Paramedic Care Principles Practice, V3, 5e Bledsoe SM Completed with answers

Paramedic Care Principles Practice, V3, 5e Bledsoe SM Completed with answers Paramedic Care Principles Practice, V3, 5e Bledsoe SM Completed with answers Paramedic CarePrinciples _ Practice, V3, 5e Bledsoe SM©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 1 Detailed Lesson Plan Chapter 1 Pulmonology 170–180 Minutes Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes 5 I. Case Study Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture. 5 II. Introduction A. The respiratory system is a vital body system responsible for providing oxygen to the tissues and removing metabolic waste. B. Respiratory emergencies are among the most common emergencies EMS personnel are called upon to treat. C. Several risk factors increase the likelihood of developing respiratory disease. 1.Intrinsic risk factors are those that are influenced from within the patient. The most important intrinsic risk factor is genetic predisposition. 2.Extrinsic risk factors are those that are external to the patient. The most important extrinsic risk factor is cigarette smoking. Teaching Tips Respiratory emergencies are some of the most common responses for the EMS provider. It is important for students to understand the importance of managing respiratory emergencies. 10 III. Review of Respiratory System Anatomy and Physiology A. Upper Airway Anatomy 1.The upper airway is responsible for warming and humidifying incoming air. 2.The nasal cavity includes turbinates, which cause turbulence that facilitates the entrapment and removal of inhaled foreign particles. 3.The pharynx is a funnel-shaped structure that connects the nose and mouth to the larynx. 4.In addition to its role in speech, the larynx serves as a filtering device for the Teaching Tips This is a review of material previously discussed. Revisit the previous topics concerning the anatomy of the respiratory system. Class Activities Because this is review material, MASTER TEACHING NOTES  Teaching Tips  Discussion Topics  Class Activities  Points to Emphasize  Knowledge Application©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 2 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes digestive and respiratory tracts. a. The opening between the vestibule and the vocal cords is the glottic opening. b. The epiglottis closes during swallowing to divert food/liquids into the esophagus. B. Lower Airway Anatomy 1.The lower airway begins at the trachea and continues into the lungs. 2.The trachea is composed of a series of C-shaped cartilaginous rings and is lined with the same type of cells that line the nares. 3.At the carina, the trachea divides into the right and left bronchi. a. The right mainstem bronchus is almost a straight continuation of the trachea, whereas the left mainstem bronchus angles more acutely to the left. b. The mainstem bronchi divide into the secondary (lobar) bronchi. c. Secondary bronchi divide into tertiary bronchi, which ultimately divide into bronchioles or small airways. d. The bronchioles are approximately 1 mm thick and contain smooth muscle that can contract, thus reducing the diameter of the airway. 4.The respiratory bronchioles divide into alveolar ducts, although limited gas exchange may occur in the alveolar sacs. a. The alveolar wall consists of a thin layer of cells that lines the surface of the lung. b. In close proximity to the alveoli are the pulmonary capillaries, which carry carbon dioxide–rich blood from the lungs for return to the heart. c. The alveolar lining, supportive tissue, and capillaries make up the respiratory membrane. d. The alveoli are moistened and kept open because of the presence of surfactant. 5.The lungs are the main organs of respiration. a. The right lung contains three major divisions or lobes; the left lung has only two. b. The lungs are covered by connective tissue called pleura. have students split into groups, and have each group present a portion of the respiratory system to the rest of the class. Then you can gauge which content students most need to review.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 3 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes 6.Blood is supplied to the lungs through the pulmonary and bronchial vessels. a. Pulmonary arteries transport deoxygenated blood, rich in carbon dioxide, from the heart to the lungs. b. The pulmonary veins transport the newly oxygenated blood from the lungs back to the heart. c. The bronchial arteries branching from the aorta provide blood supply to the lungs and the bronchial veins return it to the superior vena cava. C. Physiologic Processes 1.The major function of the respiratory system is to exchange gases with the environment. 2.Oxygen is taken in while carbon dioxide is eliminated, a process known as gas exchange. 3.Ventilation is the mechanical process of moving air into and out of the lungs. a. For ventilation to occur, several body structures must be intact, including the chest wall, nerve pathways, diaphragm, pleural cavity, and brainstem. b. During inspiration, air is drawn into the lungs, the diaphragm flattens, and the intercostal muscles contract, which expands the chest and decreases air pressure within the chest cavity, drawing air into the respiratory system. c. During expiration, air leaves the lungs by the chest wall and diaphragm recoiling to the resting state, driving air out of the lungs. d. Airway resistance and lung compliance also play a role in the amount of airflow into and out of the lungs. i. More airway resistance means less airflow into the chest cavity. a)Asthma results in bronchospasm, which reduces the diameter of the airways. ii. Lung compliance refers to the ease with which the chest expands. a)The more the chest wall expands, the greater the volume of air entering the chest cavity.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 4 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes b)Loss of elasticity in the muscles of the chest wall with age decreases lung compliance. e. The volume of air entering the lungs varies on the basis of the metabolic needs of the patient f. Ventilation is controlled by the lower portion of the brainstem, specifically the medulla 4.Diffusion is the process by which gases move between the alveoli and the pulmonary capillaries. a. Gases flow from areas with high concentration to areas of low concentration. b. In the alveoli, oxygen flows from areas of high concentration to areas of low concentration in the pulmonary capillaries; conversely, carbon dioxide flows from the capillaries into the alveoli. c. High concentrations of oxygen can help to address problems with diffusion by increasing the amount available. 