The 60-Second EMT

Rapid BLS/ALS Assessment, Diagnosis & Triage

Gideon Bosker, Donald Weins, Michael Sequeira

I The Golden Minute

A. What is “The Golden Minute”?

1. The “Golden Minute” is to the 60-Second EMT what the “Golden Hour” is to the emergency
department physicians: The crucial unit of time in which to interview assess, inspect and
determine a likely course of action in the pre-hospital setting.

B. The Five Golden Rules

1. Stay Calm
2. Use a systematic approach
3. Assume the worst
4. Look and inquire beyond the obvious.
5. Use protocols when warranted and be aggressive with stabilization.

C. The Golden Minute Objectives

1. Detect diagnostic clues early in the pre-hospital encounter.
2. Elicit capsule histories that yield action-oriented approaches to pre-hospital care.
3. Move rapidly down established EMT algorithms and standardized treatment protocols.
4. Select and institute appropriate, often life-saving therapy within moments

D. Golden Minute Pathways

1. One of the following pathways usually will become more appropriate that the other. Use the
one, or some combination, that suits the patient’s problem.
a. Contemplative, History-Oriented Response, also known as “CHOR”
b. Fast Action Saves Time (FAST)

II Information Processing During the Golden Minute

Three types of information “set the tone” for diagnosis, assessment, and treatment during the first 60
seconds. This information must be obtained quickly and efficiently. Note: Often these facts can be
gathered before arrival at the scene.

E. Clinical History:
While the patient is being stabilized, the EMT should obtain relevant data, including past medical
history, history of present medication dosages, important historical features include:
1. Mechanism of injury (in trauma cases)
2. Is this a new problem or a worsening of an old problem
a. Congestive Heart Failure (CHF)
b. Chronic Obstructive Plumonary Disease (COPD)
c. Asthma: Has patient ever required intubation in the past? What medications seem to
work for the patient? How long has this attack lasted?
d. Altered mental status: Recent or preexisting? Associated Fever?
e. Medication reactions: Ask the patient whether there is the possibility of adverse reaction.
Has medication dose changed recently?
f. Respiratory distress. Immediately consider the following:
i. Pulmonary edema
 ii. COPD
iii. Asthma
iv. Pneumonia
v. Allergic Reaction
vi. Tension pneumothorax
vii. Foreign body aspiration
g. Seizures: Determine whether patient has a seizure disorder.
F. Mechanism of Injury
1. Critical information for multiple trauma victims:
a. Was the victim in a high-speed or a low-speed motor vehicle accident?
b. In cases of violation of the passenger compartment: was the passenger restrained or
unrestrained? (Passive restraints such as deployed airbag; seatbelt; child safety seat)?
c. Was the victim thrown from a vehicle?
d. Was the mechanism of injury blunt or penetrating
e. With lacerations, injury to tendons and nerves is likely
f. Is the neck hyper extended?
g. How far did the victim fall? (A fall from a height of three stories or greater has a 50%
mortality rate.)
G. Evidence at the Emergency Scene
1. Critical information to guide the EMT during Golden-Minute assessment of major trauma:
a. Blood loss: A large amount of blood at the scene suggests severe hemorrhage, but
absence of blood does not rule out severe blood loss.
b. Level of consciousness: Any alteration or depression of consciousness in a setting of
major trauma is indicated for rapid stabilization and transport.
c. Distance fro vehicle: Victims thrown from a vehicle are likely to have severe internal
injuries with hemorrhage.
d. Vital Signs: Use initial vital signs as a guide to rapid intervention. Respiratory rate
greater that 30, heart rate greater that 110 and systolic blood pressure less that 100
indicate the necessity for immediate stabilization. Note: Drop in BP is a late sign of
shock.
2. Critical information to guide the EMT during Golden minute assessment of Medical
Emergencies:
a. In cases of cardiopulmonary arrest, was bystander CPR initiated? If so, how long after
the collapse?
b. Have ABC’s been maintained.
c. Look for evidence of toxic ingestion or drug overdose:
i. Seizures in the setting or cardiac arrest suggest a possible “upper” overdose
ii. Severe respiratory depression suggests a “downer” overdose
d. Is CPR in progress? If so, Prognosis is improved
e. Check Medic-Alert bracelets, tags, necklaces (diabetes? Anticoagulants? Pacemaker?)
f. Coma protocol. Administer 50 ccs D50DW, 2 mg Narcan, and 100 mg thiamine IM if
patient is comatose.
g. General environmental condition. Evaluate the patient for the possibility of hypothermia
or hyperthermia.
h. Evaluate the home environment. Look for signs of a patient’s inability to care for
themselves, drugs, alcohol, evidence of recent meals, and medications.
I Action Pathways for the Golden Minute Fast Action Aves Time (FAST) vs. Contemplative, History-
Oriented Response (CHOR) pathway.
A. FAST Track is used when speed is of the essence; immediate intervention regardless of the clinical
history.
1. Cardiopulmonary respiratory arrest
2. Major Trauma
3. Respiratory distress
4. Apnea
5. Severe CHF
6. Drug overdose
7. Coma
8. Severe Asthma
9. Seizures
10. Shock
11. “C-Spine” injury
12. Infant Distress
13. Child Abuse

B. The CHOR track is used in non life-threatening situations; these cases the most appropriate course of
action is determined by the clinical history and features of the illness.
1. Geriatric patients with ALOC, fever, falls, adverse drug reactions, syncope or gradual
deterioration
2. Patients with chest pain who are not hemodynamically unstable.
3. Patients with SOB who do not appear to have life-threatening distress
4. Patients with syncope who are hemodynamically stable and who do not have cardiac
arrhythmias.

