
either radio or telephone (Figure 2-6). Medical direction
cedures, and practices that a system medical director has
may be delegated to a mobile intensive care nurse (MICN),
established in advance of a call. It includes prospective
medical oversight such as guidelines on the selection of
personnel and supplies, training and education, and proto-
col development. An important part of medical oversight
is participation in the selection of medical equipment. Off-
line medical oversight also includes retrospective medical
oversight, such as auditing, peer review, conflict resolu-
tion, and other quality assurance processes.
Clinical protocols are the policies and procedures of all
medical components of an EMS system and are the respon-
sibility of the medical director. Many EMS systems use
committees, often made up of physicians within the com-
munity, to develop medical treatment protocols. EMS pro-
tocols provide a standardized approach to common patient
Figure 2-6  The medical director can provide on-line guidance to problems and a consistent level of medical care, as well as a
EMS personnel in the field. standard for accountability. When treatment is undertaken
(© Dr. Bryan E. Bledsoe) based on such protocols, the on-line physician, if needed,
26  Chapter 2

can assist prehospital personnel in interpreting the patient’s

complaint, understanding the findings of their evaluations,
and providing the appropriate treatment.24 Protocols are
designed around the four “Ts” of emergency care:

• Triage. Guidelines that address patient flow through

an EMS system, including how system resources are
allocated to meet the needs of patients.
• Treatment. Guidelines that identify procedures to be
performed on direct order from medical direction and
procedures that are preauthorized protocols called
standing orders.
• Transport. Guidelines that address the mode of travel
(air vs. ground) based on the nature of the patient’s
injury or illness, the condition of the patient, the level
of care required, and estimated transport time.
• Transfer. Guidelines that address receiving facilities to
ensure that the patient is admitted to the one most
appropriate for definitive care.

Protocols also are established for special circumstances,

such as the proper handling of “Do Not Resuscitate” orders,
patients who refuse treatment, sexual abuse, abuse of chil-
dren or elderly people, termination of CPR, and intervener
physicians. Although protocols standardize field proce- Figure 2-7  Providing disease and injury prevention education to the
dures, they should allow the paramedic the flexibility nec- public has become an important role of EMS in the twenty-first century.
essary to improvise and adapt to special circumstances. (© Dr. Bryan E. Bledsoe)

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

the widespread availability of auto-

mated external defibrillators
(AEDs) in private homes and public
places, early defibrillation has
become more commonplace and
more successful. Cardiac arrest sur-
vival takes a fully engaged public
and an effective EMS system.

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

shown that defibrillation is most effective when delivered

in 4 minutes or less after patient collapse. If EMS respond-
ers arrive more than 4 minutes after patient collapse,
patient outcomes are better if the patient receives at least
90 seconds of CPR prior to defibrillation. For many years,
the desired EMS response time was established at 8 min-
utes, but recent studies have shown that a response time
of 8 minutes has not been associated with improved out-
comes. A response time of 4 minutes or less has been
highly associated with improved outcomes in cardiac
arrest. However, few EMS systems can routinely deliver
response times of 4  minutes or less. Further research is
needed to determine the best desired response times for a
specific EMS system26,27 and how to achieve them.
Figure 2-9  The modern EMS dispatcher plays a major role in
EMS system operations and can affect the quality of emergency
care provided. Initial and Continuing
Education Programs
to respond. EMDs must be both medically and technically
The two kinds of EMS education programs for EMS per-
trained. Their training should cover basic telecommunica-
sonnel are initial education and continuing education. Ini-
tion skills, medical interrogation (questioning), giving pre-
tial education programs are the original courses for
arrival instructions, and dispatch prioritization. The course
prehospital providers. They involve the completion of a
should be standardized, and it should include certification
standardized course that meets or exceeds recommended
by a government agency.
standards. (As noted earlier, instead of various curricula
EMS Dispatch for the various levels of EMS, the National EMS Instruc-
Emergency medical dispatching is the nerve center of an tional Guidelines now allow instructors more latitude in
EMS system. It is the means of assigning and directing instructional strategies.) Continuing education programs
appropriate medical care to patients and should be under include refresher courses for recertification and periodic
the full control of the medical director and the EMS agency. in-service training sessions. All education programs should
An emergency medical dispatch plan should include inter- have medical oversight and a medical director who is
rogation protocols, response configurations, system status involved in the process. The EMS agency is responsible for
management, and prearrival caller instructions. ensuring funding for its education programs.
Another management method is called “priority dis-
patching,” which was first used by the Salt Lake City Fire
Initial Education
A paramedic’s initial education is accomplished by suc-
Department. Using a set of medically approved protocols,
cessfully completing a course following the most recent
EMDs are trained to medically interrogate a distressed
National EMS Education Instructional Guidelines published
caller, prioritize symptoms, select an appropriate response,
by the U.S. DOT. The guidelines establish the minimum
and give life-saving prearrival instructions.25
content for the course and set a standard for paramedic
In 1974, the Phoenix Fire Department introduced a
programs across the country. The Instructional Guidelines
prearrival instruction program developed by medically
offer guidance of three specific learning domains:
trained dispatchers. In that program, callers initiate life-
saving first aid with the dispatcher’s help while they wait • Cognitive, which consists of facts, or information
for emergency units to arrive on scene. In 1985, the Seattle knowledge
EMS system initiated a successful program of instructing • Affective, which requires students to assign emotions,
callers in CPR. Critics point out that prearrival instruction values, and attitudes to that information
programs may result in increased liability. Even so, the
• Psychomotor, which consists of hands-on skills students
increased liability of not providing such a service may far
learn while in laboratory and clinical settings
outweigh the risk of providing it.
An effective EMS dispatch system places the first There is a national effort to have all paramedic educa-
responding units on scene within minutes of the onset of tion programs accredited. The accreditation process
the emergency. The American Heart Association reports ensures that all paramedic education programs meet mini-
that brain resuscitation will not be successful if response mal guidelines in regard to faculty, facilities, equipment,
time exceeds 4 minutes unless there was proper basic life medical oversight, clinical affiliations, and financial stabil-
support (BLS) intervention (CPR). Many studies have ity.28 The primary accrediting organization in EMS is the
 EMS Systems 29

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

Staying Abreast • Emergency Medical Services

• Journal of Emergency Medical Services (JEMS)
In EMS, it is important to stay abreast of new develop-
ments and information. Professional organizations, profes- • Journal of Pediatric Emergency Medicine
sional publications, and the Internet provide opportunities • Journal of Trauma: Injury, Infection and Critical Care
to keep yourself professionally up to date. • Prehospital Emergency Care
Professional Organizations
The public image of EMS is often shaped by the profes- The Internet
sional organizations that represent that profession. Mem- The Internet has changed the world and certainly has
bership in professional organizations is a great way to stay changed EMS. There are now numerous websites designed
abreast of changes in the profession and to interact with for EMS providers. Many trade magazines and similar enti-
members from other parts of the country. It also provides ties offer websites with constantly updated content and
an excellent opportunity to share ideas. National EMS news. There are numerous websites that provide quality,
organizations include the following: accredited continuing education programs. There has been a
similar trend in placing much of the didactic portion of ini-
• National Association of Emergency Medical Techni- tial EMS education on the Internet. This allows students to
cians (NAEMT) receive initial and continuing education in their local com-
• National Association of Search and Rescue (NASAR) munities. Interestingly, several EMS-oriented social commu-
• National Association of EMS Educators (NAEMSE) nities have been developed. These have allowed
• National Association of EMS Physicians (NAEMSP) international EMS discussions and networking and have a
considerable following among EMS providers (Figure 2-10).
• International Flight Paramedics Association (IFPA)
• National EMS Management Association (NEMSMA)
Effective Patient Transportation
• National Council of State EMS Training Coordinators
Patients who are transported under the direction of an EMS
(NCSEMSTC)
system should be taken to the nearest appropriate medical
In addition to these, most states have EMS organizations facility whenever possible. Medical oversight should desig-
that provide information and assistance at a state or local nate that facility, based on the needs of the patient and the
level. availability of services. In some cases, the patient’s need for
These are just some examples of organizations through special services (such as care for burns) means designating
which paramedics, emergency physicians, and nurses can a facility that is not nearby. At other times, the closest facil-
enrich themselves and pursue their particular interests. ity will be designated for stabilization of the patient while
Such organizations assist in the development of educa- transfer is arranged. The ultimate authority for this decision
tional programs, operational policies and procedures, and remains with on-line medical direction.
the implementation of EMS. They establish guidelines with
input from the public and the profession, which ensure Air Transport
that the public interest is served in the delivery of emer- Patients may be transported by ground or air (Figure 2-11).
gency medical services. They also provide a means to pro- As noted earlier, use of helicopters for medical transport
mote and enhance the status of EMS within the health care was introduced during the Korean War and expanded in
community, and their efforts help to create a unified voice
for EMS providers.

Professional Journals and Magazines

A variety of journals are available to keep the paramedic
aware of the latest developments in this ever-changing
industry. These journals provide an abundant source of
continuing-education material, as well as an excellent
opportunity for EMS professionals to write and publish
articles. The following is just a partial list of journals that
routinely publish articles relating to the medical care of
patients in EMS:

• Academic Emergency Medicine

• American Journal of Emergency Medicine
Figure 2-10  The Internet has allowed paramedics, regardless of
• Annals of Emergency Medicine their location, to obtain quality continuing education.
 EMS Systems 31

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.

In 1974, in response to a request from the DOT, the

General Services Administration (GSA) developed the
“KKK-A-1822 Federal Specifications for Ambulances.”
This was the first attempt at standardizing ambulance
design to permit intensive life support for patients en route
Figure 2-11  Patients may be transported by ground or air. Medical
helicopter transport was introduced in the 1950s during the Korean War. to a definitive care facility. The act defined the following
(© Ed Effron) basic types of ambulance:

• Type I (Figure 2-13). This is a conventional cab and

Vietnam, and success of military evacuation procedures chassis on which a module ambulance body is
led to their use in civilian ambulance systems. In 1970, the mounted, with no passageway between the driver’s
Military Assistance to Safety and Traffic (MAST) program and patient’s compartments.
was established. This demonstration project set up 35 heli- • Type II (Figure 2-14). A standard van, body, and cab
copter transportation programs nationwide to test the fea- form an integral unit. Most have a raised roof.
sibility of using military helicopters and paramedics in
civilian medical emergencies.29
Today, trauma care systems use law enforcement,
municipal, hospital-based, private, and military helicopter
transport services to transfer patients. Fixed-wing aircraft
also are used when patients must be transported long dis-
tances, usually more than 200 miles (Figure 2-12).

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 2-12  Fixed-wing aircraft, as well as helicopters, have become

an important part of patient transport in the modern EMS system.
(© REACH Air Medical Services) Figure 2-14  Type II ambulance.
32  Chapter 2

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.

Appropriate Receiving Facilities

Not all hospitals are equal in emergency and support ser-
vice capabilities. So how do you get the right patient to the
right facility in an appropriate amount of time? EMS sys-
tems organize hospitals into categories that identify the
readiness and capability of each hospital and its staff to
receive and effectively treat emergency patients. EMS coor-
Figure 2-16  Some EMS systems have elected to use medium-duty dinators can use these categories to quickly recognize the
ambulances that are built on a commercial truck chassis. most appropriate medical facility for definitive treatment
(© Pat Songer) or life-saving stabilization.
 EMS Systems 33

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.

departments, municipalities, systems, or states. Coopera-

tion among EMS agencies must transcend geographical,
Figure 2-18  The development of specialized trauma centers has political, and historical boundaries.
resulted in significant improvements in trauma morbidity and Each EMS system should put a disaster plan in place for
mortality.
catastrophes that can overwhelm available resources. There
(© Dr. Bryan E. Bledsoe)
should be a coordinated central management agency that
identifies commanders within the framework of the incident
Categorization was initially designed to identify command system and an existing mutual-aid agreement.
trauma care capabilites for hospitals. The hospitals that The plan should integrate all EMS system components and
made a commitment to providing accredited trauma care have a flexible communications system. Frequent drills
were designated as trauma centers. As the system has should test the plan’s effectiveness and practicality. The com-
evolved, other categorizations have been developed, munications and control systems should be capable of coor-
including various categories of chest pain centers, stroke dinating a systemwide response to a major medical incident
centers, and other specialized care capabilities.31 without a major change in personnel, equipment, or operat-
Once categorization has been established, regionaliz- ing protocol.
ing available services helps give all patients reasonable
access to the appropriate facility. Burn, trauma, pediatric, Quality Assurance and Improvement
psychiatric, perinatal, cardiac, spinal, and poison centers An EMS system must be designed with the needs of the
are examples of specialty service facilities that offer high- patient as its chief concern. The only acceptable level of qual-
level care for specific groups of patients (Figure 2-18). ity is excellence, and systems should take the approach that
Large EMS systems should designate a resource hospital they will never fully attain total excellence. For quality assur-
that will coordinate specialty resources and ensure appro- ance and improvement programs to be effective, they must
priate patient distribution. be dynamic and comprehensive. The EMS system must con-
Ideally, all receiving facilities should have the follow- stantly monitor the community’s expectations and standards
ing capabilities: an emergency department with an emer- of practice, and be willing to
gency physician on duty at all times, surgical facilities, a initiate, change, or eliminate
lab and blood bank, medical imaging capabilities available Content Review
its practices accordingly.
around the clock, and critical and intensive care units. In 1997, the National ➤➤ Guidelines for Quality
They should have a documented commitment to partici- Improvement
Highway Traffic Safety
pate in the EMS system, a willingness to receive all emer- • Leadership
Administration (NHTSA)
gency patients in transport regardless of their ability to • Information and analysis
released a manual called A • Strategic quality planning
pay, and medical audit procedures to ensure quality care Leadership Guide to Quality • Human resources
and medical accountability. Finally, receiving facilities Improvement for Emergency development and
should exhibit a desire to participate in multiple-casualty Medical Services Systems. Its management
preparedness plans. guidelines are based on the • EMS process
following components: management
• EMS system results
Mutual Aid and Mass-Casualty • Leadership • Satisfaction of patients
Preparation • Information and anal- and other stakeholders
The resources of any one EMS system can be overwhelmed. ysis ➤➤ Customer satisfaction can
be created or destroyed
A mutual-aid agreement ensures that help is available when • Strategic quality plan-
with a simple word or deed.
needed. Such agreements may be between neighboring ning
34  Chapter 2

• Human resources development and management

• EMS process management
Legal Considerations
• EMS system results QI: A Risk Management Strategy.  A good EMS quality
improvement (QI) program is also an excellent risk manage-
• Satisfaction of patients and other stakeholders
ment strategy. Problems in the system or with individual
Many EMS systems have developed ongoing quality EMS providers can often be identified early through the QI
assurance programs, while others have gone a step further program and remedied before patient care is harmed. Experi-
with quality improvement programs. A quality assurance ence has shown that EMS services with an ongoing QI pro-
gram have a decreased incidence of being sued. EMS cases
(QA) program is designed primarily to maintain continu-
can be divided into four areas of risk: high frequency/low
ous monitoring and measurement of the clinical care deliv-
risk; high frequency/high risk; low frequency/low risk; and
ered to patients. It is in essence a problem-identifying
low frequency/high risk. A good QI program should contin-
mechanism. QA programs tend to look at the results, or the uously monitor all high-risk cases and procedures, especially
outputs, of the EMS system, much as a manufacturer looks those that fall into the low-frequency category.
at the finished product coming off the assembly line. QA High-risk cases in EMS include cardiac arrest patients,
programs document the effectiveness of the care provided patients who must be restrained, patients who refuse EMS
after the fact. They help to identify problems and selected care, those who later file a complaint about care, and others.
areas that need improvement. The limitation with QA is High-risk procedures include endotracheal intubation, medi-
that it tends to address the actions of individuals within cation administration, and others. A good QI program will
the system, and looks at established performance measure- continuously monitor high-risk cases and procedures such as
ments. These performance measurements are often based these at both the system and provider levels. If a provider
is determined not to be managing these cases appropriately,
on criteria that are set in an arbitrary manner. These crite-
that provider can be referred for additional education. Simi-
ria—for example, that an IV success rate will be greater
larly, if it is learned that the system is not managing these
than 80 percent—tend to become a ceiling. As long as the
cases appropriately, then changes must be made in the sys-
paramedics in the system are establishing 8 of 10 IV starts tem to ensure that the problems are corrected.
successfully, no one looks any further. If the success rate Never look at an EMS QI program as punishment; look
drops below 80 percent, however, the QA process may look at it instead as an educational opportunity. If properly used,
at the individuals and miss that a change to new IV cathe- it will make you a better paramedic and your system a better
ters has caused the decline. Furthermore, the QA system EMS system.
will probably not look at future improvements that could
increase the success rate to 85 percent, 90 percent, or higher.
A common complaint about QA programs is that they tend the findings of the previous step, and the process repeats
to identify only the problems and therefore focus only on itself. This process helps to ensure that the improvement in
punitive corrective action. Thus, prehospital personnel the system is ongoing and does not stall.
often view QA programs negatively. In general, EMS quality can be divided into two cate-
As a result, many EMS systems have taken the quality gories: “good enough” quality and “best possible” quality.
process a step further with continuous quality improve-
ment (CQI). In a CQI program, there is an ongoing effort to
“Take-It-for-Granted” Quality
People take it for granted that EMS will respond quickly to a
refine and improve the system to provide the highest level
911 call. Because patients do not usually have medical train-
of service possible. CQI can be thought of as a problem-
ing, they must assume that we are always acting in their best
solving methodology. CQI programs are based on facts,
interests and at the highest level of professionalism. Thus,
data, and specifications, or management by fact. By its very
they also take it for granted that the care they receive from
nature, the statistical approach of CQI looks at the group as
us is safe, appropriate, and the best that is available.
a whole, looking at the processes in an EMS system instead
Quality improvement in this area is accomplished
of the individual provider. In short, CQI is development of
through continuous evaluation. Such clinical evaluation
the “best possible” system, whereas the QA approach
and improvement should be subject to rigorous examina-
accepts a system that is “good enough.”32
tion prior to implementation and periodically thereafter.
A CQI program emphasizes the improvement of the
When considering a new medication, process, or proce-
overall process that will, in turn, lead to improved patient
dure, for example, we must follow set rules before permit-
care. The dynamic process of CQI includes a four-step
ting its use in EMS. These rules, often called rules of
cycle known as “plan, do, check, and act.” In this process,
evidence, were developed by Joseph P. Ornato, MD, PhD,.
data are analyzed and a plan of action developed. In the do
They include the following guidelines:
phase, the plan is implemented; additional data are col-
lected in the check phase to assess the viability of the • There must be a theoretical basis for the change. That is,
changes. Finally, action is taken in the act phase to address the change must make sense based on relevant anatomy,
 EMS Systems 35

physiology, biochemistry, and other basic medical

sciences.
• There must be ample scientific human research to sup-
port the idea. Any device or medication used in patient
care must have adequate scientific human research to
justify its use.
• It must be clinically important. The device, medica-
tion, or procedure must make a significant clinical dif-
ference to the patient. For example, a device such as an
automated external defibrillator (AED) may mean the
difference between living and dying for some patients,
whereas color-coordinated stretcher linen has little
clinical significance.
• It must be practical, affordable, and teachable. Some
medical devices remain too expensive and too imprac-
Figure 2-19  Our patients are our customers. We must strive to pro-
tical for use in routine prehospital emergency care.
vide them with service that is compassionate and kind.
If a clinical innovation or improvement meets all these
guidelines, then the change should be made. Only devices, their patients communicate it in many subtle ways. From
medications, and procedures that pass these rigorous tests the patient’s perspective, this is much more important than
should be implemented. IVs, backboards, and ECGs. It is essential to remember the
Another way to accomplish “take-it-for-granted” qual- ultimate reason for our existence: to serve the patient by
ity improvement is through the ongoing education of per- providing the highest quality service and care available
sonnel. Paramedics can improve their skills by reading, (Figure 2-19).
taking classes, soliciting feedback on clinical performance
from receiving hospitals, and following up on patients. Patient Safety
Peer review—the process of EMS personnel reviewing The primary tenet of medicine is primum non nocere (first,
each other’s patient reports, emergency care, and interac- do no harm). The safety of the patient must be considered
tions with patients and families—is another way for para- in any medical endeavor. This holds true for EMS as well.
medics to improve their knowledge and skills. As the health care system becomes more complicated, the
Ethics are the rules or standards that govern the con- chances for errors and accidents increase. In 2000, the Insti-
duct of members of a particular group or profession. Pre- tute of Medicine of the National Academies of Sciences
hospital providers at all levels have an ethical responsibility published To Err Is Human: Building a Safer Health System. In
to their patients and to the public. (See the chapter “Ethics this document, the institute estimated that between 44,000
in Paramedicine” for a detailed discussion of professional and 98,000 Americans die annually because of medical
ethics.) The public expects excellence from the EMS sys- errors. EMS is a part of the health care system—and medi-
tem, and we should accept no less than excellence from cal errors occur.33 Three areas have been identified as
ourselves. causes for medical errors:

• Skills-based failures. Skills-based failures occur

Service Quality and Customer Satisfaction
because a health care worker failed to perform a skill
In the business world, service quality is equated with “cus-
or procedure properly. These often occur in a skill that
tomer satisfaction.” This is the kind of quality that individ-
is almost automatic to a provider and can occur when
ual customers get excited about, feel good about, and tell
the provider’s “routine” is interrupted.
stories about. These are the little extras that exceed a cus-
tomer’s expectations and elicit thank-you letters. Prime • Rules-based failures. All health care systems, includ-
examples of customer satisfaction include patient state- ing EMS, have rules in place to ensure safety and pre-
ments such as: “You fed my cat before we left.” “You vent medical errors. Rules-based failures occur when a
remembered my name and introduced me to the nurse.” provider fails to follow the relevant rule, misapplies a
“You held my hand.” “You seemed like a friend when I good rule, or applies a bad rule.
needed one.” • Knowledge-based failures. Knowledge-based failures
Customer satisfaction can be created or destroyed with are the most complex of the three causes of medical
a simple word or deed. A significant part of the way we errors. They result primarily from insufficient infor-
communicate with one another is through body language mation or misinterpreting the situation. They tend to
and tone of voice. Paramedics who genuinely care about occur when the provider is stressed or pressured. They
36  Chapter 2

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

them approved through the appropriate investiga-

tional review process.
• Begin the study, and collect raw data.
• Analyze and correlate your data in a statistical
application.
• Assess and evaluate the results against the original
hypothesis or question.
• Write a concise, comprehensive description of the
study for publication in a medical journal.

Current EMS practice must be justified by hard clinical

data derived from an objective, valid program of ongoing
research. EMS providers at all levels share the responsibil-
Figure 2-20  The future of EMS will be driven by research and para- ity for identifying research opportunities, conducting peer
medics should try to participate in research projects when possible. review programs, and publishing the results of their proj-
(© Dr. Bryan E. Bledsoe) ects. As leaders in the prehospital care environment, para-
medics should set an example in the development of and
financial, and practical reasons. The future enhancement of participation in research projects.37
EMS depends strongly on the availability of quality For a more detailed discussion of research in EMS, see
research.37 Future changes in EMS procedures, techniques, the chapter “EMS Research.”
and equipment must be evaluated to prove that they make
a positive difference prior to implementation. The current
trend of introducing “new and improved” ideas or new
Evidence-Based Medicine
“high-tech” equipment to existing procedures must be A movement has been building in the house of medicine
evaluated scientifically. Unfortunately, many EMS proto- called evidence-based medicine (EBM). This movement
cols and procedures in use today have evolved without has been widely embraced by those in emergency medicine.
clinical evidence of usefulness, safety, or benefit to the It is only logical that the principles of EBM be applied to
patient. EMS. After all, EMS is an extension of the practice of emer-
One particular area that will rely heavily on research is gency medicine. There is really nothing all that new about
funding. As managed care increases its influence on the EBM. Its roots can be traced back to the mid-nineteenth cen-
delivery of emergency care, EMS systems will be forced to tury and beyond. The current resurgence of EBM began in
scientifically validate their effectiveness and necessity. The Great Britain and has spread throughout the medical world.
restrictions on reimbursement by managed care organiza- EBM is the conscientious, explicit, and judicious use of
tions, accountable care organizations (ACOs), and govern- the current best scientific evidence in making decisions
mental agencies will drive the need for quality EMS about the care of individual patients. It requires combining
research. Outcome studies will also be required to justify clinical expertise with the best available clinical evidence
funding and ensure the future of EMS (Figure 2-20). from systematic research. Thus, to practice effective EBM,
Future EMS research must address the following EMS personnel must first be proficient in prehospital care
issues: Which prehospital interventions actually reduce and exercise sound clinical judgment. These traits can be
morbidity and mortality? Are the benefits of certain field developed only by following a comprehensive initial educa-
procedures worth the potential risks? What is the cost–ben- tion program, followed by clinical experience and practice.
efit ratio of sophisticated prehospital equipment and pro- To move to the next level, prehospital personnel must
cedures? Is field stabilization possible, or should be familiar with the current and past research pertinent to
paramedics begin immediate transport in every case? prehospital care and be able to integrate that knowledge
Paramedics can play a valuable role in data collection, into the care of individual patients. An essential skill is
evaluation, and interpretation of research. The components knowing how to read and interpret the scientific literature
of a research project include the following: and to determine whether the information is sound.
(Again, refer to the chapter “EMS Research,” which dis-
• Identify a problem, explain the reason for the proposed
cusses how to read and evaluate research.)
study, and state the hypothesis or a precise question.
External clinical evidence can invalidate previously
• Identify the body of published knowledge on the accepted treatments and procedures and replace them with
subject. new ones that are more powerful, more effective, and safer.
• Select the best design for the study, clearly outline all Good paramedics can become excellent paramedics by
logistics, examine all patient consent issues, and get using both their clinical expertise and the best available
38  Chapter 2

external evidence. In today’s medical setting, neither clini- System Financing

cal experience nor external evidence alone is enough; there
At present in the United States, there are a wide variety of
must always be a balance between the two.
EMS system designs. EMS can be hospital-based, fire or
Some might say that EBM is simply “cookbook” medi-
police department–based, a municipal service, a private
cine. This is simply not true. As previously noted, EBM
commercial business, a volunteer service, or some combi-
requires paramedics to be, first, clinically proficient. Any-
nation. Major differences exist in methods of EMS system
body can follow simple “cookbook” directions and pro-
finance, too. They range from fully tax-subsidized munici-
vide some level of patient care. To achieve excellent patient
pal systems to all-volunteer squads supported solely by
care, however, external evidence can inform, but never
contributions.
replace, the individual paramedic’s clinical expertise. Clin-
EMS funding can come from many sources. However,
ical expertise is required to form the best determination of
the most common is fee-for-service revenue, which may be
the optimum treatment for each individual patient.
generated from Medicare, Medicaid, private insurance
There has been a trend in EMS over the past decade or
companies, specialty service contracts, or private paying
so to study the various practices and procedures of out-of-
patients. Most of these sources of revenue are referred to as
hospital care. When studied, some treatments, such as
“third-party payers,” because payment comes from some-
pneumatic anti-shock garments (PASG), did not stand up
one other than the patient. To date, almost all third-party
to the test. Likewise, some treatments, such as early defi-
payers require the patient to be transported or the EMS ser-
brillation, were found to have significant positive impact
vice will not be compensated for a response. Reimburse-
on survival following out-of-hospital cardiac arrest. Look-
ment may also be based on the level of care the patient
ing at this from a different perspective, by using the best
receives during transport. For the most part, third-party
research data available, we were able to abandon a practice
reimbursement rarely covers the expenses of operating an
(PASG) that helped few, if any, patients. Later, we were
EMS system. Because of this, many EMS systems are subsi-
able to embrace a practice (early defibrillation) that has
dized by local taxing entities (e.g., city or county govern-
saved countless lives through diverse programs that
ment) to remain operational. For the most part, funding
include bystander defibrillation.
has been, and remains, one of the biggest problems faced
Practicing EBM helps to ensure that we are providing our
by EMS systems.
patients the best possible care at the lowest possible price.

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.

You Make the Call

While you and your family are watching a fireworks display, one of the rockets tips over, shoots
into the air, and explodes just above the crowd. There is a mad rush of people, and moments later
everyone has scattered, leaving 11 injured people lying on the ground. You and your family are
unhurt and move to a safe distance from the scene.
Luckily, the local fire and ambulance service has units on stand-by at the show. The crews
immediately call dispatch and request additional ground and air transport units. The 911 dis-
patcher puts the region’s mass casualty plan into effect and dispatches the appropriate law
enforcement and fire personnel.
Meanwhile, the EMS crews on scene are triaging the patients. Five minutes after the incident,
a breakdown of patients is reported to the incident commander. There are seven injured adults:
one immediate, three delayed, and three minor. There are four injured children: one delayed and
three minor.
It isn’t long before the top-priority patient is transported by helicopter to a regional burn cen-
ter, which is 80 miles from the scene. As the ambulances arrive on scene, the remaining patients
are loaded and transported to appropriate receiving facilities. During transport, EMS providers
follow local protocols for patient care. One EMS provider radios medical direction for guidance
in the care of the youngest injured child. All units radio the receiving facility to provide updated
patient information and an estimated time of arrival.
1. Which of the “ten system elements” identified by NHTSA are mentioned in this scenario?
2. For what possible reason was the top-priority patient sent so far from the scene?
3. How important was the role played by the emergency medical dispatcher in this scenario?
Explain.
4. How might the EMS system benefit from an evaluation of this incident?
See Suggested Responses at the back of this book.

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.

Introduction As a paramedic, the most highly trained prehospital

emergency care provider in the EMS system, you will often
In the past several years, the United States has seen dra- serve people who are unaware of your knowledge and
matic changes in the health care delivery system. The skills. However, if self-satisfaction and pride in a job well
Patient Protection and Affordable Care Act was signed into done are rewards enough—and if you have a genuine
law on March 23, 2010. This law was the most significant desire to help people in need—then being a paramedic will
health care regulatory change since the establishment of be a very fulfilling career.
Medicare and Medicaid in 1965, and is bringing important
changes to the U.S. health care system. EMS has not been
immune to these changes. Driving forces such as technol- Primary Responsibilities
ogy, cost, and trends in patient population are forcing
A paramedic’s responsibil-
change. One such change involves the paramedic, whose
ities are diverse. They
roles and responsibilities are dramatically different from Content Review
include emergency medi-
what they were 10 or 15 years ago. ➤➤ Primary Responsibilities
cal care for the patient
Today, paramedicine is an enormous responsibility for • Preparation
(Figure 3-1) and a variety
which you must be mentally, physically, and emotionally • Response
of other responsibilities
prepared. You will be required to have a strong knowledge • Scene size-up
that are attended to before,
of pathophysiology and of the most current medical tech- • Patient assessment
during, and after a call.1,2
nology. You will have to be capable of maintaining a pro- • Treatment and
fessional attitude while making medical and ethical management
decisions about severely injured and critically ill patients. Preparation • Disposition and transfer
You will be required to provide not only competent emer- Before responding to a call, • Documentation
• Clean-up, maintenance,
gency care, but also emotional support to your patients you must be mentally,
and review
and their families. physically, and emotionally
44  Chapter 3

• Support agencies, including services available from

neighboring EMS systems, and the methods by which
efforts and resources are coordinated

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

Patient Management Legal Considerations

Almost all EMS systems have a set of protocols or treat-
Gatekeeper to the Health Care System.  The EMS sys-
ment guidelines that providers follow. As a paramedic,
tem is often the initial point of contact for a person entering
you must always follow your system’s protocols. They the health care system. Thus, to a certain extent, a para-
ensure that various personnel, when presented with the medic frequently functions as a sort of gatekeeper to the
same emergency, will respond in the same manner. Proto- health care system as a whole.
cols related to patient care also specify when it is necessary Part of a paramedic’s responsibility is to ensure that
for you to communicate with medical oversight. In a patient is taken to a facility that can appropriately care
response, medical direction will give you instructions on for the patient’s condition. Today, hospitals have become
how to proceed with emergency care, permission to per- more specialized—that is, some hospitals have chosen
form certain procedures, or alternatives to standard care. to provide certain services and not provide others. For
Patient management includes the task of moving the example, one hospital may elect to specialize in cardiac
care, another in stroke care, another in burn care, and so
patient from one location to another. To do so, you must
on. This is especially true in communities with multiple
make sure that the proper equipment is used and that
hospitals. Because of this, it is essential that paramedics
there are adequate personnel available. Remember, back
understand the capabilities of the hospitals in the system
injury is the number one career injury in EMS. Ensure where they work. Also, with overcrowding in modern
your own safety, and call dispatch for any additional emergency departments, diversion of ambulances by hos-
assistance needed whenever you must lift or move a pitals whose emergency departments are full has become
patient. commonplace.
For all these reasons, local EMS system protocols must
Appropriate Disposition be available to guide prehospital personnel in ensuring that
each patient is delivered to a facility that can adequately
The paramedic must ensure, within the constraints of the care for the patient’s condition.
EMS system and local protocols, that the patient gets to
the appropriate facility by the appropriate mechanism of
transport. With emergency department crowding on the
• Operating suites available 24 hours a day and 7 days a
increase, many EMS systems are looking at strategies to
week
route patients to facilities that may be more appropriate
for the patient’s specific condition. In some situations, • Critical care units, such as postanesthesia recovery
these facilities may not be traditional hospital emergency rooms and surgical intensive care units
departments. Many factors affect ultimate patient dispo- • Cardiac facilities with on-staff cardiologists (chest pain
sition, including hospital capabilities, medical staffing, centers)
technology, transfer agreements, and reimbursement • Neurology department that provides a “stroke team”
issues.
• Acute hemodialysis capability
Transportation • Pediatric capabilities, including pediatric and neonatal
A critical decision to be made is the mode of transporta- intensive care units
tion for your patient. Time and distance are key factors • Obstetric capabilities, including facilities for high-risk
to consider. For example, if an unstable patient needs to delivery
be taken to a facility that is far from the scene, an air
• Radiological specialty capabilities, such as angiogra-
medical service—helicopter or fixed-wing aircraft—
phy, computerized tomography (CT), and magnetic
rather than ground transport may be the best choice.
resonance imaging (MRI)
However, there may be only a single receiving facility
option if you practice in a rural setting. Know the • Burn specialization for infants, children, and adults
resources available in your EMS system. Follow all local • Acute spinal cord and head injury management
protocols on their use. capability
• Rehabilitation staff and facilities
Receiving Facilities
Selecting the appropriate receiving facility for your patient • Clinical laboratory services
is your responsibility. To do so, it is important for you to • Toxicology, including hazmat decontamination
know which medical facilities in your area offer the follow- facilities
ing services: • Hyperbaric oxygen therapy capability
• Fully staffed and equipped emergency department • Microvascular surgical capabilities for replants
• Trauma care capabilities • Psychiatric facilities
 Roles and Responsibilities of the Paramedic 47

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

in its entirety as soon as emergency care has been com-

pleted—no later. Any brief notes that were taken during
Additional Responsibilities
patient assessment—vital signs, for example—should be The role of the paramedic involves duties in addition to
copied into the report. those associated with emergency response. They may
The importance of accurate and complete documenta- include training civilians in CPR, running EMS demon-
tion cannot be overemphasized. Proper record keeping strations and seminars, teaching first aid classes, organiz-
helps to ensure continuity of patient care from the emer- ing prevention programs, and engaging in professional
gency scene to the hospital setting. To avoid potential legal development activities. All involve taking an active
problems and embarrassing court situations, record only role  in promoting positive health practices in your
your observations, not your opinions. For example, record ­community.
“patient has an odor of alcohol on his breath,” rather than
“patient is drunk.” The former cannot be disputed, and the Administration
latter cannot be proved.
The paramedic has administrative duties that ensure that
Your final report should be complete, neat in appear-
the EMS system operates as efficiently as possible. These
ance, and written legibly with no spelling errors. This
include such things as station duties, record keeping and
ensures that other health care providers can readily under-
reporting, special projects, and developing interagency
stand your assessment and interventions as well as the
relationships. Station duties include such activities as
patient’s responses to your treatment. It is important to
stocking the ambulance, washing and cleaning the ambu-
note that your patient care report will be a reflection of the
lance, and general housekeeping. EMS and fire stations
emergency care you provided if a lawsuit is filed in the
are, in essence, a small community, and all members of
future.6
that community must share housekeeping responsibili-
ties. Record keeping is also extremely important to ensure
Returning to Service that the system operates cohesively. Much of necessary
Once you have completed patient care, turned the patient EMS system record keeping and documentation is elec-
over to the hospital staff, and completed all documenta- tronic; this allows easier data entry and faster sharing of
tion, immediately prepare to return to service (Figure 3-4). information. Regardless of the type of record keeping
Clean and decontaminate the unit, properly discard dis- used, it is an essential part of the job.
posable materials, restock supplies, and replace and stow
away equipment. If necessary, refuel the unit on the way Community Involvement
back to your station or post. Review the call with crew Prehospital providers should take the lead in helping the
members, including any problems that may have public learn how to recognize an emergency, how to pro-
occurred. Such a dialogue can lead to solutions that vide basic first aid measures, and how to properly access
enhance the delivery of quality patient care. Finally, the the EMS system. A successful effort can save lives. Pro-
paramedic team leader should check crew members for viding educational programs, such as the American
signs of critical incident stress and assist anyone who Heart Association’s “prudent heart living” campaign,
needs help. can also encourage positive health practices in the com-
munity. EMS injury prevention projects, such as seat belt
awareness and the proper use of child safety seats, are
essential to the reduction of long-term disability and
accidental death.
To decide what injury prevention projects need to be
developed in a community, EMS systems often conduct
illness and injury risk sur-
veys, both formally and Content Review
informally. For example, ➤➤ Additional Responsibilities
consider an EMS service • Community
that reviews run reports involvement
for a six-month period. • Support for primary
They might find that for care
a  single county they • Citizen involvement
responded to ten vehicle • Personal and
Figure 3-4  A paramedic’s responsibility does not end with pro-
professional
viding patient care. Documentation, restocking, and cleaning of collisions at various rail-
development
the ambulance and emergency equipment are equally important. road crossings. A public
50  Chapter 3

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

certified or licensed. The EMS profession has regulations Professional Attitudes

that ensure that members maintain standards. For the
A commitment to excellence is a daily activity. While on
paramedic, these regulations come in the form of periodic
duty, health care professionals place their patients first;
recertification with a specified amount of continuing edu-
nonprofessionals place their egos first. True professionals
cation time.
establish excellence as their goal and never allow them-
In addition, the term professionalism refers to the
selves to become complacent about their performance.
conduct or qualities that characterize a practitioner in a
They practice their skills to the point of mastery and then
particular field or occupation. Health care professionals
keep practicing them to stay sharp and improve. They also
promote quality patient care and generate pride in their
take refresher courses seriously, because they know they
profession. They set and strive for the highest standards.
have forgotten a lot and because they are eager for new
They earn the respect and confidence of team members
information. Nonprofessionals believe that their skills will
and the public by performing their duties to the best of
never fade.
their ability. Attaining professionalism is not easy. It
Professionals set high standards for themselves, their
requires an understanding of what distinguishes the
crew, their agency, and their system. Nonprofessionals aim
professional from the nonprofessional.9
for the minimum standard and can be counted on to take
the path of least resistance. Professionals critically review
Professional Ethics their performance, always seeking ways to improve. Non-
Ethics are the rules or standards that govern the conduct professionals look to protect themselves, hide their inade-
of members of a particular group or profession. Physi- quacies, and place blame on others. Professionals check
cians have long subscribed to a body of ethical standards out all equipment prior to the emergency response. Non-
developed primarily for the benefit of the patient. These professionals hope that everything will work, supplies will
standards cover the allied health professions, such as be in place, batteries will be charged, and oxygen levels
paramedic, respiratory therapist, and physical therapist. will be adequate.
Ethics are not laws, but they are standards for honorable A professional paramedic is responsible for acting in a
behavior. Conformity to ethical standards is expected. professional manner both on and off duty. Remember, the
As members of an allied health profession, paramedics community you serve will judge other EMS providers, the
must recognize a responsibility not only to patients, but service you work for, and the EMS profession as a whole
also to society, to other health professionals, and to by your actions.
themselves.10 Professionalism is an attitude, not a matter of pay. It
In 1948, the World Medical Association adopted the cannot be bought, rented, or faked. Although it is a young
“Oath of Geneva” (Figure 3-5). In 1978, the National industry, EMS has achieved recognition as a bona fide
Association of Emergency Medical Technicians adopted allied health profession. Gaining professional stature is the
the “EMT Code of Ethics” (Figure 3-6). These documents result of many hard-working, caring individuals who
detail the guiding principles for professional EMT refused to compromise their standards. Always strive to
­service. maintain that level of performance and commitment.

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.

Figure 3-5  The Oath of Geneva.

52  Chapter 3

EMT CODE OF ETHICS

Professional status as an Emergency Medical Technician-Paramedic is maintained and enriched by the willingness of the indi-
vidual practitioner to accept and fulfill obligations to society, other medical professionals, and the profession of Emergency
Medical Technician.As an Emergency Medical Technician at the basic level or an Emergency Medical Technician-Paramedic, I
solemnly pledge myself to the following code of professional ethics:
A fundamental responsibility to the Emergency Medical Technician is to conserve life, to alleviate suffering, to promote health,
to do no harm, and to encourage the quality and equal availability of emergency medical care.

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.

National Association of Emergency Medical Technicians

Figure 3-6  The EMT Code of Ethics.

(Charles B. Gillespie, M.D. Adopted by the National Association of Emergency Medical Technicians (NAEMT), 1978. Reprinted with permission by NAEMT.)

Professional Attributes certain characteristics are common to all great leaders.

They include:
There are several traits and attitudes that characterize a
professional. True EMS professionals exemplify the traits • Self-confidence
detailed below (Table 3-1). • Established credibility
• Inner strength
Leadership • Ability to remain in control
Leadership is an important but often forgotten aspect of
• Ability to communicate
paramedic training. Paramedics are the prehospital team
leaders (Figure 3-7). They must develop a leadership style • Willingness to make a decision
that suits their personalities and gets the job done. • Willingness to accept responsibility for the conse-
Although there are many successful styles of leadership, quences of the team’s actions
 Roles and Responsibilities of the Paramedic 53

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:

Integrity • Being supportive and reassuring

Paramedics assume the leadership role for patient care in • Demonstrating an understanding of the patient’s feel-
the prehospital setting. As a paramedic, you represent the ings and the feelings of the family
EMS service and the health care system. The patient and • Demonstrating respect for others
other members of the health care team assume you are sin-
• Having a calm, compassionate, and helpful demeanor
cere and trustworthy. The single most important behavior
that you will be judged by is honesty. The environment
you work in will often put you in the patient’s home or in
Self-Motivation
The environment in which you work is often unsuper-
charge of the patient’s wallet and other personal posses-
vised, so it is up to you to be able to motivate yourself and
sions, such as jewelry and items left in a vehicle. You must
establish a positive work ethic. The following are examples
be trustworthy. The easiest way for a paramedic to lose
of a positive work ethic:
respect is to be dishonest.12
• Completing assigned duties without being asked or
told to do so
• Completing all duties and assignments without the
need for direct supervision
• Correctly completing all paperwork in a timely manner
• Demonstrating a commitment to continuous quality
improvement
• Accepting constructive feedback in a positive manner
• Taking advantage of learning opportunities

Self-motivation is an internal drive for excellence.

Remember, providing adequate patient care is not enough.
You must strive for excellence in the care that you provide.

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.

You Make the Call

The First Response Ambulance Service receives a call for a patient experiencing chest pain and
difficulty breathing. You, as a paramedic, and your EMT partner are immediately dispatched to
the scene. While en route, the dispatcher tells you that the patient is a 55-year-old man who has
had a sudden onset of chest pain while shoveling snow in his driveway and has audible labored
breathing. The dispatcher also informs you that the patient has a history of heart disease and rou-
tinely takes multiple medications.
Approximately 7 minutes later, your ambulance arrives on scene. You observe that your
patient, Mr. Yates, is sitting on his porch, clutching his chest. His wife and son are sitting beside
56  Chapter 3

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.

c. taking on the occupational safety role in an a. Ethics c. Etiquette

industrial setting. b. Morals d. Protocols
d. all of the above. See answers to Review Questions at the back of this book.

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

circadian rhythms, p. 76 isometric exercise, p. 61 Standard Precautions, p. 66

cleaning, p. 70 isotonic exercise, p. 61 sterilization, p. 70

Code Green Campaign, p. 78 pathogens, p. 65 stress, p. 74

disinfection, p. 70 personal protective equipment stressor, p. 74

exposure, p. 70 (PPE), p. 66 Tema Conter Memorial Trust, p. 78

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.

Basic Physical Fitness

Prevention of Work-Related Unfortunately, physical fitness has not been a major
emphasis in EMS. In a study of back injuries in EMS work-

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

8. Eat some foods less often. Cut back on foods high in

solid fats, added sugars, and salt. These include cakes,
cookies, ice cream, candies, sweetened drinks, pizza,
and fatty meats such as ribs, sausages, bacon, and hot
dogs. Use these foods as occasional treats, not every-
day foods.
9. Compare sodium in foods. Use the Nutrition Facts
label to choose lower sodium versions of foods like
soup, bread, and frozen meals. Select canned foods
labeled “low sodium,” “reduced sodium,” or “no salt
added.”
10. Drink water instead of sugary drinks. Cut calories
Figure 4-1  Dietary guidelines from the U.S. Department of by drinking water or unsweetened beverages. Soda,
Agriculture are summarized in the ChooseMyPlate chart that energy drinks, and sports drinks are a major source of
uses a dinner-plate–shaped chart to represent appropriate food-
added sugar and calories.
group portions.
(U.S.Department of Agriculture, www.ChooseMyPlate.gov) The standardized Nutrition Facts label provides abun-
dant information about nutritional content. Learn to read
Good nutrition is fundamental to your well-being. The it. Be sure to check the serving size to avoid misinterpret-
following are dietary guidelines published along with the ing the food’s overall nutritional value (Figure 4-2).
ChooseMyPlate chart (Figure 4-1) by the U.S. Department Eating on the run can be less detrimental if you plan
of Agriculture.6 ahead and carry a small cooler filled with whole-grain
sandwiches, cut vegetables, fruit, and other wholesome
10 Tips to a Great Plate
foods. If you must obtain food during your shift, stop at a
1. Balance calories. Find out how many calories YOU local market instead of the fast-food place next door. Buy
need for a day. (Go to www.ChooseMyPlate.gov to fresh fruit, yogurt, and sensible deli selections. They are
find your calorie level.) Physical activity also helps bal- more nutritious and much cheaper than fast foods.
ance calories. Finally, monitor your fluid intake. Your body needs
2. Enjoy your food but eat less. Take the time to enjoy plenty of fluids to flush food through your system and
your food as you eat it. Pay attention to hunger and eliminate toxins. Pay attention to what you are drinking.
fullness clues. Fill a “go-cup” with fresh ice water when you stop at the
3. Avoid oversized portions. Use a smaller plate. Portion
out foods before you eat. When eating out, choose an
appetizer-size portion, share a dish, or take some home
for later.
Nutrition Facts
Serving size Serving Size 8 fl oz (240 mL)
4. Eat certain foods more often. Eat more fruits and vegeta- Number of servings Servings Per Container 8
per container
bles, whole grains, and fat-free or low-fat dairy products.
Amount Per Serving
5. Make half your plate fruits and vegetables. Choose Calories per Calories 110 Calories from Fat 0
red, orange, and dark green vegetables such as toma- serving
% Daily Value*
toes, sweet potatoes, and broccoli. Add fruit to meals Total Fat 0g 0%
as part of main or side dishes or dessert. Sodium 0mg 0%
6. Switch to fat-free or Potassium 450mg 13%
Content Review low-fat (1%) milk. These Total Carbohydrate 26g 9%
Nutrients per serving
have the same nutrients as actual weight and Sugars 22g
➤➤ Dietary Guidelines
as whole milk but fewer as a % of daily diet Protein 2g
• Enjoy your food but
avoid oversize portions. calories and less fat.
Vitamin C 120% • Calcium 2%
• Eat more fruits, 7. Make half your grains Thiamin 10% • Niacin 4%
vegetables, whole whole grains. Eat whole Vitamin B6 6% • Folate 15%
grains, and low-fat wheat bread instead of Not a significant source of saturated fat,
dairy items. cholesterol, dietary fiber, vitamin A and iron.
white bread. Eat brown
• Eat less sodium and * Percent Daily Values are based on a
rice instead of white 2,000 calorie diet.
sugar.
rice. Eat oatmeal instead
➤➤ Avoid junk foods.
of a sugary cereal. Figure 4-2  Example of a standardized food label.
 Workforce Safety and Wellness 63

emergency department instead of spending your money

on soft drinks. Water is more thirst quenching, cheaper, Legal Considerations
and much better for you. Substance Abuse in EMS.  As in the rest of society, sub-
Exercising and eating well can help you prevent both stance abuse in EMS is a growing problem. There is no evi-
cancer and cardiovascular disease. For the typically youthful dence that substance abuse in EMS is any greater than in
EMS provider, the likelihood of being hit by either of these other professions. However, the subject has been inade-
diseases may seem remote, but it happens. You can do a lot to quately studied, and we just don’t know. Regardless, there
prevent these diseases. Minimizing stress through healthy has been an increase in media stories about paramedics steal-
ing and abusing controlled substances such as morphine or
stress management practices, for example, can work won-
fentanyl. Often, clandestine drug use such as this adversely
ders. In addition, assess yourself and your family history.
affects patient care. The abuser will often remove the desired
Exercise will improve cardiovascular endurance, help
drug and replace the drug with water or saline. Another
lower blood pressure, and tip the balance of your body paramedic, unaware of the tampering, may administer the
composition favorably—all good measures against cardio- medication to a patient. In this case, the patient will not
vascular disease. Know your cholesterol and triglyceride derive any benefit from the drug and could possibly develop
levels and keep them in check. For women who are meno- a complication such as infection. In addition, if an impaired
pausal, be informed of current research on the risks and paramedic is allowed to continue to work, his decision mak-
benefits of hormone replacement therapy. ing will ultimately be affected, which can adversely affect
Diet can also do much to minimize the chances of get- patient care.
ting certain cancers. Certain foods, such as broccoli and Paramedics impaired by substance abuse must be imme-
high-fiber foods, are thought to help reduce the incidence diately removed from patient care responsibilities while an
objective investigation is completed. Substance abuse should
of cancer; others, such as charcoal-cooked foods, may
be considered a medical condition—a disease—and should
increase it. The connection between sun exposure and skin
be treated as such. This attitude is not intended to excuse ille-
cancer is well known. Therefore, take the precaution of
gal behavior such as drug tampering, but rather to ensure
using sunblocks, and wear sunglasses and a hat when you the paramedic gets the help he needs. States should have a
can. Watch out for the warning signs of cancer, such as system in which impaired paramedics can self-report their
blood in the stools (even in young people, especially men), addiction (or be referred) so they can obtain the necessary
a changing mole, unexplained weight loss, unexplained treatment and possibly salvage their careers. These pro-
chronic fatigue, and lumps. grams, commonly referred to as diversion programs, usually
Be sure to include appropriate periodic risk-assess- require the impaired provider to enter and complete a sub-
ment screening and self-examination habits in your per- stance abuse treatment program. Following completion of
sonal well-being program. That includes tests such as the program and other requirements, the paramedic may be
mammograms and prostate exams as you get older. allowed to return to work under a very strict surveillance
program (called an aftercare contract) that includes periodic
medical and addiction assessments, randomized observed
Habits and Addictions drug screens, and, often, participation in 12-step or similar
support programs.
Many people who work high-stress jobs overuse and abuse Substance abuse is a real problem and must be dealt with
substances such as caffeine and nicotine. These bad habits swiftly, yet compassionately. However, our first consideration
are rampant in EMS. Each can contribute to long-term dis- should always be the safety of the patient and of coworkers.
eases such as cancer and cardiovascular disease. Choose a Diversion programs must be available in each state to preserve
healthier life, and avoid overindulging in these and other the careers of those suffering substance abuse disorders.
harmful substances such as alcohol.
Smoking cessation programs are usually easily
accessed in local areas or on the Internet. There are abun-
dant approaches to this common addiction, including Back Safety
medications, behavior modification, nicotine replacement EMS is a physically demanding endeavor. Of the host of
therapy (“patches”), aversion therapy, hypnotism, and movements required—scrambling down embankments,
going “cold turkey.” Part of understanding your addiction climbing ladders or trees, squeezing into narrow spaces,
is knowing whether it is a psychological dependency, and so on—none will occur more frequently than lifting
sociocultural dependency, or a true physical addiction. and carrying equipment and patients. To avoid back injury,
Whatever it takes, the message is clear: Free yourself of you must keep your back fit for the work you do. You also
addictions, particularly those that threaten your well- must use proper lifting techniques each time you pick up a
being. Substance-abuse programs, nicotine patches, 12-step load, whether the load is heavy or light.
groups, and the like all exist to help you help yourself. But Back fitness begins with conditioning the muscles that
the first step has to be yours.7 support the spinal column. These are the “guy wires” that
64  Chapter 4

Ears, shoulders, and hips Ears, shoulders, and hips

are in vertical alignment. are in vertical alignment.

Pelvis is slightly
tucked forward.

Pelvis is slightly Weight is evenly

tucked forward. distributed on
both ischia.

Feet are flat on floor

or crossed at ankles.
Knees are
slightly bent. Figure 4-4  Correct sitting posture.

• Do not hurry. Take the time you need to establish good

footing and balance. Keep a wide base of support, with
one foot ahead of the other.
• Bend your knees, lower your buttocks, and keep your
chin up. If your knees are bad, do not bend them more
Figure 4-3  Correct standing posture. Note the straight line from than 90 degrees.
the ear through the shoulder, hip, and knee to the arch of the foot.
• “Lock in” the spine with a slight extension curve, and
tighten the abdominal muscles to support spinal
positioning.
stabilize the spine, much the way cables help keep tele-
phone poles upright. Note that the muscles of the abdo-
men are also crucial to overall spinal-column strength and
safe lifting. Never perform old-fashioned sit-ups. They can
seriously strain your lumbar spine. Instead, use abdominal
crunches, which target only the stomach muscles. Consult
an exercise coach or trainer for specifics.
Correct posture will minimize the risk of back injury
(Figures 4-3 and 4-4). Good nutrition helps to maintain
healthy connective tissue and intervertebral disks. Excess
weight contributes to disk deterioration. So does smoking.
Thus, proper weight management and smoking cessation
are relevant to back health. Finally, adequate rest gives the
spine non–weight-bearing time to nourish disks and
repair itself.
Proper lifting techniques should ideally be taught by
and practiced with a trainer who understands the variety
of challenges faced by EMS providers.8 Important princi-
ples of lifting are as follows (Figure 4-5):

• Move a load only if you can safely handle it.

• Ask for help when you need it—for any reason.
• Position the load as close to your body and center of
gravity as possible.
Figure 4-5  For back safety, always employ the important princi-
• Keep your palms up whenever possible. ples of lifting.
 Workforce Safety and Wellness 65

Legal Considerations Infectious Diseases

Infectious diseases are caused by pathogens such as bac-
Back Injuries.  Back injuries are one of the greatest risks to
teria and viruses, which may be spread from person to per-
EMS providers and account for a significant monetary expen-
diture in workers’ compensation claims. Programs to help son. For example, infection by way of bloodborne
reduce the incidence of such injuries should be an ongoing pathogens can occur when the blood of an infected person
aspect of any EMS system. comes in contact with another person’s broken skin (cuts,
sores, chapped hands) or by way of parenteral contact
(stick by a needle or other sharp object). Infection by air-
borne pathogens can occur when an infected person
• Always avoid twisting and turning. sneezes or coughs, causing body fluids in the form of tiny
• Let the large leg muscles, not your back, do the work droplets to be inhaled or to come in contact with the
of lifting. mucous membranes of another person’s eyes, nose, or
• Exhale during the lift. Do not hold your breath. mouth.
HIV/AIDS, hepatitis B, hepatitis C, and tuberculosis
• Given a choice, push. Do not pull.
are diseases of great concern because they are life threaten-
• Use help when moving patients up and down stairs
ing. However, one may be exposed to many different infec-
and into and out of the ambulance.
tious diseases. See Table 4-2 for some common ones, their
• Look where you are walking or crawling. If you are modes of transmission, and their incubation periods.
walking, take only short steps. Move forward rather New and emerging diseases also can pose threats to
than backward whenever possible. EMS personnel. International travel now allows individu-
• When rescuers are working together as a team to lift a als to move quickly between continents—sometimes bring-
load, only one person should be in charge of verbal ing endemic diseases with them. In some instances, EMS
commands. personnel can inadvertently be exposed to rare and deadly
diseases. Such was the case in 2004 when EMS providers in
Heed your own body’s signals. You are stronger on
Dallas were exposed to the deadly Ebola virus in a patient
some days than on others. Know when you are physically
who had recently flown from Liberia to Dallas and who
depleted from exhaustion, lack of food, or minor illness.
then, feeling ill, had called EMS. Because of this and other
Use volunteers as helpers wisely, and be sure to ask
such outbreaks—now more than ever—it is essential that
whether their backs are strong enough for the job.
EMS personnel receive training in disease prevention strat-
Never reach for an item and twist at the same time.
egies and that they have the necessary equipment when
Most back injuries occur because of the cumulative effect
suspect patients are encountered.
of such low-level everyday stresses. Everything you do on
Even when someone is carrying pathogens for disease,
behalf of back safety adds up to choices that can mean the
signs of an illness may not be apparent. For this reason, you
difference between a long and rewarding career in EMS, or
must consider the blood and body fluids of every patient you
one shortened by an injury. Be careful!
treat as infectious. Safeguards against infection are manda-
tory for all medical personnel.

Personal Protection Standard Safety Precautions

from Disease Each profession has its occupational hazards and risks.
EMS is no different. EMS straddles the disciplines of health
In recent years, the emphasis on infection control has care and public safety and the associated risks of both.
focused on the most devastating diseases, such as HIV/ Anything you do as a paramedic should start with consid-
AIDS, hepatitis B, hepatitis C, tuberculosis, and influ- erations about minimizing risk for you, your patient, your
enza—and rightly so. There is enough risk in EMS without partners, other responders, and the community. Various
having to worry about dying of a disease you caught while strategies for this are discussed in detail in this chapter.
caring for others. Fortunately, you can do a lot to minimize
your risk of infection. A good first step is to develop a habit
of doing the things promoted in this chapter. Eating well, Infection Control Measures
getting adequate rest, and managing stress are among the Infection control practices are those procedures and prac-
building blocks of a good defense against infection. In tices used by health care personnel to minimize disease
addition, it is a good idea to periodically assess your risk transmission and transmission of infectious agents. Infec-
for infection, such as noticing when you are run down or tion control is a fundamental tenet of health care and must
when your hands are dangerously chapped. be practiced proficiently by all EMS personnel.
66  Chapter 4

Table 4-2  Common Infectious Diseases

Disease Mode of Transmission Incubation Period
AIDS (acquired immune AIDS- or HIV-infected blood via intravenous drug use, semen and vaginal fluids, blood Several months
deficiency syndrome) transfusions, or (rarely) needle sticks. Mothers also may pass HIV to their unborn children. or years

Hepatitis B, C Blood, stool, or other body fluids, or contaminated objects. Weeks or months

Tuberculosis Respiratory secretions, airborne, or on contaminated objects. 2 to 6 weeks

Meningitis, bacterial Oral and nasal secretions. 2 to 10 days

Pneumonia, bacterial and viral Oral and nasal droplets and secretions. Several days

Influenza Airborne droplets, or direct contact with body fluids. 1 to 3 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

Whooping cough (pertussis) Respiratory secretions or airborne droplets. 6 to 20 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

Standard Precautions are designed to reduce the risk of

transmission of microorganisms from both recognized
and unrecognized sources of infection in hospitals.
Standard Precautions dictate that all EMS personnel
take the same (standard) precautions with every patient. To
achieve this, appropriate personal protective equipment
(PPE) should be available in every emergency vehicle. The
minimum recommended PPE are the ­following:

• Protective gloves. Wear disposable protective gloves

before initiating any emergency care. When an emer-
gency involves more than one patient, change gloves
between patients. When gloves have been contami- Figure 4-6b  Then slide the fingers of the ungloved hand under the
nated, remove and dispose of them properly as soon as remaining glove’s cuff. Push that glove off, being careful not to touch
possible (Figure 4-6). the glove’s exterior with your bare hand.
 Workforce Safety and Wellness 67

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.

• Masks and protective eyewear. (Figure 4-7). These

should be worn together whenever blood spatter is
likely to occur, such as with arterial bleeding, child-
birth, endotracheal intubation and other invasive pro-
cedures, oral suctioning, and cleanup of equipment
that requires heavy scrubbing or brushing. Both you
and your patient should wear masks whenever the
potential for airborne transmission of disease exists.
• HEPA and N-95 respirators. (Figure 4-8). Because of the
resurgence of tuberculosis (TB), you must protect your-
self from infection through the use of a high-efficiency
particulate air (HEPA) or N-95 respirator. Wear one
whenever you care for a patient with confirmed or sus-
pected TB. This is especially true during procedures
that involve the airway, such as the administration of
nebulized medications, endotracheal intubation, or
suctioning.
• Gowns. Disposable gowns protect your clothing from
splashes. If large splashes of blood are expected, such
as with childbirth, wear an impervious gown.
• Resuscitation equipment. Use disposable resuscita-
tion equipment as your primary means of artificial
ventilation in emergency care. Such items should be
used once, and then disposed of properly.9 Figure 4-8a  A high-efficiency particulate air (HEPA) respirator. .
68  Chapter 4

Figure 4-8b  An N-95 respirator.

• Hand-washing supplies. Non–water-based hand-

washing solutions should be widely available for EMS Figure 4-9  To wash your hands properly, lather up well and be
personnel. These alcohol-based hand sanitizers are sure to scrub under your nails. When you rinse off your hands, point
available in various forms, including gels and pre- them downward so that soap and water run off away from your arms
and body.
wrapped hand towels. The prewrapped towels can be
kept in a pocket for ready use.
control practice is handwashing (Figure 4-9). As soon as pos-
The garments and equipment described previously are sible after every patient contact and decontamination proce-
intended to protect against infection through contact with dure, thoroughly wash your hands. To do so, first remove
both potentially contaminated body substances, such as blood, any rings or jewelry from your hands and arms. Then use
vomit, and urine, and other agents such as airborne droplets. soap and water. Lather your hands vigorously front and
These garments and equipment will assist you in achieving, to back for at least 15 seconds up to 2 or 3 inches above the
the extent possible, the precautions recommended by the Cen- wrist. Be sure to lather and rub between your fingers and in
ters for Disease Control and Prevention (CDC). the creases and cracks of your knuckles. Scrub under and
Infectious diseases also are minimized through the use around the fingernails with a brush. Rinse your hands well
of appropriate work practices and equipment especially under running water, holding your hands downward so
engineered to minimize that the water drains off your fingertips. Dry your hands on
Content Review risk. For example, most a clean towel.
➤➤ Handwashing invasive equipment is now Plain soap works perfectly well for handwashing. At
• Lather with soap and used on a one-time, dispos- those times when soap is not available, you might use an
water. able basis. Of course, it is antimicrobial handwashing solution or an alcohol-based
• Scrub for at least 15 important to launder reus- foam or towelette.
seconds. able clothing with infection
• Rinse under running control in mind. Ebola Virus Disease
water. General cleanliness and The appearance of the Ebola virus in the United States in
• Dry on a clean towel. appropriate personal 2014 brought a new level of infectious disease threat to
➤➤ Handwashing is perhaps hygiene will do much to EMS providers. The Ebola virus is the causative agent of
the most important
prevent infection. Probably Ebola virus disease (EVD), formerly called Ebola hemor-
infection control practice.
the most important infection rhagic fever. People can contract EVD (through broken
 Workforce Safety and Wellness 69

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

inadvertently touching their faces under the face Signs/Symptoms Definition

shield during patient care.
Asymptomatic No symptoms relevant to an infectious disease.
• Single-use (disposable) fluid-resistant or impermeable
Fever Measured temperature ≥ 100.4°F.
gown that extends to at least mid-calf or coverall with-
out integrated hood. Coveralls with or without inte- Body fluids Patient has fever with vomiting, diarrhea, blood
in vomitus and/or feces, is incontinent of urine
grated socks are acceptable. Consideration should be or stool, or is sweating, salivating, or otherwise
given to selecting gowns or coveralls with thumb hooks producing blood and body fluids to which
emergency responders could be exposed.
to secure sleeves over inner gloves. If gowns or coveralls
70  Chapter 4

Vaccinations and Screening Tests

Immunizations against many illnesses are available. Get
them. Even “nuisance” illnesses can be avoided if you get
vaccinated. Immunizations that are available include those
for rubella (German measles), measles, mumps, chicken
pox, and other childhood diseases, as well as for tetanus/
diphtheria, polio, influenza, hepatitis A, hepatitis B, and
Lyme disease. Some, such as tetanus, may require booster
shots periodically, so monitor your personal medical his-
tory well. Also arrange for routine tuberculosis (TB) screen-
ings and record the results.
Influenza kills thousands of people each year. Some
strains of influenza, such as H1N1 (swine flu) or H5N1
(bird flu), can quickly reach pandemic or epidemic states.
Health care workers will be among the first to be exposed
to novel viruses. Because of this, EMS personnel and other
emergency responders are often the first to receive vac-
cines when a virus becomes a threat. It is important for
EMS personnel to follow warnings and recommendations
from the World Health Organization (WHO), the Centers
for Disease Control and Prevention (CDC), and state and
local public health officials. Figure 4-10a  Dispose of biohazardous wastes in a bag that is
properly marked.
Decontamination of Equipment
Any PPE designed for a single use should be properly dis-
posed of after use. The same is true of contaminated medi-
cal devices designed for a single use. Such materials should
be discarded in a red bag marked with a biohazard seal
(Figure 4-10a). Needles and other sharp objects should be
discarded in properly labeled, puncture-proof containers
(Figure 4-10b). Once an item is placed in the appropriate
container, the container should be disposed of according to
local guidelines.
Nondisposable equipment that has been contaminated
must be cleaned, disinfected, or sterilized:
• Cleaning. Cleaning refers to washing an object with
soap and water. After caring for a patient, wash your
work areas thoroughly with approved soaps. Throw
away single-use cleaning supplies in a proper biohaz-
Figure 4-10b  Discard needles and other sharp objects in a
ard container.
­properly labeled, puncture-proof container.
• Disinfection. Disinfection means cleaning with a dis-
infecting agent, which should kill many microorgan-
If your equipment needs more extensive cleaning, bag
isms on the surface of an object. Disinfect equipment
it and remove it to an area designated for this purpose. Dis-
that had direct contact with the intact skin of a patient,
posable work gloves worn during cleaning and decontami-
such as backboards and splints. Use a commercial dis-
nation should be properly discarded. If your clothing has
infectant or bleach diluted in water (one part bleach to
become contaminated, bag the items and wash them in
10 parts water), or follow local guidelines.
accordance with local guidelines. After removing contami-
• Sterilization. Sterilization is the use of a chemical or a nated clothing, take a shower before dressing again.
physical method such as pressurized steam to kill all
microorganisms on an object. Items that were inserted Post-Exposure Procedures
into the patient’s body (a laryngoscope blade, for exam- By definition, an exposure is any occurrence of blood or
ple) should be sterilized by heat, steam, or radiation. body fluids coming in contact with nonintact skin or the
There are also EPA-approved solutions for sterilization. eyes or other mucous membranes or by parenteral contact
 Workforce Safety and Wellness 71

INFECTIOUS DISEASE EXPOSURE PROCEDURE

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.

(needle stick). In most areas, an EMS provider who has had

an exposure should (Figure 4-11):
Death and Dying
Most paramedics agree that of all out-of-hospital situa-
• Immediately wash the affected area with soap and water.
tions, those involving death or dying are among the most
• Get a medical evaluation. personally uncomfortable and challenging. There are
• Take the proper immunization boosters. many reasons for this. Of course, a death is normally a
• Notify the agency’s infection control liaison. sad event. There is an air of unalterability, of finality.
Each person experiences a death in an individual way
• Document the circumstances surrounding the expo-
because of that person’s prior experiences of loss, coping
sure, including the actions taken to reduce chances of
skills, religious convictions, and other personal back-
infection.
ground. Paramedics encounter death much more fre-
In general, the EMS provider should cooperate with the quently than most other people do. They often see it as it
incident investigation and comply with all required report- happens. This can lead to a cumulative sense of overload,
ing responsibilities and time frames. which the smart paramedic recognizes and deals with in
72  Chapter 4

their loved ones experience the stages in their own unique

Cultural Considerations ways. They may jump around among the stages, they may
Responses to Death. The emotional response to the death go back and forth, or they may never finish them. It is
of a friend or family member varies significantly among cul- important for you to remain flexible, so you can decide
tures as well as among individuals. Some people will accept how best to help, if asked.
the news quietly, whereas others will react with an emotional Because paramedics encounter death and dying often,
outburst. Use simple terms and avoid euphemisms. Realize there is a mistaken belief that they handle it better. How-
that grieving is a cultural as well as a personal phenomenon, ever, paramedics are human, too. Let yourself deal with
and that it is normal for people to respond to bad news in
death and dying when they occur. Do not shirk the support
different ways.
of friends and family. Do not try to “tough it out.” Use
every opportunity to process a specific incident in a healthy
manner by appropriately grieving losses that have an
a healthy manner through appropriate grief work and
impact on you.
stress management.
Grief is a feeling. Mourning is a process. A grieving
person feels mostly sadness or distress. A person in mourn-
Loss, Grief, and Mourning ing is immersed in the process of undergoing, perhaps dis-
For decades, discussing death and dying openly was dif- playing, and ultimately dissipating the feelings of grief.
ficult because of cultural taboos. This began to change The sense of loss is predictably most intense immediately
when pioneer Elisabeth Kübler-Ross braved the backlash after the news is received. Although numerous models for
to meet with terminally ill hospital patients to discuss the mourning process exist, a good rule of thumb is that
their feelings about death and dying.10 Before then, it was after the loss of a close friend or relative, a period of one
assumed dying people did not want to talk about the year of mourning is normal.
experience. Kübler-Ross found that there are five predict- On initially hearing the news of a death, a person
able stages of grief: experiences a paralyzing, totally incapacitating surge of
grief that is exactly comparable to the incapacitating pain
• Denial, or “Not me.” This is an inability or refusal to
of an acute blow to an eye or testicle—in that the whole
believe the reality of impending death. It is a defense
world shrinks down to that acute pain. Typically, the feel-
mechanism, during which the patient puts off dealing
ing lasts for 5 to 15 minutes. When you deliver the news of
with the inevitable end of life.
a death, remember that a survivor cannot function during
• Anger, or “Why me?” The patient’s anger is really frus- this grief spike. After delivering the news, wait until it is
tration related to his inability to control the situation. past and the survivor is ready and able to receive informa-
That anger could focus on anyone or anything. tion and make decisions.
• Bargaining, or “Okay, but first let me . . .” In the A period of intense feelings that continues for around
patient’s mind, he tries to make a deal to “buy addi- four to six weeks follows the grief spike. Feelings may
tional time” to put off or change the expected outcome. include loss, anger, resentment, sadness, and even guilt,
• Depression, or “Okay, but I haven’t . . .” The patient is depending on the relationship and the circumstances sur-
sad and despairing, often mourning things not accom- rounding the death. Gradually, the intensity and immedi-
plished and dreams that will not come true. The acy of the loss fade into a phase dominated by a sense of
patient withdraws or retreats into a private world, loneliness, which lasts about six months. Finally, a period
unwilling to communicate with others. of recovery usually ensues. The survivor begins to view
the loss more objectively and rediscovers an interest in liv-
• Acceptance, or “Okay, I’m not afraid.” The patient
ing. Key to the process of mourning is the passage of sig-
may come to realize his fate and achieve a reasonable
nificant dates and anniversaries, such as birthdays,
level of comfort with the anticipated outcome. At this
holidays, and the monthly (then annual) date when the
stage, the family may need more support than the
loss occurred.
patient does.
People cope in various ways with difficult moments
A person experiencing such as death. If you are dealing with a child, understand
Content Review any significant loss usually that children’s perceptions are different from an adult’s.
➤➤ Stages of Grief works through these (See Table 4-4 for a summary.) This is true of all the special
• Denial stages, given enough time. populations you will encounter, such as the elderly and
• Anger Although there is a ten- people with mental disabilities. The elderly, for example,
• Bargaining dency to progress from one may be particularly concerned about the effects of the loss
• Depression
stage to the next in order, on other family members, about further loss of their own
• Acceptance
both dying patients and independence, and about the costs of a funeral and burial.
 Workforce Safety and Wellness 73

Table 4-4  Needs and Expectations of Children Regarding Death

Age Range Characteristics Suggestions
Newborn to age 3 Senses that something has happened in the family, and notices Be sensitive to the child’s needs.
that there is much activity in the household. Realizes that people Try to maintain consistency in routines.
are crying and sad.
Watch for irritability and changes in eating, sleeping, or other Maintain consistency with significant people in child’s life.
behavioral patterns.

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

• Give information about local procedures for out-of-

hospital death, such as the inspection of the scene by
Stress and Stress
the medical examiner or coroner, and so on.
Management
Do not include statements about God’s will or relief Many aspects of EMS are stressful.12 A time-honored defi-
from pain or any subjective assumption. You do not know nition of stress, according to stress researcher Hans Selye,
the people well enough to know the details about their is “the nonspecific response of the body to any demand.”13
relationship or their religious preferences.11 The word stress also refers to a hardship or strain, or to a
physical or emotional response to such a stimulus. Stress
When It Is Someone You Know responses are natural reactions that help the organism
Many paramedics serve in small communities where calls adapt to a new environment or a sudden change in the
often involve people they know. Some elements of this are usual environment. Stress results from the interaction of
rewarding, and others are heart-wrenching. People may be events and the capabilities of each individual to adjust to
greatly relieved to see a familiar, trusted face among the those events. A person’s reactions to stressful events are
ambulance crew. There also is a lot of support for paramed- individual and are affected by that person’s previous expo-
ics in small communities, because you are from the com- sure to the stress-causing event, perception of the event,
munity itself and are there to help fellow community general life experience, and personal coping skills. A stim-
members during their most fearful moments. However, ulus that causes stress is known as a stressor.
being involved when the life of someone you know is Stress is both beneficial and detrimental. Stress is usu-
threatened—or lost—can have a powerful impact on your ally understood to generate a negative effect, or distress, in
own emotions. If it is too much, you must find a way to an individual. There is also “good” stress, which is called
manage the stress. Often, you must grieve as well. Your eustress (for example, seeing a lost loved one for the first
well-being demands it. time in years). Even eustress, however, generates physio-
logical and psychological signs and symptoms.
Adapting to stress is a dynamic, evolving process.
Legal Considerations As a person adapts, he uses or develops any or all of the
following:
Field Pronouncements.  It has been well established that
victims of blunt trauma who are pulseless on EMS arrival • Defensive strategies. Though sometimes helpful for
have virtually no chance of survival, and treatment efforts the short term, defensive strategies may deny or dis-
are almost always futile. Because of this, many EMS systems tort the reality of a stressful situation.
have established a policy whereby pulseless victims of blunt • Coping. This is an active process of confronting the
trauma are not treated or transported by EMS. Likewise, as stressful situation. By acknowledging the existence of
more is learned about cardiac arrest resuscitation, it is appar-
stressors, the patient is able to gather information
ent that there is virtually no benefit to be gained from hospi-
about them and then change or adjust as necessary.
tal transport of patients who have received full advanced
Coping may or may not serve as the best strategy for
cardiac life support (ACLS) measures in the field but have
not been resuscitated. There are always exceptions, such as
the long term, however.
pediatric cases and hypothermia. However, more and more • Problem-solving skills. These skills are regarded as
paramedics will find themselves, in consultation with medi- the healthiest approach to everyday concerns. They
cal control, terminating resuscitative efforts in the field. involve problem analysis, which generates options for
Field pronouncement can be a touchy situation. The gen- action, and determination of a course of action. Mas-
eral public is under the mistaken impression that patients are tery—reflected in the ability to recognize multiple
not dead until they arrive at a hospital and a physician pro- options and potential solutions for stressful situa-
nounces them dead. When you make a field pronouncement,
tions—generally comes only as a result of extensive
always let the family know that all appropriate measures
experience with similar situations.
were provided but failed. Also, let them know that the deci-
sion to terminate resuscitative efforts was made by a physi- EMS practice, of course, involves abundant stressors,
cian. Do not bring up such topics as “not transporting saves which provide ample opportunities for the development of
money” or not transporting “keeps the ambulance available problem-solving skills. There are administrative stressors,
for others,” as most family members will not have the capac- such as waiting for calls, shift work, loud pagers, and inad-
ity to appreciate the benefit of these in their time of grief. The
equate pay. There are scene-related stressors, such as vio-
principal task in field pronouncements is to provide the fam-
lent and abusive people, flying debris, vomit, loud noises,
ily adequate information, help them with their grief to the
and chaos. There are emotional and physical stressors,
extent possible, and activate their personal support system
(e.g., friends, neighbors, clergy members).
such as fear, angry bystanders, abusive patients, frustra-
tion, exhaustion, hunger or thirst, and lifting heavy objects.
 Workforce Safety and Wellness 75

Environmental stress may be provided by siren noise, threat. The pituitary

Content Review
inclement weather, confined workspaces, and the fre- gland begins by releas-
➤➤ Phases of a Stress
quent urgent need for rapid scene responses and life-or- ing adrenocorticotropic
Response
death decisions. In addition, the often-difficult world of (stress) hormones.
• Alarm
EMS can strain a paramedic’s family relationships and Hormones continue to
• Resistance
may also lead to conflicts with supervisors and cowork- flood the body via the • Exhaustion
ers. Add this to some personality traits commonly found autonomic nervous ➤➤ Identify your own personal
among paramedics, such as a strong need to be liked and system, coordinated by stressors and find out
often unrealistically high self-expectations, and the com- the hypothalamus. Epi- what stress management
bination can lead to disturbing feelings of guilt or anxiety. nephrine and norepi- techniques work for you.
All these stressors and stress responses take a toll on the nephrine from the
paramedic. adrenal glands increase heart rate and blood pressure,
To help you manage your own stress, you should learn dilate pupils, increase blood sugar, slow digestion, and
these things: relax the bronchial tree. These alarm-stage responses
end when the event is recognized as not dangerous.
• Your personal stressors. Each person has an individual
list. What is stressful to you may be enjoyable to some- • Stage II: Resistance. This stage starts when the indi-
one else. What was stressful to you last year may be vidual begins to cope with the stress. Over time, an
replaced by new stressors this year. individual may become desensitized or adapted to
stressors. Physiological parameters, such as pulse and
• The amount of stress you can take before it becomes a
blood pressure, may then return to normal.
problem. Stress occurs in a tornado-like continuum. It
may start with a few breezes, but it can increase in • Stage III: Exhaustion. Prolonged exposure to the same
force until it is whirling out of control. Stopping the stressors leads to exhaustion of an individual’s ability
“storm” early is key to your well-being. You need to to resist and adapt. Resistance to all stressors declines.
know which stress responses are early indicators for Susceptibility to physical and psychological ailments
you so you can deal with them at that point. increases. A period of rest and recovery is necessary
for a healthy outcome.
• Stress management strategies that work for you.
Again, this is totally individual. Those who seek per- It would be great if we could manage each stressor to
sonal well-being must become well versed about per- the point of recovery before the next one hits, but of course
sonally appropriate stress management options. that is not how it works. Typically, people are still dealing
with one stress (or the same ongoing one, such as the
Adapting to stressors is a dynamic process of receiv-
chronic stress of shift work) when additional stressors pile
ing, processing, and dissipating stressors and their effects.
on, resulting in cumulative stress. If stress accumulates
You bring your life experience, temperament, emotional
without intervention, the consequences can be serious.
maturity, spiritual convictions, habits (good and bad),
Stress also helps us to function optimally. In fact,
interpersonal skills, ability to be self-aware, gender, and
heightened stress levels improve our ability to function.
recent activity to each moment of adapting to the world. If
You have surely experienced this phenomenon. For exam-
a person experiences a pile-on of stressor after stressor
ple, you are awakened from your sleep to respond to a
without regard for the consequences, the results are likely
motor vehicle collision. When you arrive on scene you find
to be bad. In fact, the U.S. Surgeon General once estimated
several critical patients. Although you may still be sleepy
that stress-related diseases kill 80 percent of people who
when you are first called to the scene, the stress responses
die of nontraumatic causes. Stress-related disease is avoid-
heighten your alertness and your ability to perform the
able if you make a habit of doing what is necessary to pre-
needed skills and procedures (Figure 4-12).
serve your personal well-being. (Specific stress
management techniques will be discussed later.)
Resistance
Ex

Phases of Stress Response m

ha

ar
Al
us
tio

There are three phases of a stress response: alarm, resistance,

n

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

Shift Work to revert to a daytime lifestyle on days off. For exam-

ple, if you work 9 pm to 5 am and your anchor time is
There will always be shift work in EMS. Because EMS is a
8 am to 12 noon, then go to bed “early” on days off and
24-hour, 7-days-a-week endeavor, someone must be func-
on workdays sleep from 8 am to 3 pm.
tional at all times. But working odd hours is inherently
stressful because of disruptions in the biorhythms of the • Unwind appropriately after a shift to rest well. Do not
body that are known as circadian rhythms and because of eat a heavy meal or exercise right before bedtime.
sleep deprivation. • Post a “day sleeper” sign on your front door, turn off
Circadian rhythms are biological cycles that occur at your phone’s ringer, and lower the volume of the
approximately 24-hour intervals. These include hormonal answering machine.
and body temperature fluctuations, appetite and sleepi-
ness cycles, and other bodily processes. When life patterns
disrupt the circadian rhythms, such as with extensive
Signs of Stress
travel between time zones, the biological effects can be A variety of factors can trigger a stress response. They
stressful. Sleep deprivation is common among people who include the loss of something valuable, injury or the threat
work at night. The inherent dangers to paramedics are of injury, poor health or nutrition, general frustration, and
clear. A recent study estimated that up to 20 percent of ineffective coping mechanisms. Remember, each individ-
fatal crashes resulted from driver fatigue. The hours at ual is susceptible to different stressors and therefore has a
which fatigue-related collisions most often occur are different constellation of signs and symptoms.
between 2:00 am and 6:00 am (early morning) and between However, the signs and symptoms of stress can be
2:00 pm and 4:00 pm (midafternoon), when our circadian beneficial, because they are the body’s way of warning that
rhythm is at its lowest points. Males ages 18 to 30 are in corrective stress management is needed. The warnings
the high-risk category. They tend to be overconfident typically are mild at first, but if left uncorrected, they will
about their driving ability and believe they can handle the build in intensity until you are forced to rest. If it means
situation. Women are less likely to be involved in fatigue- having a heart attack or collapsing, that is what the body
related crashes.14 will do. So pay attention early.
If you work at night and have to sleep in the daytime, The signs and symptoms of excessive stress can be
here are some tips to minimize the stress: physical, emotional, cognitive, or behavioral (Table 4-5).
They are unique to each person. Once again, an individual
• Sleep in a cool, dark place that mimics the nighttime must perform a self-assessment. If you catch a warning
environment. sign of excessive stress early and manage it, there is no
• Stick to sleeping at your anchor time (time you can need to reach the extreme endpoint commonly referred to
rest without interruption), even on days off. Do not try as burnout.

Table 4-5  Warning Signs of Excessive Stress

Physical Cognitive Emotional Behavioral
Nausea/vomiting Confusion Anticipatory anxiety Change in activity
Upset stomach Lowered attention span Denial Hyperactivity, hypoactivity
Tremors (lips, hands) Calculation difficulties Fearfulness Withdrawal
Feeling uncoordinated Memory problems Panic Suspiciousness
Diaphoresis (profuse sweating), Poor concentration Survivor guilt Change in communications
flushed skin Difficulty making decisions Uncertainty of feelings Change in interactions with others
Chills Disruption in logical thinking Depression Change in eating habits
Diarrhea Disorientation, decreased level Grief Increased or decreased
Aching muscles and joints of awareness Hopelessness food intake
Sleep disturbances Seeing an event over and over Feeling overwhelmed Increased smoking
Fatigue Distressing dreams Feeling lost Increased alcohol intake
Dry mouth Blaming someone Feeling abandoned Increased intake of other drugs
Shakes Feeling worried Being overly vigilant to environment
Headache Wishing to hide Excessive humor
Vision problems Wishing to die Excessive silence
Difficult, rapid breathing Anger Unusual behavior
Chest tightness or pain, heart palpitations, Feeling numb Crying spells
cardiac rhythm disturbances
Identifying with victim
 Workforce Safety and Wellness 77

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

Mental health professionals can provide the information

and education needed for rescuers to understand psycho- Disaster Mental Health Services
logical or emotional trauma, what to expect, and where to
The emotional well-being of both rescuers and victims is
get help, if needed. In addition, competent mental health
an important concern in any multiple-casualty incident. In
personnel should be available at all major incidents to pro-
the past, Critical Incident Stress Management (CISM) was
vide psychological first aid to rescuers and victims.
recommended for use in emergency services. However,
The basic principles of psychological first aid as may
evidence has clearly shown that CISM and Critical Inci-
be practiced by mental health professionals are quite
dent Stress Debriefing (CISD) do not appear to mitigate the
straightforward:
effects of traumatic stress and, in fact, may interfere with
• Contact and engagement. Making contact with those the normal grieving and healing process and should not be
in need of assistance; providing practical, instrumental used. The American Psychological Association judges the
assistance with compassion and care. status of psychological debriefing as “no research support/
 Workforce Safety and Wellness 79

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

Considerations this increase in size come increased braking distances, less

responsive steering systems, and slower acceleration
The topic of scene safety is vast and requires career-long (which decreases the ability to avoid certain collisions).
attention. Considering the many problems that can occur, Several ambulance types have a high center of gravity or
it is impressive how few injuries there are. Your risks are somewhat unstable. In addition, the person designated
include violent people, environmental hazards, structural to drive the ambulance is often the person with the least
collapse, motor vehicles, and infectious disease. Many of training and the least experience. In many instances, an
these hazards can be minimized with protective equip- introductory emergency vehicle operator course (EVOC) is
ment, such as helmets, body armor, reflective tape for night not provided or does not have an adequate session to prac-
visibility, footwear with ankle support, and Standard Pre- tice driving and emergency techniques.19
cautions against infectious disease. You should use what- Roadways are unsafe places. There are good books,
ever protective equipment you have. classes, and mentors to help you become aware of the vari-
ous roadway hazards. For all related emergency situations,
acquire the necessary training for emergency rescue and
Interpersonal Relations
Safety issues that arise in out-of-hospital care often stem
from poor interpersonal relations. Paramedics are public
ambassadors of health care. Interpersonal safety begins
with effective communication. If you can build a rapport
with the strangers you have been sent to serve, you will
gain their trust. Suspicious, angry, and upset people are far
more likely to be defensive and inflict harm than those
who see a reason to trust what you are doing.
Building rapport depends on the ability to put your
personal prejudices aside. Everyone has prejudices, but as
a representative of an institution far greater than yourself,
you must never allow them to interfere with appropriate
patient and bystander management. In fact, go beyond
curbing prejudice and challenge yourself to treat every
person you meet with dignity and respect.
You can begin by taking time to pay attention to the Figure 4-13  Ambulance collisions pose the greatest risk of injury
rich array of cultural diversity that exists in our nation and or death for EMS providers.
learning to see those differences as valuable and positive. (© Canandaigua Emergency Squad)
80  Chapter 4

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.

You Make the Call

It’s been a tough year for you on the paramedic squad. Lately, it just seems as if everything that
can go wrong does. Arguing (again) with your spouse about paying the mortgage is not helping
your irritation one bit. It is 2300 hours. You are tired, and all you ate all day was glazed doughnuts
and fast food. Suddenly, the tone alert sounds: “Ambulance 44, respond to the corner of Fero and
Bailey on a two-vehicle crash. Number of victims unknown.”
You are the second EMS crew to arrive. You prefer the job of triage, and the paramedic who is
doing it is too new to know much. Anyway, he has already triaged four patients. As you walk up
to the scene, you notice the bumper sticker on one crash vehicle and realize it is your neighbor’s
daughter’s car. You do not see her in the group of patients, and your heart leaps into your throat
when you see the DOA covered with a sheet.
You are assigned two patients, one an unconscious teen with a crushed leg and the other an
adult with a broken arm.
You take pride in your medical abilities, so handling the immobilization and other medical
care is smooth. On the way to the hospital, the teen wakes up and presses you to tell him, “Is Deb-
bie okay? Is she? Please! Tell me, is she all right?” Thus you find out that, indeed, the other person
in your neighbor’s car was Debbie, their daughter.
After delivering the patients to the hospital, you pop an antacid for your sour stomach and
chew out your partner for his bumpy driving.
A couple of days later, you take on yet another overtime shift. Your mortgage payment is due,
and besides, you can’t face going to the funeral of your neighbor’s daughter. You’ve seen enough
death. Who needs another funeral anyway?
1. Are your stress levels inappropriately high? What are the indications?
2. Might it be a good idea for you to go to the funeral? Why or why not?
3. How can you improve stress management in the future?
See Suggested Responses at the back of this book.

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:

1. Define key terms introduced in this 6. Define the categories of experimental

chapter. designs and discuss the various types of
studies within these general categories.
2. Explain the relationship between EMS
research and EMS practice. 7. Given a research proposal, identify the
ethical considerations for human subjects
3. Discuss how the National EMS Research
that must be considered.
Agenda and its recommendations could
improve future EMS research and 8. Discuss the proper use of various descriptive
practice. and inferential statistics in a research study.
4. Describe each of the steps of the scientific 9. Describe the purpose and intended content
method. of each section of a research paper.
5. Differentiate among the types of research 10. Describe what to look for and how to
paradigms, including quantitative, complete a review of published research.
qualitative, and mixed, and discuss the
11. Discuss the roles and responsibilities of the
prospective and retrospective approaches to
EMS provider who decides to participate in
doing so.
or undertake a research study.

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.”

Introduction • Facilitate collaboration between EMS researchers and

those from other disciplines (e.g., social scientists,
Scientific research has played a major role in the evolu- economists, epidemiologists, and others).
tion of modern EMS. When EMS was developed more • Establish a reliable funding stream for EMS research
than 30 years ago, there were no scientific studies or within government.
objective evidence to guide development. Instead, vari-
• Establish an alternate funding source for EMS research
ous practices from other areas (e.g., hospital medicine,
outside of government.
fire departments, the military) were applied to EMS. In
many instances, these practices were based on expert • Recognize the need for EMS research.
opinions and rational conjecture. Now, as we have moved • View research as necessary for the improvement of
into the twenty-first century, many EMS practices have patient care.
been examined through research methods. To the surprise • Enhance ethical approaches to research.
of many, some EMS practices that were considered intui-
They concluded that a national investment in EMS
tive, such as endotracheal intubation and medical anti-
research infrastructure is necessary to overcome the obsta-
shock trousers (MAST), have been found to be less
cles that currently impede EMS research. Funding is needed
effective than once thought.1,2 One of the hallmarks of a
to train new researchers and to establish their careers.
profession, when compared to a trade, is the ability to
Increased financial support is necessary to develop
change practices and procedures based on evolving
effective treatments for the diseases that drive the design
research. Thus, a solid and objective research program is
of the EMS system, including injury and sudden cardiac
what should and will drive EMS practices in the coming
arrest. Innovative strategies to make EMS research easier
years.
to accomplish in emergency situations must be legitimized
The importance of research to EMS cannot be over-
and implemented.
stated. To continue to receive the required funding and
Researchers must have access to patient outcome
support, EMS must prove that the care and service it pro-
information so that the impact of prehospital and out-of-
vides truly benefit the patients and the community and are
hospital patient care can be evaluated and improved.
cost effective. This is demonstrated primarily through out-
Incorporating standard scientific methodology into the
comes-based research. Outcomes-based research can help
evaluation of biomedical and technical advances in prehos-
determine whether a procedure, drug, treatment, or simi-
pital and out-of-hospital care is crucial.
lar strategy actually improves patient outcomes (e.g., mor-
In summary, research is the key to maintaining an
tality, morbidity, and quality of life). If you can’t prove it
appropriate focus on improving the overall health of the
makes a difference, then why do you do it?
community in a competitive and cost-conscious health care
The National EMS Research Agenda, published in
market. Most important, research is essential to ensure that
2001 by the National Highway Traffic Safety Administra-
the best possible patient care is provided in the prehospital
tion (NHTSA), provided a guide to future EMS research in
and out-of-hospital setting.
the United States.3 The document drew several conclusions
This chapter will provide an overview of research and
about the need for EMS research and made several recom-
the scientific method. It will detail some of the research meth-
mendations. These included:
odologies and provide insight to how EMS personnel should
• Develop a cadre of EMS researchers and support them evaluate research studies. Hopefully, it will encourage you,
early in their careers. as a paramedic, to venture into the world of research.
 EMS Research 87

Research and the Observe and

Scientific Method ask questions

The word science literally means “knowledge.” However,

science is generally defined as “knowledge attained
Conduct research, data
through study or practice.” Science is the state or fact of collection, analysis,
having knowledge that is derived through the scientific synthesis
method (defined in the next paragraph). Use of the scien-
tific method to study a given issue is known as research.
Research is patient, careful, systematic study and investi- Construct a
Revise hypothesis
gation in some field of knowledge, undertaken to discover hypothesis
or establish facts or principles. In EMS, we use research to
understand how EMS works and how it does not. How-
ever, as you will learn, paramedicine is a part of the disci-
pline of medicine, and medicine is both an art and a Test the hypothesis
by experimentation
science. The knowledge of EMS is science. How we apply
that knowledge is art. Excellent paramedics know the sci-
ence of EMS and use the art of EMS to apply the science.
The fundamental principle behind scientific research Analyze results
is the scientific method—a process by which scientists, and draw conclusions
collectively and over time, endeavor to construct an accu-
rate representation of the world. This representation must
be reliable, consistent, and nonarbitrary. The advantage
of the scientific method is that it is unprejudiced if prop-
Hypothesis is true Hypothesis is false
erly applied and reproducible.
The scientific method follows these distinct steps
(Figure 5-1):

• Observe and ask questions. The first step in the scien-

Report results
tific method is to observe something in the universe
and ask a question. For example, you and your EMS
colleagues have observed that calls for psychiatric Figure 5-1  Steps of the scientific method.
patients are more common when the moon is full.
Thus, you decide to determine whether this observa-
tion is true. You have made an observation and are phenomena, such as the rate of obstetrical deliveries
now asking a question. when the moon is full. When embarking on a study,
• Conduct research, data collection, analysis, and syn- make it easier on yourself and see if your question or
thesis. The first step in answering your question is to similar questions have already been addressed.
do some background • Construct a hypothesis. In your background research
research. Today, this can be you fail to find any study that has looked at whether
Content Review
easily done through the there is an increase in psychiatric calls when the moon
➤➤ Steps of the Scientific
Internet or through scien- is full, so you decide to move forward with your
Method
tific databases such as research. The next step will be to construct a hypothe-
• Observe and ask
PubMed, which is oper- sis. Your hypothesis is the specific question your study
questions.
• Collect, analyze, and ated by the U.S. National will answer. It must be something that can be clearly
synthesize data. Library of Medicine.4 In defined and measured. It must be constructed care-
• Construct a hypothesis. your study about the fully so it will answer your original question. As you
• Test the hypothesis by effects of a full moon on move forward with your psychiatric call study, a suit-
experimentation. psychiatric illness, you able hypothesis might be, “Psychiatric emergencies
• Analyze results and may find several prior are more common when the lunar cycle is in a full
draw conclusions. studies and publications moon phase.”
• Revise the hypothesis. on the subject. You can also • Test the hypothesis by experimentation. The next step
• Report results.
look at similar perceived is to set up an experiment to test your hypothesis to
88  Chapter 5

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.

• Analyze results and draw conclusions. After you have

completed your study, you must collect and analyze
the results. This will typically involve some level of Types of Research
statistical analysis. Then, based on your analysis, you There are various types of research. Typically, research is
can determine whether your hypothesis is true or described as quantitative, qualitative, or mixed. Stated
false. If, in fact, your hypothesis is found false, you can simply, quantitative research describes phenomena in
revise or construct a new hypothesis. numbers, whereas qualitative research describes them in
• Revise the hypothesis. If your hypothesis is found to words. Mixed research is a combination of quantitative
be correct, you do not need to revise it. However, you and qualitative research and uses both numbers and words
might want to revise one parameter and run the exper- to describe the phenomena being studied. These are totally
iment again. For example, you decide to change the different approaches and each has its strengths and weak-
definition of full moon to the single day of the lunar nesses (Table 5-1). Most medical research is quantitative.
cycle when the moon is truly full, instead of the five- In addition, research is either retrospective or prospec-
day definition you were initially using. Interestingly, tive. Retrospective research examines information that
in your study, you may actually find that psychiatric already exists, whereas prospective research involves

Table 5-1   Summary of Research Types

Quantitative Research Mixed Research Qualitative Research
Scientific method Researcher tests the hypothesis The researcher generates a hypothesis after Deductive and inductive
with data (deductive approach) collecting data (inductive approach)

Focus Narrow topic Variable topic Wide topic

Behavior Studied under controlled conditions Studied in more than one context Studied in natural environment

Nature of reality Objective Commonsense (pragmatic) Subjective

Nature of data Numbers Numbers and words Words

Data analysis Statistical Statistical and words Words

Results Generalizable May be generalizable Nongeneralizable

Report Statistical Mixed Narrative

 EMS Research 89

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

quasiexperimental studies are generally considered less

Study B Study C
valid than experimental studies. However, quasiexperi- results results
mental studies are quite useful, because in some situations Study A Study D
randomization is not possible or is unethical. results results
An observational study is one that does not have a
control group. Instead, a single group or multiple groups
are studied without comparison to a control. In an observa-
tional study, the scientist does not control the variables.
Observational studies are considered less valid than exper-
imental or quasiexperimental studies but have an impor-
tant role in medicine. In many situations, it is unethical to
withhold treatment from a group simply for the purposes
of experimentation. For example, hydroxocobalamin has
been found to be a safe antidote for cyanide poisoning, and
failing to treat a victim of cyanide poisoning with a safe
antidote might result in the victim’s death. Because of this,
it would be ethically and humanely impossible to study
hydroxocobalamin in anything but an observational study. Meta-analysis of
combined results
Observational studies are common in medicine.

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.