5.Perfusion is the circulation of blood through the lungs—specifically, through the pulmonary capillaries—and is dependent on three conditions. a. Adequate blood volume because of the concentration of hemoglobin in the blood b. Intact pulmonary capillaries where the gas exchange takes place c. Efficient pumping of blood by the heart for delivery of oxygen and elimination of carbon dioxide 15 IV. Pathophysiology A. Disruption in Ventilation 1.Disruption of ventilation can occur when the normal conducting pathways are obstructed, the normal chest wall function is impaired, or there is an abnormality with the nervous system’s control 2.Disease states that affect the upper respiratory tract will result in obstruction of airflow to the lower structures. a. Upper airway trauma, infections, foreign bodies, and other structures (such as the tongue) are causes of obstruction. 3.The chest wall and diaphragm are essential components in ventilation, and Class Activities Map a molecule of oxygen moving through the body, beginning with inhalation and ending with a target organ. Briefly discuss different areas where respiratory emergencies may affect its travel through the body. Knowledge Application©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 5 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes traumatic injuries to these areas disrupt normal mechanics. a. Pneumothorax, hemothorax, flail chest, and diaphragmatic rupture are examples of traumatic injuries to these areas. 4.Any disease process that impairs the nervous system’s regulation of breathing may also alter ventilation. a. CNS depressants such as alcohol or barbiturates can alter the brain’s response. b. Certain abnormal respiratory patterns are produced by specific brain injury. i. Cheyne-Stokes respirations – seen in older patients with terminal illness or brain injury ii. Kussmaul’s respirations – result as a corrective measure against conditions such as diabetic ketoacidosis that produce metabolic acidosis iii. Central neurogenic hyperventilation – caused by strokes or injury to the brainstem iv. Ataxic (Biot’s) respirations – seen in patients with increased intracranial pressure v. Apneustic respirations – a result of stroke or severe central nervous system disease B. Disruption of Diffusion 1.Disruption of diffusion can be caused by many disease processes and situations, causing hypoxia 2.Changes in oxygen concentration affect diffusion. 3. Any disease that alters the structure or patency of the alveoli will limit diffusion. 4.Disease states that alter the thickness of the respiratory membrane will limit diffusion of gases. (The most common cause of this alteration is accumulation of fluid and inflammatory cells in the interstitial space.) 5.Changes in permeability of the pulmonary capillaries affect diffusion. C. Disruption in Perfusion 1. Disruption in perfusion is caused by alteration of blood flow through the Respiratory physiology is fundamental in the management of respiratory emergencies. It is important to be able to tie the concepts of respiratory emergencies to the functions and structures within the body they affect. For example, correlate the pulmonary circulation with the disorders that affect it.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 6 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes pulmonary capillaries. 2.Any disease state that reduces the normal circulating blood volume will limit perfusion in the lungs. 3.If a portion of lung is without blood flow, it becomes unavailable for perfusion regardless of oxygenation. 10 V. Assessment of the Respiratory System A. Scene Size-Up 1.When you first approach the scene, consider two major questions: a. Is the scene safe to approach the patient? b. Are there visual clues that might provide information regarding the patient’s medical complaint? B. Primary Impression 1.Take the following considerations and steps to help form your initial general impression of the patient’s respiratory status: a. Position of the patient b. Color c. Mental status d. Ability to speak e. Respiratory effort 2.Signs of respiratory distress include: a. Nasal flaring b. Intercostal muscle retraction c. Cyanosis d. Pursed lips e. Tracheal tugging 3.Airway assessment should be done immediately. a. Note whether the airway is open and patent and whether there are abnormal noises. b. If the airway is compromised, it must be corrected before you move on. 4.Breathing is the next step in respiratory assessment 5.The following signs suggest a possible life-threatening respiratory problem Discussion Topics How does the assessment of a respiratory patient differ from that of other patients? What is important to consider when assessing respiratory patients? Class Activities If possible, demonstrate the use of a pulse oximeter, capnogram, or other tools used to assess respiratory illnesses. Take some time for the class to become comfortable using them on one another.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 7 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes in adults: a. Alterations in mental status b. Severe central cyanosis c. Absent breath sounds d. Audible stridor e. One-to two-word dyspnea f. Tachycardia ≥130 beats per minute g. Pallor and diaphoresis h. Presence of intercostal and sternocleidomastoid retractions i. Use of accessory muscles C. Secondary Assessment 1.History should be directed at problem areas determined by the chief complaint or primary problem. a. Obtain a SAMPLE history. b. Ask the OPQRST questions, including questions about current symptoms. c. Ask whether the patient has had similar symptoms in the past. d. Ask whether the patient has a known respiratory disease. e. A good history of medication use is essential and may provide useful clues to the diagnosis. 2.The physical examination should focus on the respiratory system and address the patient’s head and neck and include the following: a. Inspection b. Palpation c. Percussion of the chest wall d. Auscultation i. Normal breath sounds are described as bronchial, bronchiovesicular, or vesicular. ii. Abnormal breath sounds include: a)Snoring b)Stridor c)Wheezing©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 8 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes d)Rhonchi e)Crackles f) Pleural friction rub 3.The patient’s vital signs may also provide information regarding the severity of the respiratory complaints. 4.Three diagnostic measurements are of value in assessing the patient’s respiratory status: pulse oximetry, peak flow, and capnography. 5.Pulse oximetry offers a rapid and accurate means of assessing oxygen saturation. a. Most pulse oximeters cannot discern between hemoglobin saturated with oxygen and carbon monoxide. 6.Peak flow is used to determine a patient’s peak expiratory flow rate (PEFR). a. This requires a cooperative patient who understands the use of the device to get an accurate reading. 