IV. Golden Minute Assessment for the 60-Second EMT

A. The Golden Minute evaluation
B. The Golden Minute Nine-Point plan in Multiple Trauma
1. Vital Signs
2. Primary Survey
3. Secondary Survey
4. Circulation Management
5. Cardiac Monitor
6. Fracture Stabilization
7. Neurovascular Status assessment
8. Tension Pneumothorax
9. Teamwork
V. The Golden Minute Curriculum for the 60-Second EMT
A. Medical Emergencies
a. Syncope
b. Chest Pain
c. Cardiac Arrest
 d. Abdominal Assessment
e. Toxicology Assessment
f. HazMat Assessment
g. Respiratory Exam
h. Thermoregulatory Disorders
i. Neurologic Assessment
j. Geriatric Assessment
k. Pediatric Assessment
B. Traumatic Emergencies
a. Multiple Trauma
C. Communication Emergencies
a. Hospital Case Presentation
i. R.U.S.H.E.D
VI. Conclusion
A. The Golden Minute evaluation can be the key to rapid treatment and assessment. The evaluation
requires assessing multiple organ systems simultaneously and keeping a mental log of many factors.
 Medical Emergencies:
I Syncope
A. Preliminary Red-Flags: S.C.E.N.T
1. Supine Posture when syncope Occurs
2. Cardiac Symptoms just before syncope (CP, SOB, Palpations)
3. Elderly patients should always be considered for serious causes.
4. No Warning of the syncope: Think cardiac or neurological
5. Trauma associated with the syncope (as a result or cause)

B. Syncopal Event: During the syncope, watch for the following “TIPS”
1. Tongue-Biting
2. Incontinence of urine, or stool
3. Prolonged duration of unconsciousness
4. Seizure Activity

C. Post-Syncopal red Flags: Watch for these like Charley “C.H.A.N”

1. Confusion
2. Headaches
3. Abnormal Vitals
4. Neurological Dysfunction; especially focal dysfunction
D. Tips and Tricks
1. Take and Orthostatic Pulses and Blood Pressure: Measures the volume status and fall risk. Ideally as
lying, sitting and standing. Ask about insulin use.
a. Significant Declines
i. Pressure decline of 20mm/hg systolic
ii. Pulse increases ≥ 20 bpm
E. Types of Syncope
1. Vasovagal Syncope: Usually position-dependant and rarely occur when a person is supine or sitting.
Recover fairly fast.
a. Causes:
i. Emotional Distress
ii. Prolonged Standing in warm, crowded rooms
iii. Alcohol involvement
iv. Pain
v. Prolonged bed rest or fasting
vi. Mild Blood loss
vii. Anemia
viii. Fever
b. No warning = Cardiac, orthostatic syncope, or seizure is more likely than Vasovagal
c. Aggressive approach for: respiratory, Neurologic, hemodynamic compromise.
2. Orthostatic Syncope
a. Causes:
i. Diuretics
 ii. Beta-blockers
iii. Antihypertensive
iv. Narcotic analgesics
v. Cardiac medications

II Chest Pain
A. C.R.A.M.P.S.
1. Costochondral chest wall pain
2. Rebound pain from withdrawal of cardiac medications
3. Angina: Aortic aneurism, anxiety
4. Myocardial Infractions
5. Pneumonia: Pericarditis, Pneumothorax, Pulmonary Embolism, Pleurisy
6. Spasm of the esophagus

P Q R S T
C.R.A.M.P.S Provocative Palliative Quality Region Radiation Time

Costochondral Respirations Shallow Breathing Sharp Anterior & Lateral Locally After Exercise
Movement Splinting
Palpation
Cough

Rebound Pain (Same as for MI)

Aneurysm None None Deep Tearing Substernal Back Sudden Onset
May subside
Spontaneously
Anxiety Stress Relaxation Sharp, Varies in Chest Usually None Subacute
Stimulants Occasional Onset
MI None None Crushing Substernal Jaw After Exercise
Heavy (Can Vary) Either Arm Heavy Meals
Dull Pressing Stress w/SOB
Band-Like NV/Sweating
Pneumonia Respirations Shallow Breathing Sharp Laterally None With Fever
Cough Dull Achy Cough
Slow onset
Pericarditis Supine Posture Upright posture Sharp Substernally Usually none Subacute onset
Respirations Shallow Breathing Tip of Shoulder
Cough
Pleurisy Respirations Shallow Breathing Sharp Laterally None Subacute onset
Cough Flu symptoms
Spasm Supine (delayed) Antacids Dull Pressing Substernally Jaw Subacute onset
(Esophageal) Posture Collicky Epigastric Either Arm after meals, at
night with acid
taste.