Figure 5-5  In the double blind study Half the patients

are given Pill X
illustrated here, neither the experimenter
nor the subjects know what drug they are Only the trial manager Physician does not
taking. (The pills are not identified by drug knows what drug or know what drug or Patients do not know what drug
name but only as “Pill A” and “Pill B.”) nondrug is in each pill. nondrug is in each pill. or nondrug they are taking.
92  Chapter 5

Nonrandomized Controlled Trial Cohort Study

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

became established because an expert thought them LEVELS OF EVIDENCE

appropriate or effective. However, as additional infor- Ia. Meta-analysis of randomized
mation has been revealed by the research process, controlled trials
these practices, or specific aspects of these practices, Ib. One randomized controlled trial
are now considered to be of questionable benefit. IIa. Controlled trial without
randomization
• Animal research. Animal research, also called in vivo IIb. Other type of quasiexperimental
(within the living) research, is important in under- study
standing how certain drugs and procedures affect bio- III. Descriptive studies (e.g.,
comparative studies, correlation
logical systems. Humans are mammals, and there has studies, and case-control studies)
certainly been some important information learned IV. Expert committee reports or
from animal research, especially research on other opinions, or clinical experience of
respected authorities, or both
mammals. However, findings in one species do not
necessarily apply to other species. Computer modeling Figure 5-9  Oxford Center for Evidence-Based Medicine levels of
is starting to replace some aspects of animal research. evidence.
• Bench research. Bench research is scientific research at
its most basic level. This type of research, often called
in vitro (within the glass) or “test tube” research, is
extremely important in learning how the universe
Ethical Considerations
functions. Bench research is often the first step in a in Human Research
research strategy that ultimately leads to animal and
Medical research is essential, but an overriding concern is
human research.
the rights of those who serve as subjects in the studies.
When evaluating the quality of research supporting a During the Nazi regime in Germany in the twentieth cen-
clinical practice, reviewers will typically stratify the scien- tury, the physician Josef Mengele and others conducted
tific evidence based on the type and validity of the experi- experiments on prisoners, primarily Jews, in German
mental designs used (Figures 5-8 and 5-9). concentration camps. All these studies were performed
without the consent of the subjects and often ended in the
Study Validity death of the subject. Some of the experiments had devas-
tating effects, such as when injection of chemicals into the
Validity is an important part of scientific research. Validity eyes of children to change their eye color resulted in
concerns whether or how well the study supports the con- blindness.
clusions—that is, is the interpretation of the results appro- After the Nazi experimental atrocities came to light, an
priate? We often look at a study as having external validity international consensus developed that it was necessary to
and internal validity. External validity assures that the protect the rights of humans who participate in research
results can be generalized, or possess generalizability (i.e., studies. Following the postwar trials of key Nazis at
the results will hold true for other persons at other places Nuremburg, Germany, the trial verdict included a set of
and in other times). Internal validity ensures that the guidelines to protect human subjects in research. These
results can be attributed to the cause (e.g, an increase in guidelines, called the Nuremburg Code of 1947, were the
psychiatric calls can be attributed to the full moon) and not first code to guide ethical practice in human research.5
to other possible causes. The United States has not been free of unethical
research, even after the Nuremburg guidelines were pro-
mulgated. As a notorious example, between 1928 and 1972
LEVELS OF EVIDENCE
the U.S. Public Health Service and researchers from Tuske-
Prospective randomized controlled trials
gee University in Alabama allowed African American men
Natural randomized controlled trials
infected with syphilis to remain untreated in order to
Prospective, nonrandomized
­controlled trials
study the natural progression of the disease. The men
were never told they were infected and little, if any, treat-
Retrospective nonrandomized
­controlled trials ment was provided.6
Case series (no control group) Additional strategies
Content Review
Animal studies and guidelines regarding
protection of human sub- ➤➤ An overriding concern in
Extrapolations
jects have been developed medical research is the
Rational conjecture rights of those who serve
since the Nuremburg Code.
as subjects.
Figure 5-8  The American Heart Association levels of evidence. These include the Helsinki
94  Chapter 5

categories of statistics: descriptive statistics and inferential

Legal Considerations statistics. Descriptive statistics are used to describe the
The Law and Ethical Medical Research.  The Nurem- basic features of the data obtained in a study. They provide
burg Code did not have the force of law, but it influenced a summary of the sample. Together with simple graphics
laws and rules for the same purpose that were subsequently analysis, they form the basis of virtually every quantitative
adopted in various countries, including regulations issued analysis of data. Inferential statistics draw information
by the U.S. Department of Health and Human Services gov- from the sampled observations of a population and make
erning federally funded research in the United States. conclusions about the population. Both kinds of statistics
Today, medical research in the United States is closely
are important in research.10
regulated. All studies must be approved by an independent
review board and subjects must provide informed consent
in order to participate. The study is continuously monitored Descriptive Statistics
and certain groups (e.g., prisoners) are not allowed to partici-
pate. Although there is a potential for harm in many studies, Descriptive statistics describe the nature of a sample. The
research overall is now a much safer endeavor and has pro- most common descriptive statistic you will encounter is
vided many of the advancements in modern medical care— the mean, or average. It is calculated by adding the values,
including many of those in prehospital care. and then dividing the sum by the number of values
involved. This provides the average or typical value of a
group of numbers or cases. The mean is especially useful
Declaration of 1964, developed by the World Medical Asso-
when the data are what statisticians call “normally distrib-
ciation, and amended in 1975, 1983, 1989, 2000, 2008, and
uted.” This means that if you graphed the data, they would
2013.7 The fundamental principles of the Helsinki Declara-
form a shape similar to a bell curve—a symmetrical or
tion are respect for the individual, the ability of the subject
nearly symmetrical curve with most data falling in the cen-
to make an informed decision about participating in the
ter of the graph and fewer data falling at the beginning and
research (initial and ongoing), and assurance by the
end. Height of individuals is an example of a normally dis-
researcher that the patient’s safety will be protected. Partly
tributed variable. Most people have a height close to the
as a result of the Tuskegee experiment, in 1979 the U.S.
average, with a few very short and a few very tall people at
Department of Health, Education, and Welfare released the
each end of the graph.
Belmont Report, which was formally titled Ethical Princi-
When the data are not normally distributed, the
ples and Guidelines for the Protection of Human Subjects of
median is a better way of finding a typical value. To com-
Research.8 In 1991, 14 other federal agencies joined what is
pute the median, put the values into numerical order and
now the Department of Health and Human Services (HHS)
find the middle value. This is the median, also known as
in adopting uniform rules for protection of human sub-
the “fiftieth percentile.” For example, if you have seven
jects. The Office for Human Research Protections (OHRP)
exam scores, to find the median, you put the scores in
was also established within HHS.
order and find the fourth highest (or fourth lowest, as this
is the same).
Institutional Review Boards Here is an example of how the median can be more
To ensure the protection of human subjects in research, insti- useful than the mean in some situations: In many states,
tutions that perform these studies must have an institutional the number of emergency calls received by EMS agencies
review board (IRB). The IRB (sometimes called the ethical is not normally distributed. There are frequently a few
review board or independent ethics committee) is a commit- very busy services in urban areas, a good number of
tee that approves, monitors, and reviews human research.9 moderately busy services, and a larger number of ser-
The goal of the IRB is to protect human subjects. IRBs have vices in rural areas that receive a much smaller number
the power to approve or disapprove a study before it begins. of calls. If you were to compute the mean, or average
They also have the power to require researchers to modify or number of calls, it would be skewed by the very busy
even terminate a study if they feel the subjects are at risk. services, even though there are only a few of them,
Most journals will not consider a study for publication unless because they receive such a high number. However, if
it has been formally approved by an IRB. you computed the median, you would get a smaller
number that would better reflect the number of calls
received by a typical service.

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

Examples of Variance and Standard Deviation

To see how the variance and standard deviation can give valuable information about data,
consider this example: Two different EMT-P classes take the same midterm exam. The
classes are the same size (seven students each) and have the same mean (or average)
score, 85%. If we did not look any further, we might think the two classes performed the same
on the exam. By looking at the variance and standard deviation, though, we can see that they
are actually quite different.

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 5-10  Examples of variance and standard deviation.

 EMS Research 97

Another test you may see is the odds ratio. This is

used in case-control studies and consists of the odds of
Table 5-2  Research Paper Format for Some Emergency
Medicine Journals
having a risk factor if the condition is present, divided by
the odds of having the risk factor if the condition is not Prehospital Annals of Academic
present. Simply put, the odds ratio describes how strong Emergency Emergency Emergency
Care Medicine Medicine
the association is between a risk factor and the condition
with which it is associated. The larger the risk factor, the Abstract Abstract Abstract
Introduction Introduction Introduction
stronger is the association. When you see an odds ratio, Methods Methods Methods
look for the confidence interval. Because an odds ratio of 1 Results Results Results
Discussion Limitations Discussion
indicates that there is no risk associated with the risk fac- Conclusions Discussion Limitations
tor, if the confidence interval includes 1, there is no statisti- References References Conclusions
References
cally significant risk.
For example, suppose investigators survey paramedic
students regarding how much education they had received
The introduction is the first section of the paper itself.
before enrolling in their course. They wish to test the
This is a brief description of pertinent, previously pub-
hypothesis that having at least a college degree is associ-
lished papers on the subject of the investigation. It should
ated with passing the paramedic certification exam. After
describe why the study was undertaken and what the pur-
the course is over, they perform the proper calculations
pose of the study was or what hypothesis the authors
and determine that the odds ratio is 1.6. This means a stu-
wanted to test.
dent who passes is 1.6 times as likely to have at least a
Next comes the methods section. This describes exactly
college degree compared with someone who does not pass
how the authors conducted the study, including what pop-
the exam. The 95 percent confidence interval, though, is
ulation they wished to study, how subjects were selected
0.8 to 2.4.
(and excluded), and what intervention was performed, if
This means we are 95 percent confident that the true
any. There should be enough information for interested
odds ratio lies between 0.8 and 2.4. Because this interval
readers to repeat the experiment should they so desire. The
includes 1 (keep in mind that an odds ratio of 1 means that
authors should also describe how they determined the
there is no association), we cannot be 95 percent confident
sample size, how much statistical power there was to
that there really is an association, so we conclude that there
detect a difference, which statistical tests they used to ana-
is no statistically significant relationship between having at
lyze the data, and what level of significance they chose for
least a college degree and passing the paramedic exam in
their statistical tests.
this group. However, if the 95 percent confidence interval
The results come next. Here the researchers provide
had been 1.2 to 2.0, an interval that does not include 1, we
their data (or a summary of the data), frequently with
would have concluded with 95 percent confidence that
tables, charts, and graphs to help make sense of the infor-
there is a statistically significant relationship and that a
mation they gathered. This section presents the data, but
person who passes the paramedic exam is between 1.2 and
does not elaborate on them.
2.0 times as likely to have at least a college degree.
The discussion section is where the authors interpret
Many other statistical tests are used for different kinds
their findings and describe their significance. There is usu-
of studies and different kinds of data. The References sec-
ally a description of how this new information fits into the
tion at the end of this chapter lists several sources from
field of study and whether it supports or refutes previous
which you can learn more about them.
research. There should also be a discussion of the limita-
tions of the study, frequently followed by a call for further
research to answer the questions raised by the study.
Format of a Research Paper The summary, or conclusion, is a very brief (no more
than a few sentences) recap of the main findings of the study.
When authors submit their findings to a journal, they
structure their results in a standardized fashion that
allows others to quickly understand what the researchers
did and what they found (Table 5-2). The first thing to How a Research Paper
appear after the title and names of the authors is the
abstract. This is a brief paragraph that summarizes the Is Published
need for the study, the research methods used, and the Once the authors of a study have drafted their paper, they
results encountered. Many people use the abstract to submit it to a scientific journal for publication. Each journal
determine whether the paper is one of interest to them has its own rules, but all peer-reviewed journals follow the
and therefore worth reading. same general procedure. After receiving the paper, the edi-
98  Chapter 5

tor sends it to one or more members of a review board—

people who have significant expertise either in the field
Accessing the Scientific
covered by the journal or in a related area, such as statistics
or research methodology. Generally, the reviewers are
Literature
blinded as to the names of the authors and the institution Medical school and university libraries have multiple
with which they are affiliated. This serves to ensure objec- floors containing stacks and stacks of scientific journals.
tivity and minimize bias. The reviewers read the paper and In the past, accessing the scientific literature was a labor-
evaluate it for its adherence to standards of research meth- intensive endeavor. Now, in the Internet age, a great deal
ods, its pertinence to the field, and the potential value it of the scientific literature is readily available. For many
has for practitioners. The reviewers send their comments years, journal publishers have archived their publications
to the editor, who then decides whether to publish it, send online. These can be downloaded as portable document
it back for revisions, or reject it. A copy editor may review files (PDF) or directly. Most journals require a subscrip-
the paper to correct grammar, spelling, and syntax. Many tion or library affiliation to access. Some are free and
papers submitted by researchers are not published, and referred to as open access journals without financial,
some journals have reputations for being very selective. legal, or technical barriers. If you don’t have access to a
A note here about the term “abstract”: In the preceding medical or university library, many community college
section, we mentioned that the first part of a research paper and hospital libraries can access the papers for you.
is a brief summary paragraph called the abstract. The term In addition, the National Libraries of Medicine have
abstract more commonly describes a brief form of a longer long provided an accessible database of the medical
scientific research paper that is often published before the and  scientific literature called PubMed. It is free and
full research paper. The abstract may be presented at allows users to enter various search terms to find the
national peer meetings, and responses to the abstract may material needed (Figure 5-11). A page will open that lists
form the basis for adjustments to the full research paper all the references that are related to your search term
that is subsequently published. Abstracts are also pub- (Figure 5-12). You can further refine your search by
lished and cited in peer review journals. choosing all articles or review articles. When you find a
The peer review process has recently begun to receive reference that meets the needs of your research, you can
greater attention than it has in the past. This has been the click on the citation and the information about the article
result, ironically, of several studies looking at the quality of and the abstract for the article will open (Figure 5-13).
published papers. A surprisingly large number of papers, You can then determine whether this is an article worthy
when evaluated objectively for adherence to principles of of retrieving and reading. Because searching PubMed is
research methodology, have been shown to be deficient. This a somewhat complex and specialized task, you may
has led at least one journal, Annals of Emergency Medicine, to want to have a librarian help you with your search to
review and revamp its review procedures.11 Reviewers now ensure that you get exactly the information you are look-
get training in what to look for and how to evaluate papers, ing for. If you do not have access to a library, the National
and closer attention will be paid to how statistics are used. Libraries of Medicine operates a document retrieval ser-
This may be the beginning of a trend that should improve the vice known as Loansome Doc. It can be accessed through
quality of the research that is conducted and published. the web.

Figure 5-11  Opening screen of the PubMed database search engine.

(Source: NIH National Libraries of Medicine)
 EMS Research 99

Figure 5-12  Secondary scene of the PubMed database search engine after entering search term “paramedic.”

Figure 5-13  Individual citation screen of the PubMed database.

100  Chapter 5

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

Applying Study particular intervention (end-tidal CO 2 monitoring, for

example) is clearly going to have more impact on EMS than

Results to Your Practice finding out whether ambulances carry 24 four-by-four

gauze pads or 48 four-by-four gauze pads.
Once you have evaluated a study, you will be in a better Once you have focused on the issue and determined
position to determine whether it should change your prac- exactly what you wish to discover, you can go to the next step.
tice. Before you do so, though, you need to consider sev- This is where you generate your hypothesis, a statement of
eral factors. Rarely do clinicians make significant changes exactly what you are going to test. The null hypothesis is
on the basis of just one study. Because no study can defini- usually a statement that there is no difference between the
tively prove a hypothesis, the reader must look at other
studies and his own experience to construct an informed
opinion. If every other study published on a particular Table 5-4  What to Do When You Participate in a Study
topic comes to very different conclusions than the study at • Determine the question.
hand, the reader must wonder whether the study was • Prepare your hypotheses (null hypothesis and research hypothesis).
poorly designed, subject to bias of some sort, affected by • Decide what you wish to measure and how you will do it.
unknown confounding variables, or just the result of • Define the population you are studying.
chance. One must evaluate the field and its knowledge • Identify the limitations of your study.

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

Decision Making medical literature is searched and organized for additional

evaluation. Next, the scientific evidence is stratified based
In the past, traditional medical practices have been based on validity and reliability (see Table 5-5 for the classifica-
on medical knowledge (often learned during initial educa- tion recommendations of the American College of Cardiol-
tion), intuition, and judgment. Although all of these are ogy and the American Heart Association). Then, if the

Table 5-5  Applying Classification of Recommendations and Level of Evidence

Size of Treatment Effect
Class I Class IIa Class IIb Class III
Benefit >>> Risk Benefit >> Risk Benefit ≥ Risk Risk ≥ Benefit
Additional studies with Additional studies with No additional studies
Procedure/Treatment focused objectives needed broad objectives needed; needed
SHOULD be performed/ Additional registry data
administered IT IS REASONABLE to would be helpful Procedure/Treatment
perform procedure/ should NOT be performed/
administer treatment IT IS NOT administered SINCE IT IS
UNREASONABLE to NOT HELPFUL AND MAY
Estimate of Certainty (Precision) of Treatment Effect

perform procedure/ BE HARMFUL

administer treatment

Level A • Recommendation that • Recommendation in • Recommendation’s • Recommendation that

procedure or treatment favor of treatment or usefulness/efficacy less procedure or treatment
Multiple (3–5) is useful/effective procedure being useful/ well established not useful/effective and
population risk strata effective may be harmful
evaluated • Sufficient evidence from • Greater conflicting
multiple randomized • Some conflicting evidence from multiple • Sufficient evidence from
General consistency trials or meta-analyses evidence from multiple randomized trials or multiple randomized trials
of direction and randomized trials or meta-analyses or meta-analyses
magnitude of effect meta-analyses

Level B • Recommendation that • Recommendation in • Recommendation’s • Recommendation that

procedure or treatment favor of treatment or usefulness/efficacy less procedure or treatment
Limited (2–3) is useful/effective procedure being useful/ well established not useful/effective and
population risk strata effective may be harmful
evaluated • Limited evidence from • Greater conflicting
single randomized trial • Some conflicting evidence from single • Limited evidence from
or non-randomized evidence from single randomized trial or non- single randomized trial or
studies randomized trial or non- randomized studies non-randomized studies
randomized studies

Level C • Recommendation that • Recommendation in • Recommendation’s • Recommendation that

procedure or treatment favor of treatment or usefulness/efficacy less procedure or treatment
Very limited (1–2) is useful/effective procedure being useful/ well established not useful/effective and
population risk strata effective may be harmful
evaluated • Only expert opinion, • Only diverging expert
case studies, or • Only diverging expert opinion, case studies, • Only expert opinion, case
standard of care opinion, case studies, or standard of care studies, or standard of
or standard of care care

Source: Circulation. http://circ.ahajournals.org/manual/manual_IIstep6.shtml

104  Chapter 5

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.

You Make the Call

One day, you and your partner are restocking the ambulance and notice that the crew that pre-
cedes you seems to be using a lot more naloxone (Narcan) than your crew. At a shift meeting you
bring up the fact that some crews are using more naloxone than others. A discussion ensues, and
the consensus is that there are not a great number of narcotic overdoses in the community, so the
usage of naloxone might be a misapplication of a protocol. Because you and your partner brought
up the issue, you have been asked to study the problem.
You and your partner decide to develop a research question. However, you feel that you really
need to get a handle on the number of overdoses in the community that required naloxone. So
you first do a retrospective study looking at all run reports over the last year. One of your fellow
employees, who is on light duty following surgery, goes through all run reports for the prior year.
He records the number of total runs, the number of times an opiate overdose was encountered, the
number of times naloxone was given, the number of total doses of naloxone administered, and the
ID number of the paramedic who administered the drug in each case. These data are placed into
an Excel computerized database and analyzed.
When you analyze the data, you see that the incidence of narcotic overdoses requiring nalox-
one was 0.12 percent of all calls—a pretty low incidence. However, you note that two paramedics
were responsible for 45 percent of all naloxone administrations during the study period.
You discuss your findings with your clinical manager and medical director. The medical direc-
tor directs the clinical manager to provide a continuing education seminar on narcotic overdoses
and the usage of naloxone to all paramedics in the system—including the part-timers.
For the next three months, you and your partner prospectively monitor the daily run
reports and see whether any of the parameters in your initial study have changed. At three
months, you find that the incidence of opiate overdoses requiring naloxone remains low, at 0.14
percent. The total amount of naloxone administered has diminished significantly, and statisti-
cal analysis finds that all paramedics in the system have been using the naloxone similarly. The
medical director feels that the education program worked and thanks you and your partner for
your efforts.

1. What is your study’s hypothesis?

2. Did you prove or disprove your hypothesis?
3. What was the derived benefit from the study?
See Suggested Responses at the back of this book.
 EMS Research 105

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.

Introduction communicable diseases, application of sanitary measures,

and monitoring of environmental hazards. Public health
Many EMS providers are first drawn to emergency medi- measures have played a significant role in improving the
cal services because of the opportunity to make a dramatic safety and quality of life of humankind. The primary tenet of
contribution to society and those in need. We respond to public health is to identify and prevent injury and illness—
countless scenes of crisis and tragedy and feel genuine that is, to take steps to remedy a situation before it results in
excitement when the critically ill or injured patient an injury or an illness. The roles of public health in modern
improves after receiving emergency medical care. Beyond society are diverse and extremely important (Figure 6-1). As
the excitement of the moment, however, is a sobering real- EMS has evolved, it has become clear that EMS has some
ity. How often do EMS crews respond to incidents that roles and responsibilities that are clearly within the domain
could easily have been prevented? How often have you of public health (Figure 6-2). In fact, some communities are
thought to yourself, “What a shame” or “I wish there was working to closely link their EMS and public health systems.
something I could have done” in the wake of senseless cir- To achieve this, a community must have the following:
cumstances surrounding an accidental injury or illness?
Such thoughts are all too common after an incident. But • Strong medical oversight of both public health and EMS
what if EMS providers, leaders, and administrators asked • A desire and an effort to educate both emergency care
these questions before an incident occurred? How many inju- and public health providers about the others’ roles
ries could be prevented? How many lives could be saved? • Recognition of the role of and a commitment to devel-
This chapter focuses on these questions and discusses the oping and maintaining relationships among leaders of
interaction between paramedicine and public health. the component groups through regular meetings,
team-building exercises, and planning

Basic Principles • Bringing community stakeholders (businesses, clinics,

universities, and others) into the planning process
of Public Health • Creating disaster plans that are developed locally,
Public health is defined as the science and practice of pro- involve public health and emergency care, and are
tecting and improving the health of a community through repeatedly drilled
the use of preventive medicine, health education, control of • Aggressively pursuing and securing funding
108  Chapter 6

Public Health Functions Table 6-1  Public Health Accomplishments (United States)

As Public Health Accomplishments (United States)

se
ss Vaccination

m
Motor vehicle safety
Monitor

en
Evaluate
health

t
Safer workplaces
Assure
ce

competent Diagnose Control of infectious diseases

S y s t em
Assuran

workforce & investigate

Decline in deaths from coronary artery disease and stroke

Safer and healthier foods

Link Research Inform,
to/provide educate,
Healthier mothers and babies
care empower
Ma t Family planning
nage men
Mobilize
Enforce Fluoridation of drinking water
community

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.

Public Health Laws

Figure 6-1  An overview of public health.
(Source: Centers for Disease Control and Prevention)

Public health laws—laws that affect public health practice

and strategies—are generally divided into three categories:

• Illness and prevention. These laws give public health

officials the necessary legal tools to perform their jobs.
Health Care Public Safety
• Police powers for public health agencies. These laws
allow public health entities to act in the general inter-
EMS est of the public, when necessary. Sometimes these
Roles and actions are in conflict with individual civil liberties.
Responsibilities However, in certain situations, such as epidemics and
disasters, the needs of the public as a whole generally
outweigh the needs of the individual.
• Epidemiological tools. These laws give public health
agencies the power to use epidemiological tools to
analyze legal issues related to public health practice
and enforcement.
Public Health
In 2009, the Public Health Law Research Program
(PHLRP) was established at Temple University in Philadel-
phia. This program, funded by the Robert Wood Johnson
Figure 6-2  Much of the role of EMS falls within the domain of Foundation, aids public health entities in promoting effective
public health. regulatory and legal solutions to public health problems.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

Note that although lifting and

moving techniques and back safety
programs have become routine for
prehospital staff, back injuries
remain a leading cause of disability
among EMS workers. Make a solid
effort to follow proper lifting tech-
niques in order to prevent bodily
injury, strain, and pain.

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.

Physical Fitness Driving Safety

The often hectic and chaotic lifestyle of a paramedic may Safe driving is an essential part of EMS response. As an
often interfere with your normal, healthy daily routine. emergency vehicle operator, be familiar with traffic laws
Therefore, you must make an extra effort to consistently and obey them. Never drink and drive. Always fasten
incorporate exercise, fitness, and a health-minded atti- your seat belt. In addition, you must be able to under-
tude into your life to minimize the risk of injury and to stand the capabilities and limitations of your emergency
improve your overall quality of life. Encourage your part- vehicle, handle weather and road conditions with preci-
ner, crew members, and other coworkers to do the same. sion, and accurately respond to all traffic conditions
A wellness program that includes a proper diet, cardio- quickly. Safe emergency operation of EMS vehicles can
vascular fitness, and strength training can increase energy be achieved only when proper use of warning devices is
levels, boost immune systems, and help fend off disease coupled with sound emergency and defensive driving
and injury. practices.
 Public Health 113

Figure 6-6  Every paramedic should have the appropriate safety

equipment readily available and in good repair.
(© Ken Kerr)

most convenient place to load the patient as well as to

leave the scene. Consider traffic, road conditions, and all
other possible hazards. Directing traffic is primarily the
responsibility of local law enforcement agencies. The
safest method for traffic control at serious vehicle colli-
sions is to stop all traffic and reroute it to different roads.
This is for the safety of patients, bystanders, and rescue
personnel.
If you are called to an area with potential health haz-
ards, such as an industrial park or a chemical plant or an
area with high crime rates, approach the scene with cau-
tion. Be sure to protect yourself appropriately. If you do not
have adequate protection or are not specifically trained to
control the specific hazards, never enter a hazardous scene.
Call in specialized teams, such as a hazardous materials
crew, if necessary. Law enforcement agencies should be
contacted for any violent, potentially violent, or dangerous
scene, including those involving domestic abuse or other
crimes.
If the scene is safe to enter, be sure to wear reflective
clothing to provide added protection on the scene. With
Standard Precautions in place, approach patients with
your own safety in mind. Determine the mechanisms of
injury (forces that caused injury) or the nature of illness.
Treat the patient according to protocol.
After patient care is addressed and a transport deci-
Figure 6-5  Disease prevention starts with health care workers. sion is made, make sure your unit is secure before depar-
(Top Photo: Dr. Bryan E. Bledsoe) ture. Have your partner check the outside of the unit to
make certain that all doors are secured. The patient
Scene Safety should be secured on an ambulance stretcher with at
Safety is always your first priority. Once your unit is dis- least three straps, as well as shoulder straps if available.
patched to a call, evaluate the dispatch information prior If a family member is allowed to accompany the patient,
to arrival. Focus your attention on the response and that person should be placed in the passenger seat in the
equipment that will be needed (Figure 6-6). Do not front compartment with vehicle restraints in place. All
approach potentially dangerous scenes until law crew members, including those caring for the patient,
enforcement has arrived and deemed the scene safe for should be adequately restrained while the ambulance is
EMS to enter. On arrival, park the unit in the safest and in motion.
114  Chapter 6

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

Most geriatric patients are coherent, although some Implementation

may suffer from some degree of dementia. Alzheimer’s
disease is merely one example of the conditions that can
of Prevention Strategies
affect the elderly. The associated confusion can contribute The following is a list of prevention strategies that you
to dangerous behaviors such as wandering away from should be able to implement:
home or into a roadway, which places these patients at • Preserve the safety of the response team. Always
greater risk of injury. remember that your first priority is your safety and the
safety of your fellow crew members. (If you and other
Work and Recreation Hazards crew members are ill or injured, you cannot help oth-
In the workplace, back injuries account for 22 percent of all
ers.) The next priorities are the patient and, finally,
disabling injuries. Injuries to the eyes, hands, and fingers
bystanders. Do what you can and what is within your
are responsible for another 22 percent. Even the quietest
training to maintain a safe and secure working area. If
office setting can be hazardous. Never underestimate the
there is a chance of risk or further danger on scene, act
potential dangers in an area that appears to be safe. Many
quickly and appropriately to correct the situation. Do
areas and aspects of the work environment are potentially
not hesitate to contact backup units and law enforce-
dangerous, including copy machines, electrical cords,
ment personnel, if necessary.
faulty wiring, and shoddy building construction, among
others. • Recognize scene hazards. To prevent illness or injury
Sports injuries are commonly seen in persons of all to EMS personnel and further illness or injury to
ages as a result of the increased popularity and participa- patients, size up the scene for potential risks or dan-
tion in outdoor recreational activities. Football, soccer, and gers before entering. Be aware of your surroundings.
baseball, as well as running, hiking, and biking, are among Is there anyone or anything that could cause harm to
popular sports that can result in fractures, dislocations, you, your crew, or the patient? Does the mechanism
sprains, and strains. that injured the patient still pose a threat to the rescu-
ers? Are there any hazardous materials in the area?
Medications Has any crime been committed? Are there structural
When an illness or injury occurs and treatment is sought, risks? Are there temperature extremes for which you
medications are often part of the treatment regimen. These are unprepared? If the scene is not safe and there is an
medications are occasionally taken improperly (too much immediate and imminent danger, retreat immediately
or not enough or in dangerous combinations), or they are and call for the appropriate assistance.
taken by others, sometimes causing serious medical prob- • Document findings. Document your patient care find-
lems. Medications of any kind should be taken only by ings at the end of every call. EMS patient forms often
those for whom they are prescribed. They should be stored can be designed to include specific data on injury pre-
according to label directions. They should also be contin- vention, to benefit researchers and implement future
ued until the prescription is completed. Following the phy- prevention programs. Such a form should include scene
sician’s, the pharmacist’s, and the label directions is conditions at the time of EMS arrival, which may play a
imperative. major role in determining intentional and unintentional
injuries, and the mechanism of injury, which is the best
Early Discharge determinant of patient care on scene. It should also
Managed care organizations, such as HMOs and insurance include a place where
companies, often mandate shorter hospital stays and early you can describe any
discharges from hospitals, urgent care centers, and other Content Review
risks that were over-
outpatient facilities. Such policies often result in more come. If protective ➤➤ Prevention Strategies for
patients being at home sooner with illnesses that are less EMS Personnel
devices were used (or
completely treated. These patients may call 911 for sup- • Preserve response
not used) during the
portive care and intervention. team safety
e m e rg e n c y, t h e s e
• Recognize scene
should also be docu- hazards
mented (Figure 6-7).
Cultural Considerations • Document findings
• Engage in on-scene edu- • Conduct on-scene
Elderly and Impoverished Populations. Studies have education
cation. Taking advan-
shown that the incidence of EMS calls is higher in areas • Know your community
tage of a teachable
where there is poverty or where there are many elderly peo- resources
moment is a chance to
ple. EMS personnel must recognize that this will be a signifi- • Assess community
cant part of the job. decrease future emer-
needs
g e n c y re s p o n s e s .
116  Chapter 6

Figure 6-7  Example of documentation of primary and secondary injury prevention.

Remember that to communicate effectively, you must Cultural Considerations

gain your listeners’ trust. Remain objective, nonjudg-
mental, and nonthreatening. Inform them of how they Immunizing At-Risk Populations. Many illnesses can
be prevented through immunization of at-risk populations.
can prevent the recurrence of a similar emergency and, if
The Centers for Disease Control and Prevention (CDC) and
needed, instruct them on the use of protective devices.
other organizations frequently update and publish a list of
• Know your community resources. Treating the medical recommended immunizations for children and persons at
needs of a patient is often not enough. You must also increased risk of contracting a preventable disease. How-
seek to identify and meet the psychosocial needs of ever, for various reasons, some patients are hesitant to obtain
your patient. At times, you may find it appropriate to these life-saving immunizations. This is especially true in
communities with a large number of illegal immigrants.
consider your patient a “customer.” Determine what
People who are in the country illegally often will not seek
his needs are and how you may assist him. Your
health care for fear that their presence in the country will be
patient may require a referral to an outside agency
revealed to immigration authorities and they will be
such as a prenatal clinic; a social service organization deported. As a result, this population is at increased risk of
that offers food, shelter, clothing, mental health developing diseases that could be prevented through proper
resources or counseling; or other services. Your system immunization.
may also allow for referral or transportation to a clinic, In several areas, paramedics have been called on to
urgent care center, or alternative form of health care. provide immunizations as a community service. In these
Be aware of the presence of both licensed and unli- situations, it has been demonstrated that persons unlikely
censed child care centers in your area. Encourage par- to go to a standard health clinic for immunizations are
ents to provide preexisting consent for treatment and more likely to attend an immunization session provided
transport in case of illness or injury at a child care facil- by EMS. Thus, by using the trustworthy image of EMS,
paramedics can help target populations for preventive
ity. Be sure to follow local protocols and report sus-
immunizations who might not obtain them by traditional
pected abuse situations to the appropriate child
means.
protective agency. Consider developing a social ser-
It is important to remember that, for many conditions,
vice resource guide for your organization to determine the best treatment is prevention.
solutions and ideas for these and other situations.
 Public Health 117

• Conduct a community needs assessment. Each com- • Workplace safety courses

munity should determine its own specific approaches • Health clinics (cosponsored by local hospitals or
to prevention. Conducting a formal needs assessment health care organizations)
will assist in identifying priorities. Consider the fol-
• Prevention information on your agency’s website
lowing that your community may already have or
may need to develop: These are just a few of the ideas that may be appropri-
• Childhood and flu immunizations 9 ate for your organization. The population served and its
ethnic, cultural, and religious makeup may affect the needs
• Prenatal and well-baby clinics
and approaches that are most appropriate. Also consider
• Elder-care clinics community members who are learning disabled or physi-
• Defensive driving classes cally challenged.

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.

You Make the Call

As you walk into work on a sunny, warm Saturday morning, your supervisor greets you at the
door. He is beaming with excitement as he tells you, “The boss just approved our budget for EMS
Week. And he and I agree that you are just the person to coordinate this year’s effort.” He contin-
ues by insisting that the organization must become “more active” in injury and illness prevention,
and EMS Week is the perfect platform to begin such a campaign. You agree to the concept and
accept the assignment. The supervisor responds, “Here is the budget overview and the planning
kit for last year and this one. I would like a preliminary plan from you by the end of today’s shift,”
and wanders back into his office. You briefly scan the packet and proceed to prepare for your shift.
Later, during an hour or so of downtime, you and your partner decide to brainstorm ideas
on how best to prepare for the event. Your partner mentions that he thinks “this whole idea of us
doing prevention is hokey and ridiculous.” He continues by saying, “That stuff is for the public
health people. I’m a paramedic. I don’t have time to be working on prevention.” Another para-
medic, fresh out of medic school, joins in the conversation and adds, “Yeah. If we prevented all the
injuries and illnesses, we would be out of a job. I don’t want that after all I went through to get my
certification.” You slump slightly into your chair as you begin to discover how difficult this task
might become.

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.

The Legal System Categories of Law

The United States has two general categories of law: civil
Sources of Law
law and criminal law. Criminal law deals with crime and
In the United States, there are four primary sources of law:
punishment. It is an area of law in which the federal, state,
constitutional law, common law, legislative (or statutory)
or local government will prosecute an individual on behalf
law, and administrative (or regulatory) law.
of society for violating laws meant to protect society. Homi-
Constitutional law is based on the Constitution of the
cide, rape, and burglary are examples of criminal wrongs.
United States. The U.S. Constitution sets forth our basic gov-
Violations of criminal laws are punished by imprisonment,
ernmental structures, which include the executive branch
a fine, or a combination of the two.
(the president), legislative branch (Congress), and judicial
Civil law deals with noncriminal issues, such as per-
branch (the Supreme Court). Constitutional law also pro-
sonal injury, contract disputes, and matrimonial issues. In
tects people against governmental abuse. For example, the
civil litigation, which involves conflicts between two or
Fourth Amendment to the Constitution protects people from
more parties, the plaintiff (person initiating the litigation)
unreasonable searches and seizures by the government.2
will seek to recover damages from the defendant (person
Common law, which also is referred to as “case law”
against whom the complaint is made). Tort law, which is a
or “judge-made law,” originated with the English legal
branch of civil law, deals with civil wrongs committed by
system and was adopted by Americans in the 1700s. It was
one individual against another (rather than against soci-
derived from society’s acceptance of customs and norms
ety). Tort law claims include negligence, medical malprac-
over time. Common law changes and grows over the years
tice, assault, battery, and slander.
as established principles are tested and adapted to meet
The United States has a federal court system and a state
new situations. It is a fundamental principle of our legal
court system. The federal court system was created by the
system that precedents set by the courts should be fol-
U.S. Constitution. Generally, only cases that involve a
lowed by other courts. This means that cases with similar
question of federal law or cases in which the parties are
facts should be decided in the same way.
citizens of different states will be heard in a federal court.
For example, the U.S. Supreme Court issued a decision
The state court system is the location for most of the cases
in the case of Miranda v. Arizona in 1966. In Miranda, the
in which a paramedic may become involved. Note that
Court said that a person who is taken into police custody
each state has its own sets of laws, each of which only
must be informed prior to interrogation that (1) he has the
apply to matters within that particular state. Thus, the
right to remain silent, (2) anything he says can be used
decisions of another state’s court system another state’s
against him in court, (3) he has the right to the presence of
statutes or regulations are unlikely to impact an EMS pro-
an attorney, and (4) if he cannot afford an attorney, one will
vider in a different state.
be appointed to him if he so desires. In 2000, the Supreme
In trial courts, a judge or jury determines the outcome
Court upheld the rules set forth in Miranda, affirming that
of individual cases. Appellate courts hear appeals of deci-
a confession will not be admissable at trial if it is found that
sions by trial courts or other appeals courts. The decisions
the defendant was not advised of his rights before making
of appellate courts may set precedents for later cases.
his statement.3
Statuatory law (or legislative law) does not come from
court decisions; it is created by lawmaking or legislative Anatomy of a Civil Lawsuit
bodies. Statutes are enacted at the federal, state, and local If you have ever been served with legal papers, you know
levels by the legislative branches of government. Examples that being sued or even being called to testify at a trial can
of legislative bodies include the U.S. Congress, state assem- be very unsettling. A basic understanding of the legal sys-
blies, city councils, and district boards. Legislative law is tem can help. The following is a brief description of the
written in a very clear and concise manner and takes prece- components of a civil lawsuit:
dence over common-law decisions.
Regulatory law (or administrative law) is enacted by • Incident. For example, a person is driving on a road
an administrative or governmental agency at either the and fails to see a stop sign. When he passes through
federal or state level. Administrative agencies, such as the the intersection, he hits another car and that driver
Occupational Safety and Health Administration (OSHA), sustains several injuries.
will produce rules and regulations necessary to implement • Investigation. The injured driver’s attorney makes a
a statute enacted by a legislative body. The agency is given preliminary inquiry into the facts and circumstances
 Medical–Legal Aspects of Out-of-Hospital Care 123

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

with hazardous materials. Because the laws affecting para-

medic practice vary from state to state, your agency should
Table 7-1  EMS Liability Claims
obtain the advice of an attorney in order to minimize Summary of 275 EMS Liability Claims from a Large National
EMS Insurer for a Two-Year Period
potential exposure to liability.
Other laws are designed to protect the paramedic in Cause Percentage
the event of exposure to bloodborne or airborne patho- Patient handling 45%
gens. For example, the Ryan White Comprehensive AIDS
Emergency vehicle movement or collision 31%
Resources Emergency Act (Ryan White CARE Act)
requires hospitals and EMS agencies to create a notifica- Medical management 11%
tion system to provide information and assist the para- EMS response or transport  8%
medic when an exposure occurs. This law allows the
Lack or failure of equipment  4%
paramedic who has been exposed to certain diseases (such
as hepatitis B, AIDS, and tuberculosis) access to medical Other Causes  9%
records to determine whether the patient has tested posi-
tive for, or is exhibiting signs and symptoms of, an infec-
tious disease. The Ryan White CARE Act is a federal law, Components of a Negligence Claim
but many states have enacted similar or even more com- To prevail in a negligence claim against a paramedic, the
prehensive laws to protect paramedics who may have plaintiff must establish and prove four particular elements:
been exposed to infectious diseases. It is important for a duty to act, a breach of that duty, actual damages to the
each agency to appoint an infection control officer and for patient or other individual, and proximate cause (causa-
this individual to implement protocols and an appropriate tion of damages).
infection control plan. First, the plaintiff must establish that the paramedic
had a duty to act. That is, he must prove that the paramedic
had a formal contractual or informal legal obligation to pro-
Legal Accountability vide care. Note that the act of voluntarily assuming care of
a patient may imply that there was a duty to act, which cre-
of the Paramedic ates a continuing duty to act. For example, in some states, if
As a paramedic, you are required to provide a level of care an off-duty paramedic witnesses a person choking, he may
to your patients that is consistent with your education and be under no legal duty to act. However, if that paramedic
training and equal to that of any other competent para- initiates care, then he has a duty to continue care. The ratio-
medic with equivalent training. You also are expected to nale behind this rule is that if bystanders see that a victim is
perform your duties in a reasonable and prudent manner, being helped, they may walk away. If the paramedic ren-
as any other paramedic would in a similar situation. Any dering assistance walks away after initiating treatment, but
deviation from this standard might open you to allegations not completing it, the patient may actually be left in a worse
of negligence and liability for any resulting damages. condition than if the paramedic never tried to help.
Most civil claims against EMS providers center around Duties that are expected of the paramedic include:
claims for negligence, but some are based on intentional • Duty to respond to the scene and render care to ill or
torts. An intentional tort is a civil wrong committed by one injured patients
person against another based on a willful act. Most forms
• Duty to obey federal, state, and local laws and regu-
of immunity do not provide protection when the claim is
lations
based on an intentional tort.
• Duty to operate the emergency vehicle reasonably and
prudently
Negligence and Medical Liability • Duty to provide care and transportation to the
Negligence is defined as a deviation from accepted stan- expected standard of care
dards of care recognized by law for the protection of • Duty to provide care and transportation consistent
others against the unrea- with the paramedic’s scope of practice and local medi-
Content Review sonable risk of harm. It cal protocols
➤➤ The Four Elements of can result in legal account-
Negligence • Duty to continue care and transportation through to
ability and liability. In the
• Duty to act appropriate conclusions
health care professions,
• Breach of that duty negligence is synony- Second, the plaintiff must prove there was a breach
• Actual damages
mous with malpractice of duty by the paramedic. A paramedic always must
• Proximate cause
(Table 7-1). exercise the degree of care, skill, and judgment that
126  Chapter 7

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

c­ ontinuing education; receive appropriate medical direc-

Legal Considerations tion, both on-line and off-line; always prepare accurate,
High Risks for Lawsuits.  Most lawsuits filed against thorough documentation; have a professional attitude and
EMS personnel allege negligence or a failure to act. Many demeanor at all times; always act in good faith; and use
involve allegations of misplaced endotracheal tubes, prob- your own common sense. In addition, several studies have
lems related to patient restraint, or medication errors and shown that health care providers who have a positive,
omissions. Be aware of high-risk areas in EMS practice, make pleasant attitude are less likely to be the subjects of com-
sure that you adhere closely to your system’s treatment pro- plaints or lawsuits.
tocols, and document your care in detail.
It is essential for every paramedic to be covered by
medical liability insurance. Liability insurance contains a
“duty to defend” clause that provides the insured party
with legal counsel to represent them during litigation.
Defenses to Charges of Negligence
Although many agencies have liability insurance that cov-
If you are accused of negligence, you may be able to avoid
ers their employees, there are two drawbacks to relying on
liability if you can establish a defense to the plaintiff’s claim.
it. First, your agency’s coverage may be inadequate. Addi-
The following is a list of potential defenses to negligence:
tionally, you and your employer may not have the same
• Good Samaritan laws. If the paramedic can establish interests. For these reasons, paramedics should consider
that his actions were protected by a Good Samaritan obtaining their own liability insurance coverage.
law, liability may be avoided. Note that such laws gen-
erally do not protect providers from acts of gross neg-
ligence, reckless disregard, or willful or wanton Special Liability Concerns
conduct (such as an intentional tort), and they do not Medical Direction
prohibit the filing of lawsuits. If a paramedic makes a mistake in the field and is sued by
• Governmental immunity. In many states, these laws the injured patient, it is possible that the patient will also
do not offer much protection for the individual para- sue the paramedic’s medical director and the on-line phy-
medic accused of negligence. The breadth of govern- sician. The on-line physician may be liable to a patient for
mental immunity established varies from state to state. giving the paramedic medically incorrect orders or advice,
You may want to become familiar with the govern- for the refusal to authorize the administration of a medi-
mental immunity law in the state where you practice. cally necessary medication, or for directing an ambulance
• Statute of limitations. This is a law that sets the maxi- to take a patient to an inappropriate medical facility.
mum time period during which certain actions can be A paramedic’s medical director may be liable to the
brought in court. After the time limit is reached, no patient for the negligent supervision of the paramedic. For
legal action can be brought regardless of whether or the patient to be successful in this type of claim, he would
not a negligent act occurred. Statutes of limitations have to prove that the physician breached a duty to super-
vary from state to state, so review the laws in your vise the paramedic and that breach was the proximate
state carefully. Note that they may vary for different cause of the patient’s injuries. Examples include the medi-
negligent acts and for cases involving children. cal director’s failure to establish medication protocols or
standing orders consistent with the current standards of
• Contributory or comparative negligence. Some state
medical practice for the paramedic to use in the field; the
laws will reduce or eliminate a plaintiff’s award of
medical director observing but failing to correct a para-
damages if the plaintiff is found to have caused or
medic’s poor intubation technique; or the medical director
worsened his own injury. For example, imagine that a
receiving complaints of inappropriate care by a paramedic
patient involved in a car crash complained of neck
and then failing to effectively investigate and resolve the
pain but refused to let the paramedics properly immo-
problem.6
bilize his spine. The paramedics explained the risks of
refusing treatment, but the patient signed a release-
Borrowed Servant Doctrine
from-liability form anyway. Later, the patient learns
As a paramedic, you may find yourself in the position of
that he has permanent spinal cord damage and sues
supervising other emergency care providers, such as EMTs
the paramedics for negligence. Many courts will find
or AEMTs. When doing so, it will be your responsibility to
that the paramedics were not negligent because, by
make sure they perform their duties in a professional and
refusing necessary treatment, the patient contributed
medically appropriate manner. Depending on the degree
to the exacerbation of his own injury.
of supervision and the amount of control you have, you
To protect yourself against claims of negligence, you may be liable for any negligent act they commit. This is
should receive appropriate education, training, and called the “borrowed servant” doctrine. For it to apply, the
128  Chapter 7

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).

REFUSAL OF TREATMENT AND TRANSPORTATION

I, THE UNDERSIGNED, HAVE BEEN ADVISED THAT MEDICAL ASSISTANCE ON MY BEHALF IS

NECESSARY AND THAT REFUSAL OF SAID ASSISTANCE AND TRANSPORTATION MAY RESULT IN
DEATH, OR IMPERIL MY HEALTH. NEVERTHELESS, I REFUSE TO ACCEPT TREATMENT OR
TRANSPORT AND ASSUME ALL RISKS AND CONSEQUENCES OF MY DECISION AND RELEASE
GOLD CROSS AMBULANCE COMPANY AND ITS EMPLOYEES FROM ANY LIABILITY ARISING FROM
MY REFUSAL.

________________________________________
SIGNATURE OF PATIENT
________________________________________
WITNESSED BY
________________________________________
DATE SIGNED

Figure 7-3  Example of a “release-from-liability” form.

132  Chapter 7

refusal and your efforts to change the patient’s mind. If an

Cultural Considerations on-line physician was involved, it is a good idea to obtain
Religious and Cultural Beliefs. Religious and cultural his signature on your patient care report. (See Figure 7-4
beliefs affect a patient’s health care decisions. Some, such as for an example of an EMS patient refusal checklist.)
Christian Scientists, prefer to use prayer instead of tradi-
tional health care and may refuse treatment on religious Problem Patients
grounds. Similarly, Jehovah’s Witnesses believe that blood As a paramedic, you will occasionally encounter a “prob-
transfusions are prohibited by biblical teachings. lem patient”—one who is violent, a victim of a drug over-
dose, an intoxicated adult or minor, or an ill or injured
minor with no adult available to provide consent for medi-
Sometimes patients choose to accept one recom-
cal treatment. Such a patient can present you with a medi-
mended treatment, but refuse others. For example, a
cal–legal dilemma. For example, consider the patient who
patient involved in a motor vehicle crash may refuse to be
has allegedly taken an overdose of medication. Concerned
fully immobilized but ask to be transported to the hospital.
family members may panic and activate the EMS system.
It is very important for you to do everything in your power
However, on your arrival at the scene, you find the patient
to be sure he understands why spinal precautions are nec-
alert, oriented, denying that he has taken any medication,
essary and what may happen if they are not taken. If a
and refusing to give consent for treatment or transport.
competent adult continues to refuse care, be sure to thor-
In a case such as this, attempt to develop trust and
oughly document his reason for refusal and your attempts
some rapport with the patient. If he continues to refuse,
to convince him to change his mind. Have the patient and
and remains alert and oriented, a refusal form should be
a witness sign a release-from-liability form.
completed and witnessed by a police officer. If the patient
will not sign the form, have a police officer or family mem-
Refusal of Service
ber sign it, indicating that the patient verbally refused care.
Not every EMS run results in the transportation of a patient
If, however, the situation becomes dangerous, or you have
to a hospital. Emergency care should always be offered to a
reason to suspect the patient has tried to injure himself,
patient, no matter how minor the injury or illness may be.
police officers or family members should consider legal
However, often, the patient will refuse. If this occurs, you
measures to force the patient to receive treatment.
must:
The intoxicated person who refuses treatment and
• Be sure that the patient is legally permitted to refuse transport also poses a problem for the paramedic. Every
care; that is, the patient must be a competent adult. effort should be made to encourage the patient to accept
• Make multiple and sincere attempts to convince the care and transport to the hospital. If the patient refuses,
patient to accept care. explain to him in a calm and detailed manner the implica-
• Enlist the help of others, such as the patient’s family or tions of refusal. However, if you determine that the patient
friends, to convince the patient to accept care. cannot understand the nature of his illness or the conse-
quences of his refusal, then he may not refuse treatment
• Make certain that the patient is fully informed about
because he is not competent to do so. Involve law enforce-
the implications of his decision and the potential risks
ment at this point. If the patient is competent to make such
of refusing care.
a decision, then have him sign a refusal form. Your conver-
• Consult with on-line medical direction. sation with the patient and his refusal should be witnessed
• Have the patient and a disinterested witness, such as a by a disinterested third party, such as a police officer.
police officer, sign a release-from-liability form. Regardless of the type of problem patient, always doc-
• Advise the patient that he may call you again for help, ument the encounter in detail. Your records should include
if necessary. a description of the patient, the results of any physical
• Attempt to get the patient’s family or friends to stay examination (or reasons for the lack of one), important
with the patient. statements made by the patient and other persons at the
scene, and the names and addresses of any witnesses. If
• Document the entire situation thoroughly on your
you are going to include an important statement from the
patient care report.12
patient or witnesses in your patient care report, put the
Remember, the refusal of care must be informed. That exact statement in quotation marks.
is, the patient must be told of and understand all possible Ideally, a police officer should respond to the scene of
risks of refusal. Decisions not to transport should involve all problem patients and should either sign the patient care
medical direction. It is a good idea to put the patient report as a witness or, if the paramedic’s safety is at risk,
directly on the phone with the on-line physician. If all accompany the patient and paramedic to the emergency
efforts fail, be sure to thoroughly document the reasons for department.
 Medical–Legal Aspects of Out-of-Hospital Care 133

EMS PATIENT REFUSAL CHECKLIST

PATIENT’S NAME: AGE:

LOCATION OF CALL: DATE:
AGENCY INCIDENT #: AGENCY CODE:
NAME OF PERSON FILLING OUT FORM:

I. ASSESSMENT OF PATIENT (Check appropriate response for each item)

1. Oriented to: Person? Yes No
Place? Yes No
Time? Yes No
Situation? Yes No
2. Altered level of consciousness? Yes No
3. Head injury? Yes No
4. Alcohol or drug ingestion by exam or history? Yes No
II. PATIENT INFORMED (Check appropriate response for each item)
Yes No Medical treatment/evaluation needed
Yes No Ambulance transport needed
Yes No Further harm could result without medical treatment/evaluation
Yes No Transport by means other than ambulance could be hazardous
in light of patient’s illness/injury
Yes No Patient provided with Refusal Information Sheet
Yes No Patient accepted Refusal Information Sheet
III. DISPOSITION
Refused all EMS assistance
Refused field treatment, but accepted transport
Refused transport, but accepted field treatment
Refused transport to recommended facility
Patient transported by private vehicle to
Released in care or custody of self
Released in care or custody of relative or friend
Name: Relationship:
Released in custody of law enforcement agency
Agency: Officer:
Released in custody of other agency
Agency: Officer:
IV. COMMENTS:

Figure 7-4  Some EMS systems have checklists for procedures to follow when a patient refuses care and/or transport.
134  Chapter 7

Patho Pearls Boundary issues can be avoided by adhering to one’s

Patients with Mental Disorders.  Several types of mental personal ethics and integrity and to the ethics expected of
disorders are frequently encountered with problem patients. the profession. 13 Try to look down the road and see
In addition to intoxication with alcohol or drugs, many prob- whether any of your thoughts, actions, or circumstances
lem patients suffer from personality disorders. These disor- could cause problems in the future. Generally, signs of
ders cloud judgment and significantly impact interactions potential trouble will be obvious. Keep in mind that lone-
with others. liness and isolation can lead to boundary crossings.
Always maintain a healthy lifestyle and have a life and
Boundary Issues circle of friends outside EMS. Keep your priorities straight
There are ethical and societal limits to the interactions and maintain high standards and ethics. As Ralph Waldo
between paramedics or other health care personnel and the Emerson said, “Character is higher than intellect.”
patients they serve. These are called professional bound-
aries and serve to protect both the paramedic and the
patient. EMS professionals have certain legal and ethical
Legal Complications
responsibilities to their patients, themselves, and the EMS Related to Consent
system. Crossing professional boundaries can result in There are many legal complications related to consent to treat-
breaching these responsibilities. Danger zones for bound- ment. If the paramedic does not obtain the proper consent to
ary crossing include being tired, being seduced, and being treat or fails to continue appropriate treatment, he may be
unprepared. liable for damages based on a tort cause of action, such as
• Being tired. Fatigue can lead to problems such as med- abandonment, assault, battery, or false imprisonment.
ication errors, poor decision making, vehicle crashes,
and more. EMS must be provided 24 hours a day, and
Abandonment
Abandonment is the termination of the paramedic–patient
long shifts and a heavy workload are common. You
relationship without providing for the appropriate contin-
owe it to yourself and your patients to see to it that
uation of care while it is still needed and desired by the
you are well rested and clear-headed.
patient. You cannot initiate patient care and then discon-
• Being seduced. In modern society “being seduced” is
tinue it without sufficient reason. You cannot turn the care
generally thought of as being enticed into some sort of
of a patient over to personnel who have less training than
sexual liaison. However, by definition, “being
you without creating potential liability for an abandon-
seduced” means being led away from one’s principles,
ment action. For example, a paramedic who has initiated
ethics, faith, or allegiance. Certainly, a sexual relation-
advanced life support should not turn the patient over to
ship between a health care provider and a patient is
an EMT or an AEMT for transport.
unethical and must be avoided at all costs. There are
Abandonment can occur at any point during patient con-
other temptations, though—such as money, food,
tact, including in the field or in the hospital emergency
items of value, and drugs—that may cause some to
department. Physically leaving a patient unattended, even for
stray from honorable and appropriate behavior. The
a short time, may also be grounds for a charge of abandon-
physical and mental demands of EMS work, including
ment. If, for example, you leave a patient at a hospital without
the isolation, can sometimes lead to addictive behavior
properly turning over his care to a physician or nurse, you
and lapses in judgment.
may be liable for abandonment. It is always a good idea to
• Being unprepared. The motto of the Boy Scouts is “Be have the nurse or physician to whom you have passed
Prepared,” and preparation is also a fundamental tenet responsibility for patient care sign your patient care report.
of EMS. At some point in your EMS career you will
encounter a situation for which your education and Assault and Battery
experience has not prepared you. Unfortunately, when Failure to obtain appropriate consent before treatment
we don’t have the time and opportunity to think could leave the paramedic open to allegations of assault
through a situation, we make errors. For example, sev- and battery. Assault is defined as unlawfully placing a per-
eral years ago, two paramedics encountered a pregnant son in apprehension of immediate bodily harm without his
woman who was killed in a motor vehicle collision. consent. For example, your patient states that he is scared
The death was sudden, and their response time was of needles and refuses to let you start an IV. If you then
short. They decided to attempt to save the life of the show him an IV catheter and bring it toward his arm as if
baby through a postmortem Caesarean section. This to start an IV, you may be liable for assault.
was a procedure that their education and experience Battery is the unlawful touching of another individual
had not prepared them for, and it was met with sanc- without his consent. It would be battery to actually start an
tions from the state and the local medical director. IV on a patient who does not consent to such treatment. A
 Medical–Legal Aspects of Out-of-Hospital Care 135

paramedic can be sued for assault and battery in both

criminal and civil contexts.

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.

Signed on (date): _____________________________________________________

Signature: ___________________________________________________________

Witness: _____________________________________________________________

Witness: _____________________________________________________________

Figure 7-6  Example of a living will.

this through execution of a document called a “durable Do Not Resuscitate Orders

power of attorney for health care” or “health care proxy.”) A Do Not Resuscitate (DNR) order is a common type of
Living wills, once signed and witnessed, are effective until advance directive (Figure 7-7). Usually signed by the
they are revoked by the patient. patient and his physician, the DNR order is a legal docu-
Be sure you know your local protocols concerning liv- ment that indicates to medical personnel which, if any,
ing wills. If any question arises on scene, contact medical life-sustaining measures should be taken when the
direction for instructions. patient’s heart and respiratory functions have ceased.
138  Chapter 7

PREHOSPITAL DO NOT RESUSCITATE ORDERS

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.

A) ______________Do Not Resuscitate (DNR):

No Cardiopulmonary Resuscitation or Advanced Cardiac Life Support to be
performed by prehospital personnel
B) ______________Modified Support:
Prehospital personnel administer the following checked options:
_____________Oxygen administration
_____________Full airway support: intubation, airways, bag-valve mask
_____________Venipuncture: IV crystalloids and/or blood draw
_____________External cardiac pacing
_____________Cardiopulmonary resuscitation
_____________Cardiac defibrillator
_____________Pneumatic anti-shock garment
_____________Ventilator
_____________ACLS meds
_____________Other interventions/medications (physician specify)
_____________________________________________________________________________
Prehospital personnel are informed that (print patient name)_____________________________________
should receive no resuscitation (DNR) or should receive Modified Support as indicated. This directive
is medically appropriate and is further documented by a physician's order and a progress note on the
patient's permanent medical record. Informed consent from the capacitated patient or the incapacitated
patient's legitimate surrogate is documented on the patient's permanent medical record. The DNR order
is in full force and effect as of the date indicated below.

______________________________________________ ____________________________________________
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)

Figure 7-7  Example of an EMS Do Not Resuscitate (DNR) order.

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

physician have an opportunity to consult on the patient’s

wishes and incorporate these wishes into a set of specific
Crime and Accident Scenes
orders as to the patient’s care, signed by the physician, to Because it may be your duty as a paramedic to treat a
be honored by health care providers who deal with that patient found at a crime scene, you should be aware of
patient during a medical crisis. crime-scene preservation issues. However, you must not
Although not all states have adopted POLST, some sacrifice patient care to preserve evidence or to become
states have already enacted a version of POLST as state involved in detective work. You can best assist investigat-
law. States that do have POLST laws usually allow for the ing officers by properly treating the patient and by doing
POLST order to be honored and followed throughout the your best to avoid destroying any potential evidence. As a
health care system, from prehospital care to inpatient and paramedic, your responsibilities at a crime scene include
hospice care. the following:

• If you believe a crime may have been committed on

Potential Organ Donation
scene, immediately contact law enforcement if they are
Over the past few years, advances in medicine have led to
not already involved.
an increased number of organ transplants and a higher
survival rate of transplant patients. Because organs and • Protect yourself and the safety of other EMS person-
tissues are in very high demand and short supply, many nel. This should always be your primary consider-
EMS systems are now becoming a vital link in the organ ation. You will not be held liable for failing to act if a
procurement and transplant process. Some have devel- scene is not safe to enter.
oped protocols that specifically address organ viability • Once a crime scene has been deemed safe, initiate
after a patient’s death. These include providing circula- patient contact and medical care.
tory support through IV fluids and CPR and ventilatory • Do not move or touch anything at a crime scene unless
support via endotracheal tube. Whether or not your EMS it is necessary to do so for patient care. Observe and
has protocols in place for potential organ donation, it is document the original placement of any items moved
important for you to consult with on-line medical direc- by your crew. If the patient’s clothing has holes made
tion when you have identified a patient as a potential by a gunshot or a stabbing, leave them intact, if possi-
donor (Figure 7-8). ble. If the patient has an obvious mortal wound, such
as decapitation, try not to touch the body at all. Do
Death in the Field your best to protect any potential evidence.
• If you need to remove items from the scene, such as an
Whether you arrive at the scene of a patient who has died
impaled weapon or bottle of medication, be sure to doc-
prior to your arrival or you make an authorized decision to
ument your actions and notify investigating officers.
terminate resuscitative efforts, a death in the field must be
appropriately dealt with and thoroughly documented. You should treat the scene of an accident in the same
Paramedics should carefully follow state and local proto- way. Your goals are to ensure your own safety and the
cols. It is also important for the paramedic to contact on- safety of your crew and to treat your patients as medically
line medical direction for guidance. indicated. Use the resources available to you, and be pre-
pared to summon additional personnel and rescue equip-
ment as necessary.

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

the proper authority in an objective and timely manner. You

should not confront the abuser. It is not necessary for you to
prove that abuse or neglect occurred before reporting. As a
rule, you will be doing the proper thing if you report acting
in the patient’s best interest. You should learn and review the
rules and requirements for reporting abuse and neglect in
your state. Often, the failure to report abuse or neglect is a
bigger liability than reporting.

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-

Employment Laws ment, regardless of grade level or position, are covered

under this legislation. The Age Discrimination and
Employment laws are laws that address employee– Employment Act of 1967 (ADEA) and the Age Discrimi-
employer relationships. Even volunteer agencies fall under nation Act of 1975 prohibit discrimination on the basis
the jurisdiction of many of these laws. Employment law can of age and protect individuals who are 40 years of age
be complex; you should consult an attorney with expertise or older from employment discrimination based on age.
in this area of law should a problem arise. There are several • Family Medical Leave Act. The Family and Medical
employment laws that paramedics should be familiar with. Leave Act of 1993 (FMLA) allows eligible employees
Many states have employment laws that parallel federal to take off for up to 12 workweeks in any 12-month
laws. Some state laws may even expand employees’ rights period for the birth or adoption of a child, to care for a
beyond those provided under federal law. family member, or if the employees themselves have a
• Americans with Disabilities Act. The Americans with serious health condition. This act was amended in
Disabilities Act (ADA), enacted in 1990, prohibits pri- 2008 to permit a spouse, son, daughter, parent, or next
vate employers, state and local governments, employ- of kin to take up to 26 workweeks of leave to care for a
ment agencies, and labor unions from discriminating member of the Armed Forces.
against qualified individuals with disabilities in job • Fair Labor Standards Act. The Fair Labor Standards
application procedures, hiring, firing, advancement, Act of 1938 (FLSA) was enacted following the Great
compensation, job training, and other terms, condi- Depression and established certain standards with
tions, and privileges of employment. The ADA covers regard to employment. It has been amended multiple
employers with 15 or more employees, including state times over the years. FLSA establishes the minimum
and local governments. It also applies to employment wage, overtime pay, record keeping, and child labor
agencies and to labor organizations. The ADA’s non- standards. It applies to both full-time and part-time
discrimination standards apply to federal employees workers in the private sector as well as those employed
as well. An employer is required to make a reasonable in federal, state, and local government.
accommodation to the known disability of a qualified • Occupational Safety and Health Act. The Occupa-
applicant or employee if it would not impose an tional Safety and Health Act was signed into law in
“undue hardship” on the operation of the employer’s 1970. The purpose of OSHA was to ensure that employ-
business. Reasonable accommodations are adjust- ers provide employees with an environment that is
ments or modifications provided by an employer to healthy and safe. The act also established the Occupa-
enable people with disabilities to enjoy equal employ- tional Safety and Health Administration (OSHA) to
ment opportunities. EMS agencies should abide by oversee workforce safety, and the National Institute
the ADA, both for employees and for those patients for Occupational Safety and Health (NIOSH) to guide
requesting accommodations under the ADA. occupational health and safety research.
• Title VII. A federal law that prohibits workplace • The Ryan White CARE Act. The Ryan White Compre-
harassment and discrimination, Title VII is a part of hensive AIDS Resources Emergency (CARE) Act was
the Civil Rights Act of 1964. It covers all private enacted in 1990 and was designed to fund programs to
employers, state and local governments, and educa- improve the availability of health care for victims of
tional institutions with more than 15 employees. It AIDS and their families. The act also mandated that
prohibits discrimination against employees on the EMS personnel learn whether they have been exposed
basis of race, color, national origin, religion, and gen- to life-threatening diseases while providing emer-
der. It has been extended to protect against discrimi- gency care. The Ryan White act was set to expire on
nation on the basis of pregnancy, sex stereotyping, September 30, 2009, but the Ryan White HIV/AIDS
and sexual harassment. EMS agencies, regardless of Treatment Extension Act of 2009 extended the benefits
the type, should have well-established policies and for an additional four years. August 18, 2015 marked
procedures to address the requirements of Title VII. the 25th anniversary of the act. Although it has not
• Amendments to Title VII. The Civil Rights Act of 1964 been extended, lawmakers have continued to fund it
has been amended several times. The Equal Employ- through annual appropriations, and it provides assis-
ment Opportunity Act of 1972 made discrimination in tance to over 500,000 Americans living with HIV.
 Summary
The very nature of a paramedic’s job requires interaction with law enforcement authorities and
frequent involvement in situations that can give rise to litigation. For example, not only will police
be called to the same emergencies to which paramedics are called, such as motor vehicle collisions
or scenes where violence caused injuries, but paramedics also may become material witnesses to
crimes or domestic disputes. It is therefore in your best interest to learn and follow all state laws
and local protocols related to your practice as a paramedic.
In addition, be sure to receive good training and keep current by attending continuing medi-
cal education programs and conferences, reading industry journals, and obtaining recertification
or relicensure as required by state law.
Remember, a paramedic is not immune from allegations of negligence or malpractice. How-
ever, the potential for liability may be limited or avoided by adhering to the following guidelines:

• Always obtain informed consent before initiating treatment and/or transport.

• Practice only the skills and procedures that a reasonable and prudent paramedic would, given
the same or similar circumstances.
• Practice only procedures that you are trained to perform and are directly authorized to per-
form by a medical-control physician or by approved local standing orders.
• Prepare accurate, legible, and complete medical records that thoroughly document the entire
EMS incident, from initial response to the transfer of patient care to hospital emergency
department staff.
• Discuss patient information only with those who need to know. Limit writings and oral reports
to information essential to patient care.
• Purchase and maintain malpractice insurance, and see that your employer does the same.
• Be nice to your patients and their families.

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.

You Make the Call

You and the rest of the crew of EMS Unit 116 receive a call to assist an unconscious 5-year-old girl.
On arriving at the scene, you are met by the child’s babysitter, who states that for the past hour the
child had been acting “strangely,” after which she fell asleep and would not wake up. The babysit-
ter also tells you that the child had been playing in her bedroom alone all afternoon. You ask the
babysitter to call the child’s parents immediately. She tells you that they are unreachable but are
expected home in approximately 20 minutes.
While your partner searches the child’s room, you assess the patient and note the follow-
ing physical findings: respiratory depression, hypotension, bradycardia, and constricted pupils.
Quickly searching, your partner finds an empty bottle of Darvocet under the child’s bed. You now
suspect a narcotic overdose and determine that the child needs immediate medical intervention
and transport to an appropriate medical facility. You prepare to start an IV, when the babysitter
tells you that she will not consent to treatment and tells you to wait for the parents to return home.
A neighbor arrives on scene and insists that the child’s parents would want only the family physi-
cian to treat her, and begs you to drive her to the physician’s office.
1. You believe that the child needs emergency care, but the child’s parents are unavailable. What
should you do?
2. If you decide to treat the child without consent, can you be sued for doing so?
3. What would you do if the parents returned home and refused to grant permission for treatment?
See Suggested Responses at the back of this book.
142
 Medical–Legal Aspects of Out-of-Hospital Care 143

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.

a. appellate court system d. all of the above.

b. state court system 8. Which court-ordered type of consent is most com-

c. federal court system monly encountered with patients who must be held
d. supreme court system for mental-health evaluation or as directed by law
enforcement personnel who have the patient under
4. On-scene licensed physicians who are professionally arrest?
unrelated to the patient and who are attempting to
a. Implied c. Involuntary
assist with patient care are called
b. Expressed d. Guardianship
__________________
a. intervener physicians. 9. ______________ is the termination of the paramedic–
b. direct control physicians. patient relationship without providing for the
appropriate continuation of care while it is still
c. on-line medical control.
needed and desired by the patient.
d. indirect control physicians.
a. Libel c. Neglect
5. Legislative statutes that generally protect the person b. Slander d. Abandonment
who provides care at no charge at the scene of a
medical emergency are called 10. A well-documented patient care report is
_____________________________ ______________________

a. medical practice laws. a. accurate. c. thorough.

b. scope of practice laws. b. objective. d. all of the above.

c. Good Samaritan laws. See Suggested Responses at the back of this book.

d. standard of care laws.

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.

Introduction Although ethical problems often have a legal aspect,

most ethical problems are solved in the field and not in a
Consider the following: A physician administers 15 milli- courtroom. However, there are times when ethical prob-
grams of intravenous morphine to a dying patient to alle- lems spill over into the legal arena and become the subject
viate pain and suffering. Another physician administers of legislation or regulations. The federal government, for
15 milligrams of intravenous morphine to a dying patient instance, recently instituted rules to protect patients who
to end the patient’s life. What’s the difference? Although are unable to consent to emergency care.
the question is seemingly simple, it is actually quite com- Ethical issues often begin with specific circumstances
plex. Is there a moral difference between these two actions? and lead to broad general rules or principles for behav-
When asked what the most difficult part of the job is, ior. This chapter examines how the most common prin-
most paramedics do not say “ethics.” Nonetheless, in one ciples and approaches are applied to common prehospital
recent survey almost 15 percent of ALS calls in an urban situations.
EMS system generated some ethical conflict.1 In another
survey, EMS providers responded that they frequently
have ethical problems related to patients refusing care,
conflicts regarding hospital destination, and difficulties Overview of Ethics
with advance directives.2 Other aspects of prehospital care Ethics and morals are closely related concepts. Morals
present potential ethical problems. These include patient are generally considered to be social, religious, or per-
confidentiality, consent, the obligation to provide care, and sonal standards of right and wrong. Ethics, also known
research. as moral philosophy, is a branch of philosophy that
 Ethics in Paramedicine 147

addresses questions about morality. Generally speaking,

ethics more often refers to the rules or standards that Cultural Considerations
govern the conduct of members of a particular group or The population of North America has certainly become a cul-
profession and how our institutions should function. tural blend. You can see it in the different ways people
Both ethics and morals address a question Socrates respond to serious illness or injury. Some may look at an ill-
asked: “How should one live?” ness as a disease process with predictable results. Others
may look at it as destiny. Others will simply attribute an ill-
ness to God’s will. In some cultures, certain illnesses and
Relationship of Ethics injuries are believed to be the work of the devil or a result of
to Law and Religion witchcraft, curses, or spells. To those who believe, such inter-
pretations are as real and as plausible as any other. For them,
Ethics and the law have a great deal in common, but they
the only successful treatment possible may involve counter-
are distinctly separate disciplines (Figure 8-1). Although
ing the effects of the curse or spell in question. Thus, they
ethical discussions have an unfortunate tendency to degen- may not have much confidence that your skilled prehospital
erate into arguments about what is legal and who might be care will make much of a difference.
liable, ethics is not the same as law. In general, laws have a Paramedics must recognize that people of different cul-
much narrower focus than ethics. Laws frequently describe tural backgrounds respond to illnesses and injuries in differ-
what is wrong in the eyes of society. Ethics goes beyond ent ways. Never criticize or chastise patients for beliefs that
examining what is wrong. It also looks at what is right, or differ from yours. These beliefs are so culturally ingrained
good, behavior. As a result, the law frequently has little or that a single contact with an EMS provider is unlikely to
nothing to say about ethical problems. In fact, laws them- change them. It is important to acknowledge such beliefs and
selves can be unethical. For example, for many years, laws never to ridicule those who hold them.
existed and were enforced that perpetuated racial segrega-
tion in the United States. These were ethically wrong and,
range of religious beliefs, or no religious beliefs at all. Thus,
ultimately, made legally wrong.
ethics cannot derive from a single religion. It is true, how-
Even though ethics and the law are different, ethical
ever, that religion can enhance and enrich one’s ethical
discussions can sometimes benefit from techniques devel-
principles and values.
oped by the law over the centuries. In particular, the law
emphasizes impartiality, consistent procedures, and meth-
ods to identify and balance conflicting interests. Making Ethical Decisions
Just as ethics differs from the law, it also differs from There are many different approaches one can use to deter-
religion. In a pluralistic society such as ours, ethics must be mine how a medical professional should behave under dif-
understood by and applied to people who hold a broad ferent circumstances. One approach is to say that each
person must decide how to behave and whatever decision
that person makes is okay. This approach is known as ethi-
Relationship of Ethical and Legal Issues
with Medicine cal relativism. People sometimes say that they believe in
ethical relativism. However, when questioned, they typi-
cally admit they do not find it satisfactory. For example, no
reasonable person would say that it was acceptable for the
Nazis, especially Nazi physicians, to behave as they did.
A similar approach is to say, “Just do what is right.”
This sounds fine, but in reality it does not answer the ques-
LEGAL ETHICAL
tion of how a health care professional should act. This
occurs because different people have different beliefs about
what is “right.” Ethics and morality overlap, but profes-
sional ethics go beyond what one individual thinks is right
or wrong. Even the Golden Rule—“Do unto others as you
would have them do unto you”—is not a sufficient guide-
line. What happens when the person making the decision
MEDICAL has desires and values that are radically different from the
patient’s? It becomes clear that reason and logic must be
used and emotion must be excluded as much as possible
from the decision-making process.
Another approach is to say that people should just ful-
Figure 8-1  The relationship of ethical and legal issues and medicine. fill their duties. This is known as the deontological method.
148  Chapter 8

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

Approach to Ethical Decision Making

Identify the problem.

List the possible actions to take.

Test one action.

State it in universal form.

List the immediate and long-term implications of taking that action.

Compare those implications with relevant values.

If implications are If implications are consistent with

inconsistent with relevant relevant values, conclude that
values, reject that action. the action (at least provisionally)
is ethically valid.

Test other actions.

If no action is ethically valid, reconsider and test again.

(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.)

FIGURE 8-2  An approach to ethical decision making.

 Ethics in Paramedicine 151

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

Quick Approach to New Ethical Problems

Consider the ethical problem.

*Do you already have a rule for dealing with this problem?
*Or, can you reasonably extend a rule to apply to the situation?

If yes to either of the above, follow the rule.

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.)

FIGURE 8-3  A quick approach to new ethical problems.

152  Chapter 8

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:

Considering the lack of verifiable information and the

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.

You Make the Call

You are transporting a 32-year-old male patient, Phil Cornock, who has a long history of kidney
stones and has all the classic signs of having another one now. He is in severe pain and is unable to
find a comfortable position. You know that although this condition can be excruciating, it is not gen-
erally life threatening. He is allergic to the only narcotic analgesic you can administer for pain. He
asks you, “Can’t you use the lights and sirens to get to the hospital faster?” Your service’s policy
regarding the use of lights and sirens restricts their use to cases in which the paramedic believes there
is a significant threat to life or limb. This patient’s condition does not qualify. You wonder, though,
whether you should use the lights and sirens to speed up transport since the patient is in severe pain.
1. What potential benefits are there in yielding to the patient’s request (beneficence)?
2. What potential harm is there in yielding to the patient’s request (nonmaleficence)?
3. How does justice come into play in this situation?
4. How should paramedics in general respond when a patient requests an intervention that is
not medically indicated?
See Suggested Responses at the back of this book.

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

2. What is the Latin-derived term used in medicine for c. Universalizability test

not doing harm to the patient? d. Interpersonal justifiability test
a. Autonomy 5. Every state has laws requiring the reporting of cer-
b. Maleficence tain health facts, such as
c. Nonmaleficence _____________________________
d. Beneficence a. births.
b. deaths.
3. Which groups serve to protect the rights of subjects
participating in research projects? c. child neglect and abuse.

a. IRBs c. EMS d. all of the above.

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:

1. Define key terms introduced in this 6. Depict the sequence of communications in

chapter. an EMS response.
2. Identify the parties with whom you must 7. List and describe emerging technologies
communicate in the course of an EMS designed to enhance communication to and
response and what you must communicate within EMS.
with each.
8. Describe the typical equipment, including
3. Explain how the basic communication advantages and disadvantages, and types
model applies to EMS communications. of frequencies used in EMS system
communication.
4. Follow standard reporting procedures and
format when communicating in the EMS 9. Discuss the regulation of public safety
system. communications.
5. Identify the uses of written communication 10. Explain the importance of the ability to
in EMS, particularly those of the patient communicate effortlessly between multiple
care report (PCR). agencies and jurisdictions.

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

Introduction • Your patient, his family, bystanders, and others who

may, at times, not understand what you are doing and
The way people communicate has changed radically in the become obstructive. Quite often, people misconstrue
past 40 years. Coincidentally, this is also the period during your actions and words. You must try to keep them
which modern EMS went from birth to maturity. Unfortu- well informed.
nately, in that same time span, the way we communicate in
• Personnel from other responding agencies, such as the
EMS has remained largely unchanged.
police department, fire department, or mutual aid
In society, person-to-person communication has
ambulances who may not share your priorities at the
evolved from face-to-face, telephoned, telegraphed, radi-
scene. You must communicate effectively with other
oed, and postal dialogue to face-to-face, telephoned,
responders to coordinate and implement your treat-
mobile-phoned, radioed, e-mailed, texted, and social-
ment plan. You will accomplish this face to face, via
network-messaging dialogue. In EMS, person-to-person
the radio, and through data messages and other data
communication has typically been face to face, telephone,
transmission. These communications require you to
and voice radio dialogue; cycles of telemetry data use; and
exhibit confidence and authority.
handwritten records. Mobile phones and other voice radio
systems (e.g., trunked systems) have augmented these • Health care staff from physicians’ offices, health care
methods, but, EMS, by and large, still communicates as it facilities, and nursing homes that frequently do not
did in the 1970s. understand the extent of your training or abilities.
This lag in the development of EMS communications Often, uninformed staff may think you are just “ambu-
technology has resulted in two impacts on current para- lance drivers.” In these cases, you must exhibit profes-
medic practice. First, for the near future, face-to-face, writ- sionalism and a calm demeanor while you ask
ten records (whether handwritten or electronic records), pertinent questions and discuss the case intelligently.
and voice radio or wireless telephone will continue to be • The medical direction physician who teams with you
the prime methods of communication in EMS. The first to interpret patient findings and make medical deci-
part of this chapter focuses on effective verbal and written sions that will best benefit your patient. The physi-
communications and the sequence of communications on a cian’s expertise and advice can be a tremendous
typical EMS call as they take place today. resource for you during the call. You will need to
Second, the availability of increasingly sophisticated communicate patient information and scene assess-
diagnostic and treatment technology and the busier environ- ment effectively to him.
ments in which paramedics, medical direction physicians, The medical direction physician can prepare for
and other EMS team members work will soon force changes your arrival if you have communicated to him the
in the information communications technology used in EMS. needs of your patient. For example, you are transport-
The last part of this chapter discusses those changes. ing a patient with a serious head injury who exhibits
a decreasing level of consciousness. By reporting this
information, the emergency department can arrange
Effective Communications for the trauma team, including a neurosurgeon, to
Knowledge of communications plays an important role in meet you in the ED on arrival. In such cases, good com-
your paramedic training. All aspects of prehospital care munication results in good patient care.
require effective, efficient communications. During a rou-
You must interact effectively with everyone involved
tine transfer or a life-threatening emergency run, you will
in the call to coordinate a unified effort resulting in top-
communicate with a wide variety of people, including the
quality patient care. EMS is the ultimate team endeavor.
following:
Your performance as a paramedic is just one component in
• The emergency medical dispatcher (EMD), whose job a series of interactions that ensure continuous first-rate
it is to manage an entire system of EMS response and care. From the call taker to the rehabilitation specialist, all
readiness, not just your call. You will transmit admin- the players in this continuum are equally important—only
istrative information such as “responding,” “arrived,” their specific roles differ.
“transporting,” and “back in service.” The EMD must Communication is not merely one aspect of an EMS
know the location of all his resources to manage the response; it is the key link in the chain that results in the
system effectively. On a serious emergency call, the best possible patient outcome. Effective communication
EMD can be your best ally by securing for you the optimizes patient care during every phase of the EMS
resources you need to manage your incident. response.
 EMS System Communications 163

Basic Communication Verbal Communication

Model Factors that can enhance or impede effective communica-
tion may be semantic (the meaning of words) or technical
Communication is the process of exchanging information (communications hardware). Communication requires a
between individuals. It begins when you have an idea or mutual language. For example, a city unit and a county
message you would like to convey to someone else. You unit that use different 10-code systems will find it difficult
then encode that information in the language best suited to communicate effectively. A “10-10” may mean a work-
for the situation. The language you use might include ing fire in one system and a cardiac emergency in another.
words, numbers, symbols, or special codes. For instance, Therefore, many EMS systems have stopped using 10-codes
if you wanted to describe a patient’s condition to the and changed to plain English. In fact, it is now a standard,
medical direction physician, you would ideally choose embraced by all major public safety associations in an
medical terminology that is precise and takes less time to effort through U.S. Department of Homeland Security’s
convey than a description using nonmedical terms. In SafeCom Program, to use plain English emergency radio
some systems, we communicate using codes. For exam- communications.1 Although regional variations in the use
ple, a “Code Blue” might mean a cardiac arrest. of plain English terminology exist, stopping the practice of
In addition to encoding your message, you must enshrouding messages in coded substitutions for plain
select the medium for sending it. You can speak face to English is a reasonable start at clarifying communications
face, send a fax, leave a voice message, send a letter or in an emergency environment.
electronic mail (email), or speak directly by telephone or When reporting your patient’s condition to the medi-
radio. You might send your encoded message via a pag- cal direction physician, you should use terminology that is
ing system that posts words or numbers; some pagers widely accepted by both the medical and emergency ser-
allow you to speak your message. Next, your intended vices communities. Telling the medical direction physician
receiver must decode and understand your message. that you have a victim of a “MAC 10 drive-by” or “Signal
Finally, that person must give you feedback to confirm G” (by which you mean “assault with a gun”) may be
that he received your message and understood it. You meaningless. Conversely, if the medical direction physician
might then confirm his reply and conclude the communi- asks you for your pregnant patient’s EDC (due date) or her
cation. Consider the following example of an effective LMP (last menstrual period) and you do not know those
radio communication:
Dispatcher: Control to Unit 192,
respond high priority
to 483 County Route
22, cross street Can-
field Road, on a pos-
sible heart.
Unit 192: Control, Unit 192 copy,
responding high pri-
ority to 483 County
Route 22.
Dispatcher: Unit 192 responding,
1228 hours.
In this simple example, the
sender (dispatcher) encodes his
message in a language that he
knows the receiver (Unit 192) will
understand. Unit 192 receives the
­m essage and acknowledges by
repeating the key data. Finally,
th e s end er c onfirm s and
c oncludes the communication
­ FIGURE 9-1  Communication occurs when individuals exchange information through an encoded
(Figure 9-1). message.
164  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:

• Identification of unit and provider

• Description of scene
• Patient’s age, sex, and approximate weight (for drug
orders)
• Patient’s chief complaint and severity
FIGURE 9-2  The professionalism of your communications reflects
• Brief, pertinent history of the present illness or injury on the professionalism of your patient care.
• Pertinent past medical history, medications, and allergies (© Kevin Link)
 EMS System Communications 165

4. Speak slowly and clearly. Pronounce each word dis-

tinctly, avoiding words that are difficult to understand.
5. Speak in a normal pitch, keeping your voice free of
emotion.
6. Be brief. Know what you are going to say before you
press the transmit button.
7. Avoid codes unless they are part of your EMS system
(if they are, work to change to plain English).
8. Do not waste airtime with unnecessary information.
9. Protect your patient’s privacy. When appropriate:
• Use the telephone rather than a radio.
• Turn off the external speaker.
FIGURE 9-3  The prehospital care report is as important as the run
• Do not use your patient’s name; doing so violates itself. Complete it promptly and legibly.
FCC regulations (unless your system is considered
a closed system by the FCC). use it. The data collected from your PCR can help to moni-
10. Use proper unit or hospital numbers and correct names tor and improve patient care through medical audits,
or titles. research, education, and system policy changes. Further-
11. Do not use slang or profanity. more, your written documentation becomes a legal record
of the incident and may become part of your patient’s per-
12. Use standard formats for transmission.
manent medical record. All legal rules regarding confiden-
13. Be concise, to hold the attention of the person receiving
tiality and disclosure pertain to your PCR.
your radio report.
Most of the same factors that influence verbal communi-
14. Use the echo procedure when receiving directions cation also affect written communication. Be objective, write
from the dispatcher or orders from the physician. legibly (the written version of speaking clearly), thoroughly
Immediately repeating each statement will confirm document your patient’s assessment and care, and use termi-
accurate reception and understanding. nology that is widely accepted in the medical community
15. Always write down addresses, important dispatch (Figure 9-3). Finally, your PCR illustrates your professional-
communications, and physician orders. ism. A sloppy, incomplete PCR suggests sloppy, inefficient
16. When completing a transmission, obtain confirmation care. The chapter “Documentation” deals with PCRs and
that your message was received and understood. other written communications in much greater detail.
The data elements that are collected on the PCR and
Occasionally, communications equipment will not how they are interpreted are usually defined in a data
function properly. Even a weak battery can disrupt clear ­dictionary. All states and territories have agreed to adopt, as
communication. If you are far from the base station, par- soon as is practical for each, the National Emergency Medi-
ticularly if you have a portable radio, try to broadcast from cal Services Information System (NEMSIS) data dictionary
higher terrain. Structures that contain steel and concrete and to participate in reporting some data to a NEMSIS
can interfere with radio transmission. Simply moving out- national database.2 This will, for the first time, allow national
side the building or standing near a window may improve EMS performance to be assessed.
communications. If that does not work, try a telephone.

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

management plan will be

Table 9-1  Common Radio Terminology CONTENT REVIEW
futile if you cannot com-
➤➤ Sequence of Communi-
Term Meaning municate it to others.
cations in EMS Response
Dealing effectively
Copy, 10-4, roger I understand • Detection and citizen
with your patient and
access
Affirmative Yes bystanders requires a vari- • 911
Negative No ety of communication • Advanced automatic
skills, such as empathy, crash notification
Stand by Please wait
confidence, self-control, • Emergency medical
Repeat Please repeat what you said authority, and patience. dispatch
Landline Telephone communications Your clinical experience • Discussion with
will suggest which skills to medical direction
Rendezvous Meet with • Transfer communications
use in any particular situa-
LZ Landing zone (helicopter) tion. For example, you
ETA Estimated time of arrival might display confidence and use an authoritative posture
when dealing with unruly bystanders. On the other hand,
Over I am finished with my transmission
you would need to be gentle and empathetic with a child
Mobile status On the air, driving around or an elderly grandmother. If you were in charge of an inci-
Stage Wait before entering a scene dent, you would have to communicate authoritatively
within the structure of the emergency scene to providers
Clear End of transmission
from other responding agencies. Delegating tasks, listen-
Unfounded We cannot find the incident/patient ing to initial reports, and coordinating the scene require
Be advised Listen carefully to this effective communication and interpersonal skills.

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

Emergency Medical Dispatch These predetermined guidelines are based on criteria

Once a 911 call is received at a PSAP and determined to approved by the medical director. For example, an elderly
have emergency medical consequences, it should be man- man with a history of heart problems who is complaining
aged from then on by a dispatcher with the special training of chest pain radiating to his left arm may indicate a high-
and resources to do so. This is the emergency medical dis- priority response (life-threatening emergency, lights and
patcher (EMD), who is the public’s first contact with the siren). In some systems, the appropriate response may
EMS system and who plays a crucial role in every EMS include a fire department basic life support first respond-
response. ing unit, a paramedic engine company, and a transporting
In a coordinated system known as priority dispatch- ambulance. Other systems may require only a paramedic
ing, emergency medical dispatchers interrogate a dis- ambulance. Another type of call may result in a nonemer-
tressed caller using a set of medically approved questions gency response, and another call may be transferred to a
to elicit essential information about the chief complaint consulting-nurse advice line because it would not be an
(Figure 9-5). Then, the dispatcher follows established appropriate use of EMS resources to respond.
guidelines to determine the appropriate level of response This form of call screening, when done appropriately,
(Figure 9-6). saves time and money, because only the necessary
resources are sent. It also limits the liability associated with
a lights-and-siren response to possible life-threatening inci-
dents by authorizing such responses only when necessary.
Because these systems make decisions that may result in a
nonemergency response or in no EMS response, they must
be undertaken cautiously, using only priority dispatch sys-
tems that have been proven to support these decisions
effectively. Many private and public EMS systems through-
out the United States use the priority dispatching system.8

PREARRIVAL INSTRUCTIONS  Many EMS systems

provide prearrival instructions, a service that is considered
the standard of care. Prearrival instructions complement
the call-screening process in a priority dispatch system
and are an essential part of the EMD function. As the dis-
patcher sends the appropriate response, the caller remains
FIGURE 9-5  Priority dispatching and prearrival medical instructions
on the line and receives instructions for suitable emergency
are commonly used in EMS.
measures to carry out while waiting for the emergency
(From Advanced MPDS v13.0 © 1979–2015 International Academies of Emergency
Dispatch and ProQA Paramount v5.1 © 2007–2015 Priority Dispatch Corp. All
responders to arrive, such as cardiopulmonary resuscita-
Rights Reserved. Used by permission.) tion or hemorrhage control.
During prearrival instructions, the dispatcher also can
obtain further information for the responding units. In the
case of cardiac arrest, the dispatcher can relay information
concerning the presence of a living will, a Do Not Resusci-
tate (DNR) form, or other advance directives. In another
case, paramedics en route to help a baby who had stopped
breathing could reduce their response speed if they
learned that the child had now started breathing and was
conscious.
Prearrival instructions have saved many lives. They
also are useful for comforting a distressed caller or provid-
ing emotional support to bystanders, family members, or
the patient himself.9

CALL COORDINATION AND INCIDENT RECORDING 

After sending the appropriate response and providing
prearrival instructions, the EMD’s main duties are sup-
port and coordination. He will provide the responding
FIGURE 9-6  The dispatcher determines the appropriate level of units with any additional resources needed and will record
response according to established guidelines. information about the call, such as times, locations, and
170  Chapter 9

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 )

FIGURE 9-10  Example of EMS repeater system.

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

Portable unit tions. Trunked systems pool all

Base station
Voice and ECG
frequencies. When a radio trans-
(not at same time) mission comes in, a computer
routes it to the first available
Frequency 1 frequency. The computer routes
Voice the next transmission to the next
available frequency, and so on.
Frequency 2
When a transmission terminates,
that frequency becomes available
and reenters the pool of unused
FIGURE 9-12  Duplex communications systems use two frequencies for each channel.
frequencies. Trunking thus frees
the dispatcher or field unit from
channel (Figure 9-12). Each radio must be able to transmit having to search for an available frequency.
and receive on each channel. For example, on a UHF radio, Trunked 800-MHz systems have been developed over
a hospital base station might transmit on 468.000 mega- the past 20 years, usually by one sponsoring state system
hertz (MHz) and receive on 478.000 MHz. Field radios user (e.g., police, transportation). When states began to suf-
would then transmit on 478.000 MHz and receive on 468.000 fer financial setbacks in the 1990s and more recently, these
MHz—just the opposite. Either party could then transmit systems became forced to seek other users, generally at a
and receive on the same channel simultaneously. “per device per month” or “per year” cost. Trunked sys-
Duplex systems work like telephone communications. tems appeal to potential fire and EMS users because they
Many areas use them for communications between the field offer more channels to use and the ability to configure spe-
paramedic and the medical direction physician. The duplex cial “talk groups” (a preselected set of users who can be
system’s major advantage is that one party does not have to instantly keyed up and addressed as a group with no oth-
wait to speak until the other party finishes his transmission. ers participating).
This allows for a much freer discussion and consultation EMS users now using VHF and UHF systems should
between physician and paramedic. For example, the medi- be aware of the need to plan, engineer, and coordinate sys-
cal direction physician can interrupt your report with an tem development if they expect to change to a trunked sys-
important question or concern. On the other hand, this abil- tem. A city jurisdiction that switches to this system and
ity to interrupt can be a disadvantage if abused. includes all hospitals may create problems for rural EMS
All duplex systems allow you to transmit either voice units that occasionally transfer patients into those hospi-
messages or data such as ECG strips. tals and use only VHF or UHF frequencies. Suburban and
rural users may find that the cost of new antennas needs to
MULTIPLEX  Multiplex systems are duplex systems with be factored in, because transmission distances and cover-
the additional capability of transmitting voice and data age will be less with 800-MHz equipment than with UHF
simultaneously (Figure 9-13). This enables you to carry on and VHF systems. Buyers beware!
a conversation with the medical direction physician while
you are transmitting an ECG strip. Speaking while you are DIGITAL COMMUNICATIONS Voice transmission
transmitting the ECG strip, however, causes much interfer- can be time consuming and difficult to understand. The
ence on the ECG strip. trend toward combining radio technology with com-
puter technology (ICT) has encouraged a shift from ana-
TRUNKING  Many communications systems operating log to digital communications. Digital radio equipment
in the 800-MHz range use trunking to hasten communica- is becoming increasingly popular in emergency services
communication systems. This
technology translates, or encodes,
Portable unit
Voice and ECG (at same time) Base station sounds into digital code for
broadcast. Digital transmission
is much faster and much more
Frequency 1
accurate than analog transmis-
sion. Because the messages are
transmitted in condensed form,
Voice
they help to ease the overcrowd-
ing of radio frequencies. Mobile
Frequency 2
phone companies now use digital
FIGURE 9-13  Multiplex systems can transmit voice and data at the same time. transmissions. Issues remain with
 EMS System Communications 175

the use of digital communications in certain noise envi-

ronments, such as fire grounds, that cause distortion of
voice transmissions. This may be a­ lleviated with changes in
radio technology but may also constrain the abandonment
of analog voice communications altogether.
The mobile data unit (MDU) in many emergency vehi-
cles (typically a “ruggedized” or “hardened” laptop com-
puter) is a robust form of digital communications. MDUs are
mounted in the vehicle cab or patient compartment (depend-
ing on use) and wired to the radio, a wireless hotspot
modem (in urban settings), or through a wireless provider
air card. These are replacing mobile data terminals that are
radio-based devices (more often used in law enforcement)
that have limited applications because they have no broad- FIGURE 9-14  Modern mobile phones have amazing capabilities and
band capacity. MDUs, however, may be used for receiving are becoming increasingly more sophisticated.

dispatch and other information and sending status informa-

tion such as “en route,” “arrived,” or “transporting to the telephones. When the transmission leaves one cell’s range,
hospital,” but may also be used to send electronic PCR data another cell picks it up immediately, without interruption.
to the hospital or back to quarters for processing. Agreements among wireless providers now allow seam-
It is a positive step forward to begin to use data com- less roaming across cell regions and states, coast to coast.
munications on a daily basis in EMS. These cutting-edge Limitations in any one provider’s roaming arrangements,
applications are increasingly widespread, and gaining expe- however, can limit access in certain areas of the country.
rience with them is instructive for all of us. Dependence on Handheld cell phone devices still exist with capabilities
commercial cellular and other wireless providers (air cards that do not extend beyond simple voice communications.
and hotspots) and on unlicensed, municipal hotspot/”mesh” These can also send limited data such as ECGs when con-
technology (2.4-GHz systems) for mission-critical commu- nected to a heart monitor that is set up for this operation.
nications (e.g., when the information must get through However, these devices are “narrowband” and, like the
without fail because a patient’s well-being depends on it) is VHF/UHF/800-MHz radio systems we commonly use
not recommended. These systems are not built to public today (which are also narrowband—and with the VHF/
safety reliability, security, or infrastructure hardening stan- UHF systems, as discussed earlier, getting even narrower),
dards. Furthermore, they are shared with the general public they support limited data transmission. In fact, they send
whose use is rapidly increasing, and offer no higher priority data more slowly than the first dial-up Internet connections
of use for EMS. If mission-critical data communications are 20 years ago and only about 20 percent as fast as basic dial-
required, explore the public safety licensed option of 4.9 GHz up connections today.
in urban areas or teaming with transportation colleagues for More common today are smart phone devices, in
use of 5.9 GHz intelligent transportation systems (ITS) chan- which the voice capability of a basic cell phone is joined by
nels. Another, better solution is under development—the the ability to perform a variety of data messaging func-
FCC’s proposed national public safety broadband network at tions, such as taking and sending photos and video, send-
700 MHz. This solution promises broadband coverage in ing and receiving e-mail and text messages, and connecting
areas beyond urban centers. with the Internet and its variety of communications options
Although means of digital communication are devel- (e.g., using the handheld as a wireless hotspot VOIP device
oping rapidly, it is important to remember that voice com- to save cell phone call charges).
munications will always have a place in emergency Smart phones incorporate broadband data capability
services. Crews will always need to speak to one another, to be able to accomplish these functions by, essentially,
to physicians and nurses, or to dispatchers. widening the “pipe” through which data flow, allowing
more data to flow faster and increasingly supporting data-
CELL PHONES AND MOBILE BROADBAND  Many and bandwidth-hungry operations (e.g., gaming with mul-
EMS systems have found that a cellular telephone system tiple players and sophisticated, highly responsive graphics
provides a cost-effective way to transmit essential patient in real time; and the sending of video and higher quality
information to the hospital (Figure 9-14). Cellular technol- photos in social networking environments while texting/
ogy is available in even the most remote areas of the coun- instant messaging among recipients).
try, though availability is wireless provider dependent. A Broadband data capabilities are rapidly expanding
cell phone service is divided into regions called cells. These and becoming more sophisticated as technology moves
cells are radio base stations that communicate with mobile from second to third and, now, fourth generations (“2G”,
176  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.