7.Capnography measures levels of carbon dioxide in the exhaled breath. a. Decreased carbon dioxide levels can be found in shock, cardiac arrest, pulmonary embolism, bronchospasm, and with incomplete airway obstruction. b. Increased carbon dioxide is found with hypoventilation, respiratory depression, and hyperthermia. 10 VI. Management of Respiratory Disorders A. Management Principles 1.The airway always has the first priority. 2.Any patient with hypoxia should receive oxygen. 3.Any patient whose illness or injury suggests the possibility of hypoxia should receive oxygen until pulse oximetry is available. 4.If there is a question whether oxygen should be given, as in COPD, administer enough oxygen to maintain an adequate SpO2 level (typically ≥96%). Strive for normoxia in your patient to avoid both hypoxia and hyperoxia if possible. 5.Supplemental oxygen administration is the mainstay of respiratory emergency management. Teaching Tips Don’t forget to focus on the importance of good basic skills of airway and breathing management, including ventilation. Points to Emphasize Oxygen should be treated like any other drug. You must be careful to provide just enough to treat hypoxia without causing hyperoxia.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 9 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes 90 VII. Specific Respiratory Diseases A. Upper Airway Obstruction 1.The most common cause of upper airway obstruction is the relaxed tongue. 2.Assessment of the patient with an upper airway obstruction varies depending on the cause of the obstruction and the history of the event. 3.Management of the obstructed airway is based on the nature of the obstruction. a. In a conscious adult, ask the patient whether he is choking; if the patient can speak, encourage him to cough the foreign body out. b. If obstruction is severe or the patient has poor air exchange, perform rapid abdominal thrusts. c. In the unconscious adult, open the airway using the headtilt/chin-lift or jaw-thrust without head extension maneuver in an attempt to open the airway. i. Begin CPR. ii. Each time you open the airway during CPR, look an object in the victim’s mouth and remove it. iii. If the obstruction persists and ventilation cannot be provided, visualize the airway with a laryngoscope. If you can see the foreign body, grasp it with the Magill forceps and remove it. iv. Once the obstruction has been removed, begin ventilation and administer supplemental oxygen. v. In cases of airway obstruction caused by laryngeal edema, supplemental oxygen and rapid airway management are necessary. B. Noncardiogenic Pulmonary Edema/Adult Respiratory Distress Syndrome (ARDS) 1.ARDS is a life-threatening condition that adversely affects gas Teaching Tips Specific respiratory diseases are treated on the basis of the underlying cause. It is more important to stress the priorities of care for airway and breathing rather than attempting to diagnose the respiratory problem. Discussion Topics This chapter covers several different pathophysiologies. Assign groups to cover different topics and find unique ways to discuss them with the class. Perhaps students can build case studies around a patient and have the other students try to determine the cause of illness and treatment of each. Class Activities Each respiratory complaint has different components of the history, physical exam, and treatment. Have students attempt to figure out the matching respiratory disease when given clues in pathophysiology, assessment, or management.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 10 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes exchange in the lungs. 2.It is a form of pulmonary edema that is caused by fluid accumulation in the interstitial spaces within the lungs. 3.It occurs in response to a wide variety of lung insults, including sepsis, aspiration, pneumonia, pulmonary injury, burns, inhalation injury, oxygen toxicity, drugs such as aspirin or opiates, high altitude, hypothermia, near drowning, head injury, emboli, tumor destruction, pancreatitis, procedures such as cardiopulmonary bypass or hemodialysis, and other insults such as hypoxia, hypotension, or cardiac arrest. 4.Increases in pulmonary capillary permeability, destruction of the capillary lining, and increases in osmotic force draw fluid into the interstitial space and contribute to interstitial edema. 5.Specific clinical symptoms are related to the underlying cause of ARDS. 6.Specific management of the underlying cause is the hallmark of treatment for ARDS. a. Use positive pressure ventilation to support any ARDS patient who demonstrates signs of respiratory failure. b. PEEP and CPAP will help to maintain patency of the alveoli. C. Obstructive Lung Disease 1.The most common lung diseases that are encountered in prehospital care are asthma, emphysema, and chronic bronchitis D. Emphysema 1.Emphysema results from destruction of the alveolar walls distal to the terminal bronchioles. 2.The major factor contributing to emphysema in our society is cigarette smoking. Significant exposure to environmental toxins is another contributing factor. a. Pathophysiology i. Continued exposure to noxious substances results in the gradual destruction of the walls of the alveoli,©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 11 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes lessening the area available for gas exchange. ii. Pulmonary capillaries decrease in number, which leads to pulmonary hypertension and right heart failure. iii. Emphysema weakens the walls of the small bronchioles. b. Assessment i. The emphysema patient may report a history of recent weight loss, increased dyspnea on exertion, and progressive limitation of physical activity. ii. Physical examination usually reveals a barrel chest and a pink hue to the skin resulting from polycythemia. iii. Emphysema patients often involuntarily purse their lips to create continuous positive airway pressure. iv. Clubbing of the fingers is common. c. Management i. The primary goal of management is relief of hypoxia and reversal of bronchoconstriction. E. Chronic Bronchitis 1.Chronic bronchitis results from an increase in the number of goblet cells in the respiratory tree. a. Pathophysiology i. Unlike emphysema, the alveoli are not severely affected, and diffusion remains normal. ii. Gas exchange is decreased because of lowered alveolar ventilation secondary to chronic inflammation of the airways. iii. Increased PaCO2 causes pulmonary vasoconstriction, resulting in pulmonary hypertension, and eventually, cor pulmonale. b. Assessment©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 12 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes i. Patients will often have a history of heavy cigarette use, but the disease may also occur in nonsmokers. ii. There may also be a history of respiratory infections. iii. Patients tend to be overweight and cyanotic, leading to their being termed ―blue-bloaters.