B. Tips and Tricks

1. Within the 1st minute you should know if the pulse is irregular
2. If the pain stops the patients in their tracks; think MI
3. Often CP in MI is brought on by physical stress, emotions, large meals or extreme temperature.
4. Pleuritic Pain: Very sharp, stabbing pain that increased at the end of ever inspired breath.
 5. If dyspnea occurs in the setting of CP think CHF.
6. If temp is above 102.5 then infection is probably causing the CP.
C. Symptoms of a Cardiac Nature:
1. Belching
2. Involuntary defecation
3. syncope
4. dyspnea on exertion
5. nocturnal dyspnea
6. palpitation

III Code Blue

A. ABC’s still prime importance
B. Tips & Tricks
1. Venous pooling + arrest situation = Neck Vein Distention
2. JVD + Trach. Dev. + Decreased LS = Tension Pneumothorax
3. Decreased LS (especially on left) = Tube Placement
4. JVD + Midline Trach + non-chest trauma = Cardiac Tamponade.
5. JVD + rec. surgery or blue color = Pulmonary Embolus
a. Shock Vfib/Vtach
i. 200/200-300/360

IV Abdominal Assessment
A. Think G.U.T. P.A.I.N.S.
1. G: Gall Bladder stones, Gas pains, Gastroenteritis, Gastritis
2. U: Ulcer Disease
3. T: Trauma-induced abdominal injury
4. P: Pancreatitis PID, Pregnancy (Ectopic)
5. A: AAA, Appendicitis, Alcoholic Gastritis, Angina
6. I: Ischemia, Intestinal Obstruction, Infections
7. N: Neoplasm
8. S: Spasm of the esophagus and Splenic Rupture
 B. Common Anatomic Pain Sites for Specific Causes of Acute Ab. Pain

RIGHT UPPER QUADRANT AND FLANK

• Cholecystitis • Intestinal Obstruction
• Pyelonephritis • Retrocecal appendicitis
• Penetrating ulcer • Pancreatitis
• Choledocholithiasis • Gastric Ulcer
EPIGASTRIUM
• Pancreatitis • Gastritis
• Duodenal ulcer • Early appendicitis
• Penetrating ulcer • Mesenteric ischemia
• Colon carcinoma • Abdominal aortic Aneurism
LEFT UPPER QUADRANT AND FLANK
• Splenic enlargement • Diverticulitis
• Pyelonephritis • Bowel Obstruction
• Splenic rupture •
RIGHT LOWER QUADRANT
• Appendicitis • Bowel Obstruction
• Hernia • Pyelonephritis
• Cholecystitis • Diverticulitis
• Psoas Abscess • Leaking aneurysm
• Ectopic Pregnancy •
LEFT LOWER QUADRANT
• Diverticulitis • Bowel Obstruction
• Hernia • Leaking Aneurysm
• Pyelonephritis • Abdominal Wall Hematoma
• Ectopic Pregnancy •
HYPOGASTRIUM
• Diveriticulitis • Cystitis
• Bladder Obstruction • Appendicitis
• Prostatism • Hernia
• Bowel Obstruction • Colon carcinoma

C. Causes of Abdominal Pain in the elderly:

Constipation
Cholelithiasis
Acute Cholecystitis
Intestinal Obstruction
Acute Pancreatitis
Gastroenteritis
Duodenal ulcer
Aortic Ab. Aneurism
Appendicitis
Mesenteric Ischemia
Obstructive Uropathy
Volvulus
D. Tips & Tricks
1. Patients with Cholelithiasis (gallstones) may have right-upper quadrant pain after eating a fatty meal,
along with severe Nausea/Vomiting.
2. Conditions that present back pain as a predominant symptom: Pancreatitis & Perforated peptic
ulcer.
a. Perforated Peptic Ulcer: Ask about ulcer disease, aspirin, and ibuprofen or anti-inflammatory
drugs.
b. Patients often exhibit board-like stomachs
3. Back Pain: WATCH OUT! Every patient who complains of back pain should have an abdominal
assessment. Make sure palpation does not reproduce the back pain.
a. Causes:
i. AAA: Patient May have sciatica (pain shooting down the leg from the back) from
dissection of the aneurysm into the sciatic nerve. Check for a history of hyperten,
lack of pulses in the legs and hypoten.
ii. Cholelithiasis: Sometimes occurs as isolated right-thoracic or interscapular pain.
Usually occurs with nausea and 1-2 hours after a meal. Palpation of the right-
upper quadrant will reproduce the back pain
iii. Pancreatitis: Most frequently associated with alcoholism or trauma. Often causes
vomiting and hypovolemia. Movement does not make the pain worse; PT can not
find a comfortable position.
iv. Perforated Ulcer: Back pain associated with peritoneal signs
4. Colicky Pain: An intense spasmodic pain caused by smooth muscle contractions in a hollow viscous
organ against a mechanical obstruction
a. Can be very intense, subside and return with more force.
b. Comes in waves or spasms
c. Palpation does not affect the severity of the pain
d. Causes:
• Bowel Obstruction: adhesions, sigmoid Volvulus, or neoplasm
• Bile Duct Obstruction: Gall Stones, Pancreatitis, ulcer disease
• Renal Obstruction: Pain occurs in the flanks. Radiates to the groin or
testis. Associated with vomiting
• Gall Bladder Obstruction: (See Back pain)

5. Peritoneal Pain: A constant, severe, and generalized abdominal discomfort caused by irritation
inflammation of the peritoneal wall.
a. The physical hallmark: Rebound tenderness; guarding.
b. Coughing usually produces pain and Patients try and remain as motionless as possible. Patients
will also have absent bowel sounds.
c. Causes: Irritation of the peritoneum from blood, contents from any ruptured organ, or primary
infection.
6. Vomiting Syndromes
a. Non specific syndrome. Presenting symptom for bowel obstruction, gallstones, and kidney
stones.
i. Causes:
 • Pain
• MI
• Elevated Intracranial Pressure

7. Hemorrhagic Syndromes:
a. Distinguish these into upper and lower GI bleeding sources. Upper GI bleeding will often
result in hemodynamic compromise (hypovolemia shock), where as lower GI bleeding most
often will not.

b. UPPER GI BLEED LOWER GI BLEED

Gastric Ulcer Neoplasm
Gastritis Hemorrhoids
Peptic ulcer Angioma
Esophageal Varices Diverticulitis

• Upper GI Bleeding: Hallmarks include a previous history of peptic ulcer

disease (epigastric pain relieved by food ingestion: duodenal ulcer; pain
worsened by food ingestion while swallowing: esophageal; or pain 5 to 30
minutes after ingestion: gastric); the ingestion of substances corrosive to
the gastric lining (aspirin, alcohol, anti-inflammatory agents).
a. Bleeding from esophageal varices occurs in patients with a history
of cirrhosis
i. Blood originating from the esophagus to the mid-small
intestine will turn the stool black. If the UGI bleeding is
brisk, the stool will appear maroon.
ii. Vomited blood originating from the Upper GI tract will
look red to maroon. If not brisk, it will turn black and
spear in small clumps (coffee emesis).