Since 9/11, the need for statewide systems with nationwide

capability for interoperability has changed the ways public
safety communications systems are planned and imple- Public Safety
mented. No longer can EMS communications systems be
planned as a “stovepipe” activity. Today, they must be part Communications Regulation
of larger local, regional, statewide, and national interopera- The Federal Communications Commission (FCC) controls
ble public safety and health care communications systems. and regulates all nongovernmental communications in the
To that end, and because EMS has a poor track record of United States. This includes AM and FM radio, television,
participating in and benefiting from federal and state plan- aircraft, marine, and mobile land-frequency ranges. The
ning and funding initiatives compared with the success of FCC has designated frequencies within each radio band for
fire and law enforcement, today’s paramedic and agency special use. They include public safety frequencies in all
officials should be aware of opportunities to be a part of bandwidths. In 2008, the FCC established a new office to
communications system planning and funding initiatives. handle public safety issues, the Public Safety and Home-
Under the auspices of the U.S. Department of Home- land Security Bureau. The FCC’s primary functions include:
land Security’s Office of Emergency Communications
• Licensing and allocating radio frequencies
(OEC), much progress has been made in ensuring well-
planned development of interoperable public safety com- • Establishing technical standards for radio equipment
munications systems on the national, state, regional, and • Licensing and regulating the technical personnel who
local levels. In 2009, for the first time ever, a National Emer- repair and operate radio equipment
gency Communications Plan (NECP) was developed by • Monitoring frequencies to ensure appropriate usage
OEC. Also, for the first time ever, virtually every state and
• Spot-checking base stations and dispatch centers for
territory developed a statewide communications interoper-
appropriate licenses and records
ability plan (SCIP) under the leadership of a statewide, mul-
tidisciplinary public safety committee (generically referred The FCC requires all EMS communications systems to fol-
to as a statewide interoperability executive committee low appropriate governmental regulations and laws. In
[SIEC] but given different names in various states). States licensing activities, the FCC requires public safety agencies
are now developing statewide interoperability coordinator to use frequency coordinators. For EMS, this is the Interna-
(SWIC) positions as a single point of responsibility for sys- tional Municipal Signal Association (IMSA). You must stay
tem development and funding disbursement. All states are abreast of and obey any FCC regulations that apply to your
encouraged by OEC, and by grant incentives, to have SCIPs, communications.

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.

You Make the Call

A call comes into your unit for a “possible heart attack” on State Route 11. You and your part-
ner climb into Palermo Rescue, a nontransport first-response vehicle. Your response time is
about 10 minutes. On arrival, a family member meets you. He leads you into the den of a small
farmhouse. Here, you see your patient sitting in an overstuffed chair. You note that your patient
is a 69-year-old man in obvious distress.
You begin questioning your patient to develop a history. As he speaks, you immediately notice
that he has difficulty breathing. He complains of severe chest pain, which began about 30 minutes
ago. With his hand, he indicates that the pain is pressure-like and substernal. He also indicates
that it radiates to his left arm and jaw. He describes a history of heart disease, including two prior
heart attacks. Three years ago, he had cardiac bypass surgery. He currently takes Lanoxin, Lasix,
Capoten, and an aspirin a day. He is allergic to Mellaril.
You and your partner complete your assessment. Your patient says he weighs about 250 pounds.
He is alert, but anxious. He exhibits jugular venous distention and bibasilar crackles. His abdomen
is nontender. His distal pulses are good. Vital signs include blood pressure 210/110 mmHg, pulse
of 70 per minute and regular, and respirations of 20 breaths per minute and mildly labored. Pulse
oximetry is 93 percent on supplemental oxygen. During your assessment, your patient becomes
progressively more dyspneic. The transporting ambulance arrives and the paramedic asks you
to give a radio report to the receiving hospital based on your assessment while she prepares her
patient for transport.
• Based on the information above, organize and prepare your radio report to inform the receiv-
ing hospital of your patient’s condition.
See Suggested Responses at the back of this book.

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.

Introduction effects of your interventions. It can be your best friend—or

your worst enemy—in a court proceeding.
The prehospital care report (PCR) is a factual record of Your PCR is your sole permanent, complete written
events that occur during an EMS call or other patient con- record of events during the ambulance call. The dispatch
tact. When written correctly, it accurately describes your center may have a record of the call times and audiotapes
assessment and care throughout the emergency call. It doc- of radio transmissions, and your patient will have his
uments exactly what you did, when you did it, and the memory of the call. You and other responders also may
 Documentation 185

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

Emergency MVA ( seat belt used ) Knife

example, they may want a chrono- AT DESTIN
Non-Emergency Fall of feet Machinery
logical account of your patient’s IN SERVICE
Stand-by Unarmed assault
mental status from the time you
GSW IN QUARTERS
arrived on the scene. Your PCR can
tell the emergency department staff Figure 10-1  The run data in a prehospital care report is vital to your agency’s efforts to improve
of your patient’s condition before patient care.
he arrived at the hospital. It serves (© Kevin Link/Science Source)
186  Chapter 10

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

Table 10-1  Standard Charting Abbreviations

Patient Information/Categories
Asian A Medications Med

Black B Newborn NB

Chief complaint CC Occupational history OH

Complains of c/o Past history PH

Current health status CHS Patient Pt

Date of birth DOB Physical exam PE

Differential diagnosis DD Private medical doctor PMD

Estimated date of confinement EDC Review of systems ROS

Family history FH Signs and symptoms S/S

Female ♀ Social history SH

Hispanic H Visual acuity VA

History Hx Vital signs VS

History and physical H&P Weight Wt

History of present illness HPI White W

Impression IMP Year-old y/o

Male ♂

Body Systems
Abdomen Abd Gynecological GYN

Cardiovascular CV Head, eyes, ears, nose, and throat HEENT

Central nervous system CNS Musculoskeletal M/S

Ear, nose, and throat ENT Obstetric OB

Gastrointestinal GI Peripheral nervous system PNS

Genitourinary GU Respiratory Resp

Common Complaints
Abdominal pain abd pn Lower back pain LBP

Chest pain CP Nausea/vomiting n/v

Dyspnea on exertion DOE No apparent distress NAD

Fever of unknown origin FUO Pain pn

Gunshot wound GSW Shortness of breath SOB

Headache H/A Substernal chest pain Sscp

Diagnoses
Abdominal aortic aneurysm AAA Chronic obstructive pulmonary disease COPD

Abortion Ab Chronic renal failure CRF

Acute myocardial infarction AMI Congestive heart failure CHF

Adult respiratory distress syndrome ARDS Coronary artery bypass graft CABG

Alcohol ETOH Coronary artery disease CAD

Atherosclerotic heart disease ASHD Cystic fibrosis CF

(Continued)
190  Chapter 10

Table 10-1  Standard Charting Abbreviations Continued

Diagnoses
Dead on arrival DOA Multiple sclerosis MS

Deep vein thrombosis DVT Non-insulin-dependent diabetes mellitus NIDDM

Delirium tremens DTs Organic brain syndrome OBS

Diabetes mellitus DM Otitis media OM

Dilation and curettage D&C Overdose OD

Duodenal ulcer DU Paroxysmal nocturnal dyspnea PND

End-stage renal failure ESRF Pelvic inflammatory disease PID

Epstein-Barr virus EBV Peptic ulcer disease PUD

Foreign body obstruction FBO Pregnancies/births (gravida/para) G/P

Hepatitis B virus HBV Pregnancy-induced hypertension PIH

Hiatal hernia HH Pulmonary embolism PE

Hypertension HTN Rheumatic heart disease RHD

Infectious disease ID Sexually transmitted disease STD

Inferior wall myocardial infarction IWMI Transient ischemic attack TIA

Insulin-dependent diabetes mellitus IDDM Tuberculosis TB

Intracranial pressure ICP Upper respiratory infection URI

Mass casualty incident MCI Urinary tract infection UTI

Mitral valve prolapse MVP Venereal disease VD

Motor vehicle crash MVC Wolff-Parkinson-White syndrome (disease) WPW

Medications
Angiotensin-converting enzyme ACE Lactated Ringer’s, Ringer’s lactate LR, RL

Aspirin ASA Magnesium sulfate MgSO4

Bicarbonate HCO−3 Morphine sulfate MS

Birth control pills BCP Nitroglycerin NTG

Calcium Ca2+ Nonsteroidal anti-inflammatory agent NSAID

Calcium channel blocker CCB Normal saline NS

Calcium chloride CaCl2 Penicillin PCN

Chloride Cl− Phenobarbital PB

Digoxin Dig Potassium K+

Dilantin (phenytoin sodium) DPH Sodium bicarbonate NaHCO3

Diphendydramine DPHM Sodium chloride NaCl

Diphtheria-pertussis-tetanus DPT Tylenol APAP

Hydrochlorothiazide HCTZ

Anatomy/Landmarks
Abdomen Abd Anterior-posterior A/P

Antecubital AC Distal interphalangeal (joint) DIP

Anterior axillary line AAL Dorsalis pedis (pulse) DP

Anterior cruciate ligament ACL Gallbladder GB

 Documentation 191

Table 10-1  Standard Charting Abbreviations Continued

Anatomy/Landmarks
Intercostal space ICS Midaxillary line MAL

Lateral collateral ligament LCL Posterior axillary line PAL

Left lower lobe LLL Posterior cruciate ligament PCL

Left lower quadrant LLQ Proximal interphalangeal (joint) PIP

Left upper lobe LUL Right lower lobe RLL

Left upper quadrant LUQ Right lower quadrant RLQ

Left ventricle LV Right middle lobe RML

Liver, spleen, and kidneys LSK Right upper lobe RUL

Lymph node LN Right upper quadrant RUQ

Medial collateral ligament MCL Temporomandibular joint TMJ

Metacarpophalangeal (joint) MCP Tympanic membrane TM

Metatarsophalangeal (joint) MTP

Physical Exam/Findings
Arterial blood gas ABG Heel-to-shin (cerebellar test) H→S

Bilateral breath sounds BBS Hemoglobin Hgb

Blood sugar BS Inspiratory Insp

Breath sounds BS Jugular venous distention JVD

Cardiac injury profile CIP Laceration Lac

Central venous pressure CVP Level of consciousness LOC

Cerebrospinal fluid CSF Moves all extremities (well) MAEW

Chest X-ray CXR Nontender NT

Complete blood count CBC Normal range of motion NROM

Computerized tomography CT Palpation Palp

Conscious, alert, and oriented CAO Passive range of motion PROM

Costovertebral angle CVA Point of maximal impulse PMI

Deep tendon reflexes DTR Posterior tibial (pulse) PT

Dorsalis pedis (pulse) DP Pulse P

Electrocardiogram EKG, ECG Pupils equal and reactive to light PEARL

Electroencephalogram EEG Pupils equal, round, reactive to light and PERRLA

accommodation

Expiratory Exp Range of motion ROM

Extraocular movements (intact) EOMI Respirations R

Fetal heart tones FHT Tactile vocal fremitus TVF

Full range of motion FROM Temperature T

Full-term normal delivery FTND Unconscious Unc

Heart rate HR Urinary incontinence UI

Heart sounds HS

(Continued)
192  Chapter 10

Table 10-1  Standard Charting Abbreviations Continued

Miscellaneous Descriptors
After (post-) p– Not applicable n/a

After eating pc Number No or #

Alert and oriented A/O Occasional Occ

Anterior ant. Pack years pk/yrs, p/y

Approximate ≈ Per /

As needed prn Positive +

Before (ante-) a– Posterior post.

Before eating (ante cibum, before meal) a.c. Postoperative PO

Body surface area (%) BSA Prior to arrival PTA

Celsius C Radiates to →

Change Δ Right R

Decreased ↓ Rule out R/O

Equal = Secondary to 2°

Fahrenheit F Superior sup.

Immediately stat Times (for 3 hours) × (×3h)

Increased ↑ Unequal ≠

Inferior inf. Warm and dry W/D

Left L While awake WA

Less than < With (cum) c–

Moderate mod. Within normal limits WNL

More than > Without (sine) s–

Negative – Zero 0

No, not, none Ø

Treatments/Dispositions
Advanced cardiac life support ACLS Intermittent positive-pressure ventilation IPPV

Advanced life support ALS Long spine board LSB

Against medical advice AMA Nasal cannula NC

Automated external defibrillator AED Nasogastric NG

Bag-valve mask BVM Nasopharyngeal airway NPA

Basic life support BLS No transport—refusal NTR

Cardiopulmonary resuscitation CPR Nonrebreather mask NRM

Carotid sinus massage CSM Nothing by mouth NPO

Continuous positive airway pressure CPAP Occupational therapy OT

Do not resuscitate DNR Oropharyngeal airway OPA

Endotracheal tube ETT Oxygen O2

Estimated time of arrival ETA Per square inch psi

External cardiac pacing ECP Physical therapy PT

 Documentation 193

Table 10-1  Standard Charting Abbreviations Continued

Treatments/Dispositions
Positive end-expiratory pressure PEEP Treatment Tx

Short spine board SSB Turned over to TOT

Therapy Rx Verbal order VO

Medication Administration/Metrics
Centimeter cm Keep vein open KVO

Cubic centimeter cc Kilogram kg

Deciliter dL Liter L

Drop(s) gtt(s) Liters per minute Lpm, L/min, liters/min

Drops per minute gtts/min Microgram mcg

Every Q Milliequivalent mEq

Grain gr Milligram mg

Gram g, gm Milliliter mL

Hour h, hr, or ° Millimeter mm

Hydrogen-ion concentration pH Millimeters of mercury mmHg

Intracardiac IC Minute min

Intramuscular IM Orally PO

Intraosseous IO Subcutaneous SC, SQ

Intravenous IV Sublingual SL

Intravenous push IVP To keep open TKO

Joules J

Cardiology
Atrial fibrillation AF Paroxysmal atrial tachycardia PAT

Atrial tachycardia AT Paroxysmal supraventricular tachycardia PSVT

Atrioventricular AV Premature atrial contraction PAC

Bundle branch block BBB Premature junctional contraction PJC

Complete heart block CHB Premature ventricular contraction PVC

Electromechanical dissociation EMD Pulseless electrical activity PEA

Idioventricular rhythm IVR Supraventricular tachycardia SVT

Junctional rhythm JR Ventricular fibrillation VF

Modified chest lead MCL Ventricular tachycardia VT

Normal sinus rhythm NSR Wandering atrial pacemaker WAP

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.

Completeness and Accuracy

Oral Statements The accurate PCR should be precise but comprehensive.2
Also essential to every PCR, regardless of approach, are the Include all the relevant information that anyone might be
statements of witnesses, bystanders, and your patient. expected to want later, and exclude superfluous informa-
They help to document the mechanism of injury, your tion. For example, if your patient’s foot was run over by a
patient’s behavior, the events leading up to the emergency, lawn mower, reporting that his great toe on that foot had
and any first aid or medical care others rendered before been amputated six years ago would be important; docu-
you arrived. They also may include information regarding menting that he had his tonsils removed when he was
the disposition of personal items such as wallets or purses. three years old probably would not. That you applied
At crime scenes, document safety-related information such direct pressure to the bleeding foot is pertinent; that the
as weapons disposition. Your PCR may be the only written lawn mower was a John Deere model 6354 is not.
report of what happened to a murder weapon. Other Many PCRs provide check boxes and a space for writ-
details such as where you first saw a victim, what position ten narratives (Figure 10-4). You should complete both the
he was in, and the time you arrived on the scene may narrative and check-box sections of every PCR. All check-
someday be crucial evidence in a criminal proceeding. box sections of a document must show that you attended
Whenever possible, quote the patient—or other source to them, even if you did not use a given section on a call.
of information—directly. Clearly identify the quotation The check boxes can help to ensure that routine, common
with quotation marks, and identify its source. For example: information is recorded for every call, but no PCR has a
Bystanders state the patient was “acting bizarre and check box for every possible chief complaint, assessment
threatening to jump in front of the next passing car.” finding, or intervention.
The narrative is the
core of the documentation. Content Review
Additional Resources Even if you document
➤➤ Elements of Good
Document all the resources involved in the event. If an something in a check box, Documentation
air medical service transported your patient, your docu- repeating that information • Complete
mentation should include your assessment and all inter- in the narrative might be • Accurate
ventions up to the point when you transferred care. worthwhile. By doing so, • Legible
Identify the air medical service and your patient’s ulti- you can expand on the yes- • Timely
mate destination, if you know it. If other EMS, fire, rescue/ or-no limitations of the • Without alterations
extrication, or law enforcement agencies were involved check box to explain the • Professional
in the call, document their roles. This can be particularly timing, the assessment ➤➤ Document exactly what
findings, the circumstances, you did, when you did it,
important in mutual aid calls, when many different
and the effects of your
agencies cooperate in your patient’s care. Also include or the changes in patient
interventions.
information about personnel from law enforcement and condition associated with
 Documentation 195

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.

Figure 10-5  The proper way to correct

a PCR is to draw a single line through the
error, write the correct information
beside it, and initial the change.
 Documentation 197

Professionalism HPI Gradual onset of severe shortness of breath

Write your report in a professional manner. Remember that for the past 3 hours; began while sitting in
someday it may be scrutinized by hospital staff, quality living room watching television; nothing pro-
improvement committees, supervisors, lawyers, and the vokes or relieves the dyspnea; her son states
news media. Your patient’s family may request, and is enti- this is worse than usual for her. She has had
tled to, a copy of your report from your agency. Write cau- a three-day history of some vague chest dis-
tiously and avoid any remarks that might be construed as comfort. She denies any chest pressure, nau-
derogatory. Jargon can be confusing and does little to sea, or dizziness.
enhance your image. Do not describe a patient well known PH She has a five-year history of heart problems
to EMS providers as a “frequent flyer.” Never include and congestive heart failure; hospitalized for
slang, biased statements, or irrelevant opinions. Include this problem three times in the past five years;
only objective information. “The patient smelled of beer no surgeries.
and had slurred speech and difficulty walking” are factual
statements. “The patient was very drunk” is an inference; CHS Meds: Isosorbide, nitroglycerin, furosemide,
even if accurate, it is still just your opinion. Libel and slan- digoxin, potassium; no known drug allergies;
der are, respectively, writing or speaking false and mali- 50 pack/year smoker; nondrinker; non-drug
cious words intended to damage a person’s character. abuser.
Always write and speak carefully. A seemingly innocent ROS Resp: Unproductive cough for one day; audi-
phrase or comment can come back to haunt you. ble wheezing; no hx of COPD or asthma; last
chest X-ray one year ago. Card: no palpita-
tions, pressure, or pain; + orthopnea; + par-
Narrative Writing oxysmal nocturnal dyspnea; + edema for past
few days; past ECG one year ago. GU: No
The narrative is the part of the written report in which you
changes in urinary patterns. Per. Vasc: + pit-
depict the call at length. Less structured than the check-box
ting edema for few days; cold feet.
or fill-in sections of your report, the narrative allows you
the freedom to describe your assessment findings in detail.
When other people read your report, they usually will rely Objective Narrative
on your written narrative for the most relevant informa- The objective part of your narrative usually includes your
tion. For example, as you transfer care to the emergency general impression and any data that you derive through
nurse, the nurse will usually scan your PCR for informa- inspection, palpation, auscultation, percussion, and diag-
tion concerning your patient’s history, vital signs, and nostic testing. This includes vital signs, physical exam, and
physical exam. tests such as cardiac monitoring, pulse oximetry, and blood
glucose determination.
To document your physical exam, you can use either
Narrative Sections of two approaches: head-to-toe or body systems. Although
Any patient documentation includes three sections of the medical community accepts both extensively, emer-
importance: the subjective narrative, the objective narra- gency medical services more often use the head-to-toe
tive, and the assessment/management plan. approach.

Subjective Narrative Head-to-Toe Approach  The head-to-toe approach

The subjective part of your narrative typically comprises
is well suited for any call when you perform an entire
any information that you elicit during your patient’s his-
physical exam, because you document your findings in the
tory. This includes the chief complaint (CC), the history of
same order in which you conducted the exam—from head
present illness (HPI), the past history (PH), the current
to toe. However, even though you may have conducted
health status (CHS), and the review of systems (ROS). In
your pediatric assessment from toe to head, you should
trauma, this also includes the mechanism of injury (MOI),
document it in head-to-toe order. This style encourages
as told to you by your patient or bystanders. The following
you to be systematic and
is a typical subjective narrative on a patient complaining of
thorough. It is appropriate
shortness of breath: Content Review
for major trauma and seri-
ous medical emergencies, ➤➤ Physical Exam Documen-
CC: The patient is a 74-year-old conscious black tation Approaches
when you examine every
female who complains, “I can’t catch my • Head-to-toe approach
body area and system.
breath.” • Body systems approach
Include all circulatory and
198  Chapter 10

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

other invasive procedures. because they group infor-

Content Review Content Review
Include the results of ongo- mation in categories that
➤➤ Narrative Formats ➤➤ CHART
ing assessments and any differentiate between sub-
• SOAP • Chief complaint
changes in your patient’s jective and objective infor-
• CHART • History
condition. Finally, describe mation. For example,
• Patient Management • Assessment
• Call incident your patient’s condition someone wanting only to • Rx (treatment)
when you transferred care determine your patient’s • Transport
to the emergency staff. The following example is a manage- medications can find that
ment plan for a trauma patient with a pelvic fracture whose list easily in history or current health status segments of
condition deteriorates en route to the hospital: either the SOAP or the CHART format. Either pattern is
acceptable and effective when used consistently.
On-Scene
Extrication Rapid extrication from vehicle, placed SOAP Format
supine on backboard SOAP stands for Subjective, Objective, Assessment, and
Plan. The detailed SOAP format includes:
Airway Airway cleared with suctioning, naso-
pharyngeal airway inserted Subjective • Chief complaint
Breathing Oxygen @ 15 liters/min via nonre- • History of present illness
breather mask
• Past history
Circulation Foot of stretcher raised 30°; bleeding
• Current health status
from arm laceration controlled with
• Family history
dry sterile dressing and direct pres-
sure; PASG applied; IV—16 ga. left • Psychosocial history
antecubital area—normal saline run • Review of systems
KVO per Dr. Johnson. Objective • Vital signs
Transport • General impression
Transported by ground ambulance to University Hospital • Physical exam
with full body immobilization supine on long spine board; • Diagnostic tests
ETA 10 minutes. Assessment • Field diagnosis
Ongoing Patient becomes restless and anxious; Plan • Standing orders
VS: pulse—120 weak carotid only, • Physician orders
BP—50 palpated, resp—28, skin: cool, • Effects of interventions
pale, clammy with some mottling;
• Mode of transportation
PASG inflated; initial IV run wide
• Ongoing assessment
open; second IV 16 ga. right antecu-
bital normal saline—run wide open.
CHART Format
Arrival CHART stands for Chief complaint, History, Assessment,
Rx (treatment), and Transport. The detailed CHART for-
Patient transferred to ED staff; restless; VS: pulse 120, BP—
mat includes:
80 palpated, resp—26, skin—mottled and cool.
Chief complaint • Primary problem or complaint
General Formats History • History of present illness
The acronyms SOAP and CHART are memory aids that • Past history
identify two common p ­ atterns for organizing a narrative
• Current health status
report. These acronyms provide templates that can be used
• Review of systems
for most medical and
Content Review trauma reports. They help Assessment • Vital signs
➤➤ SOAP you to arrange your his- • General impression
• Subjective tory, physical exam, and • Physical exam
• Objective management plan into a
• Diagnostic tests
• Assessment logical, readable structure.
• Plan • Field diagnosis
They are widely used
200  Chapter 10

Rx • Standing orders Time Intervention

• Physician orders 1335 Patient has spontaneous respirations @ 20/
Transport • Effects of interventions min, + bilateral breath sounds; becoming more
• Mode of transportation awake; HR—72, BP—120/76.

• Ongoing assessment 1340 Arrived at UH—Patient is conscious, alert,

and oriented with retrograde amnesia.
Other Formats
Like patient assessment itself, documentation is not “one Call Incident  The call incident approach simply
size fits all.” No one narrative format is ideal for all situa- emphasizes the mechanism of injury, the surrounding
tions. Two additional formats—patient management and circumstances, and how the incident occurred. Use this
call incident—are appropriate in certain circumstances. approach to begin documenting a trauma call with a sig-
nificant mechanism of injury. It is most suitable when the
Patient Management  The patient management
events surrounding the call might be significant. It would
format is preferred for some critical patients, such as those
be inappropriate for a man sitting in his living room with
in cardiac arrest, when you focus on immediately managing
chest pain or for someone who simply cut his finger with a
a variety of patient problems and not on conducting a thor-
carving knife. You may use this style in both the subjective
ough history and physical exam. This format is a chrono-
and objective sections of your PCR. The following example
logical account from the time you arrived on the scene until
shows call incident documentation for a motor vehicle crash:
you transferred care to someone else. It emphasizes your
assessment and management of the conditions you found.
Subjective The patient is a 46-year-old conscious and
Simply begin your chart with a description of the event and
alert white male who was an unrestrained
any other pertinent information and then document your
driver in a low-speed, head-on, two-car
management, starting with your airway, breathing, and cir-
motor vehicle crash, moderate front-end
culation (ABC) assessment. Record everything in real time
damage, no passenger compartment intru-
and in absolute chronological order, and always include
sion, deformity to windshield, dashboard,
the results of your interventions. A patient management
and steering wheel. Patient states he
chart would look like this:
“reached for cigarette on floor and when
Patient is an 89-year-old Hispanic male who was found he looked up, there was another vehicle in
by his wife unconscious on the floor immediately after front of him.” He denies any loss of con-
collapsing. He presents pulseless and apneic. sciousness and can recall all details prior
to and immediately following the crash.
Time Intervention Patient complains of pain to the head,
1320 Immediate CPR while monitor applied. neck, chest, and hip from being thrown
against the dashboard and windshield.
1322 Quick look—ventricular fibrillation.
Objective The patient presents in the front seat of
1322 Defibrillation @ 200 joules—no change. the car, appears in moderate distress with
1323 CPR resumed; IV access 18 gauge left antecu- bruises to his forehead, facial lacerations,
bital area—normal saline KVO; epinephrine and a deformed left leg. His left leg is
1:10,000 1 mg IVP. pinned underneath the dashboard with
his left foot hooked around the brake
1325 Defibrillation @ 200 joules—no change; pedal. On arrival, fire department rescue
1326 CPR resumed; amiodarone 300 mg IVP. personnel were holding manual stabiliza-
tion of his head and neck and stabilizing
1328 Defibrillation @ 260 joules—patient converts
the vehicle.
to normal sinus rhythm rate of 72 with strong
peripheral pulses, BP—110/76, no sponta-
These are not the only systems of documentation.
neous respirations. ET tube inserted. + lung
Indeed, you may use some combination of these systems
sounds bilaterally with BVM.
or develop a unique format for your regional system. The
1330 Ventilation continued @ 12/min via BVM; important thing is for your documentation to be complete,
accurate, and consistent. By using the same system to doc-
1332 Patient transferred to ambulance on stretcher—
ument every call, you will be less likely to accidentally
transported to University Hospital.
overlook or omit something.
 Documentation 201

Special Considerations Table 10-2   Refusal of Care Documentation Checklist

Some circumstances create special problems for EMS docu- • Thorough patient assessment
mentation. Patient refusals, calls when transport is unnec-
• Competency of patient
essary, multiple patients, and mass casualties are among
the more common examples. In these and other unusual • Your recommendation for care and transport
circumstances, take extra care to document everything that • Explanation to the patient about possible consequences of refusing
happened during the call. care, including possibility of death, if appropriate

• Other suggestions for accessing care

Patient Refusals • Willingness to return if patient changes mind

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

Figure 10-6  One example of a refusal of care form.

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 report, it is useless despite

the importance of its infor-
to good care.
• Legal:
Inappropriate documentation can have both medical and mation. Good documenta- • Poor documentation
legal consequences.6 The medical consequences of inade- tion now enables good encourages frivolous
quate documentation are potentially the most serious. care later. 7 lawsuits; good
documentation
Health care providers across several disciplines may refer The potential legal con-
discourages them.
to your PCR in planning their care for a patient. Do not sequences of inadequate
204  Chapter 10

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,

Care Records there may be yearly fees for technical support, upgrades,

A growing trend in EMS is the use of computerized patient

record-keeping software, also known as electronic patient
care records, or ePCRs.8 A number of ePCR systems are
available. These platforms offer some advantages over the
traditional paper chart; however, they also carry some
drawbacks.9
The benefits of ePCR systems are numerous. The fol-
lowing is a partial list:

• Greater ease of data collection and analysis. These

systems are built on a database platform, which makes
data analysis and reporting significantly faster than
trying to read through hundreds of paper charts, look-
ing for a specific key word. Figure 10-8  A sample screen snap from ePCR.

• A consistent, uniform, easily read patient chart, which (© ESO Solutions)

can be a benefit to hospitals, nurses, and physicians.

• The reduction of poor penmanship and spelling errors
common to handwritten charts.
• The opportunity for an EMS administrator to config-
ure and alter the software to best suit that service’s
particular operational model, needs, and require-
ments. Because different states use different manda-
tory data sets for reporting, different fields may be
required.
• Integration with dispatch software, billing services,
and regulatory agencies.
• Interface with medical devices. For example, cardiac
monitor data can be uploaded into the ePCR Figure 10-9  A graphic interface on ePCR.
­software. (© ESO Solutions)
 Documentation 205

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.

You Make the Call

While helping the quality assurance officer in your agency, you come across the following narra-
tive: “We were dispatched to a 10-48, coroner Main/Spice. Vehicle is upside down. PMD on scene
reports no serious injuries. Patient is nasty and abusive. Looks like a drug abuser. Is walking
around acting abnoctious. Minor injuries identified and treated per protocol. Police arrested
patient. EMS transport not needed.”
1. What is wrong with this narrative? (You should be able to identify at least ten faults.)
2. What will you do to make sure your documentation is better than this?
See Suggested Responses at the back of this book.

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:

1. Define key terms introduced in this chapter. 5. Describe the physiologic/psychosocial

development and characteristics of
2. Describe the physiologic/psychosocial
adolescents.
development and characteristics of infants.
6. Describe the physiologic/psychosocial
3. Describe the physiologic/psychosocial
development and characteristics of early
development and characteristics of toddlers
adulthood and middle adulthood.
and preschoolers.
7. Describe the physiologic/psychosocial
4. Describe the physiologic/psychosocial
development and characteristics of aging
development and characteristics of school
and late adulthood.
age children.

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

• Preschool age—3 to 5 years

• School age—6 to 12 years
• Adolescence—13 to 18 years
• Early adulthood—19 to 40 years
• Middle adulthood—41 to 60 years
• Late adulthood—61 years and older

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

Table 11-1  Normal Vital Signs

Pulse (Beats Respiration Blood Pressure
per Minute) (Breaths per Minute) (Average mmHg) Temperature
Infancy:

At birth: 100–180 30–60 60–90 systolic 98–100°F 36.7–37.8°C

At 1 year: 100–160 30–60 87–105 systolic 98–100°F 36.7–37.8°C

Toddler (12 to 36 months)  80–110 24–40 95–105 systolic 96.8–99.6°F 36.0–37.5°C

Preschool age (3 to 5 years)  70–110 22–34 95–110 systolic 96.8–99.6°F 36.0–37.5°C

School-age (6 to 12 years)  65–110 18–30 97–112 systolic 98.6°F 37°C

Adolescence (13 to 18 years) 60–90 12–26 112–128 systolic 98.6°F 37°C

Early adulthood (19 to 40 years)  60–100 12–20 120/80 98.6°F 37°C

Middle adulthood (41 to 60 years)  60–100 12–20 120/80 98.6°F 37°C

Late adulthood (61 years and older) * * * 98.6°F 37°C

*Depends on the individual’s physical health status.

 Human Life Span Development 211

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

Psychosocial CONTENT REVIEW

Development ➤➤ Depression and suicide
are more common during
Family adolescence than in any
Adolescence can be a time other age group.
of serious family conflicts
as the adolescent strives
for autonomy and parents strive for continued control.
The many biological changes that occur at this stage cause
inner conflict in both adolescents and their parents. Pri-
vacy becomes extremely important at this stage of life and,
because of modesty, the adolescent prefers that parents not
be present during physical examinations. It also is likely
that when a patient history is being taken, questions asked
in the presence of parents or guardians may not be
answered honestly.
Children experience an increase in idealism during
adolescence. They believe that adults should be able to live
up to their expectations, which of course they cannot
always do, which leads to disappointment.

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

Early Adulthood Middle Adulthood

Between the ages of 19 and 40 years, heart rate averages Between the ages of 41 and 60 years, average vital signs are
70 beats per minute, respiratory rate averages between 12 as follows: heart rate, 70 beats per minute; respiratory rate
and 20 breaths per minute, blood pressure averages between 12 and 20 breaths per minute; blood pressure
120/80 mmHg, and body temperature averages 98.6°F averages 120/80 mmHg; and body temperature averages
(37°C). This is the period of life during which adults 98.6°F (37°C).
develop lifelong habits and routines. The body still functions at a high level with varying
Peak physical condition occurs between the ages of degrees of degradation based on the individual (Figure 11-8).
19 and 26 years of age, when all body systems are at opti- There are usually some vision and hearing changes during
mal performance levels. At the end of this period, the this period. Cardiovascular health becomes a concern, with
body begins its slowing process. Spinal disks settle, lead- cardiac output decreasing and cholesterol levels increas-
ing to a decrease in height. Fatty tissue increases, leading ing. Cancer often strikes this age group, weight control
to weight gain. Muscle strength decreases, and reaction becomes more difficult, and, for women in the late 40s to
times level off and stabilize. Accidents are a leading cause early 50s, menopause commences.
of death in this age group. Adults in this age group are more concerned with the
The highest levels of job stress occur at this point in “social clock” and become more task oriented as they see
life, the time in which the young adult strives to find his the time for accomplishing their lifetime goals recede.
place in the world. Love develops, both romantic and Still, they tend to approach problems more as challenges
affectionate. Childbirth is most common in this age than as threats. This is also the time of life for “empty-nest
group, with new families syndrome,” or the time after the last offspring has left
Content Review providing new challenges home. Some women feel depression or a sense of loss and
➤➤ Peak physical condition is and stress (Figure 11-7). In purposelessness at this time, feelings that are made worse
reached in early adult- spite of all this, this period by aging and menopause. Sometimes a father also becomes
hood; accidents rather is not associated with depressed, but the syndrome seems to affect mothers to a
than disease are a leading ­p sychological problems greater extent. Many parents, however, view the period
cause of death. related to ­well-being. after children have left home as a time of increased free-
dom and opportunity for self-fulfillment. Unfortunately,
adults in this age group
often find themselves
Content Review
b urdened by financial
­
commitments for elderly ➤➤ Cardiovascular health be-
parents, as well as for comes a concern during
middle adulthood.
young adult children.

Figure 11-8  People in middle adulthood still function at a

Figure 11-7  Peak physical conditions occur in early adulthood. high level.
 Human Life Span Development 219

Late Adulthood The myocardium is less

able to respond to exercise,
Content Review
Maximum life span is the theoretical, species-specific, lon- ➤➤ In late adulthood, heart
and the SA node and other
rate, respiratory rate, and
gest duration of life, excluding premature or “unnatural” cells responsible for pro-
blood pressure depend
death. For human beings, maximum life span is approxi- ducing heartbeats become
on the individual’s physi-
mately 120 years. Life expectancy, which is based on the infiltrated with fibrous cal health.
year of birth, is defined as the average number of addi- connective tissue and fat.
tional years of life expected for a member of a population. Pacemaker cells diminish,
Human beings almost always die of disease or accident resulting in arrhythmia. Because of prolonged contraction
before they reach their biological limit. time, decreased response to various medications that
would ordinarily stimulate the heart, and increased resis-
Physiologic Development tance to electrical stimulation, the heart also becomes less
able to contract. Tachycardia (abnormally rapid heart
Vital Signs action) is not well tolerated.
At 61 years of age and older, vital signs—heart rate, respi- Functional blood volume decreases in late adulthood.
ratory rate, and blood pressure—depend on the individu- Decreases also can be expected in platelet count and the
al’s physical health status. Body temperature still averages number of red blood cells (RBCs), which can lead to poor
98.6°F (37°C). iron levels.

Cardiovascular System Respiratory System

During late adulthood, the cardiovascular system changes The trachea and large airways increase in diameter in late
in ways that affect its overall function. The walls of the blood adulthood, and enlargement of the end units of the airway
vessels thicken, causing increased peripheral vascular resis- results in a decreased surface area of the lungs. Decreased
tance and reduced blood flow to organs. There is decreased elasticity of the lungs leads to an increase in lung volume
baroreceptor sensitivity and, by 80 years of age, there is and to a reduction in surface area. The decreased elasticity
approximately a 50 percent decrease in vessel elasticity. also causes the chest to expand and the diaphragm to
In addition, the heart tends to show disease in the descend. The ends of the ribs calcify to the breastbone,
heart muscle, heart valves, and coronary arteries. Increased producing stiffening of the chest wall, which increases the
workload causes cardiomegaly (enlargement), mitral and workload of the respiratory muscles.
aortic valve changes, and decreased myocardial elasticity. These changes lead to an increased likelihood for older
adults to develop lung disease and progressive declines in
Patho Pearls lung function. Metabolic changes also may lead to
decreased lung function, and because of lifelong exposure
Life Span and Disease.  The life span of individuals in most to pollutants, diffusion through alveoli is diminished.
countries in the industrialized world continues to increase.
Coughing also becomes ineffective because of a weakened
This is due to many factors, which include better health care,
chest wall and bone structure. Of all the factors that influ-
widespread availability of vaccinations, safer agricultural and
ence lung function, smoking continues to produce the
manufacturing equipment, safer automobiles, the absence of
major wars, and many others. With an extended life span, we
greatest amount of disability.
are starting to commonly see diseases that were once uncom-
mon. For example, only in the past 20 to 30 years have we Endocrine System
started to see an increase in cases of Alzheimer’s disease. But is During this stage of life, there is a decrease in glucose
the incidence of Alzheimer’s disease now more common, or is metabolism and insulin production. The thyroid shows
it just that people are now living long enough for the disease to some diminished triiodothyronine (T3) production, corti-
manifest itself? Although it will take structured research to sol (from the adrenal cortex) is diminished by 25 percent,
determine this for sure, the latter part of the statement is surely the pituitary gland is 20 percent less effective, and repro-
true. Typically, approximately 10 percent of people age 65 show ductive organs atrophy in women.
signs of the disease, whereas 50 percent of persons age 85 have
symptoms of Alzheimer’s. The proportion of persons with
Alzheimer’s begins to decrease after age 85 because of the
Gastrointestinal System
increased mortality caused by the disease, and relatively few
One way the gastrointestinal system is affected at this stage
people over the age of 100 have the disease. Thus, the increased of life is by way of tooth loss. Age-related dental changes
incidence of Alzheimer’s disease may simply be due to the fact do not necessarily lead to loss of teeth. Usually tooth loss is
that people are living longer. caused by cavities or periodontal disease, both of which
220  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

work than younger workers are. Another problem older

adults face at this stage of life is a feeling of declining
well-being. It is not until adults reach the age of 40 that ill
health—as opposed to accidents, homicide, and sui-
cide—becomes the major cause of death. Arteriosclerotic
heart disease is the major killer after the age of 40 in all
age, sex, and racial groups.

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.

You Make the Call

You are dispatched to respond to a patient who is complaining of abdominal pain. When you
arrive at the scene, you are met at the door by a middle-aged man who tells you that the patient is
his daughter. She is upstairs in her bedroom, and her mother is with her. You climb the stairs, fol-
lowed closely by the father. When you enter the bedroom, you find a 16-year-old female lying on
the bed. Her mother is sitting beside her, holding a damp cloth to her forehead. A younger sister is
hovering around, trying to help.
The mother tells you that the patient woke about an hour ago, crying that her stomach hurt.
The pain has gotten progressively worse over the last hour, and the patient has been complaining
of nausea as well.
You begin your assessment of the patient, but she will not allow you to examine her abdomen.
When you attempt to ask questions about what led up to this pain, the date of her last menstrual
period, and whether or not she could possibly be pregnant, she refuses to answer you, shifting her
eyes toward her parents and sister, who are still in the room. Her mother tells her to please answer
your questions, but the patient just begins to cry.
1. Do you believe that this is normal behavior for a patient of this age and in this particular situ-
ation?
2. What is a likely reason for this behavior?
3. What might you do to make this patient more cooperative?
See Suggested Responses to “You Make the Call” at the end of this book.

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

chemotactic factors, p. 329 disease, p. 229 germ layers, p. 284

chemotaxis, p. 329 dissociate, p. 264 glucose, p. 240
chromatin, p. 272 dissociation reaction, p. 249 glycogen, p. 241
chromosomes, p. 272 dynamic steady state, p. 342 glycogenolysis, p. 241
chronic, p. 232 dysplasia, p. 283 glycolysis, p. 276
cilia, p. 276 dysplastic, p. 292 Golgi apparatus, p. 273
cisternae, p. 273 ectoderm, p. 285 granulation, p. 335
citric acid cycle, p. 277 edema, p. 267 granulocytes, p. 332
clinical presentation, p. 232 electrolyte, p. 264 granuloma, p. 334
clonal diversity, p. 321 electron, p. 235 half-life, p. 236
clonal selection, p. 321 electron shells, p. 236 haptens, p. 319
coagulation system, p. 331 electron transport chain, p. 277 hematocrit, p. 269
coenzymes, p. 243 element, p. 235 hemoglobin, p. 268
cofactors, p. 243 endocrine secretions, p. 287 histamine, p. 328
collagen, p. 289 endocytosis, p. 260 histology, p. 284
colloid, p. 270 endoderm, p. 285 histopathology, p. 284
compensated shock, p. 306 endoplasmic reticulum, p. 272 HIV (human immunodeficiency
complement system, p. 330 endotoxins, p. 315 virus), p. 340
complications, p. 232 enzymes, p. 243 HLA antigens, p. 320
compound, p. 239 enzyme–substrate complex, p. 243 homeostasis, p. 229
concentration, p. 249 eosinophils, p. 333 humoral immunity, p. 317
concentration gradient, p. 257 epithelial tissue, p. 286 hydrogen bond, p. 239
congenital metabolic diseases, p. 243 epithelialization, p. 335 hydrophilic, p. 259
connective tissue, p. 286 epithelium, p. 286 hydrophobic, p. 259
contraction, p. 335 erythrocytes, p. 268 hydrostatic pressure, p. 267
cortisol, p. 344 etiology, p. 231 hypercapnia, p. 252
covalent bond, p. 237 eukaryotic cells, p. 254 hyperplasia, p. 280
cristae, p. 275 exocrine secretions, p. 287 hypersensitivity, p. 336
crystalloid, p. 270 exocytosis, p. 260 hypertonic, p. 258
cytokines, p. 325 exotoxins, p. 315 hypertrophy, p. 280
cytoplasm, p. 255 extracellular fluid (ECF), p. 261 hyperventilation, p. 253
cytoskeleton, p. 275 exudate, p. 332 hyperventilation syndrome, p. 253
cytotoxic, p. 282 facilitated diffusion, p. 258 hypocapnia, p. 253
debridement, p. 335 fermentation, p. 278 hypoperfusion, p. 299
decompensated shock, p. 306 fibroblasts, p. 289 hypotonic, p. 258
degranulation, p. 328 Fick principle, p. 302 hypoventilation, p. 252
dehydration, p. 262 filtration, p. 267 hypovolemic shock, p. 308
delayed hypersensitivity reaction, flagella, p. 276 hypoxemia, p. 313
p. 336 free radicals, p. 243 hypoxia, p. 282
denaturation, p. 243 free water, p. 257 iatrogenic disease, p. 233
deoxyribonucleic acid (DNA), p. 244 fructose, p. 240 idiopathic, p. 231
diagnosis, p. 232 galactose, p. 240 immediate hypersensitivity
diapedesis, p. 332 general adaptation syndrome reaction, p. 336
disaccharides, p. 240 (GAS), p. 342 immune response, p. 317
 Pathophysiology 227

immunity, p. 317 metaplasia, p. 281 osmosis, p. 257

immunogens, p. 318 metastasis, p. 292 osmotic diuresis, p. 308
immunoglobulins, p. 317 minute volume (Vmin), p. 253 osmotic gradient, p. 257
inflammation, p. 326 mitochondria, p. 275 osmotic pressure, p. 258
inorganic chemicals, p. 239 molarity, p. 249 osteocytes, p. 290
insidious, p. 232 mole, p. 249 overhydration, p. 263
interstitial fluid, p. 261 molecule, p. 237 oxidation, p. 276
intracellular fluid (ICF), p. 261 monoclonal antibody, p. 323 PaCO2, p. 251
intravascular fluid, p. 261 monocytes, p. 333 pathogenesis, p. 231
ion, p. 238 monokine, p. 325 pathologist, p. 229
ion channels, p. 259 monomer, p. 240 pathology, p. 229
ionic bond, p. 238 monosaccharides, p. 240 pathophysiology, p. 229
irreversible shock, p. 306 multiple organ dysfunction peptide, p. 242
ischemia, p. 282 syndrome (MODS), p. 312 peptide bond, p. 242
isoimmunity, p. 336 muscle tissue, p. 286 perfusion, p. 299
isotonic, p. 257 natriuretic peptides (NPs), p. 301 peroxisome, p. 274
isotopes, p. 235 natural immunity, p. 317 peripheral vascular resistance, p. 300
kinin system, p. 331 necrosis, p. 281 pH scale, p. 249
lactose, p. 240 negative feedback loop, p. 300 phagocytes, p. 333
leukocytes, p. 268 neoplasia, p. 233 phagocytosis, p. 260
leukotrienes, p. 330 neoplasm, p. 233 phospholipids, p. 246
lipid bilayer, p. 255 nerve tissue, p. 286 physiologic stress, p. 342
lipids, p. 245 net filtration, p. 267 pinocytosis, p. 260
logarithm, p. 249 neurogenic shock, p. 309 plasma, p. 268
lymphocyte, p. 317 neuroglia, p. 291 plasma membrane, p. 255
neuron, p. 291 plasma protein systems, p. 330
lymphokine, p. 325
neutron, p. 235 platelets, p. 333
lysosome, p. 274
neutrophils, p. 333 pOH scale, p. 250
macrophages, p. 289
nonmetallic elements, p. 238 polar bond, p. 238
major histocompatibility complex
(MHC), p. 320 nuclear envelope, p. 272 polar molecule, p. 238
malignant, p. 233 nuclear pores, p. 272 polymer, p. 240
maltose, p. 240 nucleolus, p. 272 polypeptide, p. 242
margination, p. 332 nucleoplasm, p. 272 polysaccharides, p. 240
mass number, p. 235 nucleotides, p. 244 predisposing factors, p. 230
mast cells, p. 289 nucleus, p. 254 preload, p. 300
maturation, p. 335 oncotic force, p. 267 primary immune response, p. 317
memory cells, p. 321 orbital, p. 236 primary intention, p. 335
mesoderm, p. 285 organ, p. 295 prognosis, p. 232
metabolic acid–base disorders, organ system, p. 295 prokaryotic cells, p. 254
p. 252 organelles, p. 254 prostaglandins, p. 330
metabolic acidosis, p. 253 organic chemicals, p. 239 proteins, p. 241
metabolic alkalosis, p. 254 organism, p. 295 proton, p. 235
metabolism, p. 232 osmolality, p. 258 psychoneuroimmunological
metallic elements, p. 238 osmolarity, p. 258 regulation, p. 343
228  Chapter 12

pus, p. 334 semipermeable, p. 255 sucrose, p. 240

radioactive decay, p. 236 septic shock, p. 311 sugars, p. 240
radioactive isotopes, p. 236 septicemia, p. 315 symptom, p. 232
reduction, p. 276 sequelae, p. 232 syndrome, p. 232
regeneration, p. 334 serotonin, p. 328 T cell receptor (TCR), p. 325
repair, p. 334 shock, p. 299 T lymphocytes, p. 318
resolution, p. 334 sign, p. 232 teratogens, p. 233
respiratory acid–base simple diffusion, p. 256 thrombocytes, p. 268
disorders, p. 252 smooth endoplasmic reticulum tissue, p. 284
respiratory acidosis, p. 252 (SER), p. 272 tonicity, p. 270
respiratory alkalosis, p. 253 sodium–potassium pump, p. 259 total body water (TBW), p. 261
Rh blood group, p. 320 solute, p. 257 trauma, p. 233
Rh factor, p. 320 solvent, p. 262 triglycerides, p. 245
ribonucleic acid (RNA), p. 244 starches, p. 240 tumor, p. 291
ribosome, p. 272 stem cells, p. 291 turgor, p. 263
rough endoplasmic reticulum steroids, p. 247 turnover, p. 342
(RER), p. 272 stress, p. 342 unsaturated fatty acids, p. 246
saturated fatty acids, p. 245 stress response, p. 343 vacuole, p. 274
secondary immune response, p. 317 stressor, p. 342 valence electrons, p. 236
secondary intention, p. 335 stroke volume, p. 300 valence shell, p. 236
secretory immune system, p. 323 substrate, p. 243 virus, p. 315

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.

Introduction In this chapter we

examine the disease pro-
CONTENT REVIEW
The human body normally maintains its internal environ- ➤➤ Hierarchy of the Body
cesses that arise from the
• Cells
ment in a steady state of balance that is termed homeostasis. human body’s cells, tissues,
T
A significant disruption in homeostasis often leads to dis- organs, organ systems, and,
• Tissues
ease. Disease is an abnormal structural or functional ultimately, the organism T
change within the body. The study of disease is called (body) itself. • Organs
pathophysiology and can be defined as the functional Cells, the smallest unit T
changes that occur within living cells and tissues that are of life, are made up of • Organ systems
associated with, or result from, disease or injury. Pathology chemical molecules (which T
is the medical science that deals with all aspects of disease. are made up of individual • Organism
There is an emphasis on the essential nature, causes, and atoms). A group of similar
development of abnormal conditions, as well as with the cells that performs a common function is known as a tissue.
structural and functional changes that result from disease A group of tissues working together to perform a similar
processes. A physician who specializes in pathology is function is called an organ. A group of organs working
called a pathologist. together to perform a common or similar function is referred
Before embarking on the study of pathophysiology, it is to as an organ system. Finally, a group of organ systems func-
essential that you first master the related normal anatomy tioning together is called an organism. A human being is an
and physiology. Only through understanding how the organism. Humans have 11 different organ systems.
body is normally structured and works can one understand The organism, or individual, is the unit of life that is
abnormal processes. To be an effective health care profes- capable of surviving and reproducing in the environment.
sional, the paramedic must understand the basic principles Humans, like many other “higher” animals, are social crea-
of pathophysiology so you can properly assess and treat the tures. That is, we tend to associate with others of our kind.
disease and injury processes that affect humankind. Humans are unique in that we also use other organisms for
This chapter is divided into six parts: work and companionship.
Part 1: Disease Life can also be organized and stratified beyond the
individual. For example, all the organisms of the same spe-
Part 2: Disease at the Chemical Level
cies residing in a distinct
Part 3: Disease at the Cellular Level geographic area (e.g., con- CONTENT REVIEW
Part 4: Disease at the Tissue Level tinent, city) are called a
➤➤ Levels of Life beyond the
Part 5: Disease at the Organ Level population. A community is
Individual
the sum total of all living • Individual organism
Part 6: The Body’s Defenses against Disease and Injury
organisms occupying a T
defined geographic area. A • Population
community and its physical
Hierarchical Structure
T
environment are referred to • Community

of the Body as an ecosystem. An ecosys- T

tem can vary in size, based • Ecosystem
We start with the concept that all living things that share on the construct being stud- T
this big blue-and-green planet known as Earth interact ied, but is self-contained. • Biome
T
with each other at some point and on some level. Scientists Any number of ecosystems
• Biosphere
have organized Earth’s biological life into levels. may exist within a biome. A
230  Chapter 12

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.

PART 1: Disease For example, people of African and Mediterranean

descent tend to develop sickle cell disease. People of
All cells and tissues are vulnerable to the effects of disease Native American and Mexican descent tend to develop
or injury, which can adversely affect the biology of the cells diabetes mellitus. Ashkenazi Jews (Jews of central
or tissues in question. Predisposing factors may lead to European descent) are vulnerable to many diseases,
disease. These factors tend to increase the body’s vulnera- such as cystic fibrosis and Tay-Sachs disease, among
bility to a specific disease. For example, it has been demon- others. This is thought to be due to significant inter-
strated that prolonged exposure to cigarette smoke changes marriage within the group, resulting in a small gene
the cellular structure of the respiratory tract. Sometimes pool. A small gene pool from intermarriage can result
these changes can result in abnormal cell function and can- in expression of disease-causing genes that would
cer. Thus, cigarette smoking is a predisposing factor to the likely not be expressed if the gene pool were more var-
development of lung cancer. ied. In fact, genetic testing has shown that 40 percent
of the current Ashkenazi population is descended from
just four women.1
Predisposing • Lifestyle. Another major factor in the development of
Factors to Disease disease is lifestyle. This is particularly evident in today’s
society. A century ago, people ate primarily unprocessed
Factors that lead to the development of disease include foods. Today, foods are processed, removing many of
age, gender, genetics, lifestyle, and environment. the healthful ingredients that protected our ancestors
• Age. A factor that leads to the development of disease from some of the diseases that are common today. Heart
is age. Humans at both ends of the age spectrum are disease was much less common in the nineteenth cen-
especially vulnerable to disease. Infants, for example, tury when compared to the latter half of the twentieth
are vulnerable because their immune systems are and the first part of the twenty-first century.
immature and they have not developed the necessary • In addition, the modern population obtains consider-
defenses. We augment these defenses by providing ably less exercise than earlier generations because of
timely immunizations to enhance the infant’s immune the availability of cars and other forms of mechanized
system. As we age, there is a decline in immune func- transportation and the fact that many farm and indus-
tion that places us at increased risk for disease in our try jobs that demanded intense physical labor have
later years. This is due to a general decline in homeo- been replaced by more sedentary occupations. When
static function. you combine a lack of exercise with a diet that is
• Gender. Gender also plays a role in disease develop- devoid of quality calories (but rather is high in fats and
ment. For example, men tend to develop heart disease carbohydrates), you end up with obesity. Obesity is
at a younger age than women. Women are predisposed one of the biggest health problems in the United States
to certain diseases, such as osteoporosis, as they age. and is quickly becoming as great a problem in other
Often, these differences developed countries, such as the United Kingdom,
CONTENT REVIEW in disease development Australia, and Canada.
➤➤ Predisposing Factors to are due to the effects of • Environment. Finally, our environment can predispose
Disease the sex hormones. us to disease. Native Americans have long believed
• Age • Genetics. A major factor that an individual’s health and the health of the com-
• Gender in the development of munity are directly related to the environment. We
• Genetics disease is genetics. Only now know that numerous environmental factors are
• Lifestyle
in recent years has the associated with the development of disease. For exam-
• Environment
human genetic code ple, exposure to asbestos has been directly linked to
 Pathophysiology 231

the development of an uncommon lung cancer called

mesothelioma.2 Pollutants have been linked to the
development of significant birth defects (such as anen-
cephaly, lack of parts of the brain or skull, in babies
born to Mexican mothers in the lower Rio Grande river
valley in south Texas, presumably caused by chemicals
dumped into the river upstream.3 In Ukraine, the inci-
dence of cancers—specifically, thyroid cancer—has
increased dramatically following the nuclear disaster
in 1986 at Chernobyl.4 Cumulative exposure to toxic
substances also plays a role in disease development.

Any of these factors, or a combination of them, can

lead to the development of disease. The effects of these fac-
tors can sometimes be cumulative. For example, an older FIGURE 12-1  Obesity is one of many risk factors for cardiovascular
person who smokes and also has a family history of lung disease.

cancer may be at a risk of developing the disease that is

significantly increased over a person who has just one of blood pressure. Abandonment of cigarette use further sig-
those risk factors—age, or smoking, or family history—but nificantly decreases his risks for early development of
not two or three of them. heart disease. Together, these can modify or attenuate the
development of cardiovascular disease, even though he is
genetically predisposed to it. As he ages, he should stay
Risk Analysis abreast of practices that continue to minimize his risk for
It is important to point out that some predisposing factors developing heart disease. For example, when he turns 50,
can be modified, whereas others cannot. Although we can- he may be advised to begin taking an aspirin a day.
not control our genetics, gender, or age, we can certainly Risk analysis can now be used to look at a person’s
control our lifestyle and, to a lesser degree, our environ- whole life. There are programs that can actually predict
ment. Minimizing some of these predisposing factors can one’s life expectancy. These take into consideration health
also slow the effects of age. In the near future, genetic engi- factors such as have been presented here, but they also take
neering may allow us to manipulate genes to prevent their into consideration environmental and lifestyle practices.
expression and subsequent disease development. High-risk behaviors such as scuba diving, skydiving, pilot-
We also know that there is a kind of cross-pollination ing single-engine aircraft, and rock climbing can statisti-
of pathophysiologic factors, where risk factors figure in cally decrease projected life expectancy. Other more
more than one kind of disease, and diseases become risk common behavioral practices that are risk factors include
factors for other diseases. For example, various studies driving long distances, not wearing seatbelts, carrying a
have identified as risk factors for cardiovascular disease handgun, practicing unsafe sex, illicit drug or significant
such things as smoking, elevated blood pressure, choles- alcohol use, and so on. Minimizing any of these risks can
terol levels (“good” cholesterol versus “bad” choles- increase life expectancy and, in some instances, also
terol), diet, family history, age, gender, weight, level of enhance the quality of life.
exercise, obesity, diabetes, kidney disease, and lung dis-
ease (Figure 12-1).
Using data from large-population studies, one can
actually predict, with some degree of accuracy, whether a Disease
given person will develop any particular disease and how Disease is an abnormal structural or functional change
rapidly he will develop it. These data can, therefore, be within the body. There is normally a defined sequence of
used to modify the risk factors that can be modified, thus events that leads to development of a disease. This is
holding off disease development. For example, a 34-year- referred to as the pathogenesis of the disease. As already
old male paramedic is 30 pounds overweight, gets little noted, a number of factors can be identified that predis-
exercise, routinely eats fast food, smokes half a pack of pose a person to certain diseases. In some instances, pre-
cigarettes a day, has a moderate family history of heart dis- disposing factors cannot be identified. In that case, we say
ease, and has mild hypertension. Although he cannot mod- the disease is idiopathic.
ify his gender or genetics, he can increase his exercise and The study of disease causes is termed etiology. Etiol-
decrease his fast food intake. This will allow him to lose ogy comprises the occurrences, reasons, and variables of a
weight and improve the ratio of bad to good cholesterol. disease. Etiology is often defined as consisting of causality,
Concurrently, the weight loss can lead to reduction in his contribution, and correlation. Again using the example of
232  Chapter 12

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

referred to as neoplasia. The result is a tumor, or neo-

plasm (Figure 12-3). A neoplasm can be benign (not
cancerous, not able to spread to other tissues) or malig-
nant (cancerous, able to spread), depending on the
changes present in the cell line. Often, the body’s
immune system is successful in removing cells that
begin abnormal growth. However, when the cell
growth is rapid, or if the cell is particularly resistant to
removal by the body’s defenses, the disease progresses
and can eventually kill the patient. Fibroid tumors in
the uterus, more accurately called uterine leiomyomas,
are an example of a benign neoplastic process. Breast
cancer (which usually arises from the breast ducts) is
an example of a malignant neoplastic process.
FIGURE 12-2  Down syndrome is a congenital disease. • Trauma. External physical forces can mechanically
(© Daniel Limmer) change or disrupt the structure of the body and, as a
result, affect body function. These external forces are
referred to as trauma. An example might be blunt
levels of thyroid hormones that can markedly increase
trauma to a kidney that fractures the kidney into mul-
the basal metabolic rate, causing significant signs and
tiple portions. This can cause the kidney to totally fail
symptoms.
or to significantly decrease its ability to function.
• Nutritional. Nutritional diseases primarily result from
• Physical agents. Myriad physical agents can adversely
a deficiency in one or all of the major nutritional
affect body structure and function. These include
sources (carbohydrates, proteins, fats). Vitamin defi-
chemicals, poisons, ionizing radiation, extremes in
ciencies can also lead to nutritional diseases, because
temperature, changes in atmospheric pressure, and
vitamins are required for normal metabolic processes.
electrical shock. Examples of diseases caused by phys-
Examples of nutritional diseases are malnutrition and
ical agents include transitional-cell bladder cancer,
diseases that result from vitamin deficiency, such as
caused by exposure to chemicals such as ink, and
scurvy and rickets.
ultraviolet keratitis (welder’s flash) that results from
• Genetic. Genetic diseases are those that are coded for looking at a welding arc that is producing ultraviolet
in a person’s genetic material and thus are passed from radiation.
parent to child. Examples of genetic diseases are hemo-
• Iatrogenic. Medical treatments for a disease can
philia, Huntington’s disease, and color blindness.
sometimes result in the development of other dis-
• Congenital. Certain diseases can result from problems eases or problems. A disease that occurs in this way is
that occur during fetal development. Most fetal devel- referred to as an iatrogenic disease. For example, a
opment occurs during the first trimester of life. It is subclavian central intravenous line is placed into a
during this period that the fetus is most susceptible to patient to administer intravenous nutrition following
external factors that can adversely affect development a severe burn. During the line insertion, the dome of
(teratogens). However, many cases of congenital dis- the lung is inadvertently punctured, resulting in a
ease never have an identifiable cause. Examples of pneumothorax. This would then be termed an iatro-
congenital diseases are cleft lip and palate, congenital genic pneumothorax.
heart disease, and Down syndrome (Figure 12-2). Some procedures or treatments are so complicated
• Neoplastic. On occasion, certain cells will begin abnor- or harsh that iatrogenic effects may be expected. The
mal or uncontrolled cell growth. This process is chances of developing iatrogenic complications are

Neoplasia

FIGURE 12-3  How cancers grow. Factors

such as genetic predisposition, smoking,
pollution, and exposure to radiation or
the sun’s ultraviolet rays can trigger
abnormal cell growth. Abnormal or uncontrolled cell growth results in a tumor, or neoplasm.
234  Chapter 12

weighed against the perceived benefit of the treatment.

An example is vaginal candidiasis following antibiotic
PART 2: Disease
therapy. The vagina normally has microorganisms
present on its surface. These include both bacteria and
at the Chemical Level
fungi. The bacteria usually keep the fungi concentra- To fully understand and appreciate anatomy, physiology,
tion low. However, if the patient is placed on potent and pathophysiology, as a paramedic you must under-
antibiotics, the antibiotics can kill the normal vaginal stand some basic chemistry and biochemistry as discussed
bacteria (flora), which allows the fungus to proliferate, in this chapter. Virtually every medical condition involves
resulting in candidiasis. The disease is iatrogenic in or affects biochemical mechanisms.
that it resulted directly from medical treatment. When did human life begin? This question has been a
subject of discussion for thousands of years. In the sixth cen-
Patho Pearls tury B.C.E., pre-Socratic Greek philosophers spent a great
The practice of medicine has become so complex that many
deal of time discussing the possible origins of life. Although
patients actually die from the very treatments that are sup- the true answer may never be known, the prevailing theory
posed to help them. It has been estimated that almost 200,000 is that the universe was created almost 15 million years ago
patients a year suffer in-hospital deaths that are possibly pre- in a phenomenon referred to as the “Big Bang.” The Big
ventable. Little is known about preventable out-of-hospital Bang theory (Figure 12-4) was first put forth in 1927 by Bel-
deaths. Further, a recent medical study found that medical gian priest Georges Lemaître. He proposed that the universe
errors caused up to 98,000 deaths annually and should be con- began with the explosion of a primeval atom. Years later, the
sidered a national epidemic. Many of us forget that the primary noted astronomer Edwin Hubble found experimental evi-
dictum of medicine is primum non nocere (first, do no harm). We dence to help validate Lemaître’s theory. He found that dis-
owe it to our patients, present and future, to ensure that our
tant galaxies in every direction were moving away from us
practices do not violate this dictum and bring them harm when
at speeds proportional to their distance.
they are seeking our help.
The theory of a Big Bang explained why distant galax-
• Idiopathic. In many instances, as noted earlier, the ies were traveling away from the earth at great speeds. The
specific cause of a disease is unknown. In this case, the theory also predicted the existence of cosmic background
disease is classified as idiopathic. Sometimes, a cause radiation (the energy left over from the explosion itself).
may be identified later. However, in many cases a spe- The Big Bang theory received its strongest confirmation
cific cause is never found. when, in fact, cosmic radiation was discovered in 1964 by

The Big Bang Theory

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.

Electrons spin in shells

around the nucleus.

Electron shell

Proton (1)
Electron (2)
2

1 2p 8p
1 8n
2n

2 Nucleus

Neutron (no charge)

Helium (He) Helium (He) Oxygen (O)

(a) A three-dimensional representation of an atom (b) A two-dimensional representation (c) A two-dimensional representation of an
of helium, showing protons and neutrons in the of an atom of helium. atom of oxygen.
nucleus and electrons occupying a region around
the nucleus.

FIGURE 12-5  Atoms can be represented in various ways.

(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.)
236  Chapter 12

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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.)  
 

Some combinations of neutrons and protons make the  

 
nucleus that contains them inherently unstable. These
atoms are called radioactive isotopes because their nuclei
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break down and emit radiation, or alpha, beta, and gamma r#Ot[GCTU
rays, until the atom regains stability. This process is referred r#OtJQWTU
to as radioactive decay. The initial isotope is referred to as r#Ot[GCTU
the parent and the resulting isotope is the daughter. The FIGURE 12-7  The half-life of a radioactive isotope is the time it takes for
rate of radioactive decay is constant and specific for a given half the atoms of that substance to disintegrate into another form. The
isotope. The rate of decay is usually measured in a unit half-life of any radioactive isotope is unique to that isotope, so that a
called a half-life. A half-life is the time it takes for the par- substance can be identified by discovering its half-life. (a) As half-lives
ent isotope to decrease by one-half (Figure 12-7). elapse, smaller and smaller fractions of the original substance remain.
(b) Half-lives can range from fractions of a second to billions of years. For
Electrons rotate around the nucleus of the atom in a spe-
example, the element americium has many isotopes with vastly different
cific region referred to as an orbital. Each orbital has a specific half-lives, three of which—americium 241, 242, and 243—are listed here.
shape and can hold two or more electrons. Orbitals occupy

levels that are defined based on their distance from the

Clinical Note nucleus. These levels are referred to as electron shells and are
There are numerous medical uses of radiation. These include numbered starting with the closest shell to the nucleus. Elec-
the diagnosis of disease, radiation therapy, and many aspects trons first fill the electron shells closest to the nucleus and
of research. Many of the diagnostic modalities that use radia- then progressively fill the more distant shells. The filling order
tion range from fairly routine X-rays to complex computed of the more distant shells is complicated. The first shell can
tomography (CT) scans and the injections of radioactive hold two electrons, and the second shell can hold eight elec-
material for nuclear medicine imaging. In general, radiation trons. The number of electrons a shell can hold increases with
therapy involves delivering a large dose of radiation to a
each level (2, 8, 18, 32, 50) (Figure 12-8). The outermost shell of
small area of the body. Therapy is directed primarily to the
an atom is referred to as the valence shell. The electrons
killing of tumor cells as part of the treatment of cancer. Radi-
found in that shell are referred to as valence electrons. An
ation is also used in research to find new ways to diagnose
and treat disease. atom is most stable when the valence shell is full. The only
elements that have a full valence shell are the six that are

The shell closest to the

nucleus can hold up to
2 electrons.
FIGURE 12-8  Hydrogen, carbon,
and oxygen atoms. Each concentric
6p 8p The next shell out can circle around the nucleus represents
1p hold up to 8 electrons
6n 8n an electron shell.
(the shell shown here
has 6). Atoms with more (Goodenough, Judith and Betty A. McGuire,
than 10 electrons have Biology of Humans: Concepts, Applica-
additional shells.
tions, and Issues, 3rd Edition, © 2010.
Hydrogen atom Carbon atom Oxygen atom Reprinted by permission of Pearson Educa-
(atomic number 5 1) (atomic number 5 6) (atomic number 5 8) tion, Inc., Upper Saddle River, NJ.)
 Pathophysiology 237

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

Carbon atom 4 Hydrogen atoms Methane (CH4)

(a) The molecule methane (CH4) is formed by the sharing of electrons between one carbon atom and four hydrogen
atoms. Because in each case one pair of electrons is shared, the bonds formed are single covalent bonds.

Double Double
covalent covalent
bond bond
O

C 1 O C O 5 O C O
Double covalent bonds

Carbon atom 2 Oxygen atoms Carbon dioxide (CO2)

(b) The oxygen atoms in a molecule of carbon dioxide (CO2) form double covalent bonds with the carbon atom.
In double bonds, two pairs of electrons are shared.

Triple covalent bond

N 1 N N N 5 N N
Triple covalent bonds

Nitrogen atom Nitrogen atom Nitrogen gas (N2)

(c) The nitrogen atoms in nitrogen gas (N2) form a triple covalent bond in which three pairs of electrons are shared.

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

An atom of sodium Having given up an Having received an

transfers the electron electron, sodium becomes electron, chlorine becomes
in its outer shell to an a positively charged ion. a negatively charged ion.
atom of chlorine.
Sodium ion Chloride ion
(1) (2)

Na 1 Cl Na1 Cl2

Sodium atom 1 Chlorine atom Sodium chloride

(NaCl)

The oppositely charged

sodium and chloride ions
are attracted to one
another, forming sodium
chloride.

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

Cellulose  Like starch, cellulose is a polysaccharide

polymer with glucose as its monomer. However, cellulose Clinical Note
differs significantly from starch in its chemical proper- It is common practice in EMS to administer glucagon to
ties. Cellulose is the most abundant organic molecule in patients with hypoglycemia. Glucagon elevates the blood
the world and the major structural material of plants. For glucose indirectly by stimulating glycogenolysis. Although
example, wood is largely cellulose, and cotton and paper this is usually effective, many patients, such as chronic alco-
are almost pure cellulose. Humans do not have the enzyme holics, have limited stores of glycogen because of their liver
necessary to digest cellulose; thus, it passes through our disease and associated malnutrition; thus, glucagon may be
ineffective in this population. Decreased glycogen stores are
gastrointestinal systems undigested. However, the fiber
also associated with increased physical activity, as is seen
that cellulose provides is important in creating bulk and
with endurance events (e.g., marathon races, football
moving fecal matter through the large intestine.
matches). Decreased glycogen stores are also often present in
patients with malnutrition. In neonates it is important to
Glycogen  In terms of human pathophysiology, glyco-
remember that liver glycogen stores become rapidly depleted
gen is certainly the most important polysaccharide. Glycogen
within hours of birth. When you suspect that your patient
(Figure 12-15) is a glucose polymer much like amylopectin
might have inadequate glycogen stores, administer glucose
except that the branches tend to be shorter and less frequent. (orally or intravenously) to increase blood glucose levels
Glycogen is stored primarily in the liver and skeletal muscle. (Figure 12-16).
When needed, it is broken down to glucose in a process
called glycogenolysis. Glycogenolysis is controlled by the
hormones glucagon and epinephrine. In persons with liver
disease, such as chronic alcoholics, glycogen stores may be
scant, and thus administration of glucagon is often ineffec-
tive in elevating the blood glucose level in hypoglycemia.

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.

Table 12-1  Protein Functions

Protein Type Function
O
Antibodies and complement Defense (destruction of disease-
Glycogen granules protein causing agents)
O
Contractile and motor proteins Movement

O O Enzymes Catalyze chemical reactions

O Peptide hormones Signal and control the activities of cells

O
Receptor proteins Receive chemical signals from outside
of the cell and initiate cellular response
O O O O
Structural proteins Support cells and tissues; major factor
O O O in various body structures

Transport proteins Move substrates across cell

FIGURE 12-15  Glycogen is the storage polysaccharide in animals. It
membranes and throughout the body
is stored primarily in the liver and in skeletal muscle.
242  Chapter 12

Polypeptide chain Amino acids joined by peptide bonds

N-terminus C-terminus
H H O H H O H H O H H O H H O H H O H H O H H O Peptide-
+ – bonded
H N C C N C C N C C N C C N C C N C C N C C N C C O backbone

H H CH3 CH2 CH2 CH2 CH CH2 CH2

Amino OH C H 3C CH3 SH Carboxyl

group –O O group

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).

Table 12-2  Protein Structure

Level Description Stabilized by Example: Hemoglobin
Primary The sequence of amino Peptide bonds
acids in a polypeptide Gly Ser Asp Cys

Secondary Formation of alpha helices Hydrogen bonding between

and beta-pleated sheets in a groups along the peptide-
polypeptide bonded backbone; thus,
depends on primary structure One -helix

Tertiary Overall three-dimensional Bonds and other interactions

shape of a polypeptide between side chains or
(includes contribution from between side chains and the
secondary structures) peptide-bonded backbone; One of
thus, depends on primary hemoglobin’s
structure
subunits
Quaternary Shape produced Bonds and other interactions
by combinations of between side chains, and
polypeptides (thus, between peptide backbones
combinations of tertiary of different polypeptides; thus,
structures) depends on primary structure
Hemoglobin,
which consists
of four
polypeptide
subunits
 Pathophysiology 243

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.

denaturation. The classic example of this is the act of Substrate

cooking an egg. The egg white is primarily protein. When
heat is applied, the proteins in the egg white denature Products
and lose their shape. This causes the egg white to change
from a translucent substance to the white cooked egg.

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

(Source: Michal Heron)

significant benefit on aging from the dietary addition of anti-

oxidants (Figure 12-19). A T

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

Table 12-3  RNA and DNA Structural Differences

Phosphate
Characteristic RNA DNA
Ribose C
Sugar Ribose Deoxyribose

Bases Adenine, guanine, Adenine, guanine,

Phosphate OH cytosine, uracil cytosine, thymine

Number of One Two, twisted to form

Ribose strands a double helix
A

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

Bond broken Lipids

to release energy

Adenine
Phosphate Phosphate Phosphate

Ribose

Triphosphate Adenosine

ATP (adenosine triphosphate)

Triglycerides have three fatty acid chains

attached to a molecule of glycerol

Adenine
Phosphate Phosphate

Ribose

Diphosphate Adenosine

ADP (adenosine diphosphate)

Phospholipids have two fatty acid chains
1
attached to glycerol and phosphate

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.

Phospholipids  Another important lipid class is the

phospholipids. These are extremely important in biolog-
ical systems, as they form the membrane that surrounds
Figure 12-25  A triglyceride consists of a molecule of glycerol linked
the cells. Structurally, phospholipids are similar to tri- to three fatty acids.
glycerides in that they contain a glycerol base. Instead of (Freeman, Scott, Biological Science, 4th Edition, © 2011. Reprinted by permission of
three fatty acid chains, they contain two fatty acid chains Pearson Education, Inc., Upper Saddle River, NJ.)
 Pathophysiology 247

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

A phospholipid when the species went from a vegetarian to a carnivo-

rous diet.
Polar or
Polar head charged group Water
(hydrophilic)
Phosphate
Water has been called the “universal solvent.” It is abun-
dant in the body and plays a significant role in numerous
Glycerol
biological processes. In fact, the physical properties of
water are essential for life as we know it. As discussed ear-
lier, water is a polar molecule and has the tendency to cre-
ate hydrogen bonds, which causes water molecules to
adhere to each other (Figure 12-30). This gives water its liq-
uid property. However, hydrogen bonds are the weakest of
Nonpolar tail
(hydrophobic) the chemical bond types. Consequently, the hydrogen
Fatty acid

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.)

FIGURE 12-28  Two layers of phospholipids form a biological

Variable R membrane, with hydrophobic tails oriented to the inside of the
group membrane and hydrophilic heads oriented to the outside.
O
O P O2 (Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts,
Phosphate
O ­Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson
Education, Inc., ­Upper Saddle River, NJ.)
CH2 CH CH2
Glycerol
O O
C O C O
Polar
hydrophilic
CH2 CH2 head
CH2 CH2 Extracellular fluid
CH2 CH2
Hydrophilic
CH2 CH2
heads
CH2 CH2 Hydrophobic
Bilayer tails
CH2 CH2 Nonpolar
CH2 CH2 hydrophobic
Hydrophilic
tail
CH2 CH heads
CH2 CH
Intracellular fluid
CH2 CH 2 (cytoplasm) Extracellular fluid
CH2 CH 2

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

Cholesterol HO Estrogen O Testosterone

HO

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

concentration increases, buffers remove excess hydrogen

Table 12-4  The pH Scale and Hydrogen Ion Concentrations ions from the solution. Conversely, when the hydrogen ion
pH Example Hydrogen Ion Concentration concentration falls, buffers add hydrogen ions to the solu-
tion. The body has three major buffer systems:
Acidic 0 Hydrochloric acid 10-0 (1.0)
• Carbonic acid–bicarbonate buffer system. The car-
1 Stomach secretions 10-1 (0.1)
bonic acid–bicarbonate buffer system is the most
2 Lemon juice 10-2 (0.01) important buffer system in the extracellular fluid
3 Cola drinks 10-3 (0.001) (ECF), including the blood. It is also the most rapidly
acting of the three buffer systems.
4 White wine 10-4 (0.0001)
• Protein buffer system. The protein buffer system
5 Tomato juice 10-5 (0.00001) works by way of selective amino acid monomers
6 Coffee, urine, saliva 10-6 (0.000001)
accepting or releasing hydrogen ions. This system
plays a major role in pH regulation in both the ECF
Neutral 7 Distilled water 10-7 (0.0000001) and intracellular fluid (ICF) compartments. It interacts
Basic 8 Blood, semen 10-8
(0.00000001) significantly with the other buffer systems.
9 Bile 10-9 (0.000000001) • Phosphate buffer system. The phosphate buffer system
plays a role in buffering the pH of the ICF and the urine.

CARBONIC ACID–BICARBONATE BUFFER SYSTEM 

Pure water has a pH of 7.0 (1.0 * 10-7 M). Thus, a solution
The pH of the blood is primarily regulated by the carbonic
with a pH of 7.0 has an equal number of hydrogen ions and
acid–bicarbonate buffer system. The primary role of this
hydroxide ions. Substances with a pH of <7.0 are acidic,
system is to buffer changes in pH caused by organic acids
whereas substances with a pH >7.0 are basic. The normal
and fixed acids in the ECF. When carbon dioxide (CO2) is
pH of arterial blood is slightly basic, ranging from 7.35 to
added to water (H2O), it forms carbonic acid (H2CO3). Car-
7.45 (Table 12-4).
bonic acid, in turn, quickly dissociates into hydrogen ions
Just as there is a pH scale, there is also a pOH scale,
(H+) and bicarbonate ions (HCO-3 ). Carbonic acid is a vola-
although that scale is infrequently used in medicine. The
tile acid in that it will readily leave a solution and enter the
pOH scale represents the number of hydroxide ions pres-
atmosphere. In the lungs, carbonic acid breaks down into
ent in a solution. The pOH is the opposite of pH.
carbon dioxide and water. The carbon dioxide diffuses into
pH + pOH = 14 the alveoli and is expelled with ventilation. In the periph-
eral tissues, carbon dioxide, a waste product of metabolism,
The pOH of water is equal to the pH (7.0). When the pH
combines with water to form carbonic acid. Carbonic acid
goes up, the pOH comes down, and vice versa.
then dissociates to release hydrogen ions and bicarbonate
Buffer Systems ions. This can be represented by the following equation:
Free hydrogen ions are being constantly produced by the
CO2 + H2O 4 H2CO3 4 H + + HCO3-
body, primarily from glycolysis, and result in the formation
of carbon dioxide. These free hydrogen ions determine the Water plays a significant role in the carbonic acid–bicarbonate
body’s pH. It is important to understand that all of the system and is better represented by the following equation:
body’s metabolic processes operate properly only when
H3O + + HCO3- 4 H2CO3 + H2O 4 2 H2O + CO2
the pH is normal. In addition, all chemical reactions that
depend on enzymes are susceptible to changes in pH. In This reaction occurs spontaneously in body fluids. How-
fact, significant changes in pH can destroy these needed ever, it occurs much faster in the presence of the enzyme
enzymes. Thus, biological systems function properly only carbonic anhydrase. Carbonic anhydrase is found in red
within a very limited pH range. blood cells, the liver, kidneys, stomach, and other struc-
Buffers are needed to tures. Carbonic anhydrase promotes the rapid formation of
CONTENT REVIEW counter the body’s normal water and carbon dioxide, thus making the reaction signifi-
➤➤ Major Acid–Base Buffer production of acids and to cantly faster.
Systems prevent significant varia- Carbonic anhydrase
CO2 + H2O H2CO3 4 H + + HCO3-
• Carbonic acid– tions in the body’s pH. A
bicarbonate buffer buffer is a substance dis- The carbonic acid–bicarbonate buffer system has sev-
system solved in water that coun- eral important limitations. First, it does not effectively
• Protein buffer system
teracts changes in pH. protect the extracellular fluid from changes in pH that are
• Phosphate buffer system
When the hydrogen ion due to changes in carbon dioxide levels. Because carbon
 Pathophysiology 251

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

occurs primarily through a change in respiratory rate.

Chemoreceptors in the carotid and aortic bodies sense
Table 12-6  pH as a Function of Metabolism and Respiration
changes in the PCO2 in the circulating blood. Similar che- Base Bicarbonate (HCO3-)
pH = thus pH =
moreceptors are present in the medulla oblongata of the Acid Carbonic Acid (H2CO3) or Carbon Dioxide (CO2)
brain. When these receptors are stimulated, the respiratory
Metabolic Function
rate increases, which leads to increased CO2 loss through pH =
Respiratory Function
the lungs, which then increases the pH. Increasing or
decreasing the respiratory rate will affect the PCO2 that, in Renal Compensation
pH =
Respiratory Compensation
turn, affects the pH.
When the PCO2 rises, the pH will fall, and the carbonic
acid–bicarbonate equation will be driven to the right:

c H + + HCO3- S H2CO3 S c CO2 + H2O

Acid–Base Disorders
Any significant deviation of pH outside the normal operat-
Once enough carbon dioxide is lost to the environment, the ing parameters (7.35–7.45) can be classified as an acid–base
respiratory rate returns to normal. disorder (Table 12-6). The two major body systems
Conversely, when the PCO2 of the blood falls, the che- involved in acid–base balance are the respiratory system
moreceptors are inhibited, and the respiratory rate falls, and the renal system.
thus causing a return of the PCO2 to normal levels. There are two classes of acid–base disorders: respiratory
The renal system also plays a major role in acid–base acid–base disorders and metabolic acid–base disorders. Of
balance. However, it tends to work more slowly than the these, there are two types. Acidosis is an excess of acids in
other body systems. The renal effect is referred to as renal the body, and alkalosis is an excess of bases in the body.
compensation and is due to the selective secretion or reab- Respiratory acid–base disorders result from an inequality in
sorption of hydrogen ions or bicarbonate ions in response carbon dioxide generation in the peripheral tissues and car-
to changes in the plasma pH. In this way the kidneys effec- bon dioxide elimination in the respiratory system. The hall-
tively assist the lungs in maintenance of acid–base balance. mark of respiratory acid–base disorders is a change in the
When the pH falls, the kidneys respond by increasing the PaCO2. Respiratory acid–base disorders can be classified as:
levels of bicarbonate to supply the carbonic acid–bicarbonate
buffer system with adequate amounts of buffer. When the • Respiratory acidosis
pH rises, bicarbonate ions are excreted from the body, thus • Respiratory alkalosis
removing the excess base. When the bicarbonate is lost
The second class of acid–base disorders is the metabolic
from carbonic acid, hydrogen ions are liberated, thus fur-
acid–base disorders. These result from the production of
ther lowering the pH.
either organic or fixed acids or by conditions that affect the
The pH can also be affected by movement of electro-
levels of bicarbonate in the ECF. Metabolic acid–base disor-
lytes from the inside of cells to the ECF. That is, sodium
ders can be classified as:
(Na+) and potassium (K+) ions can be exchanged for hydro-
gen ions (H+) in the ECF, thereby moving the acid. Thus, • Metabolic acidosis
potassium levels and hydrogen ion levels are a major • Metabolic alkalosis
aspect of pH (Table 12-5).
Respiratory Acidosis
Respiratory acidosis occurs when the respiratory system
Table 12-5  Maintenance of Acid–Base Balance cannot effectively eliminate all the carbon dioxide gener-
ated through metabolic activities in the peripheral tissues.
System Mechanism Rate of Action
Normally, the respiratory system reacts rapidly and cor-
Buffer pairs Releases or absorbs Immediate rects changes in carbon dioxide levels before the ECF pH is
• Carbonic hydrogen ions
acid–bicarbonate
affected. However, in respiratory acidosis, the respiratory
• Proteins/ system cannot maintain the pH within accepted values.
hemoglobin With respiratory acidosis,
• Phosphate
there is an increase in PCO2
Respiratory system Retain or remove CO2 (H2CO3) Minutes to hours and a decrease in pH. An CONTENT REVIEW
Electrolyte shifts Exchange Na+ and/or K+ Minutes to hours elevation in the plasma ➤➤ Acid–Base Disorders
for H+ in ECF CO2 level is referred to as • Respiratory acidosis
hypercapnia. The usual • Respiratory alkalosis
Renal system Secretion or absorption of Hours to days
H+ and/or HCO3-, phosphate, • Metabolic acidosis
cause is hypoventilation.
and ammonia buffering • Metabolic alkalosis
Hypoventilation can occur
 Pathophysiology 253

from emotional situations, metabolic disorders, medical

Clinical Note conditions, environmental factors, or a combination of
In the prehospital setting, acid–base disorders are detected these. For example, anxiety, fear, or hysteria stimulates the
primarily by physical exam techniques. The introduction of respiratory centers in the brain, resulting in what is referred
capnography, which measures end-tidal carbon dioxide to as hyperventilation syndrome. This results in excessive
(CO2) levels, provides additional important information. Ini- CO2 elimination and thus a respiratory alkalosis. Fever and
tially, these devices detected only end-tidal CO2 (ETCO2) lev- hyperthyroidism can cause respiratory alkalosis. These
els. Modern capnography measures the exhaled CO2 level
conditions increase the body’s metabolic rate, resulting in
throughout the respiratory cycle. CO2 can be displayed as the
increased CO2 elimination. Medical conditions such as
partial pressure or maximal concentration of carbon dioxide
congestive heart failure (CHF) and liver failure can cause
at the end of an exhaled breath and is expressed as a percent-
age of CO2 or partial pressure of CO2 in mmHg. Normal lev-
increased CO2 elimination. CHF can cause a respiratory
els are 5–6 percent or 35–45 mmHg. When the value is alkalosis because of hypoxia-induced hyperventilation.
expressed as a partial pressure of CO2 in mmHg, it is nor- Liver failure results in the accumulation of ammonia in the
mally called the PETCO2. For example, you might state, “The blood. Increased levels of ammonia can stimulate the respi-
patient had a PETCO2 of 22.” ratory center, causing hyperventilation with resultant met-
During normal circulatory and respiratory function, the abolic alkalosis. Ascension to a high altitude can cause
alveolar carbon dioxide partial pressure (PACO2) is closely hyperventilation. At higher elevations, oxygen levels are
comparable to arterial carbon dioxide partial pressure (PaCO2) markedly decreased and the victim must increase respira-
and thus to exhaled CO2. Therefore, PaCO2 is equivalent to tions to ensure adequate oxygen levels until becoming
exhaled CO2. The difference between PaCO2 and exhaled CO2
acclimated to the altitude or descending to lower levels.
is known as the CO2 gradient. Normally, PETCO2 is about
38 mmHg at 760 mmHg of atmospheric pressure, and thus
Metabolic Acidosis
less than a 6-mmHg gradient between PaCO2 and exhaled car-
Metabolic acidosis is a deficiency of bicarbonate (HCO-3 )
bon dioxide. Thus, for most conditions, except extremely low-
in the body. It usually results from an increase in metabolic
flow states, capnography can aid in the diagnosis of respiratory
acid–base disorders (Figure 12-31).
acids—primarily through anaerobic metabolism. When
oxygen stores are low, energy production switches from
 aerobic metabolism to anaerobic metabolism. Anaerobic
 metabolism results in the production of pyruvic acid,
 which is rapidly converted to lactic acid.
%CTDQPFKQZKFG


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

the total amount of acids increases 2NCUOCOGODTCPG /KETQƂNCOGPV %GPVTKQNGU

while bicarbonate levels remain the r4GIWNCVGUOQXGOGPVQH r2NC[UCTQNGKPOWUENG r/C[HWPEVKQP
OCVGTKCNUKPVQCPFQWVQHEGNN EQPVTCEVKQPCPFEGNNFKXKUKQP KPEGNNFKXKUKQP
same. This mechanism also results in a
%[VQRNCUO
relative decrease in HCO-3 levels. True /KETQVWDWNG
r6JGOCVGTKCNUWTTQWPFKPIVJGPWENGWU
HCO-3 deficits result when the kidney .[UQUQOG
r/CKPVCKPUEGNNUJCRGCPFHQTOU
VTCEMUQPYJKEJXGUKENGUOQXG
excretes bicarbonate. Metabolic acido- r&KIGUVUUWDUVCPEGU
sis is a common problem and can be DTQWIJVKPVQEGNNCPF
FGUVTQ[UQNFRCTVUQHEGNNU
caused by disease processes such as
/KVQEJQPFTKQP
diabetes, kidney disease, and similar r2TQXKFGUEGNNYKVJGPGTI[
conditions. VJTQWIJVJGDTGCMFQYP
QHINWEQUGFWTKPI
Metabolic Alkalosis EGNNWNCTTGURKTCVKQP

Metabolic alkalosis is relatively 0WENGWU

r%QPVCKPU&0#CPF
uncommon and is due to an increase in EQPVTQNUEGNNWNCTCEVKXKV[
HCO-3 levels or a decrease in circulat- 0WENGQNWU
ing acids. Metabolic alkalosis results r2TQFWEGUEQORQPGPVU
from an abnormal loss of hydrogen QHTKDQUQOGU

40#CPFRTQVGKPU
ions (H+), an increase in HCO-3 levels,
4KDQUQOG
or a decrease in extracellular fluid r5KVGYJGTGRTQVGKP
­levels. Vomiting (or nasogastric suc- U[PVJGUKUDGIKPU
tioning) is the most common cause of 4QWIJGPFQRNCUOKE
metabolic alkalosis. Stomach secre- TGVKEWNWO
r5VWFFGFYKVJTKDQUQOGU
tions are highly acidic—primarily CPFRTQFWEGU
hydrochloric acid (HCl). Vomiting or OGODTCPG
suctioning removes the HCl, leaving a 5OQQVJGPFQRNCUOKE
TGVKEWNWO
deficit in both H+ and chloride ions r&GVQZKƂGUFTWIUCPFRTQFWEGU
(Cl-). When this occurs, the bicarbon- OGODTCPG
ate anion shifts from the ICF to the ECF )QNIKEQORNGZ
to replace the lost Cl- ions, causing an r5QTVUOQFKƂGUCPF
 RCEMCIGURTQVGKPU
increase in ECF HCO-3 levels and thus
a metabolic alkalosis. Several other s
mO
conditions can cause metabolic alkalo- FIGURE 12-32  Eukaryotic cells, such as the generalized animal cell shown here, have internal
sis, all of which involve either the loss membrane-bound organelles.
of H+ or variations in circulating HCO-3 (Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, 3rd Edition,
levels. © 2010. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.)

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,

at the Cellular Level including humans, are eukaryotes (Figure 12-32).

The Cell The Plasma Membrane

The cell is the basic unit of all living organisms. The cell is
capable of independent functioning and can typically be and Cytoplasm
divided into two types: eukaryotic cells and prokaryotic Cells are so small that they can be visualized only with a
cells. Distinction between the two is based on whether or microscope. Their small size is necessary because they
not the cell has internal compartments—a nucleus and need a small surface-area-to-volume ratio that will allow
organelles—that are enclosed by membranes. The nucleus movement of substances into and out of the cell.
 Pathophysiology 255

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.

Plasma Membrane Functions

The plasma membrane has several functions in
addition to the obvious function of separating
the extracellular from the intracellular environ- Cell-adhesion
molecules
ment (Table 12-7). First, the plasma membrane
plays a major role in the ability of cells to adhere
to one another, or stick together. This is achieved
primarily through proteins (linkers) called cell Plasma membrane
adhesion molecules (CAMs) that extend out of the
FIGURE 12-35  Cell adhesion molecules (CAMs) extend out of the plasma mem-
plasma membrane. CAMs hold cells together
brane to bind cells to each other.
and play a role in cellular movement, tissue
development, and healing (Figure 12-35).
The plasma membrane helps with cell–cell recognition, hormones, will bind to the receptor proteins in the plasma
the ability of a cell to distinguish one type of cell from membrane. The plasma membrane protein then relays the
another. Peripheral membrane proteins, often glycoproteins, message of the bound substance to the interior of the cell,
differ from cell to cell and from species to species. Cell–cell where it is transmitted to nearby molecules. Through a
recognition allows the body to recognize foreign cells, series of biochemical reactions, the message ultimately ini-
including cells that may cause infection or even cancer. tiates the desired response by the cell.
The plasma membrane maintains the structural integ- Finally, the cell membrane regulates the movement of
rity of the cell. It provides anchor sites for the interior cyto- substances into and out of the cell. A large number of sub-
skeleton, which is both a muscle and a skeleton and is stances are routinely moved across the plasma membrane,
responsible for cell movement and the organization of the but these are highly regulated by the cell. Because of this,
organelles within the cell. (The cytoskeleton will be the plasma membrane is said to be semipermeable.
described in more detail later.)
The plasma membrane also plays a major role in com-
Simple Diffusion
munications between cells. Certain substances, such as
Substances will move across a membrane from an area of
higher concentration on one side to an area of lower con-
Table 12-7  Mechanism of Transport across the Plasma centration on the other side until the concentration of the
Membrane substance is equal in both areas (a state of equilibrium)
(Figure 12-36). Even after the concentrations reach equilib-
Mechanism Description
rium, because of random movement, the substance contin-
Simple diffusion Random movement from region of high to region ues to move back and forth across the membrane. However,
of low concentration
the net rate of movement in each direction now remains
Facilitated diffusion Movement from region of high to region of low the same. This process of passive movement across a mem-
concentration with the aid of a carrier or channel
protein
brane is called simple diffusion.
The plasma membrane essentially creates an intracel-
Osmosis Movement of water from a region of high water
concentration (low solute concentration) to a region
lular environment separate
of low water concentration (high solute concentration) from the extracellular envi- CONTENT REVIEW
ronment. Thus, the concen- ➤➤ Types of Movement
Active transport Movement from region of high to region of low
concentration with the aid of a carrier or channel tration of substances inside through a Cell Membrane
protein and energy, usually from ATP the plasma membrane is • Simple diffusion
Endocytosis Materials engulfed by the plasma membrane and often different from those • Osmosis
drawn into the cell in a vesicle outside the membrane. • Facilitated diffusion
Smaller molecules, such as • Active transport
Exocytosis Membrane-bound vesicle from inside the cell
fuses with the plasma membrane and spills • Endocytosis
water, carbon dioxide,
contents outside the cell • Exocytosis
oxygen, ethanol, and urea,
 Pathophysiology 257

FIGURE 12-36  Simple diffusion is Simple Diffusion

the random movement of molecules
Separated solutions Diffusion Equilibrium
from a region of higher concentra-
tion to a region of lower concentra- Membrane
tion. Solutes diffuse across the
membrane until equilibrium is
reached on both sides.

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

more concentrated (has a greater quantity of solute) than Facilitated Diffusion

the solution on the other side, the solution is said to be Water-soluble molecules and ionized molecules cannot
hypertonic. Conversely, when a solution on one side of a move through the plasma membrane by simple diffusion.
membrane is less concentrated than the solution on the Because of this, their transport must be assisted, or “facili-
other side, it is said to be hypotonic (Figure 12-38). tated,” by integral proteins in the plasma membrane
Osmosis generates a pressure called osmotic pressure. through a process called facilitated diffusion. Facilitated
If the pressure in the compartment into which water is diffusion, like simple diffusion, does not require an expen-
flowing is raised to the equivalent of the osmotic pressure, diture of metabolic energy. The force driving facilitated dif-
movement of water will stop. (Osmotic pressure and its fusion, as with simple diffusion, is the concentration
opposite, hydrostatic pressure, will be described in more gradient. There are many important substances that are
detail later.) The concentration of solute particles in a solu- moved across the plasma membrane by facilitated diffu-
tion is called the osmolarity. A similar measurement, the sion, including glucose, sodium ions, and chloride ions.
osmolality, is used to measure the concentration of parti- Glucose is water soluble; sodium and potassium are ion-
cles in body fluids such as plasma and urine. The body’s ized and are thus classified as lipid-bilayer-excluded sub-
osmolality increases with dehydration and decreases with stances (Figure 12-39). That is, they cannot pass through the
overhydration. Normal human osmolality ranges from 280 lipid bilayer by simple diffusion but rather, as just
to 300 mOsm/kg. described, their passage across the plasma membrane must
be assisted, or facilitated.
Tonicity There are two major groups of integral membrane pro-
teins involved in the process of facilitated diffusion:
Outside solution
hypertonic to inside • Carrier proteins. Carrier proteins, also called trans-
porters, bind a specific type of solute and are induced
to undergo a series of conformational changes that
effectively carries the solute to the other side of the
membrane. The carrier protein then releases the solute
and, through another conformational change, is
restored in the membrane to its original state. Typi-
cally, a given carrier will transport only a small group
Arrow represents the direction of Net flow of water out of related molecules.
net water movement via osmosis of cell; cell shrinks

Outside solution Glucose moves through the lipid bilayer

hypotonic to inside from high to low concentration with aid
from a carrier protein.

Extracellular fluid
High
Glucose concentration
Carrier
protein

Net flow of water into cell;

cell swells or even bursts
Plasma
Isotonic solutions membrane

Low
concentration
Cytoplasm

No change FIGURE 12-39  Glucose is unable to diffuse across a plasma

­membrane by itself but can be moved across by a carrier protein
FIGURE 12-38  Osmosis can shrink or burst a membrane-bound ves- embedded in the membrane, a process known as facilitated diffusion.
icle as water moves out of the vesicle to dilute a hypertonic outside (Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applica-
solution or into the vesicle to concentrate an outside solution, always tions, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Educa-
seeking to achieve isotonicity inside and outside the vesicle. tion, Inc., Upper Saddle River, NJ.)
 Pathophysiology 259

Ion Channels (ligand-gated channels). Ion chan-

nels are particularly important in
Hydrated potassium ion excitable cells, such as neurons
Closed Open Plasma membrane and muscle cells, because they
allow current flow to occur across
the membrane (Figure 12-40).