‖ iv. ECG changes reflect increased right ventricular size. c. Management i. The primary goal is to relieve hypoxia and reverse any bronchoconstriction that might be present. ii. Fluid administration is suggested with signs of dehydration. iii. If ordered by medical direction, administer bronchodilators via small-volume nebulizer. 2.Asthma is a chronic inflammatory disorder of the airways. a. Pathophysiology i. Asthma may be induced by one of many different factors or triggers that vary from one individual to the next. ii. Within minutes of exposure to an offending trigger, a two-phase reaction occurs. a)The first phase is characterized by the release of chemical mediators such as histamine, resulting in bronchoconstriction and bronchial edema. b)The second phase begins 6–8 hours after exposure to the trigger and is characterized by inflammation of the bronchioles as cells of the immune system invade the mucosa of the respiratory tract. b. Assessment i. The most common presenting symptoms are dyspnea, wheezing, and cough.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 13 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes ii. Other symptoms include a)One- to two-word dyspnea b)Pulsus paradoxus (a drop of systolic BP of 10 mmHg or more with inspiration) and tachycardia c)Decreased oxygen saturation on pulse oximetry iii. Determine whether this has happened previously, when the symptoms started, and what steps the patient has taken to correct symptoms already. iv. Note abnormal breath sounds such as wheezing. v. Patients will have low peak flow rates. vi. Capnogram will show a ―shark fin‖ pattern, indicating bronchoconstriction. c. Management i. Treatment is designed to correct hypoxia, reverse any bronchospasm, and treat inflammatory changes associated with the disease. ii. Administer supplemental oxygen to correct hypoxia. iii. Establish intravenous access, and place the patient on an ECG monitor. iv. Administer beta-agonist preparations such as albuterol or levabuterol in conjunction with ipratropium bromide. v. Be prepared for the patient to fatigue and require aggressive airway management and ventilation d. Special Cases i. Status asthmaticus is a severe, prolonged asthma attack that cannot be broken with repeated doses of bronchodilators. a)Recognize that respiratory arrest is imminent, and be prepared for endotracheal©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 14 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes intubation. ii. Asthma in children is common, and the pathophysiology and treatment are the same as in adults, with altered medication dosages. iii. Several additional medications are used in the treatment of childhood asthma (discussed in greater detail in ―Pediatrics‖: Volume 5, Chapter 4). F. Upper Respiratory Infection(URI) 1.Infections involving the upper airway and respiratory tract are among the most common infections for which patients seek medical attention. a. Pathophysiology i. Viruses cause the vast majority of URIs. ii. Most are self-limiting illnesses and resolve after several days of symptoms. b. Assessment i. The major symptoms of URI are determined by the portion of the upper respiratory tract that is predominantly affected. ii. Patients with URIs will often have accompanying symptoms such as fever, chills, myalgias, and fatigue. c. Management i. In most cases, diagnosis and treatment is based on history and physical findings. ii. Focus on the patient’s airway and ventilation. iii. Most URIs are treated symptomatically. G. Pneumonia 1.Pneumonia is an infection of the lungs and a common medical problem, especially in the aged and those infected with HIV. a. Pathophysiology i. Bacterial and viral pneumonias are the most©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 15 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes frequent, although fungal and other forms do exist. ii. The infection begins in one part of the lung and often spreads to nearby alveoli. iii. Pneumonia is primarily a ventilation disorder. b. Assessment i. Patients will generally appear ill and report a fever and chills. ii. Many cases involve associated pleuritic chest pain. iii. Physical exam will commonly reveal fever, tachypnea, tachycardia, and cough. iv. Rales in the involved lung segment may be noted as well as egophony (―E‖ to ―A‖ changes on auscultation). c. Management i. Place the patient in a position of comfort and use supplemental oxygen to correct hypoxia. H. Severe Acute Respiratory Syndrome (SARS) 1.SARS is a viral respiratory illness that is highly infectious. a. Pathophysiology i. SARS is caused by SARS-associated coronavirus and is spread by close person-to-person contact ii. The incubation period is generally 2–7 days, although some cases have had an incubation period of as long as 10–14 days. b. Assessment i. If a SARS outbreak has been identified, be sure to utilize strict personal protective equipment (PPE) protocol. ii. Look for altered mental status, dyspnea, cough, cyanosis, and hypoxia. iii. Associated symptoms include sore throat, rhinorrhea, chills or rigors, myalgias, headache, and©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 16 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes diarrhea. This can progress to cough, sputum production, respiratory distress, and eventual respiratory failure. c. Management i. Administer supplemental oxygen to correct hypoxia. ii. If the patient is wheezing, consider administration of a nebulized bronchodilator. iii. If SARS is suspected, notify the receiving hospital of your suspicions so that it can take appropriate measures for isolation of the patient and protection of health care workers. I. Middle East Respiratory Syndrome (MERS) 1. MERS is a viral respiratory infection that is new to humans. 2. It is caused by the Middle East respiratory syndrome coronavirus (MERS-CoV). 3. It is a very dangerous infection, causing death in 3–4 of every 10 patients infected. 4. It appears to be spread from person to person through close contact, including caring or living with a person who has the infection. 5. Primary signs include fever, cough, shortness of breath. 6. Some patients will develop nausea, vomiting, and diarrhea. 7. People with coexisting illnesses are more severely affected and can develop pneumonia and renal failure. 8. Currently, there is no vaccine for MERS. 9. Standard respiratory illness protection measures are recommended (similar to those employed for SARS). J. Lung Cancer 1.Lung cancer is the leading cause of cancer-related death in the United States. a. Pathophysiology i. The vast majority of lung cancers are caused by carcinogens.