• Lower GI Bleeding: Patients with lower GI bleeding frequently have

cramps lower abdominal pain that is relived by bowel movements. The
bowel movements are usually bright red in appearance. REMEMBER:
Bright red lower blood coming from the rectum may actually be coming
from a massive UGI Hemorrhage. LGI: Hemorrhages usually do not bleed
appreciably and do not often produce hemodynamic impairment.

8. Gynecological Syndromes: Ectopic symptoms

a. LAB Pain
b. Hypotension
c. Shoulder-Tip pain
d. Vaginal Bleeding
e. Syncope

9. Pain + Vomiting:
a. Bowel Obstruction
b. Gastroenteritis
 c. Gallstones
d. Kidney Stones
e. Myocardial Infraction
f. Elevated Intracranial Pressure

10. ALS Abdominal Calls:

a. Any back pain in the elderly patients with no prior history of trauma or previous back pain—
especially if associated with orthostatic Hypotension, history of hypertension, and/or unequal
or absent pulses n the lower extremities
b. All patients with peritoneal signs
c. Any abnormal pain with hemodynamic compromise (including orthostatic hypotension).
d. Patients with colicky pain consistent with intestinal obstruction.
e. Any elderly patient with nausea and vomiting of uncertain etiology
f. Upper GI bleed.

V Assessment of the HIV Patient

A. The 4 “M’s” for ALOC is Aids
1. Meningitis
2. Malnutrition
3. Medication
4. Missing Oxygen (Hypoxia)
B. High risk of HIV infection
1. ALOC
2. obtundation
3. seizure
4. fever
5. dehydration

C. Gastrointestinal infections and fever are common in AIDS patients

D. ALOC is a common c/c of AIDS patients
1. Meningitis is a very common complication of AIDS
a. Mild headache, apparent psychotic behavior, and confusion can all be subtle presentations of
meningitis
E. 15% of transports involve HIV positive patients.

VI Coma Assessment: The 60-second program calls for immediate implementation of the coma protocol regardless
of what bystanders offer. Institute the three-drug coma protocol in all unresponsive patients, regardless of what
the evidence at the scene suggests. Look for signs of impending coma within the first 60 seconds.
A. More than one cause for the coma:
1. Chemical intoxication and coexistent head trauma
2. multiple drug ingestion (most OD’s)
3. Other organ system involvement, such as shock, aspiration, or sepsis
B. If the patient has been comatose for too long, fixed and dilated pupils can result from cerebral hypoxia.
C. Remember patients who ‘talked and died’ will frequently have intracranial hematoma (either epidural or
subdural).
D. Never assume that when a patients smells of alcohol that they are comatose on alcohol alone.
 E. Reevaluate patients continuously
F. Signs and Symptoms of Signs and Symptoms of Hypoglycemia
Hypoglycemia: Adrenergic Activation Disturbed Cortical Function
Beta Stimulation Weakness
Tremulousness Headache
Tachycardia Blurred or double vision
Palpations Disturbed intellectual function
Diaphoresis Amnesia
Faintness Incoordination or paralysis
Anxiety Seizures
Hunger Coma
Gastric Hypermotility Brainstem Dysfunction
Nausea

G. Glasgow Coma Scale

Eye Opening:
(4) Spontaneous
(3) To Voice
(2) To Pain
(1) None
Verbal Response:
(5) Oriented
(4) Confused
(3) Inappropriate Words
(2) Incomprehensible words
(1) None
Motor Response:
(6) Obeys commands
(5) Localizes pain
(4) Withdrawn (pain)
(3) Flexion (pain)
(2) Extension (pain)
(1) None
Total Trauma Score: 1-16
Total GCS Points:
14-15 = 5
11-13 = 4
8-10 = 3
5-7 = 2
3-4 = 1
VII Toxicology Assessment
A. Conscious v. unconscious
1. Administer the drug ‘trio’
2. Always consider the possibility of multiple drug ingestion.
3. Never forget the possibility of concurrent head injury.
4. Ipecac
a. Contraindications:
i. Acid and alkalis
ii. Those who have ingested hydrocarbons (petroleum), strychnine, iodides, or silver
nitrate
iii. Always search the premises for pill bottles, prescriptions, pill fragments, and drug
paraphernalia regardless of what story the patient tells.
B. Uppers:
1. Cocaine, amphetamines, phencyclidine (PCP), tricyclic antidepressants, anticholinergics
2. Toxicity is primarily:
a. Cardiovascular: Tachycardia, arrhythmias, hypertension, hypotension
b. CNS: Behavioral changes (usually hyperkinetic), mydriasis (dilated pupils), seizures.
Tricyclics and phencyclidine (PCP) characteristically can product fluctuating mental status
with sudden cataclysmic lapse into comma (Tricyclics) or rage (PCP) and/or seizures.
C. Downers:
1. Include: narcotics, sedatives, hypnotics, anticonvulsants
D. OD can cause sudden changes in a patient status. Certain substances are notorious for causing patients to
‘crash’. Remember that propoxyphene (Darvon) and meperidine (Demerol) can caused dilated pupils and/or
seizures in contrast to other narcotics.
1. Tricyclic antidepressants can cause sudden coma and/or cardiovascular collapse with hypotension
and/or arrhythmias.
2. Cocaine and amphetamines can cause sudden cardiovascular collapse with hypotension and/or
arrhythmias and seizures.
3. Overdoses of calcium channel blockers (Calan, Procardia) and beta blockers (Lopressor, Tenormin)
are more prevalent.
a. Calcium chloride is the antidote for calcium channel blocker—overdose. Aggressive fluid
therapy and dopamine may also be necessary. Atropine can be used for bradycardia but its
results vary.
b. Beta-agonist agents and glucagons are beneficial in symptomatic beta-blocker overdose.
Higher doses may be needed to counteract the substance.