Ion binding Active Transport

site Inactivation particle
Sometimes it is necessary for a cell
Channel to move a solute across the plasma
Ion selectivity Channel gating
inactivation membrane against the concentra-
of channels
tion gradient. As with facilitated
FIGURE 12-40  The function of a voltage-gated ion channel. (a) Several ways a channel can select diffusion, this process, called
for different ions are shown: (1) Negative charges at the opening of the channel repel anions and
active transport, uses a carrier
attract cations. (2) The pore diameter restricts the size of ions that can pass. (3) Ion-selective binding
strips off water molecules so ions can pass through. (b) Channel gating occurs when a portion of protein but also uses energy in the
the channel changes conformation when the membrane potential changes, effectively swinging the form of ATP (Figure 12-41). Thus,
gate open or shut. (c) Inactivation of the sodium channel occurs when an inactivating particle with active transport substances
blocks the pore. are moved from areas of lower sol-
ute concentration to those with
• Ion channels. Ion channels are essentially hydrophilic higher solute concentration. This is especially important in
pores through the membrane that open and allow cer- regard to sodium and potassium ions. The concentration of
tain types of solutes, usually inorganic ions, to pass sodium ions outside the cell membrane is much higher
through. (Note that the term hydrophilic, meaning than inside the membrane. Conversely, the concentration
attracted to water, is the opposite of the term hydro- of potassium ions is much higher inside the cell membrane
phobic, meaning repellent to water.) Typically, these than outside. The transport of sodium ions out of the cell
ion channels are quite specific for a particular type of and potassium ions into the cell, against the concentration
solute. Transport through ion channels is considerably gradient, is achieved by the sodium–potassium pump.
faster than transport by carrier proteins. In addition, The sodium–potassium pump is an enzyme (Na+-K+-
many ion channels are gated, which in effect controls ATPase) in the plasma membrane and is powered with
the channel’s permeability. When the gate is open, the ATP. Each of these enzymes binds three sodium ions on the
ion channel transports the desired substance. When inside of the cell membrane and transports them to the out-
the gate is closed, no transport occurs. Ion channel side of the cell membrane. ATP is used in this step. Follow-
gates can be controlled either by voltage across the ing that, two potassium ions are bound on the outside of the
membrane (voltage-gated channels) or by having a cell and transported to the inside of the cell. During this part
binding site for a ligand (a molecule that will bind to a of the process, ATP rebinds to the pump and is ready for
site) that, when bound, causes the channels to open another cycle. (Figure 12-42).

Extracellular fluid Extracellular fluid

Low
Plasma concentration
membrane

A substance moves through the

lipid bilayer from low to high
concentration with the aid of a
carrier protein and energy. Carrier
protein

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

FIGURE 12-43  Phagocytosis. The cell engulfs large particles or

­bacteria.
(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.)

'ZVTCEGNNWNCT
ƃWKF

FIGURE 12-42  The sodium–potassium pump. 2NCUOC

OGODTCPG

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

%[VQRNCUO compartment contains the

CONTENT REVIEW
remaining 30 percent of all
8GUKENG ➤➤ Distribution of Fluid among
body water. It contains the
Body Compartments
extracellular fluid (ECF),
5VGR6JGXGUKENG • Intracellular fluid (ICF)
OQXGUVJTQWIJVJG all the fluid found outside
• Extracellular fluid (ECF)
2NCUOC E[VQRNCUOVQYCTFVJG the body cells. • Intravascular fluid
OGODTCPG RNCUOCOGODTCPG
There are two divi- • Interstitial fluid
sions within the extracellu-
lar compartment. The first contains the intravascular
5VGR6JGOGODTCPG fluid—the fluid found outside cells and within the circula-
QHVJGXGUKENGHWUGUYKVJ
VJGRNCUOCOGODTCPG tory system. It is essentially the same as the blood plasma
and accounts for about 5 percent of body water. The
remaining compartment contains the interstitial fluid—all
5VGR6JGXGUKENG the fluid found outside the cell membranes, yet not within
URKNNUKVUEQPVGPVU
QWVUKFGVJGEGNN

Table 12-8   Body Fluid Compartments

Percentage of Volume in 70-kg Adult
Compartment Total Body Water (42 L total body water)
Intracellular fluid 70.0 percent 29.40 L

Extracellular fluid 30.0 percent 12.60 L

Interstitial fluid 25.0 percent 10.50 L

'ZVTCEGNNWNCTƃWKF
Intravascular fluid   5.0 percent   2.10 L
FIGURE 12-45  Exocytosis. A membrane-bound vesicle is taken into
the cell membrane and its contents are released to the exterior.
(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.)

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.

Hydration DEHYDRATION  Dehydration, an abnormal decrease in

Water is the universal the TBW, can result from several factors:
CONTENT REVIEW
­solvent. That is, most sub- • Gastrointestinal losses result from prolonged vomiting,
➤➤ Factors That May Cause stances dissolve in water.
Dehydration diarrhea, or malabsorption disorders.
When they do, chemical
• Gastrointestinal losses • Increased insensible loss is loss of water through normal
changes take place. For this
(vomiting, diarrhea, mechanisms that is difficult to detect or measure (e.g.,
reason, the water content
malabsorption) perspiration, water vapor from the lungs, saliva).
• Increased insensible of the body is crucial to vir-
These can be increased in fever states, during hyper-
loss (perspiration, water tually all of the body’s bio-
ventilation, or with high environmental temperatures.
vapor, saliva) chemical processes.
• Increased sweating Normally, the total volume • Increased sweating (also called perspiration or diapho-
(diaphoresis) of water in the body, as resis) can result in significant fluid loss. Although
• Internal losses well as the distribution of sweating is a form of insensible water loss, it is a sig-
(“thirdspace” losses to fluid in the three body nificant concern with many medical conditions or high
the interstitial space) compartments, remains environmental temperatures.
• Plasma losses (from relatively constant. This • Internal losses are commonly called “third-space” losses
burns, drains, fistulas,
occurs despite wide fluctu- because fluid is lost from intravascular or intracellular
open wounds)
ations in the amount of spaces into the interstitial space. With dehydration,
 Pathophysiology 263

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.

Major Element Symbol Percent Trace Element Symbol

Hydrogen H 62.0% Calcium Ca

Oxygen O 26.0% Chlorine Cl
Carbon C 10.0% Iodine I
Nitrogen N 1.5% Iron Fe
Magnesium Mg
Phosphorus Ph
Potassium K
Sodium Na
Sulfur S

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.

CO2 ∙ H2O n H2CO3

Read as: (carbon dioxide + water = carbonic acid) or (carbonic acid = water + carbon dioxide).

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:

cH+ (an increase in hydrogen ions)

TCO2 (a decrease in carbon dioxide)

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.

Transport of Water and Electrolytes

In this section, we will review the concepts of diffusion,
osmosis, active transport, and facilitated diffusion across a
membrane—discussed earlier under “Plasma Membrane
Functions”—as they concern the movement of water and
electrolytes.
Intracellular
As noted earlier, the body’s fluid compartments are fluid
separated by cell membranes. These membranes are called
semipermeable or selectively permeable, meaning that
they allow the easy passage of certain materials while Lower concentration
restricting the passage of others. Compounds with small
molecules, such as water (H2O), pass readily through the Cell
membrane
membrane; larger compounds, such as proteins, are
restricted. The movement of fluids through a membrane FIGURE 12-47  Diffusion is the movement of a substance from an
is enabled by the presence of pores (openings) in the area of great concentration to an area of lesser concentration.
266  Chapter 12

Water also moves across the cell membrane Osmosis

so as to dilute the area of increased electrolyte
Interstitial 1 Interstitial 2
concentration. The movement of water is more fluid fluid
rapid than the movement of electrolytes. This
form of diffusion (the passage of any solvent, 30% Solute 25% Solute
usually water, through a membrane) is referred concentration concentration
to as osmosis (Figure 12-48). It occurs in the direc-
tion opposite to the direction of solute move-
ment. For example, if a semipermeable
membrane separates solutions of water and
sodium, and if the concentration of sodium is H2O
two times higher on one side of the membrane 20% Solute
concentration 25% Solute
than on the other, then two things will occur: concentration H2O
Sodium will diffuse from the area of higher con-
centration (the hypertonic side) to the area of
Intracellular Intracellular
lesser concentration (the hypotonic side). Con- fluid fluid
currently, water will diffuse in the opposite
direction. That is, water will leave the hypotonic FIGURE 12-48  Osmosis is the movement of water from an area of higher water
side and diffuse across the membrane to the concentration to an area of lesser water concentration. Because water is a solvent,
hypertonic side. These actions will continue until it moves from an area of lower solute concentration to an area of higher solute
concentration.
the concentration of water and sodium on both
sides has equalized.
In addition to diffusion, two other mechanisms— Water Movement between Intracellular
active transport and facilitated diffusion—can transport and Extracellular Compartments
substances across cell membranes. Active transport is the The mechanisms by which water and solutes move across
movement of a substance across the cell membrane against cell membranes ensure that the osmolality of body water
the osmotic gradient (that is, toward the side that already (the concentration of particles within the water) inside and
has more of the substance). For example, the body outside the cells is normally in equilibrium. Sodium, the
requires cells of the myocardium to be negatively charged most abundant ion in the extracellular fluid, is responsible
on the inside of the cells as compared to the outside. for the osmotic balance of the extracellular space. Potas-
However sodium, with its positive charge, tends to dif- sium plays the same role in the intracellular space.
fuse passively into the cell. This would destroy the nega- Generally, the osmolality of intracellular fluid does not
tive charge inside the cell. To maintain the desired change very rapidly. However, when there is a change in
negative charge, sodium ions are actively pumped out of the osmolality of extracellular fluid, water will move from
the cell, while potassium ions are pumped into the cell, by the intracellular to the extracellular compartment, or vice
a mechanism known as the sodium–potassium pump. versa, until osmotic equilibrium is regained.
(Sodium and potassium ions are both positive, but more
sodium ions are pumped out of the cell than potassium Water Movement between Intravascular
ions are pumped in, creating the desired negative charge and Interstitial Compartments
inside the cell.) Active transport is faster than diffusion, Within the extracellular compartment, movement of water
but it requires the expenditure of energy, which diffusion between the plasma in the intravascular space and the
does not. Proteins are moved across the cell membrane in interstitial space is primarily a function of forces at play in
a similar fashion. the capillary beds.
Certain molecules can move across the cell membrane In general, the movement of water and solutes across a
by another process known as facilitated diffusion. Glucose is cell membrane is governed by osmotic pressure. Osmotic
an example of such a molecule. Facilitated diffusion pressure is the pressure exerted by the concentration of sol-
requires the assistance of “helper proteins,” parts of a utes on one side of a semipermeable membrane, such as a
membrane transport system that exist on the surface of the cell membrane or the thin wall of a capillary. Osmotic pres-
cell membrane. These proteins, once activated, bind to the sure can be thought of as a “pull” rather than a “push,”
glucose molecule. Following binding, the protein changes because a hypertonic concentration of solutes tends to pull
its configuration and transports the glucose molecule to water from the other side of the membrane until the
the inside of the cell, where it is released. Depending on the osmotic pressure on both sides is equal.
substance that is being transported, facilitated diffusion Generally, as already described, this is a two-way
may or may not require energy. street as solutes move out of a space while water moves
 Pathophysiology 267

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

Body water that is retained in the interstitial spaces Intravenous Therapy

is body water that is not available for metabolic pro-
Intravenous (IV) therapy is the introduction of fluids
cesses in the cells. Therefore, even though the total body
and other substances into the venous side of the circula-
water is normal, edema can cause a relative condition of
tory system. It is used to replace blood lost through
dehydration.
hemorrhage, for electrolyte or fluid replacement, and for
The body has regulatory mechanisms that help to
introduction of medications directly into the vascular
maintain homeostasis by controlling total body water and
system.
water distribution. Antidiuretic hormone (ADH), also
known as vasopressin, is the chief regulator of water reten-
tion and distribution. Throughout the body, a network of
Blood and Blood Components
To understand IV therapy, it is necessary to understand
sensors detects fluctuations in fluid and changes in the
the function of blood and its components. The blood is
osmolar concentration of plasma. Osmoreceptors are
the fluid of the cardiovascular system. An adequate
located in the anterior hypothalamus. If there is an increase
amount of blood is required for the transport of nutrients,
of 1 to 2 percent in osmolality—that is, if there is relatively
oxygen, hormones, and heat. Blood consists of the liquid
less fluid in the plasma—the osmoreceptors will stimulate
portion, or plasma, and the formed elements, or blood
the release of ADH in an attempt to retain more fluid.
cells (Figure 12-49).
Another type of receptor, baroreceptors, will detect both
high and low pressure levels. Baroreceptors located in the Plasma  Plasma is made up of approximately 92 per-
carotid sinus, aortic arch, and kidney detect increases and cent water, 6 to 7 percent proteins, and a small portion
decreases in pressure. Signals from the baroreceptors are consisting of electrolytes, lipids, enzymes, clotting factors,
relayed to the hypothalamus, which, again, will stimulate glucose, and other dissolved substances.
release of ADH as needed.
Definitive treatment of edema requires treatment of Formed Elements  The formed elements include the
the underlying cause. Supportive care may include apply- red blood cells, or erythrocytes; the white blood cells, or
ing compression stockings, restricting salt intake, improv- leukocytes; and the platelets, or thrombocytes. More than
ing nutritional status, avoiding prolonged standing, and 99 percent of the blood cells are erythrocytes. Erythrocytes
taking diuretics. Little can be done in the prehospital set- contain hemoglobin and are responsible for transporting
ting except elevation of edematous limbs. oxygen to the body’s peripheral cells. Hemoglobin is an

White blood cells Red blood cells

Plasma: 54%

Eosinophil
Monocyte
White cells & platelets: 1%

Red cells: 45%

Basophil
Neutrophil Electrolytes,
enzymes, fats,
proteins, and
carbohydrates

Lymphocyte
Platelets

Figure 12-49  Blood components.

 Pathophysiology 269

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

people. Because of this, blood is often fractionated, or sep-

arated into parts. The red cells are packaged separately as
4GFEGNNU

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.

Table 12-9   Resuscitation Fluids

Resuscitation Fluid Used
Diagnosis 1st Choice 2nd Choice 3rd Choice 4th Choice
Hemorrhagic shock Whole blood Packed RBCs Plasma or plasma Lactated Ringer’s
substitute or normal saline

Shock due to plasma Plasma Plasma substitute Lactated Ringer’s —

loss (burns) or normal saline

Dehydration Lactated Ringer’s — — —

or normal saline
270  Chapter 12

Intravenous Fluids • Hypotonic solutions have a lower solute concentration

Intravenous fluids are the most common products used in than the cells. When administered to a normally
prehospital care for fluid and electrolyte therapy. Intrave- hydrated patient, they will cause a movement of fluid
nous fluids occur in two standard forms—colloids and from the intravascular space into the interstitial space
crystalloids. and intracellular compartment. Later, solutes will
move in an opposite direction. An example is 5 percent
COLLOIDS  A colloid contains proteins or other high- dextrose in water (D5W).
molecular-weight molecules that tend to remain in the
intravascular space for an extended period of time. In Intravenous replacement fluids should be chosen
addition, as described earlier, colloids have oncotic force based on the needs of the patient and the patient’s underly-
(colloid osmotic pressure), which means that they tend to ing problem. This is typically guided by laboratory studies
attract water into the intravascular space from the intersti- obtained in the hospital. However, these studies are not
tial space and the intracellular space. Thus, a small amount available in the prehospital setting. Hemorrhage occurs so
of a colloid can be administered to a patient with a greater- fast that there is usually not time for a significant fluid shift
than-expected increase in intravascular volume. The fol- to occur between the intravascular space and interstitial/
lowing are examples of colloids: intracellular spaces. Because of this, isotonic replacement
fluids, such as lactated Ringer’s and normal saline, should
• Plasma protein fraction (Plasmanate) is a protein-containing be used (Figure 12-51).
colloid. The principal protein present is albumin,
which is suspended along with other proteins in a
saline solvent.
Net water
• Salt-poor albumin contains only human albumin. Each
movement
gram of albumin holds approximately 18 milliliters of
water in the bloodstream.

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

with osmotic properties similar to protein. It does not

appear to share many of dextran’s side effects. Colloid
replacement therapy, at present, does not have a sig-
nificant role in prehospital care except under rare cir- (b)
Normal
cumstances. The colloid products are expensive and
have a short shelf life.

CRYSTALLOIDS  Crystalloids are the primary com-

pounds used in prehospital intravenous fluid therapy.
There are multiple fluid preparations. It is often helpful to
classify them according to their tonicity relative to plasma:
Hypotonic

(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

Certain conditions, such as gastroenteritis (character- membrane, and cytoplasm.

CONTENT REVIEW
ized by diarrhea, vomiting, and fever), can cause a patient Within the cell are numer-
➤➤ Organelles within Cells
to lose water more rapidly than sodium. These patients ous specialized structures
• Nucleus
will have a deficit in TBW due to reduced water intake, called organelles, as well as
• Ribosomes
excessive water loss, or a combination of both. When water a permeating structure
• Endoplasmic reticulum
is lost in this manner, the level of sodium in the serum can called the cytoskeleton, • Golgi apparatus
increase, resulting in hypernatremia (elevated sodium lev- which will be described • Lysosomes
els). Patients with hypernatremia primarily need water. next. • Vacuoles
Because of this, hypotonic intravenous solutions, such as • Peroxisomes
0.45 percent sodium chloride (half-normal saline), are often Organelles and • Mitochondria
chosen, because they provide the needed water with less
sodium. However, it is important to point out that, even in
Their Functions
cases of hypernatremia, initial fluid replacement therapy As discussed previously, eukaryotic cells contain special-
should consist of an isotonic solution until adequate blood ized internal compartments, enclosed by membranes,
pressure and adequate tissue perfusion have been restored. called organelles. Various biochemical processes that are
Some replacement fluids contain a single element, necessary to cell survival and reproduction occur within
such as sodium chloride or dextrose, whereas others con- the organelles. This is a much more efficient system than
tain multiple elements. Solutions such as lactated Ringer’s that seen in prokaryotic cells, because, in eukaryotic cells,
are designed so that the concentration of electrolytes is molecules that perform a similar task are situated together
very similar to that of the plasma. As a result, these solu- for efficiency.
tions are referred to as balanced salt solutions. The roles and functions of the organelles are diverse.
The most commonly used solutions in prehospital care The following sections describe the major intracellular
are lactated Ringer’s solution, 0.9 percent sodium chloride organelles and their functions.
(normal saline), and 5 percent dextrose in water (D5W).
Nucleus
• Lactated Ringer’s is an isotonic electrolyte solution of The nucleus is among the largest organelles and contains all
sodium chloride, potassium chloride, calcium chlo- of the cell’s genetic information (Figure 12-52). Genetic
ride, and sodium lactate in water. information is encoded by base sequences on the DNA
• Normal saline is an electrolyte solution
of sodium chloride in water. It is iso- In some areas, the nuclear
tonic with the extracellular fluid. membrane is continuous with
Nucleus the endoplasmic reticulum.
• D5W is a hypotonic glucose solution
used to keep a vein open and to sup-
ply calories necessary for cell metabo- Rough
endoplasmic
lism. It will have an initial effect of reticulum
increasing the circulatory volume, but
glucose molecules rapidly diffuse Nucleus
across the vascular membrane. Water Nucleolus
follows the glucose into the interstitial
space, resulting in an increase in inter- Nucleoplasm
stitial water.

Both lactated Ringer’s solution and Nuclear

envelope
normal saline are used for fluid replace-
ment, because their administration causes
an immediate expansion of the circulatory Chromatin
volume. However, as was noted earlier, due (DNA and its
associated
to the movement of electrolytes and water, proteins)
two-thirds of either of these solutions is lost
Nuclear pore
into the interstitial space within 1 hour.
Diagram of the nucleus.
The Internal Cell FIGURE 12-52  Diagram of the nucleus.
Earlier in this chapter, we discussed the (Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues,
basic structure of the cell, its plasma 3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.)
272  Chapter 12

Chromosomes and joins with messenger RNA (mRNA) to form a ribo-

some. Ribosomes then manufacture the protein coded for
by the RNA.

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

cells serves as a store of calcium that is released

as one step in the contraction process. Calcium
pumps move the calcium.
Endoplasmic
The endoplasmic reticulum also plays a
reticulum
major role in replenishment and maintenance
of the plasma membrane. The protein compo-
nents of the plasma membrane come from the
RER, whereas the lipid components come from
Nucleus
the SER (Figure 12-55).

Rough endoplasmic reticulum Golgi Apparatus

(RER) has ribosomes attached
to its surface and is involved in The Golgi apparatus, also called the Golgi
modifying proteins made by complex, is an important organelle whose func-
the ribosomes.
tion is to process proteins for the cell mem-
brane and other cell organelles. The Golgi
apparatus serves as a sort of “post office” for
the cell, as it is essentially a protein-process-
ing and packaging center. The transport vesi-
Smooth endoplasmic reticulum cles (cisternae) from the endoplasmic
(SER) lacks ribosomes and is
involved in detoxifying certain reticulum fuse with the face of the Golgi appa-
drugs and in producing
phospholipids for ratus and empty their protein content into the
incorporation into membranes. lumen of the Golgi apparatus. The proteins
are then transported to the opposite side of
the Golgi apparatus and are modified along
the way. They are labeled with a sequence of
molecules according to their final destination.
FIGURE 12-55  The endoplasmic reticulum has rough and smooth portions. Rough
Some proteins, such as those bound for the
endoplasmic reticulum (RER) has ribosomes attached during protein synthesis.
Smooth endoplasmic reticulum (SER) has no attached ribosomes and serves vari- plasma membrane, are packaged in vesicles
ous functions, depending on the cell type. (Figure 12-56). Other proteins are packaged in
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts, Applications, and Issues, lysosomes (described next).
3rd Edition, © 2010. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.)

Rough
endoplasmic
reticulum

Proteins

Ribosome

Transport Vesicles carrying proteins from the RER

vesicle arrive at the “receiving” side of the Golgi
complex and empty their contents to the
inside, where the proteins are modified.

Golgi complex

FIGURE 12-56  The route by which Lysosome

with Secretory
protein-filled vesicles from the rough proteins vesicle
endoplasmic reticulum travel to the
Golgi complex for processing and then
move on to the plasma membrane for
release. Plasma membrane
Vesicles containing the Protein
(Goodenough, Judith and Betty A. McGuire, modified proteins leave the expelled
Biology of Humans: Concepts, Applications, “shipping” side of the
Golgi complex and travel to
and Issues, 3rd Edition, © 2010. Reprinted by their specific destinations.
permission of Pearson Education, Inc., ­Upper
Saddle River, NJ.)
274  Chapter 12

Nucleus Step 1: Cell engulfs

bacterium through
phagocytosis.
Bacterium

Rough ER Transport Step 2: Lysosome fuses

with vesicle containing
vesicle bacterium.
Vesicle
containing
Golgi bacterium
complex

Damaged
organelle Step 3: Lysosomal enzymes
Lysosome break the bacterium down
into smaller molecules that
Digestion diffuse into cytoplasm.

Step 1: Lysosome engulfs

a damaged organelle.

Step 4: Some indigestible

substances leave the cell
by exocytosis.

Step 2: Lysosomal enzymes break down Step 5: Other indigestible

the organelle into smaller molecules that substances remain in the
will return to the cytoplasm for reuse. cell.

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.)

Lysosomes enzymes. The vacuole thus becomes a secondary lysosome

Lysosomes serve as the “garbage disposal system” of the and degrades the bacterium. Lysosomes also degrade
cells. That is, they degrade and remove products of inges- worn-out organelles such as mitochondria. The remnants
tion (the process called phagocytosis) and worn out parts of the process are either reprocessed for use again or
from the cell. They also play a role in converting complex released from the cell through exocytosis.
nutritional molecules to simple nutritional molecules. Lysosomes also process the macromolecule products
Lysosomes are spherical in shape and surrounded by a needed for cell energy production. The macromolecule
single membrane. Each lysosome can contain up to ultimately winds up in food vacuoles. These vacuoles then
40 digestive enzymes and has an extremely low pH (pH fuse with primary lysosomes, where digestive enzymes
4.8). The enzymes and membranes of lysosomes are manu- break down the macromolecules into simple molecules
factured by the RER and sent to the Golgi apparatus for that diffuse out of the vesicle into the cytoplasm for use as
packaging. Ultimately, a lysosome that contains all the nec- energy substrates for the cell.
essary digestive enzymes surrounded by a plasma mem-
brane will bud from the Golgi apparatus into the cytoplasm Vacuoles
(Figure 12-57). Vacuoles are membrane-bound organelles used for tempo-
One of the major functions of lysosomes is to break rary storage or transport of substances such as food
down foreign substances and invaders, such as a bacte- sources. The lysosome can fuse with the vacuole mem-
rium. Once a bacterium is isolated through the process of brane and place digestive enzymes into the food vacuole to
phagocytosis, it is enclosed in a large vesicle called a vacu- break down the food source within.
ole. (Vacuoles will be described next.) Soon, vesicles con-
taining lysosomal enzymes (primary lysosomes) will fuse Peroxisomes
with the vesicle. The pH of the newly formed complex then Peroxisomes are similar to lysosomes in size and the lack
becomes more acidic, and this activates the digestive of obvious internal structure. Peroxisomes have the ability
 Pathophysiology 275

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

Glucose Plasma Electrons

membrane transferred
by NADH
and FADH2
Carrier
protein

Citric Electron
Glycolysis Transition Transport
Acid
glucose pyruvate Reaction Chain
Cycle

Oxygen

Mitochondrion

Extracellular fluid 12 ATP 12 ATP 132 ATP 5 36 ATP

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

Pyruvate (from glycolysis)

&WTKPIVJGƂTUVUVGRU
VYQOQNGEWNGUQH#62CTG C C C
EQPUWOGFKPRTGRCTKPI
One carbon (in the form
INWEQUGHQTURNKVVKPI
of CO2) is removed from
)NWEQUG pyruvate.
% % % % % % A molecule of NADH is
formed when NAD1
gains two electrons
and one proton. CO2
#62 &WTKPIVJGTGOCKPKPI
'PGTI[ UVGRUHQWTOQNGEWNGUQH NAD 1
KPXGUVOGPV #62CTGRTQFWEGF
#&2
RJCUG
#&2
NADH Coenzyme A
(electron passes The two-carbon
#62 to electron molecule, called
6JGVYQOQNGEWNGUQH 'PGTI[ transport chain) an acetyl group,
R[TWXCVGVJGPFKHHWUG [KGNFKPI binds to
0#&1
HTQOVJGE[VQRNCUOKPVQ RJCUG coenzyme A
VJGKPPGTEQORCTVOGPV (CoA), forming
QHVJGOKVQEJQPFTKQP acetyl CoA,
YJGTGVJG[RCUUVJTQWIJ C C CoA which enters the
CHGYRTGRCTCVQT[UVGRU 0#&* Acetyl CoA citric acid cycle.

VJGVTCPUKVKQPTGCEVKQP
DGHQTGGPVGTKPIVJG
EKVTKECEKFE[ENG
% % % 6YQOQNGEWNGUQHPKEQVKPG
CFGPKPGFKPWENGQVKFG
2[TWXCVG
0#&*CECTTKGTQH
JKIJGPGTI[GNGEVTQPU
% % % CNUQCTGRTQFWEGF
Citric Acid Cycle

FIGURE 12-63  The transition reaction is the link between glycolysis

and the citric acid cycle.
(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.)

In fermentation, the glucose molecule proceeds

FIGURE 12-62  Glycolysis is a sequence of reactions in the cytoplasm through glycolysis, as it does in cellular respiration, as gly-
in which glucose, a six-carbon sugar, is split into two three-carbon colysis does not require oxygen. This results in the creation
molecules of pyruvate.
of two molecules each of pyruvate, NADH, and ATP. Dur-
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts,
ing fermentation, the chemical reactions continue in the
­Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson
Education, Inc., Upper Saddle River, NJ.) cytoplasm instead of entering the mitochondria. In fermen-
tation, the final electron acceptor is pyruvate, not oxygen.
Electrons are transferred from the NADH molecule to
produced at any given time varies and is dependent on
pyruvate, which generates NAD+. This helps generate ATP
numerous factors (Figure 12-65).
through glycolysis. Fermentation is very inefficient and
produces only 2 ATP, compared to 36 ATP from cellular
Fermentation respiration.
An alternative pathway to energy production is available Two types of fermentation can occur in humans: lac-
during times when oxygen is unavailable. The breakdown tic acid fermentation and alcohol fermentation. As just
of glucose without oxygen is called fermentation. discussed, NADH passes electrons directly to pyruvate.
 Pathophysiology 279

Citric Acid Cycle (in mitochondrion) 'NGEVTQP6TCPURQTV%JCKP

KPPGTOGODTCPGQHOKVQEJQPFTKQP

Acetyl CoA, the 6JGOQNGEWNGUQH0#&*CPF(#&*

two-carbon compound RTQFWEGFD[GCTNKGTRJCUGUQH
formed during the EGNNWNCTTGURKTCVKQPRCUUVJGKT
transition reaction, GNGEVTQPUVQCUGTKGUQHRTQVGKP
enters the citric acid OQNGEWNGUGODGFFGFKPVJGKPPGT
The citric acid cycle also cycle. OGODTCPGQHVJGOKVQEJQPFTKQP
yields several molecules of
FADH2 and NADH, carriers
of high-energy electrons Acetyl CoA
that enter the electron
transport chain. C C CoA *KIJ

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

NADH The citric acid cycle yields .QY

one ATP from each acetyl *111
CoA that enters the cycle, 'PGTI[TGNGCUGFKUWUGF
for a net gain of two ATP. HQTU[PVJGUKUQH#62

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.)

Clinical Note increased respirations. Very high levels of exposure result in

an abrupt loss of consciousness, respiratory depression, and
Hydrogen cyanide gas and cyanide salts are among the most
cardiac arrest.
rapidly acting of all known poisons. Even small concentra-
An antidote, called hydroxocobalamin, is effective in
tions are extremely hazardous. Cyanide is a byproduct of the
the treatment of cyanide poisoning if given early enough.
combustion of burning rubber and plastic and is often found
Hydroxocobalamin is a precursor to cyanocobalamin
in smoke from fires. Cyanide binds to the iron in the enzyme
­(vitamin B12). When administered, it removes the cyanide
of the fourth complex in the electron transport chain (cyto-
molecule, the cytochrome oxidase (forming harmless vita-
chrome oxidase). This deactivates the enzyme, thereby pre-
min B12), thus allowing the cell to resume normal metabolic
venting the final transport of electrons from cytochrome
­processes.
oxidase to oxygen. Thus, the electron transport chain is dis-
rupted, and the cell can no longer produce ATP aerobically
for energy. Recent research has shown that carbon monoxide
(CO) acts on cytochrome oxidase in a similar fashion, but to a Pyruvate is converted by an enzyme called lactate dehy-
lesser degree. drogenase (LDH) into the waste product known as lac-
The signs and symptoms of cyanide intoxication are
tate or lactic acid (lactate is the anion of lactic acid).
dose dependent. Low to intermediate levels of exposure
During periods of extreme stress or exercise, oxygen lev-
produce vague and nonspecific symptoms such as head-
els in muscle tissue become low. In this case, muscle tis-
ache, vertigo, nausea, and vomiting. Higher levels of expo-
sure can result in altered mental status, seizures, and sues may use lactic acid fermentation to generate ATP
(Figure 12-66).
280  Chapter 12

are necessary to restore sta-

2 ADP 1 2 Pi 2 ATP Content Review
bility when it is disrupted.
➤➤ Cellular Adaptation
2 NAD1 Severe stresses and patho-
• Hyperplasia
Glycolysis logical conditions may
• Hypertrophy
require the cell itself to
• Atrophy
2 NADH change. Such physiologic • Metaplasia
and structural changes to
the cell, in response to change or stress, are referred to as
Muscle
cells cellular adaptation.
C C C
2 Pyruvate Cellular Adaptation
C C C There are several possible cellular responses to an increase
in stress. Some cellular responses can come in the form of
normal growth, whereas others involve abnormal changes
in size or function. There are two types of normal-growth
responses to cellular stress: an increase in the number of
C C C
cells (hyperplasia) and an increase in the size of the cells
2 Lactate
(hypertrophy). Other types of responses to stress may
C C C involve a decrease in the size and function of the cell (atro-
phy) or a change from one cell type to another (metaplasia)
Figure 12-66  Lactic acid fermentation does not require oxygen and
yields two molecules of ATP per molecule of glucose.
(Figure 12-67).
(Goodenough, Judith and Betty A. McGuire, Biology of Humans: Concepts,
­Applications, and Issues, 3rd Edition, © 2010. Reprinted by permission of Pearson Hyperplasia
Education, Inc., Upper Saddle River, NJ.) An increase in the number of cells in a tissue or organ is
termed hyperplasia. This usually results in the tissue or
Alcohol fermentation is more complex. In alcohol organ in question increasing in size. Hyperplasia can be
fermentation, a molecule of carbon dioxide is removed divided into two functional categories: hormonal hyper-
from pyruvate, leaving a two-carbon molecule called plasia and compensatory hyperplasia. Hormonal hyper-
acetaldehyde. With alcohol fermentation, electrons are plasia results from stimulation by hormones. Examples of
not passed to pyruvate. Instead, NADH passes electrons hormonal hyperplasia are the development of the breasts
to acetaldehyde, forming ethanol (ethyl alcohol). during puberty and enlargement of the breasts during
pregnancy. Compensatory hyperplasia is an increase in tis-
sue mass following tissue injury or loss. An example of

Cellular Response to Stress compensatory hyperplasia is regeneration of the liver fol-

lowing partial hepatic lobectomy.
The cell normally functions within a stable environment. It Sometimes hyperplasia is pathological. That is, if the
can react to changes in its environment through homeosta- hyperplasia is not compensatory and is not due to hor-
sis, the tendency of the body to initiate whatever processes monal stimulation (or does not revert to normal after hor-
monal stimulation is removed),
Cellular Adaptation the process may be pathologi-
cal and a possible precursor of
Normal cancer.
Nucleus
Basement membrane Hypertrophy
An increase in the size of cells
in a tissue or organ is referred
to as hypertrophy. Hypertro-
Hyperplasia Hypertrophy Atrophy Metaplasia Dysplasia phy is not due to the cells
swelling. Instead, it is due to
the creation of more structural
components (i.e., organelles)
Figure 12-67  Abnormal cell responses to stress include hypertrophy, hyperplasia, atrophy, metapla- within the cell. An organ that is
sia, and dysplasia. hypertrophied does not contain
 Pathophysiology 281

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

Phagocytic cell Cervical Dysplasia

Figure 12-69  The process of apoptosis. Once the cell is dead, Normal cervix
fragments called apoptotic bodies are cleared by scavenger cells
(phagocytosis).

genetic material within the nucleus of the cell and

selected proteins in the cytoplasm. Fragments of the dead
cell (apoptotic bodies) are then cleared by scavenger cells
before the toxic contents leak out and cause inflamma-
tion (Figure 12-69). Normal cervical cells
Apoptosis can be physiologic or pathological. Causes
of physiologic apoptosis include the programmed destruc-
Cervical dysplasia
tion of the cell just described, involution of the cell follow-
ing removal of a hormonal stimulus, normal cell deletion
in areas where there is a proliferating cell population, cells
that have served their purpose, elimination of cells that are
potentially harmful to the organism, and through a defen-
sive mechanism in which cytotoxic cells of the immune
system cause the cell death.
Pathological apoptosis results from cell death sec-
ondary to cell injury, cell death from viral infections, cell
death from atrophy after destruction or blockage of a Cancerous or
duct, and cell death in tumors. Even in cells that die by pre-cancerous cells
necrosis, there may be a component of apoptosis present
Figure 12-70  Cervical dysplasia is the presence of abnormal,
to help minimize the possibility of an inflammatory precancerous cells on the surface of the cervix or its canal.
response.
284  Chapter 12

immature squamous metaplastic epithelial cells. Trauma, PART 4: Disease

chronic irritation, and cervical infections play a role in the
development and maturation of the squamous epithelium of at the Tissue Level 
the cervix. The squamocolumnar junction is the point at
which cervical dysplasia often arises and should be moni- Tissues
tored yearly through a sampling called a Pap smear (more
A group of cells that serve a common purpose is called a
frequently if there is a history of cervical dysplasia).
tissue. There are four general categories of tissue: epithe-
It has been established that there is a relationship
between the human papillomavirus (HPV) and cervical dys-
lial, connective, muscle, and nervous. The study of tissues
plasia and cancer. In fact, more than 90 percent of women is called histology. The study of abnormal or diseased tis-
with cervical cancer carry HPV. HPV is the virus that causes sue is called histopathology.
genital warts and is quite common, affecting more than 24 In this section we describe the types of tissue as they
million Americans. The warts are sometimes hard to detect, apply to emergency care. In addition, we discuss the devel-
as they can be skin colored or occur only in the vagina. opment of cancerous tissues and factors that contribute to
The risk of cervical dysplasia is increased in women the process.
who have multiple sex partners, who had unprotected sex at
a young age (under 18) or with partners who have had mul-
tiple partners, who have a history of sexually transmitted Origin of Body Tissues
diseases, or who smoke cigarettes.
All the tissues of the body are derived from three distinct
Cervical dysplasia, carcinoma in situ, and cervical can-
cer can be successfully treated if detected early enough. A
cell lines seen during early embryonic development.
vaccine is now available that can protect women against About two weeks after conception, the cells of the embryo
HPV infection, which helps to mitigate the chances of cervi- start to differentiate into three layers (Figure 12-71). These
cal cancer. cell layers are referred to as germ layers and consist of
primitive cell types that differentiate into the various

Germ Cell Theory

Nerve cord Amniotic fluid Embryo in the third week

Skin Ammon

Heart
Digestive tract
Brain
Chorion

Tail end

Body stalk with

umbilical vessels

Endoderm Mesoderm Ectoderm

Liver and associated ducts Skeletal muscles Skin, glands, hair, nails
Pancreas Cardiac muscle Epithelium
Epithelium of the auditory tube and Smooth muscle Lens and cornea of the eye
tympanic cavity Kidney tissues Pigment cells
Trachea, bronchi, and alveoli (except the Fibrous tissue Peripheral nervous system
nasal cavity) Bone and cartilage Adrenal medulla
Urinary bladder and part of the urethra Fat (adipose) tissue Meninges
Lining of follicles in the thyroid and thymus Blood and lymph vessels Facial cartilage
glands Blood cells Dentin in teeth
Brain
Spinal cord and motor neurons
Retina
Posterior pituitary

FIGURE 12-71  Embryonic germ layers: endoderm, mesoderm, and ectoderm.

 Pathophysiology 285

Germ Cell Differentiation

Ectoderm Germ cells

(External Layer) Sperm
Skin cells of epidermis Egg
Neuron of brain
Pigment cell

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

• Facial cartilage Epithelial Tissue CONTENT REVIEW

• Dentin (in teeth) Epithelial tissue includes
➤➤ Tissue Types
• Neural tube the epithelia (plural of epi- • Epithelial tissue
thelium) and the glands • Connective tissue
• Brain
associated with the epi- • Muscle tissue
• Spinal cord and motor neurons thelia (Figure 12-73). The • Nervous tissue
• Retina epithelium forms a bar-
• Posterior pituitary rier between the organism and the environment. The
specific characteristics of epithelial tissues include the
Epithelium is derived from all three germ layers. In following:
summary, cells from the endoderm form the epithelial lin-
ing inside viscera, cells from the mesoderm form the lining • Epithelial tissue covers surfaces with an uninter-
outside viscera, and cells from the ectoderm become the rupted layer of cells.
epithelium in skin. • Epithelial cells are attached to one another.
• Intercellular spaces in epithelia are small.
Tissue Types • Epithelial cells are polarized.
The germ layers just described ultimately differentiate into • Epithelial cells are separated from the underlying tis-
four primary tissue types: sue by a basement membrane.
• Epithelial tissue. Epithelial tissues cover the body • There is an absence of blood vessels within epithe-
surfaces. In addition, they line all passageways that lial ­tissue.
communicate with the outside.
Distribution of the epithelial tis-
sues includes the interior of body Stratified squamous

cavities, the l­ining of organs and

blood vessels, the outer layers of
skin, and others.
Simple squamous
• Connective tissue. Connective tis-
sues provide a framework on
which epithelial tissue rests and
within which nerve tissue and
muscle tissue are embedded. Blood
vessels and nerves travel through
Stratified cuboidal
connective tissue. Connective tis-
sue not only functions as a
mechanical support for other tis- Simple cuboidal
sues but also provides an avenue
for communication and transport
among other tissues. Connective
tissues play a major role in protect-
ing the body through immunity
and inflammation.
• Muscle tissue. Muscle tissues are Pseudostratified columnar
responsible for the movement of Simple columnar
the organism and for movement of
substances through the organism.
• Nervous tissue. Nerve tissues
coordinate the activities of the
body. They are capable of conduct-
ing electrical impulses from one
region of the body to another. Most
nervous tissue is found within the
brain and the spinal cord. FIGURE 12-73  Types and locations of epithelial tissue.
 Pathophysiology 287

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.

Table 12-10  Types of Epithelial Tissue

Shape Number of Layers Example Locations Functions
Squamous (flat, scale-like cells) Simple (single layer) Linings of heart and blood vessels; Allows passage of materials
air sacs of lungs by diffusion

Striated (multilayers) Linings of mouth, esophagus, Protects underlying areas

vagina; outer layer of skin

Cuboidal (cube-shaped cells) Simple Kidney tubules; secretary portions Secretion; absorption
of glands and ducts

Striated Ducts of sweat glands, mammary Protects underlying areas

glands, salivary glands

Columnar Simple Most of digestive tract; bronchi; Absorbs; secretes mucus,

excretory ducts of some glands; uterus enzymes, and other substances

Striated Rare: urethra; junction of esophagus Protects underlying areas;

and stomach secretes mucus
288  Chapter 12

Exocrine Secretions • Transitional epithelia—found in areas where there is a

need for protection and where there are significant
changes in volume that can give rise to changes in
physical factors such as pressure. Transitional cells are
found in the ureters and urinary bladder.
• Stratified squamous epithelia—found in areas where
mechanical stresses are severe. These include the sur-
face of the skin and the lining of the mouth, tongue,
esophagus, vagina, and anus.
• Glandular epithelia—selected types of epithelia produce
Merocrine Apocrine Holocrine
exocrine secretions. These are secreted by one of three
methods (Figure 12-74):
Multicellular
exocrine gland Method of Secretion Examples • Merocrine secretion—the secretion is released
1. Merocrine Watery serous fluid or mucus • salivary glands through exocytosis (the most common method).
secreted through the cell • pancreatic glands
membrane. • some sweat glands • Apocrine secretion—the part of the cell containing the
2. Apocrine The part of the cell containing • some sweat glands secretion “pinches” off and then releases the secretion.
the secretion “pinches” off and • mammary glands
then releases its contents. • Holocrine secretion—the entire cell is packed with secre-
3. Holocrine Cells fill up with secretion and • sebaceous glands tions and then bursts apart and dies in the process.
then burst, releasing their product.

FIGURE 12-74  Multicellular exocrine glands and their methods of

Connective Tissue
secretion. Connective tissues are deep tissues that are never exposed
to the external environment (Figure 12-75). They bind

Dense Connective Tissue

Loose Connective Tissue

Fat cells
Dermis (Adipose tissue)
Blood vessels
Loose Connective Tissue

Subcutaneous
Other layer
connective
tissue cells Areolar tissue
Fat cell

Collagen and Dense Connective Tissue

elastic fibers

Bone

Tendon
Bone cells
Blood vessels

Cartilage Cartilage
covering
end of
bone

Cartilage
cells

FIGURE 12-75  Types and locations of connective tissues.

 Pathophysiology 289

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).

Table 12-11  Types of Connective Tissue

Type Example Locations Functions
Connective Tissue Proper

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

Dense Tendons, ligaments Attaches bone to bone (ligaments) or bone

to muscle (tendons)

Specialized Connective Tissue

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

Bone (solid) Skeleton Provides support and protection (by enclosing)

and levers 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

Skeletal muscle Smooth Striated

Involuntary Voluntary
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

Table 12-12  Types of Muscle Tissue

Type Description Example Locations Functions
Skeletal Long, cylindrical cells; multiple nuclei Muscles attached to bones Provides voluntary movement
per cell; obvious striations

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

Neuroglia Cancer Development

Cell with genetic mutation

Capillary

Hyperplasia

Dysplasia
Three kinds of neuroglia:
astrocyte (purple)
oligodendrocyte (blue)
microglia (green)

FIGURE 12-78  Neuroglia.

to stress. However, some cells will develop abnormal In situ cancer

growth patterns. When these cells are examined under a

microscope, some of the cells may look abnormal. Such
cells are called dysplastic or atypical. Most often the
abnormalities are seen in the nucleus of the cell. A com-
mon example of dysplasia is abnormal cervical cells
found on a Pap smear. These vary in their level of dyspla-
Invasive cancer
sia with the highest level being considered cancerous (car-
cinoma in situ). (Figure 12-79)
Neoplasia, by definition, means “new growth.” The
tumors may be benign or malignant. Benign and malig-
nant tumors have different characteristics. For example,
benign neoplastic lesions are slow growing, are usually
Movement through the bloostream

FIGURE 12-80  Abnormal cell development, progressing to invasive

Differentiation cancer.

encased by cells that are adherent, do not invade local

tissue, do not spread to other body areas, and do not
recur once removed. Cancerous tumors have the oppo-
site characteristics. They grow fast and are not encapsu-
lated, thus making removal more difficult. Malignant
cells do not adhere together well, thus allowing cancer-
ous cells to shed to other areas of the body—often
through the bloodstream in a process called metastasis.
Cancer is locally invasive (Figure 12-80), and recurrence
(a) Hypertrophy (b) Hyperplasia (c) Dysplasia (d) Metaplasia
is common.
• Increase in cell size • Increase in • Disorganized • Disorganized Most cancers are either of epithelial origin or connec-
• Normal organization cell number growth growth
tive tissue origin. Some tumors contain cells that are so
• Normal • Net increase
organization in number of undifferentiated that the cell of origin cannot be deter-
dividing cells mined (Table 12-13).
FIGURE 12-79  Processes of cell differentiation: hypertrophy, hyper- Various factors have been associated with the develop-
plasia, dysplasia, neoplasia. ment of cancer, termed oncogenesis. Among these oncogenic
 Pathophysiology 293

Table 12-13  Tumor Origins and Names

Origin/Prefix Cell Type Benign Tumor Malignant Tumor
Epithelial

Adeno- Gland Adenoma Adenocarcinoma

Basal cell Basal cell Basal cell adenoma Basal cell carcinoma

Squamous cell Squamous cell Keratoacanthoma Squamous cell carcinoma

Melano- Pigmented cell Mole Melanoma

Terato- Multipotential cell Teratoma Teratocarcinoma

Supporting/Connective

Chandro- Cartilage Chondroma Chondrosarcoma

Fibro- Fibroblast Fibroma Fibrosarcoma

Hemangio- Blood vessel Hemangioma Hemangiosarcoma

Leiomyo- Smooth muscle Leiomyoma Leiomyosarcoma

Lipo- Fat Lipoma Liposarcoma

Meningio- Meninges Meningioma Meningiosarcoma

Myo- Muscle Myoma Myosarcoma

Osteo- Bone Osteoma Osteosarcoma

Rhabdomyo- Striated muscle Rhabdomyoma Rhabdomyosarcoma

Blood/Lymphatic

Lympho- Lymphocyte Lymphoma or lymphocytic leukemia

Erythro- Erythrocyte Erythrocytic leukemia

Myelo- Bone marrow Myeloma or myelogenous leukemia

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

Oncogenesis resulting radiation. Subsequently, that nuclear

disaster has produced the biggest group of can-
Healthy cell cers ever from a single incident, with almost 2,000
cases of thyroid cancer being documented since
Protein production the reactor explosion. Consequences of the dis-
Exposure to ruptions to nuclear power plants in Japan result-
carcinogens ing from the severe earthquake and tidal wave in
DNA (chemicals, drugs)
or radiation 2011 are yet to develop and be analyzed.
DNA breaks apart. Hormones are thought to play a role in the
DNA recombines development of certain cancers. Some tumors,
incorrectly, which especially tumors of the breast, have been found
may form an
oncogene. to have receptors for the female hormone estro-
Replication gen. Breast cancers with estrogen receptors have
increased growth while estrogen is present and
Oncogene decreased growth or even tumor regression when
The DNA and cell estrogen is removed. The administration of estro-
produce excessive
and abnormal
gen to men with prostate cancer sometimes inhib-
proteins. its cancer growth.
The cell transfers The process of developing a malignant neo-
Daughter cells into a cancer cell.
plasia is called carcinogenesis and occurs in three
stages: initiation, promotion, and progression
The cancer cell replicates its DNA and
divides, forming daughter cells with an (Figure 12-82). Initiation is the event that begins
identical oncogene. Replication the transformation from normal tissue to cancer.
continues, causing the cancer to grow As just discussed, the factor may be a carcinogen,
and spread.
radiation, or a combination of factors. Initiation
FIGURE 12-81  Oncogenesis (development of cancer). does not mean that malignancy will ultimately
develop, just that the process has started. For
example, a carcinogen such as tar from tobacco
(benzidine) in the ink. Again, in these cases there is an will bind to the DNA in the susceptible cells, causing errors
identified carcinogen. in replication and the subsequent formation of dysplastic
Our environment is so diverse and there are so many daughter cells. Dysplasia can result in anaplasia.
possible carcinogens present that many have not been The second phase is promotion. A promoter can be a
clearly linked to the development of cancers. Radiation is carcinogen or any of the factors discussed earlier that are
also present in the environment. For example, the inci- associated with cancer development. Promotion is neces-
dence of thyroid cancers increased markedly in Japan after sary for the continued development of the tumor and
the United States dropped atomic bombs on the cities of speeds up the process. The growth rate increases because
Nagasaki and Hiroshima in 1945. When the nuclear reactor the cells divide more rapidly. During promotion, cells
at the Chernobyl nuclear plant in Ukraine exploded in begin to change from dysplasia to anaplasia. However, the
1986, more than five million people were exposed to the promotion stage is still considered precancerous.

Carcinogenesis

Initiation Promotion Progression

Carcinogen Cell multiplication Malignant tumor

FIGURE 12-82  Carcinogenesis (development of a malignant neoplasia).

 Pathophysiology 295

The last stage in carcinogenesis is progression. At this

point, a malignancy exists and the cells are anaplastic in
PART 5: Disease
appearance. The more poorly differentiated and primitive
the cells are in appearance, the faster will be the growth of
at the Organ Level
the tumor. Progression is followed by growth and, subse-
quently, local tissue invasion and possible metastasis.
Genetic and Other
Unfortunately, in many cases, cancer is not diagnosed until
this stage of carcinogenesis.
Causes of Disease
Once cancer develops, it becomes invasive. If the When we think of disease at the organ level, at the level
affected tissue is a squamous epithelium, and the tumor of organ systems, and at the level of the total human
has not extended past the basement membrane, it is con- organism, we are likely to think first of infections caused
sidered carcinoma in situ. Cancer spreads along tissue by pathogens, including bacteria, viruses, fungi, and par-
planes and attaches to various tissues. Sometimes, individ- asites. In recent years, great strides have been made in
ual cells or clumps of cells will be shed from the primary the medical treatment of infectious diseases, but—as we
tumor and travel through a blood vessel or lymphatic have been discussing throughout this chapter—many
channel to another part of the body, where they will begin diseases result from genetic causes, which have been far
to develop a secondary tumor (metastasis). The distal more difficult to identify and treat. The picture is addi-
spread of tumor cells makes treatment difficult and often tionally complicated by the fact that many diseases result
causes death. from a combination of genetic and environmental factors
Cancer cells are usually graded by the degree of cell (including lifestyle factors), as well as factors such as age
differentiation present. The grade affects the prognosis and gender.
(likely outcome). The grading system is as follows: Even a family history of a particular disease does not
necessarily mean that the disease has a purely genetic ori-
• Grade X. The grade cannot be assessed (undetermined gin, because families also share environmental and lifestyle
grade). Prognosis: undetermined. factors that may cause or contribute to the family disease.
• Grade 1. The cells are well differentiated and closely Although family history may point to the possibility of
resemble the cells of the tissue of origin. Few mitotic genetic causes, these cannot be confirmed, much less
figures (cells undergoing division) are seen (low treated, until scientists are able to make definitive identifi-
grade). Prognosis: good. cations of the defective genes or chromosomes that cause
• Grade 2. The cells are moderately differentiated, with or contribute to particular diseases.
some structural similarity to the tissue of origin. Mod- At present, there is increasing progress in identifying
erate mitotic figures are seen (intermediate grade). and understanding genetic and other noninfectious causes
Prognosis: fair. of disease. Many promising advances toward gene thera-
pies (the replacement of defective genes with normal
• Grade 3. The cells are poorly differentiated, with little
genes) and other therapies for diseases have been made.
resemblance to the tissue of origin. Many mitotic fig-
ures are seen (high grade). Prognosis: fair to poor.
• Grade 4. The cells are undifferentiated or dedifferenti- Genetics, Environment,
ated, appear bizarre and primitive, and do not Lifestyle, Age, and Gender
resemble the tissue of origin. Many mitotic figures are
As noted earlier, our inherited traits are determined by
seen (high grade). Prognosis: poor.
molecules of deoxyribonucleic acid, or DNA, which form
Grading is somewhat subjective. Nevertheless, the higher structures called genes that reside on larger structures
the grade, the more the cells are undifferentiated and the called chromosomes within the nuclei of all our cells. We
worse the prognosis. inherit our genetic structure from our parents. Every one of
Often, cancer is staged based on numerous findings, a person’s somatic cells (all the cells except the sex cells)
but primarily indicating the degree to which the cancer is contains 46 chromosomes. The sex cells, however, contain
spread. Stages 1 to 4 are usually described, with stage 1 only 23 chromosomes each. The sex cells contribute these
being the least advanced state of the cancer’s progression 23 chromosomes to the offspring. Thus, the offspring
and stage 4 being the most advanced. Staging is usually receives 23 chromosomes from the father and 23 chromo-
based on the size of the tumor, whether lymph nodes con- somes from the mother, resulting in a total of 46 chromo-
tain cancer, and whether the cancer has spread from the somes. Occasionally, one or more of a person’s genes or
original site to other parts of the body. Staging is particu- chromosomes is abnormal; this may cause a congenital dis-
larly important in planning treatment strategies and in ease (one we are born with) or a propensity toward acquir-
determining the prognosis. ing a disease later in life.
296  Chapter 12

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

Hematologic Disorders approximately 20 to 40 percent of the causation of hyper-

Hereditary coagulation disorders have been studied by tension is genetic. The remaining causative factors, then,
geneticists and physicians in great detail. Hereditary are environmental, and may include high sodium inges-
hematologic disorders have many causes, such as gene tion, lack of physical activity, stress, and obesity.
alteration and histocompatibility (tissue interaction) Not all cardiac disorders have a genetic component.
dysfunctions. For example, cardiomyopathy (disease affecting the heart
Hemophilia is a bleeding disorder that is caused by a muscle) is thought to occur secondarily to other causes,
genetic clotting factor deficiency. It can be mild, but if such as infectious disease, toxin exposure, connective tis-
severe, it can cause not only serious bruising but also sue disease, or nutritional deficiencies, which may be par-
bleeding into the joints, which can lead to crippling tially or totally environmental.
deformities. A slight bump on the head can cause bleed-
ing within the skull, often resulting in brain damage and Renal Disorders
death. The heredity is sex linked (associated with the sex Renal (kidney) failure is caused by a variety of factors (pri-
chromosomes), inherited through the mother, and affects marily hypertension) that may eventually require a patient
male children almost exclusively. There is no cure, but to receive dialysis treatment several times a week. As the
administration of concentrated clotting factors can location of dialysis treatment shifts from medical centers to
improve the condition. homes and community satellite centers, EMS personnel are
Hemochromatosis is another genetic disorder, but this increasingly being called to deal with the complications of
time it is caused by a histocompatibility complex dysfunc- dialysis. These include problems with vascular access
tion. It is marked by excessive absorption and accumulation devices (shunts, fistulas), localized infection and sepsis,
of iron in the body, causing weight loss, joint pain, abdomi- and electrolyte abnormalities (hyperkalemia), which can
nal pain, palpitations, and testicular atrophy in males. It is result in cardiac arrest.
treated by removing blood from the body at intervals.
Not all blood disorders are genetic. Environmental fac- Rheumatic Disorders
tors, for example, can cause anemia (reduction in circulat- Gout is a condition that may have both genetic and envi-
ing red blood cells). For instance, some antihypertensive ronmental causes. It is characterized by severe arthritic
medications and other drugs may cause a drug-induced pain caused by deposit of crystals in the joints, most com-
hemolytic (red-blood-cell–destroying) anemia. monly in the great toe. The crystals form as the result of an
abnormally high level of uric acid in the blood that may be
Cardiovascular Disorders caused when the kidneys do not excrete enough uric acid
The cardiovascular system can be greatly affected by or by high production of uric acid. High production of uric
genetic disorders. Disorders such as prolongation of the QT acid may be caused by a hereditary metabolic abnormality.
interval (a delay between depolarization and repolarization Although the underlying cause may be genetic, attacks of
of the ventricles as revealed in an electrocardiogram) and gout can be triggered by environmental factors such as
mitral-valve prolapse (an upward ballooning of the valve trauma, alcohol consumption, ingestion of certain foods,
between the left ventricle and atrium that allows blood to stress, or other illnesses. Patients with gout also have a ten-
regurgitate back into the atrium when the ventricle con- dency to develop kidney stones.
tracts) tend to cluster in families.
The American Heart Association lists heredity as a Gastrointestinal Disorders
major risk factor for cardiovascular disease. Those with Gastrointestinal disorders have a variety of causes, and the
parents who have coronary artery disease (deposits on the causes of some are not known. Lactose intolerance, for exam-
walls of the coronary arteries that reduce blood flow to the ple, is usually identified by the inability of the patient to
heart muscle) have an approximately fivefold greater risk tolerate milk and some other dairy products. The patient
of developing the disease than those whose parents do not lacks lactase, the enzyme that usually breaks down lactose
have it. This is why it is important to ask about family his- in the digestive tract. This enzyme deficiency may be con-
tory of congenital heart disease (CHD), hypertension, and genital (inborn) or may develop later on. It is more com-
stroke when assessing patients with possible cardiovascu- mon in those of Asian, African, Native American, or
lar disease. However, environmental factors, such as a diet Mediterranean ancestry than it is among northern and
high in saturated fats and cholesterol (or a diet high in car- western Europeans.
bohydrates) and lack of exercise, also play a large role in Crohn’s disease is a chronic inflammation of the wall of
cardiovascular disease. the digestive tract that usually affects the small intestine,
Hypertension (high blood pressure) is a major risk fac- the large intestine, or both. The cause is not known, but
tor not only for cardiac disease, but also for stroke and medical researchers have focused on immune system dys-
kidney disease. Studies of family history show that function, infection, and diet as the major probabilities. A
 Pathophysiology 299

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.

Neuromuscular Disorders The Physiology of Perfusion

Diseases of the nervous and muscular systems also have a As discussed earlier, all body cells require a constant sup-
variety of causes. Huntington’s disease (which results in ply of oxygen and other essential nutrients (primarily glu-
uncontrollable jerking and writhing movements) and mus- cose), whereas waste products, such as carbon dioxide,
cular dystrophy (which results in progressive muscle must be constantly removed. The circulatory system, in
weakness) are both known to be caused by genetic defects. conjunction with the respiratory and gastrointestinal sys-
Multiple sclerosis (which affects the nerves of the eye, tems, provides the body’s cells with these essential nutri-
brain, and spinal cord) seems to have some hereditary fac- ents and removal of wastes. This is accomplished by the
tor, with clustering among close relatives. Its exact cause is passage of blood through the capillaries, the small vessels
unknown, but it seems to result when the virus-triggered that interface with body cells, while oxygen, carbon diox-
autoimmune response begins to attack the myelin sheath ide, nutrients, and wastes are exchanged by movement
that protects the nerves. across the capillary walls and cell membranes. This con-
Alzheimer’s disease is thought to cause about 50 percent stant and necessary passage of blood through the body’s
of dementias, or progressive mental deterioration. Its cause tissues is called perfusion.
is unknown, but it does cluster strongly in families and Inadequate perfusion of body tissues is hypoperfu-
appears to be either caused or influenced by specific gene sion, which is commonly called shock. Shock occurs first
abnormalities. at a cellular level. If allowed to progress, the tissues, organs,
organ systems, and, ultimately, the entire organism are
Psychiatric Disorders affected.
Genetic and biological causes of psychiatric disorders are
being studied and increasingly understood. An example is Components of the Circulatory System
schizophrenia, which affects about 1 percent of the popula- Perfusion is dependent on a functioning and intact circu-
tion worldwide and is more prevalent than Alzheimer’s latory system. A derangement in any component of the
300  Chapter 12

increasing the amount of blood delivered to the heart. The

greater the preload, the greater the stroke volume.
Preload also affects cardiac contractile force. The
greater the volume of preload, the more the ventricles are
stretched. The greater the stretch, up to a certain point, the
Container greater will be the subsequent cardiac contraction. This is
referred to as the Frank-Starling mechanism and can be illus-
trated through the example of a rubber band. The more the
rubber band is stretched, the greater will be its velocity
when released.
In addition, cardiac contractile strength is affected by
circulating hormones called catecholamines (epinephrine
and norepinephrine) controlled by the sympathetic ner-
vous system. Catecholamines enhance cardiac contractile
Pump
strength by action on the beta-adrenergic receptors on the
surface of the cells.
Finally, stroke volume is affected by afterload. After-
load is the resistance against which the ventricle must con-
tract. This resistance must be overcome before ventricular
contraction can result in ejection of blood. Afterload is
Volume (blood within determined by the degree of peripheral vascular resistance
circulatory system) (defined later). This, in effect, is due to the amount of vaso-
constriction present. The arterial system can be expanded
FIGURE 12-83  Components of the circulatory system.
and contracted to meet the metabolic demands of the body.
The greater the resistance offered by the arterial system,
system can adversely affect perfusion (Figure 12-83). The the less the stroke volume.
three components of the circulatory system are: The amount of blood pumped by the heart in 1 minute
• The pump (heart) is referred to as the cardiac output. It is a function of stroke
volume (milliliters per beat) and heart rate (beats per min-
• The fluid (blood)
ute). Cardiac output is usually expressed in liters per min-
• The container (blood vessels) ute. It can be defined by this equation:

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.

• Afterload Cardiac output * Peripheral vascular resistance = Blood pressure

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

the adrenal gland) is stimulated. This results in the secre- CVP

tion of epinephrine and norepinephrine, which further Renin

enhance the response. CO Release

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

Anaerobic metabolism Aerobic metabolism

(without oxygen) (with oxygen) 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

Increased Serum Release of Catecholamines, Cortisol, and Acidosis Causes

Anaerobic
Glucose Levels Growth Hormone Decreased Oxygen Affinity
Metabolism
for Hemoglobin

Increased Increased Lipid Increased Increased

Pyruvic Acid Breakdown Glucose Glycogen Increased Lactic Decreased
(Lipolysis) Production Breakdown Acid Energy (ATP)

Increased Triglycerides Decreased Metabolic Decreased Sodium/

and Fatty Acids Energy Reserves Acidosis Potasium Pump

Increased Protein Influx of intracellular

Breakdown sodium and water

Increased Serum Decreased Serum Increased Amino Decreased Circulatory

Cellular Edema
Alanine Albumin Acids Volume

Decreased Colloid
Cellular Rupture
Osmotic Pressure

Loss of Worsening Release of Digestive Inflammatory Activation of

Intravascular Fluid Hypotension Lysosomal Enzymes Response Clotting Cascade

FIGURE 12-86  The pathogenesis of shock in the human.

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

Pathogenesis of Cardiogenic Shock

Systolic Diastolic
Dysfunction Myocardial Dysfunction Dysfunction

Decreased Decreased Stroke Increased Left

Cardiac Output Volume Ventricular End-
Diastolic
Pressure
(LVEDP)
Activation of Antidiuretic
Increased Catecholamine
Renin/Angiotensin Hormone (ADH)
Aldosterone Release
System Release Pulmonary
Congestion

Increased
Increased Systemic
Blood Volume Vascular
Resistance

Increased Preload
Increased Heart Rate
Increased Stroke Volume

Increased Cardiac Work

Increased Myocardial Oxygen Use

Decreased Cardiac Output Fall in Blood

Decreased Ejection Fraction Pressure

Decreased
Tissue Perfusion

Impaired Cellular
Metabolism

FIGURE 12-87  The pathogenesis of cardiogenic shock.

brain) and oliguria (diminished urination resulting from • Traumatic injury

compensatory mechanisms that stimulate reabsorption of • Long bone or open fractures
water by the kidneys to enhance circulating volume).
• Severe dehydration from vomiting or diarrhea
Treatment of cardiogenic shock includes the support-
ive measures that should be provided for shock of any ori- • Plasma loss from burns
gin: Ensure an open airway, administer supplemental • Excessive sweating
oxygen if the patient is hypoxic and assist ventilations if • Diabetic ketoacidosis with resultant osmotic diuresis
necessary (to support oxygenation of myocardial and other
Hypovolemic shock can also be due to internal third-
body cells), and keep the patient warm (because impaired
space loss (loss from intracellular or, more commonly, from
cellular metabolism is no longer producing enough energy
intravascular spaces into the interstitial spaces). Such a con-
to keep body temperature normal).
dition can occur with bowel obstruction, peritonitis, pan-
Hypovolemic Shock creatitis, or liver failure resulting in ascites (accumulation of
Shock due to a loss of intravascular fluid volume is referred fluid within the abdominal cavity) (Figure 12-88).
to as hypovolemic shock. Possible causes of hypovolemic
EVALUATION AND TREATMENT  The signs of hypo-
shock include:
volemic shock are considered the “classic” signs of shock.
• Internal or external hemorrhage (This type of hypovo- The mental status becomes altered, progressing from anxi-
lemic shock is also known as hemorrhagic shock.) ety to lethargy or combativeness to unresponsiveness. The
 Pathophysiology 309

quite controversial. It has been

Pathogenesis of Hypovolemic Shock demonstrated that the body pro-
vides a natural compensation for
Decreased Intravascular
Fluid Volume
low-flow states when the sys-
tolic pressure is maintained
between 70 and 85 mmHg. In a
few studies, elevating the sys-
tolic blood pressure to greater
Decreased than 85 mmHg has been associ-
Cardiac
Output ated with worsened outcomes.
The worsened outcomes are
attributed to the fact that aggres-
Splenic Antidiuretic Increased sive fluid resuscitation, before
Interstitial Aldosterone
Discharge Hormone
Fluid Shift Release
Catecholamine the source of bleeding is
(ADH) Release Release
repaired, causes progressive
dilution of the blood, which
Increased Increased decreases the oxygen-carrying
Intravascular Heart Rate capacity of the blood. Thus,
Volume Increased
Stroke Volume
many surgeons and EMS medi-
cal directors are now recom-
Increased mending administering only
Cardiac enough fluid to maintain a sys-
Output
tolic blood pressure between
70  and 85 mmHg—a process
Continued called “permissive hypotension.”
Fluid
Loss
Neurogenic Shock
Neurogenic shock results from
Decreased Systematic Decreased injury to either the brain or the
and Cardiac spinal cord. Spinal cord injuries
Pulmonary Pressures Output
can result in an imbalance
between sympathetic and para-
Decreased sympathetic tone depending on
Tissue the level of the spinal cord
Perfusion
injured. This can result in an
interruption of nerve impulses
Impaired to the arteries. The arteries lose
Cellular tone and dilate, causing a rela-
Metabolism
tive hypovolemia. There has
been no loss of fluid, but the
container has been enlarged.
FIGURE 12-88  The pathogenesis of hypovolemic shock.
With this inappropriate vasodi-
lation, a disproportionate
skin becomes pale, cool, and clammy (sweaty). The blood amount of blood collects in the capillary bed. This
pressure may be ­normal during compensated shock, but reduces venous return, cardiac output, and arterial blood
then begins to fall. The pulse may be normal in the begin- pressure. Sympathetic nerve impulses to the adrenal
ning, then become rapid, finally slowing and disappear- glands are lost, which prevents the release of catechol-
ing. As the kidneys continue to reabsorb water, urination amines and their compensatory effects. With injury high
decreases. Cardiac arrhythmias may develop in late shock, in the cervical spine, there may be interruption of
deteriorating to asystole (absence of heartbeat). impulses to the peripheral nervous system, causing
Although it is accepted practice to administer crystal- paralysis and loss of sensation. The respiratory and car-
loid or colloid solutions to replace fluids lost through vom- diac centers of the brain may also be affected.
iting, diarrhea, burns, excessive sweating, or osmotic The usual cause of neurogenic shock is central nervous
diuresis, the replacement of fluids in trauma patients is system injury. Neurogenic shock is most commonly due to
310  Chapter 12

support of the airway, oxygenation, ventilation, mainte-

Pathogenesis of Neurogenic Shock nance of body temperature, and intravenous access. Spi-
nal shock is characterized by hypotension, reflex
Spinal Cord Injury bradycardia, and warm, dry skin.

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-

Self-Defense Mechanisms tion by phagocytes. Some bacteria, such as Mycoplasmic

bacteria, have no protective capsule but rely on other
So far in this chapter, we have discussed normal body con- mechanisms to survive and attack the body. Mycobacte-
ditions (the normal cell and its environment: fluids and rium tuberculosis, which has no protective capsule, can
electrolytes, the acid–base balance) and how the body may actually survive and be
be attacked or injured (cellular injury, infection, genetic transported by phago- CONTENT REVIEW
and other causes of disease, hypoperfusion, and multiple cytes. Other bacteria sim- ➤➤ Infectious Agents
organ dysfunction syndrome). In the remainder of the ply multiply faster than • Bacteria
chapter, we will discuss how the body defends itself from the body’s defense systems • Viruses
infection and injury. can respond. Still others • Fungi
• Parasites
It is important to keep in mind that the body has pow- overpower the body’s
• Prions
erful ways of defending and healing itself (restoring defenses by producing
 Pathophysiology 315

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

other than minor skin infections such as athlete’s foot and

some common vaginal infections. Fungus infections are
Table 12-15  Characteristics of the Inflammatory and
Immune Responses
called mycoses. Patients with an impaired immune system,
such as HIV patients or patients with organ transplants, Inflammatory Immune
suffer fungal infections more commonly than healthy peo- Response Response
ple. In such patients, the fungi can invade the lungs, blood, Speed Fast Slow
and several organs. Treatment of complicated, deep fungal
Specificity Nonspecific Specific
infections has proven difficult, even in the hospital setting.
Parasites range in size from protozoa (single-celled ani- Duration Transient (no memory) Long-term (memory)
(memory)
mals not much larger than bacteria) to large intestinal
worms. Parasites tend to be more common in developing Involving which Multiple plasma protein One plasma protein
plasma systems (complement, coagulation, (immunoglobulin)
nations than in the United States. Treatment depends on kinin systems)
the organism and the location.
Involving which Multiple cell types One blood cell type
Prions are the most recently recognized classification cell type (granulocytes,monocytes, (lymphocytes)
of infectious agents. Initially thought to be slow-acting macrophages)
viruses, prions differ from viruses in that they are smaller,
are made entirely of proteins, and do not have protective
capsids. enzymes. Various mechanical responses also work to get
For more about infectious diseases, see the Medical rid of invading substances. For example, the invader may
Emergencies chapter titled “Infectious Diseases.” be coughed or sneezed out of the respiratory tract, flushed
out of the urinary tract, or eliminated from the gastrointes-
tinal tract by vomiting or diarrhea.
Three Lines of Defense The anatomic defenses are external and nonspecific. They
There are three chief lines of self-defense against infection are considered external because they prevent substances
and injury. One involves anatomic barriers. The other from penetrating the skin or the coverings of internal pas-
two—the inflammatory response and the immune sageways. They are nonspecific because they defend against
response—rely on actions of the leukocytes (white blood all invaders, such as foreign bodies, chemicals, or microor-
cells). Each line of defense can be characterized as external ganisms, without targeting any specific type of invader.
or internal, nonspecific or specific (Table 12-14)—character- If an invading foreign body, chemical, or microorgan-
izations you may want to keep in mind as you read the ism penetrates the anatomic barriers and begins to attack
following sections and compare the ways these defenses internal cells and tissues, two other lines of defense are
protect the body. triggered: the inflammatory response and the immune
Before an infectious agent can attack the body, it has to response. These twin responses of the immune system
get past the body’s natural anatomic barrier, the epithelium have contrasting characteristics of speed, specificity, dura-
(the skin and the mucous membranes that line the respira- tion (memory), and of the plasma systems and cell types
tory, gastrointestinal, and genitourinary tracts). The epithe- that are involved in the response (Table 12-15).
lium is more than just a physical barrier; it also provides a The inf lammatory response, or inf lammation, begins
chemical defense against within seconds of injury or invasion by a pathogen. As
infection. The sebaceous noted earlier, it is nonspecific, attacking any invader by
CONTENT REVIEW glands of the skin secrete surrounding it with cells and fluids to isolate, destroy, and
➤➤ Three Lines of Defense fatty and lactic acids, which eliminate it. Inflammation is mediated by multiple plasma
against Infection and Injury attack bacteria and fungi. protein systems, especially the complement system, the
• Anatomic barriers Sweat, tears, and saliva coagulation system, and the kinin system (which will be
• Inflammatory response
secreted by other glands explained later) and involves a variety of cell types as it
• Immune response
contain bacteria-attacking attacks the invader.
The immune response develops more slowly (one
type of response requires a second exposure after prim-
Table 12-14  Three Lines of Defense against Infection and Injury ing by the first exposure to the invader). The immune
External Internal Nonspecific Specific response is specific, in that it will develop a specialized
response for each different invader. It is mediated by
Anatomic barriers External Nonspecific
just one plasma protein system (immunoglobulin) and
Inflammatory response Internal Nonspecific attacks the invader mainly with a single cell type (lym-
phocytes, which are one type of leukocyte, or white
Immune response Internal Specific
blood cell).
 Pathophysiology 317

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.

The Immune Response

Primary versus Secondary
How the Immune Response Immune Responses
Works: An Overview There are two phases to the immune response to an antigen:
Most viruses, bacteria, fungi, and parasites—as well as the primary immune response and the secondary immune
noninfectious substances such as pollens, foods, venoms, response.
drugs, and others that may enter the body—have proteins On exposure to an antigen, B lymphocyte cells
on their surface called antigens. The immune system (explained in the next section) produce antibodies to attack
detects these antigens as being foreign, or “non-self,” and the antigen. These antibodies are called immunoglobu-
responds to produce substances called antibodies that lins, which are proteins present in the plasma portion of
combine with antigens to control or destroy them. This is the blood. There are five classes of immunoglobulins—
known as the immune response. As part of this process, IgM, IgG, IgA, IgE, and IgD.
memory cells “remember” the antigen and will trigger an On first exposure to an antigen, after a lag time of five
even faster and more effective response to destroy the to seven days, the presence of IgM antibodies can be
same antigen if it enters the body again. Such long-term detected in the blood, with a lesser presence of IgG anti-
protection against specific foreign substances is known as bodies. This constitutes the primary immune response,
immunity. also called the initial immune response. If there is no further
exposure to the antigen, the antibodies are catabolized
(broken down)—but the immune system has been
Characteristics of the Immune “primed.” If there is a second exposure to the antigen, the
Response and Immunity body responds much faster, and a far greater quantity of
The immune response and immunity can be classified in IgG antibodies is produced. The level of IgG antibodies,
various ways: natural versus acquired immunity, primary with their memory for the specific antigen, will remain
versus secondary immune responses, and humoral versus elevated for many years. This constitutes the secondary
cell-mediated immunity. immune response, also called the anamnestic (or memory-
assisting) immune response.
The primary and secondary immune responses
Natural versus Acquired Immunity
together create active acquired immunity to the specific
Natural immunity is not generated by the immune
antigen.
response. It is inborn, part of the genetic makeup of the
individual or of the species in general. For example, the
measles virus cannot reproduce in canine cells, so dogs are Humoral versus Cell-Mediated
naturally immune to measles. Conversely, canine distem- Immunity
per cannot thrive within human cells, so humans are natu- A special type of leukocyte (white blood cell) is the lym-
rally immune to that disease. (Some diseases, however, phocyte. Lymphocytes (which constitute about 20 to 35 per-
such as leukemia, can affect more than one species.) cent of all leukocytes) are responsible for several critical
Acquired immunity functions of the immune response, including recognizing
CONTENT REVIEW develops as an outcome of foreign antigens, producing antibodies (the immunoglobu-
➤➤ Classifications of the the immune response. lins such as IgM and IgG, previously mentioned), and
­Immune Response Acquired immunity can be developing memory (Figure 12-92)
• Natural versus acquired either active or passive. As lymphocytes mature, they become one of several
immunity Active acquired immunity is types, including B lymphocytes and T lymphocytes. B lym-
• Primary versus generated by the host’s phocytes do not attack antigens directly. Instead, they pro-
secondary immune (infected person’s) immune duce the antibodies (immunoglobulins) that attack
responses system after exposure to an antigens. B lymphocytes also develop memory, and confer
• Humoral versus cell-
antigen. Passive acquired long-term immunity to specific antigens. This type of
mediated immunity
immunity is transferred to a immunity is called humoral immunity. (Humor refers to
318  Chapter 12

IMMUNE
RESPONSE
Cell-
Humoral Based on activation of mediated
immunity specific lymphocytes immunity
by an antigen
(antigen recognition)

Memory B cells Antigen Regulatory T cells Memory

B cells activated presentation T cells activated T cells

Regulatory Regulatory
activity activity

PLASMA CYTOTOXIC
CELLS T CELLS

Chemical attack Boost Direct physical

by secreted antibodies nonspecific attack on foreign
defenses or virus-infected cells

FIGURE 12-92  Humoral and cell-mediated immunity—an overview.

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

Macrophage Self-antigens As mentioned earlier, the body can distin-

Nucleus guish between self and non-self, or foreign,
Helper T Cell antigens. Normally, the immune system is not
triggered by self-antigens. In fact, the immune
system does not just “tolerate” self-antigens,
it also actively protects them through sup-
pression of the immune system by T lympho-
Receptor sites cytes and a special antibody called
anti-idiopathic antibody.
Large molecules, such as proteins, poly-
saccharides, and nucleic acids, are the most
Foreign likely to trigger the immune response. Smaller
Antigen B Cell
molecules, such as amino acids, monosaccha-
rides, and fatty acids, are less likely to induce
the immune response. Some small molecules,
Plasma
Cell
however, can function as haptens, meaning
that they can become immunogenic when
Memory B Cell combined with larger molecules.
More complex molecules, and molecules
that are present in sufficient numbers, are
Antibodies more likely to trigger an immune response.
Opsonization Additionally, different routes of entry can
Suppressor T Cell
stimulate different types of cell-mediated or
humoral immune response (which dictates
the route by which serum antigens may be
Antigen-Antibody
Complex
administered, such as intravenous, subcuta-
neously, orally, intraperitoneally, intrana-
sally). Other substances present in the body
can help to stimulate the immune response.
Macrophage
Also, as noted earlier, the person’s genetic
makeup can affect the ability to respond to
Complement Fixation antigens.
Lysis of Cellular Antigen
FIGURE 12-93  Humoral immune response.
Macrophage Nucleus Self-antigens

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

enough to trigger the immune system in the first place. To

Memory T Cell Cytotoxic T Cell Suppressor T Cell
be immunogenic—able to trigger an immune response—
an antigen must have certain additional characteristics.
Chemically destroys foreign cells Produces cytokines to attract
Characteristics of Antigenic Immunogenicity macrophages

• 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

ipated—how does a B cell develop a receptor that is spe-

Table 12-17  Compatibility among ABO Blood Groups cialized to a specific antigen?
Reaction with Serum of Recipient It is thought that this specialization of B cells takes
place through the processes of clonal diversity and clonal
Cells of Donor AB B A O
selection. Clonal diversity is generated as the precursors
AB - + + + of mature B cells develop in the bone marrow. During this
B - - + +
process, a B cell precursor develops receptors for every
possible kind of antigen it may ever encounter. Later, after
A - + - +
the immature B cells have migrated into the peripheral
O - - - - lymphoid organs, primarily the spleen and the lymph
- = No Reaction
nodes, antigen that is present in the system reacts with the
+ = Reaction appropriate receptors on the surfaces of B cell clones,
which is the process of clonal selection.
donors, because type O blood has no antigens that will trig- Clonal selection activates the immature B cell, prompt-
ger an immune response in any other group. Those with ing it to proliferate and differentiate, the end result being
type AB blood are known as universal recipients, because the mature B cell that produces plasma cells that secrete
they have both types of antigens and will not produce anti- immunoglobulin antibodies into the blood and secondary
bodies in response to any other blood groups (Table 12-17). lymphoid organs. The mature B cell also produces memory
ABO incompatibility between mother and fetus is more cells that will trigger a swifter and stronger immune
common than Rh incompatibility, occurring in about 20 to 25 response if they encounter the same antigen again (the sec-
percent of pregnancies. However, only 10 percent of ABO ondary immune response). The process of clonal selection
incompatibilities will result in hemolytic disease of the infant. is probably responsible (during the primary immune
response) for the lag time of five to seven days between
introduction of an antigen and the first detectable appear-
Humoral Immune Response ance of antibodies in the blood.
Earlier, we identified the humoral immune response as the
long-lasting response provided by production in the blood- Immunoglobulins
stream of antibodies (immunoglobulins) and memory cells IMMUNOGLOBULINS AND ANTIBODIES  Antibod-
by B lymphocytes (review Figure 12-93). This is sometimes ies are proteins secreted by plasma cells that are produced
called the internal or systemic immune system. Another kind by B cells in response to an antigen. All antibodies are
of humoral immunity is provided by secretions at the body immunoglobulins, but researchers have not yet determined
surfaces, such as sweat and saliva, and is sometimes called whether all immunoglobulins function as antibodies.
the external, mucosal, or secretory immune system. These
types of humoral immune responses will be discussed in THE STRUCTURE OF IMMUNOGLOBULINS  The
the following sections. structure of immunoglobulin molecules consists of Y-shaped
chains, arranged somewhat differently in the different
B Lymphocytes immunoglobulin classes (Figure 12-95). At the two “upper”
The blood cells that are involved in immune response, as tips of the Y are the antigen-binding sites. The interaction of
noted earlier, are lymphocytes, which are one type of white amino acids with parts of the chain determines the shape of
blood cell. Lymphocytes are generated from stem cells in the immunoglobulin molecule’s antigen-binding site. The
the bone marrow, from which all blood cells are generated. shape of the antigen-binding site determines which anti-
Lymphocytes then take one of two paths as they mature. In gen the immunoglobulin molecule will bind to—because
one path, lymphocytes that travel through the thymus there is an area on the antigen (the antigenic determinant)
gland mature into T lymphocytes, which are involved in that will fit the shape of the antigen-binding site like a key
cell-mediated immunity and will be discussed in detail in a lock (Figure 12-96). In some cases, substitution of a
later. On the other path, lymphocytes that travel through a single amino acid changes the conformation of the antigen-
set of lymphoid tissues, including the spleen and lymph binding site and, therefore, the antigen it will combine with.
nodes, mature into B lymphocytes, which are involved in
humoral immunity. THE FUNCTIONS OF ANTIBODIES  An antibody cir-
Each mature B cell recognizes, through an antigen culates in the blood or is suspended in body secretions until
receptor on its surface, a single type of antigen and then it meets and binds to its specific antigen. The antibody can
produces antibodies to that antigen. But since there are then have either a direct or an indirect effect on the target
many, many kinds of antigens—and since exactly which antigen that results in inactivation or destruction of the anti-
foreign antigens may ever invade the body cannot be antic- gen. Both direct and indirect effects result from the binding
322  Chapter 12

• 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.

Indirect Effects of Antibodies

on Antigens

• 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.

Through the direct and indirect

effects previously described, antibodies
Antigen A Antibody A serve four main functions: neutralizing
bacterial toxins, neutralizing viruses,
opsonizing bacteria, and activating por-
tions of the inflammatory response.

• Neutralization of bacterial toxins.

As noted earlier, many bacteria pro-
Antigen-binding duce harmful toxins that increase
Antigenic determinants site of antibody
molecule their pathogenic effect. However,
bacterial toxins sow the seeds of their
own destruction by triggering the
humoral immune response. In this
case the antigen–antibody complex
is a toxin–antitoxin complex. Antibod-
Antigen B Antibody B ies neutralize the bacterial toxins by
occupying their antigenic determi-
nant sites, which prevents them from
binding to and harming tissue cells.
Figure 12-96  Antigen–antibody binding. The shape of the antigen fits the shape of the
Detection of specific antitoxins aids
antigen-binding site on the immunoglobulin (antibody) molecule like a key in a lock. in the diagnosis of disease. Vaccines
against diseases such as diphtheria
and tetanus work by injecting a form
of antibodies and antigens, forming antigen–antibody com-
of the bacterial toxin, which is altered to greatly reduce
plexes, also called immune complexes.
its toxic effects but to retain its immunogenicity.
Direct Effects of Antibodies on Antigens • Neutralization of viruses. Antibodies can prevent
• Agglutination—A soluble antibody combines with a some viruses from attaching to and entering body
solid antigen, causing it to clump together. cells. The antibodies attach to the viruses, causing
 Pathophysiology 323

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.

T Lymphocytes and Their Major Effects Cellular Interactions

In contrast to B lymphocytes, which travel through the
spleen and lymph nodes as they mature, T cells travel
in Immune Response
through the thymus gland (hence the name T cell). The immune and inflammatory responses are interacting,
T cells become specialized through processes that are not separate. For example:
similar to the processes described earlier for B cells: clonal Sequence of Events Interaction
diversity and clonal selection. After generation by stem
Macrophages released Inflammatory response
cells in the bone marrow, lymphocytes destined to become
during an inflammatory interacting with cell-
T cells travel to the thymus. There, through the process of
response activate the helper mediated immune
clonal diversity, maturing T cells develop the capacity to
T cells (Th cells). response
recognize all the antigens they will ever encounter. Later,
The helper T cells (Th cells) Cell-mediated immune
after the T cells have migrated into the peripheral lym-
activate other T cells, and response interacting with
phoid organs, they undergo the process of clonal selection.
they also activate B cells. humoral immune response
In this process, the immature T cells encounter antigens
that react with appropriate receptors on the surfaces of the Delayed hypersensitivity Cell-mediated immune
T cells, causing them to proliferate and differentiate into T cells (Td cells) stimulate response interacting with
five different types of mature T cells, each with distinct the production of more inflammatory response
functions. ­macrophages.
 Pathophysiology 325

Direct contact and

release of perforin

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

FIGURE 12-97  The physiology of cytotoxic 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

Chemical ANTIGEN Physical

attack attack
triggers

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

FIGURE 12-98  The immune response.

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

inflammation. After each phase, healing may take place,

Bacteria
Bacteria
and that will be the end of it. If healing doesn’t take place, enter
entertissue
tissue
inflammation moves into its next phase. However, healing
is the goal of all the phases.
Tissue
Tissue
Phases of Inflammation damage
damageoccurs
occurs

Phase 1: Acute inflammation

(If healing doesn’t take place, moves to phase 2) Mediators
Mediators
are
arereleased
released
Phase 2: Chronic inflammation
Increased
Increased
(If healing doesn’t take place, moves to phase 3) Chemotaxis vascular
vascular
Chemotaxis permeability
Increased permeability
Phase 3: Granuloma formation Increased
blood flow
blood flow
Phase 4: Healing

During each phase, the components of inflammation

Increased numbers
work together to perform four functions. of leukocytes and
mediators at site
The Four Functions of Inflammation (during All Phases) of tissue damage

• Destroy and remove unwanted substances

Bacteria
• Wall off the infected and inflamed area are
Bacteria
Bacteria arecontained,
contained,
Bacteriagone
gone destroyed,
destroyed,and
Bacteria
Bacteriaremain
remain
• Stimulate the immune response and
phagocytized
phagocytized
• Promote healing
Additional
Additional
Tissue
Tissue mediators
mediators
Acute Inflammatory Response repair
repair activated
activated

Acute inflammation is triggered by any injury, whether lethal

FIGURE 12-99  The inflammatory response.
or nonlethal, to the body’s cells. As discussed earlier in this
chapter, cell injury can result from causes such as hypoxia,
chemicals, infectious agents (bacteria, viruses, fungi, para- environment. This occurs when the mast cell is stimulated
sites), trauma, heat extremes, radiation, nutritional imbal- by one of the following events:
ances, genetic factors, and even the injurious effects of the
• Physical injury, such as trauma, radiation, or tempera-
immune and inflammatory responses themselves. When
ture extremes
cells are injured, the acute inflammatory response begins
within seconds (Figure 12-99). • Chemical agents, such as toxins, venoms, enzymes, or a
The basic mechanics are always the same: (1) Blood protein released by neutrophils (the latter an example of
vessels contract and dilate to move additional blood to the inflammatory response causing further cellular injury)
site. Then, (2) vascular permeability increases so that (3) • Immunologic and direct processes, such as hypersensitivity
white cells and plasma proteins can move through the cap- (allergic) reactions involving release of IgE antibody or
illary walls and into the tissues to begin the tasks of destroy- activation of complement components (discussed later)
ing the invader and healing the injury site (Figure 12-100).
During degranulation, biochemical agents in the mast
cell granules are released, notably vasoactive amines and
Mast Cells chemotactic factors.
Mast cells, which resemble bags of granules, are the chief
activators of the inflammatory response. They are not VASOACTIVE AMINES  Histamine is a vasoactive amine
blood cells. Instead, they reside in connective tissues just (organic compound) released during degranulation of mast
outside the blood vessels. cells. The effect of vasoactive amines is the constriction of
Mast cells activate the inflammatory response through the smooth muscle of large vessel walls and dilation of the
two functions: degranulation and synthesis (Figure 12-101). postcapillary sphincter, resulting in increased blood flow at
the injury site.
Degranulation Basophils (a type of white blood cell) also release his-
CONTENT REVIEW
Degranulation is the pro- tamine, with the same effect. Additionally, serotonin,
➤➤ Mast Cell Functions cess by which mast cells released by platelets, can have effects of both vasoconstric-
• Degranulation
empty granules from their tion and vasodilation that may affect blood flow to the
• Synthesis
interior into the extracellular affected site.
 Pathophysiology 329

Mast cell Vasodilation

degranulation (redness, heat)

Vascular
permeability
(edema)

Cellular Complement Cellular

Activation of
injury clotting infiltration
plasma systems
kinin (pus)

Thrombosis
(clots)

Release of Stimulation of
cellular nerve endings
components (pain)

FIGURE 12-100  The acute inflammatory response.

CHEMOTACTIC FACTORS  Another consequence of Synthesis

degranulation of mast cells is the release of chemotactic When stimulated, mast cells synthesize, or construct, two
factors. Chemotactic factors are chemicals that attract white substances that play important roles in inflammation: leu-
cells to the site of inflammation. This attraction of white kotrienes and prostaglandins.
cells is called chemotaxis.

Cause: Mast cell stimulated by:

• Physical injury (e.g., trauma, radiation, temperature extremes)
• Chemical agent (e.g., toxin, venom, enzyme, neutrophil-produced protein)
• Immunologic process (e.g., allergic reaction/IgE antibody, activated complement)

Plasma membrane Granules

Result: Degranulation Result: Synthesis

(release of histamine, (construction of leukotrienes
serotonin, and chemotactic factors) and prostaglandins)

Nucleus

FIGURE 12-101  Mast cell degranulation and synthesis.

330  Chapter 12

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).

PROSTAGLANDINS  Like leukotrienes, CLASSIC

prostaglandins cause increased vasodila- PATHWAY

tion, vascular permeability, and chemo- Antigen-

taxis. They are also the substances that antibody
cause pain. In addition, prostaglandins act complex

to control some inflammation by suppress-

ing release of histamine from mast cells and Activated
suppressing release of lysosomal enzymes C1
C1
from some white cells.
ALTERNATIVE
PATHWAY
Plasma Protein Systems C4
Activated
C4
Properdin
The actions of white blood cells and Spontaneous
other components of inflammation are activation
Activated
mediated by three important plasma C2 C3
C2
protein systems. (Plasma proteins are
proteins that are present in the blood.)
One group of plasma proteins, the
immunoglobulins, or antibodies, are key Activated
C3
factors in the immune response, as dis- Stabilization
cussed earlier. Three other plasma pro- of activated C3
Inflammation
tein systems are critical to inflammation: Activated and phagocytosis
the complement system, the coagulation C5 C5
Chemotaxis
system, and the kinin system.
Important to an understanding of
these plasma protein systems is the concept Activated
C6 C6
of cascade. In a cascade, a first action is
stimulated, that action causes the next
action, which causes the next action, and so Activated
on until a final action has been completed. C7 C7
Lysis

The Complement System

The complement system consists of 11 Activated
C8 C8
proteins (numbered C-1 through C-9,
plus factors B and D) and comprises
about 10 percent of all the proteins that
Activated
circulate in the blood. The complement C9 C9
proteins lie inactive in the blood until
they are activated. The complement sys-
tem can be activated by formation of
antigen–antibody complexes, by prod- Cell
lysis
ucts released by invading bacteria, or by
components of other plasma protein
systems.
Once the C-1 complement is activated,
the complement cascade proceeds through FIGURE 12-102  The complement cascade. The classic pathway is activated at C1, whereas
the rest of the sequence of proteins. When the alternative pathway is activated at C3.
 Pathophysiology 331

THE CLASSIC PATHWAY  Extrinsic pathway Intrinsic pathway

CONTENT REVIEW
In the classic pathway,
➤➤ Plasma Protein Functions Injured cells Collagen or other activators
the complement system is
In immune response:
activated by formation of XIIa XII
• Immunoglobulins
an antigen–antibody com-
In inflammatory
response: plex during the immune X Xa
• Complement system response. Complement fac- Va
• Coagulation system tor C-1 is activated, and the Phospholipid
• Kinin system cascade proceeds through
complement factor C-9. Prothrombin Thrombin
Only a few antigen–antibody complexes are required to acti-
vate the complement cascade. The enzymes that are formed
Fibrin + Fibrinopeptide
stimulate formation of increasing numbers of enzymes as Fibrinogen
monomer
the cascade proceeds, so that a very large response ensues,
even from a small initial stimulus.
A number of effects that result from the complement Fibrin polymer
cascade assist in destroying or limiting the damage of the
FIGURE 12-103  The coagulation cascade.
invading organism. These include opsonization (coating)
and phagocytosis (ingesting) of the organism, lysis (rup-
turing of bacterial cell membranes), agglutination (caus- and the intrinsic pathway. The extrinsic pathway of coagula-
ing invading organisms to clump together), neutralization tion begins with injury to the vascular wall or surrounding
of viruses, chemotaxis of white cells, increased blood flow, tissues. It requires exposure of the blood to a tissue factor
and increased permeability. Complement proteins also that originates outside the blood. The intrinsic pathway of
lodge in the tissues and help to prevent spread of the coagulation begins with exposure to elements in the blood
infection. itself, such as collagen from a traumatized vessel wall.
As with the complement cascade, the two pathways
THE ALTERNATIVE PATHWAY  In some instances, the converge at a certain point and continue toward the same
complement cascade can be activated without an inter- end product, fibrin. Substances produced during the com-
vening antigen–antibody complex formed by the immune plement cascade also enhance the inflammatory response,
response. Substances produced by some invading organ- including increase of vascular permeability and chemotaxis.
isms are capable of reacting with complement factors B and
D, which produce a substance that activates complement
The Kinin System
The kinin system has, as its chief product, bradykinin,
factor C-3, and the complement cascade then proceeds to
which causes vasodilation, extravascular smooth muscle
its end.
contraction, increased permeability, and possibly chemo-
Because the alternative pathway begins without wait-
taxis. It also works with prostaglandins to cause pain. Its
ing for the development of an antigen–antibody complex,
effects are similar to the effects of histamine, but bradyki-
it is much faster than the classic pathway and acts as part
nin works more slowly than histamine and so is probably
of the first line of inflammatory defense.
more important during the later phases of inflammation.
The plasma kinin cascade is triggered by factors associ-
The Coagulation System
ated with the coagulation cascade. The sequence of the
The coagulation system, also called the clotting system,
kinin cascade is conversion of prekallikrein to kallikrein,
forms a network at the site of inflammation. The network
which then converts kininogen to kinin. Another source of
is composed primarily of a protein called fibrin, which is
kinin is the tissue kallikreins in saliva, sweat, tears, urine,
the end product of the coagulation cascade. The fibrinous
and feces. Whatever the source, kinin is the end product,
network stops the spread of infectious agents and products
with bradykinin being the chief kinin.
of inflammation, keeps microorganisms “corralled” in the
area of greatest phagocyte concentration, forms a clot that
Control and Interaction
stops bleeding, and forms the foundation for repair and
healing (Figure 12-103).
of Plasma Protein Systems
Control of the plasma protein systems is important for two
The coagulation cascade can be activated by many sub-
reasons:
stances released during tissue destruction and infection. As
with the complement cascade, the coagulation cascade can • The inflammatory response is essential for protection
be activated through either of two pathways. The pathways of the body from unwanted invaders. Its functioning
of coagulation cascade activation are the extrinsic pathway must be guaranteed. Therefore, there are numerous
332  Chapter 12

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

CONTENT REVIEW Mechanisms of • Nervous system—dizziness, headache, convulsions,

Hypersensitivity tearing
➤➤ Four Types of Hypersensi-
tivity Reactions Usually, when a hypersen- There is a genetic component to Type I, IgE-mediated
• Type I—IgE reactions sitivity reaction takes place, responses. Some individuals suffer from atopia, in which
• Type II—Tissue-specific inflammation is triggered higher amounts of IgE are produced, and there are more
reactions that results in destruction receptors for IgE on the mast cells. In families in which one
• Type III—Immune- of healthy tissues. Four parent has an allergy, approximately 40 percent of the off-
complex-mediated mechanisms, or types, of spring will also have allergies. If both parents are atopic,
reactions hypersensitivity that cause approximately 80 percent of their offspring will also be
• Type IV—Cell-mediated
this destructive reaction atopic.
reactions
have been identified. Anaphylactic reactions are life threatening. Therefore,
people who have reason to believe they are susceptible
Mechanisms of Hypersensitivity Reaction
need to find out what specific allergens they are sensitized
• Type I—IgE-mediated allergen reactions to so they can avoid them. A number of tests have been
• Type II—tissue-specific reactions developed that are successful in making these identifica-
• Type III—immune-complex-mediated reactions tions. Additionally, there has been some success in desensi-
tizing some individuals by injecting small but increasing
• Type IV—cell-mediated reactions
doses of the offending allergen over a long period of time.
In reality, hypersensitivity reactions are not so easy to Research in desensitization techniques is ongoing.
categorize. Most involve more than one type of mechanism.
TYPE II—TISSUE-SPECIFIC REACTIONS  Most cells of
TYPE I—IgE REACTIONS  As noted earlier in the chap- the body present HLA antigens, the antigens that the body
ter, IgE is the type of immunoglobulin (antibody) that con- recognizes as self or non-self. In addition to HLA antigens,
tributes most to allergic and anaphylactic reactions. The most tissues have other antigens, but these are not the
first exposure to the allergen (antigen that causes allergic same in all tissues. They are called tissue-specific antigens
reaction) stimulates B lymphocytes to produce IgE antibod- because they exist on the cells of only some body tissues.
ies. These bind to receptors on mast cells in the tissues near An immune response against one of these antigens will
blood vessels. On reexposure (or after several reexposures), affect only the organs or tissues that present that particular
the allergen binds to the IgE on the mast cell, which causes antigen; this is called a tissue-specific reaction.
degranulation of the mast cell, release of histamine, and There are four mechanisms by which Type II tissue-
triggering of the inflammatory process. specific reactions attack cells. The first involves the com-
The potency of the inflammatory response is con- plement system. Antibody bound to the antigen of the
trolled in two ways. As discussed earlier, H1 receptors on target cell initiates the complement cascade, which causes
target cells promote inflammation when contacted by his- lysis (dissolving) of the cell’s plasma membrane. The sec-
tamine, whereas H2 receptors inhibit inflammation when ond mechanism is clearance of the target cells by macro-
contacted by histamine. Another control mechanism is the phages. In the third mechanism, antibody bound to the
autonomic nervous system, which stimulates production antigen on the target cell also binds to cytotoxic cells,
of chemical mediators (epinephrine, acetylcholine) that which release toxins that destroy the target cell. In the
govern release of inflammatory mediators from the mast fourth mechanism, the antibody disables the target cell by
cells and the degree to which target cells will respond to occupying receptor sites on the cell, preventing them
inflammatory processes. from binding to molecules that are needed for normal cell
The clinical indications of type I IgE-mediated functioning.
responses are the familiar signs and symptoms of allergic
and anaphylactic response. TYPE III—IMMUNE-COMPLEX-MEDIATED REAC-
TIONS  Type III immune-complex-mediated reactions
Clinical Indications of IgE-Mediated Responses result from antigen-antibody complexes (also called
• Skin—flushing, itching, urticaria (hives), edema immune complexes) that, as discussed earlier, are formed
when antibody circulating in the blood or suspended in
• Respiratory system—breathing difficulty, laryngeal
body secretions meets and binds to a specific antigen. The
edema, laryngospasm, bronchospasm
immune complexes generally circulate for a time before
• Cardiovascular system—vasodilation and permeability, finally being deposited in vessel walls or other tissues. For
increased heart rate, increased blood pressure this reason, which organs are affected may have very little
• Gastrointestinal system—nausea, vomiting, cramping, connection with where or how the antigen or the immune
diarrhea complex originated.
338  Chapter 12

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

connective tissues and organs. The diversity of anti- caused by or associated

CONTENT REVIEW
bodies in maternal blood can cause a variety of prob- with pregnancy, infections,
➤➤ Two Types of Immune
lems, such as congenital heart defects, in the infant. and diseases such as diabe-
Deficiency
• Rh and ABO isoimmunization, or hemolytic disease of tes or cirrhosis. The elderly
• Congenital (inborn)
the newborn, was discussed earlier in the chapter. It is are more prone to acquired
• Acquired (after birth)
an isoimmune disease that causes severe anemia in the immune deficiencies than
neonate. Immune problems occur if antigens on fetal the young. Among the factors that can severely affect
red blood cells are different from antigens on maternal immune function are nutritional deficiencies, medical
red blood cells. treatment, trauma, and stress. Of special interest is the fatal
acquired immune disorder AIDS.