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 17 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes a)Adenocarcinoma, small cell carcinoma, epidermoid carcinoma, and large cell carcinoma are the four types. b. Assessment i. Patients with lung cancer will present with a variety of complaints depending on whether they are related to direct lung involvement. ii. Hoarseness, vague chest pain, and hemoptysis are common complaints. iii. Physical findings are nonspecific. c. Management i. Administer supplemental oxygen as needed to correct hypoxia/ ii. Be attentive for do not resuscitate (DNR) orders, advanced directives, or end-of life-care wishes. K. Toxic Inhalation 1.Inhalation of toxic substances into the respiratory tract can cause pain, inflammation, and destruction of the pulmonary tissues. a. Pathophysiology i. Causes include superheated air, toxic products of combustion, chemical irritants, and inhalation of steam. b. Assessment i. Determine the nature of the inhalant or combusted material. ii. During the physical examination, pay particular attention to the face, mouth, and throat. c. Management i. Remove the patient from the hazardous environment. ii. Establish and maintain an open airway. iii. Administer supplemental oxygen to correct hypoxia.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 18 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes iv. Laryngeal edema is ominous and may require prompt endotracheal intubation. v. As a precaution, place a saline lock for venous access. vi. Transport promptly. L. Carbon Monoxide Inhalation 1.Carbon monoxide is an odorless, tasteless, colorless gas produced from the incomplete burning of fossil fuels and other carboncontaining compounds. 2.Carbon monoxide is the number one cause of poisoning in industrialized countries. a. Pathophysiology i. CO easily binds to the hemoglobin molecule and has an affinity for hemoglobin 200–250 times that of oxygen. ii. Hemoglobin with carbon monoxide bound is referred to as carboxyhemoglobin; it results in hypoxia at the cellular level and, ultimately, metabolic acidosis. b. Assessment i. After removing the patient to a safe environment, determine the source of exposure, its length, and the location. ii. Be alert for complaints of headache, nausea, vomiting, confusion, agitation, loss of coordination, chest pain, loss of consciousness, and seizures. iii. Cherry red skin is a very late finding. c. Management i. Remove the patient to a safe environment and administer supplemental oxygen to correct hypoxia. ii. Hyperbaric oxygen (HBO) therapy may be used in the treatment of severe cases, although the effectiveness of this treatment is questionable.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 19 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes M. Pulmonary Embolism (PE) 1.A pulmonary embolism is a blood clot (thrombus) or some other particle that lodges in a pulmonary artery, effectively blocking blood flow through the vessel. a. Pathophysiology i. Any condition that results in immobility of the extremities can increase the risk of thromboembolism, including recent surgery, longbone fractures (with immobilization), bedridden condition, and venous pooling that occurs during pregnancy. ii. Sources of PE include air embolism, fat embolism, amniotic fluid embolism, amniotic fluid embolism, and blood clots. iii. PE blocks blood flow through affected pulmonary arteries, which causes the heart to pump against increased resistance, leading to an increase in pulmonary capillary pressure. iv. The affected portion of the lung can no longer exchange gases, resulting in a perfusion and ventilation mismatch. b. Assessment i. Signs and symptoms will vary on the basis of the size and location of the obstruction. ii. Be alert for sudden, unexplained dyspnea; recent surgery; or prolonged immobilization. iii. Physical exam may reveal labored breathing, tachypnea, and tachycardia. iv. Right heart failure is a sign of a massive PE, resulting in jugular venous distention and falling blood pressure. v. Many cases exhibit a warm, swollen extremity with a©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 20 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes thick cord palpated along the medial thigh and pain on palpation or with extension of the calf. c. Management i. Your first priorities are always the airway, breathing, and circulation. ii. Administer supplemental oxygen at the highest possible concentration. iii. Endotracheal intubation may be required. iv. Place a saline lock. v. Carefully monitor the patient’s vital signs and cardiac rhythm. vi. Quickly transport the patient to a facility with the capabilities to care for the critical needs of the patient. N. Spontaneous Pneumothorax 1.A spontaneous pneumothorax occurs in the absence of blunt or penetrating trauma. a. Pathophysiology i. Ventilation is diminished as a result of loss of integrity of the pleural space. b. Assessment i. The patient presents with a sudden onset of sharp, pleuritic chest or shoulder pain. ii. Dyspnea is commonly reported. iii. Decreased breath sounds on the involved side may be difficult to note. c. Management i. Use the patient’s symptoms and pulse oximetry readings as guides to therapy. ii. Supplemental oxygen is usually all that is required. iii. Be careful when managing patients with positive pressure ventilation by mask or endotracheal tube,©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 21 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes as the increased pressure may cause a tension pneumothorax, which will require needle decompression. O. Hyperventilation Syndrome 1.Hyperventilation syndrome is characterized by rapid breathing, chest pains, numbness and other symptoms usually associated with anxiety or situational stress. a. Pathophysiology i. Hyperventilation frequently occurs in the anxious patient. ii. Hyperventilation in a purely anxious patient results in excess elimination of carbon dioxide, causing respiratory alkalosis. b. Assessment i. A history of fatigue, nervousness, dizziness, chest pain, and numbness and tingling around the mouth, hands, and feet may indicate hyperventilation. ii. The physical examination will reveal an anxious patient with tachypnea and tachycardia. iii. Spasm of the fingers and feet also may be present. iv. If the patient has a history of seizure disorder, the hyperventilation episode may precipitate a seizure. c. Management i. The primary treatment for hyperventilation syndrome is reassurance. ii. Instruct the patient to voluntarily reduce the respiratory rate. iii. Breath holding or breathing into a paper bag is discouraged. P. Central Nervous System (CNS) Dysfunction 1.CNS dysfunction, with the exception of drug overdose and massive stroke, is rarely a cause of respiratory emergencies but should be©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 22 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes considered in the dyspneic patient. a. Pathophysiology i. Head trauma, stroke, brain tumors, and various drugs can