VIII HazMat Assessment

A. The EMT should consider four basic patterns and be aware of his/her own exposure risk. These patterns
are:
B. Dermal exposure resulting in local effects
C. Dermal exposure resulting in systemic effects
D. Inhalation resulting in local effects
E. Inhalation resulting in systematic effects
F. Field Management begins with eliminating the exposing agent. Lavage should follow for 15 minutes if the
patient is not otherwise injured and in need of immediate transport.
G. POISONS ANTIDOTES
Acetaminophen N-acetylcysteine (NAC, Mucomyst)
Anticholinergics Physostigmine
Arsenic Dimercaprol (BAL), D-penilillamine
Beta-adrenergic antagonists Glucagon
Benzodiazepine Flumazenil
Botulism Botulineum antitozin (ABE trivalent)
Cadmium CaNa2 EDTA, D-penicillamine
Calcium channel blocker Calcium Chloride
Cardiac glycosides Digoxin immune FAB (Digibind)
Carbamates Atropine, pralidoxime (2-PAM)
Chlorine Gas Sodium bicarbonate
Cobaltn CaNa2 EDTA
Copper Dimercaprol (BAL), D-penicillamine, CaNa2 EDTA
Coumarin derivatives Vitamin K1 (Phytonadione)
Cyanide Amyl nitrate, NaNitrate, Na thiosulfate, O2, Hydroxocobalamin
Tricyclic antidepressants Sodium Bicarbonate
Ethylene glycol Ethanol, pyridoxine, thiamine
Hadrazines Pyridozine (Vitamin B6)
Hydrogen Sulfide Amyl nitrate, sodium nitrate, oxygen
Hydrofluoric Acid Calcium gluconate, magnesium sulfate
Hypoglycemic Dextrose, glucagon, hydrocortisone, diazoxide
Iron Deferoxamine
Inorganic mercury Dimercaprol (BAL), dimercaptosuccinic acid (DMSA), D-penilillamine
Lead “”, CaNa2, EDTA, dimercaptosuccinic acid (DMSA), D-penilillamine
Magnesium Calcium gluconate
Methanol Ethanol, folinic acid (Leucovorin)
Methemoglobinemia Methylene Blue
Methotrexate None
Mushrooms
Clitocybe/inocybe Atropine
Amanita Phalloides Penicillin G, silibinin, silimaryn
Gyromitra esculenta Pyridoxine
Neuroleptics (extrapyramidal symptoms) Diphenhydramine, Benztropine
Phenothiazines None
Butyrophenones None
Thioxanthenes None
Metoclopramide None
Opioids Naloxone
Zinc CaNa2, EDTA, dimercaprol (BAL)
 [HAZ Mat Picture]
Health Hazard:
4.Deadly
3. Extreme Danger
2. Hazardous
1. Slightly Hazardous
0. Normal Material
Fire Hazard:
4. Flashpoint below 73ْْ
3. Flashpoint below 100ْْ
2. Flashpoint below 200ْ
1. Flashpoint above 200ْ
0. Will not burn
Reactivity:
4. May Detonate
3. Shot and Heat may detonate
2. Violent Chemical Change
1. Unstable if heated
0. Stable
Specific Hazard:
4. OXY: Oxidizer
3. ACID: Acid
2. ALK: Alkali
1. W: No Water
0. Radioactive Symbol: Radioactive