Deficiencies in Immunity NUTRITIONAL DEFICIENCIES  Critical deficits in cal-

and Inflammation orie or protein ingestion can lead to depression of T cell
production and function. Complement activity, neutrophil
Immune deficiency disorders result from impaired func-
chemotaxis, and the ability of neutrophils to kill bacteria
tion of some component of the immune system, includ-
are also seriously affected by starvation. Zinc deficiencies
ing phagocytes, complement, and lymphocytes (T cells
and vitamin deficiencies can affect both B cell and T cell
and B cells), with lymphocyte dysfunction being the pri-
function.
mary cause. Immune deficiency can be congenital
(inborn) or acquired (after birth). The most common IATROGENIC DEFICIENCIES  Iatrogenic deficiencies
manifestations of immune deficiency are recurrent infec- are those that are caused by medical treatment. Some drugs
tions, because the body’s ability to ward off invaders has depress blood cell formation in the bone marrow. Oth-
been damaged. ers trigger immune responses that destroy granulocytes.
Immunosuppressive drugs administered in the treatment
Congenital Immune Deficiencies for transplants, cancer, or autoimmune diseases suppress
Congenital, or primary, immune deficiency develops if the B and T cell function and antibody production. Radiation
development of lymphocytes in the fetus or embryo is treatment for cancer exacerbates this effect. Surgery and
impaired or halted. Different immune-deficiency diseases anesthesia also can suppress B and T cell function, with
may develop, depending on whether the T cells, the B cells, severely depressed white cell levels persisting for sev-
or both have been affected. eral weeks after surgery. Surgical removal of the spleen
In the DiGeorge syndrome, there is a lack or partial lack depresses humor response against encapsulated bacteria,
of thymus development, resulting in a severe decrease in T depresses IgM levels, and decreases the levels of opsonins.
cell production and function. Bruton agammaglobulinemia is
caused by impaired development of B cell precursors, DEFICIENCIES CAUSED BY TRAUMA  Burn victims
resulting in B cells that cannot produce IgM or IgD anti- are especially susceptible to bacterial infection. Not only
bodies. In bare lymphocyte syndrome, lymphocytes and mac- has the normal barrier presented by the skin been dis-
rophages are unable to produce Class I or Class II HLA rupted, but thermal burns also appear to decrease neu-
antigens, which disrupts the ability of cells to recognize trophil function, complement levels, and other immune
self or non-self substances, resulting in severe infections functions while increasing immunosuppressive functions,
that are usually fatal before age 5. which further depress immune function.
Sometimes there is a defect that depresses the function DEFICIENCIES CAUSED BY STRESS  It has long
of just a small portion of the immune system. For example, been suggested that persons undergoing emotional stress
in Wiskott-Aldrich syndrome, IgM antibody production is (major stresses such as divorce, but also minor stresses
reduced. Selective IgA deficiency is the most common such as studying for final exams) are more prone to illness.
immune deficiency. IgA is the antibody present in mucous The speculation was that stress has deleterious effects on
membranes. People with IgA deficiency frequently suffer immune function. Research into the possible mechanisms
from sinus, lung, and gastrointestinal infections. of stress-induced immune deficiency are just getting under
Some immune system deficiencies cause a decreased way. (Stress and susceptibility to disease will be discussed
ability to respond to one particular antigen. For example, later in the chapter.)
in chronic mucocutaneous candidiasis, the T lymphocytes are
unable to respond against candida infections. AIDS  AIDS is an acronym for acquired immunodeficiency
syndrome, which has become the best known acquired
Acquired Immune Deficiencies immune deficiency disorder. AIDS is a syndrome of dis-
Acquired, or secondary, immune deficiencies develop after orders that develop from infection with HIV, the human
birth and do not result from genetic factors. They can be immunodeficiency virus.
 Pathophysiology 341

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

particularly, that there is a responses and circulating hormones return to normal.

CONTENT REVIEW
cause–effect relationship In most situations, this is the last stage; the stress is
➤➤ General Adaptation
between stress and dis- resolved. If the stress is very severe or prolonged,
­Syndrome (GAS)
ease—date primarily from however, stress is not resolved and stage III occurs.
• Stage I—Alarm
the work of Hans Selye, an • Stage III, exhaustion. This is the stage sometimes
• Stage II—Resistance,
or adaptation Austrian-born Canadian known as “burnout.” During this stage, the triad of
• Stage III—Exhaustion physician and educator, in physiologic effects described by Dr. Selye occurs. The
the 1940s. person can no longer cope with or resolve the stress,
and physical illness may ensue.
General Adaptation Syndrome
The stages of GAS begin with physiologic stress,
Dr. Selye was not studying stress when he made his dis-
defined by Dr. Selye as a chemical or physical disturbance
covery. Instead, he was trying to identify a new sex hor-
in the cells or tissue fluid produced by a change, either in
mone. He was injecting ovarian extracts into laboratory
the external environment or within the body itself, that
rats when he discovered the following triad of physiologic
requires a response to counteract the disturbance. Selye
effects:
identified three components of physiologic stress: (1) the
Triad of Stress Effects stressor that initiates the disturbance, (2) the chemical or
• Enlargement of the cortex (outer portion) of the adre- physical disturbance the stressor produces, and (3) the
nal gland body’s counteracting (adaptational) response.

• Atrophy of the thymus gland and other lymphatic

structures Psychological Mediators and Specificity
Since Dr. Selye defined GAS, others who have studied
• Development of bleeding ulcers of the stomach and
adaptation to stress have refined the concept. For example,
duodenum
more attention has been paid to the psychological media-
Dr. Selye soon discovered that this triad of effects was not a tors of stress. Experiments have shown that there isn’t a
response only to the ovarian extracts. The same effects direct correlation between stressor and response. People
occurred when he subjected the rats to other stimuli, such react differently to the same stressor. One person may take
as cold, surgical injury, and restraint. He concluded that in stride the same situation that greatly upsets another per-
the triad of effects was not specific to any particular stimu- son, and the degree of physiologic response may be gov-
lus but comprised a nonspecific response to any noxious erned more by the psychological, emotional, or social
stimulus, or stressor. (Stress is generally defined as a state response to the stressor than to the stressor itself. In partic-
of physical and/or psychological arousal to a stimulus. Dr. ular, research has demonstrated pituitary gland and adre-
Selye originally intended to use the word stress for the nal cortex sensitivity to emotional/psychological/social
stimulus, or cause, but through a mistranslation of his influences.
work, stress came to mean the arousal, or effect. Dr. Selye Another way in which recent research has diverged
then coined the word stressor for the stimulus/cause.) from Dr. Selye’s original hypotheses regards specificity.
Because the same responses occurred to a wide array Dr. Selye postulated that the triad of physiologic
of stimuli, Dr. Selye named it the general adaptation syn- responses he identified were nonspecific, or the same for
drome (GAS). Later, he identified three stages in the devel- any stressor. It is now thought that, although the triad of
opment of GAS: responses he identified may occur in response to a wide
variety of stressors, the total body response to different
Stages of GAS stressors must be specific—that is, targeted toward cor-
• Stage I, alarm. The sympathetic nervous system is rection of the specific disturbance. For example, the body
aroused and mobilized in the “fight-or-flight” response reacts to cold by shivering, and to heat through vasodila-
syndrome. Pupils dilate, heart rate increases, and tion and sweating.
bronchial passages dilate. In addition, blood glucose
levels rise, digestion slows, blood pressure rises, and Homeostasis as a Dynamic Steady State
the flow of blood to the skeletal muscles increases. At An older definition of homeostasis states that the body
the same time, the endocrine system is aroused, result- maintains itself at a “constant” composition. More recently,
ing in secretion of hormones by the pituitary and adre- homeostasis has been described as a dynamic steady state.
nal glands that enhance the body’s readiness to meet This takes into account the concept of turnover, the con-
the challenge. tinual synthesis and breakdown of all body substances
• Stage II, resistance, or adaptation. The person begins (e.g., fats, proteins). Thus, the internal environment of the
to cope with the situation. Sympathetic nervous system body is always changing, not constant, but the net effect of
 Pathophysiology 343

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

CENTRAL NERVOUS SYSTEM PSYCHOLOGICAL RESPONSE

HYPOTHALAMUS RELEASES
CORTICOTROPIN-RELEASING FACTOR (CRF)

SYMPATHETIC NERVOUS SYSTEM ENDOCRINE SYSTEM

Norepinephrine Norepinephrine Anterior pituitary gland

released and epinephrine released produces adrenocorticotropic
from nerve ends from adrenal medulla hormone (ACTH)

Adrenal cortex releases

steroid hormones,
primarily cortisol

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

Additionally, sympathetic nervous system stimulation

results in direct stimulation of the adrenal medulla, the
Table 12-19  Physiologic Effects of Catecholamines
inner portion of the adrenal gland. The adrenal medulla, in Organ Effects
turn, releases the norepinephrine and epinephrine into the
Brain Increased blood flow
circulatory system. Approximately 80 percent of the hor-
Increased glucose metabolism
mones released by the adrenal medulla are epinephrine,
and norepinephrine accounts for the remaining 20 percent. Cardiovascular Increased contractile force and rate
system Peripheral vasoconstriction
Once released, these hormones are carried throughout the
body, where their effects (preparing the body to deal with Pulmonary Increased ventilation
stressful situations) act on hormone receptors. system Bronchodilation
Both epinephrine and norepinephrine interact with Increased oxygen supply
specialized adrenergic receptors on the membranes of tar- Liver Increased glucose production
get organs. These receptors are located throughout the Increased gluconeogenesis
body. Once stimulated by the appropriate hormone, they Increased glycogenolysis
cause a response in the organ or organs they control. Decreased glycogen synthesis
The adrenergic receptors are generally divided into Gastrointestinal Decreased protein synthesis
five types, designated alpha 1 (α1), alpha 2 (α2), beta 1 (β1), and genitourinary
tracts
beta 2 (β2), and beta 3 (β3). The α1 receptors cause periph-
eral vasoconstriction, mild bronchoconstriction, and stim- Muscle Increased glycogenolysis
ulation of metabolism. The α2 receptors are found on the Increased contraction
presynaptic surfaces of sympathetic neuroeffector junc- Increased dilation of skeletal muscle vasculature
tions. Stimulation of α 2 receptors is inhibitory. These Skeleton Decreased glucose uptake and utilization (insulin
receptors serve to prevent over-release of norepinephrine release decreased)
in the synapse. When the level of norepinephrine in the Adipose (fatty) Increased lipolysis
synapse gets high enough, the α2 receptors are stimulated tissue Increased fatty acids and glycerol
and norepinephrine release is inhibited. Stimulation of β1
Skin Decreased blood flow
receptors causes increases in heart rate, cardiac contrac-
tile force, and cardiac automaticity and conduction. Stim- Lymphoid tissue Increased protein breakdown (shrinkage of
lymphoid tissue)
ulation of β 2 receptors causes vasodilation and
bronchodilation. Stimulation of β3 receptors causes fat to
be broken down in adipose tissues and heat production in also promotes lipolysis (fat breakdown) in the extremi-
muscle tissue. ties and lipogenesis (fat synthesis and deposition) in the
All the effects of the catecholamines prepare the body face and trunk.
to “fight-or-flight” in response to a stressor. Their physio- Cortisol acts as an immunosuppressant by inhibiting
logic effects are summarized in Table 12-19. protein synthesis, including synthesis of immunoglobulins
(antibodies). Additionally, it reduces the numbers of lym-
CORTISOL  Cortisol is another hormone produced in phocytes, eosinophils, and macrophages in the blood. In
response to stress. The corticotropin-releasing factor (CRF) large amounts, cortisol can cause lymphoid atrophy.
that stimulates the sympathetic nervous system, as pre- Through a series of actions, cortisol diminishes the actions
viously discussed, simultaneously stimulates the ante- of helper T cells, which results in a decrease in B cells and
rior pituitary gland to produce adrenocorticotropic hormone antibody production. It inhibits production of interleu-
(ACTH), which, in turn, stimulates the adrenal cortex to kin-1 and interleukin-2 and, consequently, blocks cell-
produce a variety of steroid hormones, primarily cortisol. mediated immunity and generation of fever. It inhibits the
One of the primary functions of cortisol is the stimula- accumulation of leukocytes at the site of inflammation and
tion of gluconeogenesis. It enhances the elevation of blood inhibits release of substances that are critical in the inflam-
glucose by other hormones and also inhibits peripheral matory response, including kinins, prostaglandins, and
uptake and oxidation of glucose by the cells. Because of histamine. Cortisol also inhibits fibroblast proliferation
these functions, it has the overall effect of elevating blood during inflammatory response, which, in turn, causes poor
glucose. wound healing and increased susceptibility to wound
Cortisol also affects protein metabolism—increasing infection.
synthesis of proteins in the liver but increasing break- In the gastrointestinal tract, cortisol increases gastric
down of proteins in the muscle, lymphoid tissue, fatty secretions, occasionally enough to cause ulcer formation.
tissues, skin, and bone. The breakdown of proteins Cortisol also suppresses the release of sex hormones,
results in increased blood levels of amino acids. Cortisol including testosterone and estradiol.
 Pathophysiology 345

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

Table 12-20   Physiologic Effects of Cortisol

Function Effects
Carbohydrate metabolism Diminished peripheral uptake/use of glucose; promotes gluconeogenesis; elevates blood glucose levels

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

Lipid metabolism Increases lipolysis in extremities, lipogenesis in face and trunk

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

Digestive function Promotes gastric secretions; at high levels, causes ulceration

Urinary function Enhances production of urine

Connective tissue function Decreases proliferation of fibroblasts (delays healing)

Muscle function Maintains normal contractility and work output for skeletal and cardiac muscle

Bone function Decreases bone formation

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).

These are only two examples of the

many pathways and interactions that take
place among the nervous, endocrine, and
immune systems.
CENTRAL NERVOUS SYSTEM
The suppression of immune system
function that is caused by stress-related
stimulates products of the sympathetic nervous and
endocrine systems—especially catechol-
HYPOTHALAMUS stimulate amines and cortisol—has been linked to a
number of immune-mediated diseases, as
listed in Table 12-21.
produces

Stress, Coping, and Illness

CRF
Interrelationships
Research has shown that the ability to cope
stimulates CYTOKINES with stress has significant effects on associ-
ated illnesses. Those who cope positively
with stress have a reduced chance of
PITUITARY GLAND
becoming ill in the first place and a better
chance of getting better or getting better
produces faster if they do become ill. Conversely,
those who don’t cope as well with stress
have a greater chance of becoming ill or of
ACTH secrete
prolonging the course of illness or of not
surviving an illness.
stimulates Physiologic stress is caused by events
that directly affect the body, such as a burn,
extreme cold, or starvation. Psychological
ADRENAL GLAND stress consists of the unpleasant emotions
caused by life events, such as taking exams
produces MACROPHAGES or a divorce. The effects that these stresses
will have on the body depend on the indi-
vidual’s ability to cope with them. Some
CORTISOL people are “thrown” by events others
would perceive as relatively minor, such as
a traffic jam or a sprained ankle. Others can
suppresses
take in stride events that others would find
very difficult, such as loss of a job or a long-
IMMUNE RESPONSE produces term disability.
The effects of stress, including the
degree to which stress causes or affects ill-
ness, are moderated by the type, duration,
FIGURE 12-105  Interactions among the nervous, endocrine, and immune systems. and severity of the stressor in combination
 Pathophysiology 347

Effective and ineffective coping has been seen to have

Table 12-21  Stress- and Immune-Related Diseases potentially different effects in healthy persons, symptom-
and Conditions
atic persons (those who already have some manifestations
Target Organ Diseases and Conditions of disease), and persons who are undergoing medical
Cardiovascular Coronary artery disease
treatment.
system Hypertension
Stroke
Potential Effects of Stress Based on Effectiveness of
Arrhythmias Coping
• In a healthy person:
Muscles Tension headaches
Muscle-related backaches Effective coping u Transient effects, return to normal
function
Connective tissues Rheumatoid arthritis
Ineffective coping u Significant stress effects, illness
Pulmonary system Asthma
Hay fever • In a symptomatic person:

Immune system Immunosuppression or immune deficiency

Effective coping u Little or no effect on symptoms
Ineffective coping u Exacerbation of symptoms, illness
Gastrointestinal system Ulcer
Irritable bowel syndrome • In a person undergoing medical treatment:
Ulcerative colitis Effective coping u Person does not perceive the treat-
Genitourinary system Diuresis ment itself as stressful u Treatment is more likely to
Impotence have a positive effect on symptoms and the course
of illness
Skin Eczema
Acne Ineffective coping u Person perceives the treatment
itself as stressful u Treatment is more likely to
Endocrine system Diabetes mellitus
have a negative effect on symptoms and the course
Central nervous Fatigue of illness
system Depression
Insomnia Because of the importance of coping ability in the
interplay between stress and illness, attention is increas-
ingly being paid to providing counseling and support sys-
with the individual’s perception and ability to cope with it. tems—including family members, friends, and other
Stressors that are the most likely to have a negative effect on support networks—to assist persons who are ill or in
immunity and disease have been characterized as those stressful life situations. There is recognition that support-
that are not only undesirable but also are uncontrollable ing the patient’s ability to cope is a critical adjunct to medi-
and that overtax the person’s ability to cope. cal treatment itself.

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.

You Make the Call

You have volunteered to work at a high school rodeo for your fire department. You and another
paramedic take the backup EMS unit to the arena. This event brings in participants from several
states. More than 300 people are expected to attend. On arrival at the arena, you park the unit at
the designated spot and move your equipment to the “first-aid room.”
Shortly after the rodeo is under way, an elderly gentleman stumbles into the first-aid
room and slumps onto the treatment table. He states that he feels very weak and wants to be
“checked out.” You perform a quick assessment. The patient is pale but dry. His pulse rate is
110 beats per minute, blood pressure is 110/60, and his respirations are 36 per minute. You
notice the characteristic odor of ketones on his breath. You ask the patient if he is diabetic. He
says he is, but has not had his insulin in two days, as he ran out of syringes. A finger-stick
glucose reads “HIGH.” On further exam, you note that the patient’s mucous membranes are
very dry.
1. Explain the physiologic basis for the patient’s apparent dehydration.
2. Describe the role of insulin in glucose transport into the cell.
3. Prepare a prehospital treatment plan given the information provided.
See Suggested Responses to “You Make the Call” at the end of this book.

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.

a. Inadequate blood flow a. T c. Immune

b. Inadequate blood flow and inadequate b. Mast d. Histamine

oxygenation 25. ___________ occurs when a mother has developed
c. Inadequate blood flow, inadequate oxygenation, antibodies that attack and severely reduce the level
and inadequate waste removal to organs of neutrophils in her blood.
d. Inadequate blood flow, inadequate oxygenation, a. Myasthenia gravis
and inadequate wate removal to organs and cells
b. Rheumatoid arthritis
22. With a mortality rate of ___________ percent, MODS c. Isoimmune neutropenia
is the major cause of death in patients with signifi- d. Systemic lupus erythematosus
cant injuries or illnesses.
See Answers to Review Questions at the end of this book.
a. 40–50 c. 60–90
b. 50–60 d. 80–90

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

pharmacokinetics, p. 362 prototype, p. 372 sympatholytic, p. 396

pharmacology, p. 354 psychotherapeutic medication, p. 381 sympathomimetic, p. 396
placental barrier, p. 365 receptor, p. 367 synapse, p. 387
plasma-level profile, p. 370 second messenger, p. 368 teratogenic drug, p. 360
platelet aggregation inhibitor, p. 414 sedation, p. 378 termination of action, p. 370
postganglionic nerves, p. 387 serum, p. 431 therapeutic index, p. 370
preganglionic nerves, p. 387 side effect, p. 369 up-regulation, p. 368
prodrug, p. 365 surfactant, p. 420 vaccine, p. 431

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.

Introduction Part 1: Basic Pharmacology

The use of herbs and minerals to treat the sick and injured
has been documented as long ago as 2000 b.c.e. Ancient General Aspects
Egyptians, Arabs, and Greeks probably passed formulations
down through generations by word of mouth for centuries
Names
until they were finally recorded in pharmacopoeias. By the Drugs may be broadly defined as foreign substances placed
end of the Renaissance, pharmacology was a distinct and into the body. The term drugs is also used as a synonym for-
growing discipline, separate from medicine. During the sev- medications, chemicals used to diagnose, treat, or prevent
enteenth and eighteenth centuries, tinctures of opium, coca, disease. Pharmacology is the study of drugs and their
and digitalis were available. The related concept of vaccina- actions on the body. To study and converse about pharma-
tion with biological extracts began in 1796 with Edward Jen- cology, health care professionals must have a systematic
ner’s smallpox inoculations. By the nineteenth century, method for naming drugs. The most detailed name for any
atropine, chloroform, codeine, ether, and morphine were in drug is its chemical description, which states its chemical
use. The discoveries of animal insulin and penicillin in the composition and molecular structure. Ethyl-1-methyl-
early twentieth century dramatically changed the treatment 4-phenylisonipecotate hydrochloride, for example, is a
of endocrine/metabolic and infectious diseases. Now, in the chemical name. A generic name is usually suggested by the
twenty-first century, recombinant DNA technology has pro- manufacturer and confirmed by the United States Adopted
duced human insulin and recombinant tissue plasminogen Name Council. It becomes the Federal Drug Administra-
activator (rtPA). These drugs have markedly changed the tion’s (FDA’s) official name when listed in the United States
treatment of diabetes and cardiovascular disease. Pharmacopeia (USP), the official standard for information
Currently in the United States, the Food and Drug about pharmaceuticals in the United States. In the case of
Administration (FDA) is allowing many previously pre- N-Phenyl-N-(1-(2-phenylethyl)-4-piperidinyl) propanamide,
scription-only drugs to become available over the counter. the generic name is fentanyl citrate, USP. To foster brand loy-
This is due in part to growing consumer awareness in alty among its customers, the manufacturer gives the drug a
health care and also in part to consumer marketing by the brand name (sometimes called a trade name or proprietary
pharmaceutical industry. The industry is actively seeking name)—in our example, Sublimaze or Duragesic. The brand
drugs that appeal widely to the consumer for treatments name is a proper name and should be capitalized. Most
and cures. Pharmaceutical research to limit aging or manufacturers also register the name as a trademark, so the
increase the life span is growing rapidly. The federal gov- stylized ® or ™ may follow the name, as in Duragesic®.
ernment also offers incentives to pharmaceutical compa- Another example is the widely prescribed sedative Valium:
nies to research drugs for rare diseases. These so-called Chemical Name: 7-chloro-
orphan drugs are often expensive to investigate and have a 1,3-dihydro-1-methyl-
limited sales potential, making them less profitable to 5-phenyl-2H-1, Content Review
develop and manufacture than others. 4-benzodiazepin-2-one
➤➤ Drug Names
General principles of pharmacology are presented in Generic Name: diazepam • Chemical name
this chapter, which is divided into two parts:
Official Name: diazepam, • Generic name
Part 1: Basic Pharmacology USP • Official name
• Brand name
Part 2: Drug Classifications Brand Name: Valium®
 Emergency Pharmacology 355

Sources Pharmacists. It contains an authoritative listing of mono-

graphs on virtually every drug used in the United States.
The four main sources of drugs are plants, animals, miner-
A less bulky reference to keep in an ambulance might be
als, and the laboratory (synthetic). Plants may be the oldest
one of the many drug guides for nurses. They contain
source of medications; primitive people probably used
information on hundreds of drugs in a format much like
them directly as “herbal” medicines. Indirectly, plant
the EMS drug guides, but they also offer information on
extracts such as gums and oils have long been a source of
commonly prescribed drugs rather than only on emer-
medications. Examples include the purple foxglove, a
gency drugs. The American Medical Association also
source of digitalis (a glycoside), and deadly nightshade, a
publishes a useful reference, the AMA Drug Evaluation.
source of atropine (an alkaloid). Animal extracts are
The Internet provides an enormous amount of informa-
another important source of drugs. For many years, the
tion, but you must be especially cautious when using it
primary sources of insulin for treating diabetes mellitus
as a source, because it allows anyone with a computer to
were the extracts of bovine (cow) and porcine (pig) pan-
be a publisher, with no requirement for accuracy. Exam-
creas. Minerals are inorganic sources of drugs such as cal-
ples of reputable Internet-based reference sites include
cium chloride and magnesium sulfate. Synthetic drugs are
the following:
created in the laboratory. They may provide alternative
sources of medications for those found in nature, or they • Drugs.com
may be entirely new medications not found in nature. • Rxlist.com
• WebMD
Reference Materials • eMedicine
Obtaining information on drugs can be difficult. Using
• Micromedix
multiple sources of information about drugs is usually a
good idea. Every book about drugs, including this one, has There are several widely available pharmacology ref-
a disclaimer regarding doses and current uses, referring erence programs for smartphones. Among these are:
the reader to local medical direction for the final word. • Epocrates
Using multiple sources and comparing the authors’ state-
• Skyscape/DrDrugs
ments about a drug may lead you to the best available
information. The USP is a nongovernmental, official public • MediMath
standards-setting authority for prescription and over-the- • Lexi-comp
counter medicines and other health care products manu-
factured or sold in the United States. EMS providers, Components of a Drug Profile
however, generally like small, short guides that they can
A drug’s profile describes its various properties. As a para-
carry in a shirt pocket. These usually include important
medic student, you will become familiar with drug profiles
details about drugs that out-of-hospital providers adminis-
as you study specific medications. A typical drug profile
ter, along with a long list of commonly prescribed drugs
will contain the following information:
and their classes. These EMS guides will be useful if you
clearly understand the drugs used in your system and • Names. These most frequently include the generic and
have a working knowledge of commonly prescribed drug trade names, although the occasional reference will
classes. include chemical names.
Drug inserts, the printed fact sheets that drug manu- • Classification. This is the broad group to which the
facturers supply with most medications, contain informa- drug belongs. Knowing classifications is essential to
tion prescribed by the FDA. The Physician’s Desk Reference, understanding the properties of drugs.
a compilation of these drug inserts, also includes three
• Mechanism of action. The way in which a drug causes
indices and a section containing photographs of drugs. It is
its effects; its pharmacodynamics.
among the most popular
Content Review references, but it contains
➤➤ Sources of Drug only factual information Cultural Considerations
­Information and must be interpreted by
• United States informed readers. The Folk Remedies.  Many cultures place great trust in herbal
Pharmacopeia (USP) and folk remedies. Some have been proven beneficial by
American Hospital Formu-
• Physician’s Desk modern research. It is important to ask about them when you
lary Service publishes Drug
Reference obtain your patient’s history. Some folk medications can con-
Information annually as a
• Drug inserts tain potentially toxic compounds, such as those containing
service to the American lead or arsenic.
• AMA Drug Evaluation
Society of Health-System
356  Chapter 13

• Indications. Conditions that make administration of

the drug appropriate (as approved by the FDA). Legal Considerations
• Pharmacokinetics. How the drug is absorbed, distrib- Follow Orders of the Medical Director.  The adminis-
uted, and eliminated; typically includes onset and tration of medications by a paramedic is allowed only by
duration of action. express physician order. This can be either verbal or
through approved written standing orders. Always follow
• Side effects/adverse reactions. The drug’s untoward or your medical director ’s orders in regard to medication
undesired effects. administration.
• Routes of administration. How the drug is given.
• Contraindications. Conditions that make it inappro-
priate to give the drug. Unlike conditions when the drug amendments) required pharmacists to have either a
drug is simply not indicated, a contraindication means written or verbal prescription from a physician to dispense
that a predictable harmful event will occur if the drug certain drugs. It also created the category of over-the-counter
is given in this situation. medications. The Kefauver-Harris Amendment was an
• Dosage. The amount of the drug that should be given. amendment to the Federal Food, Drug and Cosmetic Act,
added in 1962, that required pharmaceutical manufactur-
• How supplied. This typically includes the common
ers to provide proof of the safety and effectiveness of their
concentrations of the available preparations; many
drugs before being granted approval to produce and mar-
drugs come in different concentrations.
ket the products. This also stopped the process of remar-
• Special considerations. How the drug may affect pedi-
keting inexpensive generic drugs under new “trade
atric, geriatric, or pregnant patients.
names.” The Comprehensive Drug Abuse Prevention and Con-
Drug profiles may also include other components, such as trol Act (also known as the Controlled Substances Act) of
its interactions with other drugs or with foods, when 1970 is the most recent major federal legislation affecting
appropriate. drug sales and use. It repealed and replaced the Harrison
Narcotic Act.
The federal government strictly regulates controlled

Legal Aspects substances because of their high potential for abuse.

Because not all drugs cause the same level of physical or
Knowing and obeying the laws and regulations governing psychological dependence, they do not all need to be regu-
medications and their administration will be an important lated in the same way. To accommodate their differences,
part of your career. These laws and regulations come from the Controlled Substance Act of 1970 created five schedules
three distinct authorities: federal law, state laws and regu- of controlled substances, each with its own level of control
lations, and individual agency regulations. and record keeping requirements (Table 13-1). Most emer-
gency medical services administer only a few controlled
substances—usually a narcotic analgesic, such as mor-
Federal phine sulfate or fentanyl, and a benzodiazepine anticon-
Drug legislation in the United States has been aimed pri- vulsant, such as diazepam or lorazepam.
marily at protecting the public from adulterated or misla- The majority of the remaining drugs provided by an
beled drugs. The Pure Food and Drug Act of 1906, enacted to EMS are prescription drugs—those whose use the FDA has
improve the quality and labeling of drugs, named the designated sufficiently dangerous to require the supervi-
United States Pharmacopeia as this country’s official source sion of a health care practitioner (physician, dentist, and, in
for drug information. The Harrison Narcotic Act of 1914 some states, nurse practitioner or certified physician assis-
limited the indiscriminate use of addicting drugs by regu- tant). For emergency medical services, this means that the
lating the importation, manufacture, sale, and use of physician medical director is, in effect, prescribing the
opium, cocaine, and their drugs in advance, based on the assessments and judgments
compounds or derivatives. of EMS providers in the field.
Content Review The Federal Food, Drug and Over-the-counter (OTC) medications are generally
➤➤ Drug Laws and Cosmetic Act of 1938 empow- available in small doses and, when taken as recommended,
­Regulations ered the FDA to enforce and present a low risk to patients. Of the few OTC drugs that
• Federal law set premarket safety stan- EMS providers administer, acetaminophen and aspirin are
• State laws and dards for drugs. In 1951, the probably the most commonly used. Although laws vary
regulations Durham-Humphrey Amend- from state to state, they still require most EMS providers to
• Individual agency
ments to the 1938 act (also obtain a physician’s order (either written, verbal, or stand-
regulations
known as the prescription ing) to administer OTC drugs.
 Emergency Pharmacology 357

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

New Drug Development Timeline

Pre-Clinical
Testing,
Research and Clinical Research and Post-Marketing
Development Development NDA Review Surveillance

Range: 1–3 Range: 2–10 years Range: 2 months–7 years

years Average: 5 years Average: 24 months
Average: 18
months
Adverse
Phase 1
Reaction
Initial Reporting
Synthesis

Phase 2
Surveys/
Sampling/
Testing

Animal
Testing Phase 3
Short-Term
Inspections

Long-Term

30-Day FDA Time NDA NDA

Safety Review Industry Time Submitted Approved

Figure 13-1  New drug development timeline.

(United States Food and Drug Administration website, http://www.fda.gov/fdac/special/newdrug/testing.html)

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

Table 13-2  FDA Pregnancy Categories

Category Description
A Adequate studies in pregnant women have not
demonstrated a risk to the fetus in the first trimester or
later trimesters.

B Animal studies have not demonstrated a risk to the

fetus, but there are no adequate studies in pregnant
women.
OR
Adequate studies in pregnant women have not
demonstrated a risk to the fetus in the first trimester
and there is no risk in the last trimester, but animal
studies have demonstrated adverse effects.

C Animal studies have demonstrated adverse effects,

but there are no adequate studies in pregnant Figure 13-2  A Broselow tape is useful for calculating drug dosages
women; however, benefits may be acceptable despite for pediatric patients.
the potential risks.
OR
No adequate animal studies or adequate studies of
pregnant women have been done. dosages must be individualized to minimize the risks of
toxicity. Body surface area and weight are the two most
D Fetal risk has been demonstrated. In certain
circumstances, benefits could outweigh the risks. common factors in calculating dosages. The Broselow tape
gives a good approximation of average height/weight
X Fetal risk has been demonstrated. This risk outweighs
any possible benefit to the mother. Avoid using in ratio for children. It bases its calculations on the child’s
pregnant or potentially pregnant patients. height (length), and assumes the child’s weight is at the fif-
tieth percentile for his height (Figure 13-2). The Broselow
tape addresses primarily drugs administered in the critical
children up to a year old have diminished plasma protein care setting.
concentrations, drugs that bind to proteins have higher
free drug availability. That is, a greater proportion of the Geriatric Patients  Significant changes in phar-
drug will be available in the body to cause either desired macokinetics may also occur in patients older than about
or undesired effects. Water distribution is different in the 60 years. They may absorb oral medications more slowly
neonate as well. Neonates have a much higher proportion due to decreased gastrointestinal motility. Decreased
of extracellular fluid (nearly 80 percent) than adults (50 to plasma protein concentration may alter distribution of
55 percent). This higher amount of water means a greater drugs in their systems, leaving drugs free that would oth-
volume and, with less than expected protein binding, may erwise have been protein bound. Body fat increases and
require higher drug doses. The premature infant is espe- muscle mass decreases with age; therefore, lipid-soluble
cially susceptible to drugs penetrating the blood–brain bar- drugs may have greater deposition, thereby lowering the
rier because his immature connective tissues form a weaker amount of available drug. Absorption and distribution
obstacle. of intramuscular injections may change if volumes are
The newborn’s metabolic rates may be much lower inappropriate for the remaining muscle mass. Because the
than an adult’s, but they rise rapidly and by a few years of liver primarily handles biotransformation, depressed liver
age may triple those of an adult. These metabolic rates function in an aging patient may delay or prolong drug
then decline steadily until early adolescence, when they action. The aging process may also slow elimination by
reach adult levels. A newborn’s low metabolic rate and the renal system.
incompletely developed hepatic system put him at higher Older patients are also more likely to be on multiple
risk for toxic interactions. Neonates’ metabolic pathways medications or to have multiple underlying disease pro-
also are different from an adult’s, meaning that some cesses. Various medication interactions can have a severe
drugs will not have the expected effect or may have other, impact on patients. For example, sildenafil (Viagra) and
unexpected effects. Finally, the neonatal renal and hepatic nitroglycerin taken together may cause severe hypoten-
systems’ immaturity delays elimination of many drugs sion. Underlying diseases may affect therapeutics in
and their metabolites. Dosing schedules may have to be unexpected ways. Congestive heart failure, for instance,
adjusted to accommodate longer half-lives until these sys- may cause congestion of the gastrointestinal tract’s vascu-
tems mature at about 6 months to 1 year of age. lature, delaying the absorption of oral medications. The
With all these factors, a pediatric patient’s drug func- congestive heart failure patient may also have compro-
tion can differ radically from an adult’s. Pediatric drug mised renal function, delaying his elimination of drugs.
362  Chapter 13

Pharmacology Sodium/Potassium Pump

Pharmacology is the study of drugs

Extracellular fluid Na+
and their interactions with the body. Na+ Na+
Drugs do not confer any new proper-
ties on cells or tissues; they only Na+ Na+
modify or exploit existing functions.
They may be given for their local Na+ Na+
action (in which case systemic
absorption of the drug is discour- Na+
aged) or for systemic action.
Although generally given for a spe- P P
Na+
cific effect, drugs tend to have multi-
ATP ADP
ple actions at multiple sites, so they Intracellular fluid
must be thought of in terms of their
(a) (b) (c)
systemic effects rather than in terms
of an isolated single effect. Pharma-
cology’s two major divisions are
K+
pharmacokinetics and pharmacody-
namics. We have already indicated
that pharmacokinetics addresses +
how drugs are transported into and K+ K K+

out of the body and that pharmaco-

+
dynamics deals with their effects K+ K+K K+
once they reach the target tissues.

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

Figure 13-4  Transport of a glu- Facilitated Diffusion

cose molecule across a cell mem-
brane by a carrier protein. (a) A Extracellular fluid
carrier protein with an empty Glucose
Glucose carrier
binding site. (b) Binding of a glu- protein
cose molecule to the protein’s
binding site, which faces the
extracellular surface of the cell.
(c) Conformational change in the Plasma
carrier protein, such that the membrane
binding site now faces the inte-
rior of the cell. (d) Release of the
glucose molecule. The binding
site is once again empty. (e) Intracellular fluid
Return of the carrier to its origi-
(a) (b) (c)
nal conformation. The carrier is
now ready to bind another glu-
cose molecule.

This is the principal mechanism by which insulin

controls glucose use in the body (Figure 13-4).
Most drugs travel through the body by means
of passive transport, the movement of a substance
without the use of energy. This requires the pres-
ence of concentration gradients in a solution. Dif-
fusion and osmosis are forms of passive transport.
Diffusion involves the movement of solute in the (d) (e)
solution, whereas osmosis involves the movement
of the solvent (usually water). In diffusion, the sol- Diffusion
ute’s molecules or ions move down their concentra-
tion gradients from an area of higher concentration
to an area of lower concentration. Conversely, in
osmosis the solvent’s molecules move up the con-
centration gradient from an area of low solute con-
centration to an area of higher solute concentration.
Another way of looking at this is to think of osmo-
sis as simply the diffusion of solvent from an area
of high solvent concentration to an area of low sol-
vent concentration (Figure 13-5). A final type of
When solutes are differently concentrated on two sides of membranes,
passive transport is filtration. This is simply the molecules cross in both directions until equilibrium is reached.
movement of molecules across a membrane down
a pressure gradient, from an area of high pressure
to an area of lower pressure. This pressure typi- Osmosis
cally results from the hydrostatic force of blood
pressure.

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,

Figure 13-5  Diffusion is the movement of solute from an area of

higher concentration to an area of lower concentration. Osmosis is When there is more of a solute such as salt on one side of the membrane,
the movement of water from an area of lower solute concentration water is drawn across the membrane to dilute the greater concentration
to an area of higher solute concentration. until the concentration is equal on both sides.
364  Chapter 13

its absorption into the Ion Transport

Content Review
bloodstream is the first
➤➤ Pharmacokinetic Extracellular fluid
step in this process.
­Processes +
(Because drugs given intra- –
+
–
• Absorption Ions
venously or intraarterially + – +
• Distribution
• Biotransformation enter directly into the
• Elimination bloodstream, no absorp-
tion needs to occur.) Sev- Plasma
+
eral factors affect a drug’s absorption. The body absorbs membrane
most drugs faster when they are given intramuscularly
than when they are given subcutaneously. This is because Channel
– + –
muscles are more vascular than subcutaneous tissue. Of protein +
+ +
course, anything that slows blood flow will delay absorp-
tion. Shock and hypothermia are just two examples. Con- Intracellular fluid

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

metabolites with an endogenous (naturally occurring) Drug Routes Content Review

chemical, usually making the drug more polar and easier The route of a drug’s
➤➤ Drug Routes
to excrete. administration clearly has • Enteral
an impact on the drug’s • Parenteral
Elimination absorption and distribu-
Whether they are unchanged or metabolized before elimi- tion. The route’s impact on biotransformation and elimina-
nation, most drugs (toxins and metabolites) are excreted in tion may not be so clear. The bloodstream will more quickly
the urine. Some are excreted in the feces or in expired air. absorb and distribute water-soluble drugs if given in more
Renal excretion occurs through two major processes: vascular compartments than if given in less vascular com-
glomerular filtration and tubular secretion. Glomerular partments. Oral or nasogastric administration of alkaline
filtration is a function of glomerular filtration pressure, drugs may allow the gastric acids to neutralize the drug
which in turn results from blood pressure and blood flow and prevent its absorption. The liver’s first-pass effect may
through the kidneys. Conditions that affect blood pres- biotransform some orally administered drugs and degrade
sure and blood flow can affect renal elimination. Special- them almost immediately.
ized transport systems in the walls of the proximal
kidney tubules secrete drugs into the urine. These Enteral Routes  Enteral routes deliver medications
“pumps” are active transport systems and require energy by absorption through the gastrointestinal tract, which
in the form of adenosine triphosphate (ATP) to function. goes from the mouth to the stomach and on through the
Some are specialized and transport only specific chemi- intestines to the rectum. They may be oral, orogastric/
cals, whereas others can transport a range of similar nasogastric, sublingual, buccal, or rectal.
chemicals. When drugs compete for the same pump, tox- • Oral (PO). The oral route is good for self-administered
icity or other unwanted effects can result; however, com- drugs. Most home medications are administered by
binations of some drugs can take advantage of this this route. The drug must be able to tolerate the acidic
specialization to prolong their circulation. For example, gastric environment and be absorbed. Few emergency
probenecid blocks renal tubular pumps and competes for drugs are administered through this route.
them with many antibiotics, among them penicillin,
• Orogastric/nasogastric tube (OG/NG). This route is
ampicillin, and oxacillin. Thus, probenecid is sometimes
generally used for oral medications when the patient
given with those antibiotics to increase and prolong their
already has the tube in place for other reasons.
blood levels.
The same factors that affect absorption at any other • Sublingual (SL). This is a good route for self-adminis-
site also affect reabsorption in the renal tubules. Of particu- tration and excellent absorption from the sublingual
lar concern is the urine pH. Lipid-soluble and nonionized capillary bed without the problems of gastric acidity
molecules are readily reabsorbed. Changing the urine pH or absorption.
(usually by administering sodium bicarbonate to make it • Buccal. Absorption through this route between the
more alkaline) can affect the reabsorption in the renal cheek and gum is similar to sublingual absorption.
tubules. For example, if a drug becomes ionized in a more • Rectal (PR). This route is usually reserved for
alkaline environment, then making the urine more alkaline unconscious or vomiting patients or patients who
will interfere with reabsorption and cause more of the drug cannot cooperate with oral or IV administration
to be excreted. (small children).
Some drugs and their metabolites can be eliminated in
the expired air. This is the basis of the breath test that police Parenteral Routes  Broadly defined, parenteral
use to determine a driver’s blood alcohol level. Ethanol is denotes any area outside the gastrointestinal tract; how-
released in the expired air in proportion to its concentra- ever, additional, specific criteria apply to parenteral drug
tion in the bloodstream. Although the liver degrades most administration. Parenteral routes typically use needles to
ingested ethanol, exhalation releases a measurable quan- inject medications into the circulatory system or tissues.
tity. Drugs also can be excreted in the feces. In enterohe- Consequently, some forms of parenteral drug delivery
patic circulation, if a drug (or its metabolites) is excreted afford the most rapid drug delivery and absorption.
into the intestines from bile, the body may reabsorb the
• Intravenous (IV). With its rapid onset, this is the pre-
drug and experience a sustained effect. Additionally, drugs
ferred route in most emergencies.1
may be excreted through sweat, saliva, and breast milk.
Excretion through sweat glands is rarely a significant • Endotracheal (ET). This is an alternative route for
mechanism for elimination. Excretion through mammary selected medications in an emergency.2
glands becomes a concern when nursing mothers take • Intraosseous (IO). The intraosseous route delivers
medications. drugs to the medullary space of bones. Most often used
 Emergency Pharmacology 367

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.

Drug Forms Pharmacodynamics

Drugs come in many forms. Solid forms, generally given
orally, include the following: When we consider a drug’s pharmacodynamics, or effects
on the body, we are specifically interested in its mecha-
• Powders. Although they are not as popular as they nisms of action and the relationship between its concentra-
once were, some powdered drugs are still in use. tion and its effect.
• Tablets. Powders compressed into a disklike form.
• Suppositories. Drugs mixed with a waxlike base that Actions of Drugs
melts at body temperature, allowing absorption by Drugs can act in four different ways. They may bind to a
rectal or vaginal tissue. receptor site, change the physical properties of cells, chem-
• Capsules. Gelatin containers filled with powders or ically combine with other chemicals, or alter a normal met-
tiny pills; the gelatin dissolves, releasing the drug into abolic pathway. Each of these actions involves a
the gastrointestinal tract. physiochemical interaction between the drug and a func-
tionally important molecule in the body.
Liquid drugs are usually solutions of a solid drug dis-
solved in a solvent. Some can be given parenterally, Drugs That Act by Binding to a Receptor Site 
whereas others must be given enterally. Most drugs operate by binding to a receptor. Almost all
drug receptors are protein molecules on the surfaces of cells.
• Solutions. The most common liquid preparations. They are part of the body’s normal regulatory stimulation/
Generally water based; some may be oil based. inhibition function, and can be stimulated or inhibited by
• Tinctures. Prepared using an alcohol extraction pro- chemicals. . Each different receptor’s name generally corre-
cess; some alcohol usually remains in the final drug sponds to the drug that stimulates it. For example, if an opi-
preparation. ate stimulates the receptor, then the receptor is an opioid
368  Chapter 13

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

• Tolerance. Decreased response to the same amount of

drug after repeated administrations. Legal Considerations
• Cross tolerance. Tolerance for a drug that develops Safety First.  Administration of medications is one area
after administration of a different drug. Morphine and where a paramedic or advanced EMT differs from the EMT.
Most EMT skills, even if performed incorrectly, rarely have
other opioid agents are common examples. Tolerance
the potential to harm the patient. However, many advanced
for one agent implies tolerance for others as well.
skills, if performed improperly, can severely harm or even
• Tachyphylaxis. Rapidly occurring tolerance to a drug. kill the patient. Prehospital administration of emergency
May occur after a single dose. This typically occurs medications has saved countless lives. However, there have
with sympathetic agonists, specifically decongestant been instances in which patients have been given the wrong
and bronchodilation agents. medication or an incorrect dose of the correct medication,
resulting in harm to the patient. Because of this, you must be
• Cumulative effect. Increased effectiveness when a
extremely vigilant regarding medication administration. Be
drug is given in several doses.
certain always to confirm orders and write them down. Fol-
• Drug dependence. The patient becomes accustomed to low the six “rights” of medication administration. Double
the drug’s presence in his body and will suffer from check your drugs and expiration dates, the doses, the timing
withdrawal symptoms on its absence. The dependence of administration, and the intended route of administration.
may be physical or psychological. Make sure the medication is being given to the right patient.
Following administration, constantly monitor your patient
• Drug Interaction. The effects of one drug alter the
for the desired effects as well as any possible side effects.
response to another drug. Accurately document your findings, including any untow-
• Drug antagonism. The effects of one drug block the ard effects. It is essential that you make prehospital medica-
response to another drug. tion administration as safe as possible for both the patient
and you.
• Summation. Also known as an additive effect. Two
drugs that both have the same effect are given together,
analogous to 1 + 1 = 2.
• Synergism. Two drugs that both have the same effect termination of action, as well as the drug’s minimum
are given together and produce a response greater effective concentration and toxic levels. The onset of
than the sum of their individual responses, analogous action is the time from administration until a medication
to 1 + 1 = 3. reaches its minimum effective concentration (the mini-
mum level of drug necessary to cause a given effect). The
• Potentiation. One drug enhances the effect of another.
length of time the amount of drug remains above this
A common example is promethazine (Phenergan)
level is its duration of action. Termination of action is
enhancing the effects of morphine.
measured from when the drug’s level drops below the
• Interference. The direct biochemical interaction minimum effective concentration until it is eliminated
between two drugs; one drug affects the pharmacol- from the body.
ogy of another drug. The ratio of a drug’s lethal dose for 50 percent of the
population (LD50) to its effective dose for 50 percent of the
Drug-Response Relationship population (ED50) is its therapeutic index (TI) or LD50/
To have its optimal desired or therapeutic effects, a drug ED50. The therapeutic index represents the drug’s margin
must reach appropriate concentrations at its site of action. of safety. As the range between effective dose and lethal
The magnitude of the response therefore depends on the dose decreases, the value of TI decreases; that is, it becomes
dosage and the drug’s course through the body over time. closer to 1. TI values of close to 1 indicate a very small mar-
Factors that can affect the drug’s concentration may be gin of safety. In other words, the effective dose and lethal
pharmaceutical (the dosage form’s disintegration and the dose of a drug whose TI value is close to 1 are nearly the
drug’s dissolution), pharmacokinetic (the drug’s absorp- same. This drug would be very difficult to effectively dose
tion, distribution, metabolism, and excretion), or pharma- without causing toxicity.
codynamic (drug-receptor interaction). To predict how the The last component of the drug-response relation-
drug will affect different people, a drug-response relation- ship, the biologic half-life, is the time the body takes to
ship thus correlates different amounts of drug to the resul- clear one-half of the drug. Although the rates of metabo-
tant clinical response. lism and excretion both affect it, a drug’s half-life (t1/2) is
Most of the information needed to describe drug- independent of its concentration. For example, if the con-
response relationships comes from plasma-level pro- centration of a drug were 500 mcg/dL after administra-
files, which describe the lengths of onset, duration, and tion and 250 mcg/dL in 10 minutes, then its half-life would
 Emergency Pharmacology 371

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

Classifying Drugs peripheral nervous system comprises everything else. If a

neuron originates within the brain and terminates outside
The enormous amount of material that you must learn the spinal cord, it is part of the peripheral nervous system,
about pharmacology can easily become overwhelming. which, in turn, consists of the somatic nervous system and
The best way to surmount this challenge is to break the the autonomic nervous system. The somatic nervous system
information into manageable groups. Drugs can be classi- controls voluntary, or motor, functions. The autonomic ner-
fied in many ways. You will often find them listed by the vous system, which controls involuntary, or automatic,
body system they affect, by their mechanism of action, or functions, is further divided into the sympathetic and
by their indications. Drugs also can be classified by source parasympathetic nervous systems. The two major group-
or by chemical class. Understanding the properties of ings of medications used to affect the nervous system are
drug classes (or the model drug of a class) can increase those that affect the central nervous system and those that
your understanding of drugs and quicken your learning affect the autonomic nervous system.
of new drugs.
Grouping medications according to their uses is a very
practical way of classifying them. For example, one class of Central Nervous System Medications
drugs is used to treat heart arrhythmias, whereas another Many pathological conditions involve the central nervous
treats hypertension. Although the specific dosing regimens system (CNS). As a result, a great number of drugs have
and contraindications vary among medications within any been developed to affect the CNS, including analgesics,
class, their general properties are consistent. If you under- anesthetics, drugs to treat anxiety and insomnia, anticon-
stand those general principles, learning the specific infor- vulsants, stimulants, psychotherapeutic agents (antide-
mation about individual medications becomes much pressants and antimanic agents), and drugs used to treat
easier. Thinking in terms of prototypical medications usu- specific nervous system disorders such as Parkinson’s dis-
ally helps to describe each classification. A prototype is a ease. Obviously, this is a very broad classification with
drug that best demonstrates the class’s common properties many different types of agents. Having a firm grasp on the
and illustrates its particular characteristics. basic physiology involved will help you to understand the
In the rest of this chapter, we will look at specific clas- various drugs you encounter.
sifications of medications that, as a paramedic,
you will commonly either administer or
encounter. Even though you may not frequently
Nervous system
administer medications from every classifica-
tion, knowing how they work remains impor-
tant. It will help you to understand the
implications of medications your patients may
be taking themselves or getting from another
Central nervous Peripheral nervous
caregiver. An example often cited to demon-
system system
strate the importance of understanding the Brain and spinal All nervous tissue
classes of medications, even those that you will cord outside of CNS

rarely administer, is the patient who has taken

an overdose of tricyclic antidepressants. Based
on your knowledge of this classification, you
will know to increase your index of suspicion Autonomic nervous Somatic nervous
system system
for hypotension and abnormal cardiac rhythms. Controls involuntary Controls voluntary
"automatic" functions "motor" functions

Drugs Used to Affect

the Nervous System Sympathetic nervous
system
Parasympathetic nervous
system
"Fight or flight" "Feed or breed"
The two major divisions of the nervous system
are the central nervous system and the periph-
eral nervous system (Figure 13-8). The central Figure 13-8  Functional organization of the autonomic nervous system within the
nervous system includes the brain and spinal overall nervous system.
 Emergency Pharmacology 373

Analgesics and Antagonists Table 13-3  Opiate Receptor Types

Analgesics are medications that relieve the sensation of
pain. The distinction between analgesia, the absence of Receptor Name Abbreviation Effects
the sensation of pain, and anesthesia, the absence of all mu1 m1 Analgesia, euphoria
sensation, is important. Whereas an analgesic decreases
mu2 m2 Respiratory and physical depression,
the specific sensation of pain, an anesthetic prevents all
miosis, and reduced GI motility
sensation, often impairing consciousness in the process. A
frequently used class of medications, analgesics are avail- delta d Analgesia, dysphoria, psychoto­
mimetic effects (i.e., hallucinations),
able by prescription or over the counter. The two basic and respiratory and vasomotor
subclasses of analgesics are opioid agonists and their stimulation

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

Nerve terminals Nerve terminals

in nucleus in nucleus
accumbens accumbens

–
–

Delta (d) or GABA Delta (d) or GABA

kappa (k) opiate receptor receptor kappa (k) opiate receptor receptor
Synaptic Synaptic
Dopamine cleft cleft
GABA Morphine
Heroin
Dopamine receptor Dopamine receptor
Morphine Heroin
Postsynaptic membrane Postsynaptic membrane

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)

Ibuprofen NSAID Anti-inflammatory • Mild–moderate • Hypersensitivity 200–800 mg PO • Nausea • Commonly

Motrin and antipyretic pain to the drug • Vomiting causes gastric
Advil through inhibition • Fever • Bronchospasm • GI bleeding upset
of prostaglandins • Inflammation • Angioedema • Allergic reactions

Ketorolac NSAID Anti-inflammatory • Mild–moderate • Hypersensitivity 30 mg IV, IM • Nausea • Can cause

Toradol and antipyretic pain to the drug (IV and elderly) • Vomiting dizziness and
through inhibition • Fever • Bronchospasm 60 mg IM • GI bleeding headache
of prostaglandins • Inflammation • Angioedema • Allergic reactions
• Renal colic

Aspirin NSAID Anti-inflammatory • Mild–moderate • Hypersensitivity 350–650 mg PO • Nausea • Commonly

and antipyretic pain to the drug • Vomiting causes gastric
through inhibition • Fever • Bronchospasm • GI bleeding upset
of thromboxane A2 • Platelet • Angioedema • Allergic reactions • Avoid enteric-
aggregation • Patients receiving coated aspirin
inhibitor monamine oxidase in chest pain
inhibitors (MAOIs)

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

Table 13-7  Opioid Agonists–Antagonists

Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Nalbuphine Opiate agonist– Analgesia and • Moderate– • Hypersensitivity 10–20 mg IV, IO, SQ • Sedation • Use with caution
Nubain antagonist sedation through severe pain to the drug • 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.

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

Antianxiety and Benzodiazepine Receptors

Sedative–Hypnotic Drugs Synaptic cleft
GABA A receptor
Antianxiety and sedative–hypnotic drugs are Benzodiazapine GABA
generally used to decrease anxiety, induce (BDZ) binding site Cl–
Gamma Cl–
amnesia, and assist sleeping and as part of a bal-
subunit
anced approach to anesthesia. Sedation refers to Benzodiazapine
a state of decreased anxiety and inhibitions.
Sedation is often quantified and classified by the
Alpha Alpha Alpha Alpha Alpha Alpha
level of sedation. The American Society of Anes-
thesiologists (ASA) uses the following system:

• Minimal sedation, also called anxiolysis, is Postsynaptic

membrane
characterized by a normal response to ver-
bal stimuli. Cytoplasm

• 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

Table 13-8  Levels of Sedation

Minimal Sedation Moderate Sedation/Analgesia
(Anxiolysis) (Conscious Sedation) Deep Sedation/Analgesia General Anesthesia
Responsiveness Normal response to Purposeful response to verbal Purposeful response after Unarousable, even
verbal stimulation or tactile stimulation repeated or painful stimulation with painful stimulation

Airway Unaffected No intervention required Intervention may be required Intervention often required

Spontaneous Ventilations Unaffected Adequate May be inadequate Frequently inadequate

Cardiovascular Function Unaffected Usually maintained Usually maintained May be impaired

 Emergency Pharmacology 379

Generalized seizures involve both hemispheres of the

Table 13-9  Ramsey Sedation Score brain and are described in terms of visible motor activity.
Score Responsiveness Generalized tonic–clonic seizures involve periods of mus-
cle rigidity (tonic stage) followed by spasmodic twitching
1 Patient is anxious and agitated or restless, or both.
(clonic stage) and then flaccidity and a gradual return to
2 Patient is cooperative, oriented, and tranquil. consciousness (postictal stage). Absence seizures are also
3 Patient responds to commands only. generalized but do not have obvious convulsions. They
involve brief losses of consciousness that may occur hun-
4 Patient exhibits brisk response to light glabellar (between
eyebrows—just above the nose) tap or loud auditory stimulus. dreds of times a day. Absence seizures are treated differ-
ently from other types of seizures. Finally, status epilepticus
5 Patient exhibits a sluggish response to light glabellar (between
eyebrows—just above the nose) tap or loud auditory stimulus. is a life-threatening condition characterized by uninter-
rupted tonic–clonic seizures lasting more than 30 minutes
6 Patient exhibits no response.
or by two or more tonic–clonic seizures without an inter-
vening lucid interval. The preferred therapy for each type
of seizure differs.
of GABA, the amount of GABA present limits their
Seizures are treated through several general mecha-
effects. This actually makes benzodiazepines much safer
nisms. The most common is direct action on the sodium
than barbiturates, which at high doses can actually
and calcium ion channels in the neural membranes. Phe-
mimic GABA’s effects and thus can have unlimited
nytoin (Dilantin) and carbamazepine (Tegretol) both
effects. Benzodiazepines and barbiturates are also useful
inhibit the influx of sodium into the cell, thus decreasing
in treating convulsions. Common sedatives and hypnot-
the cell’s ability to depolarize and propagate seizures. Val-
ics are detailed in Table 13-10.
proic acid and ethosuximide act similarly, but they interact
Just as opiates have an antagonist in naloxone (Nar-
with calcium channels in the hypothalamus, where absence
can), benzodiazepines have an antagonist in flumazenil
seizures typically begin. These two drugs are particularly
(Romazicon). Flumazenil competitively binds with the
useful because they are specific to hyperactive neurons and
benzodiazepine receptors in the GABA receptor–chloride
therefore have few side effects. Other medications such as
ion channel complex without causing the effects of benzo-
benzodiazepines and barbiturates interact with the GABA
diazepines. This reverses the sedation from benzodiaze-
receptor–chloride ion channel complex, as explained in the
pines, but it can occasionally have untoward consequences,
section on antianxiety and sedative–hypnotic drugs.
specifically if a patient depends on benzodiazepines for
Antiseizure medications comprise several pharmaco-
seizure control, is withdrawing from alcohol, or is tak-
logical classes, including benzodiazepines (diazepam
ing tricyclic antidepressants. In these cases, the patient
[Valium] and lorazepam [Ativan]), barbiturates (phenobar-
may develop seizures following the administration of
bital [Luminal]), hydantoins (phenytoin [Dilantin] and fos-
flumazenil.
phenytoin [Cerebyx]), succinimides (ethosuximide
[Zarontin]), and miscellaneous medications such as val-
Antiseizure or Antiepileptic Drugs proic acid (Depakote), felbamate (Felbatol), lacosamide
Seizures are a state of hyperactivity of either a section of (VIMBAT), lamotrigene (Lamictal), levetiracetam (Kep-
the brain (partial seizure) or all of the brain (generalized pra), and gabapentin (Neurontin). Table 13-11 lists the pre-
seizure). They may or may not be accompanied by convul- ferred medication for treating each type of seizure.
sions. Therefore, although the medications in this func-
tional class may be called anticonvulsants, they are more
appropriately referred to as antiseizure or antiepileptic
Central Nervous System Stimulants
Stimulating the central nervous system is desirable in cer-
drugs. The goal of seizure management is to balance elimi-
tain circumstances such as fatigue, drowsiness, narcolepsy,
nating the seizures against the side effects of the medica-
obesity, and attention deficit hyperactivity disorder.
tions used to treat them. Controlling seizures is a lifelong
Broadly, two techniques may accomplish this:
process for most patients and requires diligent compliance
with medication dosing regimens. • Increasing the release or effectiveness of excitatory
Partial (or focal) seizures erupt from a specific focus neurotransmitters
and are described in terms of alterations in consciousness
• Decreasing the release or effectiveness of inhibitory
or behavior. These may be further divided into simple or
neurotransmitters
complex partial seizures based on the specific area of the
brain in which the focus is located. Complex partial sei- Within the functional class of CNS stimulants are three
zures are also known as psychomotor seizures and are pharmacological classes: amphetamines, methylpheni-
characterized by repetitive motions. dates, and methylxanthines.
Table 13-10  Common Sedatives/Hypnotics
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Benzodiazepines

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

chocolates. Theophylline’s relaxing effects on bronchial

Table 13-11  Antiseizure Medications smooth muscle make it helpful in treating asthma. The
Type of Seizure Drug of Choice methylxanthines’ mechanism of action is unclear, but it
seems to block adenosine receptors. Adenosine is an
Partial seizures Phenytoin
endogenous neurotransmitter that is used clinically for
Carbamazepine
Oxacarbazepine
certain types of tachycardias. Because methylxanthines
Felbamate block the adenosine receptors, larger-than-normal doses
Lacosamide may be needed to achieve the desired result. This class’s
Lamotrigene side effects are similar to those of the amphetamines, but
Levetiracetam they have a much lower potential for abuse and are not
controlled drugs.
Generalized seizures Carbamazepine
Phenytoin
Phenobarbital Psychotherapeutic Medications
Lamotrigene Psychotherapeutic medications treat mental dysfunc-
Levetiracetam tion. Unlike other disease states, we do not thoroughly
Gabapentin understand the pathophysiology of mental dysfunction;
therefore, we base much of our pharmacological treat-
Absence seizures Valproic acid
Ethosuximide
ment of these conditions on our limited knowledge and
on clinical correlation (scientific observation that these
medications are indeed effective, even if we do not fully
The amphetamines also include methamphetamine understand their mechanism). Medications are typically
and dextroamphetamine. These drugs all increase the only one tactic in a balanced strategy for treating mental
release of excitatory neurotransmitters including norepi- illness. Depending on the specific disorder, physicians
nephrine and dopamine. Norepinephrine is the
primary cause of these drugs’ effects, which Amphetamine Actions
include an increased wakefulness and awareness
as well as a decreased appetite (Figure 13-11). Nerve terminal
Amphetamines’ most common uses, therefore, are
treating drowsiness and fatigue and suppressing MAO
the appetite. Most of amphetamines’ side effects
result from overstimulation; they include tachy-
cardia and other arrhythmias, hypertension, con-
vulsions, insomnia, and occasionally psychoses
with hallucinations and agitation. Examples of
this class include amphetamine sulfate (the proto-
+
type) and dextroamphetamine (Dexedrine). +
Methylphenidate, marketed as Ritalin, is the
most commonly prescribed drug for attention def- Noradrenaline Amphetamine
icit hyperactivity disorder (ADHD). Although it is reuptake binding site
chemically different from the amphetamines, its transporter
Synaptic Dopamine
pharmacological mechanism of action is similar. reuptake
cleft
Also, like the amphetamines, it has a high abuse transporter
potential and is therefore listed as a Class II con- Noradrenaline
receptor Dopamine
trolled substance. Although treating hyperactivity
receptor
with a stimulant may seem odd, it is quite effec-
tive. Frequently, the cause of inappropriate behav- Dopamine Postsynaptic membrane
ior in a child with ADHD is his inability to Noradrenaline
concentrate or focus. Ritalin’s stimulant effects Amphetamine
increase this ability, and the unwanted behavior
often diminishes. Figure 13-11  The mechanism of action of amphetamines. High-dose amphet-
amines can modify the action of dopamine and norepinephrine in the brain. At
The methylxanthines include caffeine, ami-
high doses, amphetamine increases the concentration of dopamine in the synap-
nophylline, and theophylline. Although caffeine, tic cleft. High-dose amphetamine has a similar effect on norepinephrine neurons;
the prototype drug in this class, has few clinical it can induce the release of norepinephrine into the synaptic cleft and inhibit the
uses, it is frequently ingested in coffee, colas, and norepinephrine reuptake transporter.
382  Chapter 13

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)

Synaptic a adrenergic Histamine H1 Synaptic

a adrenergic receptor
receptor cleft receptor cleft
Histamine H1 5 HT2
receptor receptor
5 HT2 Dopamine Dopamine
receptor receptors receptors
D1 D2 D1 D2
Efficacy Postsynaptic membrane Adverse effects Postsynaptic membrane

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

Because the phenothiazines’ and the butyrophe- Tricyclic antidepres-

Content Review
nones’ mechanisms of action are identical, their common sants (TCAs) are frequently
➤➤ Major Classes of Antide-
side effects are also similar: extrapyramidal symptoms used in treating depression
pressant Medications
from cholinergic blockade in the basal ganglia of the because they are effective,
• TCAs
cerebral hemispheres; orthostatic hypotension from relatively safe, and have
• SSRIs
blockage of alpha1 adrenergic receptors; sedation; and few significant side effects • MAOIs
sexual dysfunction. Treatment for these side effects typi- when taken in therapeutic
cally involves modifying the drug dose. Diphenhydr- dosages. TCAs act by blocking the reuptake of norepineph-
amine (Benadryl), an antihistamine with anticholinergic rine and serotonin, thus extending the duration of their
properties, is indicated for treating acute dystonic reac- action (Figure 13-13). Unfortunately, they also have anti-
tions (manifestations of EPS), which often present with cholinergic properties that cause many side effects, includ-
tongue and neck spasm. Patients with a newly prescribed ing blurred vision, dry mouth, urinary retention, and
antipsychotic may experience these effects and contact tachycardia. Another frequent side effect, orthostatic hypo-
EMS. Fortunately, treatment with diphenhydramine is tension, is likely due to the alpha1 adrenergic blockade.
effective and rapid. Orthostatic hypotension is treated in This is commonly seen when patients try to stand up too
the usual fashion, described in the chapter “Hemorrhage quickly and become dizzy. Additionally, because TCAs can
and Shock.” lower the seizure threshold, patients with existing seizure
Other medications used to treat psychotic conditions disorders are at risk for convulsions. Unfortunately, when
are considered atypical antipsychotics. Although their taken in overdose, TCAs can have very significant cardio-
mechanisms of action are similar to those of the traditional toxic effects—including myocardial infarction and arrhyth-
antipsychotics, the atypical antipsychotics block more mias—that make them a favored means of attempting
specific receptors. This specificity allows them to function suicide among depressed patients. Partly because of this
much like traditional antipsychotics but without causing potential for overdose, TCAs have fallen behind the newer
the prominent extrapyramidal symptoms. These drugs selective serotonin reuptake inhibitors as the drug of choice
include clozapine (Clozaril), risperidone (Risperdal), for depression. Overdoses of these medications also fre-
ziprasidone (Geodon), and olanzapine (Zyprexa). See quently cause marked hypotension. Treatment of TCA
Table 13-12.
Another functional class of psychotherapeu-
Tricyclic Antidepressants
tic medications includes the antidepressants. The
DSM-5 characterizes major depressive episodes Norepinephrine Synapse Serotonin Synapse
as causing significantly depressed mood, loss of Transmitting Transmitting
(Presynaptic) (Presynaptic)
interest in things that normally give the patient Neuron Neuron
pleasure, weight loss or gain, sleeping distur- Norepinephrine and
bances, suicide attempts, feelings of hopeless- serotonin are normally
ness and helplessness, loss of energy, agitation or removed from the synapse by
reuptake sites.
withdrawal, and an inability to concentrate. Tricyclic antidepressants
Although the specific pathology of this disease is block norepinephrine and
not yet known, it appears to be related to an serotonin reuptake sites,
allowing these neuro-
insufficiency of monoamine neurotransmitters transmitters to remain active
(norepinephrine and serotonin). Thus, the phar- in the synapse longer.
maceutical interventions for this disease appear
to increase the number of neurotransmitters
Reuptake Sites
released in the brain. The several ways of doing (or Transporters)
this include increasing the amount of neurotrans-
mitter produced in the presynaptic terminal,
increasing the amount of neurotransmitter
released from the presynaptic terminal, and Neurotransmitter
Receptors
blocking the neurotransmitter’s reuptake (reab-
sorption by the presynaptic terminal). This
results in a net increase in the neurotransmitter. Receiving Receiving
(Postsynaptic) (Postsynaptic)
The antidepressants comprise three pharmaco- Neuron Neuron
logical classes: tricyclic antidepressants, selective
serotonin reuptake inhibitors, and monoamine Figure 13-13  The mechanism of action of tricyclic antidepressants (TCAs),
oxidase inhibitors. blocking the reuptake of serotonin and norepinephrine.
Table 13-12  Antipsychotics
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Haloperidol Butyrophenone Blocks • Psychosis • Hypotension 2–10 mg IM, PO • Extrapyramidal • Hypotension
Haldol dopamine • Hypersensitivity reactions more common
receptors to the drug • Insomnia in patients taking
associated • Restlessness antihypertensives.
with mood and • Dry mouth
behavior • Hypotension
• Tachycardia

Chlorpromazine Phenothiazine Blocks • Psychosis • Hypotension 25–50 mg IM, PO • Extrapyramidal • Hypotension

Thorazine dopamine • Intractable • Hypersensitivity reactions more common
receptors hiccups to the drug • Insomnia in patients taking
associated • Restlessness antihypertensives.
with mood and • Dry mouth
behavior • Hypotension
• Tachycardia

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

overdoses is primarily supportive, with sodium bicar- MAO Inhibitors

bonate given to increase the excretion of TCAs by alka-
Norepinephrine or
linizing the urine. The prototype tricyclic antidepressant, Serotonin Synapse
imipramine (Tofranil), was also the first one on the mar- Transmitting (Presynaptic)
Neuron
ket. Other common examples include amitriptyline
(Elavil), desipramine (Norpramin), and nortriptyline Norepinephrine and
(Pamelor). serotonin are normally
destroyed by the enzyme
Selective serotonin reuptake inhibitors (SSRIs) are a monoamine oxidase (MAO).
recent addition to the antidepressants. The prototype, MAO inhibitors block this
enzyme, inhibiting the
fluoxetine (Prozac), is the most widely prescribed antide- destruction of norepinephrine
pressant in the United States. These drugs’ antidepressant and serotonin, allowing the
effects are comparable to those of the TCAs, but because MAO neurotransmitters to remain
active longer.
the SSRIs selectively block the reuptake of serotonin, they
do not affect dopamine or norepinephrine. Nor do they Neurotransmitter
block histaminic or cholinergic receptors, thus avoiding Transporter
(or Reuptake Site)
many of the TCAs’ side effects (Figure 13-14). The primary
Synapse
adverse reactions to SSRIs are sexual dysfunction, head- Neurotransmitter
ache, and nausea. Other selective serotonin reuptake Receptor
inhibitors include sertraline (Zoloft), citalopram (Celexa), Receiving
escitalopram (Lexapro), and paroxetine (Paxil). (Postsynaptic)
Neuron
A third pharmacological class of psychotherapeutic
medications includes the monoamine oxidase inhibitors
Figure 13-15  The mechanism of action of monamine oxidase
(MAOIs). The monoamine neurotransmitters are thought
inhibitors (MAOIs).
to be insufficient in depression. Monoamine oxidase, an
enzyme, metabolizes monoamines into inactive metabo-
lites. MAOIs inhibit monoamine oxidase and block the release of norepinephrine. The MAOIs’ major side effect
monoamines’ breakdown, thus increasing their availabil- is hypertensive crisis brought on by the consumption of
ity (Figure 13-15). Monoamine oxidase is also present in foods rich in tyramine, such as cheese and red wine. By
the liver and has a significant role in metabolizing foods inhibiting monoamine oxidase, these drugs also decrease
that contain tyramine, a substance that increases the the body’s ability to inactivate tyramine; they therefore
promote the release of norepinephrine, a potent vaso-
SSRI Antidepressants pressor. Because of this and other unwanted side effects,
MAOIs are not commonly used anymore; rather, they are
Transmitting reserved for treating depression that is refractory to
(Presynaptic)
Serotonin Neuron TCAs and SSRIs. The prototype of this class is phenelzine
(Nardil).
Serotonin is normally removed Patients with bipolar disorder (manic depression)
from the synapse by reuptake
exhibit cyclic swings from mania to depression, with peri-
sites on the presynaptic neuron.
SSRIs block the serotonin ods of normalcy in between. According to the DSM-5, the
reuptake sites, allowing manic phases of this disease are characterized by hyperac-
serotonin to remain active in the
synapse longer. tivity, thoughts of grandeur or inflated self-esteem,
decreased need for sleep, increased goal-oriented behavior,
increased productivity, flight of ideas (moving from
Serotonin Reuptake Site thought to thought with little connection between them),
(or Transporter) distractibility, and increased risk taking. Lithium is the
drug of choice for the management of bipolar disorder. It is
Synapse frequently given in conjunction with benzodiazepines or
Serotonin
Receptor antipsychotics. Lithium’s mechanism of action is unknown,
but it effectively decreases the signs of mania without caus-
Receiving ing sedation. Adverse reactions include headache, dizzi-
(Postsynaptic)
Neuron ness, fatigue, nausea, and vomiting. Recently, two
antiseizure medications—carbamazepine (Tegretol) and
Figure 13-14  The mechanism of action of selective serotonin reup- valproic acid (Depakote)—have proven successful in treat-
take inhibitors (SSRIs). ing bipolar disorder.
386  Chapter 13

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
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388  Chapter 13

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.

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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

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Figure 13-18  Distribution of the parasympathetic postganglionic fibers.

390  Chapter 13

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

Lungs Bronchoconstriction Bronchiole smooth

Table 13-13  Comparison of Muscarinic and Nicotinic Increased mucus muscle
Receptors production Bronchial glands

Nicotinic Acetylcholine Muscarinic Acetylcholine Gallbladder Contraction

Receptors Receptors
Urinary bladder Relaxation Urinary sphincter
Found at the neuromuscular Found at the neuromuscular junction Contraction Detrusor muscle
junction of skeletal (only) muscles. of smooth and cardiac muscle.
Liver Glycogen synthesis
Found on postganglionic Found on postganglionic
parasympathetic nerves. sympathetic nerves.
Lacrimal glands Secretion (increased tearing) Eye
Found on many neurons in the brain. Found on glands.
Eye Contraction for near vision Ciliary muscle
Nicotine is an agonist. Muscarine is an agonist. Constriction Pupil

Curare is an antagonist. Atropine is an antagonist. Penis Erection

 Emergency Pharmacology 391

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)

Table 13-16   Neuromuscular Blocking Agents

Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Succinylcholine Depolarizing Binds to ACh receptors • Rapid sequence • Hyperkalemia 1–2 mg/kg IV, IO • Hyperkalemia • These agents should
Anectine neuromuscular at the neuromuscular intubation (RSI) • Neuromuscular • Bradycardia be used only by
blocker junction, causing disease • Prolonged paralysis persons skilled in their
depolarization and • Crush injury • Malignant use, competent at
subsequent paralysis • Burns hyperthermia complicated airway
• Increased intracranial • Increased management, and
pressure intracranial pressure with all necessary
• Severe trauma • Muscle resuscitative equipment
fasciculations available.
• Trismus

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

Drugs Used to Affect the Sympathetic • Bronchodilation

Nervous System • Stimulation of energy production
The sympathetic nervous system arises from the thoracic
The collateral ganglia are located in the abdominal cavity.
and lumbar regions of the spinal cord. Preganglionic
Nerves leaving the collateral ganglia innervate many of the
nerves leave the spinal cord through the spinal nerves and
organs of the abdomen. Stimulation of these fibers causes
end in the sympathetic ganglia. There are two types of
several conditions. They include:
sympathetic ganglia: sympathetic chain ganglia and collat-
eral ganglia (Figure 13-20). In addition, special pregangli- • Reduction of blood flow to abdominal organs
onic sympathetic nerve fibers innervate the adrenal • Decreased digestive activity
medulla. Postganglionic nerves that exit the sympathetic
• Relaxation of smooth muscle in the wall of the urinary
chain ganglia extend to several peripheral target tissues of
bladder
the sympathetic nervous system. When stimulated, these
• Release of glucose stores from the liver
fibers have several effects. They include:

• 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.

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 Emergency Pharmacology 395

Via post-
Ganglionic ganglionic
(second-order) fibers
neurons Target Organs

Sympathetic Visceral effectors

chain ganglia in thoracic cavity,
(paired) body wall, and limbs

Preganglionic
Sympathetic Visceral effectors
(first-order) neurons Collateral ganglia
Division in abdominopelvic
in spinal segments (unpaired)
of ANS cavity
T1– L2

Adrenal medulla Organs and systems

(paired) throughout body

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 sympathetic nervous system releases norepineph- Increased conductivity

Increased automaticity
rine from postganglionic end terminals and epinephrine
Increased contractility
from the adrenal medulla. These neurotransmitters bind
Renin release Kidney
with adrenergic receptors. (Epinephrine is also called adren-
alin because of its release from the adrenal medulla; hence Beta 2 (b2) Bronchodilation Lungs

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

such as fingers, toes, earlobes, or nose, inadequate local stimulating b2 receptors in

Content Review
blood flow due to profound vasoconstriction will likely kill the lungs, these agents
➤➤ Common Catecholamines
the tissue. In addition, a1 stimulation may cause reflex bra- relax the bronchial smooth
• Natural
dycardia due to the feedback mechanism that regulates muscle and cause broncho-
• Epinephrine
blood pressure. As baroreceptors detect a rise in blood pres- dilation. Beta2 agonists can • Norepinephrine
sure, heart rate decreases to compensate. also cause uterine smooth • Dopamine
Alpha1 antagonism is indicated almost exclusively for muscle relaxation, which • Synthetic
controlling hypertension. By preventing the peripheral may help to suppress pre- • Isoproterenol
vasoconstriction of a1 stimulation, these agents decrease term labor. Their primary • Dobutamine
blood pressure. They are also useful in treating local tissue adverse effects are muscle
necrosis caused by infiltration of a1 agonists. Injecting a1 tremors and “bleed over” effects on unintended b1 stimu-
antagonists into the area surrounding the infiltration pre- lation such as tachycardias.
vents tissue death from excessive vasoconstriction. The Although b2 blockade serves no clinically useful pur-
effects of pheochromocytoma, a tumor of the adrenal pose, nonselective beta-blockers have side effects of b 2
medulla that causes the release of large amounts of cate- blockade. Chief among these is bronchoconstriction and
cholamine, may be treated with an a1 blocker. The most inhibition of glycogenolysis, the release of stored glycogen
common adverse effects of a1 antagonism are orthostatic by the liver and skeletal muscles. Beta2 stimulation causes
hypotension and reflex tachycardia. Just as a1 stimulation glycogenesis. Antagonizing the b2 receptors can inhibit
may increase blood pressure and cause a baroreceptor- this release. Although this is not typically a problem for
mediated bradycardia, the hypotension from a1 blockage most people, it can be very problematic for diabetics. It not
may lead to reflex tachycardia from the same mechanism. only makes hypoglycemia more likely, but also masks one
Other side effects include nasal congestion and inhibition of of its common early warning signs, tachycardia.
ejaculation. These agents may also increase blood volume.
This is ironic, as their primary indication is hypertension. Adrenergic Agonists  Drugs that stimulate the
As another feedback mechanism detects hypotension, the effects of adrenergic receptors work either directly, indi-
kidneys begin to reabsorb sodium and water to increase rectly, or through a combination of the two. The direct-
blood volume. This is typically addressed by use of a acting agents bind with the receptor and cause the same
diuretic concomitant with the a1 antagonist. response as the normal neurotransmitter. In fact, most of
Beta1 stimulation increases heart rate, contractility, and the drugs in this category are either synthetically produced
conduction. Its primary indications are cardiac arrest and versions of the naturally occurring neurotransmitter or
hypotension resulting from inadequate pumping. During derivatives of those synthetically produced versions. The
cardiac arrest, b1 activation may stimulate contractions or indirect-acting agents stimulate the release of epinephrine
increase the force of any existing contractions. Even if the from the adrenal medulla and of norepinephrine from the
heart is only fibrillating, these agents may increase the effec- presynaptic terminals. In turn, the epinephrine and nor-
tiveness of electrical defibrillation. In cardiogenic shock, epinephrine stimulate the adrenergic receptors. The mixed
when the heart is not pumping with enough force to over- actions of direct–indirect-acting medications combine these
come the afterload created by peripheral vascular resistance, mechanisms.
b1 agonists can adequately increase the contractions’ force. The most frequently used adrenergic agents are chemi-
The chief adverse effects of b1 agonists include tachycardia, cally and functionally similar to the endogenous neurotrans-
arrhythmias, and chest pain from increasing workload. mitters. These drugs, which are called catecholamines,
Beta1 antagonists are among the most frequently pre- include norepinephrine, epinephrine, and dopamine.18,19
scribed medications in the United States. Their most com- Synthetic catecholamines are also available. They include
mon use is to control blood pressure. By blocking the dobutamine and isoproterenol. Noncatecholamine adrener-
effects of b1 stimulation, they decrease heart rate (chronot- gic agents, including ephedrine, phenylephrine, and terbu-
ropy) and contractility (inotropy). These agents are also taline, also affect the adrenergic receptors and have useful
effective in treating supraventricular tachycardias because clinical applications.
they decrease the rate of impulse generation at the SA node
(negative chronotropic effects) while also slowing conduc-
tivity through the AV node (negative dromotropic effects). Patho Pearls
Blocking b1 stimulation also helps treat angina pectoris
Adrenergic Agonists: Effects of Repeated Doses.  Many
and reduces the recurrence of myocardial infarction. Its adrenergic agonists (Table 13-18), particularly decongestants and
main adverse effects are symptomatic bradycardia, hypo- respiratory drugs, can result in tachyphylaxis. That is, repeated
tension, and AV block. doses of the same drug have decreasing effects. In these cases, it
Beta2 agonists are used to treat asthma and other con- may be prudent to change to a similar drug in the same family.
ditions with excessive narrowing of the bronchioles. By The effects of a different drug can often be significantly better.
Table 13-18  Adrenergic Agonists
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Vasopressors

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

problematic side effects for asthmatics and diabetics. Aten-

Table 13-19  Adrenergic Receptor Specificity olol (Tenormin) is another commonly used cardioselective
Receptor beta-blocker.
Medication
Alpha1 Alpha2 Beta1 Beta2 Dopaminergic Skeletal Muscle Relaxants  Skeletal muscle
Phenylephrine ✓ relaxants are used to treat muscle spasm from injury and
muscle spasticity from CNS injuries or diseases such as
Norepinephrine ✓ ✓ ✓
multiple sclerosis. Treatment can involve centrally acting
Ephedrine ✓ ✓ ✓ ✓ agents or direct-acting agents.
The centrally acting muscle relaxants’ mechanism is
Epinephrine ✓ ✓ ✓ ✓
not clear, but it appears to be associated with general seda-
Dobutamine ✓ tion. The prototype centrally acting skeletal muscle relaxant
is baclofen (Lioresal), which is indicated in the treatment of
Dopamine* ✓ ✓
spasticity. Although baclofen is effective in the treatment of
Isoproterenol ✓ ✓ muscle spasticity, it is generally ineffective in muscle spasm.
Terbutaline ✓ Several drugs are effective in treating muscle spasm, includ-
ing cyclobenzaprine (Flexeril) and carisoprodol (Soma).
*Receptor specificity is dose dependent. The higher the dose, the fewer dopamin-
The prototype of the direct-acting muscle relaxants is
ergic effects are seen.
dantrolene (Dantrium). Unlike the centrally acting agents,
dantrolene’s mechanism is well understood. It decreases
Almost all the drugs in this section act on more than
the release of calcium from the sarcoplasmic reticulum in
one type of receptor. Their specificity varies and is impor-
response to action potentials propagated from the neuro-
tant in determining their uses. Table 13-19 lists their actions
muscular junction. This calcium is required for the cross-
on various receptors.20–21
bridge binding of the actin and myosin filaments in the
Adrenergic Antagonists  Unlike most adrener- muscle fibers responsible for contraction. Dantrolene is
gic agonists, the majority of available adrenergic antago- indicated for treating the spasticity associated with multi-
nists are remarkably selective in which receptor they affect. ple sclerosis and cerebral palsy. It is also indicated for treat-
This selectivity, however, occurs only at therapeutic doses. ing malignant hyperthermia, which is seen, on rare
At higher doses, most agents lose their selectivity and begin occasion, with some anesthetics and succinylcholine. This
affecting other receptors as well. hyperthermia results from muscular contractions. Because
The two basic subcategories of alpha adrenergic antag- dantrolene decreases these contractions, the heat that they
onists are “noncompetitive, long-acting” and “competitive, generate also decreases. Dantrolene is not effective in treat-
short-acting.” They differ chiefly in the stability of their ing muscle spasm.
bond with the receptor. The prototype noncompetitive,
long-acting alpha antagonist is phenoxybenzamine (Diben-
zyline). The prototype competitive, short-acting antagonist
is prazosin (Minipress). Prazosin also is the prototype for
Drugs Used to Affect the
all alpha adrenergic antagonists. Phentolamine (Regitine) Cardiovascular System
is an important nonselective alpha antagonist because of
Cardiovascular drugs have traditionally comprised one of
its effects in reversing tissue necrosis caused by catechol-
the largest parts of the paramedic’s pharmacological “tool-
amine infiltration.
box.” Although this is changing with the expansion of
Beta adrenergic antagonists are more commonly
paramedic practice, cardiovascular care (and agents used
referred to as beta-blockers. Propranolol (Inderal) is the
in that care) remains an important and integral part of a
prototype beta-blocker. It is a nonselective antagonist,
paramedic’s knowledge base.
which means that it blocks both b1 and b2 receptors. It is
used to treat tachycardia, hypertension, and angina, all
results of b1 blockade. Because it is nonselective, it also has Cardiovascular Physiology Review
the side effects of b2 blockade—bronchoconstriction and To understand cardiovascular pharmacology, you must first
inhibited glycogenolysis. Propranolol was the first clini- understand how electrical conduction and mechanical con-
cally employed beta-blocker, but its use has declined since traction work together to produce an organized and effective
the development of more selective b1 antagonists. The pro- pumping action. In this section, we briefly review the anat-
totype of these cardioselective beta-blockers is metoprolol omy and physiology of the heart and then discuss the gen-
(Lopressor). At normal doses, metoprolol is selective for eration of electrical impulses and the creation of arrhythmias.
only b1 receptors; therefore, it does not cause propranolol’s Then we discuss how each classification acts on arrhythmias.
 Emergency Pharmacology 401

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

Impulse Generation Interventricular

and Conduction septum Left bundle branch
The key to the precise cardiac Right bundle branch
cycle is the electrical conduction Purkinje fibers
system (Figure 13-24). This system
is composed of specialized car-
diac tissue that generates electri-
Purkinje network
cal impulses and conducts them
rapidly throughout the heart to Figure 13-24  Cardiac conductive system.
402  Chapter 13

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

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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

Figure 13-26  Reentrant pathways.

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

Table 13-20  Antiarrhythmic Classifications and Examples

General Action Class Prototype ECG Effects
Sodium channel blockers IA Quinidine, procainamide*, disopyramide Widened QRS, prolonged QT
IB Lidocaine*, phenytoin, tocainide, mexiletine Widened QRS, prolonged QT
IC Flecainide*, propafenone Prolonged PR, widened QRS
I (Miscellaneous) Moricizine* Prolonged PR, widened QRS

Beta-blockers II Propranolol*, acebutolol, esmolol Prolonged PR, bradycardias

Potassium channel blockers III Bretylium*, amiodarone Prolonged QT

Calcium channel blockers IV Verapamil*, diltiazem Prolonged PR, bradycardias

Miscellaneous Adenosine, digoxin Prolonged PR, bradycardias

* 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

actions on the heart’s electrical activity, we do understand increases, stroke volume

Content Review
its effects. Digoxin decreases the intrinsic firing rate in the increases (up to a point),
➤➤ Pharmacological Classes
SA node, whereas it decreases conduction velocity in the and as preload decreases,
of Antihypertensives
AV node. Both these effects are due to its increasing the stroke volume decreases.
• Diuretics
strength of the parasympathetic effects on the heart. In the Drugs that affect blood vol-
• Beta-blockers and
Purkinje fibers and ventricular myocardial cells, it ume control hypertension antiadrenergic drugs
decreases the effective refractory period and increases by manipulating preload. • ACE inhibitors
automaticity, both of which may explain its ability to Several pharmaco- • Calcium channel
increase ventricular arrhythmias. To compound this, by logical classes of medica- blockers
depressing SA node activity, digoxin makes ectopic ven- tions are used to control • Direct vasodilators
tricular beats more likely to assume the pacing activity of blood pressure. The major
the heart. Its side effects include bradycardias, AV blocks, approaches to dealing with hypertension are diuretics,
postventricular contractions (PVCs), ventricular tachycar- beta-blockers and other antiadrenergic drugs, angiotensin-
dia, ventricular fibrillation, and atrial fibrillation. Actually, converting enzyme (ACE) inhibitors, calcium channel
there are few arrhythmias that digoxin does not produce. blockers, and direct vasodilators. Of these, diuretics and
In addition, digoxin has a very narrow therapeutic index, beta-blockers are the most frequently prescribed, and they
meaning that it is difficult to find a patient’s effective dose are effective in many patients. The remaining agents are
without producing side effects. Digoxin also increases car- used when diuretics or beta-blockers are contraindicated
diac contractility. It is indicated for atrial fibrillation with or when those approaches are not effective, although ACE
rapid ventricular conduction and chronic treatment of con- inhibitors are gaining increasing popularity. Often, physi-
gestive heart failure. cians must prescribe multiple drugs to manage hyperten-
Magnesium is the drug of choice in torsades de pointes, a sion effectively. In these cases, they will pick one drug
polymorphic ventricular tachycardia, and in other ventric- from two or more classes that complement each other. For
ular arrhythmias refractory to other therapy. Its mecha- example, a physician might prescribe a diuretic with a
nism of action is not known, but it may act on the sodium beta-blocker. 23
or potassium channels or on Na+K+ATPase.
Diuretics  Diuretics reduce circulating blood volume
Antihypertensives by increasing the amount of urine. This reduces preload
Hypertension affects more than 50 million people in the to the heart, which, in turn, reduces cardiac output. The
United States alone and is a major contributor to coronary main categories of diuretics include loop diuretics (high-
artery disease, stroke, and blindness. Fortunately, available ceiling diuretics), thiazides, and potassium-sparing diuret-
drugs can effectively manage blood pressure with limited ics. They all affect the reabsorption of sodium and chloride
side effects in the vast majority of patients. Multiple stud- and create an osmotic gradient that decreases the reab-
ies have shown conclusively that controlling blood pres- sorption of water. These classes differ according to which
sure decreases both morbidity and mortality. area of the nephron they affect. In general, the earlier in
Blood pressure is the force of blood against the arter- the nephron the drug works, the more sodium and water
ies’ walls as the heart contracts and relaxes. It is equal to will be affected. Almost all electrolytes and other small
cardiac output times the peripheral vascular resistance: particles in the blood are filtered through the glomerulus.
Most sodium and water (approximately 65 percent) are
Blood pressure = Cardiac output * Peripheral vascular resistance
reabsorbed in the proximal convoluted tubule. Another 20
Cardiac output is equal to the heart rate times the stroke percent are reabsorbed in the thick portion of the ascend-
volume: ing loop of Henle, whereas only about 1 to 5 percent are
recaptured in the distal convoluted tubule and collecting
Cardiac output = Heart rate * Stroke volume
duct. Therefore, a drug that decreases sodium reabsorption
Antihypertensive agents can manipulate each of these fac- in the proximal convoluted tubule will cause the kidneys to
tors. The primary determinant of peripheral vascular resis- excrete more water than will a drug that works on the distal
tance is the diameter of peripheral arterioles, which are convoluted tubule.
affected by a1 receptors. Heart rate is affected by both mus- Loop diuretics profoundly affect circulating blood vol-
carinic receptors of the parasympathetic nervous system ume. In fact, they decrease blood volume so well that they
and b1 receptors of the sympathetic nervous system; how- are typically considered excessive for treating moderate
ever, hypertension control typically manipulates only b 1 hypertension. They are, however, one of the primary tools
receptors. Stroke volume is affected by contractility and in treating left ventricular heart failure (congestive heart
volume. Recall that Starling’s law says that preload and failure). They are used for hypertension typically because
stroke volume are proportionate; that is, as preload other diuretics have failed. Furosemide (Lasix) is the
 Emergency Pharmacology 409

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

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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.

Table 13-22  Nitrates

Adverse
Name Classification Action Indications Contraindications Doses Routes Effects Other
Nitroglycerin Nitrate Relaxes • Chest pain • Hypotension 0.4 mg SL (tablet • Headache • Tablets
Nitrostat vascular • Congestive • Increased or spray) • Dizziness will lose
smooth heart failure intracranial • Weakness effectiveness
muscle pressure • Tachycardia after
causing • Hypotension exposure
vasodilation, to air.
decreased • Monitor BP
cardiac closely.
work, and
improved
coronary
blood flow.