affect the respiratory control center in the brain, leading to difficulty breathing. b. Assessment i. Assessment should follow the same approach as for any respiratory emergency. ii. Be alert for nonrespiratory system problems, such as CNS trauma or drug ingestion c. Management i. Establish and maintain an open airway. ii. If respiratory depression is noted or if respirations are absent, initiate mechanical ventilation. iii. Administer supplemental oxygen if hypoxia is detected by pulse oximetry. iv. Establish a saline lock for venous access. v. Direct specific therapy at the underlying problem, if known. Q. Dysfunction of the Spinal Cord, Nerves, or Respiratory Muscles 1.Several disease processes can affect the spinal cord, nerves, and/or respiratory muscles. a. Pathophysiology i. Numerous disorders, including spinal cord trauma, polio, ALS, myasthenia gravis, Guillain-Barré syndrome, and certain tumors can interfere with respiratory function. b. Assessment i. Assessment should follow the same approach as with any respiratory emergency. ii. Be alert for subtle findings that may indicate a problem with the peripheral nervous system.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 23 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes c. Management i. Management of spinal cord and respiratory muscle dysfunction is purely supportive. ii. Establish an open airway and provide ventilator support. iii. If myasthenia gravis is present and if transport time is long, the physician may request the administration of one of several agents effective in treating such patients. 5 VIII.Summary A. Respiratory emergencies are commonly encountered in the prehospital setting. B. The primary treatment is to correct hypoxia. Necessary steps include establishing and maintaining the airway, assisting ventilations as required, and administering supplemental oxygen. Appropriate pharmacological agents may be subsequently ordered by local protocols. C. Use tools such as capnography, end tidal CO2, pulse oximetry, and carbon monoxide detectors to help in determining a respiratory patient’s status. 5 IX. Case Study Class Activities Discuss the case with students now that they are familiar with the chapter. 5 X. You Make the Call Class Activities Read and discuss the call and questions as a group. 5 XI. Review Questions Class Activities Pass out review questions before the lesson starts. Have students answer them. Go over the questions again after the lecture to©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 24 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes assess students’ understanding of the information.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 1 Detailed Lesson Plan Chapter 2 Cardiology 350–375 Minutes Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes 5 I. Case Study Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture. 5 II. Introduction A. Coronary artery disease (CAD) is the single largest killer of Americans. 1.Nonfatal heart attacks occur in the United States every 29 seconds. B. Sudden death from CAD is preventable. 1.Facilitation of education about the risk factors for coronary heart disease (CHD) a. Smoking, older age, family history of CVD, hypertension, hypercholesterolemia, carbohydrate intolerance, substance abuse, male gender, and lack of exercise are factors proven to increase the risk of cardiovascular disease. b. Factors that are thought to increase the risk of CVD include diet, obesity, oral contraceptives, type A personality, and psychosocial tensions. 2.Teaching recognition of the signs and symptoms of heart attack a. Patients benefit from early medical intervention b. Education can occur during our contact with the patients we treat and transport. MASTER TEACHING NOTES  Teaching Tips  Discussion Topics  Class Activities  Knowledge Application©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 2 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes 30 Part 1: Cardiovascular Anatomy and Physiology, ECG Monitoring, and Arrhythmia Analysis III. Cardiovascular Anatomy A. Anatomy of the Heart 1.The heart is a muscular organ approximately the size of the patient’s closed fist. a. The bottom of the heart is the apex and lies just above the diaphragm. b. The top of the heart is the base and lies at the level of the second rib. 2.The heart consists of three tissue layers. a. The endocardium is the innermost layer. b. The myocardium is the thick, muscular, middle layer and has skeletal muscle with electrical properties. c. The pericardium is a protective sac surrounding the heart and has two layers. i. The visceral pericardium is the inner layer and is in contact with the heart muscle itself. ii. The parietal pericardium is the outer, fibrous layer iii. In between the two is pericardial fluid, which reduces friction. 3.The heart contains four chambers. a. The right and left atria are the two superior chambers that receive incoming blood. b. The right and left ventricles are larger and inferior and pump blood away from the heart. 4.The heart contains two pairs of valves. a. The atrioventricular valves control blood between the atria and the ventricles. i. The right valve is called the tricuspid valve. ii. The left valve is called the mitral valve. Teaching Tips This is a review of previously discussed material. Revisit the previous topics concerning the anatomy and physiology of the cardiovascular system. Class Activities Have students draw the heart and its chambers and valves, trace a red blood cell from the vena cava to the aorta, and label the coronary arteries.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 3 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes iii. The valves are connected to papillary muscles in the ventricles. b. The semilunar valves regulate blood flow between the ventricles and the arteries. i. The left semilunar valve is called the aortic valve and connects the left ventricle to the aorta. ii. The right semilunar valve is called the pulmonic valve and connects the right ventricle to the pulmonary artery. 5.Blood flows through the heart when it enters the right atrium from the superior and inferior vena cava. a. The superior vena cava gets deoxygenated blood from the head and upper extremities and the inferior vena cava gets deoxygenated blood from the areas below the heart. b. The right atrium pumps blood through the tricuspid valve into the right ventricle. c. The right ventricle pumps through the pulmonic valve into the pulmonary artery, where it flows into the lungs and picks up oxygen and releases carbon dioxide. d. Blood returns via the pulmonary veins into the left atrium. e. The left atrium pumps through the mitral valve into the left ventricle. f. The left ventricle pumps through the aortic valve into the aorta, where it is moved throughout the body. 6.Coronary circulation for the heart muscle itself originates in the aorta just above the leaflets for the aortic valve. a. The left coronary artery, anterior descending artery, circumflex, right coronary artery, marginal artery, and posterior descending artery all receive blood during diastole. i. Anastomoses allow for collateral circulation in case of damage or blockage.