IX Respiratory Exam
A. General Information:
1. It is difficult to distinguish between the different causes of respiratory distress (especially CHF and
COPD).
2. The 60-Second EMT stresses first an accurate history and, second, a rapid primary survey. You
want to know early if these individuals who may already have established a pattern of complications
caused by their underlying disease (whether or not there is a past history of CHF or COPD).
3.
B. Questions:
1. Ask about Previous History:
a. Have there been previous episodes of CHF?
i. Yes
• Are the current symptoms similar to those experienced in past episodes?
2. Ask about events leading up to the current episode of dyspnea:
a. What, When, Where, How
b. Lack of compliance in taking maintenance medication for either CHF or COPD
c. Any recent change in the medication history
3. CHF:
a. Orthopnea: Has the patient had to sleep in a more upright position recently? Has he or she had
to use more pillows to sleep at night?
b. Nocturnal Dyspnea: Has the patient charistically been waking up in the middle of the night
with SOB
 c. Worsening of ankle swelling also suggests CHF
i. If the swelling is sudden, unilateral, and associated with pain, heat, and redness,
you must consider thrombophlebitis, viewing the shortness of breath as a
symptom of possible pulmonary embolism.
4. COPD:
a. Recent history of increased cough and sputum production
b. Frequently the patient complains of intense congestion in his/her chest and is unable to bring
any sputum up.
c. Pleuritic chest pain: Suspect complicating spontaneous Pneumothorax
d. Exposure to environments respiratory irritants on hot, humid days.
e. Fever, especially in association with C-1
f. Pulmonary embolism
5. Physical Exam Clues:
a. CHF:
i. Patient sits bolt upright
ii. Gurgling breath
iii. Regular alteration of the strength in the patient’s pulse despite a regular sinus
tachycardia (pulse alterations)
iv. JVD present. Occasionally the JVD becomes more prominent with constant, firm
pressure over the right, upper quadrant of the patients abdomen (called
hepatojuglar reflux)
v. There is ankle edema that pits when you put prolonged pressure into the ankle.
vi. Moist, late inspiratory crackles (rales) at the base of both lungs.
b. COPD:
i. Sits upright
ii. Pursed lip-breathing
iii. Poor Air movement: occasionally you can barely hear any movement
iv. Coarse Ronchi
v. Percuss the Chest:
• If one side is abnormally flat to percussion, there is probably an effusion
• If one side is abnormally hollow (shows increased resonance), suspect
Pneumothorax
c. Asthma
i. Stridor: Suspect laryngospasm
ii. Pulsus paradoxicus: In taking the patients BP, see if you lose the top level of
systolic sounds on inspiration. If you do, your patient has a paradoxical pulse. If
the range of systolic pressure in which this occurs is over 20 mm HG, this is a
significant Pulsus paradoxicus, which signifies a severe attack

C. Beta-Adrenergic Agonists for Asthma:

PHARMACOKINETICS (INHALED)
AVAILABLE ONSET PEAK DURATION
AGENT FORMS (MIN) (MIN) (HR)
NONSELECTIVE
Epinephrine I, SC 5-10 20 1
Ephedrine O 60 (oral administ.) 120-210 3-5
BETA2-SELECTIVE
Isoproternol I, IV 5 5-10 1
BETA2-SELECTIVE
Isoetharine I 1-5 5-15 1-4
Metaproterenol I, O 5-15 30-60 2.5-6
Terbutaline I, O, SC 5-30 60-90 3-6
Albuterol I, O 5-15 30-120 3-6

X Thermoregulatory Assessment:
A. Classifications of Hypothermia:

Class Cْ Fْ Signs and Symptoms

Mild 36ْ 96.8 Increased Metabolic Rate,
Max Shivering
Moderate 34 93.2 Impaired judgment, slurred
speech.

30 86.0 Respiratory depression,

myocardial irritability,
bradycardia, atrial
fibrillation, decreased
metabolic activity.
Severe <30 <86.0 Coma, profound
hypotension, decreased
respirations, fixed and
dilated pupils, spontaneous
ventricular fibrillation.
B. In hypothermia, below 30 deg. Centigrade (86 degF), effective heat production is lost.
XI Neurologic Assessment
A. Physical Findings Suggestive of Specific Stroke Syndromes:
CAROTID TIA
HEMIPARESIS OR MONOPARESIS
HEMIPARESTHESIA OR MONOHYPESTHESIA
HEMIHYPESTHESIA OR MONOHYPESTHESIA
APHASIA
MONCULAR VISUAL LOSS (AMAUROSIS FUGAX)
HOMONYMOUS HEMIANOPIA
COMBONATION OF THE ABOVE

VERTEBROBASILAR TIA
MONOPARESIS, HEMIPARESIS, OR QUADRIPARESIS
PARESTHESIA, HYPERESTHESIA, IN VARIOUS COMBONATIONS OVER ONE OR BOTH SIDES OF THE BODY OR FACE
LOSS OF VISION, BILATERAL OR UNILATERAL HOMONYMOUS HEMIANOPSIA
ATAXIA
HEARING LOSS, UNILATERAL OR BILATERAL
COMBINATION OF THE ABOVE
B. EMT Neurologic Exam Includes:
1. Mental Status and LOC
2. Speech
3. Meninges
4. Skull and Spine
5. Station and gait
6. The twelve cranial nerves
7. Motor function
8. Sensory Function
9. Cerebellar function
10. Deep tendon reflexes
TYPES OF DELIRUM
“NOISY” “QUIET”
RESTLESSNESS DROWSINESS
AGITATION LETHARGY
FEAR POOR CONCENTRATION
ANXIETY DISTRACTIBILITY
ILLUSION
HALLUCINATIONS

Remember MADCAP:
1. Medication reactions and Metabolic derangements (e.g. hypoglycemia)
2. Alcohol and Anticholinergics
3. Dementia
4. Cardiac disorders and Cerebrovascular accident
5. Alterations in hemodynamic or respiratory status
6. Pneumonia and associated sepsis
Twelve Cranial Nerves:
CN I  Olfactory nerve—senses smell
CN II  Optic Nerve—Visual perception
CN III  Oculomotor Nerve—directional gazing
CN IV Trochlear nerve—directional gazing
CN V Trigeminal Nerve—facial sensory
CN VI Abducens nerve—Directional gazing
CN VII Facial Nerve—blinking reflex, all facial muscles
CN VIII Acoustic nerve—hearing
CN XI Glossopharyngeal nerve—innervates diaphragm, activates respiratory musculature
CN X Vagus nerve—innervates diaphragm, activates respiratory musculature
CN XI Accessory cranial nerve—innervates some muscles
CN XII Hypoglossal nerve—innervates tongue

Testing the Cranial Nerves:

1. Test the visual fields (CN II)
2. Check the patients extraocular movements (EMOS) (CN’s III, IV, VI)
3. Check for equal facial sensation (CN V)
4. Check the symmetry of the patient’s facial muscles (CN VII)
5. Check hearing to finger rub or watch tick (CN VIII)
6. Check for Gag reflex (CN IX)
7. Check for Heart rate (CN X [vagus nerve])
8. Check tongue protrusion (CN XII)

Pronator Drift: With the patient keeping his eyes closed, have him or her hold arms straight out in front with elbows
unbent and palms up. A patient with a pronator drift will exhibit a rotation of the involved arm inward, with the arm
drifting outward and down. This will show hemiparesis even in the presence of good muscle strength resting.