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

Hemostatic Agents platelet plugs and potential thrombi. Aspirin, as well as

Hemostasis is the stoppage of bleeding. It is a series of other antiplatelet and anticoagulant drugs, has no effect
events in response to a tear in a blood vessel. Damage to on existing thrombi; it only curbs the formation of new
the vessel’s intima (innermost layer) exposes the underly- thrombi. Aspirin is indicated in the acute treatment of
ing collagen and triggers a release of two naturally occur- developing myocardial infarction. It is also useful in pre-
ring substances, adenosine diphosphate (ADP) and venting the reoccurrence of MI and of ischemic stroke fol-
thromboxane A2 (TXA2). Both ADP and TXA2 stimulate the lowing transient ischemic attacks (TIAs).
aggregation of platelets and vasoconstriction. The vaso- One of aspirin’s primary side effects is bleeding. Aspi-
constriction decreases the flow of blood past the tear, thus rin also may lead to an increase in gastric ulcers, which are
allowing the newly “sticky” platelets to form a plug that a frequent source of gastrointestinal hemorrhage. By both
temporarily occludes the bleeding. stimulating the development of a potential source of bleed-
Although this plug effectively halts bleeding for the ing as well as blocking an important mechanism for stop-
short term, it must be reinforced to continue the stoppage ping that bleeding, aspirin can cause dangerous blood loss.
until the tear can be permanently repaired. Stabilizing Other antiplatelet drugs include dipyridamole (Persan-
the plug requires a complex cascade of events involving the tine). A major class of drugs in this family includes the
activation of naturally occurring factors and ending with adenosine diphosphate (ADP) and glycoprotein IIB/IIIA
the conversion of prothrombin into thrombin. The throm- inhibitors such as ticlopidine (Ticlid), abciximab (ReoPro),
bin then converts fibrinogen into fibrin, a strandlike sub- clopidogrel (Plavix), eptifibatide (Integrilin), tirofiban
stance that attaches to the vessel’s surface and contracts in (Aggrastat), and ticlopidine (Ticlid).25
a mesh web over the platelet plug to form a blood clot. Sev-
eral of the factors involved need vitamin K to carry out Anticoagulants  Anticoagulants interrupt the clot-
their functions. A vitamin K deficiency inhibits clotting ting cascade. The two main types of anticoagulants are par-
and makes uncontrolled bleeding more likely. Conversely, enteral and oral. The prototype parenteral anticoagulant
limiting the clotting cascade to the immediate area of the is heparin, a substance derived from the lungs of cattle or
vessel injury is important for obvious reasons. The protein the intestines of pigs. Its primary mechanism of action is
antithrombin III is key in this process. Antithrombin III to enhance antithrombin III’s ability to inhibit the clotting
binds with several of the factors needed for clotting, thus cascade. Because heparin is very polar, it is very poorly
inhibiting their ability to coagulate. absorbed and must be given parenterally. Heparin injec-
Once the vessel has been permanently repaired, the tions and infusions are indicated in treating and prevent-
fibrin mesh must be broken down. This process, called ing deep vein thrombosis, pulmonary embolism, and some
fibrinolysis, involves another cascading system that ends forms of stroke. Heparin also is used frequently in conjunc-
with the activation of plasminogen into plasmin, which in tion with fibrinolytics to treat myocardial infarction. Finally,
turn breaks up the clot. Tissue plasminogen activator, a it is used to keep rubber-capped IV catheters (Hep-Locks)
substance in the tissue, activates this last conversion. free from clots. As you would expect, bleeding is heparin’s
Thrombi (blood clots that obstruct vessels or heart cav- primary side effect. Other untoward effects include throm-
ities) are the primary pathology in several clinical condi- bocytopenia (decreased platelet counts) and allergic reac-
tions, including myocardial infarction, stroke, and tions. Heparin is measured in units rather than milligrams.
pulmonary embolism. Drugs can effectively treat the A unit is that amount of heparin necessary to keep 1 mL of
causes of these conditions by decreasing platelet aggrega- sheep plasma from clotting for 1 hour. Using this measure-
tion (antiplatelet drugs), by interfering with the clotting ment is necessary because heparin’s potency varies greatly
cascade (anticoagulants), or by directly breaking up the when measured in milligrams.
thrombus (fibrinolytics). Low-molecular-weight heparin (enoxaparin [Lovenox])
has become increasingly popular in emergency medi-
Platelet Aggregation Inhibitors  Platelet cine. Normal heparin has a molecular weight of 5,000 to
aggregation inhibitors decrease the formation of platelet 30 000 Da, whereas low-molecular-weight heparin has a
plugs. The prototype antiplatelet drug is aspirin. Aspi- molecular weight of 1,000 to 10 000 Da. Because of this,
rin inhibits cyclooxygenase, an enzyme needed for the low-molecular-weight heparin has greater bioavailabil-
synthesis of thromboxane ity, is easier to dose, and has fewer effects on platelet
Content Review A2 (TXA2). Remember that function.
➤➤ Drugs Used to Treat TXA2 causes platelets to Protamine sulfate is available as a heparin antagonist.
Thrombi aggregate and promotes Protamine can reverse the effects of heparin in the presence
• Antiplatelets local vasoconstriction. By of dangerous and unintended bleeding by binding with
• Anticoagulants
inhibiting TXA2, aspirin heparin. This prevents heparin from binding with anti-
• Fibrinolytics
decreases the formation of thrombin III and enhancing its anticlotting abilities.
 Emergency Pharmacology 415

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.

Table 13-23  Drugs Used in the Treatment of Asthma

Drugs Used to Affect Mechanism of Action Medication

the Respiratory System Bronchodilators

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.

Glucocorticoids  Glucocorticoids have anti- Nasal Decongestants  Nasal congestion is caused

inflammatory properties. They lower the production and by dilated and engorged nasal capillaries. Drugs that con-
release of inflammatory substances such as histamine, strict these capillaries are effective nasal decongestants.
prostaglandins, and leukotrienes, and they reduce mucus The main pharmacological classification in this functional
and edema secondary to decreasing vascular permeability. category is a1 agonists. Alpha1 agonists may be given either
These drugs may be inhaled or taken orally, or they may be topically or orally. The chief examples of these agents—
given intravenously in emergencies. The prototype inhaled phenylephrine, pseudoephedrine, and phenylpropanol-
glucocorticoid is beclomethasone; the prototype oral glu- amine—can be administered either as a mist or in drops.
cocorticoid is prednisone. Primarily preventive, they are Topical administration reduces systemic effects but has
taken on a regular schedule, as opposed to the as-needed the undesired local effect of rebound congestion, a form
administration of the b2 agonists. An injectable glucocorti- of tolerance. Rebound congestion occurs after long-term
coid (methylprednisolone) is available for use secondary to use (longer than 7 consecutive days). As the drug wears
b2 agonists in emergencies. When inhaled, glucocorticoids off, congestion becomes progressively worse. This effect
cause few side effects. Those are due mostly to direct expo- ends when the patient stops taking the drug; however,
sure on the oropharynx, and gargling after taking the drug the longer the patient has been using the drug, the more
418  Chapter 13

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.

Table 13-24  Antihistamines

Adverse
Name Classification Action Indications Contraindications Doses Routes Effects Other
Diphenhydramine Antihistamine Nonselectively • Allergies • Hypersensitivity to 25–50 mg IV, IM, • Drowsiness • If given IM,
Benadryl blocks H1 and • Extrapyramidal the drug IO, PO • Dizziness give deep
H2 histamine reactions • Glaucoma • Sedation in muscle
receptors • Parkinson’s • Pregnancy • Dry mouth
disease
• Sedation
• Anaphylaxis

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

Cough Suppressants  Coughing is a complex reflex The GI system’s structure

Content Review
that depends on functions in the CNS, the PNS, and the fits its function. Many
➤➤ Main Indications for Gas-
respiratory muscles. It is a defense mechanism that aids mucus-lined folds sur-
trointestinal Drug Therapy
the removal of foreign particles such as smoke and dust. round the GI lumen. The
• Peptic ulcers
A productive cough is one in which these particles are cells of these folds secrete
• Constipation
actually being coughed up. In general, treating a produc- acids needed to help break • Diarrhea and emesis
tive cough is not appropriate, as it is performing a useful down foods; they secrete • Digestion
function. An unproductive cough, however, usually results protective mucus that pre-
from an irritated oropharynx and can be troublesome. The vents the acid from injuring the underlying tissue; and
three classifications of cough suppressants include one that finally, they secrete bicarbonates, which buffer the effects
is supported by evidence and two that are not. Antitussive of acids on the GI system’s absorbing surfaces. To absorb
medications suppress the stimulus to cough in the central the digested nutrients and supply the mucus-producing
nervous system. This functional class includes two specific cells of the lumen wall with oxygen, the entire GI system is
pharmacological types, opioids and nonopioids. The two very vascular. If the protective lining covering these ves-
most common opioid antitussives are codeine and hydro- sels is removed, hemorrhage may occur.
codone. Both inhibit the stimulus for coughing in the brain Several pathological factors oppose the GI system’s
but also produce varying degrees of euphoria. The doses defenses. Contrary to popular belief, the most common
required for cough suppression are not high enough to cause of peptic ulcer disease is not stress or alcohol, but the
cause euphoria, but these drugs still have the potential for Helicobacter pylori bacterium. H. pylori infests the space
abuse. The nonopioid antitussives, in contrast, do not have between the endothelial cells and the mucus lining of the
the potential for abuse. Dextromethorphan is the leading stomach and duodenum. It can remain there for decades,
drug in this class. Although it is almost never given alone, protected against the acid environment by the mucus layer.
it is the most common antitussive used in over-the-counter Although we are still uncertain how this bacteria promotes
combination products for treating cold and flu symptoms. ulcers, it apparently decreases the body’s ability to pro-
Diphenhydramine (Benadryl) is also used as a nonopioid duce the protective mucus lining. H. pylori by itself, how-
antitussive, although its mechanism of action is not clear. ever, does not cause ulcers. Many people remain infected
Finally, the locally acting anesthetic benzonatate (Tessalon) for years and years without signs of PUD. Evidently, pre-
depresses the cough stimulus by directly reducing oropha- disposing and contributing factors combine with H. pylori
ryngeal irritation. Expectorants are intended to increase the to cause ulceration. Some of these factors include smoking
productivity of cough, and mucolytics make mucus more and long-term use of nonsteroidal anti-inflammatory
watery and, therefore, easier to cough up; however, little drugs (NSAIDs) such as aspirin and acetaminophen.
data support the effectiveness of either of these approaches The approaches to treating PUD include antibiotics
to cough suppression. and drugs that block or decrease the secretion of gastric
acid. Most often they are used in conjunction with each
other. First, and most effective, are antibiotics. When the H.

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 Gastrointestinal System ensure elimination of the bacteria and prevent resistance.

Common medications for this purpose include bismuth
The main purposes of drug therapy in the gastrointestinal (Pepto-Bismol), metronidazole (Flagyl), amoxicillin
system are to treat peptic ulcers, constipation, diarrhea, (Amoxil), and tetracycline (Achromycin V).
and emesis, and to aid digestion. Drugs that block or decrease the secretion of gastric
acid include H2 receptor antagonists (H2RAs), proton
Drugs Used to Treat Peptic pump inhibitors, and anticholinergic agents. Mucosal pro-
tectants and antacids are also used.
Ulcer Disease H2 receptors occur throughout the gut on the mem-
Peptic ulcer disease (PUD) is characterized by an imbal- branes of the parietal cells lining the GI lumen. When stim-
ance between factors in the gastrointestinal system that ulated with histamine, they increase the action of
increase acidity and those that protect against acidity. PUD H+K+ATPase, an enzyme that exchanges potassium for
may manifest as indigestion, heartburn, or, more seriously, hydrogen, leading to increased gastric acid secretion. Ace-
as perforated ulcers. If the imbalance becomes too severe, tylcholine and prostaglandin receptors appear along with
parts of the lining of the GI system may be eaten away, H2 receptors. Stimulating the ACh receptors (muscarinic
exposing the tissue and vasculature underneath to the receptors) increases gastric acid secretion; stimulating the
highly acidic environment of the stomach or duodenum. prostaglandin receptors inhibits it.
420  Chapter 13

H2 Receptor Antagonists  H2RA agents block Laxatives are tradi-

Content Review
the H2 receptors in the gut. This inhibits gastric acid tionally grouped into four
➤➤ Categories of Laxatives
secretion and helps return the balance between protec- categories based on their
• Bulk-forming
tive and aggressive factors. Four approved H2RAs are in mechanism of action: bulk-
• Stimulant
use: cimetidine (Tagamet), ranitidine (Zantac), famotidine forming, surfactant, stimu-
• Osmotic
(Pepcid), and nizatidine (Axid Pulvules). Cimetidine is lant, and osmotic. The • Surfactant
the oldest of these and serves as the prototype. These bulk-forming agents, such
agents’ primary therapeutic use is for ulcers, gastroesoph- as methylcellulose (Citrucel) and psyllium (Metamucil),
ageal reflux, heartburn or acid indigestion, and preventing produce a response almost identical to normal dietary fiber
aspiration pneumonia during anesthesia. Most of these intake. Fiber is undigestible and unabsorbable; therefore, it
agents have few significant side effects, with the excep- remains in the lumen of the GI system and is passed more
tion of cimetidine, which may lead to decreased libido, or less intact in stool. Most water absorption takes place in
impotence, and CNS effects in some patients. Although the colon. Fiber (or bulk-forming laxatives) in the colon
these agents could technically be called antihistamines, absorbs water, leading to a softer, more bulky stool. Fiber
that name by tradition is reserved for the H1 antagonists. can also provide nutrients for bacteria living in the colon.
The H2RAs have no effect on the H1 receptors and are of These bacteria feed and provide even more bulk. The
no value in allergic reactions. enlarged stool stimulates stretch receptors in the colonic
wall, which increases peristalsis. Softening the stool also
Proton Pump Inhibitors  Proton pump inhibi- lessens strain on defecation.
tors act directly on the K+H+ATPase enzyme that secretes The surfactant laxatives include docusate sodium
gastric acid. Omeprazole (Prilosec) and lansoprazole (Pre- (Colace). They decrease surface tension, which increases
vacid) are examples. Omeprazole is the prototype. These water absorption into the feces. They also increase water
agents irreversibly block this enzyme, which means that secretion and limit its reabsorption by the intestinal wall.
the body must produce new enzyme in order to begin Stimulant laxatives increase motility. Like the surfac-
secreting acid again. This gives proton pump inhibitors tant laxatives, they also increase water secretion and
a long duration of effect. Side effects are minor and rare, decrease its absorption. The prototype stimulant laxative is
occurring in less than 1 percent of patients. They include phenolphthalein (Ex-Lax, Correctol). Bisacodyl (Bisacolax)
diarrhea and headache. is another example.
The osmotic laxatives are poorly absorbed salts that
Antacids  Antacids are alkalotic compounds used increase the feces’ osmotic pull, thereby increasing their
to increase the gastric environment’s pH. Most available water content. Magnesium hydroxide, the active ingredi-
products are either aluminum, magnesium, calcium, or ent in milk of magnesia, is the prototype of this class.
sodium compounds. They are used in conjunction with
other approaches to PUD and are available over the counter
for relief of acid indigestion and heartburn. Drugs Used to Treat Diarrhea
Diarrhea is the abnormally frequent passage of soft, liquid
Anticholinergics  Although it might seem that all stool. It is a symptom of an underlying disease, usually a
muscarinic blocking agents would be effective in decreas- bacterial infection. It may be caused by an increased gastric
ing gastric acid secretion, most atropine-like drugs pro- motility (the stool does not stay in the colon long enough to
duce too many unwanted effects and, therefore, are not have much water absorbed), increased water secretion, or
used. The one exception is pirenzepine (Gastrozepine), decreased water absorption. Even though it is a nuisance,
because of its ability to selectively block the ACh receptors diarrhea is often a helpful process because it increases the
in the gut. expulsion of the offending agent. It is usually self-correct-
ing and does not need to be treated. When treatment is nec-
essary, either specific or nonspecific agents may be used. A
Drugs Used to Treat Constipation specific agent directly treats the cause, usually bacteria. As
Laxatives decrease the firmness of stool and increase the you would expect, antibiotics are a common specific antid-
water content. Although an uninformed public frequently iarrheal medication.
uses these agents unnecessarily, they are effective in some
situations, specifically with patients for whom excessive
strain is inappropriate. These patients include those with Drugs Used to Treat Emesis
recent episiotomy, hemorrhoids, colostomies, or cardiovas- Emesis is a complex process that involves different parts of
cular disease (for whom excessive straining may decrease the brain, as well as receptors and muscles in the stomach
heart rate). and inner ear. The two involved parts of the brain include
 Emergency Pharmacology 421

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

agonist. This chapter’s sections on anticholinergics and

adrenergic agonists discuss these pharmacological classes
Drugs Used to Affect
in more detail.
Tetracaine (Pontocaine) is a local anesthetic of the
the Endocrine System
ester class. (It is related to cocaine, another ester, but not The endocrine system and nervous system together are
to lidocaine, an amide.) It is used to decrease pain and chiefly responsible for the regulatory activities that main-
sensation in the eye from trauma or during ophthalmic tain homeostasis. The nervous system, with its direct con-
procedures. nections between nerves and organs, may be thought of as
a “wired” system, whereas the endocrine system, which
releases hormones directly into the bloodstream, may be

Drugs Used thought of as “wireless.” The endocrine system comprises

the following glands: pituitary (anterior and posterior

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

Table 13-26   Summary of Hormone Actions

Gland Hormone Action
Posterior pituitary Oxytocin Uterine contraction, milk ejection
Vasopressin (ADH) Retains salt and water, increases ECF volume

Anterior pituitary Thyroid-stimulating hormone (TSH) Increases metabolic rate

Growth hormone (GH) Increases use of stored fats, decreases glucose use
Adrenocorticotropic hormone (ACTH) Stimulates adrenal cortex to release hormones
Follicle-stimulating hormone (FSH) Males: sperm production
Females: stimulates growth and development of ovarian follicles
Luteinizing hormone (LH) Males: responsible for secretion of testosterone by testes
Females: ovulation, secretion of estrogen and progesterone
Prolactin (PRL) Enhances breast development and milk production

Thyroid Thyroid hormone Increases metabolic rate

Parathyroid Parathyroid hormone Increases calcium in ECF

Pancreas Insulin Decreases blood glucose

Glucagon Increases blood glucose

Adrenal Glucocorticoids Increases blood glucose, prevents inflammation

424  Chapter 13

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

Table 13-27  Insulin Preparations

Classification Trade Name Source Onset (Hrs) Peak (Hrs) Duration (Hrs)
Rapid-acting 0.25+ <0.75–2.5 3.5–5.0
Lispro Insulin Humalog Human
Aspart Insulin NovoRapid Human

Short-acting or regular Humulin R Human 0.5–10 2.0–5.0 5.0–8.0

Novolin R Human
Iletin II R Pork

Intermediate-acting or NPH Humulin N Human 1–2 4–12 14–18

Novolin N Human
Iletin II NPH Pork

Premixed Humulin 70/30 Human 0.5–1.0 2–12 14–18

Humulin 50/50 Human
Novolin 70/30 Human
Novolin 50/50 Human

Intermediate-acting Humulin L Human 2–4 7–15 12–24

Iletin II Lente Pork

Long-acting Humulin U Human 3–4 8–24 24–28

Ultralente

Insulin Glargine Lantus Human >1.5 No peak >20

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.

Drugs Affecting Sexual Behavior

For centuries, cultures have searched for drugs that Drugs Used to Treat Cancer
would increase libido and sexual potency. Ironically, the Drugs used to treat cancer are called antineoplastic agents.
reverse has most commonly been found. The largest cate- A detailed discussion of the many different antineoplastic
gory of drugs affecting sexual behavior do so as a side agents is beyond the scope of this text; however, this section
effect of their intended purpose. Many drug classifica- briefly overviews their main classes and prototype drugs.
tions decrease libido in both sexes and inhibit erection Cancer involves the modification of cellular DNA
and ejaculation. Examples include antihypertensives leading to an abnormal growth of tissues. Of the many
(beta-blockers, centrally acting alpha antagonists, and known types of cancer, only a few are successfully treated
diuretics) and antianxiety/antipsychotic medications with chemotherapy. In fact, most cancers are best treated
(benzodiazepines, phenothiazines, MAO inhibitors, and by surgical removal of the tumor. Unfortunately, many of
tricyclic antidepressants). the more lethal cancers do not involve a compact growth;
Many drugs are purported to increase libido. The most rather, they affect the formed elements of the blood, espe-
notable of these is cantharis (Spanish fly). Despite common cially leukocytes. Treating these widely dispersed cancers
Table 13-28  Hormones and Related Agents
Name Classification Action Indications Contraindications Doses Routes Adverse Effects Other
Vasopressin Hormone Non-adrenergic • Normovolemic • Few in the 40 units IV • Blanching of • Benefits in
Pitressin (analog of vasoconstrictor; hypotension emergency setting the skin cardiac arrest are
antidiuretic promotes fluid • Abdominal questionable.
hormone) retention in the cramping
kidney • Nausea
• Hypertension

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

Hepatitis B1 (HepB) 1st dose 2nd dose 3rd dose

Rotavirus2 (RV) RV1 (2-dose See

1st dose 2nd dose footnote 2
series); RV5 (3-dose series)
Diphtheria, tetanus, & acellular
1st dose 2nd dose 3rd dose 4th dose 5th dose
pertussis3 (DTaP: <7 yrs)
Tetanus, diphtheria, & acellular
(Tdap)
pertussis4 (Tdap: >7 yrs)
Haemophilus influenzae type b5 See 3rd or 4th dose,
1st dose 2nd dose
(Hib) footnote 5 See footnote 5

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

Varicella1 0 (VAR) 1st dose 2nd dose

Hepatitis A1 1 (HepA) 2-dose series, See footnote 11

Human papillomavirus1 2(HPV2:

(3-dose
females only; HPV4: males and series)
females)
Meningococcal1 3 (Hib-MenCY
> 6 weeks; MenACWY-D >9 mos; See footnote 13 1st dose Booster

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-

Drugs Used mine, a vitamin that plays a key role in carbohydrate

metabolism. It was once commonly administered in the
to Affect the Skin prehospital setting for presumed Wernicke’s encephalopa-
thy (a disease commonly seen in chronic alcoholics that
Dermatologic drugs are used to treat skin irritations. They results from a deficiency in thiamine).30 However, it has
are common over-the-counter medications. The many dif- been determined that delaying administration to the hospi-
ferent general preparations include baths, soaps, solutions, tal setting saves money and is just as effective. Table 13-30
cleansers, emollients (Lubriderm, Vaseline), skin protec- details selected vitamins.
tants (Benzoin), wet dressings or soaks (Domeboro Pow- Iron is an essential mineral necessary for oxygen trans-
der), and rubs and liniments (Ben-Gay, Icy Hot). port and several metabolic processes. Iron supplements are
Prophylactic agents such as sunscreens are also available to the most common mineral supplement. They are indicated
help prevent skin disease and irritation. for iron deficiency.

Fluids and Electrolytes

Drugs Used to Water comprises approximately 60 percent of a person’s

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

Table 13-30   Vitamin Sources and Deficiencies

Vitamin Problems Resulting from Deficiency Source
Fat Soluble

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

E Hyporeflexia, ataxia, anemia Nuts, green leafy vegetables, wheat

K Increased bleeding Liver, green leafy vegetables

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

B9 (folic acid) Megaloblastic anemia Liver, fresh green vegetables, yeast

B12 (cyanocobalamin) Irreversible nervous system damage, pernicious anemia Fish, egg yolk, milk

C Scurvy Citrus fruits, tomatoes, strawberries

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.

You Make the Call

You and your partner are caring for a 62-year-old man with acute pulmonary edema and cardio-
genic shock. He is responsive only to painful stimuli, has ashen skin, and is very diaphoretic. He
is in obvious respiratory distress, with a rate of 36 per minute. You note bilateral crackles in all
fields. His blood pressure is 82/50, and his heart rate is 108. The SpO2 is 84 percent. The ECG
shows atrial fibrillation. You immediately have your partner begin assisting the patient’s ventila-
tions with a bag-valve mask and 100 percent high-concentration oxygen. You place a continuous
positive airway pressure (CPAP) device set at 5 cm/H2O. You establish a saline lock and begin to
administer a dopamine infusion through one of them at 6 mcg/kg/min and move the patient to
your unit for transport to the hospital.
The dopamine appears to be helping, as your patient’s blood pressure rises to 110/60; how-
ever, your partner is having an increasingly difficult time bagging the patient, whose oxygen
saturation has not risen above 86 percent. You decide to perform a facilitated intubation and
administer the following medications: 0.5 mg of atropine and 5.0 mg of midazolam (Versed). Your
partner administers 1.5 mg/kg of succinylcholine. After placing a size 8.0 ET tube, you confirm
placement and secure the tube. Now that the patient is being successfully ventilated, you turn
your attention back to the pulmonary edema. As you are delivering your patient to the ED staff,
you note that his color and breath sounds have improved remarkably and the pulse oximeter
now reads 96 percent.
1. What is dopamine and what is its mechanism of action?
2. What was the purpose of the dopamine infusion?
3. What is atropine’s mechanism of action?
4. Why was midazolam administered before succinylcholine?
5. What are succinylcholine’s classification and mechanism of action?
See Suggested Responses to “You Make the Call” at the end of this book.
436
 Emergency Pharmacology 437

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 __________________

a. official name. a. affinity.

b. chemical name. b. efficacy.

c. generic name. c. side effect.

d. trade name. d. contraindication.

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:

1. Define key terms introduced in this pulmonary, enteral, and parenteral

chapter. medication administration.
2. Apply the six rights of medication 7. Prepare medications for administration
administration when administering patient from a variety of types of packaging,
medications. including vials, nonconstituted vials,
3. Recognize situations involving medication ampules, prefilled syringes, and packaging
administration in which you should for intravenous solutions.
communicate directly with a medical 8. Describe the indications, contraindications,
direction physician. procedure, equipment, and risks associated
4. Select the appropriate standard precautions with peripheral intravenous access.
for all medication administration situations. 9. Discuss the purposes of central venous
5. Demonstrate principles of medical asepsis access and the various types of catheters
in the administration of medications. used.
6. Describe the procedures, precautions, risks, 10. Describe the characteristics of various
equipment, advantages, and disadvantages intravenous fluids, including colloids,
of each of the routes of percutaneous, crystalloids, and blood.
440
 Intravenous Access and Medication Administration 441

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

asepsis, p. 445 drop former, p. 472 infusion, p. 463

aural medication, p. 450 drops, p. 472 infusion controller, p. 490

blood tube, p. 492 drugs, p. 443 infusion pump, p. 490

blood tubing, p. 474 embolus, p. 482 infusion rate, p. 507

bolus, p. 457 enema, p. 457 inhalation, p. 450

buccal, p. 448 enteral route, p. 452 injection, p. 450

burette chamber, p. 473 extension tubing, p. 473 intracatheter, p. 476

cannula, p. 472 extravasation, p. 481 intradermal, p. 463

cannulation, p. 469 extravascular, p. 490 intramuscular, p. 465

catheter inserted through the gauge, p. 458 intraosseous, p. 494

needle/intracatheter, p. 476 hemoconcentration, p. 494 intravenous (IV) access, p. 469
central venous access, p. 470 hemolysis, p. 494 intravenous fluid, p. 470
circulatory overload, p. 483 heparin lock, p. 487 isotonic, p. 471
colloidal solution, p. 470 hepatic alteration, p. 456 IV catheter, p. 475
concentration, p. 503 hollow-needle catheter, p. 475 local, p. 445
crystalloid, p. 471 Huber needle, p. 489 Luer sampling needle, p. 494
442  Chapter 14

macrodrip tubing, p. 472 ocular medication, p. 449 sublingual, p. 448

measured volume over-the-needle catheter, p. 475 suppository, p. 457
administration set, p. 473 parenteral route, p. 457 syringe, p. 457
medically clean, p. 446 peripheral venous access, p. 469 systemic, p. 445
medicated solution, p. 463 peripherally inserted central thrombophlebitis, p. 483
medication injection port, p. 473 catheter (PICC), p. 470 thrombus, p. 483
medications, p. 443 prefilled/preloaded topical medications, p. 447
metered dose inhaler, p. 451 syringe, p. 461 transdermal, p. 447
microdrip tubing, p. 472 pyrogen, p. 482 trocar, p. 496
Mix-o-Vial, p. 461 saline lock, p. 487 ultrasound, p. 491
nasal medication, p. 449 sharps container, p. 446 unit, p. 503
nebulizer, p. 450 spike, p. 472 vacutainer, p. 493
necrosis, p. 483 Standard Precautions, p. 444 venous access device, p. 488
needle adapter, p. 473 sterile, p. 445 venous constricting band, p. 476
nonconstituted medication stock solution, p. 503 vial, p. 460
vial, p. 461 subcutaneous, p. 464 volume on hand, p. 503

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.

Introduction Part 2: Intravenous Access, Blood Sampling, and

­Intraosseous Infusion
Drugs are foreign substances placed into the human body. Part 3: Medical Mathematics
Medications are drugs used for medical purposes. They
serve a variety of purposes, such as controlling specific dis-
eases like hypertension or helping the body cure diseases
such as cancer and infection.
Medication administration will be an important part
PART 1: Principles and
of the medical care you provide as a paramedic. You may Routes of Medication
have to use medications to correct or prevent many life-
threatening situations. You may also use them to stabilize Administration
or comfort a patient in distress. In addition to your knowl-
edge of particular medications and their properties from General Principles
the “Emergency Pharmacology” chapter, you must also be
As a paramedic, you are responsible for ensuring that all
thoroughly skilled in medication administration. Specific
emergency medications are in place and ready for immedi-
medications require specific routes and administration
ate use. Therefore, you must know your local medication
techniques. Their effectiveness depends directly on their
distribution system. You will have to know where to obtain
correct route of delivery. Incorrect or sloppy medication
and replace each medication as it expires or is used, as
administration can have tremendous legal implications for
another patient may require it at any time. You also will
the paramedic. More important, it equates to poor care that
have to thoroughly document the administration and
can harm or even kill the patient.
restocking of narcotics, as many local, state, and federal
This chapter discusses the routes and techniques you
agencies mandate such record keeping.
will use to correctly deliver your patient’s medications. It is
Always be certain that you correctly give all medica-
divided into three parts:
tions in the right dose. Medication errors may prove disas-
Part 1: Principles and Routes of Medication trous in terms of patient care and legal responsibility. Your
­Administration knowledge of medication indications, contraindications,
444  Chapter 14

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

Table 14-1  Summary of Standard Precautions

Component Recommendations
Hand hygiene After touching blood, body fluids, secretions, excretions, and contaminated items; immediately after removing
gloves; between patient contacts.

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:

1. Use Standard Precautions and avoid contaminating

Percutaneous Medication the medication and inadvertently getting it on your
skin.
Administration 2. Clean and dry your
patient’s skin at the CONTENT REVIEW
Percutaneous medications are those that are applied to and
absorbed through the skin or the mucous membranes. administration site. ➤➤ Percutaneous Routes
• Transdermal
They are easy to administer, and they bypass the digestive 3. Apply medication to
• Mucous membrane
tract, making their absorption more predictable. the site as specified by
448  Chapter 14

the manufacturer. Avoid overdosing or underdosing

when using lotion, ointment, cream, or foam.
4. Leave the medication in place for the required time.
Monitor the patient for desirable or adverse effects.

You may need to place a dressing over the medication to

protect the site and quantity of medication. Carefully fol-
low all recommendations. Administration may vary subtly,
depending on the form of medication and the specific man-
ufacturer’s instructions.
Several factors can affect how quickly the skin absorbs
transdermal medications. Thin skin, overdose, or penetrat-
ing solvents can increase the absorption rate. Conversely,
thick skin, scar tissue, or peripheral vascular disease can
decrease the rate. If these factors are present, consider
alternative sites or dosage adjustments.

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):

1. Use Standard Precautions.

2. Confirm the indication, medication, dose, sublingual
route, and expiration date.
3. Have your patient lift his tongue toward the top and
back of his oral cavity.
4. Place the pill or direct spray between the underside of
the tongue and the floor of
CONTENT REVIEW the oral cavity. Have your
➤➤ Mucous Membrane patient relax his tongue
­Medication Sites and mouth. If administer-
• Tongue ing a tablet, instruct the
• Cheek patient to let the tablet dis-
• Eye solve and not to swallow it.
• Nose
5. Monitor the patient for FIGURE 14-4  Buccal medication administration. Place the medica-
• Ear
desirable or adverse effects. tion between the patient’s cheek and gum.
 Intravenous Access and Medication Administration 449

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.

FIGURE 14-5  Eyedrop administration. Use a medicine dropper to

place the prescribed dosage on the conjunctival sac. FIGURE 14-6  Nasal medication administration.
450  Chapter 14

previously outlined, gen-

CONTENT REVIEW
tly inserting the gauze
➤➤ Pulmonary Medication
into the ear instead of
Mechanisms
instilling medicated
• Nebulizer
drops. Avoid tightly pack-
• Metered dose inhaler
ing the ear canal. • Endotracheal tube

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

FIGURE 14-8  Aural medication administration. Manually open the

ear canal and administer the appropriate dose. FIGURE 14-9  Typical small-volume nebulizer (SVN) setup.
 Intravenous Access and Medication Administration 451

To administer a medication with a nebulizer, follow

these steps:

1. Use Standard Precautions including a mask.

2. Put the medication in the medication reservoir. If the
medication is not diluted, combine it with 3 to 5 mL
sterile saline solution. This will allow adequate aero-
solization. Screw the reservoir in place.
3. Assemble the nebulizer.
4. Attach oxygen tubing to the oxygen port and oxygen
source.
5. Set the oxygen source regulator for 5 to 8 liters per
minute.
Note: Never set the oxygen pressure outside this FIGURE 14-11  Nebulized medications can be administered through
most CPAP masks.
range. Less than 5 liters per minute will not create
enough pressure to aerosolize the medication. More
than 8 liters per minute will create too much pres-
sure and destroy the oxygen tubing or nebulizer at
its weakest point. Furthermore, because of pressure
restrictions, do not attach the nebulizer to an oxygen
humidifier.
6. Place the nebulizer in the patient’s mouth. Instruct
him to exhale and then seal his lips around the mouth-
piece. Then have him hold the nebulizer and slowly
inhale as deeply as possible. On maximum inhalation,
instruct the patient to hold in the medication for 1 to
2 seconds before exhaling. This permits maximum
deposition and absorption. Continue this process
until the medication is completely gone. Typically, this
takes 3 to 5 minutes.

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.

Metered Dose Inhaler

Inhaled medications may also be delivered through a
metered dose inhaler (MDI). These small, handheld
devices produce a medicated spray for inhalation. Patients
with conditions such as asthma or COPD use metered
dose inhalers to deliver a specific, or metered, dose of
medication. A metered dose inhaler consists of two parts,
a medication canister and a plastic shell and mouthpiece
(Figure 14-13). Some MDIs come equipped with a spacer.
FIGURE 14-10  SVN medication administration through mask. The spacer is a cylindrical canister between the inhaler
452  Chapter 14

it reaches its exact site of

CONTENT REVIEW
action. The lower dosage is
➤➤ Endotracheal Medications
less likely to promote side
• Lidocaine
effects, and if the patient
• Vasopressin
has an adverse reaction,
• Epinephrine
implementing or discon- • Atropine
tinuing medication deliv- • Naloxone
ery is easy. Furthermore,
because the patient can hold the nebulizer, he will benefit
from feeling more in control of his overall therapy. Most
important, if your patient is hypoxic you can administer
inhaled medications with supplemental oxygen.
The nebulizer and MDI also have disadvantages. Mov-
ing the aerosolized medication into the lungs depends on
FIGURE 14-13  Metered dose inhaler.
adequate ventilation. For the patient with a poor tidal and
minute volume, nebulized medications are ineffective, as
and the mouthpiece. Prior to self-administration, the the medication cannot reach its site of action. In these cases,
patient will depress the inhaler, sending a measured dose you should use the nebulizer in conjunction with a bag-
of medication into the spacer. The patient will then breathe valve mask and/or endotracheal tube. In addition, the
in and out of the spacer through the mouthpiece, thus patient must exhibit an adequate level of consciousness
inhaling the medication into the lungs. The spacer system and manual dexterity to hold the nebulizer and follow
is particularly useful for patients who have a hard time instructions correctly.
operating and inhaling directly from the MDI, which is
common in the elderly and in young children. The spacer, Endotracheal Tube
when used in conjunction with an MDI, is very effective.
Although they are infrequently used, you can administer
MDIs are usually self-administered. However, if your
certain medications such as lidocaine (Xylocaine), vaso-
patient is incapacitated, you may have to physically assist
pressin, epinephrine, atropine, and naloxone (Narcan)
with the administration or educate the patient or his care-
through an endotracheal tube if an intravenous line or
givers in its use. To assist a patient in the use of an MDI,
intraosseous line is unavailable. Delivering liquid medica-
follow this technique:
tions into the lungs theoretically permits rapid absorption
1. Insert the medication canister into the plastic shell. through the pulmonary capillaries. However, recent
2. Remove the cap from the mouthpiece. Make sure the research has shown that the administration of medications
cap is clean. via an endotracheal tube is not as effective as once thought.
When using an endotracheal tube, you must increase
3. Gently shake the MDI for 2 to 5 seconds.
conventional IV dosages from two to two and one-half
4. Instruct the patient to maximally exhale. times. You also should dilute the medication in normal
5. Place the mouthpiece in the patient’s mouth and have saline to create 10 mL of solution and then quickly inject it
him form a seal with his lips. down the endotracheal tube. Several ventilations must fol-
6. As the patient inhales, press the canister’s top down- low to aerosolize the medication and enhance its absorp-
ward to release the medication. tion. Ideally, you can pass a commercially manufactured
catheter through the endotracheal tube and inject the med-
7. Have the patient hold his breath for several seconds.
ication through it.9
8. Remove the inhaler from the patient’s mouth and
instruct him to breathe slowly.
9. If a second dose is necessary, wait according to the
manufacturer’s instructions. Then repeat.
Enteral Medication
In an acute respiratory emergency involving a patient Administration
with an MDI, always use a nebulizer instead of the MDI. The enteral route is the
CONTENT REVIEW
The MDI delivers a small amount of medication, but the delivery of medication to
nebulizer delivers larger quantities of medication mixed be absorbed through the ➤➤ Enteral Routes
with water and oxygen. gastrointestinal tract. The • Oral
• Gastric tube
Nebulizers and MDIs offer several advantages. In gastrointestinal tract, or ali-
• Rectal
respiratory emergencies, less medication is needed because mentary canal, travels from
 Intravenous Access and Medication Administration 453

noncompliant in taking medications makes admin-

istration via the enteral route very difficult.

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

Procedure 14–1  Medication Administration through a Nasogastric Tube

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.

14-1E  Clamp off the distal tube.

456  Chapter 14

reattempt injection. If the saline still meets resistance,

reattach the tube to the drainage or suction unit and
contact medical direction for further directives.
4. Prepare the medication(s) for delivery. Crush tablets
or empty capsules into 30 mL of warm water. Ensure
that all particles are small so they will not occlude the
tube. You may administer liquid medications without
further preparation.
5. Draw the medication into a 30 to 50 mL cone-tipped
syringe and place the tip into the open gastric tube.
Gently administer the medication into the gastric tube;
FIGURE 14-15  Catheter placement on needleless syringe.
forceful application may create considerable distention
and patient discomfort.
easy administration and rapid absorption. To administer
6. Draw 50 to 100 mL of warm normal saline into a cone- a rectal medication in the emergent setting, follow this
tipped syringe and attach it to the open end of the gas- technique:
tric tube. Gently inject the saline. This facilitates the
medication’s passage into the stomach and rinses the 1. Use Standard Precautions.
tube, ensuring that the patient receives the entire dose. 2. Confirm the indication for administration and dose, and
Repeated administrations may be necessary. draw the correct quantity of medication into a syringe.
7. Clamp off the distal tube. Use a commercially manufac- 3. Place the hub of a 14-gauge Teflon catheter (removed
tured device or hemostat to clamp shut the distal por- from the IV catheter) on the end of a needleless syringe
tion of the gastric tube for approximately 30 minutes (Figure 14-15).
after you administer the medication. Do not reattach 4. Insert the Teflon catheter into the patient’s rectum and
to the drainage or suction unit. This will prevent the inject the medication. Try to keep the medication in the
medication’s inadvertent removal from the stomach. lower part of the rectum. Administration higher in the
rectum may result in the medication’s being absorbed by
If you must refill the syringe in order to administer the full
veins that deliver the medication to the portal circulation.
dosage of medication, do not allow the syringe to empty
completely before you detach it from the gastric tube. This 5. Withdraw the catheter and hold the patient’s buttocks
prevents drawing air into the syringe and then introducing together, thus permitting retention and absorption.
it into the stomach, which causes discomfort. An alternative technique utilizes a small endotracheal
tube instead of the Teflon IV catheter. Remove the 15/22-mm
Rectal Administration BVM adapter and connect a syringe to the proximal end of
The rectum’s extreme vascularity promotes rapid medi- the tube (Figure 14-16). Lubricate the tube and insert it into
cation absorption. Additionally, because medications the rectum. Inject the medication, remove the tube, and
given rectally do not pass through the liver, they are not hold the buttocks together.
subject to hepatic alteration; thus, their absorption is In the nonemergent setting, suppositories or enemas
more predictable. are common methods for rectal administration. Because
In the emergency setting, you may give certain medi- your responsibilities as a paramedic may include nonemer-
cations rectally if you cannot establish an intravenous line gent clinical settings, you should master these techniques.
or use the oral route. These include diazepam (Valium) or
lorazepam (Ativan) for protracted seizures or aspirin for
cardiac or neurologic emergencies. In the nonacute setting,
you may administer sedatives, antiemetics, or other spe-
cially prepared medications rectally.
Rectal administration may prove advantageous with
the unconscious or pediatric patient, or when administer-
ing medications with an objectionable taste or odor. Unfor-
tunately, medication absorption may be erratic if gross
fecal matter exists. In addition, some medications may
cause considerable anal or rectal irritation.
Rectal medications come in a variety of forms. In the FIGURE 14-16  Syringe attached to endotracheal tube for rectal
emergency setting, they are typically liquid, thus permitting administration.
 Intravenous Access and Medication Administration 457

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

end forms a tight seal from which the fluid medication

cannot escape.
The junction of the fluid and rubber stopper measures
the total volume of liquid in the syringe. The barrel’s maxi-
mum volume should correspond closely to the volume of
medication needed. For example, to administer 2 mL of
medication, a 3-mL syringe would prove most appropriate.
An adapter at the syringe’s distal end is compatible
with the hub of an IV catheter or, as many cases will
require, a hypodermic needle.

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.

These labels are printed directly on the vial, ampule, pre-

filled syringe, or IV medication bag. Always use them to
confirm the correct medication.

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

and circular tubular base for storing the medication (Fig-

ure 14-21). The thin neck is a vulnerable point at which you
intentionally break the ampule to retrieve its contents.
Ampules usually range in volume from 1 to 5 mL. The least-
expensive form of medication packaging, they contain sin-
gle doses of medication. It is essential to use a filter needle
when drawing medication up from a glass ampule. This will
help to filter any small glass shards that may be present.
To obtain medication from a glass ampule you will
need a syringe and needle. Use the following technique
(Procedure 14-2):

1. Confirm medication indications and patient allergies.

2. Confirm the ampule label (medication name, dose, and
FIGURE 14-21  Ampules.
expiration).

Procedure 14–2  Obtaining Medication from a Glass Ampule

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

3. Hold the ampule upright and tap its top to dislodge

any trapped solution.
4. Place gauze around the thin neck and snap it off with
your thumb.
5. Place the tip of the hypodermic needle inside the
ampule and withdraw the medication into the syringe.
6. Reconfirm the indication, medication, dose, and route
of administration.
FIGURE 14-22  Vials.
7. Administer the medication appropriately via the indi-
cated route.
leakage from punctures and permits multiple accesses
8. Properly dispose of the needle, syringe, and broken with a syringe and hypodermic needle. The medication
glass ampule. inside the vial is packaged in a vacuum.
To obtain medication from a vial, follow these steps
Single and Multidose Vials (Procedure 14-3):
Vials are plastic or glass containers with a self-sealing rub-
ber top (Figure 14-22). Vials may contain single or multiple 1. Confirm medication indications and patient allergies.
doses of medication; the self-sealing rubber top prevents 2. Confirm the vial label (name, dose, and expiration).

Procedure 14–3  Obtaining Medication from a Vial

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).

FIGURE 14-23  The nonconstituted drug vial actually consists of two

vials, one containing a powdered medication and one containing a
liquid mixing solution. FIGURE 14-24  Prefilled syringes.
462  Chapter 14

Procedure 14–4  Preparing Medication from a Nonconstituted Drug Vial

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

3. Assemble the prefilled syringe. Remove the pop-off

Epidermis
caps and screw together.
Dermis
4. Reconfirm the indication, medication, dose, and route 10°-15°
of administration.
5. Administer appropriately via the indicated route.
6. Properly dispose of the needle and syringe.

Intravenous Medication Solutions

Medicated solutions are another form of parenteral medi-
Subcutaneous Muscle
cation. They are packaged in an IV bag and administered tissue
as an IV infusion. IV medication solutions may be pre-
mixed, or you may have to mix them. The section on intra- FIGURE 14-25  Intradermal injection.

venous medication infusions later in this chapter discusses

layer of the skin (intra-, within; derma, skin). The amount of
their actual preparation and administration.
medication placed in the dermal layer is quite small, typi-
cally less than 1 mL (Figure 14-25).
Parenteral Routes Capillaries in the dermis afford a very slow rate of
Parenterally administered medications can be absorbed absorption, with little or no systemic distribution. Rather,
locally or systemically. In addition, depending on the route the bulk of medication remains localized in the area of
of administration, their absorption rate may be slow, sus- administration. Intradermal delivery proves useful for
tained, or rapid. Parenteral delivery bypasses the digestive allergy testing and tuberculin skin testing (PPD or Man-
tract, thus making the medication’s absorption, action, and toux) and for administering local anesthetics during sutur-
onset more predictable. Because parenteral routes use ing, wound debridement, and IV establishment.
hypodermic needles that contact body fluids, the risk of The forearm and upper back are preferred sites for
disease transmission is ever present. intradermal injections. They have little hair and are highly
Parenteral medication delivery employs the following visible. Additionally, you should look for sites free of
routes: superficial blood vessels, which increase the chance for
systemic absorption.
• Intradermal injection
To administer an intradermal injection, you will need
• Subcutaneous injection the following equipment:
• Intramuscular injection
• Personal protective equipment
• Intravenous access
• Antiseptic preparations
• Intraosseous infusion
• Packaged medication
Specific medications require specific routes of paren-
teral delivery; therefore, you must be competent with • Tuberculin syringe (1 mL)
every route. In this section, we will discuss the specialized • 25- to 27-gauge needle, ⅜ to 1 inch long
equipment, medications, and routes for intradermal, sub- • Sterile gauze and adhesive bandage
cutaneous, and intramuscular injections. Because of their
To administer an intradermal injection, follow these
complexity, we will discuss intravenous access and intraos-
steps (Procedure 14-5):
seous infusions separately in the following sections.
Whether you are administering a parenteral injection 1. Assemble and prepare the needed equipment.
or an IV bolus or infusion, you should explain the entire 2. Use Standard Precautions and confirm the medication,
procedure to the patient to help alleviate his anxiety. Finally, indication, dosage, and need for intradermal injection.
remember that hypoperfusion (hypovolemia or peripheral
3. Draw up medication as appropriate.
vascular disease, for instance) may significantly reduce par-
enteral absorption. 4. Prepare the site with antiseptic solution. The intended
CONTENT REVIEW site must be cleansed of pathogens, therein decreas-
➤➤ Parenteral Routes Intradermal ing the likelihood of infection. Generally, you will use
• Intradermal injection Injection alcohol or similar antiseptics. To appropriately cleanse
• Subcutaneous injection Using a syringe and hypo- the site, start at the site itself and work outward with
• Intramuscular injection dermic needle, intrader- an expanding circular motion. This motion will push
• Intravenous access pathogens away from the intended site of puncture.
mal injections deposit
• Intraosseous infusion
medication into the dermal 5. Pull the patient’s skin taut with your nondominant hand.
464  Chapter 14

Procedure 14–5  Intradermal Administration

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

FIGURE 14-26  Subcutaneous injection.

has few blood vessels and thus promotes slow, sustained

absorption, which prolongs a medication’s effect on the
body. Like intradermal injections, no more than 1.0 mL of
medication is administered subcutaneously. Administer-
ing more than 1.0 mL of medication can cause irritation FIGURE 14-27  Subcutaneous injection sites (injection sites shown
and, possibly, an abscess. in red).
Administer subcutaneous injections where you can
easily pinch the skin on the upper arms, thighs, or occa- 9. If no blood appears, proceed with step 10.
sionally, the abdomen (Figure 14-27). Easily pinched skin
10. Slowly inject the medication.
contains more subcutaneous tissue and readily separates
from the muscle. All sites should be free of superficial 11. Remove the needle and dispose of it in a sharps container.
blood vessels, nerves, and tendons. Additionally, avoid 12. Place an adhesive bandage over the site; use the gauze
areas with tattoos or bruising. for hemorrhage control if needed.
To perform a subcutaneous injection, you will need the 13. Monitor the patient.
following equipment:
After you give the injection, gently rubbing or massaging
• Personal protective equipment the site will help initiate systemic absorption.
• Antiseptic preparations Some authorities recommend using an air plug in the
• Packaged medication syringe. This is approximately 0.1 mL of air that follows the
injection and pushes the medication further into the subcuta-
• Syringe (1 to 3 mL)
neous tissue, thus preventing leakage or medication loss. To
• 24- to 26-gauge hypodermic needle, ⅜ to 1 inch long
place an air plug in the syringe, aspirate approximately 0.1
• Sterile gauze and adhesive bandage mL of air into the barrel after you have drawn up the medica-
To administer a subcutaneous injection, use the fol- tion. Pointing the needle downward and perpendicular to the
lowing technique (Procedure 14-6): ground, tap the syringe with your finger to dislodge the air
pocket. It will float to the top of the plunger, and from there it
1. Assemble and prepare equipment. will follow the medication into the subcutaneous tissue.
2. Use Standard Precautions and confirm the medication, You can also deliver a subcutaneous injection into the
indication, dosage, and need for subcutaneous injection. sublingual region, or fleshy tissue below the tongue. To
3. Draw up the medication as appropriate. administer a subcutaneous injection, place the hypodermic
4. Prepare the site with antiseptic solution. needle of a small, medication-filled syringe into the sublin-
gual tissue and then inject the medication as appropriate.
5. Gently pinch a 1-inch fold of skin.
Epinephrine, in severe cases of asthma or anaphylaxis, can
6. Insert the needle just into the skin at a 45° angle with be administered in this manner.
the bevel up.
7. Pull the plunger back to aspirate tissue fluid. Intramuscular Injection
8. If blood appears, the hypodermic needle is in a blood Intramuscular injections deposit medication into muscle
vessel and absorption will be too rapid. Start the pro- (intra-, within; muscular, muscle). Muscle is extremely
cedure over with a new syringe. vascular and permits systemic delivery at a moderate
466  Chapter 14

Procedure 14–6  Subcutaneous Administration

14-6A  Prepare the equipment.

14-6B  Check the medication.

14-6C  Draw up the medication.

14-6D  Prep the site. 14-6E  Insert the needle at a 45° angle. 14-6F  Remove the needle and cover the
puncture site.

14-6G  Monitor the patient. 14-6H  Apply an adhesive bandage to the

injection site.

absorption rate. Medication

CONTENT REVIEW
absorption through muscle
➤➤ Intramuscular Injection Sites
is also relatively predict-
• Deltoid
able. To reach the muscle, a
• Dorsal gluteal
needle must penetrate the Epidermis
• Vastus lateralis
• Rectus femoris dermal and subcutaneous 90°
Dermis
tissue (Figure 14-28).
Several sites are used for intramuscular injections (Fig-
ure 14-29). Depending on the site, varying quantities of
medication can be delivered. These sites and their correlat-
ing volumes of medication include the following:

• Deltoid. The deltoid muscle is 3 to 4 fingerbreadths

below the acromial process (the bony bump on the Subcutaneous Muscle
tissue
shoulder). It is highly vascular and permits easy
access. You can deliver up to 2.0 mL into this muscle. FIGURE 14-28  Intramuscular injection.
 Intravenous Access and Medication Administration 467

Vertical line

Preferred Preferred
site Deltoid
site muscle
Gluteal artery
Horizontal line

Hip

Fold separating
the buttocks

Sciatic nerve

• Dorsal gluteal. The dorsal gluteal muscle, or buttock,

is a common administration point for intramuscular
injections. Injections here can deliver 5.0 mL of medi-
cation or more. They cause little discomfort, but you
must avoid the large sciatic nerve, which is the leg’s
major motor nerve. Damage to the sciatic nerve can
decrease mobility or totally paralyze the leg. To help
prevent neurologic complications, envision an imagi-
nary quadrant over the buttock; administer all injec-
tions in the upper and outer quadrant.
Preferred
• Vastus lateralis. The vastus lateralis muscle of the thigh
site
is another common site for intramuscular injection,
especially for pediatric patients. As at the dorsal gluteal
muscle, injections here can deliver 5 mL of medication Preferred
or more. To deliver medication at this site, imagine a site
Rectus
Vastus
grid of nine boxes. Administer injections in the middle, femoris
lateralis
outer box, or anterolateral part of the muscle.
• Rectus femoris. The rectus femoris lies over the femur
and is closely associated with the vastus lateralis mus-
cle. When utilizing the rectus femoris for intramuscular
injection, place the medication into the center of the
muscle at approximately midshaft of the femur. Up to
5 mL of medication volume can be administered into
the rectus femoris.

When choosing a site, avoid bruised or scarred areas. Areas

free of superficial blood vessels are most desirable.
To perform an intramuscular injection, you will need
the following equipment:

• Personal protective equipment

• Antiseptic preparation
• Packaged medication FIGURE 14-29  Intramuscular injection sites.
468  Chapter 14

• 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.

Procedure 14–7  Intramuscular Administration

14-7B  Check the medication.

14-7A  Prepare the equipment. 14-7C  Draw up the medication.

14-7D  Prepare the site. 14-7E  Insert the needle at a 90° angle. 14-7F  Remove the needle and cover the
puncture site.

14-7G  Monitor the patient.

 Intravenous Access and Medication Administration 469

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.

Intravenous and Intraosseous Routes

Two important parenteral medication administration Types of Intravenous Access
routes—intravenous access and intraosseous infusion—are Medical care providers use two types of intravenous
discussed in detail in Part 2. access, peripheral and central. As a paramedic, you will
most often perform peripheral intravenous access. Central
venous access is rarely, if ever, performed in the out-of-
PART 2: Intravenous hospital setting.

Access, Blood Sampling, Peripheral Venous Access

Although challenging, peripheral venous access is rela-
and Intraosseous Infusion  tively easy to master. As its name implies, it uses periph-
eral veins. Common sites include the arms and legs and,
Intravenous Access when necessary, the neck. Figure 14-30 illustrates the
Intravenous (IV) access (intra-, within; venous, vein), or specific veins commonly accessed on the hand, forearm,
cannulation, is a routine paramedic procedure. Circulating and leg.
blood transports chemicals, proteins, and fluids through- Because some patients’ veins may not be readily visi-
out the body. Venous circulation can likewise deliver medi- ble, you must know venous topography. In these cases,
cations and fluids into the body and provides an invaluable you will have to locate veins based on anatomic layout and
tool for treating the sick and injured. palpation. Exhaust all possibilities on the arms before try-
The following situations indicate intravenous access: ing to locate the veins of the legs. Leg veins are more diffi-
cult to access and present complications more frequently.
• Fluid and blood replacement For neonates and infants, you may access veins in the
• Medication administration scalp. The “Pediatrics” chapter explains that technique.

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

When establishing a peripheral IV, start at the distal

end of the extremity and work proximally. Once you have
attempted cannulation, the disruption in blood flow hin-
ders using veins distal to that site. However, the purpose
of access also determines site selection. For example, rapid
fluid administration requires larger veins like the antecu-
bital fossa, as opposed to the smaller veins of the hand.
The external jugular vein is considered a peripheral vein
and can be accessed when other peripheral sites are not
available.
The major advantage of peripheral venous access is
that it is relatively simple to perform because visualizing
and accessing the veins is usually easy. In addition, you
can access peripheral veins while simultaneously doing
other life-sustaining procedures such as CPR or endotra-
cheal intubation. Conversely, peripheral veins collapse in
FIGURE 14-31  A peripherally inserted central catheter (PICC) is
hypovolemia or circulatory failure, thus becoming diffi- often used in patients with chronic illnesses who require repeated
cult to locate and access. Furthermore, the peripheral vascular access.
veins of geriatric patients, pediatric patients, or those with
peripheral vascular disease may be fragile and difficult to
cannulate. Finally, peripheral veins may roll and elude IV Equipment and Supplies
placement. for Venous Access
To establish intravenous access, you will need the follow-
Central Venous Access ing specialized equipment and supplies.
Central venous access uses veins located deep within the
body. These include the internal jugular, subclavian, and Intravenous Fluids
femoral veins. They are larger than peripheral veins and Intravenous fluids are chemically prepared solutions tai-
will not collapse in shock. Central IV lines are placed lored to the body’s specific needs. They replace the body’s
near the heart for long-term use. Typically, they are used lost fluids and/or aid the delivery of IV medications. They
when medical conditions require repeated access for also can keep a vein patent when no fluid or medication
medication and/or fluid delivery. They also are used for therapy is required.
transvenous pacing or for monitoring central venous Intravenous fluids come in three forms: colloids, crys-
pressure. talloids, and blood.
A special type of central line is the peripherally
inserted central catheter, or PICC, line. PICC lines are COLLOIDS  Colloidal solutions contain large proteins
smaller than those routinely used for central access and are that cannot pass through the capillary membrane. Conse-
threaded into the central circulation via a peripheral site quently, they remain in the circulatory system for a long
(Figure 14-31). PICC lines are most often used in infants time. In addition, colloids have osmotic properties that
and children requiring long-term care. attract water into the circulatory system. A small quantity
Central venous access is typically restricted to the of colloid can significantly increase intravascular volume
hospital setting because of its invasive nature and high (volume of blood and fluid contained within the blood ves-
risk of complications such as arterial puncture, pneumo- sels). Common colloids include the following:
thorax, and air embolism. Central veins cannot be
• Plasma protein fraction (Plasmanate). Plasmanate is a
accessed during procedures such as CPR, and they often
protein-containing colloid. Its principal protein, albu-
require a chest X-ray for placement confirmation. You
min, is suspended with other proteins in a saline sol-
may nonetheless encounter a central line during interfa-
vent.
cility transports or in a chronically ill homebound patient.
Protocols in some EMS systems allow paramedics to • Albumin. Albumin contains only human albumin.
access existing central lines during emergency care. Still Each gram of albumin will retain approximately 18 mL
other systems allow their paramedics to place certain cen- of water in the bloodstream.
tral lines. Always follow local protocols regarding central • Dextran. Dextran is not a protein but a large sugar
line access and insertion. For more information about molecule with osmotic properties similar to those of
central venous access, consult a text on advanced veni- albumin. It comes in two molecular weights: 40,000
puncture techniques. and 70,000 Daltons. Dextran 40 has from two to two
 Intravenous Access and Medication Administration 471

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

FIGURE 14-32  IV solution container. Drip chamber

spike

• Medication administration port. A medication port on

IV solution bags or bottles permits you to inject medi-
cation into the fluid for infusion. Macrodrip
• Administration set port. The administration set port is
where you place the spike from the IV administration
tubing. Drug infusion port
Microdrip

Administration Tubing FIGURE 14-33  Macrodrip and microdrip administration sets.

Intravenous administration tubing connects the solution
bag to the IV cannula that is inserted into the patient’s spike. If the spike becomes contaminated, discard the
vein. Administration tubing is made of very flexible clear administration set and start over with new tubing.
plastic. You must select from several types of administra- • Drip chamber. The drip chamber is a clear plastic
tion tubing according to your patient’s need. All tubing is chamber that allows you to view the drip rate. The
packaged in a sterile container. If the container is opened drip chamber is squeezable; when compressed, it col-
or appears damaged, select another administration set. lects fluid from the IV solution bag and acts as a reser-
Any pathogens on the tubing will enter the patient, possi- voir for administration. For optimal fluid delivery, the
bly causing long-term complications. drip chamber should be about one-third full; a line on
the chamber marks the correct fluid level.
MICRODRIP AND MACRODRIP TUBING  Microdrip
administration tubing delivers relatively small amounts of • Drop former. Inside the drip chamber is a drop former.
fluid to the patient. It is more appropriate when you need In microdrip administration tubing, the drop former is
to restrict the overall fluid volume a patient will receive. a hollow metal stylet. In macrodrip tubing, it is a large
Macrodrip administration tubing delivers relatively large circular opening at the top of the drip chamber. The
amounts of fluid. It is more appropriate when volume drop former regulates each drop’s size. The narrow
replacement is necessary, as in shock, fluid replacement, metal stylet in the microdrip tubing creates smaller
or hypotension. drops; the wider opening in the macrodrip tubing cre-
To effectively deliver intravenous fluids, you must be ates larger drops. In either case, the drop former’s pre-
thoroughly familiar with the microdrip and macrodrip cise calibration allows you to calculate fluid volumes
administration sets, their components, and their subtle dif- by counting drops:
ferences (Figure 14-33). • Microdrip 60 drops = 1 mL
• Spike. The spike is a sharp-pointed plastic device that • Macrodrip 10 drops = 1 mL
you insert into the administration set port on the IV Depending on the manufacturer, macrodrip sets may
solution bag. A plastic sheath covering the spike keeps equate 15 or 20 drops to 1 mL. You must know drops
it sterile. When the sheath is removed, you must use a per milliliter to calculate flow rates or medicated infu-
medically clean technique to avoid contaminating the sion dosages.
 Intravenous Access and Medication Administration 473

• Tubing. Intravenous administration tubing is clear and

very flexible. Thus, you can watch the solution flow
through the administration set, and you can manipu-
late the tubing in tight situations. Some medications
such as intravenous nitroglycerin are chemically
incompatible with regular tubing and require special
tubing.
• Clamp. IV administration tubing has a simple plastic
clamp. When slid over the tubing, the clamp com-
pletely stops the flow of solution from the IV bag to
the patient. It prevents both the entrainment of air into
the tubing when changing IV bags and the backflow of
medication when administering medications. You can
also use it to stop infusion without disturbing the flow
FIGURE 14-34  Extension tubing.
regulator setting.
• Flow regulator. The flow regulator is a dial enclosed
ELECTROMECHANICAL PUMP TUBING  Mechani-
in a triangular plastic casing. It allows infinite con-
cal infusion devices may require specially manufactured
trol of flow rates ranging from a continuous stream
pump tubing (Figure 14-35). Typically, pump tubing has
to completely stopped. Rolling the dial toward the
special components that attach directly to the pump.
IV solution bag increases the drip frequency; rolling
Additionally, bladders and relief points permit you to
the dial towards the patient decreases the drip
void possible air bubbles. Many specific models of elec-
­frequency.
tromechanical infusion pumps require specific pump
• Medication injection ports. The medication injection tubing. When using a mechanical infusion pump, be sure
ports have a self-sealing membrane into which you to have the appropriate tubing on hand. Consult the
can insert a hypodermic needle for medication admin- section on electromechanical infusion pumps for more
istration. Many sets now contain “needleless” medi- information.
cation ports that decrease the possibility of needlestick
injuries. Their design varies, depending on the manu- MEASURED VOLUME ADMINISTRATION SET  The
facturer. When possible, use the medication port near- measured volume administration set can deliver specific
est the patient. volumes of fluid with or without medication. It works
• Needle adapter. The needle adapter is a rigid plastic well for patients who need specific or limited volumes
device at the administration tubing’s distal end. It is of fluid, and it is especially advantageous for pediatrics,
specifically constructed to fit into the hub of an intra- renal failure, or other patients who cannot tolerate fluid
venous cannula. Similar to the spike, the needle overload.
adapter is sterile and covered by a protective cap. If it The measured volume administration set consists of
becomes contaminated at any time, start over with a either micro- or macrodrip tubing, with the addition of a
new administration set. large burette chamber marked in 1.0-mL increments

IV EXTENSION TUBING  Extension tubing is IV tubing

used to extend the original macrodrip or microdrip setup
(Figure 14-34). Its packaging clearly marks it as such. Like
administration sets, extension tubing is sterile and must be
handled accordingly.
Extension tubing also permits the paramedic to change
the original administration tubing or the IV solution bag
with little difficulty. For example, if you have to switch
from a macrodrip set to a microdrip set, you can close the
clamp on the extension and detach the primary tubing.
Once you have flushed the new tubing with fluid, you
place the needle adapter into the receiving port on the
extension tubing and release the clamp. You can now
resume fluid therapy without risking complications or
having to painfully reinitiate a second IV line. FIGURE 14-35  IV pump tubing.
474  Chapter 14

FIGURE 14-37  Blood administration tubing.

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

Hub OVER-THE-NEEDLE CATHE-

TER  Often called an IV catheter
or cannula, an over-the-needle
catheter comprises a semiflex-
Stylet
Flashback ible catheter enclosing a sharp
chamber metal stylet (needle) that is hol-
low and beveled at the distal end
FIGURE 14-38  Over-the-needle catheter.
(Figure 14-38).

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

FIGURE 14-39  Safety IV catheters. FIGURE 14-40  Hollow-needle (butterfly) catheter.

476  Chapter 14

impermeable dressing after venipuncture decreases the

chance of infection.
Once you have established an IV, you must secure it to
avoid losing the access. Medical tape and an adhesive ban-
dage are inexpensive and easy to apply. You can also apply
clear membranes over the site. Commercial devices manu-
FIGURE 14-41  Catheter inserted through the needle. factured specifically for this task are also available. Have
gauze on hand for hemorrhage control if IV cannulation is
CATHETER INSERTED THROUGH THE NEEDLE  The unsuccessful or if blood leaks from around the site.
catheter inserted through the needle is also called an intra- Obtaining a venous blood specimen at the time of
catheter. It consists of a Teflon catheter inserted through venipuncture will save the patient from being stuck with a
a large metal stylet (Figure 14-41). Used in the hospital needle again later. This chapter’s section on venous blood
setting to implement central lines, its proper placement sampling discusses this technique in detail.
requires great skill, as discussed previously.
The size of an intravenous cannula is expressed as its
Intravenous Access in the
gauge. The larger the gauge, the smaller the diameter of the
stylet and catheter. For example, a 22-gauge cannula is Hand, Arm, and Leg
smaller than a 14-gauge cannula. The larger-diameter, As a paramedic, you will most often establish peripheral IVs
14-gauge catheter allows greater flow rates than the in the hand, arm, or leg. The veins in these places are rela-
smaller-diameter, 22-gauge cannula. When establishing tively easy to locate and accessing them causes the patient
venous access, choose the cannula size most appropriate less pain. In addition, the likelihood of complications is less
for the patient’s condition. Typical uses for the various with these veins than with the external jugular vein (dis-
sizes of cannulas are: cussed later) or central IV initiation. Therefore, the veins of
the hand, arm, and leg are the primary sites for IV initiation.
• 22-gauge. Small gauges are used for fragile veins such
To establish a peripheral IV in the hand, arm, or leg,
as those of the elderly or children.
use the following technique (Procedure 14-8):
• 20-gauge. Moderate gauges are used for the average
adult who does not need fluid replacement. 1. Confirm indication and type of IV setup needed.
• 18-gauge, 16-gauge, or 14-gauge. Larger-gauge cannu- Gather and arrange all supplies and equipment before-
las are used to increase volume or to administer vis- hand to make the process easy and accessible.
cous medications such as dextrose. Blood can be • IV fluid
administered only through a cannula that is 16-gauge • Administration set
or larger.
• Intravenous cannula
The largest gauge cannula that will fit into a vein is not • Tape or commercial securing device
always appropriate. A cardiac patient with large veins
• Venous blood drawing equipment
should not receive a 14-gauge cannula for medication
• Venous constricting band
administration, just as a multisystem trauma patient with
good veins should not receive a 22-gauge cannula for fluid • Antiseptic solution
administration. Remember that intravenous access is pain- When appropriate, explain the entire process to the
ful and causes discomfort not only to those receiving it, but patient. Apply the proper Standard Precautions—gloves,
also to family members watching a loved one in distress. mask, and protective eyewear goggles—as IV access is
invasive and presents the potential for blood exposure.
Miscellaneous Equipment 2. Prepare all needed equipment. Examine the IV fluid
The venous constricting band is a flat rubber band applied for clarity and expiration date. Insert the administra-
proximal to the intended puncture site. It impedes venous tion tubing spike in the IV solution bag’s administra-
return, thereby engorging veins and making them easier tion set port. Squeeze fluid from the IV fluid container
to see. This helps you to select the best site and makes into the drip chamber until it reaches the fill line. Open
venipuncture easier. Never restrict arterial blood flow the clamp and/or flow regulator to flush the solution
with the constricting band, and never leave it in place lon- through the administration tubing and expel trapped
ger than 2 minutes. air bubbles. Shut down the flow regulator and replace
Intravenous access is an invasive procedure; therefore, the cap over the needle adapter. Remember that the
you must use medically clean techniques, including anti- IV administration set is sterile; if any contamination
septic preparations, to prevent infection. Applying a sterile, occurs, you must replace the set with a new one.
 Intravenous Access and Medication Administration 477

Procedure 14–8  Peripheral Intravenous Access

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

Procedure 14–9  Peripheral Intravenous Access in an External Jugular Vein

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.

14-9E  Enter the external jugular while withdrawing on the

plunger of the attached syringe.
480  Chapter 14

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.

Volume Administration Set Intravenous Access with Blood Tubing

When using a measured volume administration set, follow To establish an IV with blood tubing, use the following
this procedure (Procedure 14-10): procedure (Procedure 14-11):

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.

Procedure 14–10 Intravenous Access with a Measured Volume

Administration Set

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

Procedure 14–11  Intravenous Access with Blood Tubing

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

Procedure 14–12  Intravenous Bolus Administration

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.

14-12H  Monitor the patient.

14-12G  Adjust the IV flow rate.

 Intravenous Access and Medication Administration 485

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

If the infusion is not premixed,

make a label listing this informa-
tion and attach it to the bag (Fig-
ure 14-42). Additionally, note the
date and time you mixed the
infusion, and initial it.

FIGURE 14-42  If an IV solution is not

premixed, you will have to mix and
label it yourself.
486  Chapter 14

Procedure 14–13  Intravenous Infusion Administration

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.

14-13G  Insert an administration set and

connect it to the main IV line with a needle.
 Intravenous Access and Medication Administration 487

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.

To administer an IV medication bolus through a hepa-

rin lock, assemble the following equipment and supplies:
FIGURE 14-43  A saline or heparin lock can be used when a patient
• Personal protective equipment
requires occasional medications or IV drips but does not need a
­continuous infusion. • Antiseptic solution
488  Chapter 14

• Packaged medication
• Syringe (the size depends on the volume being admin-
istered)
• 18- to 20-gauge hypodermic needle 1 to 1½ inches long

After you have gathered all equipment and supplies, use

the following technique to administer an IV medication
bolus with a heparin or saline lock:

1. Confirm the medication, indication, dosage, and need

for an IV bolus.
2. Draw up the medication or prepare a prefilled syringe
as appropriate.
3. Cleanse the medication port nearest the IV site with an
antiseptic solution. Figure 14-44  Example of a tunneled venous access device.
(© Edward T. Dickinson, MD)
4. Ensure that the plastic clamp is open.
5. Insert the hypodermic needle through the port mem-
brane. internal jugular vein. The portion of the catheter
6. Inject the medication as appropriate. where medications are administered or blood is
7. Remove the hypodermic needle and dispose of it in the ­withdrawn remains outside the skin. Common exam-
sharps container. ples include the Broviac® and Hickman® catheters
(Figure 14-44).
8. Follow the medication administration with a 10- to
20-mL saline flush from another syringe. • Medication Port. Catheters with medication ports are
placed completely below the skin. The port is a raised
9. Properly dispose of the hypodermic needle and syringe.
disk about the size of a quarter or half dollar and can
Monitor the patient for desired or undesired effects.
be felt underneath the skin. Blood can be withdrawn
If fluid administration becomes necessary, you can or medication administered by placing a specialized
unscrew the medication port and insert IV administration tiny needle through the overlying skin into the port or
tubing. Periodically flush with sterile saline or heparin to reservoir. Common examples include the Portacath ®
prevent clot formation and occlusion at the Teflon cathe- and Mediport® catheters (Figure 14-45).
ter’s distal end. • Peripherally inserted central catheter (PICC). PICC
lines are not inserted directly into the central vein.
Venous Access Devices Instead, a PICC line is inserted into a large vein in the
A venous access device is an intravenous catheter that arm and then advanced into the larger subclavian vein
is placed into a large vein, allowing medicaion to be (Figure 14-46).
­delivered directly into the vein. These devices are less
likely to clot than peripheral intravenous lines, which are
inserted into smaller veins. Venous access devices can
remain in place for long periods of time; for this reason,
they are used in long-term care situations. They are typi-
cally used for:

• Administration of medications (antibiotics, chemo-

therapy agents, and other intravenous drugs)
• Administration of fluids and nutritional compounds
(hyperalimentation)
• Transfusion of blood products
• Multiple blood draws for diagnostic testing

There are three common types of venous access

devices.

• 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

To administer the medication by intravenous bolus,

use the following technique:

1. Prepare the medication, fluid, or blood for adminis-

tration.
2. Attach a 21- or 22-gauge Huber needle (or other spe-
cialized needle) to the end of the syringe.
3. Cleanse the skin over the injection port with antiseptic
solutions.
4. Insert the needle into the injection port at a 90° angle
until the needle cannot be further advanced. Pull back
on the plunger of the syringe and observe for the
return of blood. The presence of blood confirms proper
placement.
5. Inject the medication as appropriate.
6. Remove and dispose of the syringe appropriately.
7. With another syringe and attached specialized needle,
FIGURE 14-46  Example of a PICC venous access device.
administer a bolus of heparinized saline to clear the
catheter of any blood clots or other obstruction.
Most EMS systems have policies and procedures If the venous access device is not patent or access proves
regarding accessing a venous access device. Use of an difficult, contact medical direction for further directives.
indwelling central venous access medication port device To administer IV fluids, use the following technique:
requires special training. Delivering a medication through
the venous access device requires a special needle specific 1. Prepare a primary IV line. Be sure to prime or flush the
to the venous access device being used. A commonly used air from the administration tubing.
needle, the Huber needle, has an opening on the side of its 2. Attach a 21- or 22-gauge Huber needle (or other special-
shaft instead of at the tip. When the needle is placed into ized needle) to the primary IV administration tubing.
the injection port, this configuration allows easy adminis- Insert a 10-mL syringe and hypodermic needle filled
tration of medication into the venous access device. Never with 7 mL of normal saline solution into the tubing med-
access a venous access device unless you have the specific ication delivery port nearest the venous access device.
needle uniquely intended for that particular device. 3. Cleanse the skin over the injection port with an anti-
Always ask the patient, family, or nursing staff about the septic solution.
type of venous access device. Often, they will have a sup-
4. Insert the needle into the injection port at a 90° angle
ply of needles for the device.
until it encounters resistance.
To administer fluids, medication, or blood through a
venous access device, you must first prepare the site using 5. Pinch the administration tubing above the medica-
the following technique: tion administration port and pull back on the syringe
plunger. Observe for the return of blood. The presence
1. Use Standard Precautions. of blood confirms proper placement.
2. Fill a 10-mL syringe with approximately 7 mL of nor- 6. Gently inject the 7 mL of normal saline solution.
mal saline.
7. Set the primary line to the appropriate flow rate.
3. Place a 21- or 22-gauge Huber needle (or other special-
ized needle) on the end of the syringe. If administering a secondary medicated infusion, con-
4. Cleanse the skin over the injection port with an anti- tinue as follows:
septic solution. 1. Prepare a secondary line containing the fluid, blood, or
5. Stabilize the site with one hand while inserting the medicated solution for infusion.
Huber needle at a 90° angle. Gently advance it until it 2. Attach a hypodermic needle to the needle adapter of
meets resistance. This signals that the needle has con- the secondary line. Insert the secondary line into a
tacted the floor of the injection port. medication administration port on the primary tubing.
6. Pull back on the plunger and observe for blood return. 3. Shut down the primary line and infuse the medicated
The presence of blood confirms placement. solution as appropriate. Look for ease of administra-
7. Slowly inject the normal saline to ensure patency. tion as a sign of patency.
490  Chapter 14

4. When infusion is complete, administer a bolus of hepa-

rinized saline to clear the catheter of any blood clots or
other obstruction.

Using a venous access device is a very sterile proce-

dure. You must take care to clean the site before delivering
medications. Other complications of using a venous access
device include infection, thrombus formation, and dislodg-
ment of the catheter tip from the vein.

Electromechanical Infusion Devices

Electromechanical infusion devices permit the precise
delivery of fluid and/or medications through electronic
regulation. Whenever intravenous infusion occurs, electro-
mechanical infusion pumps provide optimal delivery.
Infusion devices are classified as either infusion controllers
or infusion pumps.

INFUSION CONTROLLERS  Infusion controllers are

gravity-flow devices that regulate the fluid’s passage through
the pump. Because infusion controllers do not use positive
pressure, they will not force fluids into the extravascular
space if you infiltrate the vein.

INFUSION PUMPS  Infusion pumps deliver fluids and

medications under positive pressure (Figure 14-47). This
pressure can cause complications such as hematoma or
extravasation if you infiltrate the vein. Some infusion pumps
contain a pressure monitor and will warn you if they encoun-
ter the increased resistance that occurs with infiltration.
Syringe-type infusion pumps are gaining popularity
for medical transport. Syringe pumps deliver their medi-
cations from a medical syringe without a hypodermic nee-
dle instead of from IV solution bags, fluids, or liquid
medications (Figure 14-48). You place the syringe contain-
ing the medications in the pump, which uses computer-
ized mechanics to gradually depress the plunger at the
correct rate. These compact pumps prove advantageous
during transport.

FIGURE 14-48  (a) Syringe-type infusion pump in use. (b) Dual-rate

syringe-type pump.
(Photo a: © Edward T. Dickinson, MD; Photo b: Courtesy of © Numia Medical
Technology, LLC)

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

Manufacturers make many different electromechani-

cal infusion pumps. Depending on the maker, pump
compatibility may require specialized administration
tubing. With some computerized pumps, you can enter
the basic information and then the pump will perform all
medical calculations internally and automatically set the
drip rate. Most infusion pumps contain internal monitor-
ing devices that sound an alarm for problems such as
infiltration, occlusion, or fluid source depletion. Elec-
tronic devices are prone to malfunction, however, so you
must be prepared to perform all calculations and set the
drip rate manually.

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:

• Veins collapse easily and completely when gentle pres-

sure is applied with the transducer.
• Arteries will not collapse completely, although slight
compression of artery walls can be seen. Also, arteries
will often be pulsating and the arterial walls may be
thicker than venous walls.
• Color-flow Doppler and pulsed-wave spectral Dop- FIGURE 14-50  Vascular anatomy of the forearm seen with ultra-
pler can help identify veins and differentiate them sound technology.
from arteries, if needed. (© Edward T. Dickinson, MD)
492  Chapter 14

Equipment for Drawing Blood

You will need the following equipment to obtain venous
blood.

BLOOD TUBES  Blood tubes are made of glass and have

color-coded, self-sealing rubber tops. Blood tube sizes for
adults generally range from 5 to 7 mL—for pediatrics, from
2 to 3 mL (Figure 14-52). They are vacuum packed, and some
contain a chemical anticoagulant. The different-colored tops
correspond to specific anticoagulants. A label on every blood
tube identifies the type of additive and its expiration date.
Do not use a blood tube after its expiration date, as both the
anticoagulant and the vacuum lose their effectiveness.
Using blood tubes in their correct order is essential. If
you do not follow the proper sequence, the various antico-
agulants will cause cross-contamination, skewing the
results and rendering the blood useless. Your local EMS
system and receiving hospitals can provide information
about the appropriate order of tubes.

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:

• During peripheral access

• Before medication administration
• When medication administration may be needed

Never stop to draw blood if it will delay critical measures

such as medication administration in cardiac arrest or
transport in a multisystem trauma. FIGURE 14-52  Blood tubes.
 Intravenous Access and Medication Administration 493

Blood tube Vacutainer

FIGURE 14-53  Vacutainer with multi-sampling needle.

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

FIGURE 14-54  Obtaining a blood sample with a 20-mL syringe.

494  Chapter 14

Complications from drawing blood include damage to

the vein wall, inadvertent removal of the IV catheter, and
hemoconcentration and hemolysis of the blood sample.
Hemoconcentration occurs when the constricting band is
FIGURE 14-55  Luer sampling needle.
left in place too long, elevating the numbers of red and
white blood cells in the sample. Hemolysis is the destruc-
further IV access. To draw blood directly from a vein, you tion of red blood cells. When red blood cells are destroyed,
will need the same equipment as for obtaining blood from they release hemoglobin and potassium, thus rendering
an IV catheter, but instead of a standard needle and syringe the blood unusable. Causes of hemolysis include vigor-
you can use a Luer sampling needle (Figure 14-55). A ously shaking the blood tubes after they are filled, using
Luer sampling needle is similar to a multidraw needle, but too small a needle for retrieval, or too forcefully aspirating
instead of an IV catheter adapter it has a long, exposed nee- blood into or out of a syringe.
dle. The Luer sampling needle screws into the vacutainer,
and you insert the exposed needle directly into the vein.
You will also need a constricting band and antiseptic wipes.
Removing a Peripheral IV
To obtain blood directly from a vein, use the following You should remove any IV that will not flow or has ful-
procedure: filled its need. To do so, completely occlude the tubing
with the flow regulator and/or clamp. Remove all tape or
1. Assemble and prepare all equipment. Inspect the other securing devices from the tubing and the patient.
blood tubes for expiration or damage, and insert the Place a sterile gauze pad over the puncture site. Apply
multidraw needle into the vacutainer. pressure to the gauze with the fingers or thumb of your
2. Apply the constricting band and select an appropriate nondominant hand. With your dominant hand, grasp the
puncture site. cannula at its hub and swiftly remove it, pulling straight
3. Cleanse the site with antiseptic solution. back. The site may bleed, so apply direct pressure with the
gauze for 5 minutes. Immediately dispose of all materials
4. Insert the end of the multi-sampling needle or the Luer
in the appropriate biohazard container. Apply an adhesive
sampling needle into the vein and remove the con-
bandage or tape clean gauze over the site to protect against
stricting band.
infection. Document that the catheter was removed intact.
5. In the correct order, insert each blood tube so that the
rubber-covered needle punctures the self-sealing rub-
ber top. Blood should be pulled into the tube.
6. Gently agitate the tube to evenly mix the anticoagulant Intraosseous Infusion
with the blood. Completely fill all blood tubes, as the Intraosseous (IO) infusions involve inserting a rigid needle
anticoagulant is proportional to the volume of the tube. into the cavity of a long bone or into the sternum (intra-,
7. Place sterile gauze over the site and remove the sam- within; os, bone). The bone marrow contains a network of
pling needle. Properly dispose of all sharps. venous sinusoids that drain into the nutrient and emissary
8. Cover the puncture site with gauze and tape or an veins. These sinusoids accept fluids and medications dur-
adhesive bandage. ing intraosseous infusion and transport them to the venous
system. Any solution or medication that can be adminis-
9. Label all blood tubes with the following information:
tered intravenously, either bolus or infusion, can be admin-
• Patient’s first and last name istered by the intraosseous route.
• Patient’s age and gender The National Association of EMS Physicians
• Date and time drawn (NAEMSP) has recommended that every EMS system
should have at least one method of obtaining pediatric IO
• Person drawing the blood
access and one method for obtaining adult IO access.
Again, if commercial equipment is not available, you Although intravenous lines remain the preferred route of
may use a 20-mL syringe. When using a syringe, attach an vascular access, IOs provide a rapid and reliable method
18-gauge hypodermic needle to the end of the syringe and for administering medications and fluids when an IV can-
insert it into the vein. Gently pull back the plunger to fill not be established. The most frequent need for IO access
the syringe with blood. When the syringe is full, remove will be for patients in shock and cardiac arrest. IO access
the syringe and dress the puncture site. In the appropriate may be needed in pediatric hypovolemia. Victims of mul-
order, inject the collected blood into the blood tubes and tiple trauma may benefit from IO therapy, although the
gently agitate. When you have finished, properly dispose prevailing evidence shows that out-of-hospital fluids in
of all sharps and label the blood tubes. trauma are of questionable benefit.11,12
 Intravenous Access and Medication Administration 495

Access Site one at either end. Epiphyseal disks, or growth plates,

The bone most commonly used for pediatric and adult between the diaphysis and the epiphyses allow the tibia to
intraosseous access is the proximal tibia (medial and infe- grow and develop and are present in children. Damage to
rior to the anterior tibial tuberosity). Other insertion sites these disks during intraosseous access can cause long-term
for the adult include the medial malleolus of the distal tibia, growth complications or abnormalities in children.
the humeral head, and the sternum (Figure 14-56). Overall, Within the diaphysis, the medullary canal contains the
the insertion site depends on the device being used as well bone marrow. When placed correctly, the distal part of the
as the age and condition of the patient. To properly locate intraosseous needle will lie in the medullary canal. On
appropriate sites and avoid complications, you must under- either side of the proximal tibia are the medial and lateral
stand the anatomy and physiology of the tibia (Figure 14-57), condyles. You can identify the proximal epiphysis by pal-
the other possible (device-specific) insertion sites, and the pating the condyles.
sternum. The three main sections of the tibia are the diaph- Between the condyles, on the top of the anterior tibial
ysis, which comprises the middle, and the two epiphyses, crest, is a palpable bump called the tibial tuberosity. The tibial

(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

FIGURE 14-58  Intraosseous needle.

trocar gives strength for puncture and prevents occlusion

during insertion. Upon placement, the trocar is removed.
The intraosseous needle has a plastic handle for insertion
and an adjustable plastic disk to stabilize the needle once it
Medullary is in place. You will attach a 10-mL syringe containing 3 to 5
canals
mL of sterile saline to the intraosseous needle. The syringe
Diaphysis
and saline are used similarly to IV access of the external
jugular vein. A large-bore spinal needle with a trocar in
place is an acceptable substitute for an intraosseous needle.
Other equipment for intraosseous placement is similar
to that for a peripheral intravenous access line (fluid, admin-
istration tubing, tape, antiseptics, and gauze). However,
you will not use a constricting band or traditional cannula.
A pressure infuser is often needed for IO fluid administra-
tion. Some IO devices require a specialized adapter for
flushing or using a pressure infuser. Depending on the spe-
cific intraosseous needle, you may need an adapter to con-
nect the administration tubing and the needle.
Malleolus
Several commercial devices are available for both
pediatric and adult intraosseous access. Although these
devices differ in their mechanism and location, they still
must be placed through the cortex of a bone and into the
marrow cavity where fluids and medications can be
FIGURE 14-57  Anatomy of the tibia. administered. Examples of commercial IO access devices
include the following:
tuberosity lies at the level of the epiphyseal growth plate. • Bone Injection Gun (B.I.G.). The Bone Injection Gun
Consequently, the tibial tuberosity is extremely important in (B.I.G.) was developed in Israel and is available in an
locating the appropriate pediatric intraosseous access site. adult and a pediatric model (Figures 14-59a and 14-59b).
For the pediatric patient, you will establish intraosse-
• FAST1®. The FAST1 allows adult intraosseous place-
ous access on the medial aspect of the proximal tibia. This
ment into the sternum. This site is easy to access, and
site is from two to three fingerbreadths below the tibial
the device is easy to insert. A special needle introducer
tuberosity. At this level, place the needle on the flat area
guides insertion, and a dome protects the site after
medial to the anterior tibial crest. For adult or geriatric
placement (Figure 14-60).
patients, place the needle at the distal part of the tibia, one
• EZ-IO™. The EZ-IO uses a small drill to place the nee-
to two fingerbreadths above the medial malleolus.
dle into the bone. The drill is reusable. The technique
is based on the procedure routinely used by orthope-
Equipment for Intraosseous Access dic surgeons. The manufacturer recommends place-
Intraosseous placement requires a specially designed nee- ment in the proximal or distal tibia or the proximal
dle and a 10-mL syringe. Manufactured specifically for IO humerus. The device is approved for both adults and
access, an intraosseous needle is a 14- to 18-gauge hollow children. Successful first-time placement of an intraos-
cannula with a sharp metal trocar inside (Figure 14-58). The seous device with the EZ-IO is high (Figure 14-61).
 Intravenous Access and Medication Administration 497

(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)

3. Position the patient. Rotate the leg toward the outside

to expose the medial, proximal aspect of the tibia.
4. Locate the access site. Palpate the tibia and use all
landmarks.
• Pediatric. Locate the tibial tuberosity. Move from one
to two fingerbreadths below the tibial tuberosity and
find the flat expanse medial to the anterior tibial crest.
(b)
• Adult or geriatric. Find the medial locations (based
FIGURE 14-59  The Bone Injection Gun (B.I.G.): (a) adult model (b) on the device you are using). These can include
pediatric model.
the tibial tuberosity, sternum, or humeral head. Be
(Both photos: A.C.T.N.T. Healthcare Services www.bone-gun.com)
familiar with the accepted access sites, as well as the
operation of the particular IO device you are using.
Placing an Intraosseous Infusion 5. Cleanse the site with an antiseptic solution. Start at
To place an intraosseous line, use the following technique the puncture site and work outward in an expanding
(Procedure 14-14): circular motion.
6. Perform the puncture. Holding the needle perpendicu-
1. Determine the indication for intraosseous access.
lar to the puncture site, insert it with a twisting motion
2. Assemble and check all equipment. until you feel a decrease in resistance or a “pop.” When
this occurs, the needle is in the medullary canal. Do
not advance it any further. Generally, you will need to
insert the needle only 2 to 4 mm for entry.
7. Remove the trocar and attach the syringe. Slowly pull
back the plunger to attempt aspiration into the syringe.
Easy aspiration of bone marrow and blood confirms
correct medullary placement.
8. Once you have confirmed placement, rotate the plastic
disk toward the skin to secure the needle.
9. Remove the syringe and attach the prepared administra-
tion tubing and solution. Set the appropriate flow rate.
10. Secure the intraosseous needle as if securing an
®
FIGURE 14-60  The FAST1 allows intraosseous placement in the impaled object by surrounding it with bulky dressings
sternum of an adult or adolescent (12 years of age and older). and taping them securely in place. Commercial devices
(Pyng Medical Corp.) for securing an intraosseous needle are available.
498  Chapter 14

Procedure 14–14  Intraosseous Medication Administration

14-14A  Select the medication and prepare equipment. 14-14B  Palpate the puncture site and prep with an antiseptic
solution.

14-14C  Make the puncture. 14-14D  Aspirate to confirm proper placement.

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.

14-14G  Administer the medication. Monitor the patient for

effects.

Intraosseous Access through an incorrectly placed needle or if a fracture

Complications and Precautions has occurred. An infusion that does not run freely, or
the formation of an edema at the puncture site, indi-
Intraosseous access poses serious potential complications:
cates infiltration. If infiltration occurs, immediately
• Fracture. Too large a needle or too forceful an inser- discontinue infusion and restart on the other leg.
tion can fracture the tibia, particularly in very young • Growth plate damage. An improperly located punc-
children. ture may damage the growth plate and result in long-
• Infiltration. Infiltration occurs when IV solution col- term growth complications. Locating the site with
lects in the local tissues instead of in the intramedul- proper technique is the most effective way to prevent
lary canal. Infiltration may occur if you run fluids this complication.
500  Chapter 14

• Complete insertion. Com- infection, thrombophlebitis, air embolism, circulatory

CONTENT REVIEW
plete insertion occurs overload, and allergic reaction.
➤➤ Intraosseous Access
when the needle passes
Complications
through both sides of the
• Fracture
tibia, rendering the site
Contraindications to
• Infiltration
• Growth plate damage useless. To avoid complete Intraosseous Placement
• Complete insertion puncture, stop advancing Do not attempt intraosseous placement in the following
• Pulmonary embolism the needle once you feel situations:
• Infection the pop. If complete punc-
• Fracture to the tibia or femur on the side of access
ture occurs, remove the
intraosseous needle with a reverse twisting motion and • Osteogenesis imperfecta—a congenital bone disease that
start again on the other leg. Apply direct pressure and a results in fragile bones
sterile dressing over the site(s) for at least 5 minutes. • Osteoporosis
• Pulmonary embolism. If bone, fat, or marrow particles • Establishment of a peripheral IV line
make their way into the circulatory system, pulmonary
Intraosseous placement is a relatively safe intervention
embolism may result. Proper technique and vigilance
that can be used for the critically ill patient. Its location
for signs associated with pulmonary embolism (sudden
allows access while you perform other interventions such
onset of chest pain or shortness of breath) are important
as CPR or endotracheal intubation. Because you probably
to establishing and maintaining intraosseous access.
will use intraosseous access only infrequently, you must
Other complications of intraosseous access are similar to continually refresh this skill so that you can perform it
those of peripheral intravenous access. They include local properly when needed.

PART 3: Medical Mathematics

Proper medication administration requires basic mathematical proficiency. Because medi-
cation dosages are not always standardized, you may have to calculate amounts according
to your patient’s age, weight, or other medically related criteria. To properly prepare and
administer medications, you must understand roman numerals and be proficient in the
following mathematical skills:

• 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

system adds prefixes to the fundamental units. Table 14-2

lists metric prefixes.
Table 14-2  Metric Prefixes
The most commonly used prefixes in pharmacology are Prefix Multiplier Abbreviation
kilo-, centi-, milli-, and micro-. Prefixes above the fundamental
Kilo 1,000 k
units denote quantities larger than the standard gram, liter,
or meter, whereas those below are smaller. The prefix milli- Hecto 100 h
is smaller than the fundamental unit and m refers to 1/1,000. Deka 10 D
Thus, a milliliter (mL) equals 1/1,000 (one one-thousandth)
Deci 1/10 or 0.1 d
of a liter. If you divided a liter into one thousand equal parts,
a milliliter would equal one of those parts. Similarly, a mil- Centi 1/100 or 0.01 C
ligram (mg) is 1/1,000 of a gram. If you divided a gram into Milli 1/1,000 or 0.001 m
one thousand equal parts, a milligram would equal one of
Micro 1/1,000,000 or 0.000001 (mcg or μg)
those parts. The prefix micro- expresses 1/1,000,000. A micro-
gram (mcg) is 1/1,000,000 (one one-millionth) of a gram.

Conversion between Prefixes

If you know the prefixes and their numeric equivalents, you can easily convert measure-
ments to smaller or larger units. To convert a measurement to a smaller unit, multiply the
original measurement by the numerical equivalent of the smaller measurement’s prefix.

EXAMPLE 1.  Convert 3 grams to milligrams.

Milligrams (1/1,000) are smaller than grams; therefore, multiply 3 by 1,000:

3 (grams) * 1,000 (milli) = 3,000

3 grams = 3,000 milligrams

EXAMPLE 2.  Convert 2.67 liters to milliliters.

Milliliters (1/1,000) are smaller than a liter; therefore, multiply 2.67 by 1,000:

2.67 liters * 1,000 (milli) = 2,670

2.67 liters = 2,670 milliliters

To convert a measurement to a larger unit, divide the original measurement by the numer-
ical equivalent of the smaller measurement’s prefix.

EXAMPLE 3.  Convert 1,600 micrograms to grams.

A microgram is 1/1,000,000 the size of a gram; therefore, divide 1,600 by 1,000,000:

1,600>1,000,000 = 0.0016 grams

1,600 micrograms = 0.0016 grams

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.

EXAMPLE 4.  Convert 5.6 milligrams to micrograms.

First, convert the 5.6 milligrams to grams:

5.6 milligrams>1,000 = 0.0056 grams (g)

5.6 milligrams = 0.0056 grams

Now, convert 0.0056 grams to micrograms as previously described:

0.0056 (grams) * 1,000,000 = 5,600 micrograms

5.6 milligrams = 5,600 micrograms

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

Table 14-3  Metric Equivalents Household and Apothecary

Household Apothecary Metric
Systems of Measure
1 gallon 4 quarts 3.785 liters
In the past, pharmacology traditionally used the house-
hold and apothecary systems to measure medication
1 quart 1 quart 0.946 liters
dosages. Gradually, the metric system has replaced those
16 ounces approximately 1 pint 473 milliliters
systems, but you may occasionally encounter their rem-
1 cup approximately 1/2 pint approximately 250 milliliters nants. Table 14-3 gives the metric equivalents of the
1 tablespoon approximately 16 milliliters household and apothecary units you will most likely
1 teaspoon approximately 4 to 5 milliliters
confront.

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

EXAMPLE 5.  How many kilograms does a 182-lb person weigh?

kilograms = 182 lb>2.2

kilograms = 82.7

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)

EXAMPLE 6.  Convert 98.2°F to °C.

°C = 5>9 (98.2 - 32)

°C = 5>9 (66.2)
°C = 36.8
98.2°F = 36.8 °C

EXAMPLE 7.  Convert 28.4°C to °F.

°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.

Calculating Dosages for Oral Medications

The following example illustrates how to calculate the volume of a specific medication
dosage:

EXAMPLE 1.  A physician orders you to administer 90 mg of acetaminophen to a pediatric

patient. The liquid acetaminophen is packaged as a concentration of 500 mg in 8 mL of
solution. How much of the medication will you administer?
504  Chapter 14

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)

volume to be administered = (8 mL * 90)>500 mg

volume to be administered = 720 mL>500
volume to be administered = 1.44 mL

Administer 1.44 mL of solution to deliver 90 mg of acetaminophen.

Another way to calculate medication dosages is the ratio (fraction) and proportion
MATH SUMMARY 2
method. A ratio (fraction) illustrates a relationship between two numbers. A proportion
8 mL x is the comparison of two numerically equivalent ratios. Using the variable x, the previous
*
500 mg 90 mg problem can be stated:
720 mL mg
x = 8 mL>500 mg = x mL>90 mg
500 mg
x = 1.44 mL To solve the problem, cross-multiply the numerals:

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

2,500 mL mg>2,000 mg = x 2,500 mL mg

x =
2,000 mg
1.25 mL = x
x = 1.25 mL
Tablets also come in stock doses. If the dosage of one tablet or pill is more than needed,
divide the tablet or pill to make the correct dose. Do not divide enteric or time-release
capsules.

Calculating Dosages for Parenteral Medications

You can use the same formula to calculate specific doses and volume for parenteral medi-
cation delivery.

EXAMPLE 3.  A physician wants you to administer 5 milligrams of medication subcutane-

ously. The ampule contains 10 mg of the medication in 2 mL of solvent. How much medica-
tion should you use?

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

Calculating Weight-Dependent Dosages

Occasionally, you will have to calculate the desired dose according to the patient’s weight.

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

The patient weighs approximately 72 kg.

Calculate the desired dose:
MATH SUMMARY 6
1.5 mg>kg * 72 kg = 108 mg 10 mL * 108 mg
x =
You now know these three facts: 100 mg
1,080 mL mg
desired dose = 108 mg x =
100 mg
dosage on hand = 100 mg
x = 10.8 mL
volume on hand = 10 mL
506  Chapter 14

MATH SUMMARY 7 Use the same formula as before to calculate the volume to be administered:

10 mL x volume on hand (10 mL) * desired dose (108 mg)

= volume to be administered =
100 mg 108 mg dosage on hand (100 mg)
1,080 mL mg volume to be administered = (10 mL * 100 mg)>100 mg
x =
100 mg
volume to be administered = 1,080 mL mg)>100 mg
x = 10.8 mL
volume to be administered = 10.8 mL

Administer 10.8 mL of solution to deliver 108 mg of lidocaine.

After you have calculated the desired dose, you can solve this problem using the ratio
and proportion method as previously illustrated.