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 4 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes B. Anatomy of the Peripheral Circulation 1.The peripheral circulation transports oxygenated blood from the heart to the tissues and subsequently transports deoxygenated blood back to the heart. a. The arterial system carries oxygenated blood and functions under high pressure. i. Arteries branch into arterioles and finally terminate at the capillaries. b. The venous system transports blood from the peripheral tissues back to the heart. It functions under low pressure with the aid of surrounding muscles and one-way valves within the veins. i. Capillaries drain into venules. The venules, in turn drain into the veins, the veins into the vena cavae, and the vena cavae into the right atrium. 40 IV. Cardiac Physiology A. The Cardiac Cycle 1.The cardiac cycle is the sequence of events that occurs between the end of one heart contraction and the end of the next. 2.Diastole is the first phase of the cardiac cycle and is known as the relaxation phase. a. Ventricular filling begins. b. Blood enters the ventricles. c. The pulmonic and aortic valves close. 3.Systole is the second phase and is when the heart contracts. a. The atria contract first, to finish emptying their blood into the ventricles. b. Atrial systole is relatively quick and occurs just before ventricular contraction. c. Blood flows out of the ventricles through the pulmonic and aortic valves. Teaching Tips Diagrams and anatomical models help to demonstrate some of the concepts of physiology. Have such models/diagrams nearby, or have the class participate by drawing on the board for the class. Class Activities Have the class diagram the normal sinus rhythm of an ECG and label it with the mechanical function that is occurring within the heart. Which portion of the ECG reflects systole and diastole?©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 5 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes d. The mitral and tricuspid valves close, preventing blood from flowing back into the atria. e. The normal ventricle ejects about two-thirds of the blood it contains (stroke volume). This ratio is called the ejection fraction. i. Stroke volume depends on three factors: a)Preload, or end-diastolic volume, is the pressure in the ventricle at the end of diastole. b)Cardiac contractility is dictated by Starling’s law, which states that the more myocardial muscle is stretched, the greater the force of contraction will be (up to a limit). c)Afterload is the resistance against which the ventricles must contract. f. Cardiac output is the volume of blood that the heart pumps in 1 minute. i. Cardiac output = stroke volume × heart rate B. Nervous Control of the Heart 1.The sympathetic and parasympathetic components of the autonomic nervous system work in direct opposition to regulate the heart. a. During stress, the sympathetic nervous system becomes dominant. i. It innervates the heart at the cardiac plexus. ii. Norepinephrine is the neurotransmitter that increases heart rate and cardiac contractility. iii. Alpha receptors located in the peripheral blood vessels are responsible for vasoconstriction. iv. Beta1 receptors, primarily located in the heart, increase heart rate and contractility. v. Beta2 receptors, primarily located in the lungs and Knowledge Application Ventricular filling, ejection fraction, and stroke volume play an important role in cardiac output and circulation. How does each of these components affect perfusion of the tissue and how does each affect your patient’s presentation? How do medications we regularly administer enhance or diminish these components?©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 6 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes peripheral blood vessels, cause bronchodilation and peripheral vasodilation. b. Parasympathetic control of the heart occurs through the vagus nerve. i. The parasympathetic neurotransmitter is acetylcholine, which slows the heart rate and atrioventricular conduction. ii. Chronotropy refers to heart rate. iii. Inotropy refers to strength of contraction. iv. Dromotropy refers to the rate of nervous impulse conduction. C. The Heart as an Endocrine Organ 1.The heart is both a pump and an endocrine organ. a. Left ventricular dysfunction will activate several control systems. i. The sympathetic nervous system and reninaldosterone system help to maintain perfusion and blood pressure through an increase in heart rate and contractile force. D. Role of Electrolytes 1.Cardiac function depends heavily on electrolyte balances. a. Sodium, calcium, potassium, chloride, and magnesium all affect cardiac function. E. Electrophysiology 1.The heart contains specialized cardiac muscle with excitatory and conductive fibers. a. Intercalated discs connect cardiac muscle fibers and conduct electrical impulses. b. The atrial syncytium contracts from superior to inferior so the atria express blood to the ventricles. c. The ventricular syncytium contracts from inferior to superior,©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 7 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes expelling blood from the ventricles into the aorta and pulmonary arteries. d. The syncytia are separated from one another by a fibrous structure between the atria and ventricles that prevents conduction of impulses. e. The atrioventricular (AV) bundle is the only way to conduct an impulse between the atria and ventricles. 2.Cardiac Depolarization a. The cell’s sodium–potassium pumps expel three sodium ions to the outside of the cell and allow two potassium ions into the cell. i. This causes more negatively charged anions inside the cell and is called resting potential. ii. When the cell is depolarized, the membrane allows sodium to rush into the cell, bringing the positive charge, and is called the action potential. iii. Once depolarization occurs, it is transmitted through the entire syncytium. iv. The cell remains permeable for only a fraction of a second and then pumps sodium out during repolarization, returning to its normal resting state. 