Common Causes of Seizures:

9. Idiopathic
10. Drug or alcohol withdrawal
11. Reduction or elimination of anticonvulsant medications
12. Head trauma
13. Cerebral anozia
14. intracranial infection
a. Abcess
b. Subdural empyema
15. Intracerebral gemorrhage
16. Toxic-metabolic
a. Hypoglycemia
b. Hyperglycemia
17. Brain Tumor
18. Subdural hematoma
19. Cortical vein thrombosis
Hunt and Hess Clinical Grades of Subarachnoid Hemorrhage:
Grade 1: Asymptomatic or minimum headache or stiff neck
Grade 2: More severe headache, stiff neck
Grade 3: Confused or drowsy, may have mild hemiparesis
Grade 4: Deeply stuporus, may have moderate to severe hemiparesis, early deverebrate signs
Grade 5: Comatose

II Geriatric Assessment
A.
Indications and Symptoms of Possible Drug Toxicity
CHLORPROPAMIDE (DIABINESE) Hepatic changes, signs of CHF, seizures
DIGITALIS Anorexia, N/V, arrhythmias, blurred vision (color halos)
FUROSEMIDE (LASIX) Electrolyte imbalance, impaired hearing or balance
(ototoxicity), hepatic changes, Pancreatitis, leucopenia,
thrombocytopenia
IBUPROFEN (ADVIL, MOTRIN, NUPRIN) Nephrotic syndrome, fluid retention, ototoxicity, blood
dyscrasias
LITHIUM Diarrhea, drowsiness, anorexia, N/V, slurred speech,
tremors, blurred vision, unsteadiness, polyruia, seizures
METHYLDOPA (ALDOMENT) Hepatic Changes, mental depression, nightmares, dyspnea,
fever, tachycardia, tremors
PHENOTHIAZINE TRANQUILIZERS Tachycardia, arrhythmias, dyspnea, hyperthermia,
excessive anticholinergic effects
PROCAINAMIDE (PRONESTL, PROCAN, OTHERS) Arrhythmias, mental depression, leucopenia,
agranulocytosis, thrombocytopenia, joint pain, fever,
dyspnea, skin rash.
THEOPHYLLINE (BRONKODYL, ELIXOPHYLLIN, OTHERS) Anorexia, N/V, GI bleeding, tachycardia, arrhythmias,
irritability, insomnia, muscle twitching, seizures
TRYCYCLIC ANTIDEPRESSANTS Arrhthmias, CHF, Seizures, hallucinations, jaundice,
hyperthermia, excessive anticholinergic effects

B. Presenting Signs and Symptoms of Drug Toxicity in the Elderly

Acude delirum Cardia arrhythmias Constipation Orthostatic Severe Bleeding
hypotension
Akathisia Chorea Fatigue Parethesias Tardive dyskinesia
Altered Vision Coma Glaucoma Psychic disturbance Uniary hesitancy
Bradycardia Confusion Hypokalemia Pulmonary edema

C. Drugs Causing Orthostatic Hypotension:

Benzothiadiazides Clonidine Guanidine Levodopa Methysergide
Bretylium Tricyclic Hexamethonium Lidocande Minoxidil
antidepressants
Captopril Furosemide Hydralazine Methotrimeprazine Nifedipine
Chlorisondamine Guanethidine Lopanoic acid Methyldopa Nyroglycerine
Pentolimium Phenothiazines Phenothiazines Phenoxybenzamine Prazosin
Procarbazine Reserpine Thiothizene

D. Categories of Adverse Drug Reactions in the Elderly

PRIMARY DRUG REACTIONS (ONE DRUG – ONE SIDE EFFECT)

CIMETIDINE PSYCHOSIS
NARCOTIC-INDUCED RESPIRATORY DEPRESSION
LIDOCAINE PSYCHOSIS
THEOPHYLLINE SEIZURES
INSULIN REACTION
CHRONIC SALICYLISM
SECONDARY DRUG INTERACTIONS (REQUIRES AT LEAST TWO DRUGS TO CAUSE INTERACTION)

SULFONYLUREA/SULFONAMIDE
CIMETIDINE/LIDOCAINE
ERYTHROMYCIN/THEOPHYLLINE
INDOMETHACIN/PROPRANOLOL
TRICYCLIC ANTIDEPRESSANT/ALPHA-SYMPATHOLYTIC
DRUG WITHDRAWAL SYNDROMES (ADDICTIVE AND NONADDICTIVE WITHDRAWAL)

BETA-BLOCKER WITHDRAWL (ANGINA)

CALCIUM CHANNEL-BLOCKER WITHDRAWL (ANGINA, HYPERTENSION)
“ADDICTIVE DRUG” WITHDRAW SYNDROMES (BENZODIAZEPINES, NARCOTICS, ETC)