Calculating Infusion Rates

To deliver fluid or medication through an IV infusion, you must calculate the correct infu-
sion rate in drops per minute. To do so you must know the administration tubing’s drip
factor, as well as the volume on hand, desired dose, and dosage on hand.

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

EXAMPLE 5. A physician wants you to administer 2 mg per minute of lidocaine to a

patient. To prepare the infusion, you mix 2 grams of lidocaine in an IV bag containing 500
milliliters of 5 percent dextrose in water (D5W). You will use a microdrip administration set
(60 drops/mL). Calculate the infusion rate.

desired dose = 2 mg>minute

MATH SUMMARY 8
x = 500 mL * 60 drops/mL
dosage on hand = 2,000 mg (2 grams)
* 2 mg>min volume on hand = 500 mL
2,000 mg drip factor = 60 drops>mL
60,000 mL drop mL mg min volume on hand (500 mL) * drip factor (60 drops>mL) * desired dose (2 mg)
x = drops/minute =
2,000 mg dosage on hand (2,000 mg)
x = 30 drops>min
drops/minute = (500 * 60 * 2)>2,000
drops/minute = (60,000)>2,000
drops/minute = 30

Run the infusion at 30 drops/minute to infuse 2 mg of lidocaine per minute.

Fluid Volume over Time

Fluids with or without medications may require administration over a specific period of
time. To deliver the fluid correctly, you must calculate volume/time. This calculation
requires the following information:

• Volume to be administered
• Drip factor of the administration set (drops/mL)
• Total time of infusion (minutes)
 Intravenous Access and Medication Administration 507

To calculate the infusion rate, use this formula:

volume to be administered (drip factor)
drops>minute =
time in minutes

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.

Calculating Dosages and Infusion Rates for Infants and Children

Infants and children cannot tolerate under- or overdoses of medication and fluids. When
you administer infusions to pediatric patients, you must calculate exact flow rates. Because
infants and children differ drastically from adults in size and internal development, their
dosages often depend on weight. Most weight-dependent dosages express the patient’s
weight in kilograms, so you must make the appropriate conversion from pounds as dis-
cussed earlier. Occasionally, you may encounter a medication that is based on body surface
area (BSA). Chemotherapeutic agents for children are often based on body surface area.
Although you will not initiate such medications, you may encounter them on critical care
transports either by ground or air. Many aids for calculating pediatric medication doses
and infusion rates are available, including charts, forms, and length-based resuscitation
tapes. Even though these devices are helpful, you should not rely on them exclusively.
They are no substitute for knowledge.14
 Summary
Medication administration is a fundamental skill used in the treatment of the sick and injured. For
medications to be effective, they must be safely delivered into the body by the appropriate route.
Many different routes for medication delivery are available to the paramedic; however, specific
medications require specific routes for administration. In addition, you must accurately calculate
many medication dosages. Dosage errors and inappropriate medication administration can result
in serious side effects or even death for the patient, not to mention casting serious doubt on your
ability or causing loss of your certification.
Keep in mind that medication calculations can be completed by a variety of methods. What is
important is to find a method that works for you and gets you the right answer every time you
work a problem. Once you identify this method, stick with it and practice it, because you never
know when you will need to do a calculation in less than favorable conditions.
Always remember that it is your responsibility to be familiar with all routes of medication
delivery and the techniques for establishing and using them. You will use some routes of medica-
tion administration infrequently, and they will quickly fade from memory, whereas you will use
other routes almost daily. Nonetheless, someone’s well-being may depend on your ability to use
any one of the routes of administration in an emergency. Therefore, periodic review of all routes
used in medication administration is highly recommended.

You Make the Call

You have been called for a 53-year-old male patient experiencing chest pain and shortness of
breath. After assessing the patient, you find him to be alert and oriented, with a clear airway,
and breathing adequately at a rate of 16 breaths per minute. His distal pulses are strong, and his
skin is cool and slightly diaphoretic. Your partner obtains the following vital signs: blood pres-
sure 142/88 mmHg, pulse 92 beats per minute, and respirations 16 and easy. The patient exhib-
its no jugular venous distention or peripheral edema, and breath sounds are clear bilaterally.
The 12-lead cardiac monitor shows a sinus rhythm with ST segment elevation in leads V1
through V3. The patient has no medical allergies and is on no medications. He denies any previ-
ous medical history.
In addition to high-flow, high-concentration oxygen, you elect to administer nitroglycerin,
morphine sulfate, and aspirin, based on your suspicion of an acute myocardial infarction. Accord-
ingly, you quickly establish an IV line.
1. Before administering aspirin or any other medication orally (p.o.), what major consideration
must you be sure of?
2. Of the following medications and routes of delivery, which will provide the fastest and most
predictable rate of absorption?
• Aspirin—enteral tract
• Nitroglycerin—sublingual
• Morphine sulfate—IV bolus
3. When administered sublingually, how is the nitroglycerin absorbed into the body?
4. You elect to administer 3 mg of morphine sulfate to the patient. The medication is packaged as
10 mg in 5 mL of solution in a multidose vial. How many milliliters must you administer to
give the 3 mg of morphine?
See Suggested Responses at the back of this book.

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.

a. sterile. c. disinfectant. a. LMA c. nebulizer

b. antiseptic. d. medically clean. b. ET tube d. nasal airway

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

b. nasal medication. b. 2, 3 d. 3½, 4

c. aural medication. 12. A _________________ is a liquid that contains small

d. ocular medication. particles of solid medication.
a. syrup c. emulsion
4. “Within the dermal layer of the skin”
defines_________________ b. elixir d. suspension

a. buccal. c. subcutaneous. 13. _________________ denotes any drug administration

b. intradermal. d. intramuscular. outside the gastrointestinal tract.
a. Enema c. Parenteral
5. The state in which solutions on opposite sides of a
b. Enteral d. Suppository
semipermeable membrane are in equal concentra-
tion describes a(n) _________________ state. 14. Which of the following is not a parenteral drug
a. colloid c. hypertonic delivery route?
b. isotonic d. hypotonic a. Rectal route
b. Intravenous access
6. When starting an IV, never leave the constricting
band in place for more than _________________ c. Intraosseous infusion
­minutes. d. Intramuscular injection
a. 1.5 c. 3 15. All of the following are examples of colloidal solu-
b. 2 d. 4 tions except_________________
a. dextran. c. hetastarch.
7. Medically clean techniques include_________________
b. lactated Ringer’s. d. albumin.
a. handwashing.
b. glove changing. 16. What term is used to describe inflammation of the
c. discarding equipment in opened packages. vein, which is particularly common in long-term
intravenous therapy?
d. all of the above.
a. Necrosis
8. To minimize or eliminate the risk of an accidental
b. Air embolism
needle stick, the paramedic must_________________
c. Thrombus formation
a. recap needles using two hands.
d. Thrombophlebitis
b. start IVs in the ambulance rather than in the
patient’s home. 17. Which of the following is not an enteral route of
c. immediately dispose of used sharps in a sharps drug administration?
container. a. Inhalational c. Rectal
d. wash his hands before and after needle use. b. Oral d. Buccal
510  Chapter 14

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

apneic oxygenation, p. 563 pressure (CPAP), p. 544 extubation, p. 527

arterial oxygen concentration Cormack and LeHane grading FiO2, p. 524

(CaO2), p. 523 system, p. 594 flail chest, p. 528
aspiration, p. 518 cricothyroid membrane, p. 518 free radicals, p. 533
atelectasis, p. 520 cyanosis, p. 530 French, p. 545
bag-valve mask (BVM), p. 548 demand-valve device, p. 550 gag reflex, p. 517
barotrauma, p. 582 diffusion, p. 523 glottis, p. 517
bilevel positive airway pressure dyspnea, p. 530 hemoglobin (Hgb), p. 523
(BiPAP), p. 544 ear-to-sternal-notch hemoglobin oxygen saturation
bronchi, p. 519 position, p. 540 (SaO2), p. 523
CaO2, p. 523 endotracheal tube (ETT), p. 559 hemothorax, p. 524
514  Chapter 15

Hgb, p. 523 nasopharyngeal airway ramped position, p. 541

high-pressure regulator, p. 543 (NPA), p. 545 rapid sequence intubation
hypercarbia, p. 524 nasotracheal route, p. 571 (RSI), p. 548
hyperoxia, p. 533 needle cricothyrotomy, p. 581 respiration, p. 521
hypoventilation, p. 524 normoxia, p. 533 respiratory rate, p. 524
hypoxemia, p. 525 open cricothyrotomy, p. 581 retroglottic airways, p. 551
hypoxia, p. 530 oropharyngeal airway (OPA), SaO2, p. 523
hypoxic drive, p. 526 p. 546 septum, p. 516
insufflate, p. 563 oxygen, p. 516 sinus, p. 516
intubation, p. 517 oxygen saturation percentage sniffing position, p. 540
(SpO2), p. 533 stenosis, p. 581
laryngoscope, p. 557
Pa, p. 523 stoma, p. 597
larynx, p. 517
PA, p. 523 stylet, p. 560
Lipp maneuver, p. 552
paradoxical breathing, p. 528 suction, p. 598
lumen, p. 527
parenchyma, p. 520 supraglottic airways, p. 551
Magill forceps, p. 560
partial pressure, p. 522 therapy regulator, p. 543
Mallampati classification
system, p. 593 pharynx, p. 517 tidal volume (TV), p. 526
minute volume, p. 524 pleura, p. 520 total lung capacity (TLC), p. 526
mucous membrane, p. 517 pneumothorax, p. 524 trachea, p. 518
mucus, p. 517 POGO scoring system, p. 594 upper airway obstruction, p. 527
nares, p. 517 pulmonary embolism, p. 524 vallecula, p. 517
nasal cannula, p. 543 pulse oximetry, p. 532 ventilation, p. 521
nasolacrimal ducts, p. 517 pulsus paradoxus, p. 530 Venturi mask, p. 543

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.

Introduction With regard to airway and/or ventilation problems,

paramedics should approach the patient more globally and
Airway management and ventilation are the first and most consider the whole picture, rather than blindly following
critical steps in the primary assessment of every patient predetermined steps. You cannot assess an airway if the
you will encounter (unless the patient is in cardiac arrest, patient is not breathing. You cannot assess breathing if
when chest compressions will come first). Airway manage- there is no airway. Therefore, airway and ventilation need
ment and ventilation go hand in hand. You must immedi- to be considered and managed together. Ultimately, circu-
ately establish and maintain an open airway while lation also will depend on an intact airway and adequate
providing adequate oxygen delivery and carbon dioxide ventilation and respiration. The respiratory, cardiovascu-
elimination for all patients. Without adequate airway lar, and neurologic systems all play an important role in
maintenance and ventilation, the patient will succumb to airway management and ventilation. Stated another way,
brain injury, or even death, in as little as 4 minutes. Early airway and ventilation problems must be approached in a
detection and intervention of airway and breathing prob- nonlinear fashion with a number of factors considered
lems, including dispatcher-guided interventions by simultaneously.
bystanders, are vital to patient survival. Your deliberate and precise use of simple, basic airway
Airway management and ventilation have always skills is the key to successful airway management and
been taught to occur in a stepwise (linear) process. Recom- good patient outcome. Once you have applied the basic
mended sequences include the standard ABC (airway, airway techniques to properly provide oxygenation and
breathing, circulation) sequence, as well as the CAB (com- ventilation for your patient, you can then use more sophis-
pressions, airway, breathing) sequence recommended by ticated airway maneuvers and skills, if necessary, to fur-
the American Heart Association for a patient who appears ther stabilize his airway. You must continually monitor and
to be in cardiac arrest, when chest compression must come reassess the airway, being careful to watch for displace-
first. These established sequences (ABC and CAB) can help ment of any placed airway devices, mucous plugging,
rescuers remember what to do in emergency situations. equipment failure, or the development of a pneumothorax.
516  Chapter 15

This chapter provides the lateral and superior

CONTENT REVIEW CONTENT REVIEW
the information and skills walls of the nasal cavity.
➤➤ Your deliberate and ➤➤ Upper Airway
you will need to manage The hard palate forms the
precise use of simple, Components
even the most difficult air- floor of the nasal cavity.
basic airway skills is the • Nasal cavity
way. It begins with a review The cartilaginous and
key to successful airway • Oral cavity
management and a good of the respiratory system’s highly vascular nasal sep- • Pharynx
patient outcome. anatomy and physiology tum separates the right ➤➤ Regions of the Pharynx
and then explores the pri- and left nasal cavities. • Nasopharynx
mary assessment and management of the airway and venti- Several structures con- • Oropharynx
lation. Finally, it details enhanced airway management nect with the nasal cavity. • Laryngopharynx
options for the more experienced paramedic. These include the sinuses,
The chapter is divided into four parts: the eustachian tubes, and the lacrimal ducts. The sinuses
are air-filled cavities that are lined with a mucous mem-
Part 1: Respiratory Anatomy, Physiology, and Assessment
brane. There are four pairs of sinuses: the ethmoid sinuses,
Part 2: Basic Airway Management and Ventilation the frontal sinuses, the maxillary sinuses, and the sphenoid
Part 3: Advanced Airway Management and Ventilation sinuses. The sinuses, named for the bone where they are
Part 4: Additional Airway and Ventilation Issues contained, help reduce the overall weight of the head and
are thought to assist in heating, purifying, and moistening
inhaled air. The sinuses help trap bacteria and other sub-

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

dioxide, a waste product of the body’s Superior, middle,

metabolism, to exit. This gas exchange, and inferior turbinates
called respiration, requires a patent, open Hard and soft palates
airway as well as adequate respiratory
function. Many pathological processes can NASOPHARYNX
inhibit respiration. To understand the Tonsils/adenoids
interventions that you will use to maintain Uvula
adequate airway and ventilatory function,
OROPHARYNX
you must thoroughly understand the anat-
omy of the upper and lower airway. Tongue

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

Intrinsic ligament Pyriform fossae

Cricoid cartilage
Extrinsic ligament
Trachea
Tracheal cartilages

(Anterior) (Posterior)

Figure 15-2  Internal anatomy of the upper airway.

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

FIGURE 15-3  Anatomy of the lower airway.

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.

The Respiratory Cycle

Nothing within the lung parenchyma
1
makes it contract or expand. Pulmo-
nary ventilation, therefore, depends on
changes in pressure within the thoracic 1Z[IGPCVGFDNQQF %1
&GQZ[IGPCVGF
cavity. These changes occur in a respi- EKTEWNCVGF
DNQQFHTQOVJGJGCTV
DCEMVQVJGJGCTV
ratory cycle involving coordinated
interaction among the respiratory FIGURE 15-6  Diffusion of gases across an alveolar membrane.
522  Chapter 15

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

returns from the pulmonary vein to the heart and then

Table 15-1  Partial Pressures and Concentrations of Gases moves into the systemic circulation.
Partial Pressure Concentration
Oxygen Concentration in the Blood
Atmospheric Alveolar Atmospheric Alveolar
Oxygen diffuses into the blood plasma, where most of it
Nitrogen 597.0 torr 569.0 torr 78.62% 74.9% combines with hemoglobin and is measured as oxygen
Oxygen 159.0 torr 104.0 torr 20.84% 13.7% saturation (SaO2). The remainder is dissolved in the blood
and is measured as the PaO2. Hemoglobin approaches 100
Carbon dioxide 0.3 torr 40.0 torr 0.04% 5.2%
percent saturation when the PaO2 of dissolved oxygen
Water 3.7 torr 47.0 torr 0.50% 6.2% reaches 90 to 100 torr. Each gram of saturated hemoglobin
TOTAL 760.0 torr 760.0 torr 100.00% 100.0% carries 1.34 milliliters of oxygen. Oxygen saturation is the
ratio of the blood’s actual oxygen content to its total oxy-
gen-carrying capacity:
(Note that torr and mmHg are the same measures of pres-
sure.) Earth’s atmosphere consists of four major respira- Oxygen saturation = O2 content>O2 capacity * 100(,)
tory gases: nitrogen (N2), oxygen (O2), carbon dioxide The hemoglobin molecule carries the vast majority of oxy-
(CO2), and water (H2O). Although nitrogen is metaboli- gen in the blood (approximately 97 percent). Very little
cally inert, it is needed to inflate gas-filled body cavities oxygen dissolves in the plasma. Because partial pressure
such as the chest. Table 15-1 lists these four respiratory measurements detect only the amount of oxygen dissolved
gases’ partial pressures and concentrations in the environ- in the plasma and do not always reflect the total oxygen
ment and in the alveoli. saturation of hemoglobin, they can be misleading. For
Because alveolar partial pressure and arterial partial example, a patient who has suffered carbon monoxide poi-
pressure are essentially the same in the normal lung, nor- soning cannot transport enough oxygen to the essential tis-
mal arterial partial pressures for oxygen and carbon diox- sues, because carbon monoxide displaces oxygen from the
ide may be expressed: hemoglobin molecule, but an arterial blood gas sample
Oxygen (PaO2) = 100 torr (average = 80 - 100) might reveal a normal or high PaO2. This would indicate
that adequate oxygen was reaching the blood. In fact, how-
Carbon dioxide (PaCO2) = 40 torr (average = 35 - 45)
ever, an inadequate amount of hemoglobin would be avail-
Alveolar partial pressures are abbreviated PA (PAO2 and able to transport the oxygen to the peripheral tissues, thus
PACO2), whereas arterial partial pressures are abbreviated resulting in peripheral hypoxia.
Pa (PaO2 and PaCO2). Because these values are usually the The oxygen content of the arterial blood can be calcu-
same, however, they typically appear as the shortened lated using the following standardized equation:
notations PO2 and PCO2.
CaO2 = (SaO2 * Hgb * 1.34) + (0.003 * PaO2)
Diffusion where CaO2 is the arterial oxygen concentration (mL/dL),
Diffusion is the movement of a gas from an area of higher SaO2 is hemoglobin-oxygen saturation (%), Hgb indicates
concentration (partial pressure) to an area of lower con- the amount of hemoglobin present (g/dL), 1.34 is a con-
centration, attempting to reach equilibrium. Diffusion stant and represents the amount of oxygen bound to one
transfers gases between the lungs and the blood and gram of hemoglobin at one atmosphere pressure, 0.003 is
between the blood and the peripheral tissues. The rate of the amount of oxygen dissolved in plasma (mL/g Hgb),
diffusion of a gas across the pulmonary membranes and PaO2 is the partial pressure of oxygen dissolved in the
depends on the gas’s solubility in water. For example, plasma (mmHg). Normal CaO2 is 17 to 24 mL/dL.
carbon dioxide is 21 times more soluble in water than Several factors can affect oxygen concentrations in the
oxygen and readily crosses the pulmonary capillary blood:
membranes. In the peripheral tissues, the gradient (direc-
• Decreased hemoglobin concentration (anemia, hem-
tion of diffusion) for CO2 is from the tissue, where its con-
orrhage)
centration is high, to the capillary blood, where its
concentration is low. • Inadequate alveolar ventilation due to low inspired-
In the lungs, oxygen dissolves in water at the alveolar oxygen concentration, respiratory muscle paralysis,
membrane and leaves the area of higher PO2, the alveoli, and pulmonary conditions such as emphysema,
and enters the area of lower PO2, the venous blood in the asthma, or pneumothorax
pulmonary capillaries. Concurrently, carbon dioxide • Decreased diffusion across the pulmonary membrane
leaves the area of higher PCO2, the arterial blood, and when diffusion distance increases or the pulmonary
enters the area of lower PCO2, the alveoli. The blood membrane changes—for example, when fluid enters
524  Chapter 15

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

to recoil and expel air from the Inhibition

body. As the stretch decreases,

Pneumotaxic center
the stretch receptors stop firing.
This process, called the Hering- Apneustic center Pons
Breuer reflex, prevents overex-
pansion of the lungs.
Ventral respiratory group
Respiratory (VRG)(expiratory center)
CHEMORECEPTORS  Other rhythmicity
center Dorsal respiratory group Medulla oblongata
involuntary respiration controls
(DRG)(respiratory center)
include central chemical recep-
tors in the medulla and periph-
eral chemoreceptors in the
carotid bodies and in the arch
of the aorta. These chemorecep- Internal
intercostal
tors are stimulated by decreased
muscles
PaO2, increased PaCO2, and
decreased pH. (The pH scale
expresses the degree of acidity
or alkalinity. A lower pH indi-
cates greater acidity; a higher
pH indicates greater alkalinity;
the chaper “Pathosphysiology”
discusses pH in greater detail.)
Cerebrospinal fluid (CSF) pH is
the primary control of respira-
tory center stimulation. The CSF
pH responds very quickly to
changes in arterial PCO2. Any
increase in PCO2 will decrease External
CSF pH, which will, in turn, intercostal
muscles Diaphragm
stimulate the central chemore-
ceptors to increase respiration. FIGURE 15-9  Nervous control of respiration.
526  Chapter 15

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:

Vmin = VT * respiratory rate

Measures of Respiratory Function
The respiratory rate is the number of respiratory cycles per • Alveolar minute volume (VA-min). The alveolar minute
minute, normally 12 to 20 breaths per minute in adults, 18 volume is the amount of gas that reaches the alveoli
to 24 in children, and 40 to 60 in infants. Several factors for gas exchange in 1 minute:
affect respiratory rate: VA - min = (VT - VD) * respiratory rate or
• Fever—increases rate VA - min = VA * respiratory rate
• Emotion—increases rate • Inspiratory reserve volume (IRV). The inspiratory
• Pain—increases rate reserve volume is the amount of air that can be maxi-
• Hypoxia (inadequate tissue oxygenation)—increases mally inhaled after a normal inspiration.
rate • Expiratory reserve volume (ERV). The expiratory
• Acidosis—increases rate reserve volume is the amount of air that can be maxi-
mally exhaled after a normal expiration.
• Stimulant drugs—increase rate
• Residual volume (RV). The residual volume is the
• Depressant drugs—decrease rate
amount of air remaining in the lungs at the end of
• Sleep—decreases rate maximal expiration.
Paramedics must fully understand ventilatory • Functional residual capacity (FRC). The functional
mechanics and capacities for the average adult’s respira- residual capacity is the volume of gas that remains in
tory system. This knowledge will enable you to adapt your the lungs at the end of normal expiration:
mechanical ventilation techniques to your patient’s size,
FRC = ERV + RV
lung compliance, need for hyperventilation, or other indi-
vidual requirements. It is especially crucial in situations • Forced expiratory volume (FEV). The forced expiratory
that call for advanced mechanical ventilator skills. Respira- volume is the amount of air that can be maximally
tory capacities and measurements with which you must be expired after maximum inspiration.
familiar include the following:

• Total lung capacity (TLC). Total lung capacity is the

maximum lung capacity—the total amount of air con- Respiratory Problems
tained in the lung at the end of maximal inspiration. In
Respiratory emergencies can pose an immediate life threat
the average adult male, this volume is approximately
to the patient. You must calmly and quickly assess the
6 liters.
severity of his illness or injury while considering the poten-
• Tidal volume (VT). The tidal volume is the average tial causes of and treatment for his respiratory distress.
volume of gas inhaled or exhaled in one respiratory Often, he will give you little help, because of either anxiety
cycle. In the adult male this is approximately 500 mL or difficulty speaking. His respiratory difficulty may be
(5 to 7 mL/kg). due to airway obstruction, injury to upper or lower airway
• Dead space volume (VD). The dead space volume is the structures, inadequate ventilation caused by worsening of
amount of gas in the tidal volume that remains in air an underlying lung disease and fatigue, or central nervous
passageways unavailable for gas exchange. It is approx- system problems that threaten the airway or respiratory
imately 150 mL in the adult male. Anatomic dead space effort.
 Airway Management and Ventilation 527

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.

ASPIRATION  Vomitus is the most commonly aspirated

material. Patients most at risk for this are those who are so
obtunded (drowsy) that they cannot adequately protect
their airways. This can occur with hypoxia, central nervous
FIGURE 15-10  The tongue as airway obstruction. Note that the system toxins, or brain injury, among other causes. In addi-
tongue has fallen backward, totally obstructing the airway. tion to obstructing the airway, aspiration’s other effects
528  Chapter 15

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

FIGURE 15-12  Look.

FIGURE 15-14  Bag-valve-mask ventilation.

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

Figure 15-15  Positions for auscultating breath sounds.

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

Table 15-2  Comparison of Pulse Oximetry and Capnography

Pulse Oximetry (SpO2) Capnography (ETCO2)
Gas measured Oxygen (O2) Carbon dioxide (CO2)

Parameter evaluated Oxygenation Ventilation

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?

Pulse rate abnormalities may also suggest respiratory

compromise. Tachycardia (an abnormally fast pulse) usu-
ally accompanies hypoxemia in an adult, whereas brady-
cardia (an abnormally slow pulse) hints at anoxia with
imminent cardiac arrest.

Noninvasive Respiratory Monitoring

Several available devices
CONTENT REVIEW
will help you measure the
➤➤ A fall in the pulse rate in a effectiveness of oxygen-
patient with airway com- ation and ventilation and
promise is an ominous
maintain parameters at the
finding.
appropriate levels. Those FIGURE 15-16  Pulse oximeter.
 Airway Management and Ventilation 533

faster than assessments of blood pressure, pulse, and respi-

rations. When available, you should use it in virtually any
Table 15-3  Interpretation of Pulse Oximetry Readings
and Recommended Actions
situation to determine the patient’s baseline value, to guide
patient care, and to monitor the patient’s responses to your SpO2 Reading (%) Interpretation Intervention
interventions. 95–100 Normal Change FiO2 to maintain
To determine peripheral oxygen saturation, you place saturation.
a sensor probe over a peripheral capillary bed such as a
91–94 Mild hypoxemia Increase FiO2 to increase
fingertip, toe, or earlobe. In infants, you can wrap the sen- saturation.
sor around the heel and secure it with tape. The sensor con-
86–90 Moderate Increase FiO2 to increase
tains two light-emitting diodes and two sensors. One diode hypoxemia saturation. Assess and
emits near-red light, a wavelength specific for oxygenated increase ventilation.

hemoglobin; the other emits infrared light, a wavelength <85 Severe Increase FiO2 to increase
specific for deoxygenated hemoglobin. Each hemoglobin hypoxemia saturation. Increase ventilation.

state absorbs a certain amount of the emitted light, pre-

venting it from reaching the corresponding sensor. Less
light reaching the sensor means more of its type of hemo- oximetry. Then, only enough supplemental oxygen should
globin is in the blood. The oximeter then calculates the be administered to correct hypoxia and restore normoxia
ratio of the near-red and infrared light it has received to (increase it to within a normal range). Trying to fully satu-
determine the oxygen saturation percentage (SpO2). rate hemoglobin with oxygen can cause the formation of
Pulse oximeters display the SpO2 and the pulse rate as free radicals and result in what is called oxidative stress.
detected by the sensors. They show the SpO2 either as a Excess concentrations of oxygen (hyperoxia) should be
number or as a visual display that also shows the pulse’s avoided. The production of toxic free radicals from oxygen
waveform and heart rate. The latter helps the provider administration has been associated with worsened out-
ensure that the SpO2 reading is based on good data. If the comes in patients with brain trauma and stroke, and in post-
patient’s pulse is 120 but the pulse oximetry waveform is cardiac arrest victims. It can cause numerous problems in
detecting only 60, or the waveform is nearly flat, then the neonates. Thus, always administer the lowest flow of oxy-
saturation reading is unlikely to be accurate. The relation- gen that will restore normoxia (without causing hyperoxia)
ship between SpO2 and the partial pressure of oxygen in as evidenced by dynamic pulse oximetry readings.1–3
the blood (PaO2) is very complex. However, the SpO2 does False readings with pulse oximetry are infrequent and
correlate with the PaO2. The greater the PaO2, the greater vary with the type of device used. When they do occur, the
will be the oxygen saturation. Because hemoglobin carries heart rate on the pulse oximeter may not correlate with the
98 percent of oxygen in the blood, whereas plasma carries patient’s true heart rate, the waveform may be flat or
only 2 percent, pulse oximetry accurately analyzes periph- nearly flat, and/or the oximeter will generate an error sig-
eral oxygen delivery. nal or a blank screen. Causes of false readings include car-
As a guide, normal SpO2 varies between 96 and 99 per- bon monoxide poisoning, high-intensity lighting, nail
cent at sea level. Readings between 91 and 95 percent indi- polish, poor perfusion, and certain hemoglobin abnormali-
cate mild hypoxemia and warrant further evaluation and ties. Fortunately, second-generation pulse oximeters have
supplemental oxygen administration. Readings between eliminated many of these problems. In hypovolemia and in
86 and 90 percent indicate moderate hypoxemia. You severely anemic patients, however, the pulse oximetry
should generally give these patients high-concentration reading may be misleading. Although the SpO2 reading
supplemental oxygen using a nonrebreather. Readings of may be normal, the total amount of hemoglobin available
85 percent or lower indicate severe hypoxemia and war- to carry oxygen may be so markedly decreased that the
rant immediate intervention, including the administration patient will remain hypoxic at the cellular level.
of high-concentration oxygen, ventilatory assistance, or Pulse oximetry provides key information about the
CPAP (discussed later). Your goal is to maintain the SpO2 patient and is an important part of emergency care, includ-
in the normal range (Table 15-3). ing prehospital care. However, it is only one assessment
Recent studies show that oxygen administration is not tool and does not replace other physical assessment or
without risk. Excess oxygen can cause the body to manufac- monitoring tools or skills. Do not depend solely on pulse
ture toxic chemicals called free radicals. (Free radicals were oximetry readings to guide care. Always consider and treat
also discussed in the chapter “Pathophysiology.”) These the whole patient.
toxic chemicals can damage body tissues—especially in
areas that are highly oxygen dependent, such as the brain Pulse CO Oximetry
and heart. Because of this, oxygen should be administered Pulse CO oximeters are devices that detect abnormal
only to patients who are found to be hypoxic by pulse hemoglobins such as carboxyhemoglobin (from carbon
534  Chapter 15

monoxide poisoning) and methemoglobin (as seen in met-

hemoglobinemia). Some devices can also detect total
hemoglobin. Until recently, these devices were found only
in hospital laboratories and required a blood sample.
Recently, noninvasive CO oximeters have been developed
that will detect and measure carboxyhemoglobin in the
same manner that standard pulse oximeters detect and
report oxygen saturation. These devices may prove useful
when screening patients with potential exposures or vague
unexplained symptoms.
Pulse CO oximeters use multiple wavelengths of light
to detect various forms of hemoglobin found in humans
(Figure 15-17). Like a pulse oximeter, they detect hemoglo-
bin with oxygen bound (oxyhemoglobin), and they detect
hemoglobin without oxygen (deoxyhemoglobin). Depend-
ing on the device, they can also detect the following:
FIGURE 15-18  Total hemoglobin by pulse CO oximetry.
• Carboxyhemoglobin. When carbon monoxide (CO), a (© Dr. Bryan E. Bledsoe)
toxic gas, is inhaled, it will displace oxygen from the
iron-containing heme molecules in hemoglobin. There
are four heme binding sites on each hemoglobin mol- forming deoxyhemoglobin, so it can again transport
ecule. CO will displace oxygen molecules that are oxygen. Typically, less than 2 percent of the hemoglo-
already present on the heme, allowing the CO to bind bin in the body is in the form of methemoglobin, which
and form carboxyhemoglobin. As the heme molecules cannot bind or transport oxygen. However, several
are bound with CO, the oxygen-carrying capacity of conditions and drugs can cause abnormal elevations of
the hemoglobin is reduced. Pulse CO oximeters can methemoglobin (methemoglobinemia). Selected pulse
detect increased carboxyhemoglobin. The amount of CO-oximeters can measure methemoglobin and report
carboxyhemoglobin detected is reported as a percent- it as a percentage of total hemoglobin (SpMET).7–8
age of total hemoglobin and abbreviated SpCO.4–6 • Total hemoglobin. Pulse CO oximetry now allows for
• Methemoglobin. Methemoglobin is a form of hemo- noninvasive measurement of total hemoglobin in the
globin in which the iron molecules in the heme units prehospital setting (Figure 15-18). This reading is
are in the ferric (Fe3+) state. Thus, methemoglobin can reported as SpHb. This now allows for the prehospital
neither bind nor transport oxygen. Methemoglobin detection of anemia and blood loss and can serve as a
has a bluish-brown color. Normally, there are enzyme surrogate indicator of the blood’s oxygen-carrying
systems (e.g., methemoglobin reductase) that can content. When coupled with standard pulse oximetry
restore methemoglobin to the ferrous (Fe2+) state, readings (based on the arterial oxygen content formula
discussed earlier), it is possible to noninvasively esti-
mate oxygen content in the blood (SpOC).

Noninvasive monitoring technology is evolving rap-

idly. Many of the parameters discussed here are available
on many of the popular commercial patient monitors used
in EMS (Figure 15-19). Like any other technology, prehos-
pital personnel should not solely rely on monitoring tech-
nology. Instead, they should look at the entire patient
picture and make treatment decisions based on multiple
findings and parameters.

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

• End-tidal gradient. The end-tidal gradient is the dif-

ference between the partial pressure of arterial CO2
(PaCO2) and the end-tidal CO2 (ETCO2). It is calcu-
lated as:

PaCO2 - ETCO2 = End - tidal gradient

This value is normally less than 5 mmHg. However, an

increase in dead space ventilation (ventilation of non-
perfused lung tissue) reflects a ventilation/perfusion
mismatch (V/Q mismatch). This occurs in pulmonary
embolism and similar processes. As dead space venti-
lation increases, the ETCO2 falls, thus widening the
end-tidal gradient.

CO2 is a normal end product of metabolism and is

transported by the venous system to the right side of the
FIGURE 15-19  Multiple noninvasive parameters in a single display heart and on to the lungs where it diffuses into the alveoli
monitor. and is removed from the body through exhalation. When
(© Dr. Bryan E. Bledsoe) circulation is normal, exhaled CO2 levels change propor-
tionally with ventilation and are a very reliable estimate
of the partial pressure of carbon dioxide in the arterial
into prehospital care, capnometry was used exclusively system (PaCO2). Normal PaCO2 is approximately 40 and
to verify proper endotracheal tube placement in the tra- a normal exhaled CO2 is just 1 to 2 mm less, or 38 mmHg
chea. The detection of adequate levels of exhaled CO2 (Table 15-4).
following intubation confirms the tube is in the trachea When perfusion decreases, as occurs in shock or car-
(or above) and not in the esophagus. More robust tech- diac arrest, exhaled CO2 levels reflect pulmonary blood
nology provides accurate noninvasive measurements of flow and cardiac output, not ventilation. Decreased levels
exhaled CO 2 levels, thus providing medical personnel of exhaled CO2 can be found in shock, cardiac arrest, pul-
with information about the status of systemic metabo- monary embolism, bronchospasm, and with incomplete
lism, circulation, and ventilation. The use of capnometry airway obstruction (such as mucus plugging). Increased
and capnography has become commonplace in the oper- levels of exhaled CO2 are found with hypoventilation,
ating room, in the emergency department, and in the pre- respiratory depression, and hyperthermia (Table 15-5).
hospital setting.9–10 CO2 is detected by using either a colorimetric or an
Various terms have been applied to capnography, and infrared device. It can be reported as a percentage (the
a review of them may help you to understand the material amount of CO2 in a given volume of gas) or as a partial pres-
in this section. These terms include: sure (mmHg).
• Capnometry. Capnometry is the measurement of
COLORIMETRIC DEVICES  The colorimetric device is
expired CO2. It typically provides a numeric display of
a disposable ETCO2 detector that contains pH-sensitive,
the partial pressure of CO2 (in Torr or mmHg) or the
chemically impregnated paper encased within a plastic
percentage of CO2 present.
chamber (Figure 15-20). It is placed in the airway circuit
• Capnography. Capnography is a graphic recording or between the patient and the ventilation device. When the
display of the capnometry reading over time. paper is exposed to CO2, hydrogen ions (H+) are generated
• Capnograph. A capnograph is a device that measures (change in pH), causing a color change in the paper. The
expired CO2 levels. color change is reversible and changes breath to breath.
• Capnogram. A capnogram is the visual representation A color scale on the device estimates the ETCO2 level.
of the expired CO2 waveform.
• End-tidal CO2 (ETCO2). End-tidal CO2 is the measure- Table 15-4  Comparison of PaCO2 and ETCO2
ment of the CO2 concentration at the end of expiration
(maximum CO2). Arterial CO2 (PaCO2) End-Tidal CO2 (ETCO2)
Arterial Blood Gases Capnography
• PETCO2. PETCO2 is the partial pressure of end-tidal
CO2 in a mixed gas solution. Partial Pressure 35–45 mmHg 30–43 mmHg
(mmHg)
• PaCO2. The PaCO2 represents the partial pressure of
Percentage (%) 4.6–5.9% 4.0–5.6%
CO2 in the arterial blood.
536  Chapter 15

Table 15-5  Basic Rules of Capnography

Symptom Possible Cause
Sudden drop of • Esophageal intubation
ETCO2 to zero • Ventilator disconnection or defect in ventilator
• Defect in CO2 analyzer

Sudden decrease • Leak in ventilator system; obstruction

of ETCO2 (not to • Partial disconnect in ventilator circuit
zero) • Partial airway obstruction (secretions)

Exponential • Pulmonary embolism

decrease • Cardiac arrest
of ETCO2 • Hypotension (sudden)
• Severe hyperventilation

Change in CO2 • Calibration error

baseline • Water droplet in analyzer FIGURE 15-21  Handheld capnography unit.
• Mechanical failure (ventilator)

Sudden increase • Accessing an area of lung previously obstructed

in ETCO2 • Release of tourniquet breath (Figure 15-21). A heated element in the sensor
• Sudden increase in blood pressure
generates infrared radiation. The CO2 molecules absorb
Gradual lowering • Hypovolemia infrared light at a very specific wavelength and can thus be
of ETCO2 • Decreasing cardiac output
• Decreasing body temperature; hypothermia; measured. Electronic exhaled CO2 detectors may be either
drop in metabolism qualitative (i.e., they simply detect the presence of CO2) or
Gradual increase • Rising body temperature quantitative (i.e., they determine how much CO2 is pres-
in ETCO2 • Hypoventilation ent). Quantitative devices are now routinely used in pre-
• CO2 absorption
• Partial airway obstruction (foreign body); hospital care. Exhaled ETCO2 readings can be monitored
reactive airway disease both in patients who are not intubated and in those who
are intubated (Figures 15-22 and 15-23). Most modern cap-
nometers can both display a number and provide a digital
waveform (capnogram) that reflects the entire respiratory
cycle (Figure 15-24).
There are two major types of capnography—main-
stream and sidestream. Each has its advantages and disad-
vantages. With mainstream capnography, the infrared light
is shone through the gas within the patient circuit. With
sidestream capnography, a sample of the gas is aspirated
from the main gas flow circuit, using a separate sample
line. This sample line is attached to a sensor unit that is

FIGURE 15-20  Colorimetric end-tidal CO2 detector.

(© Edward T. Dickinson, MD)

Colorimetric devices cannot detect hyper- or hypocarbia

(increased or decreased CO2 levels). If gastric contents or
acidic drugs (e.g., endotracheal epinephrine) contact the
paper in the device, subsequent readings may be unreliable.
FIGURE 15-22  End-tidal carbon dioxide monitoring in a
INFRARED DEVICES  Electronic exhaled CO2 detectors ­non-intubated patient.
use an infrared technique to detect CO2 in the exhaled (© Edward T. Dickinson, MD)
 Airway Management and Ventilation 537

Table 15-6  Comparison of Mainstream and Sidestream

Capnography

Mainstream Capnography Sidestream Capnography

CO2 sensor located between CO2 aspirated from a sampling tube
ET tube and breathing circuit and analyzed in an analyzer/sensor
away from the patient

Advantages

• Provides real-time • Lightweight

information • Less expensive
• More accurate • Can be used in non-intubated
• No sampling tube patients (including CPAP)
• Not affected by water vapor • Easy to connect
pressure changes • Disposable tubing
• Can be used with simultaneous
oxygen administration
• Calibration automatic

Disadvantages

• Bulkiness/weight of sensor • Small sampling tube easily

• Can be used only in obstructed (e.g., by water vapor)
intubated patients • Slightly less accurate
• Expensive probe • Delay of several seconds analyzing
• Requires calibration sample
FIGURE 15-23  End-tidal carbon dioxide monitoring in an • Water vapor may affect ETCO2
intubated patient. reading
• Pressure drop along sampling tube
(© Edward T. Dickinson, MD)
may affect ETCO2 reading

• Phase III. Phase III (CD in Figure 15-25) is the respiratory

plateau. It reflects the airflow through uniformly venti-
lated alveoli with a nearly constant CO2 level. The high-
est level of the plateau (point D in Figure 15-25) is called
the ETCO2 and is recorded as such by the capnometer.
• Phase IV. Phase IV (DE in Figure 15-25) is the inspira-
tory phase. It is a sudden downstroke and ultimately
returns to the baseline during inspiration. The respira-
tory pause restarts the cycle (EA in Figure 15-25).



FIGURE 15-24  Some CO2 detectors can display both a waveform  +++
&
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and a number. %


typically housed in the patient monitor. The differences are 

illustrated in Table 15-6. 
++
+8

CAPNOGRAM  The capnogram reflects exhaled CO2
concentrations over time. It is typically divided into four 

phases (Figure 15-25). 


• Phase I. Phase I (AB in Figure 15-25) is the respiratory # + $ ' #
baseline. It is flat when no CO2 is present and corre- 

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

CLINICAL APPLICATIONS  At its most basic, qualita- 

tive capnography may be used to assess correct initial and

periodic endotracheal tube placement. Continuous quan-
titative capnography may be used in intubated patients to 
confirm initial tube placement and to constantly monitor

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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). 

• Rebreathing. Rebreathing of gas can result in failure of 

the capnogram to reach the baseline. This can be due
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to hyperventilation or to problems in the breathing cir-
cuit (Figure 15-28). 

• Curare cleft. Appears when neuromuscular blockers 

begin to subside. The depth of the cleft is inversely pro-

portional to the degree of drug activity (Figure 15-29).

• Esophageal intubation. The absence of a waveform, or
the presence of a small disorganized waveform, is 
indicative of esophageal intubation (Figure 15-30).




+PURKTCVKQP 'ZRKTCVKQP
 6KOG

FIGURE 15-28  An elevation in the baseline indicates rebreathing of
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 CO2 and is generally seen with hyperventilation.



 • Endotracheal tube or circuit leak. Waveform varia-


tions are seen when there is a leak in the endotracheal
tube cuff or if the airway is too small for the patient

(Figure 15-31).

• Ventilation/perfusion (V/Q) mismatch. With a ventila-
 tion/perfusion mismatch, as occurs in pulmonary
 embolism and similar conditions, the increase in dead
+PURKTCVKQP 'ZRKTCVKQP space ventilation causes a decrease in ETCO2 levels
6KOG throughout the respiratory cycle (Figure 15-32).
FIGURE 15-26  Normal capnogram. Capnography provides immedi- • Apnea. A fall of the waveform to the baseline indicates
ate information about the patient’s ventilatory status. apnea (Figure 15-33).
 Airway Management and Ventilation 539

 

 




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+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. 

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+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 

FIGURE 15-30  Capnogram showing absent waveform consistent 

with esophageal intubation.

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• 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). 

Exhaled CO2 detection is also useful in CPR. During 

cardiac arrest, CO2 levels fall abruptly following the onset

of cardiac arrest. They begin to rise with the onset of effec-
tive CPR and return to near-normal levels with a return of 
6KOG
spontaneous circulation. During effective CPR, exhaled
CO2 levels have been found to correlate well with cardiac FIGURE 15-33  Apnea.
 540  Chapter 15

 in EMS and the documentation provided by this technol-

ogy can provide irrefutable evidence of proper endotra-
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cheal tube placement.


 Peak Expiratory Flow Testing

Peak expiratory flow testing uses a disposable plastic

chamber into which the patient exhales forcefully after
 maximal inhalation. It can be used as a crude measure of
respiratory efficacy. Improving measurements can indicate

6KOG good response to treatment of acute respiratory illness.

FIGURE 15-34  Progressive reduction in ETCO2 levels consistent

with hyperventilation.
PART 2: Basic



Airway Management
 and Ventilation
Basic airway management and ventilation includes most
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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.

Venturi Mask Small-Volume Nebulizer

The Venturi mask is a high-flow face mask that uses a Nebulizer chambers containing 3 to 5 mL of fluid are
Venturi system to deliver relatively precise oxygen con- attached to a face mask that allows for delivery of medica-
centrations, regardless of the patient’s rate and depth of tions in aerosol form (nebulization) that is more likely to
breathing. As oxygen passes into the mask through a jet pass through the upper airway to the lower airways. Pres-
orifice in the base of the mask, it entrains room air. The surized oxygen or air enters the chamber to create a mist,
device then delivers the resulting mixture to the patient. which the patient then inspires. Oxygen is the usual carrier
Some Venturi masks have dial selectors to control the but air is occasionally used in COPD patients, and a
amount of ambient air taken in; others have interchange- helium–oxygen mixture may be used in patients with
able caps. Either type can deliver concentrations of 24 per- upper airway obstruction.
cent, 28 percent, 35 percent, or 40 percent oxygen. The liter
flow depends on the oxygen concentration desired. The Oxygen Humidifier
Venturi mask is particularly useful for COPD patients, You can provide humidified oxygen to the patient by attach-
who benefit from careful ing a sterile water reservoir to the oxygen outlet. Humidified
CONTENT REVIEW control of inspired oxy- oxygen is often given to pediatric patients with upper air-
➤➤ Continually reassess the gen concentration. These way problems such as croup, although there is no evidence
patient who requires oxy- masks are rarely placed that it improves outcomes. Humidification is also useful for
gen therapy to be sure the by EMS providers, but patients receiving long-term oxygen therapy to prevent the
method of delivery and
you will encounter them complications of drying out the mucous membranes.
flow rate are adequate.
during transfers. Humidification is rarely necessary in the EMS setting.
544  Chapter 15

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.

Manual Airway Maneuvers Jaw-Thrust Maneuver

Manual maneuvers are the simplest airway management without Head Extension
techniques. They require no specialized equipment, are
safe, and are noninvasive. They are highly effective but are A jaw-thrust is acceptable for any unresponsive patient
often neglected in prehospital care. and recommended for any patient at risk for cervical
In the patient who is unconscious or has a decreased spine injury who cannot protect his airway. It may be nec-
level of consciousness, posterior displacement of the essary to remove the cervical collar to advance the jaw
tongue is often the cause of airway obstruction. The head- sufficiently to open the airway; however, the provider
tilt/chin-lift and the jaw-thrust are safe and dependable performing the jaw-thrust is usually able to maintain
maneuvers for relieving this obstruction. You should per- manual in-line immobilization simultaneously. To per-
form one of these techniques on all unconscious patients, form the jaw-thrust:
but do not perform them on responsive patients. • Lift the jaw using fingers behind the mandibular
If you suspect cervical spine injury, perform the angles; do not tilt the head (Figure 15-41). It usually
modified jaw-thrust with in-line stabilization of the cer- helps to prop the thumbs on the cheekbones to pro-
vical spine. Always follow Standard Precautions and use vide some counterforce.
a mask and face shield during airway management
Although they are simple and effective, none of these
maneuvers.
manual airway maneuvers protects the airway from aspi-
ration. Additionally, the jaw-thrust is difficult to maintain
Head-Tilt/Chin-Lift for an extended time. Placing an oral and/or nasopharyn-
In the absence of cervical spine trauma, the head-tilt/chin- geal airway, if tolerated and not contraindicated, may
lift is the best technique for opening the airway in an unre- open the airway sufficiently that a strong jaw-thrust is no
sponsive patient who is not protecting his own airway longer required until the airway can be more definitively
(Figure 15-40). This maneuver is potentially hazardous to managed.

FIGURE 15-40  Head-tilt/chin-lift maneuver. FIGURE 15-41  Modified jaw-thrust without head extension in trauma.
 Airway Management and Ventilation 545

CONTENT REVIEW Basic Airway

➤➤ Always attempt any
appropriate manual Adjuncts
­maneuvers before placing In the absence of trauma,
a mechanical airway.
secretions, foreign bodies,
and edema, basic manual
airway maneuvers should succeed in clearing the tongue
from the air passages. However, the tongue often falls
back, subsequently, to block the airway again. Two avail-
able airway adjuncts, the nasopharyngeal airway and the
oropharyngeal airway, prevent this. These adjuncts cannot
replace good head positioning, but they do help to lift the
base of the tongue forward and away from the posterior
oropharynx, establishing and maintaining a patent airway.
FIGURE 15-42  Nasopharyngeal airway.

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.

Disadvantages of the Nasopharyngeal Airway

• It is smaller than the oropharyngeal airway.

• It does not isolate the trachea.
• It is difficult to suction through.
• It may cause severe nosebleeds if inserted too forcefully.
• It may cause pressure necrosis of the nasal mucosa. FIGURE 15-43  Nasopharyngeal airway, inserted.
546  Chapter 15

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

• It is easy to place using proper technique.

• Air can pass around and through the device.
• It helps prevent obstruction by the teeth and lips.
• It helps manage profoundly unconscious patients who
are breathing spontaneously or need mechanical ven-
tilation.
• It makes suction of the pharynx easier, as a large suc-
tion catheter can pass on either side of the device.
• It serves as an effective bite block in case of seizures or
to protect the endotracheal tube.
FIGURE 15-44A  Insert the oropharyngeal airway with the tip facing
Disadvantages of the Oropharyngeal Airway the palate.

• It does not isolate the trachea or prevent aspiration.

• It cannot be inserted when the teeth are clenched.
• It may obstruct the airway if not inserted properly.
• It is easily dislodged.
• Return of the gag reflex may produce vomiting.

Do not use an oropharyngeal airway in conscious or

semiconscious patients who have a gag reflex, because it
may cause vomiting (by stimulating the posterior tongue
gag reflexes) or laryngospasm. As is often said, “If a patient
tolerates an oral airway, then he needs an oral airway.” The
converse is also true: If a patient resists placement of the FIGURE 15-44B  Rotate the airway 180° into position.
 Airway Management and Ventilation 547

decreases in mental status, creating

a vicious cycle. Hypoxemia may
also result if the decrease in breath-
ing is significant or oxygen demand
is substantial. Acidosis and/or
hypoxemia may eventually lead to
respiratory or cardiac arrest.
Effective ventilatory support
requires a tidal volume of 6 to 8
mL/kg of ideal body weight at a
rate of 12 breaths per minute. Note
that these volumes are significantly
less than the 10 to 15 mL/kg that
was formerly recommended.
When providing ventilatory
support, you must generate
enough force to overcome the
elastic resistance of the lungs and
Figure 15-45  Measure the oropharyngeal airway externally to ensure proper sizing. chest wall, as well as the frictional
resistance in the respiratory pas-
sageways, without overinflating
6. Verify appropriate position of the airway. Clear breath the lungs. This is similar to blowing up a balloon; you
sounds and chest rise indicate correct placement. must overcome the balloon’s resistance in order to
7. Apply supplemental oxygen and/or positive pressure inflate it.
ventilation if indicated. Keep in mind that air will travel the path of least
resistance. If you do not maintain a tight seal between the
An alternative insertion method useful in both pediat- ventilation mask and your patient’s face, air will flow out
ric and adult patients is to press the tongue upward and for- of the gaps rather than through the respiratory passage-
ward with a tongue blade. Then, the airway can be advanced ways. If you do not keep the airway maximally open
until the flange is seated at the teeth. This is the preferred with proper manual positioning and use of airway
method of airway insertion in infants and children. adjuncts to facilitate an open passage into the trachea, the
Oral and/or nasal airways should be considered in all airway pressure generated with PPV can open the esoph-
obtunded older pediatric and adult patients and are man- agus and allow air to flow into the stomach. Therefore,
datory whenever the patient has signs of airway obstruc- effective artificial ventilation requires a patent airway, an
tion (“noisy breathing is obstructed breathing”) or BVM effective seal between the mask and the patient’s face,
ventilation is difficult. These airways may also be used in and delivery of appropriate ventilatory volumes directed
combination, such as two nasal airways, one nasal and into the lungs and not into the stomach. Exercise care
one oral, or even two nasal and one oral airway in extreme when you attempt to generate enough pressure to venti-
circumstances. late the lungs. Too much pressure may lead to gastric dis-
tention and regurgitation. Also, be certain that you allow

Ventilation the patient to exhale between delivered breaths.

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

them behind the vocal cords (retroglottic airways); others

sit above the vocal cords (supraglottic airways).17
An EGA may be used as a primary or secondary device
depending on the provider’s scope of practice and proto-
cols and the clinical scenario. Use as a primary device
#1
means immediate use of the EGA without first trying to
achieve endotracheal intubation; secondary use means use
of the EGA only after an attempt at endotracheal intuba- #2
tion has failed. Accumulating evidence and experience
suggest that EGAs are faster and easier to insert than endo-
tracheal tubes and may be associated with fewer complica-
tions. It is very likely that these devices will play a growing
role in prehospital airway management.

Retroglottic Airway Devices:

Dual Lumen
Dual-lumen devices are designed to be inserted blindly
into the esophagus but may still be used in the event of
fortuitous tracheal placement. Clinical assessment is
required to be sure that the correct port is used for ventila-
tion. EGAs in this category include the Esophageal Tra-
cheal Combitube™ (ETC) and the Pharyngeal Tracheal FIGURE 15-49  The Esophageal Tracheal Combitube (ETC) is a
­dual-lumen airway with a ventilation port for each lumen. The
Lumen Airway™ (PTL).
­longer, blue port (#1) is the proximal port; the shorter, clear port
(#2) is the distal port, which opens at the distal end of the tube. The
Esophageal Tracheal Combitube (ETC™) ETC has two inflatable cuffs—a 100-mL cuff just proximal to the
The Esophageal Tracheal Combitube (ETC™), also called distal port and a 15-mL cuff just distal to the proximal port. First,
simply the Combitube™, is a dual-lumen retroglottic airway ventilate through the longer, blue port (#1). Ventilation will be
­successful if the tube has been placed (as is most common) in the
available in two sizes for patients over 4 feet tall. The ETC
esophagus.
is inserted blindly through the mouth into the posterior
oropharynx and then gently advanced—although directed
esophageal placement using a laryngoscope is often
employed in the operating room and may be employed by
EMS providers if it is within their scope of practice. The
tube may enter either the trachea or the esophagus (Fig-
ures 15-49 and 15-50), but esophageal placement is most
common. Because placement is nearly always esophageal,
#1
the port that ventilates in this position is longer, numbered
1, and is blue.18–19 #2

Advantages of the ETC

• Insertion is rapid and highly successful.

• It is time tested.
• Insertion does not require visualization.
• It will provide ventilation with either esophageal or
tracheal placement.
• The large pharyngeal balloon may tamponade oral
bleeding.
• It will generate high airway pressures for ventilation
when necessary.
FIGURE 15-50  If ventilation through tube #1 is not successful, then
• It offers reasonable aspiration protection in either the ventilate through the shorter clear tube (#2). Ventilation will be
esophageal or tracheal position. ­successful if the tube has been placed in the trachea.
552  Chapter 15

• 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

Pharyngeo-Tracheal • It does not require direct visualization of the larynx

Lumen Airway (PtL™) and, thus, does not require the use of a laryngoscope
The Pharyngeo-Tracheal Lumen Airway (PtL™) is a two- or additional specialized equipment.
tube system (Figure 15-52). The first tube is short, with a • It can be used in trauma patients, as the neck can
large diameter; its proximal end is green. A large cuff encir- remain in neutral position during insertion and use.
cles the tube’s lower third. When inflated, the cuff seals the • It helps protect the trachea from upper airway bleed-
entire oropharynx. Air introduced at this tube’s proximal ing and secretions.
end will enter the hypopharynx. The second tube is long,
Disadvantages of the PtL
with a small diameter, and clear. It passes through and
extends approximately 10 cm beyond the first tube. This • It does not isolate and completely protect the trachea
second tube may be inserted blindly into either the trachea from aspiration.
or the esophagus. A distal cuff, when inflated, seals off • The oropharyngeal balloon can migrate out of the
whichever anatomical structure the tube has entered. mouth anteriorly, partially dislodging the airway.
When the second tube enters the trachea, you will ventilate
• Intubation around the PtL is extremely difficult, even
the patient through it.
with the oropharyngeal balloon deflated.
Each of the PtL’s tubes has a 15/22-mm connector at
its proximal end, allowing the attachment of a standard • It cannot be used in conscious patients or those with a
ventilatory device. A semirigid plastic stylet in the clear gag reflex.
plastic tube allows redirection of the oropharyngeal cuff • It cannot be used in pediatric patients.
while the other cuff remains inflated. An adjustable cloth • It can only be passed orally.
neck strap holds the tube in place. When the long, clear
tube is in the esophagus, deflating the cuff in the orophar- Inserting the PtL
ynx allows you to move the device to the left side of the To insert the pharyngeo-tracheal lumen airway:
patient’s mouth. This may permit endotracheal intubation
1. Complete basic manual and adjunctive maneuvers and
while continuing esophageal occlusion. However, place-
provide supplemental oxygen and ventilatory support
ment of an endotracheal tube with a PtL already in place is
with a BVM and hyperventilation.
difficult at best.
2. Place the patient supine and kneel at the top of his head.
Advantages of the PtL 3. Prepare and check the equipment.
• It can function in either the tracheal or esophageal 4. Place the patient’s head in the appropriate position.
position. Hyperextend the neck if there is no risk of cervical spine
• It has no face mask to seal. injury. Maintain neutral position with stabilization of
the cervical spine if cervical spine injury is possible.
5. Insert the PtL gently, using the tongue-jaw-lift maneuver.
6. Inflate the distal cuffs on both PtL tubes simultane-
ously with a sustained breath into the inflation valve.
7. Deliver a breath into the green oropharyngeal tube. If
the patient’s chest rises and you auscultate bilateral
breath sounds, the long clear tube is in the esophagus.
Inflate the pharyngeal balloon and continue ventila-
tions via the green tube.
8. If the chest does not rise and you auscultate no breath
sounds, the long clear tube is in the trachea. Remove
the stylet from the clear tube and ventilate the patient
through that tube.
9. Attach the bag-valve device to the 15-mm connector,
secure the tube, and continue ventilatory support with
100 percent oxygen.
10. Multiple placement confirmation techniques are again
essential, as are good assessment skills. Misidentifica-
tion of placement has been reported. Frequently reas-
FIGURE 15-52  Pharyngo-tracheal lumen (PtL) airway. sess the airway and adequacy of ventilation.
554  Chapter 15

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.

• Pharyngeal or esophageal trauma from poor technique

Esophageal Obturator Airway (EOA®) and
• Unrecognized displacement of the long tube from the
trachea into the esophagus
Esophageal Gastric Tube Airway (EGTA®)
These devices were among the first extraglottic airways
• Displacement of the pharyngeal balloon introduced. The Esophageal Obturator Airway (EOA®) is a
hollow, closed-ended tube with air holes at the level of the
Retroglottic Airway hypopharynx for ventilation, a distal cuff intended to block
Devices: Single Lumen air from the esophagus, and a proximal end that fits into a
mask. Ventilation, therefore, requires creation of a tight
King LTTM Airway mask seal rather than relying on a large pharyngeal bal-
The King LTTM Airway is an airway with a large silicone loon. The Esophageal Gastric Tube Airway (EGTA®) adds
cuff that disperses pressure over a large mucosal surface the ability to place a gastric tube through the distal port
area (Figure 15-53). This serves to stabilize the airway at into the stomach for decompression of contents. These
the base of the tongue, thus minimizing the risk of injury to devices are now obsolete, because superior extraglottic air-
the vocal cords and trachea. The King LT airway allows up ways have subsequently been introduced, although they
to 30 cm H2O ventilation pressures. It is supplied in three still may be found in some areas.
sizes: one for adults less than 61 inches (5 feet, 1 inch) in
height, one for adults taller than 61 inches but less than
71 inches (5 feet, 11 inches) in height, and one for adults
Supraglottic Airway Devices
taller than 71 inches. The device can be cleaned, sterilized, A number of supraglottic airway devices have been intro-
and reused. A disposable latex-free version (King LT-D™) duced, including the S.A.L.T. and various LMA devices.
is also available.20–22
The King LT-D is a disposable single-lumen retroglot- Supraglottic Airway
tic airway available in three adult and two pediatric sizes. Laryngopharyngeal Tube (S.A.L.T.®)
(The “D” in LT-D means “disposable.”) The adult sizes are The Supraglottic Airway Laryngopharyngeal Tube TM
also available in a King LTS-D model that has a channel to (S.A.L.T.®) is an extraglottic airway. It contains a central
facilitate gastric decompression. The King has a large pha- tube with a fenestrated (with an opening) end that overlies
ryngeal balloon and smaller esophageal balloon like other the larynx in the laryngopharynx (Figure 15-54). It can
serve two purposes. First, it can be used as a simple
mechanical airway adjunct—much like an oropharyngeal
airway. It has a collar on the proximal end and can be used
with a BVM device. Alternatively, the S.A.L.T. can be used
as a blind endotracheal tube introducer when laryngos-
copy is difficult or impossible.23

FIGURE 15-53  King LT Airway.

(© Edward T. Dickinson, MD) FIGURE 15-54  S.A.L.T.® Airway.
 Airway Management and Ventilation 555

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.

Laryngeal Mask Airway (LMATM)

The laryngeal mask airway (LMATM) was the first laryn-
geal airway (Figure 15-55). As this device is now off patent,
there are multiple similar devices on the market. The LMA
is commonly used in the operating room (OR) setting for
selected cases. EMS use was becoming widespread when
this was the only supraglottic airway available. Even
though the original LMA is easily inserted, EMS use of it is FIGURE 15-56  LMA Supreme airway.
now limited because the LMA does not offer the features
available in other, more recently introduced extraglottic
devices.24–26 (Figure 15-56). The primary disadvantages of the Supreme
are that the decompression channel will not accommodate
LMA SupremeTM a gastric tube larger than 14 Fr, and blind intubation
The LMA Supreme™ is an updated version of the LMA. through the device is not possible.
The LMA Supreme has several features that are very
appealing for EMS use. The Supreme has a rigid design
LMA Fastrach
that makes for easy insertion without the need to place fin-
The LMA Fastrach™ was the first intubating laryngeal air-
gers in the mouth. The Supreme offers a very good seal
way designed to facilitate blind endotracheal intubation
against aspiration and facilitates gastric decompression
with a special tube or a regular tube reverse loaded (i.e.,
through a separate channel. The Supreme can also generate
with the curvature of the tube opposite to the curve of the
high airway pressures when necessary to ventilate an
device) (Figure 15-57). The Fastrach is a rigid, anatomically
obese patient or a patient with lung disease. Additionally,
curved airway tube that is wide enough to accept an 8.0-mm
the Supreme has a built-in bite block and a fixation tab that
cuffed endotracheal tube (ETT) and is short enough to
makes it easy to secure the device with a single strip of tape
ensure passage of the ETT cuff beyond the vocal cords. It
has a rigid handle to facilitate insertion and adjustment of
the device’s position to enhance oxygenation and align-
ment with the glottis. There is an epiglottic elevating bar in
the mask aperture that elevates the epiglottis as the ETT is
passed through and a ramp that directs the tube centrally
Soft palate and anteriorly to reduce the risk of arytenoid trauma or
Uvula
Posterior third esophageal placement. The Fastrach has been shown to
of tongue

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

FIGURE 15-59  Ambu® laryngeal mask.

FIGURE 15-58  CookGas air-Q airway

(© Dr. Bryan E. Bledsoe)

have an excellent seal to protect against aspiration and Endotracheal Intubation

generate high airway pressures when necessary. Extensive Endotracheal intubation involves inserting an endotra-
studies in the operating suite setting have demonstrated cheal tube into the trachea, usually with direct visualiza-
extremely high success rates with minimal training, even tion of the vocal cords—typically via direct laryngoscopy.
in obese patients and those with spinal precautions. Disad- Endotracheal intubation provides optimal aspiration
vantages include the inability to decompress the stomach, protection and ventilation, but it comes at a high cost.
absence of sizes for patients less than 30 kg ideal body These costs include prolonged scene times, potential air-
weight, and somewhat temperamental positioning for sus- way trauma, and potential hypoxemia and aspiration.
tained bag-valve-device ventilation. Furthermore, with this method you are bypassing impor-
tant physiologic functions of the upper airway: warming,
CookGas air-Q® filtering, and humidifying the air before it enters the
The air-Q® is another intubating laryngeal airway (Fig- lower airway. As already noted, many extraglottic air-
ure 15-58). In contrast to the Fastrach, the air-Q is avail- ways now provide excellent ventilation and significant
able in pediatric sizes and looks much more like a aspiration protection with the benefit of much faster, eas-
traditional laryngeal airway. This shape allows intuba- ier, and less traumatic insertion. Because the majority of
tion to be performed with an endotracheal tube intro- literature has failed to find a survival benefit to prehospi-
ducer as well as with direct tube placement. The major tal endotracheal intubation, and the procedure is associ-
disadvantages of the air-Q include the inability to decom- ated with serious potential complications, as discussed
press the stomach and the absence of literature validat- next, many EMS systems are moving entirely to extraglot-
ing the seal and success rates with blind intubation. tic airways or employing them earlier in the event of dif-
ficult intubation.27–30
Ambu® Laryngeal Mask If you are performing endotracheal intubation, it is
The Ambu® laryngeal mask is a supraglottic, single-use, imperative that you select patients carefully (i.e., those
disposable airway (Figure 15-59). It features a special curve most likely to benefit), perform the procedure correctly,
that replicates the natural human airway anatomy. This practice regularly, and move early to a backup plan in the
curve is molded directly into the tube so that insertion is event of difficulty. Successfully accomplishing endotra-
easy, without abrading the upper airway. The curve cheal intubation requires extensive training. Furthermore,
ensures that the patient’s head remains in a neutral posi- you must maintain ongoing proficiency to ensure patient
tion when the mask is in use. safety. To ensure the quality of your judgment and skill,
you must continually review field intubations and the cri-
teria for performing them with your peers, supervisors,
Legal Considerations and medical director. Monitoring success rates for particu-
lar skills is not hard with an appropriate quality assurance
Have a Backup.  Every EMS system should have at least
program. Evaluating your ability to judge which patients
one backup mechanical airway device in the event endotra-
you should intubate is considerably more difficult. Often it
cheal intubation fails. You must be familiar and proficient
with any backup airway device used in your system. is better for the patient if you try other therapies before
deciding to intubate.31–33
 Airway Management and Ventilation 557

Oral Endotracheal Intubation

Indications—Non–Medication-
Assisted
Oral endotracheal intubation (OETI) is generally restricted
to patients in cardiac or respiratory arrest or to patients in
extreme respiratory failure, which will allow such an inva-
sive procedure to be performed. Intubation is particularly
helpful in patients with anticipated airway swelling that
may potentially go on to occlude the airway, such as ana-
phylaxis and airway burns.

Advantages of Endotracheal Intubation

• 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).

• It is associated with many potential complications

Press
including aspiration, hypoxemia, airway trauma, Align indentation with bar, to lock
increased intracranial pressure, and others. press-forward
to lock
• It has not been shown to improve survival.

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.

tongue: the hyoepiglottic ligament. This will raise the epi-

glottis so that you can see the glottic opening.
The straight blades are designed to fit under the epi-
glottis and manually lift it out of the way (Figure 15-65).
The straight blade has no flange for sweeping the tongue
FIGURE 15-62  Activating the laryngoscope light source. and is best used by placing and maintaining it in the right
side of the mouth, between the tongue and teeth (hence
To prepare for intubation, attach the indentation on sometimes called “paraglossal” or “retromolar”), and
the proximal end of the laryngoscope’s blade to the bar of directing the distal tip toward the midline. The straight
the handle. It will click into place when properly seated. To blade may either be inserted progressively, as with a
determine whether the laryngoscope is functional, raise curved blade, or with a “hub technique,” in which the
the blade to a right angle with the handle until it clicks into entire blade is gently inserted into the esophagus all the
place (Figure 15-62). The light should turn on and be bright way to the hub and then withdrawn slowly until the epi-
and steady. A yellow, flickering light will not sufficiently glottis pops into view. Because the blade and handle are on
illuminate the anatomical structures. If the light fails to go the right side of the mouth, there is limited working room,
on, the problem may be either dead batteries or a loose so an endotracheal tube introducer (described later) is
bulb. Every airway kit should include spare parts. Infre- often helpful to facilitate tube placement.
quently, the contact points or the wire that runs through Several newer laryngoscope blades have been devel-
the blade to the bulb will fail. oped to aid in adequately visualizing the anterior airway,
Like the handle, the blade may be reusable or dispos- such as the ViewMax®, GrandviewTM, and articulating tip
able. Blades may be divided into two types: curved and blades (Figures 15-66 and 15-67).
straight. The major variety of curved blades are called The choice of straight or curved blade is often a matter
Macintosh; there are several varieties of straight blades of experience and provider preference. In most patients,
including, but not limited to, the Miller, Philips, and Wis- either will be adequate. Many providers find a curved
consin. Each has various advantages and proponents. blade easier to use, although this is often because straight-
Laryngoscope blades range in size from 00 for premature blade training has been limited. The straight-blade tech-
infants to 4 for large adults (Figure 15-63). nique is worth mastering, however, as a straight blade
The curved blade has a large flange for sweeping the
tongue from the right side of the mouth to the left side and
is generally inserted slowly, looking progressively for the
base of the tongue and epiglottis. The curved blade is
designed to fit into the vallecula (Figure 15-64) and trigger
a ligament that connects the epiglottis to the base of the

FIGURE 15-66  ViewMax® laryngoscope blade.

FIGURE 15-63  Laryngoscope blades in various sizes. (© Viewmax™, Rüsch Inc. a division of Teleflex Medical)
 Airway Management and Ventilation 559

FIGURE 15-67  Grandview laryngoscope blade.

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

FIGURE 15-72  Gum elastic bougie.

(© Dr. Bryan E. Bledsoe)

FIGURE 15-70  ETT, stylet, and syringe, unassembled.

(© Dr. Bryan E. Bledsoe) intubations when only the epiglottis may be visualized—that
is, “semi-blind” intubations or Cormack and LeHane Class 3
views (discussed later in this chapter). Tactile feedback is
Stylet
used to determine the correct intratracheal positioning; once
The malleable stylet is a plastic-covered metal wire that may
that positioning is achieved, an endotracheal tube can be
be placed inside the ETT, stopping just short of the distal end,
passed over the introducer into the trachea. This is discussed
to allow the tube to be stiffened and maintained in the opti-
further under “Objective Techniques” later in this chapter.
mal shape for intubation (Figure 15-70). Research has now
shown that the optimal shape in most cases is “straight-to-
10-mL Syringe
cuff” with the distal tip angulated less than 35 degrees (Fig-
The syringe allows you to inflate the distal cuff to avoid air
ure 15-71). Anesthesiologists and anesthetists often avoid
leaks around the tube. Although a 10-mL syringe is com-
using stylets, as they may increase the chance of airway
monly used, this much air is rarely, if ever, necessary and
trauma. Stylets are frequently used in EMS and emergency
may cause tracheal ischemia. Use a manometer to gauge
medicine to enhance control of the ETT and potentially
the correct volume, or listen for air leakage with ventila-
improve intubation success, particularly in patients with
tion. Assessment of the pilot balloon has been shown to be
challenging anatomy, but you need to use the stylet gently to
inadequate for determining safe cuff volumes.
minimize the possibility of airway trauma. Alternatively, you
may attempt intubation without a stylet and have a tracheal Tube-Holding Devices
tube introducer at the ready in case you encounter difficulty. The reasons for securing the ETT are twofold. First, mov-
ing the patient about during resuscitation or transportation
Endotracheal Tube Introducer can easily dislodge the tube and cause cardiovascular stim-
The endotracheal tube introducer, commonly called a gum-
ulation, an elevation in intracranial pressure, or injury to
elastic bougie, is a 60- or 70-cm straight, semi-rigid, stylet-like
the tracheal mucosa. Second, the person providing ventila-
device with a distal bent tip that is covered with a protective
tory support may inadvertently push down on the ETT,
resin (Figure 15-72). It is used to facilitate endotracheal
forcing it into the right or left mainstem bronchus. The tube
may be secured with tape, cloth, or a commercial device
(Figure 15-73). If not using a commercial device that has an
integral bite block, an oral airway should be inserted to pre-
vent the patient from biting down on the tube and obstructing
ventilation. Note that the airway need not be correctly sized
nor inserted in a rotary manner when used in this manner.

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:

1. Advance the proximal end of the cuff no more than 1 to

2 cm past the vocal cords.
2. Once the tube is positioned, hold it in place with one
hand to prevent it from being pushed any farther.
3. Inflate the cuff and firmly secure the tube in place with
tape or a commercial tube-holding device.
4. Note the number marking on the side of the ETT where
it emerges from the patient’s mouth at the teeth, gums,
or lips. This will allow you to quickly recognize any
changes in tube placement. Approximate ETT depth
FIGURE 15-75  To improve oxygenation during apneic intubation, for the average adult is 21 cm at the teeth for women
the nasal cannula can be placed under the BVM mask. and 23 cm at the teeth for men, although this will vary.
564  Chapter 15

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.”

Orotracheal Intubation Technique

Two paths for intubation are the orotracheal path (through
the mouth) and the nasotracheal path (through the nose).
The most widely used path for endotracheal intubation is
the orotracheal route (through the mouth), because it
allows direct visualization of the vocal cords and a clear
view of the ETT’s passage through them. Nasotracheal
intubation will be discussed later in the chapter.
To perform orotracheal intubation in the absence of FIGURE 15-76A  The curved blade is placed into the vallecula and
suspected trauma (Procedure 15–1): indirectly lifts the epiglottis.

1. Use Standard Precautions.

2. Place the patient supine and properly position the
patient’s head and neck. To visualize the larynx, you
must align the three axes of the mouth, the pharynx,
and the trachea. To do this, place the patient’s head in
a “sniffing position” by elevating the head and flexing
the neck forward and the head backward. The ear and
sternal notch should be on the same horizontal level.
(Review Figure 15-38.) In obese patients it is necessary
to place padding under the upper back, shoulders, and
head to achieve the same position. This is called the
“ramped position.” (Review Figure 15-39.)
3. Perform BVM ventilation with 100 percent oxygen
using the “rule of threes,” as mentioned earlier in
the chapter under the discussion of BVM ventilation.
Avoid aggressive hyperventilation, as this is likely to
fill the stomach with air and predispose to aspiration.
4. Prepare your intubation equipment as already discussed.
FIGURE 15-76B  The straight blade is placed under the epiglottis and
5. Turn on the suction and attach an appropriate tip.
directly lifts the epiglottis upward to expose the vocal cords and glot-
6. Remove any dentures or partial dental plates. tic opening.
 Airway Management and Ventilation 565

Procedure 15–1  Endotracheal Intubation

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.

15-1G  Secure the tube. 15-1H  Reconfirm ETT placement.

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

Tongue Verification of Proper Tube Placement

It is absolutely imperative that endotracheal placement of
Glosso- the tube be objectively confirmed immediately after place-
epiglottic
ligament ment and continuously throughout care, particularly if the
patient is moved or deteriorates. You should employ a
number of methods in the field to confirm correct ETT
placement, but do not become overly reliant on technol-
ogy. The patient’s clinical condition should be the decid-
Vallecula ing factor in your patient management decisions. There
have been countless EMS airway disasters related to
Epiglottis unrecognized esophageal intubation. The common theme
in these situations is excessive confidence and inappropri-
ate reliance on subjective measures.

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

• Auscultation. After intubation, breath sounds should

be checked bilaterally and compared to pre-intubation
breath sounds, unless ambient noise (e.g., in an air-
craft) makes this impossible. Sounds should be present
bilaterally if they were present bilaterally before intu-
bation. Newly diminished sounds on the left with
strong breath sounds on the right strongly suggest
right mainstem intubation. Absence of sounds over the
epigastrium should be confirmed. (Epigastric sounds
suggest esophageal placement.) It is important to rec-
ognize that breath sounds have proved unreliable
many times. This is particularly common in children
(sounds are easily transmitted throughout the pediat-
ric thorax), obese patients, and those with lung pathol- FIGURE 15-78  Bulb-type and syringe-type esophageal detector
ogy. Like the other subjective means of tube devices.
confirmation, breath sounds should be neither relied
on entirely nor ignored.

in the esophagus, the soft distensible tissues occlude

Objective Techniques the end of the tube when suction is applied, so air
Objective methods of tube confirmation include capnogra-
return does not occur or occurs very slowly. These
phy, esophageal detector device (EDD), endotracheal tube
devices are inexpensive and are almost as accurate as
introducer, pulse oximetry, chest rise and fall, and presence
capnography for detecting esophageal placements. In
or absence of gastric distention. Remember that objective
settings where most intubations are performed for
methods such as these must be used, in addition to subjec-
cardiac arrest—that is, most EMS systems without
tive observations, to confirm proper tube placement.
rapid sequence intubation (RSI) capability—EDDs
• Capnography. Detection of end-tidal CO2 (capnogra- may be preferred to capnography, as there is little
phy) is the gold standard for tube confirmation—if the point in measuring exhaled CO2 in a cardiac arrest
patient is producing enough CO2 to detect. As detailed patient. These devices are FDA approved down to
previously, there are two types of end-tidal CO2 detec- 20-kg patients and have been well studied down to 10
tion: qualitative (indicating only whether CO2 is pres- kg. It is important, however, to use the “off-deflate”
ent or absent) and quantitative (providing a measure, method in children—that is, squeeze the air out of the
usually with a waveform for analysis, of how much device before it is placed on the tube. Generally
CO2 is present). Either type is acceptable for initial speaking, capnography (ETCO 2 ) monitoring has
tube verification. The quantitative detectors are better replaced EDD use for tube placement verification.
for ongoing monitoring, especially during air medical • Endotracheal tube introducer. Though principally
transport, where clinical means are limited. There are used to facilitate difficult intubations, an endotracheal
virtually no false positive readings with these detec- tube introducer (bougie) may also be used to confirm
tors. This means that if the detector says that CO2 is tube placement. When a well-lubricated introducer is
present, then you are not in the esophagus, but you passed through an endotracheal tube that is correctly
may be above the trachea in the hypopharynx. On the placed in the trachea, you should be able to feel it
other hand, false negatives may occur in the setting of “hold up” (meet resistance) in the smaller airways
cardiac arrest. During cardiac arrest, CO2 production within approximately 40 cm of the teeth or about 50
and transfer eventually cease. Therefore, you may cm from the tube end. (It has been said that you should
have the tube correctly in the trachea without evidence also be able to feel “clicks” as the introducer passes
of CO2 being present. over the tracheal rings. However, clicks may not be
• Esophageal detector device. Use of an esophageal detectable because the tube bypasses most of the large
detector device (EDD) is another means of objective rings of the trachea.) Absence of hold-ups at the depth
tube verification. A syringe device or bulb is placed where you would expect to feel them with a tracheal
on the end of the endotracheal tube to create suction placement is an indication of incorrect esophageal
(Figure 15-78). If the tube is correctly placed in the placement.
trachea, the cartilaginous rings keep the trachea pat- • Pulse oximetry and other findings. As another objec-
ent when suction is applied, so there is rapid air tive finding, an increase in the oxygen saturation will
return into the device. If the tube is incorrectly placed help confirm proper placement of the endotracheal
568  Chapter 15

tube. Similarly, a rise and fall of the chest indicates cor-

rect endotracheal intubation. Worsening gastric dis-
tention may indicate esophageal placement. Any
gastric distention should be investigated. Remember,
though, that it is not uncommon for gastric distention
to develop prior to endotracheal intubation from
mechanical ventilation. Even in experienced hands, it
is very difficult to avoid gastric distention with
mechanical ventilation until an endotracheal tube is
placed.

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

Ideally, you will be able to intubate a number of live

patients under the watchful eye of an anesthesiologist or
nurse anesthetist in the operating suite. Here you should
focus on perfect technique and close observation of airway
anatomy. You should also try to place as many extraglottic
airways as possible if the opportunity presents itself.
During your field internship, hopefully, you will be
able to intubate a number of patients under the supervi-
sion of an experienced paramedic, where you can learn the
ins and outs of managing airways in bad light, with lots of
secretions, and with awkward positioning. The evidence
suggests that at least 15 intubations are necessary for most
providers to achieve at least 90 percent success in the oper-
ating suite, but more than 30 are necessary to achieve the
same success in the field. Unfortunately, opportunities for
FIGURE 15-81  GlideScope® Ranger.
operating suite practice for paramedics are very limited in
(© Kevin Link)
some locales. You cannot expect optimal performance if
you have not had sufficient experience, and your threshold
Improving Endotracheal for placing an extraglottic airway device should be lower,
in that case, to prevent patient complications.
Intubation Success
Most studies of prehospital intubation show relatively Ongoing Practice
poor success rates when using first-attempt and overall Nearly as important as your initial training is the serious-
successful endotracheal tube placement as the marker of ness with which you maintain your skills. One study has
success. It is now clear, however, that physiologic parame- demonstrated that patients cared for by a paramedic who
ters, such as maintenance of oxygen saturation and avoid- had intubated more than 25 patients in the past 5 years did
ance of aspiration and airway trauma during the intubation better than patients cared for by paramedics with lesser
process, are far more important markers of success than experience. If you do not intubate frequently in your prac-
the percentage of times an endotracheal tube is success- tice setting, you should practice the basic motor skills and
fully placed within three attempts. It has also been demon- checklists routinely on a mannequin/simulator and visit
strated that success rates rapidly plateau after two or three the operating suite if possible.
attempts, whereas complications go up exponentially.
Therefore, paramedics should strive to make their first Using the Endotracheal Tube Introducer
attempt rapidly successful. How do we maximize the The endotracheal tube introducer (gum-elastic bougie) is a
chance of rapid success on the first attempt? These include simple device that helps facilitate intubation when only the
good initial training, ongoing practice, using the endotra- epiglottis is visible. It is a flexible device, 60 to 70 cm in
cheal tube introducer, managing neck pressure, ensuring length, that is stiff enough to be directable and to transmit
optimal positioning, using video laryngoscopy and other tactile information (that is, you can feel its movements and
technology, and using responses) but flexible enough to allow a tube to be passed
rapid sequence intubation. over it. There are disposable and nondisposable products
CONTENT REVIEW
of this kind, and each brand has a different balance of these
➤➤ Maximizing Rapid Good Initial properties, creating a unique feel and different perfor-
­Success with Endotra-
cheal Intubation
­Training mance for each, especially at temperature extremes. Some
• Good initial training There is no substitute for operators prefer to preshape the bougie by holding it in a
• Ongoing practice being well trained from the curved shape for several seconds before insertion.
• Using the endotracheal beginning of your career. Once the intubator identifies a difficult airway—
tube introducer Bad habits are very difficult despite optimal positioning, removal of the cervical collar
• Managing neck to break, and in times of with in-line immobilization and jaw-thrust maneuver, and
pressure stress we all naturally external laryngeal manipulation—an introducer is placed
• Optimal positioning revert to what we learned into the pharynx with the coude tip (bent end) distal and
• Video laryngoscopy first. Take your airway edu- anterior (Figure 15-82).
• Other technology cation very seriously and If the introducer enters the airway, the operator may
• Rapid sequence
take advantage of every be able to feel “clicks” as the coude tip passes over each car-
intubation
learning opportunity. tilaginous ring of the trachea. Because clicks cannot be felt
570  Chapter 15

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.

Managing Neck Pressure

As previously discussed, well-intended cricoid
pressure can actually obscure the laryngeal
view. If the intubator is having difficulty dur-
Backward
ing normal visual laryngoscopy seeing appro-
priate landmarks, it is not recommended to just
attempt a ‘blind’ insertion into the trachea. If
the view is still limited, the assistant should
slide his hand up to the thyroid cartilage, and
Upward
the intubator should move the larynx into an
optimal position using his own right hand on
top of the assistant’s hand—a procedure called Figure 15-84  BURP airway maneuver.
 Airway Management and Ventilation 571

As these devices become more affordable, they will likely

take over EMS airway management. A number of devices
are on the market, and none has been shown to be clearly
superior to the others. Each device uses a different tech-
nique, but they are all very different from traditional
direct laryngoscopy. If you have one of these devices,
you will need specific training and regular practice in
using it.

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

• Suspected nasal fractures

• Suspected basilar skull fractures

FIGURE 15-85  IntubriteTM laryngoscope system. • Suspected elevation of intracranial pressure

(© Dr. Bryan E. Bledsoe) • Combative/uncooperative patient
572  Chapter 15

• Coagulopathy, including ther-

apeutic warfarin or heparin
• Significantly deviated nasal sep-
tum or other nasal obstruction
• Hypoxemia

Absolute Contraindications

• Cardiac or respiratory arrest

Disadvantages of Nasotracheal
Intubation
The following disadvantages of
nasotracheal intubation discourage
its use unless clearly indicated by
the patient’s condition:

• It is often more difficult and

time consuming to perform
than orotracheal intubation.
• There is a significant risk of
epistaxis (nosebleed).
• Smaller-diameter tubes must
be placed, which makes venti-
lation more difficult.
• There is a significant risk of
Figure 15-87  Blind nasotracheal intubation.
sinusitis, so these tubes must
generally be changed out in
the hospital.

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

this point. Continue passing the ETT until the distal

cuff is just past the vocal cords, which should occur at
a depth of approximately 26 cm in an average adult
female and 28 cm in an average adult male. Coughing
or bucking and anterior displacement of the larynx
generally indicate tracheal placement, whereas gag-
ging or vocal sounds indicate esophageal placement.
11. Holding the ETT with one hand to prevent displace-
ment, inflate the distal cuff with enough air to elimi-
nate any audible leak, connect a bag-valve device,
ventilate the patient with 100 percent oxygen, and
confirm proper placement of the ETT using multiple
techniques, including bilateral breath sounds, absent
epigastric sounds, and capnography.
12. Secure the ETT and reconfirm proper placement. Con-
tinue to observe the patient’s condition, maintain venti-
latory support, and frequently recheck ETT placement.
Use continuous waveform capnography to monitor
tube placement and ventilation.

FIGURE 15-89  The Burden nasoscope, a commercial nasotracheal Digital Intubation

tube auscultation device.
Digital intubation is another old technique that has largely
(© Brant Burden, EMT-P)
been replaced by newer extraglottic airways and devices
such as lighted stylets. However, digital intubation still
9. As you feel the tube drop into the posterior pharynx, lis- may be a viable option in certain circumstances, such as a
ten closely at its proximal end for the patient’s respiratory patient in a position that does not allow direct visualization,
sounds, and observe for end-tidal CO2. Sounds are loud- when there are copious secretions obscuring the airway,
est when the ETT is proximal to the epiglottis. When the and in the event of equipment failure (Figure 15-90). Digital
ETT tip reaches the posterior pharyngeal wall, you must intubation is risky for the paramedic; it may stimulate even
take care to direct it toward
the glottic opening. This may
be done with a directable-tip
tube or by inflating the cuff,
as the Endotrol tracheal tube.
At this point, the tip of the
ETT may catch in the pyri-
form sinus. If it does, you will
feel resistance, and the skin
on either side of the Adam’s
apple will tent. To resolve
pyriform sinus placement,
slightly withdraw the ETT
and rotate it to the midline.
10. With the patient’s next
inhaled breath, advance the
ETT gently but quickly into
the glottic opening, observ-
ing exhaled CO2. If you
inflated the tube cuff to help
with anterior displacement,
the cuff must be deflated at FIGURE 15-90  Blind orotracheal intubation by digital method.
574  Chapter 15

7. Palpate the arytenoid cartilage pos-

terior to the glottis and the epiglot-
tis anteriorly with your middle finger
(Figure 15-92). Press the epiglottis for-
ward, and insert the endotracheal tube
into the mouth, anterior to your fingers
(Figure 15-93).
8. Advance the tube, pushing it gently
with your right hand. Use your left
index finger to keep the tip of the ETT
against your middle finger. This will
direct the tip to the epiglottis.
9. Use your middle and index fingers to
direct the tip of the ETT between the
epiglottis (in front) and your fingers
(behind). Then, with your right hand,
advance the ETT through the cords
while simultaneously maneuvering it
forward with your left index and mid-
dle fingers. This will prevent it from
Figure 15-91  Digital intubation. Insert your middle and index fingers into the patient’s slipping posteriorly into the esophagus.
mouth.
10. Hold the tube in place with your hand
to prevent its displacement, remove
a deeply comatose patient to clamp down and bite your stylet, and inflate cuff.
finger. Do not use it with any patient who may have an 11. Confirm placement with multiple techniques.
intact gag reflex.
12. Ventilate the patient with 100 percent oxygen. Gently
To perform digital intubation:
insert an oropharyngeal airway to serve as a bite block.
1. Use Standard Precautions. Secure the ETT with umbilical tape. Repeat steps to con-
2. Continue oxygenation with bag-valve mask and high- firm proper ETT placement and maintain ventilatory
concentration oxygen. support. Continue your airway assessment periodically.
3. Prepare and check your equipment. You
will need the following items: an appro-
priately sized ETT, a malleable stylet,
water-soluble lubricant, a 5- to 10-mL
syringe, a bite block, and umbilical tape
or a commercial anchoring device. Insert
the stylet into the endotracheal tube and
bend the ETT/stylet into a J shape.
4. Remove the front of the collar and have an
assistant stabilize the neck as appropriate.
5. Place a bite block device between the
patient’s molars to help protect your fingers.
6. Insert your left middle and index fingers
into the patient’s mouth (Figure 15-91).
By alternating fingers, “walk” your hand
down the midline while simultaneously
tugging gently forward on the tongue.
You may also use gauze to hold and
extend the tongue more effectively, which
lifts the epiglottis up and away from the
glottic opening so that it is within reach of
your probing fingers. Figure 15-92  Digital intubation. Walk your fingers and palpate the patient’s epiglottis.
 Airway Management and Ventilation 575

be performed with simple modifications of

standard laryngoscopy techniques or others,
using equipment such as lighted stylets or
video laryngoscopy. Occasionally digital intu-
bation or nasotracheal intubation may be
employed.
To perform direct laryngoscopy with in-
line stabilization (Procedure 15–2):

1. Use Standard Precautions.

2. Perform basic airway management, includ­
ing BVM ventilation with simple mechani­
cal airways as needed.
3. Remove the front of the collar and have
an assistant maintain in-line stabilization.
4. Immediately before laryngoscopy, have
the assistant perform a jaw-thrust and
release cricoid pressure.
5. Perform external laryngeal manipulation
as needed to help with glottic visualiza-
tion, and have the assistant maintain this
optimal position of the larynx.

The trauma patient may present a number

of obstacles to effective airway management
and ventilation, including the need for extrica-
tion, blood in the oropharynx, distorted anat-
omy, and/or the need to protect the cervical
spine. In addition, patients with nervous sys-
Figure 15-93  Digital intubation—insertion of the ETT. tem trauma are very intolerant of hypoxemia.
Therefore, you must have a plan to optimize
your intubation attempts and must make early use of
Special Intubation extraglottic airway devices.38–42
When a patient presents in a nontraditional position,
Considerations the patient may still undergo direct laryngoscopy using an
alternative approach, such as a face-to-face technique.
Trauma Patient Intubation Alternatively, extraglottic airways may be used as a bridge
Airway management and ventilatory support in the until the patient can be positioned better, or they may be
trauma patient are essential for a successful outcome. used all the way to the receiving hospital.
Appropriate treatment of all other injuries is meaningless if To perform orotracheal intubation on a trauma patient,
you do not ensure a patent airway and adequate oxygen- you need an assistant who will both maintain in-line stabi-
ation and ventilation. lization and simultaneously perform a jaw-thrust. Main-
The trauma patient, however, presents a number of taining in-line stabilization of the cervical spine is, of
obstacles to effective airway management and ventilation. course, critical for the trauma patient who may have suf-
These include difficult access, the need for extrication, fered spinal injury. The jaw-thrust maneuver will not only
blood in the oropharynx, distorted anatomy due to injury, open the airway but also will assist with direct laryngos-
and the need to protect the cervical spine. Getting an ade- copy, as the patient cannot be placed into the optimal ear-
quate seal on a mask is very difficult when the patient is to-sternal notch position.
being extricated or has significant facial trauma. You must It is imperative that the front of the cervical collar be
keep the cervical spine in a neutral, in-line position removed during direct laryngoscopy to allow forward
throughout your management of all patients with known movement of the jaw. When using alternative techniques
or suspected cervical spine trauma. such as video laryngoscopy, intubating laryngeal airways,
Options for airway management include BVM ventila- and lighted stylets, it may not be necessary to remove the
tion, extraglottic devices, and intubation. Intubation may front of the cervical collar.
576  Chapter 15

Procedure 15–2  Endotracheal Intubation with In-Line Stabilization

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.

15-2E  Reconfirm placement.

 Airway Management and Ventilation 577

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 Intubation • Structures are smaller. The airway structures in chil-

dren are proportionally smaller and more flexible than
Pediatric airway emergencies generally produce more anx-
an adult’s.
iety than adult emergencies among both medical care pro-
• Nasal openings are small and adenoids are large.
viders and the family, although many airway procedures
Inserting any tube or device into a child’s nose often
themselves are often easier to perform in this patient popu-
causes trauma and bleeding because of the size and
lation. Historically, we have separated the parents and the
the presence of enlarged adenoid tissues.
child during resuscitation and critical procedures, but
recent experience in the emergency department has shown • Nasal airway diameters are inadequate. Nasal pha-
it to be beneficial to have parents present. As difficult as it ryngeal airways and nasotracheal intubations are gen-
may be for the providers, children who are conscious usu- erally too large to be useful in the child.
ally benefit from having their parents present, and parents • Cricoid pressure can worsen the situation. Because a
benefit from seeing all the efforts made to save their chil- child’s cricoid is less rigid than an adult’s, aggressive
dren, even if these efforts are unsuccessful. The final cricoid pressure can compress the cricoid and obstruct
decision on separation must be made on a case-by-case the airway.
• Surgical airways are unavailable. Surgi-
cal airway use is restricted to patients
older than 6 to 10 years.
• Tube size is critical. Selecting the appro-
priate tube diameter for children is criti-
cal. Too large a tube can cause tracheal
edema and/or damage to the vocal
cords, whereas too small a tube may not
allow exchange of adequate ventilatory
volumes. Table 15-7 lists general guide-
lines for selecting ETT size according to
the child’s age, and many tables or
devices based on the child’s age, weight,
or length are available. Another guide
for children’s sizes is this formula:

ETT size (mm) = (Age in years + 16) , 4

The correct tube size for an 8-year-old,

for instance, would be (8 + 16) ÷ 4, or
6  mm. You can also determine correct
tube size by matching the diameter of the
child’s smallest finger.
• Depth of ETT insertion is different. The
FIGURE 15-94  Foreign body removal with direct visualization and Magill forceps. depth of insertion of the distal tip for
578  Chapter 15

Table 15-7  Approximate Size of ETT for Pediatrics

Patient’s Age ETT Size Type Depth of ETT Insertion Laryngoscope Blade Size
Premature infant 2.5–3.0 Uncuffed 8 cm 0 straight

Full-term infant 3.0–3.5 Uncuffed 8–9.5 cm 1 straight

Infant to 1 year 3.5–4.0 Uncuffed 9.5–11 cm 1 straight

Toddler 4.0–5.0 Uncuffed 11–12.5 cm 1–2 straight

Preschool 5.0–5.5 Uncuffed 12.5–14 cm 2 straight

School age 5.5–6.5 Uncuffed 14–20 cm 2 straight

Adolescent 7.0–8.0 Cuffed 20–23 cm 3 straight or curved

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

Procedure 15–3  Endotracheal Intubation in the Child

15-3A  Ventilate the child. 15-3B  Prepare the equipment.

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

15-3G  Secure the tube. 15-3H  Reconfirm proper ETT placement.

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

hospital staff will assess cuff pressures in the initial man-

agement of a critically ill patient.
Cricothyrotomy
Ideally, cuff pressures would be assessed with a cuff With proper training and frequent practice, including the
manometer, but this is often not available. Second best is to use of rapid sequence procedures and newer technologies
place only enough air into the cuff to eliminate an audible such as video laryngoscopy, you will be able to manage
leak. Providers may be surprised to find out that only 3 or 4 most airways in the field with BVM ventilation, an extra-
mL of air may be necessary to create an appropriate seal in glottic airway device, or endotracheal intubation. Occa-
some adults. A third option is to place only half the cuff vol- sionally, though, extreme circumstances require a more
ume, but this may leave the patient at risk for both aspira- invasive approach. In these situations, performing a crico-
tion and tissue damage. Finally, some providers will inflate thyrotomy may be the only way to ensure your patient’s
the cuff with 10 mL of air but leave the syringe attached for best chance for survival. Overall, however, the incidence
10 to 20 seconds to allow any back-pressure to release.44 of these procedures being performed in both the prehospi-
tal and hospital settings has fallen precipitously in the
past five to ten years with the more widespread use of
Post-Intubation Agitation EGAs and RSI.
and Field Extubation Two different techniques, needle cricothyrotomy
(also called transtracheal jet ventilation or transtracheal jet
Occasionally, an intubated patient will awaken and be
insuff lation) and open cricothyrotomy, both provide
intolerant of the ETT. This happens most often with
access to the airway through the cricothyroid membrane.
patients who undergo rapid sequence intubation and then
A needle cricothyrotomy is generally the easier procedure
awaken from the sedative agent and paralytic. This occur-
but makes providing adequate ventilation more difficult;
rence usually indicates inadequate sedation/analgesia
this approach is generally reserved for pediatric patients.
and/or inappropriate ventilator settings. Paralytics alone
The open cricothyrotomy technique is the more difficult
should never be given to treat agitation, as the patient will
procedure but allows for more effective oxygenation and
be fully aware of the paralysis (a harrowing feeling), even
ventilation. The open approach often takes longer than
though his outward signs of agitation will resolve.
anticipated and has been associated with complications in
Only rarely should extubation be considered in the
up to 50 percent of cases. Therefore, you must master these
field, because this may be associated with serious compli-
techniques and reserve their use for situations in which
cations such as aspiration, laryngospasm, and negative-
you have exhausted your other options and have decided
pressure pulmonary edema—not to mention that the
that no other means will establish an airway. Even when
patient may deteriorate again and be difficult to reintubate.
performed correctly, these procedures are highly invasive
If the patient is clearly able to maintain and protect his air-
and prone to long-term complications, such as tracheal
way, is intolerant of the tube and ventilator, no medications
stenosis.
are available to make him comfortable, and reassessment
Indications that may warrant cricothyrotomy include
indicates that the problem that led to endotracheal intuba-
situations that prevent adequate BVM ventilation, EGA
tion is resolved (such as a narcotic overdose), extubation
placement, and endotracheal tube placement by the oral
may be indicated.
and nasal routes. An example is a patient with trismus
To perform field extubation:
(masseter muscle spasm that prevents opening the mouth),
1. Use Standard Precautions. who cannot be oxygenated with a BVM ventilation, is also
2. Ensure adequate oxygenation. A crude method for not a candidate for blind nasotracheal intubation, and
accomplishing this in the field is to be certain that the presents in an EMS system that does not permit drug-facil-
patient’s mental status, skin color, and pulse oximetry itated airway management. Another example is a hypox-
are optimal on room air with the ETT in place. emic patient who has such severe facial trauma that BVM
ventilation, EGA placement, and endotracheal intubation
3. Prepare intubation equipment and suction.
are not viable options. Other possible indications include
4. Confirm patient responsiveness. total upper airway obstruction from epiglottitis or a for-
5. Position patient on his side if possible. eign body, severe anaphylaxis, and burns to the face and
6. Suction the patient’s oropharynx. respiratory tract.
Relative contraindica- CONTENT REVIEW
7. Deflate the ETT cuff.
tions to performing crico- ➤➤ The only indication for
8. Remove the ETT upon cough or expiration. thyrotomy in the field a surgical airway is the
9. Provide supplemental oxygen as indicated. include inability to identify inability to establish an
anatomical landmarks airway by any other
10. Reassess the adequacy of the patient’s ventilation and
method.
oxygenation. (including trauma and
582  Chapter 15

short, fat necks), crush injury to the larynx, suspected tra-

cheal transection, and underlying anatomical abnormali-
ties such as tumor or subglottic stenosis. There are no
absolute contraindications to cricothyrotomy.

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

Needle Cricothyrotomy with

Jet Ventilation Technique
To perform needle cricothyrotomy with jet ventilation:

1. Use Standard Precautions, including face mask and

shield.
2. Manage the patient’s airway as well as possible with
basic maneuvers and supplemental oxygen while you
prepare your equipment. Attach a large-bore IV needle
with a catheter (adults: 14- or 16-gauge; children: 18-
or 20-gauge) to a 10- or 20-mL syringe. If time permits FIGURE 15-96  Locate/palpate the cricothyroid membrane.
 Airway Management and Ventilation 583

FIGURE 15-97  Proper positioning for cricothyroid puncture.

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.

FIGURE 15-99  Cannula properly placed in the trachea.

584  Chapter 15

FIGURE 15-100  Jet ventilation with needle cricothryrotomy.

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

Procedure 15–4  Open Cricothyrotomy

15-4A  Locate the cricothyroid membrane. 15-4B  Stabilize the larynx and make a 1- to 2-cm skin incision
over the cricothyroid membrane.

15-4D  Using a curved hemostat, spread the membrane

15-4C  Make a 1-cm horizontal incision through the ­incision open.
­cricothyroid membrane.

15-4E  Insert an ETT (6.0 or 7.0) or Shiley (6.0 or 8.0).

(Continued)
586  Chapter 15

15-4F  Inflate the cuff. 15-4G  Confirm placement.

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

Intubation challenging because of patient anxiety. Nasal intubation is

difficult and often exacerbates hypoxemia. You cannot
Medication-assisted intubation (MAI), which is also called perform oral intubation on this patient until he fatigues
drug-assisted or pharmacologically assisted intubation, is enough to have respiratory failure, with resultant uncon-
becoming more common. MAI may take several forms, sciousness and decreased muscle tone leading to loss of a
including rapid sequence intubation (RSI) and sedation- gag reflex. By then, however, the patient will have suf-
facilitated intubation. fered prolonged hypoxemia, possibly accompanied by
MAI techniques give you the option of managing air- myocardial infarction, brain or kidney damage, or vomit-
ways that you could not otherwise manage because the ing with aspiration.
patient is too awake or has trismus, and they are used early If a patient clearly is precipitously failing maximal
in the clinical course when the procedure may be easier aggressive medical management, or if the history of his
and the patient has more reserve to tolerate complications. problem clearly indicates that he will not be able to, or
The flip side is that these procedures come with great already cannot, protect his airway, then active intervention
risk, as you are employing very powerful medications that is appropriate to control
may result—and have resulted—in severe morbidity and the airway and provide CONTENT REVIEW
death when the paramedic is unable to intubate and can- adequate ventilation. ➤➤ If a patient is precipitously
not maintain adequate oxygenation through other means. One potential solution failing maximal aggressive
In the setting of cardiac arrest, of course, you cannot realis- to this problem is rapid medical management and
tically make the situation any worse. MAI, however, is sequence intubation (RSI). will be or already is unable
employed in patients who are alive and sometimes con- Classic rapid sequence to protect his airway, ac-
tive intervention—such as
scious, when both the potential benefits and the potential induction is a procedure
RSI—is appropriate.
harms are greater.45–51 borrowed from anesthesia
588  Chapter 15

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

In the last group (no reserve), positive pressure venti-

Table 15-9  Patient Categorization and Preparations lation is unavoidable; the clinician should consider CPAP/
Following Preoxygenation
BiPAP or assisted respirations before medication and be
Preoxygenation Categories and Preparations prepared to provide immediate optimal BVM ventilation
and to place a rescue airway if saturations cannot be main-
Adequate Reserve—Oxygen Saturation Near 100%
tained. Many inexperienced providers faced with a patient
• Positive pressure ventilation usually not necessary
who is desaturating make the mistake of waiting too long
• Potential false sense of security if patients have high-risk characteristics
to abort the procedure, trying even harder or trying “just
Limited Reserve—Oxygen Saturation 90–97% one more time,” only to face critical hypoxia and cardiac
• Some patients will require careful BMV ventilation arrest.
• Be prepared to abort intubation attempt
• Have rescue airway immediately available: not necessary to remove
from package in advance Airway Pharmacology
PREMEDICATIONS  Premedications are drugs given
No Reserve—Oxygen Saturation Below 90%
early in the course of RSI to mitigate anticipated complica-
• Positive pressure ventilation is unavoidable tions. Examples are lidocaine (to blunt the rise in intracra-
• Consider CPAP/BiPAP or assisted respirations before medication
• Consider planned PPV with BVM or SGA after medication and before nial pressure [ICP] associated with succinylcholine and
intubation laryngoscopy) and atropine (to prevent the bradycardia
• Have rescue airway immediately ready for insertion: out of package
and lubricated associated with succinylcholine in children).
As it turns out, none of these agents are required. Few
have been proven to do what they were hoped to do, and
all are associated with some potential adverse effects. The
that should be made (Table 15-9). Patients with underlying movement in the last few years has been away from the
lung disease, especially acute or acute-on-chronic disease routine use of premedications.
resulting in hypoxemia, are a particularly scary group to The following are agents that might still be considered
intubate because they are hypoxic to begin with, and they if time and protocols permit:
are prone to very rapid desaturation after medication.
• Fentanyl. At routine doses, fentanyl is an excellent
analgesic (pain reliever) that may keep a patient more
comfortable during a painful procedure such as intu-
Patho Pearl bation. At higher doses, fentanyl is a sympatholytic
Importance of Head Elevation.  Research has demonstrated agent that blunts the hypertension, tachycardia, and
that preoxygenation is more successful for most patients with ICP elevation associated with laryngoscopy. It is rea-
at least 20 degrees of head elevation; this is especially true for sonable to consider giving all patients analgesic doses
obese patients. This is yet another reason that all trauma of fentanyl at least 3 minutes before the procedure and
patients in spinal precautions should be considered difficult higher doses to patients at risk for life-threatening ele-
intubations. The inability to elevate the patient’s head limits vations of ICP. Although fentanyl is highly regarded
preoxygenation, and that, in turn, limits the amount of time
for its hemodynamic (blood flow/blood pressure) sta-
you will have to perform the procedure. This also emphasizes
bility, it may occasionally cause hypotension (a drop in
the importance of keeping patients, particularly those with
blood pressure) in patients who are dependent on their
respiratory distress, in their position of comfort as long as their
mental status allows.
sympathetic drive for blood pressure maintenance,
especially at higher doses.
• Atropine. Succinylcholine is associated with bradycar-
Patients with a saturation of 100 percent after preoxy- dia (slow heartbeat) in younger children and in any
genation have an “adequate reserve,” those with less than patient receiving a second dose. Historically, atropine
100 percent but above 90 percent have “limited reserve,” was recommended routinely 2 to 3 minutes before
and those with less than 90 percent have “no reserve.” In administration of succinylcholine to children less than
the first group (adequate reserve), the goal should be no 6 to 8 years of age to reduce the risk of bradycardia.
positive pressure ventilation, although some patients, par- Evidence now shows that this is optional, although
ticularly those with any of the high-risk characteristics atropine must always be at the bedside.
listed in Table 15-8, may still desaturate quickly. • Lidocaine. Although lidocaine is commonly used in
In the second group (limited reserve), the clinician head injury patients to blunt an increase in ICP, there
should plan to optimize first-pass success and anticipate has been a movement away from this practice in some
that some patients will require careful positive pressure circles because of limited evidence for benefit and the
ventilation if the intubation attempt is prolonged. potential risk of hypotension as well as time delays.
590  Chapter 15

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.

Table 15-10   Guidelines for Sedative (Induction) Agents

Guidelines for Sedative (Induction) Agents
Induction Agent Dose Onset Duration (min) Advantages Disadvantages
Midazolam (Versed) 0.1–0.3 mg/kg 1–3 min 20–30 min Amnesia effects, good sedative Hypotension

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

onset and minimal effects on blood pressure unless the

Table 15-11  Contraindications to Succinylcholine patient is sympathetic dependent. Other narcotics
Contraindications to Succinylcholine such as morphine may also be used cautiously.
(may exaggerate hyperkalemia) • Benzodiazepines. Benzodiazepines are optimal for
Disease/Injury keeping patients sedated while intubated. Midazolam
is a favorite among critical care transport crews
Neuromuscular diseases
• Muscular dystrophies
because of its rapid onset and short duration. Loraze-
• Myopathies pam and diazepam may also be used. All benzodiaze-
• Guillain-Barré
pines must be used cautiously in volume depleted and
Stroke hypotensive patients.
Parkinson’s disease (severe) • Propofol. Propofol infusions are commonly used in
the intensive care unit and during critical care trans-
Tetanus
port to maintain sedation. The very short duration of
Botulism action facilitates neurologic examination when the
Rhabdomyolysis infusion is stopped. Propofol is even more prone to
cause hypotension than the benzodiazepines and must
Burns >24–28 hours old
be used cautiously.
Spinal cord injury (>72 hours and <9 months old)

Prolonged immobility/paralysis RSI Procedure

To perform a typical rapid sequence intubation, there are
Severe infection (abdominal and neurologic)
10 steps, as listed next. As with other airway procedures,
Severe trauma (especially musculoskeletal) be sure to begin with Standard Precautions.

1. Preoxygenate to achieve nitrogen washout and create

an oxygen reserve (as discussed earlier). Use a nonre-
• Rocuronium. Rocuronium is now the most commonly breather mask with high-concentration oxygen for at
used competitive agent in emergency medicine and least 3 minutes, if possible. Consider CPAP, assisted
EMS. The onset time with rocuronium is only slightly respiration, and BVM ventilation as indicated. Avoid
longer than with succinylcholine (60 seconds) as long positive pressure if the patient is not hypoxemic.
as higher doses are used. At the recommended intuba-
2. Protect the C-spine if indicated. The front of the cervical
tion doses, rocuronium may last 30 minutes or longer.
collar should be removed and manual in-line stabili-
Although this is often used as an argument against
zation performed by an assistant who is also ready to
rocuronium for EMS use, it is used successfully by
perform a jaw-thrust maneuver.
many services that argue that even 8 minutes is too
3. Position optimally if possible. Patients not in cervical pre-
long with succinylcholine before moving on to a res-
cautions should be placed in sniffing or ramped position.
cue airway. Rocuronium has few adverse effects and
may be used for initial and ongoing paralysis. 4. Assign provider to initiate external laryngeal manipula-
tion if sufficient assistance is available, upon request.
• Vecuronium. Vecuronium is a competitive agent that is
Until the laryngoscopy blade is introduced, maintain
commonly used to maintain paralysis after succinyl-
the larynx in its normal position. External laryngeal
choline. Vecuronium is a second- or third-line agent for
manipulation should be implemented as directed by
RSI because of its long onset time. Although there are
the intubator.
tricks that may be used to shorten the onset time, they
add complexity and a very long duration of action. 5. Ponder whether intubation is really necessary. Are
there other management options, if this is likely to be a
Sedatives and Analgesics  Sedatives and anal- difficult airway? Use a checklist, if possible.
gesics are essential for keeping a patient comfortable after 6. Premedicate if time permits and allowed by protocol
intubation. Both analgesia and sedation should be pro- and scope of practice. Consider regular-dose fentanyl
vided to every patient who is chemically paralyzed, unless for most patients, high-dose fentanyl for suspected
contraindicated by hypotension, and to all other patients, critical ICP, and lidocaine for severe asthmatics.
unless you are confident that the patient is comfortable, 7. Prepare equipment, using a checklist to ensure that all
such as an un-paralyzed post–cardiac-arrest patient who is supplies are ready. This includes intubation, BVM ven-
completely unresponsive. tilation, rescue, and post-intubation supplies.
• Narcotics. Narcotics are critical to provide analgesia. 8. Sedate and paralyze, using appropriate medications and
Fentanyl is used most commonly because it has a rapid doses. Most patients should receive both an induction
592  Chapter 15

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

Predictors of a Difficult Predictors of difficult BVM ventilation include facial

trauma, facial hair, obesity, and lack of teeth (assuming you
Airway or Ventilation don’t have the dentures to replace during BVM ventila-
It would be useful if we could reliably predict which tion). Other risk factors for difficult BVM ventilation dem-
­airways are likely to cause difficulty and which will not onstrated in the anesthesia literature include age over 55,
(Table 15-12). This is particularly important if you are con- history of snoring, Mallampati class 3 or 4 (discussed later),
sidering a medication-facilitated airway procedure. For severely limited jaw protrusion, and thyromental distance
patients for whom we anticipate difficulty, we could call (the distance between the thyroid notch and the bony point
for help in advance, consider deferring the procedure, con- of the chin) less than 6 cm.
sider managing the airway with BVM ventilation or an Predictors of difficult extraglottic airway (EGA) device
extraglottic device, or simply be better prepared, such as placement include limited mouth opening. Situations in
having different blades or devices, an introducer, a backup which an EGA may be inserted easily but where it may be
airway, and cricothyrotomy supplies immediately avail- difficult to ventilate the patient include massive secretions,
able. In most emergency situations, however, a detailed morbid obesity, severe pulmonary disease, and pathology
airway assessment may not be practical. In many such below the device, such as inhalation burns, laryngeal
cases, management must proceed, even when airway trauma, and angioedema.
assessment predicts difficulty, because of patient acuity Commonly used predictors of difficult laryngoscopy
and a favorable risk-to-benefit analysis. and intubation include facial trauma/anomalies, increas-
ing Mallampati class (discussed later), short thyromental
distance, short sternomental distance (distance between
the suprasternal notch and the bony point of the chin), lim-
Table 15-12  Predictors of Difficult Airway and Ventilation ited mouth opening, limited neck mobility, obesity, and
buckteeth.
Predictors of Difficult Airway and Ventilation
Predictors of difficult surgical airway placement
Difficult Bag-Valve-Mask Ventilation Predictors include situations in which the cricothyroid membrane
• Facial trauma cannot be located—such as morbid obesity, anterior neck
• Facial hair trauma, prior radiation therapy, and infection such as Lud-
• Obesity
• Lack of teeth (and without dentures) wig’s angina (a very serious skin infection that tracks down
• History of snoring into the anterior neck, usually from a dental infection)—
• Mallampati grade 3 or 4
• Severely limited jaw protrusion and situations in which a tumor, infection, swelling, or for-
• Thyromental distance less than 6 cm eign body within the airway lumen prevents tube insertion,
Difficult Extraglottic Airway Insertion or Ventilation Predictors
even when the membrane can be located.

• Limited mouth opening

• Massive secretions
Difficult Airway Scoring Systems
• Morbid obesity Various difficult airway scoring systems have been
• Severe pulmonary disease
developed to aid the clinician in detecting and manag-
• Pathology below the device (e.g., inhalation burns, laryngeal trauma,
angioedema) ing the difficult airway. The most frequently used sys-
tem of pre-intubation airway assessment is the
Difficult Laryngoscopy and Orotracheal Intubation Predictors
Mallampati classification system (Figure 15-101). With
• Facial trauma or anomalies this system, the tonsillar pillars and the uvula are
• Increasing Mallampati grade
• Short thyromental distance assessed. The more concealed the tonsillar pillars and
• Short sternomental distance the uvula, the more difficult the intubation. Based on
• Limited mouth opening
• Limited neck mobility these features, the patient’s airway is classified into four
• Obesity classes. The higher the class, the more difficult the air-
• Buckteeth
way is expected to be.
Difficult Surgical Airway (Cricothyrotomy) Placement
Class I: Entire tonsil clearly
CONTENT REVIEW
• Cricothyroid membrane cannot be located: visible
• Morbid obesity ➤➤ Difficult Airway Scoring
• Anterior neck trauma Class II: Upper half of ­tonsil Systems
• Prior radiation therapy fossa visible
• Ludwig’s angina (skin infection to anterior neck) • Mallampati
• Tube insertion prevented by conditions within airway lumen: Class III: Soft and hard classification system
• Tumor • Cormack and LeHane
• Infection
­palate clearly visible
• Swelling grading system
Class IV: Only hard palate
• Foreign body • POGO scoring system
visible
594  Chapter 15

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.

Table 15-13  LEMONS Mnemonic Used to Evaluate

Difficult Airway

LEMONS
100%
L Look externally

E Evaluate 3-3-2 rule

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.

EVALUATE 3-3-2 RULE  The 3-3-2 rule is one tool to help

estimate the difficulty of laryngoscopy by assessing ana-
tomic limitations to visualizing the larynx—for example,
small mouth opening, short chin (no room to displace the
tongue), and superior/anterior location (Figure 15-103).
Criteria evaluated are as follows (using the patient’s finger
measurements):
Keep in mind that the measurements are based on the
patient’s fingers, not yours! (For example, two of your • Check that the mouth opening is at least 3 patient-
fingers might equal three of the patient’s.) sized fingers.
• Check that there is room for 3 patient-sized fingers
between the tip of the chin and the hyoid bone.
• Check that there is room for 2 patient-sized fingers
between the hyoid bone and the top of the thyroid
cartilage.

MALLAMPATI SCORE  The Mallampati score assesses

the working space available within the mouth (review
Figure 15-101 and see Table 15-14). To be done correctly,
the patient must be able to sit up and stick out his tongue.
Check that the mouth opening equals at least 3 A crude estimate may be substituted by manually opening
patient-sized fingers. the mouth and looking, although this technique has never
been validated. A tongue blade may be used cautiously to
avoid stimulating a gag reflex. The most important thing
is to make sure you look into the mouth before commit-
ting to intubation to assess mouth opening, size of tongue,
dentures/dentition, edema, trauma, and secretions.

OBSTRUCTION  The airway may be obstructed by a

foreign body, the tongue, secretions, blood, or vomitus
and/or edema. Edema may result from trauma, infectious
causes such as epiglottitis and abscess, or from allergic
reactions. Consider the age and history to predict possible
Check that there is room for 3 patient-sized fingers obstruction. Intubating a pediatric patient with retropha-
between the tip of the chin and the hyoid bone.
ryngeal abscess or an adult with Ludwig’s angina is a scary
proposition.

Table 15-14  Mallampati Score

Mallampati Score
Class I = visualization of the soft palate, fauces, uvula, and anterior
and posterior pillars = “Easy”

Class II = visualization of the soft palate, fauces, and uvula = “Mildly

Difficult”
Check that there is room for 2 patient-sized fingers
Class III = visualization of the soft palate and the base of the
between the hyoid bone and the top of the thyroid
uvula = “Moderately Difficult”
cartilage.
Class IV = soft palate is not visible at all = “Difficult”
FIGURE 15-103  The 3-3-2 rule.
596  Chapter 15

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

however, let the absence

CONTENT REVIEW
of any predicted difficul-
➤➤ Do not become
ties create a sense of com-
­complacent. Any patient,
placency. Any patient, no
no matter how favorable
matter how favorable his
his airway appears, may
prove difficult or impos- airway appears, may
sible to intubate. prove difficult or impos-
sible to intubate. If you
have not encountered such a patient you have not yet
intubated enough!

PART 4: Additional Airway

and Ventilation Issues
Managing Patients
with Stoma Sites
Patients who have had a laryngectomy (removal of the
larynx) or tracheostomy (surgical opening into the trachea)
may breathe through a stoma, an opening in the anterior
neck that connects the trachea with the ambient air. These
patients frequently have tracheostomy tubes, which consist
of an inner and outer cannula, in place to keep the soft-tissue
stoma open (Figure 15-105). Patients with longstanding FIGURE 15-105  Tracheostomy cannulae.
stomas may not use a tracheostomy tube.
Although providers often have anxiety about manag-
ing a patient with a stoma, this anxiety is usually unwar- into the surrounding subcutaneous tissue, which will pro-
ranted, because these patients have a secure airway. duce a false lumen. Subcutaneous emphysema, as well as
Potential problems include clogging of the tracheostomy the lack of clinical improvement in the patient, indicates a
tube with secretions, a dislodged tube, bleeding, and respi- false lumen. If difficulty persists and the patient is in
ratory distress. extremis, an endotracheal tube introducer may be passed
Tube clogging is a common problem because a laryn- into the stoma to gently confirm proper intratracheal
gectomy produces a less-effective cough, making it more positioning and the tracheostomy or endotracheal tube
difficult to clear secretions. If these secretions organize, passed over the introducer, much as with a bougie-aided
they form a mucus plug that can occlude the stoma. A cricothyrotomy.
clogged tube can usually be managed easily by removing Bleeding may come from irritation of the skin exter-
the inner cannula from the fixed external cannula and nally around the stoma site or internally. External bleeding
cleaning it. The external cannula should not be removed, is usually minor, although it may scare the patient, espe-
because the stoma may begin closing and it may be diffi- cially if the tracheostomy is new or bleeding has not
cult to replace. occurred previously. Internal bleeding, on the other hand,
If a tracheostomy tube becomes completely dislodged, may be catastrophic. This warrants very expeditious trans-
it should be replaced as soon as possible. This is particu- port and contact with medical direction.
larly critical if the tracheostomy is less than a few weeks If the patient is complaining of respiratory distress, you
old. If another tube is not available, an endotracheal tube must first make sure the tracheostomy is patent. If it is, then
may be used temporarily. In this case, choose the largest the distress is probably unrelated to the tracheostomy, and
diameter ETT that will pass through the stoma to maintain you should perform your usual history and physical exam.
the airway before complete obstruction occurs. Lubricate Other stoma-related problems to consider are excessive
the ETT, instruct the patient to exhale, and gently insert the secretions that are not obstructing the lumen of the tube but
ETT to about 1 to 2 cm beyond the distal cuff. Inflate the are nevertheless causing respiratory problems. You may
cuff, then confirm comfort, patency, and proper placement. suction the airway through the stoma, but you must use
Be certain to suspect and check for improper placement extreme caution as this process can, itself, cause soft-tissue
598  Chapter 15

Table 15-15  Advantages and Disadvantages of Various Suction Types

Type Advantages Disadvantages
Hand-powered Lightweight, portable, inexpensive, simple to operate Limited volume, manually powered, fluid contact
components are not disposable

Oxygen-powered Small, lightweight Limited suction power, uses a lot of oxygen

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).

FIGURE 15-106  Oropharyngeal suctioning.

 Airway Management and Ventilation 599

Table 15-16  Types of Suctioning Catheters

Hard/Rigid Catheter Soft Catheters
A large tube with multiple holes at the distal end Long, flexible tube; smaller diameter than hard-tip catheters

Suctions larger volumes of fluid rapidly Cannot remove large volumes of fluid rapidly

Standard size Various sizes

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

FIGURE 15-107  Tracheostomy suction technique.

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

Documentation any complications that occurred. A significant percentage

of claims and lawsuits that are filed against prehospital
Accurate and thorough documentation of airway manage- providers involve airway issues, and often these cases are
ment is critical for clinical care after the patient is trans- won or lost based on the field documentation. Therefore, it
ported, for quality assurance, and for medical–legal is crucial that the provider learn to document in medically
defense. Documentation should include not only what was correct and legally sufficient terms exactly what was done
done but also the thought process of why it was done and in managing the airway.

FIGURE 15-109  Airway reporting form.

(Courtesy of American Medical Response of El Paso County, Colorado and David Ross, DO, FACEP)
 Airway Management and Ventilation 603

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.

FIGURE 15-109  (Continued)

 Summary
Airway assessment and maintenance is the most critical step in managing any patient. If you do
not promptly establish a definitive airway and provide proper ventilation, the patient’s outcome
will be poor. Frequently reassessing the airway is mandatory to ensure that the patient has not
decompensated, requiring additional airway procedures. Successful management of all airways
requires the paramedic to follow the proper management sequence.
Basic airway and management skills can make the difference between a successful outcome
and a poor patient prognosis. Once you have mastered these basic skills and made them a part of
airway management in every patient, you should learn and use advanced skills such as intuba-
tion, RSI, and cricothyrotomy. You must maintain proficiency in all airway skills, especially the
more advanced techniques, through ongoing continuing education, physician medical direction,
and testing with each EMS service. If you cannot do this, it is in the patient’s best interest to focus
on less sophisticated airway skills. If you anticipate that every airway will be complicated, apply
basic airway skills before using advanced procedures, and perform frequent reassessments, you
will give the patient his best chance for meaningful survival.

You Make the Call

You and your paramedic partner, Preston Connelly, are assigned to District 4, a quiet suburban
neighborhood, on a warm Saturday in June. At 2:00 P.M., you are dispatched to care for a chok-
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
bystanders at the scene. On arrival, you find a frantic mother who tells you that her 6-year-old
son was eating a hot dog and drinking a soda when he started coughing and gasping for air. She
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
6-year-old boy lying on the floor, unconscious and apneic, with a pulse rate of 130. There is cya-
nosis surrounding his lips and fingernail beds, with a moderate amount of secretions coming
from his mouth. There are no signs of trauma. You and Preston immediately start management
of this child.
1. What is your primary assessment and management of this child?
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.

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”

Chapter 5—EMS Research 7. Carbon monoxide detector installing

8. Environmental assessments of homes of the elderly
1. What is your study’s hypothesis?
(heat or cold assessment)
The incidence of narcotic overdoses in our EMS system
9. Vial of life/file of life or other medical information
is low.
programs
2. Did you prove or disprove your hypothesis?
10. Stroke and heart attack awareness programs
Although the term “incidence” is not precise, overall the
number of narcotic overdoses in the system is relatively low.
To get a better handle on the issue, it would be appropriate, Chapter 7—Medical/Legal Aspects
if possible, to compare your system’s incidence of narcotic of Out-of-Hospital Care
overdoses to systems of similar size and demographics. 1. You believe that the child needs emergency care, but the
3. What was the derived benefit from the study? child’s parents are unavailable. What should you do?
The increased awareness of the low incidence of nar- Begin emergency care under the doctrine of implied
cotic overdoses in the system resulted in, at least temporar- consent.
ily, decreased overall usage of naloxone. 2. If you decide to treat the child without consent, can you be
sued for doing so?
Chapter 6—Public Health You can be sued for anything. But, in this case, assum-
ing a responsible family member could not be located, you
1. How will you counter the arguments the two paramedics
would be rendering care for an apparent life-threatening
made?
injury or illness under the doctrine of implied consent.
The fire service has been doing prevention and safety
3. What would you do if the parents returned home and refused
programs for years now, and they still have jobs. As long as
to grant permission for treatment?
there are people, there will always be a need for EMS. By
doing prevention programs, we are offering another public Make multiple and sincere attempts to convince the
service and making our community safer. Not to mention, parents to accept care for their child; make certain that they
if we can prevent slips, trips, falls, and other minor injuries, are fully informed about the implications of their decision
we will be more available for the truly life-threatening and the potential risks of refusing care; consult with on-line
emergencies. The scope of practice for paramedics is con- medical direction; have them and a disinterested witness,
stantly being expanded, but patient care and safety are still such as a police officer, sign a “release-from-liability” form;
our number one priorities. advise them that they may call you again for help if neces-
sary; document the entire situation thoroughly on your
2. Why is prevention an important responsibility of being
patient care report.
a paramedic?
As paramedics, we are part of the medical community.
In order for us to be recognized as a profession within the
Chapter 8—Ethics in Paramedicine
medical community, we need to fully participate in the 1. What potential benefits are there in yielding to the patient’s
medical community. Part of medicine is preventive medi- request (beneficence)?
cine, health education, and controlling communicable dis- The potential benefits in yielding to the patient’s
eases. These are the basic principles of public health and an request are those involving doing good (beneficence). In
under-addressed area of EMS. Prevention strategies help this case, that would mean possibly getting to the hospital
prevent the spread of communicable diseases through Stan- faster and thereby lessening the time the patient has to suf-
dard Precautions training. Additional prevention strategies fer severe pain.
help reduce injuries and long-term disability from injuries.
2. What potential harm is there in yielding to the patient’s
3. List ten ideas for an illness and injury prevention program request (nonmaleficence)?
that may be appropriate in your area. (Answers might
Nonmaleficence refers to the paramedic’s obligation to
include any of the following suggestions or others.)
“first, do no harm.” In this case, staying within the service’s
1. Seat belt campaigns policy restrictions could be described as causing the patient
2. First aid & CPR classes to suffer pain longer than may be necessary. However, if
3. Swimming lessons you consider why the policy restricts the use of lights and
siren (because they increase the risk of vehicle collision),
4. Car seat safety classes
perhaps the obligation to do no harm is better met by stay-
5. Helmet and protective padding initiatives for kids ing within those restrictions and avoiding the risk of fur-
6. Home assessments for the elderly ther injury or further delay.
 Suggested Responses to “You Make the Call” 613

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”

Chapter 12—Pathophysiology which may increase cardiac output and, subsequently,

blood pressure.
1. Explain the physiologic basis for the patient’s apparent
2. What was the purpose of the dopamine infusion?
dehydration.
Dopamine was given to increase cardiac output. The
As blood glucose levels start to rise, glucose is lost into
patient is suffering from cardiogenic shock with pulmo-
the urine through the kidneys. This typically occurs when
nary edema and needs to have his blood pressure increased.
the blood glucose level exceeds 180 mg/dL. The glucose
Raising his cardiac output with dopamine is preferable to
molecules have osmotic properties. Thus, they take water
increasing his peripheral vascular resistance (afterload),
molecules with them into the urine. This phenomenon,
because his obvious difficulty overcoming existing after-
called osmotic diuresis, ultimately causes a decrease in
load is causing the pulmonary edema.
intravascular fluid volume resulting in dehydration. This
causes tachycardia and ultimately a fall in blood pressure. 3. What is atropine’s mechanism of action?
Also, it is the pathophysiologic basis for the polyuria Atropine is a parasympatholytic that blocks the effects
(excessive urination) and polydipsia (excessive thirst) asso- of acetylcholine at the muscarinic receptors, specifically
ciated with untreated diabetes. those at the heart’s SA and AV nodes, which regulate heart
2. Describe the role of insulin in glucose transport into the cell. rate. A side effect of succinylcholine administration is bra-
dycardia (the physical act of intubation may also cause bra-
Insulin is necessary for the transport of the glucose
dycardia). Atropine is therefore given as a prophylactic
molecule into the cell (except for cells in the brain). Insulin
treatment against expected bradycardia. This bradycardic
activates specialized glucose transport proteins present on
side effect is most notable in pediatric patients.
the surface of the cell. If insulin levels are inadequate, then
glucose cannot enter the cell to fuel the various metabolic 4. Why was midazolam administered before succinylcholine?
processes. This causes the cells to shift to a less-effective Midazolam is a sedative with amnesic properties.
form of metabolism (anaerobic metabolism and lipid Succinylcholine is a neuromuscular blocker that induces
metabolism), ultimately resulting in the accumulation of muscular paralysis without affecting consciousness. This
acids and ketones. As ketones rise, they are eliminated would be a very unpleasant sensation, so some type of
through the urine and the respiratory tract. When this sedation or anesthesia is given before any neuromuscu-
occurs, the characteristic odor of ketones can often be lar blockade.
detected on the breath and in the urine. 5. What are succinylcholine’s classification and mechanism of
3. Prepare a prehospital treatment plan given the information action?
provided. Succinylcholine is a depolarizing (fasciculating) neuro-
Prehospital treatment should first address the airway muscular blocker that is given to induce paralysis. This is
and breathing. If necessary, provide airway and respiratory most frequently done to facilitate intubation in rapid
support. In most cases, the airway will be patent. Supple- sequence intubation. It acts by competing with acetylcholine
mental oxygen should be administered via a nonrebreather at the nicotinic receptors. When succinylcholine binds with
mask if the patient is hypoxic. Then, an IV should be started these receptors, it causes depolarization much like acetylcho-
with an isotonic crystalloid solution such as normal saline. line; however, it remains bound to the receptor and prevents
Often the patient will require several liters of fluid to repolarization and subsequent depolarization of the muscle.
replace lost volume. Later, the patient will require intrave- This in turn prevents muscle contraction and causes paraly-
nous insulin to move the glucose into the cells for normal sis. Pseudocholinesterase, an enzyme similar to acetylcholin-
metabolic processes. This is often administered in the form esterase, eventually breaks down succinylcholine.
of an insulin drip. Blood glucose levels must be constantly
monitored to prevent iatrogenic hypoglycemia.
Chapter 14—Intravenous Access
and Medication Administration
Chapter 13—Emergency
1. Before administering aspirin or any other medication orally
Pharmacology (p.o.), what major consideration must you be sure of?
1. What is dopamine and what is its mechanism of action? When administering a medication orally, or by way of
It is a catecholamine that stimulates alpha, beta, and, the mouth and enteral tract, you must make sure that the
supposedly, dopaminergic receptors. It was given in moder- patient has an adequate level of consciousness and can sup-
ate dosage, which stimulates the beta receptors more than port his airway. Administering a medication orally to a semi-
the others. This increases the force of cardiac contraction, conscious or unresponsive patient who cannot support his
 Suggested Responses to “You Make the Call” 615

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.

Chapter 1— Chapter 4— Chapter 7—

Introduction Workforce Medical/Legal
to Paramedicine Safety and Aspects of Out-of-
1. c Wellness Hospital Care
2. d 1. a 1. a
3. a 2. c 2. d
4. d 3. c 3. b
5. c 4. d 4. a
5. d 5. c
6. 6.
Chapter 2— c c
7. b 7. d
EMS Systems 8. b 8. c
1. b 9. a 9. d
2. b 10. d 10. d
3. c
4. b
5. a Chapter 5— Chapter 8—Ethics
6. b EMS Research in Paramedicine
7. c 1. b 1. b
8. b 2. b 2. c
9. b 3. a 3. a
10. a 4. b 4. a
5. a 5. d
6. d
Chapter 3—Roles 7. a
and Responsibilities of Chapter 9—EMS
the Paramedic Systems and
Chapter 6—Public Communications
1. b
2. c
Health 1. c
3. a 1. c 2. d
4. a 2. b 3. a
5. d 3. b 4. b
6. d 4. c 5. e
7. c 5. b 6. a
8. a 6. b 7. b

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

911, 167–168 Adipocytes, 289 organ donation, 139

Adipose tissue, 289 physician orders for life-sustaining
A Adjunct medications, 373, 375 treatment (POLST), 138–139
AACN (advanced automatic crash Administration, 49 Advanced automatic crash notification
notification), 168, 179 Administration tubing (AACN), 168, 179
Abandonment, 134 blood, 474 Advanced Emergency Medical
Abbreviations and acronyms, 188, defined, 472 Technicians (AEMTs), 3
189–193 electromechanical pump, 473 Aerobic metabolism, 303
ABCs, respiratory assessment, 528 extension, 473 Affinity, 368
ABO blood groups, 320–321 macrodrip, 472–473 Afterload, 300
Absorption, 363–364 measured volume administration against medical advice (AMA), 201
Abstract, 97 set, 473–474 Age
Accountability, legal, 125–128 microdrip, 472–473 as altering drug response factor, 371
Accreditation, 28 Administrative law, 122 disease and, 230
ACE (angiotensin-converting enzyme) Adolescence immune response and, 326
inhibitors, 410 family and, 217 Agonal respirations, 530
Acid-base balance, 251–252 physiologic development, 216–217 Agonist-antagonists
Acid-base disorders psychosocial development, 217 defined, 368
metabolic acidosis, 253–254 Adrenal cortex, 424–425 opioid, 375, 377
metabolic alkalosis, 254 Adrenergic agonists Agonists
respiratory acidosis, 252–253 defined, 397 adrenergic, 397–400
respiratory alkalosis, 253 effects of repeated doses, 397 beta2, 397
types of, 252 specificity, 400 defined, 368
Acid-base reaction, 249 types of, 398–399 opioid, 373
Acidosis, 252 use of, 397 partial, 368
Acids, 249–250 Adrenergic antagonists, 400 AIDS (acquired immunodeficiency
ACN (automatic crash notification), 167 Adrenergic inhibiting agents, syndrome), 340–341
Acquired immune deficiencies, 340–341 409–410 Air embolism, 483
Acquired immunity, 317 Adrenergic receptors Air transport, 30–31
Acquired immunodeficiency effects of stimulation, 396 Airway management and ventilation.
syndrome (AIDS), 340–341 location of, 396 See also Respiratory system
Active transport, 259, 266, 362 specificity, 400 advanced automatic crash
Actual damages, 126 types of, 395 notification (AACN), 550–597
Acute, 232 Adrenergic synapses airway adjuncts, 545–547
Acute phase reactants, 334 defined, 388 basic, 540–550
Ad hoc database, 172 physiology of, 396 blind nasotracheal intubation,
Addendums, 196 Advance directives 571–573
Addison’s disease, 425 defined, 136 cricothyrotomy, 581–587
Adenosine, 407 Do Not Resuscitate (DNR) order, difficult airway, 592–597
Adenosine triphosphate (ATP), 245, 137–138 digital intubation, 573–575
246, 276–277, 304 living will, 136–137 documentation, 602–603

644
 Index 645

endotracheal intubation, 556–571 Alveoli, 519–520 angiotensin II receptor, 411

extraglottic airway (EGA) devices, Alzheimer’s disease, 299 beta adrenergic, 409
550–557 AMA (against medical advice), 201 beta1, 397
gastric distention and AMA Drug Evaluation, 355 combined alpha/beta, 410
decompression, 599–601 Ambulance defined, 368
introduction to, 515–516 crashes, 36, 79–80 dopamine, 421
intubation considerations, 575–581 electrical systems, 32 H2 receptor, 420
issues, 597–603 standards, 31–32 muscarinic cholinergic, 391–392
manual maneuvers, 544 “Star of Life” symbol, 32 nicotinic cholinergic, 391–392
medication-assisted intubation, Type I, 31 opioid, 375, 377
587–592 Type II, 31 serotonin, 421
negligence and malpractice Type III, 32 Anterior pituitary drugs, 424
suits, 561 Ambu®, 556 Antianginals, 413
oxygenation, 542–544 Amebiasis, 431 Antiarrhythmics
patients with stoma sites, 597–598 American College of Emergency adenosine, 407
positioning, 540–542 Physicians (ACEP) paper, 22 beta-blockers (class II), 407
suctioning, 598–599 Americans with Disabilities Act calcium channel blockers
transport ventilators, 601 (ADA), 141 (class IV), 407
ventilation, 547–550 Amphetamines, 379, 381 classifications and examples, 404
Airway obstruction Ampules defined, 403
causes of, 527–528 defined, 458–459 digoxin, 407–408
upper, 527 illustrated, 459 list of, 405–406
Airway pharmacology, 589–591 obtaining medication from, 459–460 magnesium, 408
Airways Amylopectin, 240 potassium channel blockers
adjuncts, 545–547 Amylose, 240 (class III), 407
backup, 556 Anabolism, 247 sodium channel blockers (class I),
difficult, 592–597 Anaerobic metabolism, 303 404–407
as high-risk area, 36 Analgesia, 373 Antiasthmatic medications, 416–417
as liability concern, 128 Analgesics Antibiotics, 430
maneuvers, 544 defined, 373 Antibodies
nasopharyngeal airway (NPA), nonopioid, 373–375, 376 as antigens, 323
545–546 Analysis of variance (ANOVA), 95 defined, 314
oropharyngeal airway (OPA), Anaphylaxis, 310–311 direct effects on antigens, 322
546–547 Anatomy/landmarks, charting functions of, 321–323
retroglottic, 551–554 abbreviations, 190–191 indirect effects on antigens, 322–323
supraglottic, 554–556 Anchor time, 76 monoclonal, 323
Albumin, 270, 470 Anesthesia, 373 Anticholinergics
Alcohol fermentation, 280 Anesthetics, 375 in asthma treatment, 417
ALI (automatic location Angiotensin, 306 defined, 391
identification), 167 Angiotensin II receptor antagonists, 411 muscarinic cholinergic antagonists,
Alkalosis, 252 Angiotensin-converting enzyme 391–392
Allergens, 338 (ACE), 306 nicotinic cholinergic antagonists, 392
Allergic reactions Angiotensin-converting enzyme in PUD treatment, 420
as drug administration (ACE) inhibitors, 410 Anticoagulants, 414–415, 483
response, 369 ANI (automatic number Antidepressant drugs, 383–385
as intravenous access identification), 167 Antidiuretic hormone (ADH), 268
complication, 482 Anions, 238, 264–265 Antidotes, 434–435
Allergies, 232, 336, 338 ANOVA (analysis of variance), 95 Antiemetics, 421, 422
Allied health professions, 51 Anoxia, 530 Antiepileptic drugs, 379
Allocation of resources, 155 Antacids, 420 Antifibrinolytics, 415
Allotypic antigens, 323 Antagonists Antifungal agents, 430
Alpha1 antagonists, 397, 410 adrenergic, 400 Antigen processing, 325
Alveolar volume, 526 alpha1, 397, 410 Antigen-antibody complexes, 322
646 Index

Antigen-binding sites, 321 Assessments ganglionic blocking agents, 392

Antigen-presenting cells (APCs), 325 community needs, 117 ganglionic stimulating agents, 392
Antigens narrative report, 198–199 neuromuscular blocking agents,
allotypic, 323 patient, 45 392, 393
antibodies as, 323 respiratory system, 528–540 parasympathetic nervous system,
blood group, 320–321 Asthma, 297 388–393
direct effects of antibodies on, 322 Atelectasis, 520 skeletal muscle relaxants, 400
HLA, 320 Atomic number, 235 sympathetic nervous system,
immunogen, 318–319 Atoms 393–400
indirect effects of antibodies on, defined, 235 Autonomy, 149
322–323 orbitals, 236
isotypic, 323 representation, 235 B
Antihistamines, 418 subatomic particles, 235 B cells, 326
Antihyperlipidemic agents, 415–416 valence shell, 236 B lymphocytes, 317, 321
Antihypertensives ATP (adenosine triphosphate), 245, Back safety, 63–65
adrenergic inhibiting agents, 246, 276–277, 304 Bacteria
409–410 Atrial natriuretic peptide (ANP), 301 defined, 314
angiotensin II, 411 Atrophy, 281 opsonization of, 322–323
angiotensin-converting enzyme Atropine, 589 Bag-valve-mask (BVM) ventilation.
(ACE), 410 Attachment, infant, 212 See also Ventilation
calcium channel blocking agents, 411 Attention deficit hyperactivity cricoid pressure, 548–549
defined, 408 disorder (ADHD), 381 defined, 548
direct vasodilators, 412–413 Attitudes, professional, 51 devices, 548
diuretics, 408–409 Atypical antipsychotics, 383–385 difficult, 592
Antimicrobial agents, 430–431 Aural medications, 449–450 optimal, 599–600
Antineoplastic agents, 428–430 Auscultation, 530–531, 567 pediatric patient, 549–550
Antiparasitic agents, 430–431 Authoritarian parents, 215 rapid sequence intubation (RSI), 548
Antiplatelet drugs, 414 Authoritative parents, 215 rule of threes, 549
Antipsychotic drugs, 382–383, 384 Autoimmune disease, 232, 339–340 Bandwidth, 177
Antiseizure drugs, 379, 381 Autoimmunity, 336, 339 Bare lymphocyte syndrome, 340
Antiseptics, 446 Automated external defibrillators Barotrauma, 582
Antiviral agents, 430 (AEDs), 27 Baseline membrane, 286
Anxious avoidant attachment, 213 Automatic crash notification Bases, 249–250
Anxious resistant attachment, 213 (ACN), 167 Basophils, 333
Apnea, 526, 538, 539 Automatic location identification Battery, 134–135
Apneic oxygenation, 563 (ALI), 167 Bench research, 93
Apoptosis Automatic number identification Beneficence, 149
defined, 281 (ANI), 167 Benign neoplasms, 233
occurrence of, 282–283 Autonomic ganglia, 387 Benzodiazepines, 591
pathological, 283 Autonomic nervous system Beta adrenergic antagonists, 409
physiologic, 283 anatomy and physiology of, Beta1 antagonists, 397
process of, 283 387–388 Beta2 agonists, 397
Appearance and personal hygiene, components of, 387 Beta2 specific agents, 416–417
53–54 defined, 387 Beta-blockers (class II), 407
Aprons, 69 parasympathetic nervous system, Beta-endorphins, 345
Arrhythmia generation, 403 388–393 Bias, 89
Arterial oxygen concentration sympathetic nervous system, Bicarbonate, 265
(CaO2), 523 394–400 Big Bang theory, 234
Arterial puncture, 482 Autonomic nervous system Bilevel positive airway pressure
Arthrus reaction, 338 medications (BiPAP), 544
Asepsis, 445–446 adrenergic agonists, 397–400 Bioassay, 357
Aspiration, 518, 527–528, 562 adrenergic antagonists, 400 Bioavailability, 364
Assault, 134–135 anticholinergics, 391–392 Bioequivalence, 357
Assay, 357 cholinergics, 390–391 Biologic half-life, 370
 Index 647

Biological chemicals, 239–248 Buffers, 250 concentrations in blood, 524

Biotransformation, 365–366 Burette chamber, 473–474 defined, 516
Biot’s respirations, 530 Burnout, 76 measurement of, 522–524
Bipolar disorder, 299, 385 BURP airway maneuver, 570 Carbonic acid-bicarbonate buffer
Blind nasotracheal intubation, BVM. See Bag-valve-mask (BVM) system, 250–251
571–573 ventilation Carboxyhemoglobin, 534
Blood Bystanders, 14 Carcinogenesis, 294–295
carbon dioxide concentrations in, Cardiac conductive system, 401
523–524 C Cardiac contractile force, 300
components of, 268–269 Calcium, 265 Cardiac contractile tissue, action
as connective tissue, 290 Calcium channel blockers (class IV), potential, 402
drawing, 491, 492–494 407 Cardiac cycle, 401–403
as intravenous solution, 471 Calcium channel blocking agents, 411 Cardiac muscle, 291
oxygen concentration in, 523–524 Call coordination, 169–170 Cardiac output, 300
transfusion reaction, 269 Call incident format, 200 Cardiogenic shock, 307–308
Blood administration tubing, 474 Call routing, 167 Cardiology, charting abbreviations, 193
Blood flow, 302, 401 Call volume, 177–178 Cardiomyopathy, 298
Blood group antigens, 320–321 Cancer Cardiopulmonary resuscitation
Blood tubes, 492 breast, 297 (CPR), 26
Blood tubing cells, 295 Cardiovascular disorders, 298
defined, 474 colorectal, 297 Cardiovascular drugs
illustrated, 474 genetic and environmental antiarrhythmics, 403–408
intravenous access with, 480–481 causes, 297 antihyperlipidemic agents,
Blood-brain barrier, 365 lung, 297 415–416
Body, hierarchical structure of, Cancer-treating drugs, 428–430 antihypertensive, 408–413
229–230 Cannabinoids, 421 classes of, 403–416
Body substance isolation (BSI). See Cannulas hemostatic agents, 414–415
Standard Precautions abutting vein wall, 481–482 Cardiovascular system
Body systems catheter inserted through the arrhythmia generation, 403
changes in toddler/preschool age needle, 476 drugs used to affect, 400–416
children, 214 hollow-needle catheter, 475 heart, 300, 401
charting abbreviations, 189 intravenous, 475–476 impulse generation and conduction,
narrative approach, 198 nasal, 543 401–403
Bolus, 457 over-the-needle catheter, 475 infancy, 210–211
Bonding, 212 Cannulation. See Intravenous access late adulthood, 219
Bone Injection Gun (B.I.G.), 496, 497 CaO2 (arterial oxygen physiology, 400–403
“Borrowed servant” doctrine, 127–128 concentration), 523 toddler/preschool age children, 214
Boundary issues, 134 Capillaries, 301, 302 Carrier proteins, 258
Brain natriuretic peptide (BNP), 301 Capnograms, 535, 537 Carrier-mediated diffusion, 362
Breach of duty, 125 Capnography Cartilage, 290
Breast cancer, 297 basic rules of, 536 Case report, 92
Breathing clinical applications, 538–540 Case series, 92
paradoxical, 528 colorimetric devices, 535–536 Catecholamines, 300, 343–344
in stress management, 77 defined, 534–535 Catheters
Bronchi, 519 infrared devices, 536–537 hollow-needle, 475
Bruton agammaglobulinemia, 340 mainstream, 536–537 inserted through the needle, 476
Bubble sheets, 186 peak expiratory flow testing, 540 over-the-needle, 475
Buccal medications, 448–449 pulse oximetry comparison, 532 patency, 482
Buffer systems sidestream, 536–537 shear, 482
carbonic acid-bicarbonate, terminology, 535 suctioning, 599
250–251 in verification of proper tube Cations, 238, 264–265
phosphate, 251 placement, 567 Cell adhesion molecules (CAMs), 256
protein, 251 Carbohydrates, 240–241 Cell differentiation, 292, 295
types of, 250 Carbon dioxide Cell membrane, 255
648 Index

Cell-mediated immune response, 318, notation, 263 Combined alpha/beta

319, 324 organic, 239 antagonists, 410
Cells Chemoreceptors, 252, 525 Common complaints, charting
abnormal development, 292 Chemotactic factors, 329 abbreviations, 189
B, 326 Chemotaxis, 329 Common law, 122
cancer, 295 Chemotherapy, 430 Common operating picture (COP), 171
death of, 281 Cheyne-Stokes respirations, 530 Communications
defined, 175, 254 Chi square test, 95 areas of, 162
dysplastic, 292 Chloride, 265 basic model, 163
eukaryotic, 254, 271 Cholecystitis, 299 defined, 163
injury, 281–283 Cholinergic synapses digital, 174–175
internal, 271–276 defined, 388 documentation, 188–193
mast, 289, 328–330 physiology of, 390 echo procedure, 165
memory, 321 Cholinergics, 390–391 effective, 27–28, 162
nucleus, 254, 271–272 Chromatin, 272 EMD, 27–28
organelles, 254, 271–275 Chromosomes, 272 EMS, 159–181
polymorphonuclear, 332 Chronic, 232 EMS dispatch, 28
prokaryotic, 254, 271 Chronic ambulatory peritoneal hardware and software, 27–28
stem, 291 dialysis (CAPD), 454 as high-risk area, 36
T, 324, 326 Chronic inflammatory responses, 334 importance in EMS response,
Cellular adaptation Chronic mucocutaneous 166–171
atrophy, 281 candidiasis, 340 introduction to, 162
defined, 280 Cilia, 276 medical capabilities, 27–28
hyperplasia, 280 Circadian rhythms, 76 mission-critical, 175
hypertrophy, 280–281 Circulatory overload, 483 operational capabilities, 27–28
illustrated, 280 Circulatory system, 299–302 as professional attribute, 54
metaplasia, 281 Cisternae, 273 protocols, 164
Cellular respiration, 276, 277 Citizen involvement, 50 public safety, 180
Cellular telephone system, 175 Citric acid cycle, 277, 279 radio, 173–177
Cellulose, 241 Civil law, 122 radio procedures, 164–165
Centers for Disease Control (CDC), Civil lawsuits, 122–123 reporting procedures, 164
68, 69 Civil rights, 128 semantic, 180
Central nervous system (CNS) Cleaning, 70 standard format, 164
medications, 372–387 Clinical presentation, 232 technology, 171–179
stimulants, 379–381 Clinical protocols, 25–26 10-code systems, 163
Central neurogenic Clonal diversity, 321 terminology, 165–166
hyperventilation, 530 Clonal selection, 321 transfer, 170–171
Central venous access, 470 Clotting system, 331 verbal, 163–165
Centrally acting adrenergic Coagulation system, 331 written, 165
inhibitors, 409 Code Green Campaign, 78 Community involvement, 49–50
Centrioles, 275, 276 Codes of ethics, 148 Community needs assessment, 117
Certification, 29, 124 Coenzymes, 243 Community paramedicine, 4, 178
Cervical dysplasia, 283–284 Cofactors, 243 Community resources, 116
Chain of survival, 23 Cognition, toddler/preschool age Compensated shock, 306
CHART format, 199–200 children, 214 Competence, patient, 130
Chemical bonding Cognitive radio, 177 Competitive antagonism, 369
covalent bonds, 237 Cohn’s disease, 298–299 Complement system, 330–331
hydrogen bonds, 238–239 Cohort study, 91 Compliance, 531–532
ionic bonds, 238 Collagen, 289 Complications, 232
overview of, 237 Colloid osmotic pressure, 267 Compounds, 239
Chemical reactions, 264 Colloidal solutions, 470–471 Computer uses, 176
Chemicals Colloids, 270 Concentration, 249, 503
biological, classes of, 239 Colorectal cancer, 297 Concentration gradient, 257
inorganic, 239 Colorimetric devices, 535–536 Confidence interval, 95
 Index 649

Confidentiality licensure, certification, registration, Crime and accident scenes, 139

documentation and, 140 and reciprocity, 29 Criminal law, 122
as ethical issue, 153–154 medical oversight, 25–26 Cristae, 275
in paramedic-patient relationship, mutual aid and mass-casualty Critical care transport (CCT), 6–7
128–130 preparation, 33 Critical Incident Stress Debriefing
Congenital diseases, 233 oversight by local-/state-level (CISD), 78
Congenital immune deficiencies, agencies, 24 Critical Incident Stress Management
340–341 patient transportation, 30–32 (CISM), 78
Congenital metabolic diseases, 243 public information and education, Cross tolerance, 370
Congestive heart failure (CHF), 301 26–27 Cross-sectional study, 92
Connective tissues, 286 quality assurance and Crying, infant, 212
Consent. See also Paramedic-patient improvement, 33–36 Crystalloids, 270, 471
relationship receiving facilities, 32–33 Cuff pressure, monitoring, 580–581
abandonment and, 134 research, 36–37 Cumulative effect, drug, 370
assault and battery and, system financing, 38 Curare cleft, 538
134–135 Contraction, 335 Cushing’s disease, 425
boundary issues and, 134 Contracture, 336 Customer satisfaction, 35
defined, 130 Control group, 89 Cyanide, 279
as ethical issue, 154–155 Controlled Substances Act of 1970, Cyanosis, 530
expressed, 130–131 356, 357 Cytokines, 325, 333
false imprisonment and, 135 Convenience sampling, 100 Cytoplasm, 255
implied, 131 Conventional reasoning, 216 Cytoskeleton, 275–276
informed, 130 CookGas air-Q®, 556 Cytotoxic metabolite, 282
involuntary, 131 COP (common operating picture), 171
legal complications related to, Coping, stress and, 346–347 D
134–135 Cormack and LeHane grading Data dictionaries, 165
patient competence and, 130 system, 594 Data dredging, 100
patients with mental disorders Coronary artery disease, 298, 415 Data mining, 100
and, 134 Corrections medicine, 8, 9 Dead space volume, 526
problem patients and, 132–134 Corrective tissues Dead spots, 171
reasonable force and, 135 cell types in, 289 Death and dying
refusal of service, 132, 133 characteristics of, 289 challenging nature of, 71–72
religious/cultural beliefs and, 132 classes of, 289–290 field pronouncements, 74
special situations, 131 types and locations illustration, 288 late adulthood, 221
withdrawal of, 131–132 types of, 289 loss, grief, mourning, 72–73
Constipation, drugs for, 420 Corticoids, 424–425 responses to, 72
Constitutional law, 122 Corticotropin-releasing factor someone you know and, 74
Contaminated equipment/sharps, (CRF), 343 what to say and, 73–74
disposal of, 446 Cortisol, 344–345 Death in the field, 139
Continuing education, 29, 55 Cough suppressants, 419 Death pronouncements, 36
Continuous positive airway pressure Covalent bonds, 237 Debridement, 335
(CPAP) devices, 443, 544 CPAP (continuous positive airway Decompensated shock, 306–307
Continuous quality improvement pressure) devices, 443, 544 Decontamination of equipment, 70
(CQI), 34 Crackles (rales), 531 Defamation, 129
Continuum of care Cricoid pressure, 517, 548–549 Degranulation, 328
communications, 27–28 Cricothyroid membrane, 518 Dehydration, 262–263
components for, 23–38 Cricothyrotomy Delayed hypersensitivity
education quality, 24 anatomic landmarks for, 582 reactions, 336
evidence-based medicine (EBM), difficult, 592 Delivery of service, 55
37–38 indications warranting, 581–582 Demand-valve device, 550
information access, 30 minimally invasive Denaturation, 243
initial and continuing education, percutaneous, 587 Dental system, toddler/preschool age
28–29 needle, 581, 582–584 children, 214
levels of licensure/certification, 24 open, 581, 584–587 Deontological method, 147
650 Index

Deoxyribonucleic acid (DNA), Disaccharides, 240 administrative use, 185

244, 245 Disaster management, 110 airway management and
Department of Homeland Security, 21 Disaster mental health services, 78–79 ventilation, 602–603
Dependent variables, 89 Disease communications, 188–193
Descriptive statistics, 94–95 acute, 232 completeness and accuracy, 194–196
Dextran, 470–471 age and, 230 electronic patient care records,
Diabetes autoimmune, 232 204–205
causes of, 297 body defenses against, 314–347 good, elements of, 194–197
defined, 425 at cellular level, 254–284 importance of, 140
hyperglycemic agents and, 427 at chemical level, 234–254 inappropriate, consequences of,
hypoglycemic agents and, 426–427 chronic, 232 203–204
insulin and, 425–426 classification of, 232–234 introduction to, 184–185
type 1, 297, 425 clinical presentation, 232 legal use, 185
type 2, 297, 425 congenital, 233 as legal-medical issue, 140–141
Diagnoses defined, 229 legibility, 196
charting abbreviations, 189–190 environment and, 230–231 medical records, 140–141
defined, 232 gender and, 230 medical terminology, 186–188
field, 198 genetic, 233, 295–296 medical use, 185
Diagnostic and Statistical Manual of iatrogenic, 233–234 medication administration, 446–447
Mental Disorders, fifth edition idiopathic, 231 multiple casualty incidents, 202–203
(DSM-5), 382, 383, 385 immunologic, 232 narrative writing, 197–200
Diapedesis, 332 infectious, 232 oral statements, 194
Diarrhea, drugs for, 420 inflammatory, 232 as paramedic responsibility, 48–49
Diet, drugs used to supplement, 433 ischemic, 232 patient care report, 140
Difficult airway lifestyle and, 230 patient refusals, 201
concept, 592 metabolic, 232–233 pertinent negatives, 193–194
Cormack and LeHane grading nutritional, 233 as prevention strategy, 115
system, 594 at organ level, 295–314 professionalism, 197
defined, 592 predisposing factors, 230–231 in research, 185
difficulty prediction, 596–597 risk factors, 231 right, 360, 444
effects of obesity, 596 stress and, 341–347 services not needed, 201–202
LEMONS acronym for evaluation, at tissue level, 283–294 timeliness, 196
594–596 Disease surveillance, 110 times, 188
Mallampati classification system, Disinfectants, 446 uses for, 185–186
593–594 Disinfection, 70 Dosages
management algorithm, 596 Disposition calculating for oral medications,
POGO scoring system, 594 appropriate, 46–48 503–507
predictors of, 593 primary care, 48 desired, 503
scoring systems, 593–594 receiving facilities, 46 on hand, 503
Difficult child, 213 transportation, 46 for infants and children, 507
Diffusion treat and release, 48 for parenteral medications, 505
carrier-mediated, 362 Dissociation reaction, 249 ratio proportion, 505
defined, 363, 523 Distribution, 364–365 right, 360, 444
facilitated, 258–259, 266, 362 Diuretics, 408–409 volume formula, 504
illustrated, 363 DNA (deoxyribonucleic acid), 244, 245 weight-dependent, 505–506
in oxygen and carbon dioxide Do Not Resuscitate (DNR) order. See Dose packaging, 360
measurement, 523 also Resuscitation issues Double blind study, 90
simple, 256–257 as advance directive, 137–138 Down-regulation, 368
DiGeorge syndrome, 340 defined, 136 Drawing blood
Digestion, drugs used to aid, 421 illustrated, 138 blood tubes for, 492
Digital communications, 174–175 Documentation directly from vein, 493–494
Digital intubation, 573–575 abbreviations and acronyms, 188 equipment for, 492
Digoxin (Lanoxin), 407–408 absence of alterations, 196 from an IV catheter, 492–493
Diplomacy, 54 additional resources, 194 for law enforcement, 490
 Index 651

process of, 492–494 antiarrhythmic, 403–408 profile components, 355–356

with syringe, 493 antiasthmatic, 416–417 prototypes, 372
when to draw samples, 492 antibiotic, 430 reference materials, 355
Drip chambers, 472, 482 anticholinergic, 391–392 research, 357–359
Drip rate, 472 anticoagulant, 414–415 for rhinitis and cough, 417–419
Drop former, 472 antidepressant, 383–385 schedules of, 357
Dropping patients, 36 antiepileptic, 379 sources of, 355
Drops, 472 antifibrinolytic, 415 storage of, 367
Drug response antihistamine, 418 in supplementing diet, 433, 434
drug relationship, 370–371 antihyperlipidemic agents, 415–416 teratogenic, 360
factors altering, 371 antihypertensive, 408–413 termination of action, 370
side effects, 369 antineoplastic agent, 428–430 uricosuric, 431
types of, 369–370 antiplatelet, 414 Duplex, 173–174
Drug routes, 366–367 antipsychotic, 382–383, 384 Duration of action, 370
Drug-drug interactions, 371 antiseizure, 379, 381 Duty to act, 125
Drugs. See also Medication cancer-treating, 428–430 Duty to report, 139–140
administration; Medications cardiovascular, 400–416 Dynamic steady state, 342–343
act by altering metabolic central nervous system, 372–387 Dysfunctional healing
pathway, 369 cholinergic, 390–391 inflammation, 335–336
act by binding to receptor site, classifying, 372 reconstruction, 336
367–369 constipation treatment, 420 Dysplasia, 283
act by changing physical defined, 354, 443 Dysplastic cells, 292
properties, 369 dependence, 370 Dyspnea, 530
act by chemically combining, 369 development timeline, 358
actions of, 367–369 diarrhea treatment, 420 E
affecting adrenal cortex, 424–425 as digestion aids, 421 Early adulthood, 218
affecting autonomic nervous dose packaging, 360 Early discharge, 115
system, 387–400 duration of action, 370 Ears, drugs used to affect, 423
affecting ears, 423 emesis treatment, 420–421 Ear-to-sternal-notch position, 540, 541
affecting endocrine system, 423 FDA classifications of newly Easy child, 213
affecting eyes, 421–423 approved, 359 EBM (evidence-based medicine),
affecting female reproductive fibrinolytic, 415 37–38
system, 427–428 first-pass effect, 365 Ebola virus disease (EVD), 68–69
affecting gastrointestinal system, forms of, 367 Echo procedure, 165
419–421 hemostatic agents, 414–415 Ectoderm, 285
affecting male reproductive in infectious disease treatment, Edema
system, 428 430–433 defined, 267
affecting nervous system, 372–400 in inflammation treatment, 430–433 at puncture site, 481
affecting pancreas, 425–427 interaction, 370 Education
affecting parasympathetic nervous legislation, 356–357 continuing, 29, 55
system, 388–393 minimum effective concentration, 370 of EMS providers, 111
affecting parathyroid/thyroid neuroleptic, 382 initial, 28–29
glands, 424 nonsteroidal anti-inflammatory, 431 public, 26–27
affecting pituitary gland, 423–424 onset of action, 370 quality of, 24
affecting respiratory system, over-the-counter (OTC), 357 on-scene, 115–116
416–419 in Parkinson’s disease treatment, Efficacy, 368
affecting sexual behavior, 428 386–387 EGTA® (Esophageal Gastric Tube
affecting skin, 433 in peptic ulcer disease (PUD) Airway), 554
affecting sympathetic nervous treatment, 419–420 Electrolytes
system, 394–400 phases of human studies, 358–359 administration of, 433
antagonism, 370 in poisoning and overdose defined, 264
anterior pituitary, 424 treatment, 433–435 dissociate, 264–265
antianxiety and sedative-hypnotic, posterior pituitary, 424 transport of, 265–266
378–379 prodrugs, 365 types of, 264–265
652 Index

Electromechanical devices, 490–491 in 1950s, 17–18 communications in, 166–171

Electromechanical pump tubing, 473 in 1960s, 18–19 detection and citizen access,
Electron shells, 236 in 1970s, 19 166–167
Electron transport chain, 277–278, 279 in 1980s, 19–20 emergency medical dispatch, 169
Electronic charting, 205 in 1990s, 20 medical direction physician
Electronic patient care records nineteenth century, 17 communication, 170
(ePCRs), 204–205 oversight by local-/state-level 911, 167–168
Electrons, 235 agencies, 24 sequence of communications in,
Elements patient transportation, 30–32 166–171
defined, 235 providers, 3 transfer communication, 170–171
metallic, 238 public health and, 111–113 EMS Technical Assessment Program,
nonmetallic, 238 public health strategies, 110–111 19–20
Elimination, 365–366 public information and education, EMT Code of Ethics, 52
Emancipated minors, 131 26–27 EMTs (Emergency Medical
Embolus, 474, 482 quality assurance and Technicians), 3
Emergency medical dispatcher improvement, 33–36 Endobronchial intubation, 563–564
(EMD), 27–28, 162, 169 receiving facilities, 32–33 Endocrine disorders, 297
Emergency Medical Responders reciprocity, 29 Endocrine secretions, 287, 288
(EMRs), 3 registration, 29 Endocrine system
Emergency Medical Services (EMS) research, 36–37 adrenal cortex, 424–425
systems. See also EMS response service types, 23 defined, 423
ancient times, 15–17 stresses, 77 drugs used to affect, 423–428
areas lacking, 21–22 system financing, 38 glands, 423
certification, 29 tactical, 7, 8 late adulthood, 219
chain of survival, 23 tiered response, 14 pancreas, 425–427
citizen involvement in, 50 of today, 22–23 parathyroid, 424
communications, 27–28, 159–181 twentieth century, 17–21 pituitary gland, 423–424
components for continuum of care, twenty-first century, 21–22 thyroid, 424
23–38 World War I and II and, 21–22 Endocytosis, 260
at crossroads, 21–22 Emergency Medical Services for Endoderm, 285
defined, 2 Children (EMSC), 20 Endogenous pyrogen, 333
early development, 15–17 Emergency Medical Services Systems Endoplasmic reticulum, 272
education quality, 24 Act, 19 Endotoxins, 315
EMS Agenda for the Future, 20–21 Emergency Medical Technicians Endotracheal intubation
EMS Technical Assessment Program (EMTs), 3 advantages/disadvantages of, 557
elements, 19–20 Emesis aspiration and, 562
evidence-based medicine (EBM), drugs used to treat, 420–421 complications of, 561–564
37–38 in SLUDGE, 390, 391, 434 defined, 556
health care system integration, Empathy, 53 elevated ICP and, 562
23–24 Employment laws, 141 endobronchial intubation and,
historical timeline, 16 EMRs (Emergency Medical 563–564
history of, 14–22 Responders), 3 endotracheal tube (ETT), 559, 560
information access, 30 EMS. See Emergency Medical Services endotracheal tube introducer, 560
initial and continuing education, (EMS) systems end-tidal CO2 detector, 561
28–29 EMS Agenda for the Future, 20–21 equipment, 557–561
introduction to, 14 EMS dispatch system, 28 equipment malfunction, 561–562
levels of licensure/certification, 24 EMS providers esophageal intubation and, 563
licensure, 29 commitment of, 112–113 hypoxemia and, 562–563
medical oversight, 25–26 education of, 111 improving success of, 569–571
modern, 5 empowerment of, 111 laryngoscope, 557–559
mutual aid and mass-casualty protection of, 111 with in-line stabilization, 576
preparation, 33 EMS response Magill forceps, 560, 561
in Napoleonic wars, 16 advanced automatic crash neck pressure management, 570
national report card, 22 notification (AACN), 168 ongoing practice, 569
 Index 653

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

Immunizations Inflammation Injury

recommended childhood acute, 329, 333–334 defined, 109
schedule, 432 cellular components, 332–333 prevention, 60, 111
at-risk populations, 116 cellular products, 333 risk, 109
for workforce safety, 70 characteristics of, 316 Injury surveillance program, 109
Immunizing agents, 431–433 chronic, 334 In-line intravenous fluid heaters,
Immunogens, 318–319 control of, 332 474–475
Immunoglobulins deficiencies in, 340–341 Inorganic chemicals, 239
classes of, 323 defined, 327 Insidious, 232
defined, 317 drugs used to treat, 430–433 Inspection, in respiratory
structure of, 321, 322 dysfunctional healing during, assessment, 530
Immunologic disorders, 232, 297 335–336 Inspiratory reserve volume (IRV), 526
Impartiality test, 152 functions of, 328 Institutional review board (IRB), 94
Implied consent, 131 illustrated, 328 Insufflates, 563
Incident reporting, 169–170 immune response contrasted with, Insulin. See also Diabetes
Incubation periods, 65 326–327 defined, 425
Independent variables, 89 mast cells and, 328–330 preparations, 425–426
Induced therapeutic hypothermia maturation, 335 Integrity, 53
(ITH), 471 overview, 327–328 Intentional tort, 125
Inducing agents, 589–590 phases of, 328 Interference, drug, 370
Industrial medicine, 8 plasma protein systems, 330–332 Interferons, 333
Infancy. See also Human life span reconstruction, 335 Interleukins (ILs), 333
development resolution and repair, 334–335 Internal validity, 93
cardiovascular system, 210–211 sequence events in, 332 Internet, 30
family processes and reciprocal start of, 316 Interoperability, 27
socialization, 212–213 Inflammatory diseases, 232 Interpersonal justifiability test, 152
immune system, 211 Inflammatory process, activation Interpersonal relations, 79
musculoskeletal system, 212 of, 323 Interstitial fluid, 261
nervous system, 211–212 Inflammatory response Intervener physician, 25
parental-separation reactions, 213 chronic, 334 Intracellular fluid (ICF), 261
physiologic development, 210–212 local, 334 Intracellular parasites, 315
psychosocial development, 212–213 systemic, 333–334 Intracranial pressure (ICP),
pulmonary system, 211 Information communications 562–563
renal system, 211 technology (ICT) Intradermal injection, 463–464
scaffolding, 213 applications, 178–179 Intramuscular injection
situational crisis, 213 defined, 172 administration, 468
temperament, 213 EMS applications, 178–179 after administration, 469
trust vs. mistrust, 213 medical quality video/imaging, 177 defined, 465–466
vital signs, 210 overview of, 171–172 deltoid muscle, 466
weight, 210 radio, 173–177 dorsal gluteal muscle, 467
Infants and children Informed consent, 130 equipment, 467–468
dosages and infusion rates for, 507 Infrared crowd disease detection, 178 illustrated, 466
public health, 115 Infusion controllers, 490 rectus femoris, 467
Infectious agents, 314–316 Infusion pumps, 490–491 sites illustration, 467
Infectious diseases Infusion rates vastus lateralis muscle, 467
common, 66 calculating, 506–507 Intraosseous infusion
control measures, 65–69 defined, 507 access site, 495–496
defined, 65, 232 fluid volume over time, complications and precautions,
drugs used to treat, 430–433 506–507 499–500
exposure procedure, 71 for infants and children, 507 contraindications to placement, 500
incubation periods, 65 medicated infusions, 506 defined, 494
pathogens, 65 Inhalation, 450 equipment for access, 496–497
Inferential statistics, 94, 95 Initial education programs, 28–29 medication administration
Infertility agents, 428 Injection, 450 illustration, 498–499
 Index 657

placement sites illustration, 495 heparin lock and saline lock, K

placing, 497–499 487–488 Kefauver-Harris Amendment, 356
Intraosseous needle, 496–497 venous access devices, 488–490 Ketamine, 590
Intravascular fluid, 261 Intubation King LT™ Airway, 554
Intravenous (IV) therapy blind nasotracheal, 571–573 Kinin system, 331
blood and blood components, 268 defined, 517 Knowledge-based failures, 35
defined, 268 difficult, 592 Krebs cycle, 277
fluid replacement, 269 digital, 573–575 Kussmaul’s respirations, 530
intravenous fluids, 270–271 endobronchial, 563–564
transfusion reaction, 269 endotracheal, 556–571 L
Intravenous access esophageal, 563 Lactated Ringer’s, 271, 471
administration tubing, 472–474 foreign body removal and, 577 Lactic acid fermentation, 278–279, 280
cannulas, 475–476 medication-assisted (MAI), 587–592 Lactose, 240
central venous, 469–470 monitoring cuff pressure and, Lactose intolerance, 298
changing IV bag/bottle and, 483 580–581 Laryngeal Mask Airway (LMA™), 555
complications of, 482–483 orotracheal technique, 564–566 Laryngeal spasm, 527
defined, 469 pediatric, 577–580 Laryngoscopes
equipment and supplies, 470–476 post-intubation agitation and, 581 blades, 558–559
in external jugular vein, 478–480 rapid sequence intubation (RSI), 571 defined, 557
flow rate factors, 481–482 retrograde, 568 elements of, 557
in hand, arm, and leg, 476–478 special considerations, 575–581 light source activation, 558
intravenous fluids and, 470–472 trauma patient, 575–576 optical, 568
in-line IV fluid heaters, 474–475 Intubrite™, 571 video, 568–569, 570–571
with measured volume Invasion of privacy, 130 Larynx, 517–518
administration set, 480–482 In vitro research, 93 Late adulthood
medication administration, In vivo research, 93 challenges, 221
483–492 Involuntary consent, 131 death and dying, 221
peripheral venous, 469–470 Ion channels, 259 financial burdens, 221
situations indicating, 469 Ionic bonds, 238 housing, 220–221
types of, 469–470 Ionize, 364 life expectancy, 219
ultrasound-guided, 491–492 Ions, 238, 263–264 maximum life span, 219
venous constricting band, 476 IRB (institutional review board), 94 physiologic development, 219–220
Intravenous bolus, 483–485 Irreversible antagonism, 369 psychosocial development, 220–221
Intravenous fluids Irreversible shock, 306 senses, 220
administration of, 489 Ischemia, 282 Laxatives, 420
blood, 471 Ischemic diseases, 232 Leadership, 52–53
colloidal solutions, 470–471 Isoimmune disease, 339–340 A Leadership Guide to Quality
crystalloids, 471 Isoimmune neutropenia, 339 Improvement for Emergency Medical
defined, 470 Isoimmunity, 336, 339 Services Systems, 33–34
isotonic, 270–271 Isometric exercise, 60 Legal accountability, 125–128
in-line heaters, 474–475 Isotonic exercise, 60 Legal protection, 124–125
packaging of, 471–472 Isotonic solutions, 257, 265, Legal system, 122
in prehospital care, 271 270, 471 Legal-medical issues
Intravenous medicated solutions, 463 Isotopes, 235 civil lawsuits, 122–123
Intravenous medication Isotypic antigens, 323 crime and accident scenes, 139
administration Iterative process, 88 documentation, 140–141
intravenous bolus, 483–485 IV catheters, 492–493 drugs, 356–357
intravenous medication infusion, duty to report, 139–140
485–487 J employment laws, 141
overview of, 483 Jargon, 197 ethics and, 147
Intravenous medication infusion Jaw-thrust maneuver (without head legal accountability, 125–128
administration technique, 485–486 extension), 544 legal duties and ethical
defined, 485 Jet ventilation technique, 582–584 responsibilities, 121–125
electromechanical devices, 490–491 Justice, 149 legal protection, 124–125
658 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

Pediatric patients drug-response relationship, 370–371 late adulthood, 219–220

bag-valve-mask (BVM) ventilation, factors altering drug response, 371 school-age children, 215–216
549–550 responses to drug administration, toddler/preschool age children,
drug administration, 360–361 369–370 213–214
endotracheal intubation on, 578–580 Pharmacokinetics Physiologic stress, 342, 346–347
ETT size, 577, 578 absorption, 363–364 PICC (peripheral inserted central
intraosseous infusion, 497 biotransformation, 365–366 catheter), 470, 488–489
intubation, 577–580 defined, 362 Pinocytosis, 260
Peer review, 25, 98 distribution, 364–365 Pitting edema, 267
Peer-group functions, toddler/ drug forms, 367 Pituitary gland
preschool age children, 215 drug routes, 366–367 anterior, 424
Peptic ulcer disease (PUD), 419–420 drug storage, 367 defined, 423
Peptic ulcers, 299 elimination, 366 drugs affecting, 423–424
Peptide bonds, 242 Pharmacology posterior, 424
Peptides, 242 airway, 589–591 Placebo, 91
Percutaneous medication basic, 354–371 Placental barrier, 365
administration defined, 354, 362 Plasma, 268–269
defined, 447 emergency, 351–436 Plasma membrane
mucous membranes, 448–450 general aspects of, 354–356 defined, 255
transdermal, 447–448 introduction to, 354 functions, 256–260
Perfusion legal aspects of, 356–357 mechanism of transport
circulatory system, 299–302 pharmacodynamics, 362, 367–371 across, 256
defined, 299 pharmacokinetics, 362–367 Plasma protein fraction
oxygen transport, 302 Pharyngeo-Tracheal Lumen Airway (plasmanate), 470
physiology of, 299–303 (PtL™), 553–554 Plasma protein systems
waste removal, 302–303 Pharynx, 517 coagulation system, 331
Peripheral adrenergic neuron blocking Phosphate, 265 complement system, 330–331
agents, 409–410 Phosphate buffer system, 251 control and interaction of,
Peripheral inserted central catheter Phospholipids, 246–247, 248 331–332
(PICC), 470, 488–489 Physical agents, 233 defined, 330
Peripheral IV removal, 494 Physical examination kinin system, 331
Peripheral vascular resistance, 300 charting abbreviations, 191 Plasma-level profiles, 370–371
Peripheral venous access. See also in respiratory assessment, 529–532 Platelet aggregation inhibitors, 414
Intravenous access Physical fitness Platelets, 333
advantage, 469 back safety, 63–65 Play, toddler/preschool age children,
complications of, 482–483 core elements, 60 214–215
defined, 469 EMS providers, 112 Pleura, 520
in external jugular vein, 478–480 habits and addictions, 63 Pneumatic anti-shock garments
in hand, arm, and leg, 476–478 isometric exercise, 60 (PASG), 38
illustrated, 477 isotonic exercise, 60 Pneumothorax, 524
sites, 469 nutrition, 61–63 POGO scoring system, 594
Peroxisomes, 274–275 obesity and, 61 pOH scale, 250
Personal protective equipment (PPE) sitting posture, 64 Poisoning, drugs used to treat,
defined, 66 standing posture, 64 433–435
for EVD, 69 target heart rate and, 61 Polar bonds, 238
minimum recommended, 66–68 Physician orders for life-sustaining Polar molecules, 238
Pertinent negatives, 193–194 treatment (POLST), 138–139 POLST (physician orders for life-
pH scale, 249–250 Physicians sustaining treatment), 138–139
Phagocytes, 332 intervener, 25 Polymers, 240
Phagocytosis, 260 medical direction, 162, 170 Polymorphonuclear cells, 332
Pharmacodynamics Physician’s Desk Reference, 355 Polypeptides, 242
actions of drugs, 367–369 Physiologic development Polysaccharides, 240
defined, 362 adolescence, 216–217 Population, 95
drug-drug interactions, 371 infancy, 210–212 Positional asphyxia, 128
 Index 663

Positioning. See also Airway in research, 185 Prostaglandins, 330

management and ventilation times, 188 Protection from disease
ear-to-sternal-notch position, uses for, 185–186 decontamination of equipment,
540, 541 Preload, 300 70–71
endotracheal intubation, 570 Preoxygenation, 588–589 Ebola virus disease (EVD), 68–69
ramped position, 541–542 Preparation, as primary responsibility, infection control measures, 65–69
sniffing position, 540–541 43–44 infectious diseases, 65, 66
Positive airway pressure (PAP), 544 Prevention, 109 post-exposure procedures, 70–71
Post hoc analysis, 102 Primary care Standard Precautions, 66–68
Postcapillary sphincter, 301 paramedic providing of, 48 standard safety precautions, 65
Postconventional reasoning, 216 support for, 50 vaccinations and screening tests, 70
Posterior pituitary drugs, 424 Primary immune response, 317 Protective gloves, 66
Post-exposure procedures, 70–71 Primary intention, 335 Protein buffer system, 251
Postganglionic nerves, 387 Primary percutaneous coronary Proteins
Post-traumatic stress disorder (PTSD), intervention (PPCI), 24 amino acids, 241–242
77–78 Primary prevention, 109 carrier, 258
Potassium, 264 Principal investigator (PI), 102 defined, 241
Potassium channel blockers Prions, 315–316 enzymes, 243
(class III), 407 Priority dispatching, 169 functions, 241
Potassium-sparing diuretics, 408–409 Prodrugs, 365 membrane, 255
Potentiation, 370 Profession, 29 structure, 242
Powered air purifying respirator Professional attitudes, 51 Proton pump inhibitors, 420
(PAPR), 69 Professional attributes Protons, 235
PPE. See Personal protective appearance and personal hygiene, Prototypes, drug, 372
equipment 53–54 Proximate cause, 126
Prearrival instructions, 28, 169 careful delivery of service, 55 PSAPs (public safety answering
Precapillary sphincter, 301 communication, 54 points), 167
Preconventional reasoning, 216 empathy, 53 Psychiatric disorders, 299
Predisposing factors, 230–231 integrity, 53 Psychological stress, 346
Prefixes, metric, 501, 504–505 leadership, 52–53 Psychoneuroimmunologic
Preganglionic nerves, 387 patient advocacy, 55 regulation, 343
Pregnant patients, drug respect, 54 Psychosocial development
administration, 360 self-confidence, 54 adolescence, 217
Prehospital care report (PCR). See also self-motivation, 53 infancy, 212–213
Documentation teamwork and diplomacy, 54 late adulthood, 220–221
abbreviations and acronyms, 188, time management, 54 school-age children, 216
189–193 Professional boundaries, 134 toddler/preschool age children,
absence of alterations, 196 Professional development, 50 214–215
administrative use, 185 Professional ethics, 51 Psychotherapeutic medications,
communications, 188–193 Professional journals/magazines, 30 381–385
completeness and accuracy, Professional organizations, 30 PtL™ (Pharyngeo-Tracheal Lumen
194–196 Professional relations, 156–157 Airway), 553–554
defined, 165, 184 Professionalism PTSD (post-traumatic stress disorder),
electronic (ePCR), 204–205 acting at highest level of, 34 77–78
format for, 187 defined, 50 Public health
goals of, 185 documentation, 197 accomplishments in, 108
legal use, 185 elements of, 50–55 basic principles of, 107
legibility, 196 Progestins, 427 defined, 107
medical terminology, 186–188 Prognosis, 232 early discharge, 115
medical use, 185 Prokaryotic cells, 254, 271 EMS and, 111–113
multiple casualty incidents, Prolactin, 345 EMS provider commitment, 112–113
202–203 Propofol, 590, 591 EMS roles in, 110–111
oral statements, 194 Prospective medical oversight, 25 epidemiology, 108–111
pertinent negatives, 193–194 Prospective study, 89 geriatric patients, 114–115
664 Index

Public health (continued ) Quality improvement (QI) Receiving facilities

impoverished populations, 115 continuous (CQI), 34 categorization, 33
infants and children, 114 continuous evaluation, 34 categorization by level of care, 47
introduction to, 107 as EMS element, 20 in EMS system, 32–33
laws, 108 patient safety, 35–36 services offered by, 46
medications, 115 as risk management strategy, 34 Receptors
motor vehicle collisions, 114 service quality and customer adrenergic, 395–397, 400
organizational commitment, 111 satisfaction, 35 defined, 367–368
overview illustration, 108 Quality of life, 86 muscarinic, 390
prevention in the community, Quantitative research, 88, 89 nicotinic, 390
114–117 Quantitative statistics, 95 opiate types, 373
prevention strategies, Quasiexperimental study, 89–90 stretch, 525
115–117 Reciprocity, 29
work and recreation hazards, 115 R Recognition of illness or injury, 45
Public Health Law Research Program Radio bands, 172 Reconstruction, 335, 336
(PHLRP), 108 Radio frequencies, 172 Rectal administration, 456–457
Public information and education, Radio procedures, 164–165 Reduction, 276
26–27 Radio technology Reflexes, infant, 211–212
Public safety answering points cell phones, 174–175 Reframing, 77
(PSAPs), 167 cognitive radio, 177 Refusal of care, 132, 133, 201, 202
Public safety communications, 180 computer use, 176 Regeneration, 334
Public service access points digital communications, 174–175 Registration, 29
(PSAPs), 23 duplex, 173–174 “Release-from-liability” form, 131
PubMed, 87, 99 mobile broadband, 175–176 Religious/cultural beliefs,
Pulmonary circulation, 522 multiband radio, 177 132, 147
Pulmonary embolism multiplex, 174 Renal (kidney) failure, 298
defined, 524 simplex, 173 Renal disorders, 298
intraosseous infusion and, 500 software-defined radio, Renal system
Pulmonary medication administration 176–177 infancy, 211
endotracheal tube, 451–452 trunking, 174 late adulthood, 220
inhalation, 450 Radio terminology, 166 toddler/preschool age
injection, 450 Radioactive isotopes, 235 children, 214
metered dose inhaler (MDI), Ramped position, 541–542 Renin-angiotensin-aldosterone
451–452 Random sampling, 100 system, 410, 411
nebulizer, 450–451 Randomized controlled trial (RCT), Repair, 334
Pulmonary system 90–91 Repeaters, 172
infancy, 211 Rapid sequence airway (RSA), 592 Replacement therapies, 341
toddler/preschool age Rapid sequence intubation (RSI) Res ipsa loquitur, 126
children, 214 airway pharmacology, 589–591 Research
Pulse CO oximeters, 533–534 defined, 548, 587–588 application of study results, 101
Pulse oximetry indications, 588 bench, 93
capnography comparison, 532 inducing agents, 589–590 bias, 89
CO, 533–534 neuromuscular blocking agents, drug, 357–359
defined, 532 590–591 EMS, 45, 84–104
oxygen saturation percentage premedications, 589–590 ethical considerations, 93–94
(SpO2), 533 preoxygenation, 588–589 as ethical issue, 157
Pulsus paradoxus, 530 procedure, 591–592 evidence-based decision making
Pus, 334 sedatives and analgesics, 591 and, 103–104
Pyrogens, 315, 482 using, 571 future, 37
Raynaud’s phenomenon, 338 introduction to, 86
Q RCT (randomized controlled trial), in vitro, 93
Qualitative research, 88, 89 90–91 in vivo, 93
Qualitative statistics, 95 Reasonable force, 135 mixed, 89
Quality assurance (QA), 34 Rebreathing, 538 open access journals, 98
 Index 665

outcomes-based, 86 Respiratory system. See also Airway Retrograde intubation, 568

participating in, 101–103 management and ventilation Retrospective medical oversight, 25
PCRs and, 186 alveoli, 519–520 Retrospective study, 89
program, 36–37 anatomy of, 516–521 Returning to service, 49
project components, 37 bronchi, 519 Rh blood group, 320
prospective study, 89 larynx, 517–518 Rh factor, 320
qualitative, 88, 89 late adulthood, 219 Rheumatic disorders, 298
quantitative, 88, 89 lower airway anatomy, 518–521 Rheumatoid arthritis, 339
retrospective study, 89 lung parenchyma, 520 Rhonchi, 531
scientific literature access, nasal cavity, 516–517 Ribonucleic acid (RNA), 244–245
98–99 oral cavity, 517 Ribosomes, 272
scientific method, 87–88 oxygen and carbon dioxide Risk analysis, 231
statistics, 94–97 measurement, 522–524 Roadway safety, 79–80, 112
study review, 100–101 pediatric airway, 520–521 Rocuronium, 591
types of, 88–89 pharynx, 517 Rooting reflex, 212
Research papers physiology of, 521–526 Rough endoplasmic reticulum (RER),
format for, 97 pleura, 520 272, 273
peer review, 98 pulmonary circulation, 522 RSI. See Rapid sequence intubation
publication of, 97–98 trachea, 518–519 Rules of evidence, 34–35
Residual volume (RV), 526 upper airway anatomy, 516–518 Rules-based failures, 35
Resolution, 334 Response, as primary responsibility, 44 Ryan White Comprehensive AIDS
Respect, 54 Response times, 185 Resources Emergency (CARE)
Respiration Responsibilities Act, 71, 125, 141
controls, 524–526 administration, 49
defined, 521 appropriate disposition, 46–48 S
function measurement, 526 citizen involvement in EMS, 50 SA (situational awareness), 171
initiation of, 525 community involvement, 49–50 SafeCom, 163
nervous controls of, 525 documentation, 48–49 Safety
regulation of, 524–526 patient assessment, 45 back, 63–65
Respiratory acid-base disorders, 252 patient management, 46 general considerations, 79–80
Respiratory acidosis, 252–253 patient transfer, 48 patient, 35, 36
Respiratory alkalosis, 253 personal and professional response team, 115
Respiratory assessment development, 50 roadway, 79–80, 112
ABCs, 528 preparation, 43–44 scene, 113
auscultation, 530–531 primary, 43–49 standard precautions, 65
history, 529 primary care support, 50 Salicylates, 375
inspection, 530 recognition of illness or injury, 45 Saline lock, 487–488
overview, 528 response, 44 Saline solution, 471
palpation, 531–532 return to service, 49 Sampling error, 95
physical examination, 529–532 scene size-up, 44–45 SaO2 (hemoglobin-oxygen saturation),
primary, 528–529 Restraint asphyxia, 128 523
secondary, 529–532 Restraint issues, 128 Saturated fatty acids, 245
Respiratory cycle, 521 Resuscitation attempts, 152–153 Scaffolding, 213
Respiratory monitoring Resuscitation equipment, 67 Scene hazards, recognizing, 115
capnography, 532, 534 Resuscitation issues Scene safety, 113
noninvasive, 532–540 advance directives, 136–139 Scene size-up, 44–45
overview, 532 death in the field, 139 Schizophrenia, 299
pulse CO oximetry, 533–534 Do Not Resuscitate (DNR) order, School-age children, 215–216
pulse oximetry, 532–533 136, 137–138 Science, 87
Respiratory problems ethics, 152–153 Scientific method, 87–88
airway obstruction, 527–528 living will, 136–137 Scope of practice
inadequate ventilation, 528 physician orders for life-sustaining areas, 6
overview, 526 treatment (POLST), 138–139 corrections medicine, 8, 9
Respiratory rate, 524 potential organ donation and, 139 critical care transport (CCT), 6–7
666 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

deficiencies caused by, 340 Surfactant laxatives, 420 Teratogens, 233

defined, 74, 342 Sympathetic nervous system Terminal-drop hypothesis, 221
disaster mental health services and, adrenergic receptors, 395–397 Termination of action, 370
78–79 defined, 394 Terrestrial triangulation, 168
disease and, 341–347 drugs used to affect, 394–400 Tertiary prevention, 109
EMS, 77 organization of, 395 Therapeutic index, 370
exhaustion phase, 75 postganglionic fibers Therapy regulator, 543
“good,” 74 distribution, 394 Thiazides, 409
immune system role in, 345–346 stimulation, 394–395 3-3-2 rule, 595
managing, 75, 112 Sympatholytics, 396 Threshold potential, 403
mental health services and, 78 Sympathomimetics, 396, 417 Thrombocytes, 268
physiologic, 342, 346–347 Symptoms, 232 Thrombophlebitis, 483
post-traumatic stress disorder Synapses Thrombus, 483
(PTSD) and, 77–78 adrenergic, 388, 396 Thyroid glands, 424
psychological, 346 cholinergic, 388, 390 Tidal volume, 526
resistance phase, 75 defined, 387 Tiered response, 14
response stages, 75 Syndromic surveillance, 179 Time management, 54
shift work and, 76 Synergism, 370 Time sampling, 100
techniques for managing, 77 Synthesis, 329–330 Timeliness, documentation, 196
triad of effects, 342 Syringes Times, 188
warning signs of, 76 defined, 457 Tissues
Stress responses endotracheal intubation, 560 adipose, 289
defined, 343 in intramuscular injections, 468 connective, 286, 288–290
effects of, 343 in obtaining medication from defined, 284
neuroendocrine regulation, 343–345 ampules, 459–460 epithelial, 286–288
Stressors, 74, 75, 342 in obtaining medication from vials, muscle, 286, 290–291
Stretch receptors, 525 460–461 nervous, 286, 291
Stroke volume, 300 prefilled or preloaded, 461–463 origin of, 284–286
Stylets, 560, 571 Systematic sampling, 100 Title VII, 141
Subcutaneous injection Systemic complications, 445 Toddler/preschool age children
administration of, 465, 466 Systemic immune system, 321 cognition, 214
defined, 464 Systemic inflammatory response divorce and, 215
illustrated, 465 syndrome, 312 modeling, 215
sites, 465 Systemic lupus erythematosus (SLE), parenting styles and, 215
Subjective narrative, 197 339–340 peer-group functions, 215
Sublingual medications, 448 physiologic development,
Substance abuse, 63 T 213–214
Substrates, 243 T cell receptor (TCR), 325 play, 214–215
Succinylcholine, 590–591 T cells, 324, 326 psychosocial development,
Sucking reflex, 212 T lymphocytes, 318, 324 214–215
Sucrose, 240 T test, 95 sibling relationships, 215
Suctioning Tachyphylaxis, 370 television/video games and, 215
catheters, 599 Tactical EMS, 7, 8 Tolerance, drug, 370
defined, 598 Target heart rate, 61 Tongue, in airway obstruction, 527
equipment, 598–599 Tay-Sachs disease, 275 Tonicity, 270
suction types, 598 Teachable moments, 26 Tort law, 122
techniques, 599 Teaching, 156 Total body water (TBW), 261, 262
tracheobronchial, 599 Teamwork, 54 Total lung capacity (TLC), 526
Sugars, 240 Tema Conter Memorial Trust, 78 Toxin-antitoxin complex, 322–323
Summation, drug, 370 Temperature conversion, 502 Trachea, 518–519
Suppositories, 457 10-code systems, 163 Tracheobronchial suctioning, 599
Supraglottic Airway Tendons, 290 Trachlight™, 571
Laryngopharyngeal Tube™ Tension pneumothorax, 564 Transdermal administration,
(S.A.L.T.®), 554 Teratogenic drugs, 360 447–448
668 Index

Transfer Type III immune-complex-mediated Ventilation/perfusion (V/Q)

communications, 170–171 reactions, 337–338 mismatch, 538
guidelines, 26 Type IV cell-mediated tissue Venturi mask, 543
as primary responsibility, 48 reactions, 338 Verbal communication. See also
Transfusion reaction, 269 Communications
Transport ventilators, 601 U radio procedures, 164–165
Transportation Ultrahigh frequency (UHF), 173 reporting procedures, 164
air, 30–31 Ultrasound-guided intravenous standard format, 164
ambulance, 31–32 access, 491–492 10-code systems, 163
decision, 46 Units, 502 Very high frequency (VHF), 173
effective, 30–32 Universalizability test, 152 Vials
guidelines, 26 Unsaturated fatty acids, 246 defined, 460
legal aspects, 135–136 Upper airway anatomy, 516–518 illustrated, 460
patient choice of destination Upper airway obstruction, 527 nonconstituted medication, 461, 462
and, 135 Up-regulation, 368 obtaining medication from,
as unnecessary, 201–202 Uricosuric drugs, 431 460–461
Trauma Uterine stimulants and relaxants, Video laryngoscopy, 568–569,
in airway obstruction, 527 427–428 570–571
care capabilities, 33 Viruses
deficiencies caused by, 340 V defined, 315
defined, 233 Vaccines, 431 neutralization of, 322–323
Trauma centers, 33, 47 Vacuoles, 274 Vital signs
Treat and release, 48 Vacutainer, 493 infancy, 210
Treatment group, 89 Valence electrons, 236 late adulthood, 219
Treatment guidelines, 26 Valence shell, 236 Vitamins and minerals, 433, 434
Treatments/dispositions, charting Validity, 93 Voice over Internet protocol
abbreviations, 192–193 Vallecula, 517 (VOIP), 169
Triage Variance, 95, 96 Volume on hand, 503
defined, 26 Vasodilators
tags, 201–202, 203 cardiac glycosides, 412 W
Tricyclic antidepressants (TCAs), classes of, 412 Warfarin (Coumadin), 414
383–385 direct, 412–413 Waste removal, 302–303
Triglycerides, 245, 246, 247 ganglionic blocking agents, 412 Water
Trocar, 496 Vecuronium, 591 free, 248–249
Trophoblasts, 325 Vein, drawing blood directly from, hydration, 262–263
Trunking, 174 493–494 movement between compartments,
Trust vs. mistrust, 213 Venous access devices, 488–490 266–267
Tuberculosis, 431 Venous blood sampling, 492–494 polarity, 248–249
Tumors Venous constricting band, 476 total body, 261
defined, 291 Ventilation. See also Airway transport of, 265–266
origins and names of, 293 management and ventilation as universal solvent, 248, 262
Tunnels, 488 bag-valve-mask (BVM), 548–550 Weight, infancy, 210
Turnover, 342 defined, 521 Weight conversion, 502
Twentieth century EMS, demand-valve device, 550 Wireless speech-to-text translation,
17–21 difficult, 592, 593 178
Twenty-first century EMS, inadequate, 528 Wiskott-Aldrich syndrome, 340
21–22 mouth-to-mask, 548 Work and recreation hazards, 115
Type 1 diabetes, 297, 425 mouth-to-mouth, 547 Work-related injury prevention, 60
Type 2 diabetes, 297, 425 mouth-to-nose, 547 Written communication, 165
Type I IgE reactions, 337 overview, 547
Type II tissue-specific perfusion mismatch, 524 Y
reactions, 337 transtracheal jet, 582 Years of productive life, 109