3.Cardiac Conductive System a. The conduction system stimulates the ventricles to depolarize in the proper direction. b. It must be able to initiate an impulse and has important properties: i. Excitability, which is response to an electrical stimulus ii. Conductivity, which moves an impulse from one cell to the next iii. Automaticity, which is the ability to self-generate an©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 8 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes impulse; usually this is in the sinoatrial node iv. Contractility, which retains the ability to contract c. Internodal atrial pathways connect the SA node and the AV node. d. The AV node sends the impulse to the bundle of His, which divides into the right and left bundle branches. i. The right bundle branch delivers to the apex of the right ventricle. ii. The left bundle branch divides into the anterior and posterior fascicles, which eventually terminate at the Purkinje fibers. e. Repolarization occurs in the opposite direction of depolarization. f. Each component has its own intrinsic rate of excitation/ i. SA node conducts beats at 60–100/minute ii. AV node conducts beats at 40–60/minute iii. Purkinje system conducts beats at 15–40/minute 30 V. Electrocardiographic Monitoring A. The electrocardiogram (ECG) is a graphic record of the heart’s electrical activity; however, it tells you nothing about the heart’s pumping ability. 1.The ECG amplifies impulses and records them over time on the ECG paper. a. Negative impulses deflect downward. b. Positive impulses deflect upward. c. The absence of electrical impulse produces the isoelectric line. d. Artifacts are deflections in the ECG produced by factors other than the heart’s electrical activity. 2.ECG leads are a pair of electrodes placed in various places on the body. a. Bipolar leads are one negative and one positive electrode. Teaching Tips Have an ECG monitor available in the class. Spend some time explaining its components, and then use student volunteers to demonstrate placement of the electrodes. Class Activities Give the class some time to spend “playing” with the ECG. They can get comfortable placing electrodes on one another and get to see normal differences in tracings©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 9 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes i. Leads I, II, and III are bipolar limb leads. b. Augmented, or unipolar, leads are two negative bipolar leads combined to create an axis. i. aVR, aVL, and aVF are augmented unipolar leads and the “a” indicates that the lead is “augmented,” whereas the “V” indicates it is unipolar. The R, L, and F identify the extremity on which the lead is placed (right, left, or foot). c. Precordial leads are placed across the surface of the chest to measure cardiac electrical activity on a horizontal axis. i. They are designated V1–V6, with the letter V identifying them as unipolar leads. 3.Routine ECG monitoring a. The most commonly used lead is II. i. The heart’s electrical current flows toward its positive axis, giving it the best view. ii. The positive lead is placed at the apex of the heart on the chest wall with the negative electrode below the right clavicle and the ground on the left side. b. Modified Chest Lead 1 (MCL1) is also commonly used. 4.ECG graph paper a. The paper moves across the stylus at 25 mm/sec. b. The graph is divided by heavy and light lines. i. Light lines are 1 mm apart. ii. Heavy lines are 5 mm apart. iii. Heavy lines enclose large squares containing 25 smaller squares. a)1 small box = 0.04 seconds b)1 large box = 0.20 seconds iv. The vertical axis reflects the voltage amplitude in millivolts (mV). among one another. Knowledge Application ECG interpretation will be a commonly used skill in the treatment of medical patients. Getting a good system in place for each ECG and using it consistently will help to make the process easier.©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 10 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes a)Two large boxes = 1 mV v. Markings at the top are placed at 3-second intervals (15 large boxes) to measure heart rate. B. Relationship of the ECG to Electrical Events in the Heart 1.The P wave is the first component and corresponds to atrial depolarization. 2.The QRS complex reflects ventricular depolarization. 3.The T wave reflects repolarization of the ventricles. 4.The U wave occurs occasionally and may be associated with electrolyte abnormalities or may be a normal finding. a. The PR interval is the distance from the beginning of the P wave to the QRS complex, and represents the time it takes for the impulse to travel from the atria to the ventricles (normally 0.12–0.20 seconds). b. The QRS interval is the distance from the first deflection of the QRS complex to the last and represents the time necessary for ventricular depolarization (normally 0.04–0.12 seconds). c. The ST segment is the distance from the S wave to the beginning of the T wave. It may be elevated or depressed in certain disease states. i. Usually an isoelectric line ii. Ischemia causes ST depression or inverted T waves. iii. Appearance of a Q wave can indicate infarction. d. The QT interval represents the total duration of ventricular depolarization. i. A normal QT interval is 0.33–0.42 seconds ii. QT intervals and heart rate have an inverse relationship. iii. Generally, the QT interval is expressed as a©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 11 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines. Minutes Content Outline Master Teaching Notes corrected QT by taking the QT interval and dividing it by the square root of the RR interval. iv. Prolonged QT interval thought to be related to an increased risk of certain ventricular arrhythmias and sudden death e. Refractory period has two parts: absolute refractory period and relative refractory period 5.Myocardial infarctions, which are caused by lack of blood flow to a part of the heart, produce changes in the isoelectric line. 6.Lead Systems and Heart Surfaces i. Leads V1–V4 view the anterior surface of the heart. ii. Leads I and aVL view the lateral surface of the heart. iii. The inferior surface of the heart can be visualized in leads II, III, and IV. C. Interpretation of Rhythm Strips 1.The key to interpretation of rhythm strips is approaching each one logically and systematically. a. Always be consistent and analytical. b. Memorize the rules for each arrhythmia. c. Analyze a given rhythm strip according to a specific format. d. Compare your analysis to the rules for each arrhythmia. e. Identify the arrhythmia by its similarity to established rules. 2.The five-step procedure to analyze rhythms is a standard in EMS a. Analyze the rate. i. Bradycardia is less than 60 beats per minute. ii. Tachycardia is greater than 100 beats per minute. b. Analyze the rhythm. i. Occasionally irregular affects only a few intervals ii. Regularly irregular maintains a pattern iii. Irregularly irregular has no particular relationship©2017 Pearson Education, Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 12 Chapter 2 objectives can be found on text pp. 49–50. These objectives, which form the basis of each chapter, were developed from the current National EMS Education