E. Falls:
1. Remember 40% of all falls are caused by intrinsic factors such as cardiac syncope, stroke,
dehydration, subdural hematoma, medication-induced postural hypotension, seizures, and GI
bleeding.
2. Do an ‘In-home assessment of the patients surroundings’

III Pediatric Assessment

A.
APGAR SCORING SYSTEM 0 1 2
APPEARANCE (COLOR) Blue or Pale Pink Body, blue extremities Completely pink
PULSE (HR) Absent Slow (<100/bpm) >100/bmp
GRIMACE (FACIAL) No response Grimaceseems Cough or Sneeze
ACTIVITY (MUSCLE TONE) Limp Some flexion of extremities Active motion

RESPIRATORY EFFORT Absent Slow or irregular Good Crying

B. Common Disorders:
1. Acute epiglottis’s:
a. Abrupt onset of rapidly progressive respiratory obstruction in a child usually two to eight
years old.
b. Sudden onset of sore throat, then pooling of secretions, drooling, and dysphasia.
 c. High fever is usually present and Stridor and dyspnea may interfere.
d. Restlessness, cyanosis, and exhaustion can develop rapidly, and the patient’s entire effort
seems directed towards gaining air.
e. The child may be in the ‘tripod position’
2. Aspiration:
a. Sudden onset of wheezing and inspiratory Stridor without prior respiratory infection or
history of wheezing events.
3. Croup: Hoarse, barking cough associated with difficult breathing.
a. One to five-year-old with history of viral-like upper respiratory Stridor
b. Symptoms usually worsen at night
c. Treatment includes a cool, moist, humid atmosphere.
4. Seizures:
a. Think hypoglycemia
b. Electrolyte imbalance, status epileptics, meningitis
i. Febrile Seizures:
• Rarely produce status epileptics
a. Think epidural hematoma and surreptitious ingestion of poisons
C. Pediatric Awareness Factor (PAF)
1. The circulator system reserve is very small in infants. Loss of one unit of blood is sufficient to
account for severe shock or death. Also 500/ml of fluid overload can cause pulmonary edema
2. Be aware of the differences in critical interventions:
a. ET tube size: 16 + (pt age) divided by 4
b. Cricothyrotomy should not be performed on a child under 8
c. Use dextrose IV’s on all neonates because of their limited nutritional reserves
d. Keep a card of pediatric dosages handy
e. D25W should be given for all pediatric seizures. Calcium should be considered in all
seizures in neonates
IV Trauma Emergencies:
A. Multiple Traumas: THINK SHOCK! No intervention inessential for the maintenance of life should be
done in the field, because time is more important.
A. Only the primary assessment (ABC’s with C-spine immobilization) and resuscitation should be
done in the field
B. BP’s should be taken in the primary assessment. BP’s can be estimated by:
1. Palpable radial pulse, the systolic pressure will be above 88 mm
2. Femoral or carotid pulse palpable: Systolic between 70-60 mm
C. Rapid pulse may need volume replacement.
D. Indications for intubation:
1. Apnea
2. Extensive flair chest
3. Facial or laryngeal trauma with no airway
4. If the patient has marginally adequate ventilation and is either comatose, in shock, or has an
underlying pulmonary problem.

E. Multiple Trauma Patients will deteriorate from one of six causes:

1. Cardiac arrhythmias caused by metabolic acidosis
2. C-Spine instability
3. Airway problems
4. Tension Pneumothorax
5. Hemorrhagic blood loss
6. Sucking Chest wound

F. Anticipate major trauma by the mechanism of injury:

1. Penetrating injury to the chest, abdomen, head, neck and groin. Note: Never assume just
one penetrating would. Always search for additional wounds.
2. Falls from more than 20 feet.
3. Automobile accidents in which
a. The differential velocities are 25 mps
b. There is rearward displacement of the front axle
c. There is rearward displacement of the front of the car by 20 inches
d. Passenger compartment intrusion, especially of 1 feet or more
e. Ejection of the patient
f. Rollover of the vehicle
g. Death of an occupant in the same vehicle
h. Pedestrian accidents
G. 60-Second Triage:
1. ALS:
a. Any of the above listed mechanisms of injury
b. Glasgow Coma scale <13
c. Systolic blood pressure <90
d. Respirations <10 or >29
e. Flail chest
 f. Burns of >20% (adults) or 10% (children and geriatric) or those of the face, groin, or
airway.

Case Presentation:

I Emergency Department Case Presentation

A. Think of the pneumonic: R.U.S.H.E.D
1. Reason for Dispatch: Recount the information given by the radio dispatcher and the reason for
being called to see the patient. ALS or BLS unit.
2. Urgency: Explain how stable or unstable the patient was upon your arrival. Be specific with
respect to the degree of respiratory distress, level of consciousness, extent of pain, and general
condition.
3. Scene Assessment: Describe relevant data at the scent. This would include a brief description
of the patient’s environment (if relevant); mechanism of injury, and how far the patient was
from the vehicle; a general description of the environment: was the windshield cracked? Was
the passenger side compartment violated? Was a seatbelt worn? Did airbags Deploy? In the
case of an OD the EMT should note presence or absence of drugs, paraphernalia, etc.
4. History of the Patients Problem: This requires a brief description of events leading up to the
patient’s medical deterioration.
5. Evaluation of the Patient: Communicate with pertinent positive and negative features of the
primary and secondary survey.
6. Disposition, drugs and deployment of procedures: Inform the emergency physician or nurse as
to what drugs were administered, what procedures were deployed (i.e., intubation, fluid
administration, etc.), and final disposition of the patient.
Algorithms: